Note: I am not a public health expert, but an informed physician, and I did confer with an infectious disease specialist before writing this article. I invite feedback in the comments section.
Many therapists and psychiatrists in my community (including myself, as of 3/14/20) are rapidly shifting to providing sessions only via teleconferencing for the indefinite future due to coronavirus concerns. Others are offering teletherapy as options for particular individuals (those who are immunocompromised, in some other vulnerable population such as older adults, or who have great anxiety about using public transit, etc.). I was personally swayed to make the move because of the great uncertainty at this moment about who is infected and the lack of testing. When both of these variables are better defined (hopefully in 2-3 weeks), I will likely move to an approach more tailored to individual circumstances.
Of course, telehealth (including audio calls) is a privilege that not everyone can access, particularly those in community public mental health treatment. Also, telehealth is often not as good as in-person visits, especially for initial sessions. (See my article “Teletherapy: Breakthrough or Breakdown?”, September 26, 2011.)
But during this crisis, should you be seeing your therapist face-to-face? If you’re a therapist, should you be doing all your sessions via telehealth? How to protect yourself and your patients? What are the downsides?
What is Social Distancing?
Social distancing is critical during a pandemic (Mounk Y, “Cancel Everything,” The Atlantic, March 10, 2020). However, this phrase seems often misinterpreted as simply staying far away from others, even in one-on-one or small-group settings. In fact, this means canceling larger events altogether. See this great fact sheet on social distancing from Santa Clara County Department of Public Health.
“Social distancing measures are taken to restrict when and where people can gather to stop or slow the spread of infectious diseases. Social distancing measures include limiting large groups of people coming together, closing buildings, and canceling events.”
Currently, San Francisco is suggesting canceling non-essential meetings of more than 100 (beginning 3/13/20), L.A. has the number at 250, and San Francisco suggests vulnerable people not go to events of 50 or more people, for example.
Update 3/14/20: There is a wide range of interpretation of "social distancing." (See Tiffany K, "The Dos and Don’ts of ‘Social Distancing,’" The Atlantic, March 12, 2020.) I would suggest paying attention to local conditions and the health vulnerability of yourself and the people you come in contact with and go from there, as per the CDC guide this article links to. Some advocate more extreme measures right away: See "Social Distancing: This Is Not a Snow Day" on Medium, and "Why outbreaks like coronavirus spread exponentially, and how to 'flatten the curve'" in the Washington Post.
Does Social Distancing include banning one-on-one therapy or doctor visits?
To my knowledge, no.
Some think “when in doubt, don’t do it.” (Or these days, "better safe than COVID.") There’s a lot of room for doubt, anxiety, and panic right now, but these can take a big toll on mental health as well. Social isolation is also a risk factor for mental health and physical well-being (Brody, J, “The Surprising Effects of Loneliness on Health,” New York Times, Dec. 11, 2017).
Let’s do our best to weigh out the risks and benefits. These may differ from person to person. What is the risk of you traveling to see your therapist/doctor? What other measures are you taking to provide social distancing? On the pro-social distancing, use of telehealth side is that we are in the early and most uncertain phase of this pandemic in the U.S., and we are not yet sure who is infected, and what everyone's risks are.
Who should self-quarantine or stay home?
There is disagreement about this. The general weight of opinion seems to be that you should self-quarantine for 14 days+ or seek medical attention if you have tested positive, have symptoms (cough, fever >100.4 degrees F, shortness of breath), have been exposed to someone who has tested positive, or have traveled to certain countries (currently Italy, Iran, South Korea, and China). See this ProPublica article, “Should I Quarantine Because of Coronavirus? It Depends Who You Ask,” March 11, 2020.
How do you catch coronavirus?
The CDC reports that the main mode of transmission is through aerosolized droplets (e.g., breathing in coughed or sneezed virus particles), and through being in close quarters with an infectious person. There is a possibility of transmission by touching a contaminated surface and then touching your face, nose, mouth, or eyes. There are reports of people testing positive who had been within six feet of (presumably) asymptomatic carriers. (Again, see the ProPublica report cited above.) (Update 4/3/2020: Dr. Fauci reports studies pointing to asymptomatic transmission with virus carried on the breath in normal conversation conditions. Hence there does indeed seem to be a real risk for transmission in a 50-minute therapy session under the usual conditions. However, there is other equivocating data - see for example the study from Singapore in the references below.)
Some therapists in my community are worried about asymptomatic carriers coming into session and contaminating their chairs, couch cushions, handrails, etc. This seems like a very low risk of contagion. My personal opinion is that if it were this easy to get the virus, the number of cases would be dramatically, I mean dramatically, higher. (But I could be wrong—check the CDC and local Department of Public Health websites for updates.)
What are the dangers of panic and anxiety?
The coronavirus crisis comes at a time of great anxiety and distress at baseline, with climate change, recurrent environmental disasters, an extremely divided and often antagonistic government, turmoil in international relations and possible election interference, racism and White Nationalism at a visible peak, a divided electorate, and so forth, all jolting our senses and pinging us with updates multiple times a day.
I’ve noticed myself in moments anxiously interrogating every sniffle, tickle, and itch—all symptoms of anxiety, not coronavirus. I have to remind myself to not let my anxiety get the better of me, and to practice self-compassion as well as staying up-to-date on the epidemiology of this thing.
The bottom line is that we need each other. I’m personally reassured by contact with others, including my patients, whether by video sessions or in person. I hope that my presence is reassuring to them as well. Even seeing people out-and-about on the street, or in restaurants taking measures to keep the environment clean, or just going about their days makes us feel more secure.
Of course, I discuss anxiety and uncertainty with my patients. Of course, I update them with information about my practice and general health advisories. (For example, cleaning practices shared by my colleagues in our suite of offices, availability of disinfectant wipes and hand sanitizer, links to information from San Francisco’s Department of Public Health, and so forth.)
As we opt for telehealth in the short term, we look forward to human contact as soon as we get a better handle on this illness.
Our immune system includes the health care system and all the institutions that support it. Our wellness is inextricably tied with the wellness of others, and of the planet itself. The message of COVID-19 is interdependence and connection.
The key ingredient of our interdependence is compassion. Compassion is how we do human. Compassion requires taking measured actions to protect our health, and to know that we are susceptible to anxiety overwhelming our capacity to make rational, caring decisions.
Lastly, please remember that the risk of infection is not dependent on race, ethnicity, or culture. We should proceed with knowledge, understanding, compassion, and collaboration while protecting ourselves and each other. Many of us are alarmed by the racist attacks against Asians for wearing or not wearing masks, for example, and the president's rhetoric about this threat being "foreign." These are ways that our communal immune system breaks down.
We can do better. But we need each other.
(c) 2020 Ravi Chandra, M.D., D.F.A.P.A.
UPDATE 3/17/20 (copied from a message from Columbia Center for Psychoanalytic Training and Research):
"The Centers for Medicare & Medicaid Services has announced that additional emergency measures have been put into place to temporarily expand the use of telemedicine. These measures will include allowing providers to conduct telemedicine visits with patients who are located in their homes. The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site (i.e., physician's office or other location) and the patient at home.
In addition, effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. Although these less secure options are available, NYSPA suggests that psychiatrists consider using existing HIPAA-compliant secure software programs that are available in an effort to better protect patients' privacy.
The CMS Medicare Telemedicine Health Care Provider Fact Sheet can be accessed by clicking here."
Resources for Doctors: Coronavirus Tech Handbook (a crowdsourced Google Doc)
As Coronavirus Spreads, So Does Xenophobia and Anti-Asian Racism (Haynes S, Time, March 6, 2020)
What's spreading faster than coronavirus in the US? Racist assaults and ignorant attacks against Asians (Yan H, Chen N, Naresh D, CNN, February 21, 2020)
Coronavirus Racism Infected My High School, Oung K, The New York Times Op-Doc, March 14, 2020
All the ways you can—and can’t—catch the coronavirus (Baggaley K, Popular Science, March 2, 2020)
Coronavirus Anxiety? Here's How to Keep It From Spiralling Out of Control (Daniels J, Science Alert, March 8, 2020)
Coronavirus: Why You Must Act Now (Pueyo D. Medium, March 10, 2020)
Interrupting transmission of COVID-19: lessons from containment efforts in Singapore (Lee VJ et al)
"Notably, Singapore has not implemented school closures or other major social distancing measures, as there is no evidence of widespread community transmission, andr ates of COVID-19 infection among children remain low. School closures and social distancing have been performed in China and Hong Kong, where containment is also successful. However, Singapore’s experience suggests it is possible to avoid major social disruptions and contain the spread of COVID-19, as a sustainable approach over the long term."
Coronavirus: Why You Must Act Now, Pueyo T, Medium, March 10, 2020
Also see this lecture: Compassion in difficult times