Interpersonal Psychotherapy for Anxiety, Depression, and PTSD
JOHN C. MARKOWITZ
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CIP data is on file at the Library of Congress ISBN 978–0–19–755450–0
DOI: 10.1093/med-psych/9780197554500.001.0001
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Dedicated to the incomprehensible numbers of the dead, of the still living and suffering, and to those struggling to help them
Introduction: The Pandemic 1
1. In the Aftermath of Upheaval 5
2. How the Pandemic Has Transformed Psychotherapy: Remote Treatment 11
3. Interpersonal Psychotherapy: Life Event–Based Therapy 18
4. Life Crises: Grief, Role Disputes, and Role Transitions 40
5. Major Depression 55
6. Posttraumatic Stress 73
7. Anxiety and Other Distressing Symptoms 97
8. Termination 112
9. Dealing with Post-Catastrophe—Resilience 115
Acknowledgments 119
References 121 Index 131
Introduction
The Pandemic
In 2020 the world suddenly and seemingly irrevocably changed. The Covid-19 virus, previously unknown, often lethal, and without a treatment, began to devastate populations around the globe. In the absence of a vaccine, societies retreated to ancient patterns of plague control, namely social distancing. This physical isolation protected individuals, kept intensive care units (ICUs) from overflowing, and limited at least the speed of infection—but at a cost.
The anti-Covid lockdown in the United States saved lives, at least in parts of the country that obeyed it. It brought with it, however, a host of problems: loss of sense of health safety, and sometimes loss of health itself; loss of daily routine, loss of social support, loss of income, often loss of job, and sometimes loss of loved ones (see Table I.1). These losses, alone and combined, contributed to the next and, we fear, enduring wave of pathology during the spread and in the wake of the Covid-19 virus. We anticipate, and seem already to be seeing,1 psychopathology on a grand scale: anxiety, depression, traumatic stress, and substance misuse. Those who haven’t died or become physically ill still suffer.
In the midst of this pandemic, our team of psychiatric researchers at Columbia University/New York State Psychiatric Institute (NYSPI) sought to provide remote (virtual, phone and internet video) treatment to patients in need. Remote therapy is itself a major adjustment for therapists used to seeing patients in person.2 And a major adjustment for patients, too. Moreover, it was unclear whether the treatment lessons we had learned from other traumatic events, such as rape, war, the September 11 attacks, and natural disasters like hurricanes and earthquakes, applied to this catastrophe. Most traumatic events are, thankfully, brief, whereas this pandemic is (as I write in May 2020) already a siege that promises to continue. Prolonged stress is more distressing and becomes more engrained than acute stress.3 The longer it continues, the worse the effects. And while the Covid19 “plague” is an impersonal trauma, which is comparatively less distressing than interpersonal trauma,4,5 its extreme interpersonal consequences compound its damage.
Table I.1. Losses Due to the Covid-19 Pandemic Engender Psychiatric Symptoms
Loss Threat Consequences
Loss of security
Loss of income
Loss of employment
Loss of loved ones
Potentially lethal viral infection
Frontline medical and other personnel witness trauma
Disrupted social rhythms, activities, pleasures → anxiety, depression
Social isolation → anxiety, depression
A further layer of interpersonal malignity magnifies the effects of coronavirus. From the start of the pandemic, Americans have seen other countries, led by unifying, compassionate leaders, take orchestrated, scientifically driven steps to combat the spread of infection, with often beneficial results. In contrast, the U.S. federal government has been divisive, attacking, openly racist at a moment when racial and ethnic minorities are hardest hit, and strikingly anti-scientific. The President of the United States has recommended unproven and dangerous remedies such as injecting bleach (!) and turned wearing a mask into a political statement rather than a public health measure. The federal and many state governments have failed on many levels, for many people, their leaders pointedly ignoring and discounting a rising plague in defiance of basic medical tenets. Spike Lee made the point in his 2006 film When the Levees Broke that although Hurricane Katrina was an impersonal trauma, the failed, racist governmental response to the disaster gave it added interpersonal insult.
Amidst the pandemic, in the anticipation of a polarized national election, there has been a sudden explosion of national awareness and protest about structural racism following airings of videotaped evidence of the killings of George Floyd on May 25, 2020, and other African American men and women, by white policemen. The Black Lives Matter movement is a healthy, belated response to centuries of inequality and mistreatment, and its invigoration seems a healthy channeling of the frustrations of months of lockdown into an idealistic cause. Dealing with structural racism is an important cause, albeit not the focus of this book. Nonetheless, all this change adds to the turmoil in the environment individuals face.
Moreover, this is only the first wave of virus, and first aftershock of psychiatric symptoms. If there are future waves, as it appears there may well be, they will likely compound the psychiatric sequelae. What effect will this pandemic have not only on the adults who lose their jobs, but also on their children who are evicted from their schools and separated from their friends for months on end? Even after a vaccine arrives, the psychiatric consequences of this global disaster will likely be long-lasting.
This book describes the application of interpersonal psychotherapy (IPT) to treating the psychiatric consequences of Covid-19, and more generally to any terrible social disaster. IPT is one of many psychotherapies, and it is surely not the only route to treating post-Covid psychological symptoms, but many therapists and patients may find it a particularly useful approach.6 I will explain why in a moment.
Most books on IPT have followed a research data stream. Almost every IPT adaptation for a particular psychiatric disorder has been empirically tested and shown to work before it has been disseminated. We know that IPT benefits people with major depressive disorder (MDD),7,8 bipolar disorder (adapted as interpersonal social rhythms therapy [IPSRT]),9 eating disorders,7 and posttraumatic stress disorder (PTSD).3,10,11 What we don’t entirely know is how much it helps people who develop distress, depression, or PTSD in the wake of a prolonged disaster such as the Covid pandemic. We hope that the National Institute of Mental Health, which has in recent years funded neuroscience at the expense of clinical research,12 will recognize the need for immediate clinical trials as a result of the mental health fallout of the pandemic. Nonetheless, as we await research evidence, IPT appears to be a good candidate for the psychiatric consequences of disaster. All of the treatment cases described in this book, while disguised to protect patient confidentiality, are actual presentations from the pandemic.
Why should IPT work in the setting of disaster? First, IPT has been shown to alleviate MDD and PTSD, two of the most common sequelae of traumatic life events, and to lower anxiety. Second, IPT is a life event–based therapy, using life circumstances to contextualize psychiatric crises, explain strong emotional reactions, and use understanding of those emotions to negotiate interpersonal and other life difficulties.7 The worse the life circumstances, the more understandable strong feelings become. A pandemic is surely a life event, and it brings other distressing events—unemployment, financial need, strained interpersonal relationships, etc.—in its trail. Third, IPT focuses on mobilizing interpersonal support and on repairing attachment.13,14 This makes it an appropriate intervention for a time of interpersonal isolation, when physical separation threatens to deprive individuals of needed social support.6 Social support is a key protection against anxiety, depression, PTSD, and psychic and medical vulnerability more generally.5 Fourth, the loss of daily structure contributes to people’s disorientation and discomfort during the crisis. Adding components of social rhythms therapy (from interpersonal social rhythms therapy15) can help to restore the lost structure of pre-Covid daily life.
People often don’t like to have strong feelings, particularly negative feelings. Because of that discomfort, they often try to minimize their feelings through intellectualization, distraction, or suppression. The Covid pandemic inevitably evokes powerful feelings, and particularly “negative” affects such as anxiety, anger, and sadness. Some of these feelings are appropriate to the situation, others excessive. A precept of IPT is that feelings are important and informative: it is better to know how you feel, and why, in order to respond to life’s situations. It’s important to recognize that painful affects can be normal: they reflect a painful environment.3 When feelings go unrecognized and detached from context, they can become a confusing additional internal pressure for an individual to struggle with.
All of these features suggest IPT as a helpful counterweight to the stresses of the pandemic.6 We are using IPT at Columbia/New York Psychiatric Institute as well as in private practice to assess its benefits, and thus far it seems quite helpful. I hope that the reader, who is likely a psychotherapist treating patients with various emotional and psychiatric responses to these painful events, will agree.
John C. Markowitz, MD
May 2020
An update at the completion of the text: three months later, Covid-19 has not begun to disappear. While New York is no longer the American epicenter of the virus, more than three million Americans have already been infected, more than 130,000 have died, and the daily number of new infections is rising. We are in for a longer siege than anticipated, with growing psychiatric consequences.
July 2020
In the Aftermath of Upheaval
Our environment shapes us. Here in the United States, protected by two broad oceans, we had long been spared threats of invasion. Geography may have fostered a sense of security that partially explains the long-standing American ethos of confidence.16 Things have become shakier of late, however, since the September 11, 2001 attacks and now the invasion of an invisible, potentially lethal killer. As the world becomes more threatening, we feel more threatened.
THE DISASTER
Beginning in March 2020, the country and the world turned upside down. Americans began dying in incomprehensibly large numbers—more than 100,000 before the end of May. Many who didn’t die became seriously and chronically ill. The symptoms of Covid-19 took a while to fully appreciate, but it quickly became clear that acute respiratory distress often required ventilator support, and hospital ICUs became overloaded. With closed borders disrupting supply lines, a shortage arose of personal protective equipment (PPE) such as face masks and gloves, as well as access to viral testing. In the finest, most sophisticated hospitals in the world’s richest nation, doctors, nurses, and other staff were forced to reuse PPE, often inadvertently infecting patients and themselves. Bodies have piled up in refrigerated trucks as morgues have overflowed. The initial public reaction was, understandably, fear (albeit, in some quarters, denial).
Frontline medical workers are facing particular risk of infection. Poorer, minority communities, with denser housing and poorer access to treatment and whose work often put them at risk for contagion, are suffering disproportionate illness and death. So are the elderly, particularly debilitated individuals clustered in nursing homes, and inpatients in psychiatric hospitals.
While medical professionals around the country and the world have pulled together impressively to provide patients supportive treatment of Covid-19 symptoms and to study potential treatments and vaccines, the infection has no immediate cure. Protecting lives hence requires isolation, quarantine, and social distancing. When the virus struck, businesses, restaurants, and entertainment
closed. The economy ground to a near halt. Unemployment figures in the United States reached almost forty million (40,000,000) in a matter of weeks, with unemployment rates rising from 3.5% to almost 15%. People worried about how to pay the rent and to obtain food to eat. Food banks were overwhelmed by mileslong lines of cars. The federal government’s response to this catastrophic situation was and (months later!) remains disorganized, inadequate, and often counterproductive, leaving each state to fend for itself. It has been shocking and surreal to see New York City shift abruptly from bustling megalopolis to sci-fi ghost town (Figure 1.1).
Many frontline individuals caring for patients are risking their own lives and witnessing horrible events and deaths, the “Criterion A” of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) traumas that qualify for the diagnosis of PTSD.17 Compounding this has often been a sense of moral injury that lack of supplies and of governmental support is sabotaging their work and putting their patients’ and their own lives at unnecessary risk.18
Even the many Americans who have had asymptomatic infection or avoided the virus suffer. There has been a torrent of upsetting news, evoking upsetting feelings. Each of the medical and social stressors listed in Table I.1 would have sufficed to produce high levels of anxiety in the general population and, as time has dragged on in months of isolation, to breed frustration and depression and eventually boredom from the monotony. The pent-up frustration may have contributed to subsequent crowd violence. Attempts at the “reopening” of limited
Figure 1.1 Times Square, March 31, 2020. Photo by the author.
social life and business, a seemingly encouraging development, have brought new fears and realities of infectious spread. Two other central factors have extended from and compounded the anomaly of the situation: the social and economic lockdown required by social distancing disrupted social rhythms and social support.
Disruption of Social Rhythms
Part of what makes normal life normal is a familiar daily routine. Most people fare best waking up at the same hour every morning, sitting down to coffee and breakfast; then commuting to work, interacting with colleagues, and following work protocols until the time comes to return home. Then preparing dinner, eating, and spending time with one’s family, perhaps watching television or reading before heading for bed—again, often at a set hour. The temporal and behavioral landmarks of such a day, termed social zeitgebers, or “time givers,” help give us our social role and orient us to the environment.19 Such social rhythms provide a comfortable psychic structure to the day as well as conditioning a regular, healthy somatic sleep cycle.
We all rely on these patterns. Individuals with bipolar disorders are particularly sensitive to such daily stimuli, which is why interpersonal social rhythms treatment (IPSRT)9,15 was developed for their treatment. Disrupting familiar life patterns is disorienting and anxiety-provoking, particularly when the pattern shifts very suddenly for the whole population. Who am I if I’m not going to my job? How do I define my day and week if I’m stuck at home all the time? During the lockdown, not just personal patterns but also larger social patterns ceased. Public spaces and activities closed. There were no longer sports scores to check. Outside entertainment and restaurants shut down. Stores closed or had limited access, leading to runs on toilet paper and other supplies because things we took for granted could no longer be so.
While some individuals who could still work from home initially felt pleased not to have to commute, for many this pleasure quickly waned. Days lost their structure. There was no longer a boundary between work and home life, making it hard to unwind from stressful work. Parents whose children’s schools had closed struggled to work (if they still had work), teach, and simultaneously provide child care in the course of the day. College students were forced to return home, feeling cheated of their collegiate experience, distanced from their classmates, and unhappily stuck with their families at a moment of expected independence. With the breakdown in routine, many people began to feel disoriented and uncomfortable: “surreal” was an adjective frequently used. Life was no longer normal, and the abnormality was unnerving. With limited options for activity, people grew increasingly frustrated and bored.
These disruptions in schedule frequently interfered with and disrupted sleep schedules, leaving people tired, more irritable, and more anxious. All this disruption is fertile soil for distress and psychopathology.
The requirement to “shelter in place” meant having to stay home. This physical isolation of quarantine tended to cut people off from friends, family, and work colleagues, from confidants and acquaintances. Thus physical isolation risked loss of social support. As people are social animals, this isolation was palpable. Zoom parties and phone conversations compensated a bit, the “seven o’clock cheer” that rang through cities every evening to salute healthcare workers provided a bit of communal solidarity, but mostly people felt cut off.20 Even when meeting in person, behind masks and gloves, six foot social distancing meant the absence of physical contact; people missed hugs and kisses.
Social support is a crucial factor in mental and even physical health.5,21,22 Social isolation has been linked to physical decline and premature death.23 Social support means that you do not feel alone, that if you have problems and strong feelings you can share them with others, rather than keeping them in as painful secrets. Feeling anxious or depressed by various losses or other aspects of the pandemic, people were (and remain, at this writing) threatened with loss of part of the security system that stabilized their lives. Everyone has suffered, but people with already limited social support, already at higher risk for psychiatric symptoms, have suffered more.
A further problem has arisen. In the absence of the usual patterns of life, many people have turned, understandably, to virtual life. The internet provides endless diversion, news, fake news, and social media contacts to those who seek them. Keeping track of some news seems only healthy, to know what is going on so as to be able to respond. Yet it has become clear that too much social media use is a risk factor for psychiatric symptoms, ranging from anxiety to depression to suicide risk.24–31
THE SECOND WAVE: PSYCHOPATHOLOGY IN THE WAKE OF THE PANDEMIC
Thus, overnight, normal life became extremely abnormal. It remains so months later. Essentially everyone has felt stresses and suffered losses, generating anxiety, sadness, anger, and other feelings. Some of that has been warranted: anxiety, based on fear of infection, fear of an uncertain future. Sadness, reflecting loss. Anger at the frustrations of a circumscribed life, at missed opportunities, and at others in a crowded household living one on top of another. Although most people are resilient in adjusting to stressors, finding some way to roll with the punches, a substantial subset will suffer symptoms (Figure 1.2). The greater the concatenation of stressors, and the longer they persist, the greater the likelihood and severity of psychiatric symptoms.
Our PTSD team at Columbia University/NYSPI, led by my colleague Yuval Neria, PhD, remembered the psychiatric aftereffects of the September 11, 2001
Stress, Loss
Anxiety
Traumatic Stress
Depression
Bereavement
Resilience or spontaneous recovery
Need for counseling
Most people will be resilient.
Figure 1.2 Psychological fallout of the Covid-19 pandemic.
World Trade Center attack and became immediately concerned that the viral pandemic would trigger a large and long-lasting second wave of psychopathology.32 In retrospect, 9/11 was a brief if horrific trauma, yet its scars persist to this day. While most people adjusted to it, individuals vulnerable to trauma (based on prior trauma, genetics, or psychiatric history) or severe exposure to the trauma (e.g., proximity to the World Trade Center, knowing someone who died in the towers) developed PTSD, major depression, substance misuse, or some combination of these.33 In the current pandemic, we felt there were just too many stressors, too many losses, affecting the entire populace for too long. Even as the first viral wave seemed to begin to recede, a new wave of psychiatric disorders was likely to follow.
Disorders could result from stressors or possibly even from central nervous system effects of Covid-19 infection itself.34 Frontline clinicians trying to provide care face high risk. An upsetting headline in New York City on April 27, 2020 was the suicide of Dr. Lorna Breen, the forty-nine-year-old medical director of the emergency department at New York–Presbyterian Allen Hospital in Upper Manhattan, an epicenter within the epicenter of the viral assault.35 Dr. Breen had contracted Covid-19, gone home to recuperate for some ten days, and then perhaps rushed back to her emergency room (ER) service too soon. She again witnessed scores of unpreventable deaths in an overwhelmed system. The hospital again sent her home, after which she killed herself.
HOW SHOULD YOU FEEL?
Context matters: life events have emotional consequences. In a moment of great tumult, feelings grow tumultuous too. Anxiety is a normal response to threat, and the pandemic is a threat. Sadness is a normal response to loss, and people are suffering losses. Anger is a normal response to frustration, and these are frustrating times of curtailed lives. As psychotherapists surely know, people often have difficulty gauging whether their feelings are appropriate, whether they can trust their own feelings. Most of us do not like strong affects, and particularly negative affects. Under such novel and unpleasant circumstances, it is small wonder that people would struggle to tolerate their emotional responses.
It is crucial under such circumstances to distinguish between signal anxiety as the alert to a threat and symptomatic anxiety as an excessive response.36 The same holds for sadness versus depression—many people seem to confuse colloquial “depression” with a small “d” and the DSM-5 diagnosis of Major Depression. Anger scares many people, even when it’s justified and appropriate, still more if it gets out of hand. People worry about losing control of their emotions. Yet the question under these circumstances is not whether one should feel anxious, angry, or sad but how strongly it’s helpful to feel such things and how to handle those feelings.
Thus, at Columbia/NYSPI we expected a range of psychological reactions to the Covid-19 pandemic, depending upon individual experiences, histories, and vulnerabilities (Figure 1.2). Everyone was stressed, and everyone would surely be anxious at first and increasingly frustrated and demoralized as the siege dragged on. We expected that most people would be resilient, as most people— remarkably—bounce back even in the face of great stress.37,38 Resilience, “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress,”39 is a complex, important phenomenon described at length in Chapter 9 of this book. Humans are adaptable creatures, and we tend to roll with life’s circumstances. On the other hand, we expected the usual response to severe stress in vulnerable individuals. People would respond as they often did under stress: people with eating disorders might have heightened eating problems; those with trichotillomania might pull out more hair. The big quartet of syndromes were likely to be anxiety, depression, PTSD, and substance use disorders, some of them recurrences but others arising de novo based on exposure to recent circumstances. Our program is not set up to treat substance disorders, but we certainly have seen heightened PTSD, depression, and anxiety disorders. So has my private practice, with some long absent patients returning with recurrent symptoms, and others arriving with new ones. Unfortunately, even if life returns to something approaching “normal,” we can expect to keep seeing these psychiatric aftershocks for some time to come.
How the Pandemic Has Transformed Psychotherapy
Remote Treatment
While the pandemic has put millions of Americans out of work, therapists are finding plenty to do. People need psychological support and treatment. The problem has been that social distancing directly affects the practice of psychotherapy, it being no longer safe to have patient and therapist share an enclosed space for the prolonged interval of a treatment session. As a result, everything has gone remote: tele-psychiatry has taken over.* The delivery of IPT, as described in this book, will for the foreseeable future mean remote, tele-IPT.
Tele-psychiatry has been around in one form or another for decades.40 The term “tele-psychiatry” is broad and vague, encompassing telephone therapy, smartphone or computer videotherapy, as well as computer-driven programs and internet apps. Until now, tele-psychiatry had mainly been used to help hard-to-reach populations who lacked access to in-person treatment: rural HIV-positive patients,41 for example, rural military veterans far from Veteran Affairs (VA) hospitals, and nursing home patients. Whereas in-person effective psychotherapies have been extensively studied, with more than a thousand studies of MDD alone,42 the corresponding database for tele-psychiatry of any kind, for any disorder, is quite limited.2
Even the existing research has limitations. Many published studies were underpowered to show differences, or influenced by researcher enthusiasm for tele-therapy, leading to potentially biased outcomes. Moreover, because many researchers and their institutional review boards felt understandable discomfort
about treating high risk psychiatric patients at a distance, many research trials excluded highly symptomatic patients, yielding more mildly ill treatment samples. Yet because milder symptoms tend to respond to almost any benign treatment, including placebo,43 the common report that tele-therapy has comparable outcomes to in-person therapy should be skeptically received. The extant evidence appears stronger for the benefits of telephone therapy than for videotherapy, for which trials have been scarce. In any event, such research as exists is an inadequate foundation to support the sudden massive use of tele-therapy, and particularly videotherapy, as standard treatment.2
Yet overnight, tele-therapy became standard treatment nonetheless. This has required considerable adjustment for therapists. Our Columbia/NYSPI group, which had previously used telephone psychotherapy and tele-videotherapy in selected circumstances for patients with transportation difficulties, compared among ourselves our current experiences and agreed that remote therapy presents numerous issues. These relate to setting, transmission, physical discomfort, and emotional distancing (Table 2.1).
The great strength of remote therapy is that it expands access: the great majority of Americans have access to a telephone or computer.44,45 Nonetheless, recent reports suggest that many at-risk populations, including the poor and the elderly, often lack high-speed internet access.46–48 At least one formerly homeless patient we had been treating in person declined to continue therapy even by phone because sessions would have cost him precious billed minutes on his phone plan. Several other patients reported lacking any private space to speak away from difficult family members in cramped, overstuffed apartments. Remote therapy has the great benefit of maintaining a therapeutic connection and allowing treatment
Table 2.1 Remote Therapy Difficulties and Potential Remedies
Difficulty
Setting
Teletherapy
Your home background
Transmission difficulties
Physical Intrusions
Electronic intrusions
Email beeps
Your own face
“Talking heads”
Physical discomfort
Emotional distancing
Remedy
Acknowledge difference from in-person
Arrange to minimize distraction, disclosure
Bear with interruptions
“Try to find a private place where you are unlikely to be overheard or interrupted . . .”
Observe patient’s environment
Turn off email (and ask patient to)
Minimize or hide self-view
Sit at in-person session distance, away from keyboard
Relax, stretch between sessions
Use a comfortable, ergonomic chair
Minimize outside distractions
Focus on reading patient
to continue at a time of great need. In reaching patients, however, remote therapy requires important adjustments for therapists, on several levels. As therapists and supervisors, we sense great differences treating patients with psychotherapy by webcam or telephone rather than in person.
SETTING
Many clinics that have practiced telepsychiatry, including ours,49–51 had required at least one initial in-person visit to evaluate the patient and develop a therapeutic alliance before continuing treatment remotely. That is no longer practical or safe: now treatment is distanced from the start. This may subtly alter the therapeutic relationship. Nor can one offer a tearful patient a tissue. Patients who began therapy in-person and had anticipated it would continue can find the adjustment to remote therapy “weird” (as several said) and discomfiting, although they soon seem to settle in. Therapists may, too.
Maintaining a consistent intimate focus is more difficult. The patient is no longer in the room but on a screen (or a phone). Instead of two human beings fully engaging in a common space, one meets an image of a patient on a computer screen (or a disembodied voice) surrounded by too many distracting stimuli. Although studies indicate good therapeutic alliance and psychotherapeutic common factors can be established in remote therapies,52–54 they may reflect selective, enthusiastic therapist and patient samples.
Distractions abound. The usual instruction to patients is to find a private, quiet space where the patient is unlikely to be overheard or interrupted, but that is not always possible, particularly for less privileged patients under lockdown. People and pets walk in. Outside noises distract. Even if they do not, the screens themselves teem with diversions. Because the computer volume is on (sometimes set very loud) to allow therapist–patient interchange, the frequent ping of arriving email occurs at both venues. We have seen patients scanning the screen as if reading an email, rather than making eye contact. Eye contact itself is tricky: if the patient is addressing the computer camera lens, making virtual eye contact, he or she may not be looking at your image; and vice versa. Thus the patient’s gaze may be misleading. Your own image on your screen is an anomalous presence: you or your patient may be looking at oneself rather than each other.
Instead of sitting close to the camera, viewing each other as talking heads, you can sit back, and ask the patient to sit back, providing more of a full-length view, a simulacrum of the office experience. This also distances yourselves from the keyboard to avoid the temptation of email. Some video programs have a “hide selfview” option or can enlarge the patient view relative to self-view, allowing a purer focus on the patient. These maneuvers may reduce unhelpful sensory stimuli. On the other hand, too much distance from the microphone can hurt sound quality, and headphones can be obtrusive. The issues video treatment raises suggest that telephone therapy might present fewer distractions, albeit at the therapeutic cost of nonverbal cues, particularly for patients unable to easily express their feelings in words.
Remote therapy grants the therapist revealing glimpses of a patient’s home and life. This may include meeting pets, babies, and other family members, and seeing elements in the surroundings that the patient might not think to mention. One patient appeared in her childhood bedroom, where a devout religious icon hung on the wall. She had mentioned having been raised in a “kind of religious, Catholic” home, but the camera brought her mother’s consuming devout piety, and graphic reminders of the strictures this imposes on the patient’s life, into sharp relief. Other patients could only find private space in a bathroom, on the stairs of her building, or outside in a park.
Most patients seem not to mind allowing their therapists into their homes, although those preoccupied with their outward appearance, hoarders ashamed of their household interiors, and some mistrustful patients with social anxiety disorder or PTSD have requested telephone rather than video sessions. Anecdotal conversations with colleagues suggest that more than half of their patients prefer standard telephones to videophones for remote therapy purposes. One patient personalized her screen background to surround herself with a family portrait. A therapist noted that some patients have been conditioned to feel a work ethic in front of their computer screen, and seem more relaxed on the telephone. Just as good therapists offer patients informed consent and a choice of treatment modality, remote therapists might offer patients a choice of treatment medium: i.e., telephone or video.
For their part, some therapists feel odd about treating patients from their own personal spaces (e.g., a bedroom), to which a crowded house may confine them. It may be important to pre-check the camera frame so as to avoid unwanted, inadvertent self-disclosure of personal home details. Whereas many therapists do not miss commuting to work, they note in retrospect that it provided time to decompress and think through the progress of treatments prior to rejoining private or family life. That transitional buffer may no longer exist when one works from home. It may help to allot time to reflect before and after treatment sessions to ease the shift to domestic life. During the Covid-19 crisis, however, many people lack extra time as details of domestic life have become more burdensome.55
PHYSICAL DISCOMFORT
Everyone in our group has found remote psychotherapy more physically and psychically exhausting than the in-person variety. Many therapists on our academic listservs have volunteered the same response. There are several apparent reasons. It is harder to stay focused on and more difficult to read the patient’s cues across the medium. Sitting before a screen constricts physical movement, including the subconscious mirroring movements in which patients and therapists sharing a space engage. Therapists feel rigidly locked before the camera, tensing different muscles. It can feel like, and have the physical consequences, of a long haul airline flight. We encourage therapists to use comfortable, ergonomic desk chairs and
to stretch their legs and bodies and walk around their house between sessions to counter this.
TRANSMISSION
Technical difficulties can impede communication or interrupt treatment sessions: difficulty connecting, frozen screens, unstable internet warnings, garbled or delayed audio, poor lighting, dropped calls. Videotherapy has turned out to have confidentiality risks, although it can be HIPAA-secured.56 Time spent countering these inefficiencies means less time for engagement in therapy.
EMOTIONAL DISTANCING
Perhaps the greatest challenge in remote therapy is a loss of affective nuance on the telephone or screen. This factor that seems to bother therapists more than patients (albeit we have not solicited patient reactions). The affective diminution makes the experience less emotionally vibrant, particularly for patients with the psychological tendency to dissociate. Media separation makes it hard to gauge nonverbal behavioral subtleties,57 such as when a patient with PTSD may be dissociating. A pause on the phone can mean (too) many things. Although research has found tele-exposure therapy benefits patients,58,59 it seems easier for patients to avoid exposure at geographic and interpersonal distance. In affectfocused psychotherapies, distance impedes emotional engagement with the therapist in the moment, which is key to the process of change. We have arrived at no solution to this problem except to minimize distractions and to work hard to focus on understanding the patient’s emotional state.
Patients who participate in tele-therapy in the familiar “safety” of their home, particularly those with anxiety, panic, and agoraphobia, may underreport symptoms likely to be present (or activated) when presenting in clinical venues. Thus physical remoteness appears to aggravate these patients’ avoidance of uncomfortable affects and experiences.
THE PANDEMIC
It would deny reality to pretend that current tele-therapy is therapy as usual. The Covid-19 pandemic is a world crisis, and it tends to aggravate underlying anxiety in at least three ways: (1) by evoking appropriate fears of contagion, which may rapidly merge into panic attacks (anxiety as signal versus symptom)36; (2) by disrupting the comfortable structure and rhythm of the patient’s (and therapist’s) work and life schedule, often including where and with whom they are living, and sources of income and relaxation; and (3) through social distancing, which stretches attachment bonds and risks loss of social support.6 As the pandemic has
persisted, initial panic in the general population seems to be giving way to frustration, despondency, and depression for many, with concern that suicide risk may be increasing.60 As in previous pandemics61 and disasters,62 highly exposed groups such as medical teams, first responders, and the bereaved may well present with lingering PTSD and complicated grief.
Therapists should acknowledge the crisis, and perhaps that tele-therapy is a limited substitute for more direct contact. They can attempt to maintain the helpful structure of therapy by maintaining regular sessions and treatment approach. They can encourage patients to maximize their existing relationships by remote means to preserve protective social support.6
The pandemic not only evokes new symptoms but functions as a Rorschach test, magnifying aspects of patients’ ongoing inner struggles. People respond to crisis in varying, idiosyncratic ways. Patients with obsessive compulsive disorder have joked that the world has finally caught up to them on handwashing. Embarrassing behavioral differences between severely agoraphobic and social phobic patients and “normal people” have temporarily shrunk. Some depressed patients have become more depressed, whereas others say the crisis has led them to downgrade their previous concerns: that Covid-19 has been de-catastrophizing, as it were. A severely symptomatic veteran with PTSD who had been in productive, exploratory, trauma-focused psychodynamic psychotherapy,63 became distanced, repeatedly telling his therapist that all symptoms were “just the same,” that “nothing’s new really” once his treatment switched to videotherapy. He evidently said this in response to an unspoken or unconscious urge to protect her from his rage-filled fantasies and recurrent dreams after having learned early in the pandemic that she required isolation (earlier than other VA employees required it) because of an immune-compromising illness. This patient began to improve, and use therapy more productively, only after the therapist pointed out this seeming attempt to protect her. The therapist had uncharacteristically avoided making this observation for several stymied weeks because of her own concerns about being less available to the patient remotely than she would have been in person.
CONCLUSIONS
Several modalities of tele-therapy can preserve the crucially important link of psychotherapy in a highly anxiety- and depression-provoking, socially burdened time of quarantine, social distancing, and deep emotional need and despair. Tele-therapy has some empirical backing, but the outcome literature is very limited relative to that of in-person treatment and has unclear generalizability to its broad current use among a wide range of patients with various serious psychiatric problems. Tele-psychotherapy offers access and convenience during a time of unprecedented crisis, at the cost of important elements of in-person treatment. At least in the United States, Covid-19 has changed the long-standing requirement that therapists see patients in person. This may well change the face of psychotherapy and enhance the ongoing use of tele-therapy, whether or not it is an
optimal approach. Our experience to date suggests that in-person psychotherapy, now necessarily in limbo, has many advantages over remote treatment and should eventually return.
It is unclear whether videotherapy, despite its sudden wide uptake, is necessarily clinically preferable to telephone therapy. The limited empirical research does not demonstrate the superiority of video treatment. Vision, as the dominant human sense, may have prejudiced insurance reimbursement requirements for visual patient tele-contact (when insurance has paid for videotherapy at all64). Video has obvious advantages over audio for group therapy, but it may provide more distractions than a simple phone call for some or many patients in individual therapy. Such preference, which can affect treatment outcome,65,66 deserves study. Telephone may also provide broader access to economically disadvantaged patients. Perhaps insurance should reimburse both media: tele-therapy research sparked by Covid-19 could reveal that what has always been an arbitrary insurance requirement is in fact an unnecessary one.
Covid-19 will eventually be contained and the world will resume some new form of normalcy. Nonetheless, coronavirus may continue to have ongoing effects on social closeness and on how (remotely) psychotherapy is practiced. The wave of viral contagion may pass, only to be followed by a wave of psychopathology. Inasmuch as previous, far more contained disasters have raised the incidence of anxiety, mood, PTSD, and substance use, Covid-19 likely will as well.
Another historical complication of tele-therapy has been that each of the fifty United States required therapist licensure in the patient’s state of residence. This legal requirement greatly impeded a central strength of remote therapy, namely its broad and relatively inexpensive geographic reach. In response to the pandemic, the federal government in March 2020 relaxed this obligation, allowing therapists to treat patients across state lines.67 Hopefully this freedom to cross boundaries will continue after the pandemic passes.
