Working with new patients
Seeing new patients for diagnostic evaluation is always best done in person, because the information I gain from the patient’s appearance, clothing, demeanor, gait, postures, gesturing, and facial expressions (among other elements) gives me important impressions I miss with video or telephone. In many cases, patients gain a sense of who I am from sitting in my office, and using the conference room eliminates that benefit. I attempted to create a warm environment in the conference room by obtaining lamps that produce warmer indirect light and hanging artwork that reflects my tastes. There are clocks in places that allow me and my patient to keep track of time. In meeting new patients by video, I get some impressions about their surroundings that add to the information I get through our interview. I have done many diagnostic evaluations during the pandemic and gotten treatments (whether medication, psychotherapy, or both) underway without discernible problems in the outcomes. Patients who started with me in person have mostly wanted to continue with in-person meetings, but as many have told me, interspersed video sessions save them travel time.
What about vaccination?
Once COVID-19 vaccinations were widely available, I assumed patients would be as eager to get them as I had been. When I began asking patients about whether they had gotten their vaccines, I was surprised to hear that a few were not going to get vaccinated, clearly based on political views and misinformation about the danger of vaccines. (The topic of political beliefs and their impact on psychological treatment is beyond the scope of this commentary.) I tried to counter obvious misinformation, repeated my recommendation that the patient get vaccinated, and then turned to other topics. I later decided to tell all patients that vaccination was required to enter the office. Only 1 patient who had been coming to the office dropped out, and she eventually returned to meeting by video.
COVID-19’s toll on the therapist
While the first several months of the pandemic were so full of uncertainty about the future, once vaccinations were available, it seemed cause for hope of a return to normalcy. As time went on, however, it became clear that normal was still a long way off. With vaccine refusal and new variants upending my naïve view that we were near the end, I began to feel aware of the impact this had on me, and began to focus on self-care (Box). I had always seen myself as unusually lucky to have a full practice, a supportive partnership with my husband, grown children who didn’t need me to homeschool them, a strong social network of friends who could share the burden and cheer each other up at outdoor gatherings, and a wonderful group of siblings and in-laws (all in different cities) who stayed in touch via video calls and quarantined in advance of getting together in someone’s home.
Box
Suggestions for optimizing self-care
Self-care has always been a requirement of doing psychotherapeutic work, and I encourage practitioners to be sure they are attending to themselves. We can’t be effective as listeners, empathizers, diagnosticians, and problem-solvers if we ourselves aren’t healthy. We evaluate our patients in terms of mood, outlook, sleep, appetite, energy, motivation, and energy; we also investigate their capacity for relationships that are sustaining. Self-care is the same, taking care of both our physical and relationship beings. Getting enough sleep, exercising daily, cooking healthy meals, and making time to relax are all ways of caring for our physical identities that should have been in place before COVID-19. Making personal time for ourselves in the face of constant demands for time from patients, colleagues, partners, children, parents, siblings, and friends never happens without the resolve to do it. As a psychiatrist who is used to sitting for up to 10 hours per day, I strongly recommend making a daily habit of walking, running, biking, or using an elliptical trainer, treadmill, or stationary bike for 30 minutes or more. Sleep is necessary for adequate concentration and attention to patient after patient. If you have trouble sleeping, talk with your doctor about remedies. If you use a sleep aid, I strongly recommend alternating medications so you don’t develop tolerance to any of them. Plan your food and cooking ahead of time so you aren’t tempted to order out. If you cook simple meals yourself (ideally with your partner helping or in range so you can chat), you will consume fewer calories, less sodium, and more nutrients. Even if you have a spouse and young children at home, work out a plan with your partner that allows each of you time for exercise or to recoup after a long day with patients. Babysitters allow you to take the time to be with each other that is necessary to sustaining a connection. Think about time for sexual intimacy if that has dropped off the calendar. Relationships with others, such as parents, siblings and their families, and friends are invaluable. The time spent with others might seem inconsequential, but is critical to our internal sense of security, even in the face of external disorder.
Staying busy and engaged with my practice, spouse, family, and friends kept sadness away most of the time. But I surprised myself a few months ago when I sat down to reflect and check in with myself. I felt enormous loss, resentment, and exhaustion at the privations of the pandemic: every trip to the grocery story felt dangerous. I hadn’t seen the inside of a concert hall, movie theater, restaurant, or museum in nearly 2 years. Travel for meetings and visits to family and friends and various adventures had been abruptly stopped. I lost both parents (not to COVID-19) during 2020; both were older adults living in senior communities that could not allow visitors. The usual grieving process would include attending services at my synagogue where I could say Kaddish for them, and video services were simply not tolerable.
Most of us have become experts at video meetings and likely have come to despise them. While our Institute has always held classes with some out-of-town students joining by video, with a very sophisticated system that provides excellent sound and visual fidelity, teaching entirely by video is another matter. I now teach students I have never met in person and might not recognize if I passed them in public. The art of creating discussion around a table is much more difficult on a computer screen. The first class I taught to residents during the pandemic was completely disorienting as I faced a wall of black screens with names and silence. Each student had turned off their camera and muted their microphone, so I was lecturing to a computer. That never happened again after I insisted on seeing everyone’s face and hearing their voices.
Thankfully, my usual experience of a long day seeing patients followed by chatting while cooking dinner with my husband and walking the dogs before settling down to read didn’t change. But the pleasure of sitting with patients was replaced by the daily grind of figuring out who will need a video link, who will be on the telephone, and who will come to the office, and it doesn’t feel the same. Again, in the big picture, I realize how fortunate I have been, but it’s been a big change in the world of the psychotherapist.