Michael Blumenfield, M.D. -The Sidney E. Frank Professor Emeritus of Psychiatry and Behavioral Sciences- New York Medical College & in Private Practice in Los Angeles
As the coronavirus epidemic evolves, there is a variable amount of relaxing of requirements for quarantine, wearing masks and gowns, and keeping social distancing. Particularly for the medical profession, there is more pressure on physicians to allow closer contact for physical examinations, blood drawing, and of course minor and major surgical procedures. Despite everyone’s best efforts, we all realize that relaxation of these measures will lead to a certain amount of transmission of the virus with subsequent illness and fatalities (while we hope and pray for this not to happen).
As we progress towards the relaxation of these precautions, psychiatrists and other mental health professionals have been seeing patients via remote (usually video) techniques but also are considering returning to in-person face-to-face visits. Psychiatrists particularly as part of the medical profession feel a certain obligation to offer their best possible treatment to our patients and to support our colleagues. Many practitioners who have tried remote therapy believe that remote sessions are inferior to in-person sessions and feel an ethical obligation to resume in-person face-to-face meetings as soon as possible. In my opinion, this is a serious mistake. I believe that a careful consideration of all the factors will make a strong case for the maintenance of remote therapy sessions at this time and for this foreseeable future as long as there is the possibility of this deadly epidemic being present and perhaps beyond it.
Obviously, there are exceptional situations such as in consultation- liaison work, emergency rooms, certain crisis situations, drop in clinics, etc., although accommodations to maintain distant contact in these settings may be possible. There are also serious financial considerations to be taken into account, as remote sessions with patients may be reimbursed at a lower rate than face-to-face meetings. This situation needs to be immediately addressed by our various professional organizations and by the government.
Only a limited proportion of our consulting and waiting rooms can truly allow for a proper social distancing and a maintenance of sanitized furniture for the numerous occupants who will use it. We are often talking about two people sitting in a closed room probably barely six feet apart for perhaps 45 minutes directly facing each other and talking to each other (granted during psychoanalysis the patient faces away from the therapist while lying on a couch).
Many years ago, I asked an older supervisor (my age now), how he would feel if there could be a clear video connection and whether that could replace an in-person session. He said (something to the effect) “if you cannot smell the patient, it is not going to be effective treatment.” Our current experience with telepsychiatry has certainly disproved that view. Also if by some chance one or both of the participants in therapy are wearing a mask, certainly it is much less intimate than a crisp clear face on a large computer screen. Also when medication needs to be prescribed, that can easily be done by phone, fax, or electronically.
In addition, we should also take into account the travel time (as well as the potential exposure during such travel). I would estimate that the average patient spends at least a half-hour going one way from their location to my office in Los Angeles plus waiting room time. That total of about one hour certainly has value to the patient. I should also add that everything stated above applies to group therapy. Maintaining social distance for 6 to 10 people would require a very large room and telepsychiatry methods such as Zoom and other techniques have been proven to be very effective for group meetings.
In conclusion, remote telepsychiatry meetings are very feasible and effective and may very well save the health and lives of both the therapists and patients. There should be consideration of continuing this method of treatment throughout the full run of the coronavirus epidemic and perhaps into the future. It is also essential that our professional organizations play a very strong role in advocating and encouraging this technique being used by its members and also take a very active role in advocating for equal reimbursement for treatment by these techniques.
I appreciate the thoughtful discussion that this blog has been generating among colleagues. It has led me to write this addendum.
In order for remote tele-therapy to be utilized with maximum effectiveness two conditions must be considered:
- The patient and the therapist must be in a comfortable setting. In most cases this would favor using a computer or laptop screen as compared to a handheld i-phone. The participants would most probably be seated in a comfortable chair with or without earphones.
- It is essential that the session be taking place in a confidential manner. This may be difficult to achieve when the participants are at home and in a living or office environment with other people.
To the degree that these two conditions cannot be achieved, this would favor a resumption of in person face to face meetings when there is no longer danger to either patient or therapist of being infected by the deadly virus during travel to the session or during the in-person office visit.
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