We are nearing the end of our sixteenth week providing therapy services exclusively through our HIPAA-compliant Telehealth video portal. 

Can you believe it’s been that long?? It’s been a joyous experience meeting people’s pets and children and seeing clients in their home environments. Most clients have adapted well, expressing appreciation for the convenience of commute-free sessions, insurance coverage, and valuing the ability to continue therapeutic relationships throughout the pandemic. For a few clients, “it’s not quite the same” and “we miss Courtney and your office” reflect the experience. Telehealth has emboldened many new clients, as it has presented a less intimidating way to seek therapy services during a time of heightened mental health stressors. 

As our city begins a cautious trial of relaxing physical distancing restrictions, we are making decisions about the exclusive use of Telehealth in our practice. We, too, are choosing to exercise caution in transition.  

We have given thought to the preventive measures needed to safely conduct in-person therapy. Of course, we are mindful of the infection control recommendations specific to healthcare settings, including practices such as staggering appointment times to minimize clients’ waiting room exposure to one another, room sterilization between appointments, increased hand washing and sanitation, not sharing writing utensils or touch screens, and temperature checks upon arrival. 

We find ourselves in agreement with epidemiological experts. Everyone’s health benefits if services open gradually and are well-prepared for closure if we see another spike in infection rates. This is particularly true in a city such as ours, without precedent for knowing the influence of relaxed physical distancing practices.  

We recognize that many of the businesses preparing to open do not have the option of offering services electronically or through curbside accommodations. (Online haircuts or drive-through tooth extractions, anyone? How about curbside chiropractic adjustments?) We believe we can best support fellow community members who do not have the option of online service delivery by continuing to practice Telehealth ourselves, reducing exposure where we can. We have ample evidence that Telehealth is a successful means of providing mental healthcare. Doing our part for a while longer contributes to fewer community exposures for 250 of our clients per week, as well as our 6 clinicians and 3 other staff members who would all share the same space with these clients. 

We remain concerned that if a client were to be contact traced back to our office for a positive COVID-19 exposure, even though anonymous, their confidentiality may be jeopardized in a way that remains unclear. As practitioners charged with fiercely guarding privacy, we need more information on the contact tracing protocols and procedures. 

In making the continued Telehealth decision, we gave thought to the preventive measures needed to safely conduct in-person therapy. Of course, we are mindful of the infection control recommendations specific to healthcare settings, including practices such as staggering appointment times to minimize clients’ waiting room exposure to one another, hand sanitation, not sharing writing utensils, and temperature checks upon arrival. We are considerate of the staff and clients who are immune compromised and prioritize their health at every opportunity. 

Specific to mental health therapy, we note the recommended precautions include increased physical distance between therapist and client. Although not optimal, we consider this a manageable modification in which a positive outcome can still exist.  

However, one recommendation keeps arising as a barrier toward effective in-person therapy:

THE MASKS. 

Sitting at least six feet apart, the therapist and client would both need to wear masks for the entirety of the session. While this is currently an important practice in daily life, we believe that masks will serve as a barrier for conducting effective psychotherapy sessions. Therapy is about experiencing being seen and releasing the metaphoric masks, and physical masks will contribute to just the opposite.  

• First, the amount of nonverbal information conveyed by facial gestures and micro-expressions is particularly relevant in mental health therapy. We would rather see a client’s face fully expressed on a screen than covered by a mask in person. We are also quite certain that clients would prefer to receive the information they look for when briefly glancing up for a gauge on our response to their latest statement. If clinicians were masked, clients would be unable to quickly discern our expressions. Clinically speaking, that missing element could go wrong in multiple ways, none of which contribute to therapeutic attunement between our clients and ourselves. 
• Second, people cry in therapy. Let’s get real here. People blow their noses in therapy. (And on a particularly good day, this kind of healing happens a lot!) When thinking about the presence of masks, we must also consider the “masks-and-glasses-and-fog” (oh my) problem. Overall, for mask wearers, the use of tissues becomes problematic, as it involves removing the masks, touching the face, releasing aerosolized micro-droplets, and results in a trashcan full of used tissues. Add the foggy glasses (you try crying in a mask without the fog happening!) and there is more face touching, cleaning glasses, hand sanitizing, etc. Ordinarily, we have zero problems with any of these expressions of healing, and in fact, we gently prompt crying whenever possible. However, given the unique ways COVID–19 spreads, it seems prudent to wait until infection rates diminish further before re-introducing these potential modes of transmission back into the therapy room.  
• Third, masks present an intense problem for some people with asthma, autism, COPD, sensory processing issues, trauma, panic and anxiety disorders. To intentionally worsen a symptom in order to receive therapy is not the kind of therapy we practice at Kindred Psychology. We are guided by the tenant of “first, do no harm,” and in this case, the most beneficial and least harmful way forward seems to be continuing Telehealth for another month.  

Everyone is going to have a differing response to this decision and we welcome all opportunities to discuss your perspectives and needs. Know that as with every decision that influences our community, we carefully researched and contemplated this decision. We choose to wait until the end of June to re-evaluate our return to in-person sessions, exercising caution in transition, as the best available choice for the good of the whole at this time. We look forward to seeing you on screen in the upcoming weeks!

Camie Nitzel, PhD LP