Apprehension Regarding In-Person Psychotherapy Sessions during COVID-19

By: Dr. Denise Renye

We are still experiencing a pandemic but some people are acting as if we’re not. They’re under the impression things can, or should, get back to normal. The reason businesses are reopening? Because of the economy. Money is a real concern, I get that. There are many factories insisting employees return to work, thus creating conflict between choosing money (as receiving unemployment benefits would no longer be an option) or health -- possibly even life. An extension of unemployment benefits would be very useful in terms of people being able to feel more comfortable staying home (and increase safety around their  health).

Even some insurance companies are stopping payment of telehealth sessions, pressuring therapists to go against what may be ethically right for their patients. If we look at the data, the actual numbers of COVID-19 are increasing. We aren't in a second wave. We are still in the first wave. Even without the external pressure, I know people want to see each other in person. We are social and tribal beings (some of us anyway), but meeting in person is very high risk.

Clinical psychologist and psychoanalyst Todd Essig wrote, “We have to find the courage to engage the harsh realities of the pandemic however desperately one might wish things to be otherwise, and despite how some political leaders despicably try to pretend otherwise.”

I couldn’t agree more. I think meeting in person is not only unhealthy and unsafe, I believe it is unethical to bring that level of harm potential to my patients and their families. There are so many factors to consider and over the past few months I have gone back and forth about this. After much research and professional consultation, I think sitting in a walled office for an extended period of time, even with a face mask, is unethical for a number of reasons.

If a patient has COVID-19 particles on them and they sit on a chair in their therapist’s waiting room or lay on the couch in the consulting room, they could transmit those particles to the next patient who comes into contact with the couch. If the next patient (or a family member of theirs) is immunocompromised, that’s a high-risk situation. Furthermore, if the therapist (or a family member thereof) is immunocompromised, that would also pose a high risk.  

For patientss who aren’t immunocompromised who sit on a chair in the waiting room, they could still transmit COVID-19 to someone else who is. Most waiting rooms do not allow for 6 ft. of distance between chairs and there are usually multiple suites with many patients coming in and out all day long. For instance, my building has five suites. That’s a lot of foot traffic!

I have consulted with colleagues about meeting with patients in person.* From a medical perspective, setting up a plexiglass barrier between a therapist and the patient with both wearing masks, having a HEPA filter, and windows open were basic steps one could take. On top of that, fans should be blowing continuously and to increase safety, scheduling three hours in-between patients and disinfecting would be ideal. The material of the couch would need to be considered as particles can linger on fabric. From a legal and ethical perspective, patients could take legal action with their therapist or even with other patients if there was a spread through someone’s office suite. This would bring with it a potential of compromising patient confidentiality.

The confidentiality built in to psychotherapy would be broken if someone gets sick. Instead of maintaining a patient’s privacy, the therapist would need to contact the local health department and divulge the names of patients as they, too, could have picked up the virus. 

“Rather than feeling safe enough to address the private and dark, patients/clients will each in their own way labor under the burden of keeping themselves, their families, their therapist, other patients, and office staff safe,” Essig said. “The vigilance required to remain safe will inevitably reduce the therapeutic benefits one might hope would develop from being back in the office.” 

The American Psychological Association (APA) also recommends not meeting in person if that’s feasible. If a patient has access to a telehealth platform, is able to use it, they’re making progress in their treatment, and treatment can be continued remotely, the APA says to continue meeting remotely. However, the APA also says to consider whether a small subset of patients would benefit from resuming in-person therapy because they need a more intense level of care that is not met via videoconferencing. Clinical judgement and consultation are necessary.

Instances where meeting in person would be more beneficial for a patient rather than meeting online include if the person is in an abusive situation and thus cannot find a private space to talk, or feels uncomfortable doing so. Again, clinical assessment and consultation are necessary. Similarly, if a patient is at immediate risk of self-harming or committing suicide, it could be more appropriate to meet in person.

Ultimately, when it comes to meeting in person again, there are multiple variables to keep in mind – the patient’s health, therapist’s health, state guidelines. These are not decisions to take lightly and will require multiple conversations with patients and other stakeholders. Discussions of the risk, benefits, fears, and goals for meeting in person are necessary. Especially as someone who is concerned with the whole person, it’s why I named my practice Whole Person Integration after all, every one of these considerations are on the forefront of my mind and must be taken into account.

References

Boring-Bray, Dr. Wendy. “Counseling After COVID-19: What Should Providers Do?” May 13, 2020. https://www.psychologytoday.com/us/blog/new-beginning/202005/counseling-after-covid-19-what-should-providers-do

Crowell, Rachel. “Electrified Fabric Could Zap the Coronavirus on Masks and Clothing.” Scientific American. June 24, 2020. https://www.scientificamerican.com/article/electrified-fabric-could-zap-the-coronavirus-on-masks-and-clothing/

Essig, Todd. “Want To See Your Therapist In-Person Mid-Pandemic? Think Again.” Forbes.com. June 27, 2020. https://www.forbes.com/sites/toddessig/2020/06/27/want-to-see-your-therapist-in-person-mid-pandemic-think-again/#410f8e58624f

Galietti, Connie; Wright, Vaile C.; Higuchi, Shirley Ann; Bufka, Lynn. “COVID-19: When is it OK to resume in-person services?” APA Services. May 1, 2020. https://www.apaservices.org/practice/news/in-person-services-covid-19

Hawkins, Melissa. “The US isn’t in a second wave of coronavirus – the first wave never ended.” The Conversation. June 30, 2020. https://theconversation.com/the-us-isnt-in-a-second-wave-of-coronavirus-the-first-wave-never-ended-141032

 *Consultants include: Alexander Cardenas, MD, MA. Unnamed by choice: social worker, legal counsel, nurse, PsyD, PhD, MD.