September 2020 – Covid 19 has thrown everyone in the USA into a state of dislocation, isolation, financial distress, and deep uncertainty, all of which can trigger or intensify mental health problems. Telementalhealth has exploded as a result: it has been a lifeline for those alone, and opportunity for reflection for those previously too busy, a companion on the journey without apparent end for all. Psychologists, social workers, mental health counselors, substance abuse experts, and the like all have been swamped with work. Public hospitals and outpatient clinics are not taking any more cases in New York: It took me over a week to get a psychiatry appointment even virtually for a new patient. For myself I immediately got certified in telementalhealth and carried on virtually, as did most of my colleagues. It’s not the same. But I think it’s here to stay. Fortunately, to find a silver lining, it has made access more feasible for some (no childcare, no transportation, no days off work if still working, etc.). In some cases, especially the most resistant and/or anxious, I believe it has even enhanced engagement.
To their credit, many states and quite a few insurance companies have made adaptations to make service provision easier. Regulations for quality control regarding client safety and provider skill will soon return and probably increase. One arena where this can be problematic is the diaspora of patients and providers during the Pandemic, and therefore the challenges to preserving a clinical process that is underway and working. Every line of research concludes that a good therapeutic relationship is the cornerstone of productive and durable psychological treatment. Will long-standing therapeutic ties be preserved intact as restrictions on practice return (e.g., crossing state lines; a specific license or number of Continuing Education units completed, patient copays and deductibles)? Every week there is another announcement about ending accommodations. It’s an obstacle to treatment as an unknown future destabilizes the working alliance.
Telehealth in all fields is now dominant. A colleague recently was notified that henceforth only telehealth psychiatry visits would be covered. The cost savings of doing virtual business versus having bricks and mortar service locations is changing the landscape permanently. I see a threat to the intimacy, privacy, and holding environment of meeting face to face in the same place on a predictable basis. The psychologist who doesn’t want to keep up an office worries me: great care has been put into the location, décor and comfort of an office: it is a suspension of competing demands on time and attention for a predictable time. There is much more to that than just rented space: it becomes a refuge for therapist and patient alike.
So what now? I’m hoping cost cutting isn’t the only consideration when the Covid emergency period is declared over. For example, national versus state by state licensing requirements – despite basic licensing terms being national – would make sense in today’s peripatetic world. Paperwork hours could be reduced: applying one by one for cross-state licensing is a huge and not inexpensive undertaking, not to mention the insurance complications that go with varying locations. This is not “medicare for all.” It is consistency of some basic criteria.
The covid conditions are taking an escalating toll as the time expands. I see it in my patients. I feel it in myself. We could handle the emergency for the most part (just as people often respond with extraordinary strength in a crisis situation). What has become clear is that there is no actual end In sight. Information is conflicting. The consequences of premature confidence are evident. Thus the horizon recedes to the point of obscurity. This is unnerving. Reserves of good will are exhausted. Agitation and a slow erosion of identity are arriving. Who am I if I am unable to see my family or friends. What if I am camping out with parents from which separation was an arduous process some time ago? My work future is unknown. My geographic future is unknown. My community is unknown. I’m restless with myself the way hosts become restless with unloved guests who stay on and on. The tension between self-protection, civic responsibility, and deep personal longings has become palpable.
So where are we going? I will try my best to be fully and professionally present on Zoom. Patients will try their best to feel connected and to get on with the issues that may have brought them to therapy in the first place or the new ones that arrived with Covid. Will our best be good enough? Or more correctly, how close to good enough can we get this way? That’s where we are going it seems: into an undefined future without defined expectations or demands. As any mental health professional will assert, anticipatory anxiety, is corrosive, exhausting, and ultimately inviting of poor choices. Multiply that by a large number and you have the impact of anticipatory anxiety when there is nothing clear to anticipate. If I knew when the “next” is going to arrive, I would tell you. Meanwhile, I will keep trying my best.