Together, Apart: Finding Closeness in Therapy while Remote
“Don’t suffer alone!”
(Written August 2021)
I say this so often, I should make tee shirts. During this year (and a half) so ugly it launched a thousand memes, the plea seems more important - and unrealistic - than ever. Group gatherings were banned, public spaces shut down, and Zoom “parties” lost their appeal. Schools went online, extracurriculars ended, and playdates became prohibitively complicated. For a few of my young adult patients, our weekly session was their only hour of human contact. I found myself cringing as I whistled my old tune. How did I expect people to come together for their mental health, if their physical health required them to stay away?
We did what we could: we suffered together, apart.
Thrown into the deep end last March, my patients and I flailed for footing as we adjusted to the murky new pool of telehealth. Abruptly immersed, I noticed my boundaries softening with our shared fears and uncertainties. I saw pieces of myself pouring into sessions, politics and ethics dribbling into conversation and personal anecdotes splashing into moments of validation. My baby’s laugh and dog’s howl seeped around my home office door. My patients and I bathed in puddles of common experiences, joys and pain.
Maybe it was the shield of the computer screen that encouraged vulnerability. Or maybe it was just access to more of my patients’ “real” lives: the posters on a bedroom wall, the echoes of an off-screen argument, bare faces, toothpaste dribbles, pajamas. Whatever the reason(s), my patient-doctor relationships changed in a way that feels permanent and profound.
As the world shut down, I was preparing for maternity leave, so my patients were already preparing for a transition. When the shelter-in-place order started, I never doubted that I’d be back at my desk in a few weeks, meeting people face-to-face until my due date.
2020 had other plans.
More than a year later, I finally returned to my former office to re-pack my things. In the intervening months, I’d given birth, taken three months of leave, and moved to Texas. Leaving the Bay Area for my hometown of Austin felt like my only real option, but I knew how hard these changes would be on my patient relationships. I was scared of my patients’ anger, worried they’d feel abandoned or betrayed.
I shouldn’t have worried. My patients were (and continue to be) absolute rockstars. Though there are things I miss (board games, shared hot chocolates, therapy dance breaks), for most of my kids and adults, telehealth has allowed our therapeutic relationship to broaden and deepen. There are a million things that 2020 and 2021 brought that I’d gladly give back. The option for virtual sessions is not one of them.
Of the many barriers to care in mental health, geographical limitations have an inexpensive and immediately available solution, thanks to technology. Before COVID, I had patients who drove over an hour for a 30 minute session with me in horrible traffic (which did nothing for their anxiety and depression - or the environment). We regularly evaluated patients who needed treatment but had no options in their area, or who had to go to heroic measures (such as moving in with relatives) in order to participate.
A 2017 meta analysis showed improved outcomes (for example, better medication adherence), greater ease of use, and lower overall cost of switching to telehealth. Included studies also reported better access to care and more frequent communication with clinicians. More recently, the Telehealth Impact Study found high levels of satisfaction with telehealth during the pandemic.
Access to clinicians has temporarily expanded even further with emergency medical privileges, allowing us to see patients in some states where we are not licensed in certain circumstances. I deeply hope that those cross-border allowances will continue post-pandemic. I’ve seen firsthand the harm that forced transitions in care can do to patients, particularly in mental health. Our patients still need support on vacation, when they go to college, or if they move out of state, and now that telehealth is gaining traction as a preferred and insured form of treatment, the concept of a “local, accessible provider” is getting blurrier.
It makes no sense to me that medical licenses are state-based when all of our licensing exams and board requirements are nationally regulated. Though there are local laws and ordinances that vary state-to-state, most licensing bodies do not require applicants’ knowledge of these. If we can work together to share local resources and knowledge through provider networks and consultation, we can safely and effectively manage longer distance care and collaboration.
I can’t wait to see patients in the office again, to share fruit snacks and school my kids and teenagers at Uno. In the meantime, though, I’m enjoying the closeness and convenience that telehealth has brought to my practice. Until we can suffer together, together again, we’ll keep supporting each other together, apart.
