July 19th, 2021
What is a retronym?
Retronyms are adjectival qualifiers, like “acoustic” guitar and “snail” mail, that were previously unneeded — because all guitars were acoustic and all mail was slow. We only added qualifiers when alternatives arose. As these two examples illustrate, retronyms can be nearly neutral — the status and popularity of acoustic and electric guitars are roughly equal — or plainly judgmental. Snail mail is explicitly inferior to faster email. “Snail” is not a neutral term.
Psychotherapy conventionally occurred between two people in one physical room. Although teletherapy — psychotherapy conducted over telephone or video — is not new, it was previously a special case. As such, it required specification while regular therapy did not. Consider an analogy with “skateboard”: without a qualifier, the word clearly refers to the kind operated by foot power. An electric skateboard is an innovation that must be specified.
However, as alternatives become more established, we often employ retronyms. In contrast to “skateboard,” it is less clear what we mean by “scooter.” There are kick scooters, electric and gas scooters, even “stand up” scooters in contrast to those with seats. Now we routinely disambiguate the word “scooter” by specifying which kind. Likewise, the growing popularity of teletherapy, which was greatly accelerated by the pandemic, now compels many of us to disambiguate “psychotherapy” with a retronym.
Which words should we use to describe these alternatives? And what do our word choices imply about how we judge each alternative’s quality, desirability, and legitimacy?
How do we feel about teletherapy?
When it comes to psychotherapy, many argue for value-neutral contrasts such as “onsite” versus “online,” terms carefully chosen not to telegraph a preference. In particular, “online” therapy avoids the implicit negative bias in alternatives like “remote” or “distance” therapy.
But using “onsite” as a retronym levels the playing field awkwardly and artificially. “Onsite” obscures real differences between talking face-to-face with another live person in the same room, versus through screens and microphones. (And technically speaking, therapy could be onsite and online at the same time, say in adjoining rooms connected electronically.) Even an alternative such as “unmediated,” which more accurately contrasts the two options, tiptoes around the essential differences between them. We’d be more honest simply sticking with “in person” despite its positive emotional bias. Or we could use no qualifier at all, and rely on the assumption that psychotherapy is in person unless otherwise specified.
Expressing honest values is not a hard-sell
It’s nearly impossible to scrub value judgments from natural language. If a term doesn’t already come with an explicit value judgment, it often develops one over time. “Juvenile delinquent” and “mentally retarded” were both introduced to replace prior stigmatizing terms — and then became stigmatizing themselves. In similar fashion, the fortune of “online therapy” as a term will rise or fall depending on how the public comes to feel about the practice. Meanwhile, “in person” or “face to face” therapy sounds superior because intimacy is inherently good, especially in a healing context. No linguistic contortion can change that.
Of course, there are competing goods. “New, improved” teletherapy also sounds attractive, as does teletherapy that is “economical,” “accessible,” or “hassle free.” Descriptions of therapy from any angle can sound like an advertising pitch. As healing professionals, we walk an ethical tightrope between presenting alternatives realistically, even though this reveals our values and biases, versus crudely touting our own approach and denigrating others’.
Face to face therapy is different
In walking this ethical tightrope, some try too hard to be carefully neutral. The result is dry and unrealistic. The essential difference in the two types of therapy is not that one is onsite or even unmediated. It’s the difference between talking to a person and talking online to a person.
Subjectively, we all know these are quite different experiences. Moreover, barring practical considerations, the former is usually preferred. When family members meet on Zoom or FaceTime, they typically look forward with anticipation to their next meeting in person (or reminisce about past such meetings). The reverse is not true. When family members meet in person, they do not typically look forward with anticipation to their next virtual encounter. This asymmetry holds in other relationships as well, e.g., in business and romance.
Note that humans have been talking to one another for decades using telephones, and more recently computers. Yet we often don’t employ a retronym to disambiguate “talking” when we mean in person, face to face — the original kind of talking. “I talked to Mary” is usually clarified by context, e.g., where Mary is located, not by an adjective. By extension, “I had a therapy session with Mary” naturally connotes doing so in person, unless the context suggests otherwise. The choice to use (or not use) a retronym is essentially a political act: a way to grant or deny status to the new, as compared to what came before.
This isn’t going away
Looking to the future, we may someday feel pressure to specify “human” therapy in order to distinguish it from computer-generated “AI” therapy. This pressure will come from those who aim to grant AI therapy a legitimacy comparable to the human default. Advocates may even complain that “human” is unfairly positive, and suggest something more neutral.
Does “human” carry positive connotations, an implicit bias? Of course it does. This is inevitable — and it stands in clear contrast to putting our thumb on the scale with terms like “meatware therapy” (to denigrate the traditional type, see “snail mail”) or “inhuman therapy” (to denigrate the new type, see “junk food”). Sometimes accurate descriptors such as “human” or “in person” sound more attractive because they really are — if we choose to use them at all.
Image courtesy of zirconicusso at FreeDigitalPhotos.net
May 16th, 2021
Caught your attention, eh? Am I calling some political group — anti-vaxxers, anti-maskers — hysterical? What a crude charge for a psychiatrist to make, not to mention sexist!
Hang on. “Hysteresis” has nothing to do with hysteria. It’s a term from cybernetics that describes a lag in a system’s response to a change in input. A simple example is a home thermostat. Change the setting and it takes time for the house to heat up or cool down to that temperature. The system has a built-in lag.
Psychological hysteresis
While pandemic lockdown in the spring of 2020 occurred quickly, it took time for most of us to adapt to the new normal. We gradually found ways to live our lives. Even greater hysteresis is occurring now as restrictions are lifted, especially for the fully vaccinated. Here in San Francisco, where well over half of adults are fully vaccinated, most still walk outside wearing masks, weeks after the Centers for Disease Control (CDC) declared it unnecessary. Many hesitate to eat inside restaurants, visit gyms, or attend indoor concerts, even though health authorities now consider these safe.
There are many ways to characterize this widely-reported lag: anxiety, inertia, better safe than sorry, feeling socially “rusty,” and so forth. Psychological hysteresis usually goes by other names, because we have fuller accounts than a simple cybernetic description. For example, we all know that, in general, feeling unsafe happens much faster than feeling safe again. Sudden danger, such as news of a new, lethal virus, instantly erases our sense of safety and trust. Regaining that sense of safety takes a long time. Some now declare it will take forever.
Peer pressure (social learning theory) matters too. A critical mass of early adopters must perform a new behavior before others feel comfortable doing so. It’s harder to go mask-less when in the minority, harder to resume indoor activities when friends and family are still avoiding them.
What it means about us
And then there’s self-image. Many blue-state residents strictly followed pandemic guidelines this past year, and took pride in our self-sacrifice on behalf of larger society. Diligent masking and social distancing meant something about us. At times this took the form of virtue signaling, a kind of “safety theater” that telegraphs certain attitudes to oneself and others without really enhancing safety. Wearing a mask while driving alone or walking down a deserted street serves no practical purpose. But it may serve a symbolic purpose for the wearer by reinforcing self-identity and self-esteem.
With newly relaxed guidelines from the CDC, the symbolism of wearing or not wearing a mask is muddled. When we pass a masked person on the sidewalk, we can no longer tell virtue signaling from (undue?) anxiety. When we pass unmasked persons, we can no longer know if they carefully follow the latest guidelines or have been spitefully flouting them all along. A similar, more subtle confusion occurs in each of us as well. What are our true motives? Fear? Defiance? False bravado? Rational assessment? Obsessive concern? This is uncharted territory. None of us fully know ourselves.
Adopting a new normal
We cannot live as though COVID-19 never happened. The pandemic changed our work habits, our use of teleconferencing, our personal and business relationships, our attitude toward contagious viruses. Living through any routine year subtly changes us, so it’s no surprise that the past momentous year has done so. All the same, the best medical minds now say vaccinated people can do almost everything we could before — without masks, without social distancing, without worry. The hysteresis is in our heads, and we will overcome it as fast as our sense of safety allows.
April 16th, 2021
I finally returned to my office after a year and a month. Or more accurately, since I was in my office all along making video calls, it’s some of my patients who returned.
Two weeks ago the CDC issued new guidelines: people vaccinated against COVID-19 can meet safely inside without masks. The guidelines appear aimed at social occasions like dinner parties, not psychiatric practices. But after reading them I no longer felt limited to offering virtual treatment.
The mechanics
To be clear, I am fully vaccinated, and this only applies to patients who are too. I continue to see the unvaccinated virtually. And for now at least, it’s voluntary. I don’t insist that anyone return to the office if they prefer video.
I developed standards: This is not for anyone who has a high-risk person in their family/pod. I run an exhaust fan in the office. I open the windows in the waiting room and bathroom. For new patients, I ask to see their vaccine card, and I show them mine.
I have rules: Do not come to the office if you feel sick. Don’t bring anyone along, e.g., to sit in the waiting room. Wear your mask in the building until we are in my office.
And then we meet without masks in the office. I don’t disinfect surfaces. It’s pretty much like 2019.
Issues I considered
Is it discriminatory to see only the vaccinated in person? I decided it’s okay. Vaccination status is not a protected class. I already discriminate against would-be patients who seek psychiatric services I’d rather not provide, and sometimes for other reasons. Presumably it’s stickier for a publicly funded mental health clinic; fortunately not my situation. I see no reason to deny the option to some, just because others can’t (yet) partake of it.
I also decided not to exclude vaccinated folks with riskier lifestyles. For example, those who work directly with COVID patients themselves, or who sometimes ignore social distancing rules. The CDC made no such distinctions in its guidelines. Also, I’d have to make difficult judgments of risk, not a role I want.
I ask patients to choose either video or in-person appointments, not to switch back and forth haphazardly without discussion. I consider this a “frame issue,” that is, part of the consistent structure of therapy that makes it safe to feel vulnerable. (Similar frame issues include keeping sessions the same length, not varying the fee, and not shocking the patient with sudden changes in the tone or setting of treatment.) I still invite a rare phone or video session for extenuating circumstances, as I did before the pandemic. And while it hasn’t happened yet, I’d permit a rare in-person session for a vaccinated person who usually meets with me remotely.
The future
I anticipate most of my existing patients will eventually return to in-person treatment, which I’ve always believed is superior to virtual alternatives. However, some can’t. During the pandemic I began seeing a few people who live very far away. It isn’t practical to meet in person. If for no other reason, my practice will indefinitely remain a mixture of in-person and virtual.
And some can return but won’t. A few vaccinated patients recently told me they prefer meeting by video even though they could, and in some cases formerly did, come to the office. As mentioned above, I haven’t insisted they make office appointments. I’m not sure I ever will. But their refusal confirms a concern I expressed almost exactly a year ago, that some will find the compromises made for the pandemic attractive, and they won’t want to give them up.
My thinking has lately evolved on this point. The problem is not that virtual convenience is inherently bad. Some people, e.g., busy single parents, might not pursue treatment at all without a virtual option. There are situations where virtual treatment is needed, and many more where it’s a sensible choice. What’s bad is ignoring the trade-offs.
At some level, I find it hard to believe that anyone seriously doubts the superiority of in-person psychiatric treatment or psychotherapy. Those who can come to the office without undue hardship enjoy the “full-bandwidth” experience: in 3-D, with nary a video lag or audio malfunction. Subtle nonverbal cues and transient facial expressions carry important meaning. There’s a “presence” lacking in mediated communication. It’s simply a more real human relationship.
Closing the virtual door
And that’s why I made my biggest decision: I’m not taking on any more virtual patients, vaccinated or not. Many individual clinicians, not to mention startups that aggregate therapists into rows of pretty headshots on their websites, already supply the video option. More of them pop up online every day. As in fine dining versus fast food, the discerning will value quality over convenience. Granted, there’s a time for convenience: a difficult individual circumstance here, a worldwide pandemic there. We’ve all had to live on convenience food, and convenience treatment, for the past year. Now it’s time, for those who can, to improve their diet.
Photo by Daniel Schludi on Unsplash
March 29th, 2021
Quick, grab a weapon!
Millions of alarmed Americans, and people the world over, grabbed the nearest bludgeon to fend off the Trump presidency. They reached for anything handy: street marches, sympathetic pundits, counter-tweets, progressive infotainment, social media. Unfortunately, most of these reactions only fed a vicious cycle of attack and counter-attack.
For the relatively few psychiatrists and other mental health professionals who took up arms, the bludgeon readily at hand was psychiatric diagnosis and a self-proclaimed “duty to warn.” Hastily written petitions and books preached to the choir. If you already knew Trump was disturbed, here was confirmation by experts.
The converse was also true. If you believed the left played underhanded tricks to disempower a democratically elected President, these statements were your proof as well. Condemnation of Trump by woolly-headed liberal therapists was hardly news. It simply confirmed that educated elites are not above it all. We merely chant our political slogans in fancier language.
The warrior psychiatrist
A prominent voice in this chant was Bandy X. Lee MD, a psychiatrist affiliated with Yale University who helped organize a small conference to discuss Trump’s mental state — the “Duty to Warn” conference — and who later authored the bestseller, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (Thomas Dunne Books, 2017). Dr. Lee published an expanded edition in 2019, and another book about Trump in 2020.
Positions like Dr. Lee’s led to wide debate over the “Goldwater Rule” of the American Psychiatric Association (APA). This ethical standard prohibits APA members from issuing a professional opinion about a public figure’s condition unless the psychiatrist has conducted an examination “and has been granted proper authorization for such a statement.” During the Trump administration the APA defended this standard, while others, including Dr. Lee, held that a duty to warn the public superseded it.
In reality, most of the debate over the Goldwater Rule was moot. The Rule only applies to members of the APA. Dr. Lee is not a member. Nor, of course, are the vast majority of mental health professionals who are not psychiatrists. The ethical standard of a voluntary membership organization is hardly the “gag rule” Dr. Lee and others claimed.
No constitutional right to teach at Yale
However, other “gag rules” hit closer to home. As reported this week in the New York Times, Yale canceled Dr. Lee’s volunteer faculty position last year after colleagues warned that her public statements called into question her “clinical judgment and professionalism.” Dr. Lee then sued Yale, alleging that her dismissal violated her First Amendment rights and impinged on her academic freedom.
The courts will decide the merits of her case. However, on the face of it, Yale has not prevented Dr. Lee from writing or speaking. The First Amendment protects speech from government restriction, not from deplatforming by a private university. Indeed, Yale has countervailing First Amendment rights of its own.
It is also worth emphasizing that Dr. Lee had a non-tenure, volunteer faculty teaching position. I have held such positions myself throughout my career. A psychiatry department’s decision to use or not use someone to teach trainees often boils down to subjective personality factors. If an instructor has an “agenda,” or brings unwanted controversy to the department, that alone may be enough to end the affiliation.
Do we help or hurt?
The bigger question, which goes well beyond Yale’s choice of teaching faculty or a rule for APA members, is whether academically-toned denunciations of political figures by mental health professionals add anything to political discourse.
The practical implications seem quite limited. Dr. Lee’s books didn’t move the needle. They merely fed the the cycle of attack and counter-attack. Trump’s critics and supporters alike found confirmation of their prejudices. Moreover, Americans were again reminded that our means of removing a sitting president — impeachment and invoking the 25th Amendment — are political acts, not governed by medical or psychiatric wisdom. Diagnosis is a sharp instrument for helping patients, but at best a blunt weapon in politics.
Psychiatric outcry can do very little, whether in the court of public opinion or the actual machinations of government. Ours is one small voice in a sea of voices, all clamoring to be heard.
Risk of self-harm
Meanwhile, there’s a real risk of self-harm to the mental health professions. When we make dubious claims to authority, we appear smaller not larger. When we trade professional integrity for momentary media coverage, the whole field suffers.
Worse, we may unwittingly invite a dystopia where all political factions deploy mental health experts to declare their opponents unfit. A cacophony of warnings to shun the allegedly unbalanced — the very thing misguided psychiatrists did to Senator Goldwater in 1964 — bodes poorly for a democratic process premised on voters making independent assessments of character. Such warnings are also the very definition of an ad hominem attack. Little surprise Yale drew the line.
Image courtesy of bplanet at FreeDigitalPhotos.net
January 24th, 2021
The problem
In the months since the COVID-19 pandemic forced me to practice by video and phone, I’ve exchanged much more email with patients than I did before. Previously, I discouraged email from patients. For one thing, I knew it was an insecure channel, not “HIPAA-compliant.” It’s also somewhat less personal than a phone call. But starting last March I gave patients my work email, which they needed in order to connect to my video link (usually Doxy.me) for sessions. Most also use it to pay me online. Perhaps inevitably, email has become the most convenient way to send short messages back and forth, mostly medication refill requests and appointment confirmations or changes.
Due to the pandemic, I also linked an online version of my intake form to the front page of my website, so new patients could complete it remotely. The completed form was transmitted to me by non-secure email as well.
As the months dragged on, I realized I needed to treat all this electronic communication more carefully. I started researching secure email designed for medical practices. Below I’ll tell you what I found.
What is HIPAA-compliant email?
But first, a brief dive into terminology. HIPAA, short for the Health Insurance Portability and Accountability Act of 1996, is a federal statute that, among other things, regulates the secure sharing of medical information, especially electronically. Those of us who traffic in “protected health information” (PHI) — “covered entities” such as doctors, hospitals, clinical laboratories, insurance companies, and others — must store and transmit PHI in secure ways. We also sign “business associate agreements” (BAAs) with each other. A BAA is basically a contract that says covered entities will only share PHI with other covered entities.
While many people assume HIPAA exists to assure privacy, the law actually arose to facilitate electronic information exchange, often without the patient’s explicit consent. For example, HIPAA allows behind-the-scenes sharing of PHI to “coordinate care.” But for purposes of this review, I’ll focus on the privacy safeguards, not the many other parts of HIPAA.
To be HIPAA-compliant, email must be protected at both ends, e.g., with passwords, and engineered to prevent interception and reading en route. Technically, HIPAA does not demand that email be encrypted (translated into unreadable code), although that is typically the strategy used. The email provider and the covered entity using that provider should sign a BAA.
Regular email, in contrast, isn’t designed to be secure. Messages are copied in readable form from one internet node to the next. Bad actors can intercept them along the way.
What I found
So who offers HIPAA-compliant email? One option are companies that provide complete electronic practice management systems. These typically include secure messaging with patients as part of their larger range of services. I didn’t deeply research this, as I’m not in the market for such a system. Using one solely for secure messaging seemed too expensive, unwieldy, or both. But I did briefly look into ChARM EHR and Luminello, both of which include secure communication with patients, and offer a free version with limited features to try out. ChARM is designed for all types of small medical practices, not just mental health, while Luminello is for mental health only, including non-medical therapists and “wellness clinicians.” Perhaps thanks to its specificity, I found Luminello much more user-friendly; I’d seriously consider it if I were in the market.
But I’m not, so I turned to free-standing email services.
Best I can tell, all HIPAA-compliant email is actually webmail. That is, the recipient receives a regular email with a link to a secure website to pick up the message. Services differ with respect to email storage, often 1 to 5 gb; ways that non-subscribers, e.g., patients and potential patients, can reach you securely; whether you can use an existing email address versus having to get a new one; and whether you can choose an email address from a website domain you own (e.g., therapist@mycompany.com). All include a BAA.
Several companies provide secure email to larger clinics with multiple clinicians, administrative staff, and maybe a dedicated IT person. They usually charge monthly fees to match. That’s not my situation, and I do not review them here. Instead, here are a few sized for the solo practitioner:
Hushmail for Healthcare (www.hushmail.com) – $109/yr:
Pros: Secure forms submission, with two nicely customizable forms at the above price. 10 gb storage. Can use your own domain for email.
Cons: Can’t use an existing email address in a domain you don’t own (e.g., gmail, hotmail, yahoo, etc). The price doubles for more forms.
MailHippo (www.mailhippo.com) – $60/yr:
Pros: Arguably slightly stronger encryption than Hushmail (AES 256 bit versus OpenPGP). Can recall an email message, for example if addressed incorrectly. Uses your existing email address. Includes a personal URL so anyone can send you a secure email; adding this URL to your website, or to your signature at the bottom of regular email, invites secure messages from others.
Cons: No forms.
MD OfficeMail (www.mdofficemail.com) – $23/yr with their email address, $32/yr with your own
Pros: Cheapest paid HIPAA-compliant email I could find. Includes a personal URL so anyone can send you a secure email.
Cons: User interface is old and clunky. No forms.
The following offer encrypted email — and are based in Europe, not the US — but are not designed for HIPAA specifically, i.e., no BAA:
ProtonMail (www.protonmail.com) – Free, or $48/yr for more features and email storage
Tutanota (www.tutanota.com) – 12 euro/yr for “business,” free for “private.” Includes a secure calendar and address book, which would make Tutanota my choice if I merely wanted these encrypted features for personal use.
There are also a number of free, ad-supported apps that will encrypt email on handheld devices. These aren’t HIPAA-compliant either.
And the winner is… my patients
In the end I decided to go with Hushmail, mainly because it offered the secure forms I needed: a general contact form and an intake form for my website. I also was able to use my own web domain (@stevenreidbordmd.com) for my new email address. If I hadn’t needed the forms, I would have chosen MailHippo instead, to keep my existing email address.
Once signed up, I converted the contact form and intake form on my website to Hushmail. Then, using my old, unsecured email, I sent a final message to my active patients asking them to stop using that address, and to expect secure email from me going forward. Since replying to a secure email also makes the reply secure, this is a good way to start a private, HIPAA-compliant email channel with each patient.
One of the best uses I’ve found so far for secure email is sending monthly billing statements electronically, as pdf attachments, instead of by mail. If patients or potential patients want to reach me securely before I send them anything, they use the contact form on my website to start the exchange. So far, my new system has been working well.
In the comments below, let me know how any of these solutions work for you, or if you have others to recommend.
Image courtesy of Stuart Miles at FreeDigitalPhotos.net
July 19th, 2020
Back when traumatic experiments on animals weren’t ethically prohibited, human anxiety was modeled by subjecting lab animals to an irresolvable approach/avoidance dilemma. The oldest and best known example came from researchers in Ivan Pavlov’s laboratory. They classically conditioned dogs to associate food rewards with the sight of a circle, and also trained the same dogs to associate ovals with not getting food. Once trained, the dogs were shown ovals that looked more and more circular, until eventually they couldn’t tell them apart. At that point, the animals became acutely agitated.
This paradigm became known as experimental neurosis. It was offered as a behavioral account of neurosis at about the same time Freud was developing a psychoanalytic account. Experimental neurosis could be induced in many different species, and via both classical and operant conditioning. As an example of the latter, thirsty lab rats were given access to a metal water spout with an electric charge. The rats wanted the water, but didn’t want the shock. As a result, the rats had physiologic and behavioral reactions that looked a lot like human anxiety.
Many of us wince even at the description of these experiments. We empathize with the poor creatures confronted with an irresolvable problem. Nowadays, the experiments seem cruel, even though the goal was to relieve human suffering (e.g., the rat studies were done to test anti-anxiety medications before trying them on people).
The coronavirus pandemic challenges us with similar approach/avoidance dilemmas, leading to what we might call “COVID-19 neurosis.” Nearly all of us are strongly inclined to interact physically with others. We have lifelong associations of human touch and closeness with comfort and safety. Parents hugging children, lovers kissing, friends whispering comments from mouth to ear; hands on shoulders, playful roughhousing, gentle caressing: these and countless other acts of intimacy are high points in our emotional lives. They are undeniably rewarding — like meat to the dogs and water to the rats.
COVID-19 has made each of these aversive: it electrifies the water spout. Every physical encounter risks a potentially fatal disease. The threat looms even when the statistical likelihood is small; public warnings blare to shake us from our usual habits. Acts that used to be caring, comforting, or simply friendly are now threatening. We refrain from touching our grandparents. We steer clear of others on the sidewalk. In-person medical care may leave us sicker than when we arrived.
Coupling reward and punishment to the exact same behavior is crazy-making. No wonder so many of us have gone from anxious to depressed as the pandemic wears on. Indeed, that’s exactly what Pavlov described in many of his dogs: eventually the agitation died down and they gave up.
In this case, though, giving up leads to more sickness and death. The sad truth is that all infectious diseases, not just COVID-19, specifically exploit our social nature. There would be no contagion if we each lived in our own bubble. Pathogens unthinkingly, mechanically capitalize on the very traits that most make us human. That’s literally how they work.
It’s tempting to call this cruel, as though we suffer at the hands of an evil scientist torturing dogs or lab rats. Victimization leads many of us to point fingers at villains — rule mongers, rule breakers, the privileged, the needy — who represent this cruelty in our minds. But we’re not being punished, not really; no more than earthquakes or tornados punish us. The natural world has consequences. The virus doesn’t care about our political philosophy regarding masks, or whether we’re usually kind to strangers. It only cares about infectivity, immunity, and the now famous R0.
One thing Freud had over Pavlov was a cure for neurosis. But we don’t need psychoanalysis for the experimental neurosis caused by COVID-19. Unlike dogs and rats, we can understand the problem, imagine a future after the pandemic, and delay now-risky gratifications until then. It’s not easy or fun, but a number of countries have shown it’s possible. It demands imagination and will, accepting reality, and not taking the affront personally.
June 24th, 2020
I’m increasingly asked by patients and potential patients when I plan to see people in the office again. I had been an exclusively “in person” psychiatrist and psychotherapist until mid-March of this year, when the pandemic forced even skeptics like me to convert completely to remote (“virtual”) treatment. Like many of my colleagues, over the past three months I’ve made an uneasy peace with phone and video sessions, and all the accompanying rigmarole. Although I can work with it, it’s far from ideal. I look forward to dispensing with the earbuds and glitchy bandwidth and resuming my prior practice.
While some folks hope I’ll see them in the office right now, others fear I’ll “force” them back before it feels safe. I assure them I won’t. Even when the office reopens, I anticipate a hybrid situation for months to come, a combination of office and online appointments. Normality is a long way off.
After all, risk tolerance varies. Some of my fellow San Franciscans now share walks outside without masks — nominally six feet apart, but not always — and some are again dining in outdoor cafes. Others are not. Even leaving aside political theater and virtue signaling, reasonable people can disagree about what feels safe.
While it would be comforting to ascribe differing risk tolerance solely to logic and the biologic, e.g. older people are at higher risk, it is far more subjective than that. Partly it’s self-image: are we proud of being sensible and prudent, or fearless and no-nonsense? Are we the type to cite scientific studies, or our gut? Do we sacrifice on behalf of others, or believe only bleeding-hearts do that? Partly it’s modeling by others, variously called peer pressure or social learning theory. If everyone nearby wears a mask, we’re more comfortable wearing one; if others reopen their therapy offices, we’re more apt to reopen ours.
The arbitrary way most of us make these safe/unsafe determinations also reflects wishful thinking and confirmation bias, cognitive tricks we play on ourselves to rationalize unsafe behavior — or conversely to scare ourselves when the situation isn’t that bad. “COVID-sorting” is essentially the use of prejudice and stereotypes to make safety assessments. We’re loath to see our own decision-making in such unflattering light, but of course we readily see irrationality in the fools who decide otherwise.
I’ve been in online discussions with mental health professionals across the country. Some are actively strategizing how to medically screen patients at office entrances, how to disinfect surfaces between patient appointments, how to conduct sessions while masked. Others sound pessimistic about ever going back to the office. I imagine this variation isn’t unique to my field. It was far easier to hunker down uniformly a couple months ago than to customize a re-emergence now.
Adding to the challenges faced by many businesses are special considerations for therapy practices, where feeling safe is crucial. Psychotherapy can only happen when words can be said and reflected upon without harmful real-life consequences. It exists in name only if either party fears a potentially fatal illness in the encounter. Indeed, it’s the therapist’s duty to assure safety in treatment, which is why our ethics forbids sexual and other forms of exploitation. The same rationale obliges therapists to take reasonable steps to assure the safety of both parties from viral and other medical threats.
And if that weren’t enough, these practical matters pale in comparison to the realm of fantasy, where under normal conditions patients may imagine the therapist to be benevolent or evil, soothing or toxic, and themselves impervious or vulnerable, lovable or repulsive. When explored as transference fantasy, these reactions can lead to insight and change. However, when toxicity and vulnerability stem from actual health risks, their value as guideposts to the unconscious is lost.
Ultimately, my answer regarding reopening the office hinges on inertia — my willingness to take the necessary steps — and practicalities, not unconscious fantasies. Will doing so necessitate calling patients the night before to screen for illness? Checking their temperature at the sidewalk entrance, one floor down? Supplying hand sanitizer and spare masks, posting signs, cleaning chairs and other surfaces between appointments, keeping office air flowing with fans and open windows?
Is this rigmarole preferable to the rigmarole of online intake forms, frozen video feeds, garbled audio, and occasionally needing to switch to the phone halfway through a session? It’s hard to choose between two bad options. And even if I decide “in-person” is preferable, will many of my patients concur? While it was my decision to exclude them from my office in March, it will not be my decision alone to readmit them.
Deciding when to reopen a therapy office isn’t only a question of risk tolerance. It’s balancing risk against expected benefit — two subjective estimates — and weighing competing rigmaroles. Even as a fairly risk-tolerant person, I am not ready to reopen my office just yet. By my estimate, the calculus still favors waiting to reopen another day. I only hope that, somehow, that day comes soon.
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