The Curious Case of the Disappearing Patient

Every mental health professional that I know has either written, posted, or lectured about the importance of combating the sense of aloneness and disorientation that the current coronavirus pandemic is causing our patients. Troubled individuals are asked to reach out remotely.
Many of us have learned to embrace technology by providing therapy and counseling through FaceTalk or Zoom through our cell phones.

We have come to make peace with remote counseling despite our reluctance to give up the intimacy and connectedness that live therapy in our consulting rooms has always provided. Every television news show inevitably flashes the telephone numbers of counseling services and help lines. Individuals with substance abuse problems and most other emotional and behavioral problems are urged to reach out and connect to counselors for brief but often superficial connections. The National Association for the Mentally Ill reports triple the number of calls to their helplines.

But even as many individuals discover the importance of these helpful connections, a rather unusual phenomenon may be occurring amongst established patients, who have gotten used to regular office visits. Several colleagues with a cognitive behavioral orientation have reported an unexpected fall-off in the frequency of therapy sessions with such individuals.

Sometimes the fall-off is reflected in requests to reduce the frequency of sessions. Sometimes it takes the form of shifting to shorter sessions. And on occasion it results in the therapist being “ghosted.” A patient who had loyally and regularly kept their sessions throughout the year suddenly disappears! Explanations are sometimes offered but may appear hollow and contrived.

What are therapists to make of this? The obvious answers are financial (the unemployment rate is horrific), awkwardness with "phone therapy,” or even a sense that the sadness, loss, and grief, that patients are feeling are so profound that no therapy can help.

However, when I have asked colleagues their theories about this disappearance of regular patients, I have heard the following lament several times: “We are running out of things to talk about!”

How is this possible? During normal times, the therapist and patient are regularly exploring a complex three-dimensional world. A world of relationship dilemmas, social anxiety, obsessive-compulsive fears, phobias, mood disorders that swing and sway, and philosophical and existential issues.

My cognitive behavior therapy colleagues regularly assign complex real-world homework, such as assignments to counter phobic challenges, in vivo exposure and response prevention exercises, dating and intimacy approaches, workplace interpersonal decision-making strategies, and more. Very few, if any, of these activities can be carried out in the constrained environment of phone therapy and quarantine.

And so for some patients, therapy becomes less important. As one colleague offered, “How many times can I say, 'I share your struggle' and 'Have you considered these other ways of passing the time,' and 'We must use this challenge to build our resilience.'"

Of course, therapists can and must continue to provide crucial emotional support while we are all in lockdown. We continue to be the most trusted individuals in our patients' lives. We are there for them in this most traumatic period in any of our lives.

My therapist daughter regularly reminds me that, once things return to relative normalcy, our work will take a new turn: providing treatment for all the medical heroes who will surely suffer PTSD and all those others whose lives, careers, and relationships will have been broken by this dreadful virus.

Perhaps my colleagues offering psychodynamic therapy will hardly feel hobbled by the constraints that CBT therapists may be experiencing.

Whatever our therapy orientations, we all must work very hard not to “run out of things to talk about.” Even the most dyed-in-the-wool behaviorist can teach such techniques as active listening to narcissists and role play conversational skills to the shy. Our patients depend upon us, even if they disappear for a while.