The thrill of finally having my own office was somewhat thwarted by the fact that no patients would be seen in it, at least not in person. Typically third-year psychiatry residents at Montefiore Medical Center work completely in the outpatient setting. However, due to COVID-19, for the first time in history our clinic patients were to be seen virtually, either by phone or video.
Initially, I had a vision for what the year would look like and had even planned the design and theme of my office. The therapist’s space, also known as the “holding environment,” is a big part of the therapeutic intervention. But without people coming in, I only decorated the wall behind my webcam.
I found it difficult to do my work through the telepsychiatry medium. Staring into the computerized versions of my patients required extra mental energy, since engaging people in person is much easier than doing so virtually. Seeing only faces on the screen left me with no sense of my patient’s body language, something essential during in-person conversation. Sometimes the video would freeze in a crucial therapeutic moment, leading to frustration.
Still, telepsychiatry gave me a unique view into the lives of my patients. Peeking through in the background, I could see the stuff that filled their living spaces: posters, an unmade bed, a heap of unfolded laundry. Psychiatrists are allowed the privilege of being invited into the deepest, darkest corners of a person’s life and mind. This was the first time psychiatrists were allowed into patient’s homes. Glimpses into their rooms helped me visualize how their environment, not just their mental illness, might be working against them.
Despite the limitations of video sessions, they were a luxury compared to just using the phone. A few of my older patients struggled with technology; others had no access to WiFi. Some simply did not have a place to speak privately and comfortably.
One particular session I was having with a young woman felt contrived. She was not being forthcoming, and my approach became methodical. I could feel our therapeutic alliance, the basic trust that allows a therapist and patient to work together, fading. She mentioned her recent panic attacks and burst into tears. “I guess I’m anxious about meeting my new psychiatrist … and this is so awkward!” Instantly, I felt relieved, as I sensed the awkwardness too. If we had been in my office together, I imagine I would have quickly picked up on her apprehension, reading the subtleties of her facial expression, or seeing the twiddling of nervous thumbs.
We decided to meet in person the following week, which finally gave me a reason to decorate the rest of my office. When she arrived, we had to wear personal protective equipment and sit 6 feet apart. Even with her mask covering half her face, our conversation flowed much more easily this time. I felt that our connection was restored.
As I continued my sessions, there seemed to be an incompleteness to the therapeutic exchange, especially the ones that were just done over the phone. I began to wonder what was so important about seeing a person face to face. Some of the obvious reasons that sprang into mind included appearance and behavior.
But I believe there is also an energy exchange, some mystical transformation of the thoughts leaving the mind, changing from potential to kinetic form. This can only truly happen in person. The few patients I have seen in the office over the past year have been able to go deeper in their healing than those I have only seen virtually. There is something therapeutic, in itself, about being in the same space as another human being.
[Read: Telehealth for Your Pet.]
For decades psychiatry has evolved, influenced by new thinkers, inventions and politics. But core aspects of its human connection have remained the same. As psychiatry has evolved with technology, there have been many benefits including making mental health care more accessible, even in the midst of a global pandemic. Though it’s clear that telepsychiatry is here to stay, I hope it will not be at the expense of losing something as indispensable as human interaction.
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