Challenges of the pandemic

The Covid pandemic has created multiple challenges to the workings of psychotherapists in many settings-both qualified therapists and those in training. Over and above the personal impact on each therapist and each patient – including the risk of catching the virus and being sick or even dying, the fears about loved ones, the social, family and economic impact on each individual – there have been specific questions posed about the manner of work, how to continue during the pandemic and the impact of necessary modifications on the working life of a therapist.

Therapists have been on a continuum of flexibility vs rigidity, ability to ‘embrace’ remote work vs anxieties about this embrace. And the different positions have not been predictable, nor have individuals stuck to a particular ‘pole’ as time has gone on. Whilst initially it seemed the pandemic might be short lived, and modifications could be seen as temporary, as the months have proceeded we have all had to modify our expectations and working practices. And the ‘polarities’ have not been easily predicted by generational factors or other obvious predictable factors, for example, ‘older’ therapists are not necessarily more resistant to working remotely, or to adopting the new technologies.

Boundaries are crucial in therapy, as are boundary violations. Patients do not usually see into our homes, and nor do we into theirs. Yet working with Zoom has allowed this, and raises questions of what we show and hide, and also what we are invited to see. Does the patient attend the session from a neutral place, and wear neutral clothing, or do they ‘show us’ all sorts of aspects usually hidden from view – their homes, their bodies, various states of bodily exposure, as well as other people-children or partners, as well as pets? And does the therapist wittingly or unwittingly do something in parallel, exposing more of their private self than previously?

A further observation has been the increased ‘activeness’ of the therapist when working remotely, be it on the phone or Zoom. Silences which would usually be tolerated in the room, are often broken much more quickly when working remotely. Some colleagues have noticed a tendency to ‘chat’ more, or to use humour more, or to lose a certain discipline or ‘strictness’, perhaps in part due to the therapist too craving some more ‘human’ contact in the face of isolation and remoteness.

We have conducted a QI project (Quality improvement) locally (in the Adult Complex Needs Department of the Tavistock Clinic), wherein we are interviewing a number of staff members about their personal experiences of working during the pandemic, and in parallel there is a project focussing on patient experience.

No doubt the findings will be mixed. Whilst working remotely has been challenging, and some patients have opted to defer or abort therapy until face-to-face work can resume, for others it has been extremely helpful especially during this time of isolation and anxiety. Indeed for some who are struggling with issues such as shame, or extreme social anxiety, remote working without face to face contact appears to have been truly facilitating.

What about the time when the pandemic is history? Most of us are anticipating that some work will continue remotely, and this might be facilitating to patients who struggle to travel, or are ill, or live far away. The challenge is how to discriminate between those for whom it will be truly helpful, as opposed to those ‘hiding behind the phone/computer’ who in all likelihood would better be served by confronting their anxieties in the consulting room. In addition, economics will play its role. It is cheaper to provide a service where patients can be seen from a therapist’s computer or phone, than providing rooms and buildings. The fear some of us have, is that this economic factor will ‘trump’ patient care. We are hoping that what has been learned during the pandemic can be retained and built upon, both, the value of remote work but also the importance, and the benefits of the immediacy, and the intimacy, of working in the same room as our patients.