Reconceptualizing Social Distancing: Teletherapy and Social Inequality During the COVID-19 and Loneliness Pandemics

Introduction

During our last meeting, my supervisor said to me (JGLH) “sometimes we’re all our clients have” as a response to my anxieties about doing teletherapy, or “psychotherapy by telephone . . . or videoteleconference” (Scharff, 2013, p. xvii). Because of the COVID-19 pandemic, public health institutions have recommended practicing social distancing to contain the spread of the virus and reduce its hastily increasing incidence. Social distancing is a public health intervention designed to diminish physical human interaction within communities in which individuals who may be infected with an easily transmittable disease and have not yet been identified. It becomes especially useful for the prevention of diseases such as COVID-19, since its transition depends on droplets entering people’s respiratory system (Wilder-Smith & Freedman, 2020).

As an ethical response to the pandemic, the clinic in which we practice cancelled all in-person sessions, rescheduling appointments as teletherapy sessions after receiving consent from clients who were informed of the possible limitations and risks associated with these services. This is an ethical response not just because it could prevent future transmission of the COVID-19, but because these social distancing practices are occurring amid a loneliness epidemic, and amid other social dynamics with negative psychological impact. Practicing social distancing could exacerbate preexisting feelings of loneliness, as we isolate further. This makes continuity of mental health care imperative during these times. Public mental health researchers are aware of the negative psychological impact that interventions such as social distancing and quarantines can have (Brooks et al., 2020), so preemptively addressing the long-term psychological effects of necessary public health interventions can reduce their negative impacts.

Loneliness Epidemic

Like COVID-19, Loneliness has been conceptualized as an epidemic by public health professionals, researchers, and institutions, including the 17th Surgeon General of the United State (Murthy, 2016) as research suggests that its prolonged experience affects about one third of people from industrialized countries (Cacioppo & Cacioppo, 2018). This experience has further physical and psychological repercussions. Among the biological effects of loneliness are “higher systolic blood pressure, body mass index, and high-density lipoprotein cholesterol . . . [and] increases the likelihood of early death by 26%” (Holt-Lunstad et al., 2015; King, 2018). Loneliness also affects mental health, as it has been associated with depression, personality disorders, psychoses, and even suicide (Hawkley & Cacioppo, 2010; King, 2018). Yet by treating loneliness as a risk factor for disease or as a disease itself, psychiatric and public health discourses medicalize it, rather than understand it as a profound human experience.

Humanistic psychologists and existential philosophers have historically engaged in a deeply complex understanding of the lived experience of loneliness. Many saw it as being part of the human condition (Heidegger, 1998/1927; Moustakas, 1961/2016; Sartre, 1998; Yalom, 1980), since “loneliness is a phenomenon that belong to life, to existence . . . ” (Dahlberg, 2007, p. 195). For philosophers like Heidegger (1998/1927) and Sartre (1998), loneliness presents to us through the absence of others. For example, even though some of us continue to be in communication with friends, family, and coworkers during this pandemic through technological advancements, their absence is still apparent by their remoteness.

Humanistic Psychologist, Clark Moustakas (1961/2016) also understood loneliness to be an essential condition of being human. It has been characterized by feelings of “emptiness, sadness, and longing that result from the awareness of one’s fundamental separateness as a human being” (Ettema et al., 2010, p. 142). This condition and its awareness are what Moustakas refers to as existential loneliness. With the rapid spread of COVID-19 and its ever-increasing mortality rate, the loneliness that may result from precautionary distancing measures can be exacerbated as it becomes more present in life-threatening situations, as death highlights our existential separateness (Lars, 1985; Sand & Strang, 2006). Distancing limits the ways in which many manage their existential anxieties, especially if one is to die of COVID-19 related complications.

Yet existential loneliness should not only be conceptualized through its difficulties, as one’s reactions to it are central to human being’s continual growth (Moustakas, 1961/2016). Moustakas pointed at the importance of accepting, tolerating, and engaging with one’s experience of loneliness. By doing so, clients can express their feelings and concerns about their aloneness and in turn gain greater insight and self-understanding, process how they wish to manage it, cultivate meaningful relationships, live more authentically, and ultimately leading to personal growth (Moustakas, 1972). On the other hand, those who do not recognize or engage with their loneliness might “stop feeling altogether and try to live solely by rational means” (Moustakas, 1961/2016, p.100).

It is also important to understand loneliness as a profound human experience. Moustakas (1961/2016) termed the awareness of our isolation and individual experience existential loneliness. By it he meant that loneliness is an essential part of being human and it is the acceptance of loneliness which he deems central to human beings’ own development. With the rise and spread of COVID-19 and the precautionary measures that have been recommended, clients are once again having to deal with the awareness of feeling alone. The existential loneliness has entered the awareness of clients once again and Moustakas approach to loneliness would suggest embracing it. There is profound power in clients accepting their loneliness since it expresses clients’ true feelings and concerns about their feeling-alone-in-the-world. It points to their growing edges as humans and how they are more able to tolerate their sole existence in times of uncertainty. Also, it gives clients tools “to face one’s essential loneliness openly and honestly” (p. 99); this is not to say without support of other people, but the experience of loneliness can feel individual at times. The danger of avoiding this existential loneliness by “fear, evasion, denial, and the accompanying attempts to escape the experience of being lonely . . . ” (p. 100) might lead to deeper feelings of isolation and numbness. Clients might become numb or avoidant to the idea that they might need help from others.

Another consequence of not dealing with loneliness is what Yalom (1980) calls isolation denial: a psychological defense in which a person seeks relationships and fails to acknowledge how they might serve as an escape from loneliness, since being alone may present a confrontation with oneself and one’s existence. People who experience isolation denial may live inauthentically as they become enmeshed with others. This might express itself in clients’ needing to fill their individual feelings of loneliness with others; by treating them as “tools or equipment” (p. 363). Yalom (1980) suggests that therapists should address clients’ isolation in a direct way to connect them with their fears and loneliness itself. As Yalom (1980) states “though interpersonal encounter may temper isolation, it cannot eliminate it” (p. 397). Facing isolation can happen when clients accept their fears around being or dying alone. Public health measures during COVID-19 have accentuated these issues for some, but could be fertile ground to explore client’s fears around loneliness.

Psychology as Human Science also allows us to comprehend loneliness critically as it understands that this, like any lived experience, is co-constituted by the person experiencing it, others’ existence, and the context in which the experience is embedded (Brooke, 2016). In this case, the so-called loneliness epidemic (or the global increase in people’s conscious experiences of loneliness) is occurring within neoliberal industrialized societies, which often adopt individualist ideologies, and are also highly affected by COVID-19 due to frequent international travel and highly dense populations. These ideologies reproduce social structures, practices, and discourses that negatively affect our psychological lives. For example, through two cross-sectional studies in European countries, Hue et al. (2019) found that people holding individualist ideals were more likely to experience loneliness than those who held collectivist ideals.

For Marx, these societies also alienate, or estrange people from themselves, from their community, and form nature (Fromm, 1961/2003). Contemporary human scientists such as Sociologist Eric Klinenberg (2018) was suspicious of these ideologies and wrote,

Today, two major causes of loneliness seem possible. One is that societies throughout the world have embraced a culture of individualism. More people are living alone, and aging alone, than ever. Neoliberal social policies have turned workers into precarious free agents, and when jobs disappear, things fall apart fast. Labor unions, civic associations, neighborhood organizations, religious groups and other traditional sources of social solidarity are in steady decline. Increasingly, we all feel that we’re on our own.

Prolonged periods of isolation due to social distancing and quarantines measures are then added to the policies, dynamics, and habitual practices within contemporary neoliberal societies.

Additional Sociopolitical Concerns

But this particular form of isolation is creating another set of issues. Many of those whose employment depends on them being physically present are unable to generate income as they cannot work for the foreseeable future or because they are being laid off. The sudden financial loss and insecurity during quarantines has been found to increase levels of anger and anxiety (Brooks, et al., 2020). People with low incomes, and people who experience long periods of unemployment often experience mental health issues and are more likely to attempt suicide than people with stable, better paying jobs (Kaufman et al., 2020). Furthermore, people who have kept their jobs and who are underemployed or with lower wages are less likely to have paid sick days (U.S. Bureau of Labor Statistics, 2019), health insurance, or seek health care services as they cannot afford them. Because of their precarious situation, many are forced to continue working. For these reasons, they are more likely to become infected, spread, and die from the disease (Fisher & Bubola, 2020). Like Klinenberg’s claims about ideology and the increase in loneliness, the conditions created by the socioeconomic aftermath of Neoliberal policies and practices worsen the COVID-19 pandemic and the lives of those most vulnerable to it (Fisher & Bubola, 2020).

Against Social Distancing

Because distancing and loneliness are both existential and socially embedded experiences, we (and others; Kort, 2020; World Health Organization, 2020) argue that practice of social distancing should be reconceptualized as physical distancing, as manifold social experiences and interventions can and should occur alongside the physical distancing of bodies in order to ameliorate the negative effects of the public health measures being taken to decrease the spread of COVID-19. Additionally, we argue that physical distancing is a collectivist prosocial behavior, as it prevents infecting others and minds those who are at risk of medical complications or dying. Unfortunately, recent research indicates how education, race and ethnicity, and social capital relate to being unable to properly practice physical distancing (Sharkey, 2020). These factors, among others, make it difficult for many to practice physical distancing as recommended since they need to continue working to afford their basic needs, work in health care, and need to reduce their psychological distress through accompaniment, among other issues.

Some neglect to keep physical distancing measures due to their individualist beliefs. For example, although the City of Pittsburgh cancelled the official St. Patrick’s Day Parade, many congregated in bars and other locations, one of them saying “I’ll live my life, I’ll do my thing and then address it if I have to” (Simonton, 2020). Other factors associated to neglecting physical distancing are political identity and not believing in global warming (Sharkey, 2020). Regardless, it becomes evident how one’s ideological beliefs partially influence choosing or not choosing to comply with physical distancing. It also becomes evident how sociopolitical and economic issues influence those who can or cannot participate in these measures, as they might have to be physically present at their place of employment.

On Teletherapy During COVID-19 Isolating Measures

As clinicians, we must recognize the value of teletherapy as a tool for providing continuity of care, and an opportunity for mutual accompaniment during a time of increased social isolation in which face-to-face encounters could be dangerous. Some of us will continue sessions as usual, while others might have to address the psychological consequences (and side-effects) of physical distancing, and fears related to COVID-19 infections. Isolation for long periods of time can lead to heightened states of anxiety—as community and social engagement are understood to be an ontological necessity (Jordan, 2017). Others might play out their usual modes of being through their reactions to current events.

Yet as the pandemic uncovers—or makes conscious—the inequalities that our clients are living through and how they play a role in their psychological lives, we must also be willing to actively engage with the political dimensions of our clients’ lives. Just as we often implicitly or explicitly encourage our clients to change their intrapersonal and interpersonal lives by developing increased personal and relational awareness, we must also allow for the development of a critical consciousness that “enable[s] [our clients] to choose action (or passivity) with respect to . . . the social structure” (Fanon, 2008, p. 80), as “the psyche determines its own historical determination” (Pavón-Cuellar, 2017, p. 15). Keeping in mind the sociopolitical issues that exacerbate the COVID-19 pandemic, and that could in turn be worsened by it, psychotherapy (whether face-to-face or teletherapy) can provide an experience for clients in which they can reflect on (a) how these issue affect them personally and (b) on the kinds of engagements they wish to pursue during and after the physical distancing measures in order to change not just their individual circumstances, but those of the historical moment in which they exist. Therapists from different traditions who are active in working on the sociopolitical dimension of suffering use distinct forms of engagement such as exploring how oppression and suffering are normalized and made unconscious (Layton, 2006, 2018; Russell & Bohan, 2007; Spurling, 2019), working through political dynamics that are enacted through transference and countertransference (Britton, 1989; Davids, 2011; Ferro, 2009; Gentile, 2013; Knafo, 1999; Spurling, 2019), changing negative thoughts that result from racist and classist discourses and experiences (David, 2009), acknowledging “the power of contextual factors [that] create psychological suffering” (Jordan, 2017), and identifying the clients’ (limited) agency within oppressive conditions (Frankl, 1992). Regardless of the theoretical framework, these approaches are not based on adaptation to the environment (Bugental, 1971), but on hoping to change the client’s awareness of their situation that will enable them toward changing their circumstances.

Barriers and Limitations of Teletherapy

We must also be aware of the barriers to teletherapy. For some, teletherapy is not being covered by their health insurance companies in the United States and its territories. When the crisis began, Medicare and many insurance companies across the United States did not cover teletherapy sessions. Fortunately, both Medicare and private insurance companies began covering telephonic or video-based psychotherapy sessions—although it is not the case for all companies and specific health plans. As the Puerto Rican Senate voted against a resolution that would have allowed psychotherapists to provide teletherapy, the Puerto Rican Psychological Association urged communities to join them in advocating in favor of this measure (Lozada Laracuente, 2020). Like face-to-face therapy, there are also financial barriers to providing teletherapy as well, as people with low resources might not have access to the Internet or own computers or phones, while others might not be able to afford psychotherapy or health insurance at all.

Teletherapy is no doubt an excellent response for emergencies such as the COVID-19 pandemic. It has also served in the efforts of increasing access to psychotherapy in places with limitations to local mental health resources (e.g., rural areas) and treating individuals with substantial disabilities (Gallego et al., 2017; Hines et al., 2019; Kingsley & Henning, 2015). Nevertheless teletherapy should not always replace the face-to-face therapeutic encounter. Using teletherapy beyond these contexts could pose the risk of eliminating the social activity and physical, embodied closeness that often facilitates healing. This modality, be it just audio or video, also limits the interaction to tone and moving images (which can at times be advantageous for language-focused theoretical orientations such as Lacanian psychoanalysis), restricting the presence and affective energy of bodies to a virtual realm. Some approaches to psychotherapy make use of changes in comportment and body language (Kingsley & Henning, 2015) by providing comments and feedback on these changes or on incongruences between what they are narrating and their postures or facial expressions. These approaches also understand the importance of the synchrony between the bodies of the therapist and clients in the process of psychotherapy (Koole & Tschacher, 2016) and outcome (Ramseyer & Tschacher, 2014). For this reason, we hold that face-to-face therapy should not be replaced, as it would further deny the psychotherapeutic process of its distinctive social and embodied nature. Where individualism and the loneliness epidemic are already having significant negative consequences, permanently replacing face-to-face therapy with teletherapy after these measures are over would further contribute to our overwhelming isolation.

Conclusion

Due to the physical distancing practices necessary to prevent the incidence of COVID-19, clinical psychologists and other mental health professions have been resorting to teletherapy to continue care. This is an appropriate ethical decision as it not only addresses needs of our communities, country and of the rest of the world, but it also serves as an attempt to diminish the negative psychological impact of the public health interventions. The pandemic is occurring during times of heightened social isolation that have resulted from Neoliberal policies and practices. This same economic model and capitalist ideology has created deep, ever increasing social inequalities between the rich and poor, affecting those who are more likely to be part of the latter; such as people of color, immigrants, women, and other underprivileged communities and countries. Because of the social distancing and quarantine measures, people are becoming even more isolated. The effects of these measures will also more dramatically affect those who were vulnerable to becoming infected, and who were already impoverished; who are more likely to experience depression and attempt suicide.

For these reasons, therapists must be prepared to work with client’s experiences of loneliness, possible fears of contagion, and with the social dynamics that could worsen their mental health. But as responsible psychologists cannot sit idly by. If we are truly invested in the well-being of our clients and society at large, we must also dare to advocate for our clients and for substantial social change that will decrease people’s suffering. This includes advocating for teletherapy coverage (and traditional therapy coverage, as we begin to prepare to leave these social distancing measures), and affordable services for those who cannot afford them. It also includes advocating for social programs that will address the socioeconomic result of this pandemic, which will assure the physical and psychological needs of the population.