Are Therapists COVID-19 Hotspots?
Therapists can (and did) spread COVID-19 to their patients.
Posted Oct 27, 2020
Since April 1 of this year, my home state of New Mexico, like many other states, has been under an Emergency Order due to the COVID-19 pandemic. In March and April, I, along with other healthcare leaders and providers, worked with the state of New Mexico Human Services Division, the federal Centers for Medicaid and Medicare (CMS), as well as SAMHSA, numerous managed care companies, Superintendents of Insurance (who oversee commercial insurance companies) and national organizations such as the National Council for Behavioral Health. We worked to craft policies and directives that allowed behavioral health providers to provide telephonic and remote services in order to help control the spread of COVID-19, while still providing critical and essential mental health and substance use services to highly vulnerable populations.
Some states and professions moved more quickly than others did. In some states, professional licensing boards over professions such as social work, psychiatry, or counseling moved more slowly to authorize their licensees to provide remote services. Rural states such as Alaska already had robust infrastructures and policies to ensure the public had access to remote services, and those states were able to pivot much more easily than some others, which had strong limits on the provision of remote therapies and cumbersome mandates regarding authorization of remote mental health services. Different managed care organizations had different mazes of authorization procedures that providers had to navigate in order to offer remote therapy to their patients and be paid by the managed care organization (MCO). The US Department of Health and Human Services indicated a temporary suspension of enforcement of aspects of HIPAA, allowing providers to use whatever technological means necessary to provide needed healthcare services, without worrying overly about compliance with complex aspects of the Hi-Tech Act.
However, by mid-summer, in general, most of these obstacles, hoops, challenges, and loopholes had been navigated. Agencies and providers acquired webcams, laptops, Zoom accounts, and dived in. At my agency, our clinical productivity dropped by about 50 percent in April, was back at around 95 percent in June, and is now about 5 percent above our historical average for this time of year, and it is growing. We, like most therapists and behavioral health providers, are seeing a strong surge in demand, from new patients and old alike. Many people we’ve treated in the past have reached out to reconnect, to have support in self-monitoring, in addressing their anxiety, depression, substance use, and relationship struggles during this unprecedented time. Most are deeply appreciative of the opportunity to access services remotely.
My agency conducted a survey of our clinical providers and found that about 60 percent of our services are provided telephonically, around 30-35 percent are via video (we have the authorization to provide and bill for services in either modality). We still have very few in-person services happening with small children who cannot really do play therapy over the video screen and where we are providing/administering medications, though our staff and patients wear masks and social distance in all these encounters.
Forty-five percent of our staff felt that telehealth services are as effective as in-person treatment, 31 percent felt it is even more effective, and 10 percent reported it was less effective, and interfered in clinical progress. Forty-eight percent of our staff felt that their patients viewed telehealth as equivalent to in-person treatment, 22 percent actually reported that their patients preferred telehealth over in-person treatment, and not a single clinical staff reported that their patients strongly disliked telehealth. (There is a potential sample bias here, as services to patients who are unable or unwilling to participate in telehealth aren’t reflected in these data.)
However, this has all gone on much, much longer than any of us really thought it would! A few months ago, I started hearing about therapists in the community who were returning to in-person services. I started seeing requests for referrals to therapists who would provide in-person services, to patients who didn’t want to use electronic means. I saw my colleagues discussing whether they were safe, wearing masks, seeing patients outside on the patio, or in their offices with the windows open and outside air coming in. People are getting tired of social distancing and technological barriers, and they want to see their therapists and patients in person.
Unfortunately, therapists aren’t immune to the politics and ideological conflicts that are sweeping our country, regarding mask-wearing and COVID-19. I saw one colleague make public her opposition to wearing a mask, claiming that she shouldn’t have to wear one due to an unnamed disability and refusing to wear masks in public stores. All therapists have patients who don’t want to wear masks or are asking therapists to write them letters that they don’t have to. Hint: This is absolutely something that I, and others, discourage therapists from doing. It is a forensic and medical and public health assessment and opinion that licensed therapists are simply not qualified to provide. Further, even where anxiety or autism is a legitimate mental health issue that makes wearing a mask challenging, the clinically appropriate response is to recommend desensitization and exposure techniques (to mask-wearing, not to COVID-19) in order to help individuals learn to cope with their anxious feelings while wearing a mask.
Now, in Albuquerque, New Mexico, two therapists have been identified by public health authorities as “hot spots.” A hot spot designation in our public health terminology describes businesses that have had several positive tests for COVID-19 within a limited time frame. According to state officials, these therapists were providing indoor, in-person therapies while neither the therapist nor the patient was wearing a mask. To protect confidentiality, state officials are not releasing more information.
It’s unclear if the therapists were conducting regular COVID-19 screening (temperature, potential exposures, potential symptoms) of their patients or themselves. It’s also unclear whether they were practicing social distancing during therapy, refraining from touching, and remaining six feet apart. We don’t know if they were disinfecting their offices between patients or limiting traffic in their waiting room. But, the therapists didn’t want to wear masks, neither did their patients, and they didn’t feel like they needed to. And unfortunately, they ended up spreading COVID-19 as a result.
Psychotherapy, in a closed-office for 50 minutes while not wearing a mask, is a high-risk encounter. Even if you remain six feet apart, you are exposed to the breath and exhalation of the other person in the room, exposed over a long enough period of time that your risk of infection is potentially quite high if the other person is infected. There are not very many degrees of separation between therapists, as health care providers, and hospitals, long-term care facilities, and high-risk populations such as the disabled, elderly, and those with compromising medical conditions. In these new and fast-changing times, it remains extremely unclear what level of liability mental health providers may hold if they spread COVID-19 through negligence.
As a result, it’s critical that therapists model for our patients how to maintain safety, responsibility, and ethical citizenship behavior. We fought hard to get access to remote services in order to protect ourselves, our families, and our patients. Unlike many other healthcare professions, we are able to provide a great majority of our services remotely, reducing the risk of exposure for ourselves and the people we treat. It’s our professional responsibility to do so, to resist the temptation to give in to fatigue, frustration, and ideology, and potentially sacrifice health or lives.
The American Psychoanalytic Association crafted very thoughtful guidelines on the resumption of in-person therapy, available here. To be safe, and part of the solution rather than part of the problem, therapists must continue to:
- Provide remote, telehealth services wherever and whenever possible;
- Conduct regular, daily screenings of themselves and any patients they must encounter in-person;
- Get tested if exposed, quarantine until cleared, and encourage their patients to do the same;
- Wear masks themselves, require their patients to wear them, and practice social-distancing during in-person services;
- Eliminate a waiting room and have patients wait in their car or outside until beginning therapy;
- Limit the duration of any in-person contact, wherever possible. If in-person contact is necessary, do a hybrid model for part of the encounter, and telephone or telehealth for the longer part of the session.
- Encourage their patients to maintain motivation and patience during these trying times.