Updated: Mar 23, 2020
On Monday of this week, I decided to move my entire therapy practice online. Seattle was home to the first major outbreak of the novel Coronavirus (COVID-19) in the United States, and of course, this is where I practice. After monitoring health and safety agencies (city, state, federal, and international) and consulting with colleagues, I contacted each of my patients to inform them we would need to meet virtually. This was not a surprise to them—we had talked about this possibility the prior week—but it was a significant change.
Changing the frame of psychotherapy is a difficult decision. By “frame” of therapy, I mean all the aspects of the relationship and environment in which therapy takes place. Everything from the setting (e.g., office location, design, furniture type and placement), topics of conversation (e.g., limited therapist self-disclosure, trying not to censor oneself), the therapist’s presentation (e.g., introductions, endings, dress and hairstyle), and other ground rules (e.g., starting and ending on time, phones turned off) count as “the frame.”
Keeping a good therapy frame seems something like editing a movie—you only notice it when it is done poorly, which takes you out of the experience of the movie (or therapy). Most folks do not realize the effort made to ensure a consistent, stable, reliable frame. Obviously, that is totally fine, and because of this, most patients do not mind the transition to teletherapy as much as therapists fear.
However, changing therapy from in person to online is a big change in the frame. Some therapists may take this lightly, but I certainly do not, and I am encouraged by the thoughtful discussion I have seen from colleagues surrounding these strange times. So why did I make this decision?
First, in an article widely shared by now, Tomas Pueyo explained the severity of the spread, the lag in official numbers to real cases, and the need to act soon. As soon as I read this article, I began to consider seriously a transition to full telehealth. I began to distrust my intuition regarding the virus—I realized that what I feltto be the appropriate amount of action was likely a severe under-reaction to what was happening in reality.
Second and related to my new distrust in my feelings, I knew that this virus was exploiting cognitive biases. (This is true for me and likely for you as well.) Specifically, the availability heuristic/bias (e.g., “how bad was my last flu?”; h/t to Michelle Kabuye for this insight) and the Dunning-Kruger effect (i.e., over-estimating one’s competence—such as one’s ability to understand this Coronavirus). These kinds of biases make calculating risk very difficult, especially regarding a completely novel virus. Two experiences highlighted these cognitive biases for me. (1) I read an interview with an epidemiologist who explained that he was not sure of his own risk (I cannot find this interview, but if I do, I will update with a link here). If even an expert does not know their risk, how sure can I be of my own? I am reasonably certain (though not completely certain) that as a young, healthy adult I will not die from this virus. However, I am very uncertain about other risks. Thus, my second point: (2) I read reports that there may be lung scarring left over in otherwise healthy adults (preliminary reports here, here, here). If the scarring is chronic, the risk profile of this disease for even younger adults changes drastically. Mitigating unknown risk is difficult, but as a healthcare provider, I opt to behave with an abundance of caution regarding unknown chronic risk. Until these two experiences, I thought too highly of my ability to judge the risk and underestimated the effect of being sick.
Third, I learned that even many psychoanalysts were moving to teletherapy. There is a range of therapy modalities, each lending themselves to a spectrum of intimate personal connection to impersonal coaching and homework (though meta-analyses consistently find that the quality of the interpersonal relationship is a common factor for all effective therapies). My modality is deeply interpersonal, with some coaching/psychoeducation when appropriate. However, analysts rely even more than I do on the presence of patient and therapist in the same room—and if they can do it for the sake of social wellbeing, so can I.
Last, an author for the New York Times in an interview titled The Exponential Power of Now made a compelling argument that preventative action taken now makes an enormous difference in the spread of this virus. In sum, the transmission of the virus follows an exponential curve. That is scary. However, this means that non-transmissions also follow an exponential curve—that is, one prevented transmission today reduces the total number of cases not by one, but by many more (2400 in a month, assuming 30% growth in cases each day). Learning (and finally understanding, at an intuitive level) the importance of early action regarding COVID-19 was the final experience that settled my mind.
There are many thoughtful therapists taking a different approach. However, after these lessons, I became much more averse to endangering my (mostly younger) patients or myself. Though I was not very concerned with transmitting the disease in my office, there were many factors outside my control such as folks taking public transportation, entering the building, etc.
I would encourage all therapists of all modalities in all locations to move to teletherapy for a time. Overwhelmingly, my patients have been understanding of the change and willing to engage in therapy with as much vigor as they did before. The work is different, the frame is different, and I wish I was with my patients in person. Yet, good work is still being done.