On Masks, Goggles and Screens
I must begin by stating that I am old. At 60, I was trained in a certain approach to the practice of psychiatry. One of the first lessons learned was the need to make the space welcoming and to remove barriers that would interfere with the development of the therapeutic relationship. Chairs were to be close but not too close, and at a slight angle. There were to be no desks between you and the patient. In sharp corners of table were considered problematic since they connoted an almost violent separation. As senior residents, we took great care in the set-up of our space to ensure that the patient is comfortable and this tradition has continued over the next 30 years.
I understood the need to embrace technology with the coming of the electronic medical record and knew that it was a matter of time before this would become more common. I applauded tele psychiatry as a way to provide care in areas where there was a lack of trained mental health providers. I also felt that it would have a minimal impact on me personally. I have been providing care face to face for years and did not see any reason why I would stop. Younger faculty was interested in the new technology and began creating these services. While this work was occurring I would sit in my well-worn armchair and conduct my individual sessions the old fashion way.
In March of 2020, everything changed. COVID-19 created a reality where tele psychiatry was required in order to ensure the help of the patient and the provider. I bought a Chromebook, signed up with Doxy.me (a tele psychiatry platform), and began doing virtual sessions. Within a month, I adapted to the new normal. I was at least able to see my patients face. For psychotherapy it removed the ritual of the in person session but with time I was able to create some rituals. I would of course ensure that I was dressed to go out of the house. No loungewear allowed while doing tele psychiatry. I had to set up an area where my cat would not leap on the keyboards and disconnect the session, but otherwise it was an easier transition than I would like to admit.
By August of 2020, with the curve “flattened” in New York, clinics began to open, and our inpatient census began to rise again. Nevertheless, despite the opening of the clinics, we were still required to take precautions. Both the patient and the clinician needed to be masked and most recently, the clinician needs to have a N95 mask and either goggles/or face shield on. We became even more distant from our patients and barely able to read the others facial expressions. For psychotherapy, it felt more distant than using tele psychiatry and I stopped seeing psychotherapy patients in person. My psychiatric inpatients however had to be seen while wearing the full PPE. I wondered what it must be like, admitted to an inpatient psychiatric service, staring at people who are dressed the way we were. You could not see our lips move, could not tell whether we were smiling or frowning. The goggles and face shields interfered with the ability to see our eyes. We were truly “blank slates” that the patient could project their emotions onto; however, this is at times terrifying for our most vulnerable patients. I wonder how a paranoid individual can feel comfortable in this environment.
I come to be with people via screens or hiding behind PPE. I realize that this is required and will continue to so until the pandemic is tamed and I am told it is safe for others and me. However I miss being with patients. I miss walking around on an inpatient unit, sitting across from a patient and chatting. The informality of the action allows me to make a deeper human connection. It is easier to see a person as a patient from behind a screen or PPE. It is more personal to sit with someone and allow them to see your facial features. Allow them to see whether you are fidgeting. Allow them to see your choice of clothing for the day. It allows me to see the same things. It allows me to smell things. Did they shower? How much cologne do they wear? Did they dress up for the appointment? What does their style say about them? Did they gain or lose weight? Did they sneak a drink before they came in? Do they smell of stale cigarettes? I can also feel the cold sweaty palm of anxiety. The weak shake. The avoidance of any touch. All these things were once a part of the treatment setting. It was once a multidimensional world and these various dimensions became a central part of the therapy.
There is no real answer. This is just one of the things that I miss due to the pandemic. Like many others I miss my family, I miss live music, I miss crowded restaurants, I miss movie theaters. I knew that I would miss these things but I am struck by how much I miss being in the room with a fellow human being and providing care. I like others felt that the screens would be ok. The goggles would be ok. In the end, they are necessary, but imperfect.
