Medical Examiner

Therapists Are Doing Sessions in Locked Bathrooms While Patients Call in From Their Cars

Sessions have moved out of the office. Will we ever go back?

Five different people look at laptop screens.
Photo illustration by Slate. Photos by Getty Images Plus.

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Here is a short list of what it’s like to live through the coronavirus: heightened feelings of anxiety, hopelessness brought on by social distancing and self-isolation, a 24-hour death toll to keep track of, life or death decisions facing health care workers, struggles to make rent, worries about keeping your job or maintaining your business, and, on top of all of that, the stress of whether you yourself or your loved ones might get sick. These forms of anguish usher in a pandemic all its own—a relentless surge of mental health concerns of all varieties originating in this perfect recipe for anxiety, depression, and hopelessness. Trauma tends to be thought of as belated, after the fact, but it can also be prefatory: a suspended state of knowing that loved ones will die or suffer but not yet knowing who or when.

In other words, even as some people weather the pandemic reasonably well, the need for mental health care like therapy has rarely been more pressing. Teletherapy has always been thought of as a crisis measure—whether that crisis is collective or individual. It has been evangelized for its capacity to go where therapy can’t: to locations where there are no specialists available, to those who, for whatever reason, cannot leave their homes, to vulnerable or at-risk populations. Still, mental health care is patchwork in the best of times, and teletherapy has its own drawbacks: It presumes that people can overcome barriers to access (for example, programs only run in English), it introduces privacy concerns (especially for those working from home), or it requires that people can be reached via a computer, a tablet, or a smartphone, media that are still far from ubiquitous. With demand skyrocketing and most of the U.S. sheltering in place, therapy can’t go anywhere, which, paradoxically, might send it further out into the world than it’s ever been before.

In the United States, the move to remote treatment during the pandemic has been supported structurally in unprecedented fashion: By March 19, three major insurance companies—Cigna, Aetna, and Anthem—had all updated their insurance policies to completely cover all out-of-pocket costs for teletherapy, for a provisional period until at least June 4. The Office for Civil Rights in the U.S. Department of Health and Human Services waived HIPAA compliance for ubiquitous media including FaceTime, Skype, and Zoom. This has allowed a greater degree of freedom, and therefore experimentation, in connecting mental health professionals with those in need, despite stay-at-home orders nationwide.

Therapists around the world are grappling with what digital media are doing to their practices. For many, this includes a shock at the intimacy that teletherapy can bring, or surprise at how similar practicing over video chat is. Psychoanalysts have seemed particularly surprised—finding that there is something more intense about having the patient at an ear’s distance (on the phone or over video) rather than on the couch. Bruce Weitzman, practicing in the Bay Area (whom I met through a working group on technology and psychotherapy), says, “I feel a closeness that is unusual even for in-person sessions … particularly when I use my noise-canceling headsets. It often feels as though the patient has been transported into my mind, and my mind into theirs.”

Some therapists have shared moving stories about the ingenuity tele-media can produce. Eric Linsker, a psychotherapist based in New York City (and a friend), is still taking on new patients, mostly children, since moving to remote work. He was initially quite worried about switching to videoconferencing with children, including those he had never met in person, because of the need to translate play and art therapy into the digital, but he found that the whiteboard feature of Zoom allowed for this work to continue. He reports, “My child patients and I can draw together, as we would in person. … What matters is finding a way to help a child play through drawing, speak about the drawing, and feel seen and heard. What’s evocative and meaningful is still evocative and meaningful. And what’s curative—what unblocks someone—is still curative.”

For some therapists, keeping a private practice going over digital media is far from ideal even though it allows patients to keep up with their treatments. Many are reporting exhaustion and screen fatigue. Gillian Isaacs Russell, a psychotherapist and psychoanalyst in Boulder, Colorado, is serving as part of the American Psychoanalytic Association’s COVID-19 Advisory Team. She says of the transition that the need to give up in-person therapy is part and parcel of the harm COVID-19 brings: “Some patients and therapists will have found the transition all of a sudden … that in itself is a trauma.”

The star of Showtime’s Couples Therapy, Orna Guralnik, who works with both individuals and couples in private practice in New York, feels that it is the experience of living through a pandemic, more than working remotely, which has shifted the nature of therapy. She says that while the loss of a space together has been acute, “the work has been surprisingly—shockingly good. People really need the help. And to be in their home with them, and for them to see I’m at home is helpful.” She thinks that screens are a factor in both the intimacy of these sessions and a subsequent exhaustion from the work: “The heat is on in terms of dynamics. … It’s extreme couple conditions.” While not all of the couples she works with have both members at home full time, and some are essential workers in New York, many are sheltering in place, and are simultaneously dealing with the pressures in their relationships, working full time from home, and home-schooling children.

For those patients who have established relationships with mental health practitioners, the switch to meeting virtually or speaking by phone has been a lifeline, but it isn’t without drawbacks, shock, and disruption. Many patients and therapists alike commented that the tenor of therapeutic work has changed. One patient said, “The topic of our conversations has been COVID-19 almost continuously. I feel like my analyst is processing with me too; it can’t be helped.” The screen not only permits and maintains intimacy, it can even offer a little too much. Patients are seeing the insides of their therapists’ homes (and the other way around) for the very first time. With many schools closed, and therapists working from home, children, cats, pet birds, and dogs are all making sonic, if not visual, appearances in sessions. Guralnik recounted a patient seeing her child’s yearbook, which immediately gave information about schooling choices and their age. Some report these kinds of incursions into privacy as upsetting, but Guralnik sees them as productive: “Anything that can come in and we can work with, I welcome. I take it as a fun moment as a surprise erupts and we get to follow the thinking there. And often I’m in my patient’s bedroom with them, and they’re in their pajamas. … It’s intimate!”

To avoid the breakdown in long-held boundaries, some therapists are practicing out of less typical places, including at least one therapist who confessed to taking calls in a locked bathroom so as not to be overheard, or even an unoccupied apartment next door, as is the case for one New York psychoanalyst, who secured its use via his landlord. At the same time, patients are trying to navigate their own privacy issues and are having their sessions in cars for fear of being overheard, or outside while trying to keep distance between themselves and others.

During the pandemic, Neil Leibowitz, chief medical officer of Talkspace, a teletherapy company that facilitates sessions over its proprietary app, reports that he has seen a massive increase in therapists seeking to partner with the app, as well as a 65 percent increase in people seeking therapy. “The majority of clients coming through are nurses,” he said. “We’re also seeing a large number of couples start to come in, as well as clients relating severe loneliness from the isolation, clients feeling stuck and trapped, and a large number of grocery store workers and other miscellaneous retailers struggling with feelings of fear and anxiety about their exposure, bringing it home to their family, coupled with guilt as they grapple with trying to still feel grateful they have a job.”

Some traditional therapists are wary of mental health care being outsourced to large apps like Talkspace that already don’t have a great reputation for protecting patient privacy, and some even question their efficacy. Todd Essig is a psychologist and psychoanalyst in private practice in New York, an expert on tele–mental health, and the co-chairman of the American Psychoanalytic Association’s COVID-19 Advisory Team. He worries that the current conditions are enabling a lower standard. “There’s a differentiation taking place in the therapy world between people who are doing whatever they can to make it work and be helpful, and people who are viewing this as an opportunity to promote a particular product to sell,” he said. “There is an assumption among some of the mental health technology entrepreneurs that this will result in an explosion in the products they’re selling.” Essig has published an instructional video and, along with Gillian Isaacs Russell, some guidelines for patients on how to begin, or switch to, remote therapy effectively.

Part of the mental health crisis stems from the fact that most people didn’t have any access to ongoing mental health care prior to the pandemic, and thus still don’t. But the extreme conditions of this moment are encouraging therapists to do outreach to populations that usually go without, using every possible form of teletherapy over every possible medium. The Italian Psychoanalytic Institute, for instance, opened a free hotline, inviting children, adults, families, and couples, as well as doctors and nurses, to call for advice and to be listened to. In New York state, more than 2,000 mental health professionals have signed up to provide their services for free via telephone in an initiative called the NYC COVID Care Network. Through it, essential workers—from nurses to taxicab drivers—seeking mental health and spiritual support can match with specialists offering particular forms of wellness care. Deborah Starr, a Ph.D. at Columbia University, was an early volunteer and consultant with the program, and hopes that this kind of work can be replicated across the country. Starr is concerned about all essential workers, including caregivers who are experiencing extreme duress on the job. Starr terms this “moral injury,” referring to decisions medical staff might have to make, like “who should get the respirator? Who should be taken care of and who should not? It’s like combat veterans.”

Other sources of mental health outreach don’t aim to treat individuals but the collective experience of living through the pandemic. The Pandemic Check In podcast began broadcasting on March 18, out of the Brooklyn Minds clinic in Brooklyn. Michelle Bernabe, a registered nurse and a co-host of the Pandemic Check In, says that this and the other programs (including virtual groups) at Brooklyn Minds are aimed at everyone living through COVID-19. The call-in show takes questions over text and voicemail, both anonymously and named. Bernabe terms this work “psychological first aid” as opposed to ongoing, individual treatment. She recently had to change the voicemail greeting urging callers to seek immediate help after the account received a voicemail where the caller was in active distress. She says that beyond helping address callers’ needs, she sees it as a way of telling the mental health stories we are collectively experiencing: “To me, this sharing is another way to generate a sense of community, normalcy, and belonging in this time of isolation and absurdity.”

Peer support—or counseling provided by nonprofessionals—is also in high demand, filling in some of the gaps between the number of clinicians available to take on new patients and the number of people needing aid. Beyond long-standing suicide hotlines and the Crisis Text Line, mutual aid projects, connecting those who feel at risk with those who feel they can help, are forming across the nation, via activist networks, churches, schools, and local associations. Al-Anon and Alcoholics Anonymous meetings went digital immediately, recognizing the importance of keeping a space for peer support in a high-stress time when some might be at greater risk of relapse. Again, this move has not been without shock and disruption. Moving online has made preserving a core tenet of the program—fellows’ anonymity—more difficult. Group meetings have been Zoom bombed. Some aren’t able or willing to continue with attending groups because they live with their “qualifiers,” the people whose impact on their life makes them eligible to attend.

The crisis of COVID-19 recalls all the other crises across the 20th century that have brought teletherapy forward as a salve, or as the only way for people to access mental health care at all: Freud demanded mental health care for all at the close of World War I, and after the 1918–1920 influenza pandemic, to which he lost his daughter Sophie; during World War II,  many psychotherapists in London hosted mental health broadcasts over the BBC. The ever-present crisis of suicidality itself—both historical and contemporary—is what prompted the first crisis hotlines in the 1950s. More recently, Hurricane Sandy yielded digital cognitive behavioral therapy programs in New York, and suicide hotlines grew in Puerto Rico post–Hurricane Maria.

For some therapists, a preoccupying worry is that the move to the digital en masse will make it the rule after the pandemic rather than the exception. Gillian Isaacs Russell worries that some patients will have found teletherapy convenient or more comfortable, and will want to keep working that way. “The shift back to in-person will mean having to trust again,” she says, “and trust is a big issue.” Vanessa Sinclair, a psychoanalyst and psychotherapist in Sweden, hopes that instead of being threatened by remote therapy, the field will embrace it and “see it as a way to expand outreach—an added tool, not a replacement for the traditional setting.”

Looking back on the crises that shifted the traditional parameters of therapy and opened new technological avenues by which patients and therapists could meet, we can see that these new modes usually stick around long after the crisis that engendered them has passed—but without replacing face-to-face encounters, either. Under the present needs and conditions of COVID, teletherapy has been radically expanded, reaching both long-term patients and those who’ve never had access to mental health care. It remains to be seen whether the concerted effort of mental health outreach during this crisis can be maintained after the pandemic abates. Though, who can say when the trauma of the pandemic will be over? The therapeutic resources now deployed will need to be present long after the virus has been contained.