Patients and therapists have suffered from the pandemic, but some have benefited.
Aleena* was halfway through a series of cognitive behavioural therapy sessions at a small NHS clinic in London, where she was finishing her last year of university, when the pandemic forced her to travel back to her hometown in Pakistan. Now she has to sneak off to her bedroom for sessions that, due to the time difference, interrupt her day. The sudden changes in her routine caused a definite setback, with her weekly mood chart showing significantly elevated signs of depression and anxiety.
The impact of the pandemic on mental health has been the subject of much discussion. But more needs to be done to address the needs of those who saw their therapy disrupted by a sudden change in daily routine and geographical location. Like the pandemic, the interruption in access to mental healthcare is a global problem. Aleena has not been able to return to the routines that had started working for her. She worries that she never will.
Some have had better experiences in navigating a more flexible, hybrid work-life balance that brings together online work and in person experiences. Dr Becky Clark, a licensed clinical social worker and psychotherapist based in New York, said that some of her patients benefited from flexible scheduling and the convenience of remote therapy.
Dr. Naomi Graham is an occupational therapist and founder of Growing Hope, a Christian charity based in London that provides free services for children with special needs, including therapy. By working with families and school services, the charity created successful hybrid models that have worked for their patients. They expect more families to come in for help as the pandemic’s toll on mental health continues to grow. For families isolated from support networks while living with digital poverty, the pandemic has been particularly difficult, said Dr. Graham, noting that “not everyone has been able to move online the same way.”
For some, digital poverty means being unable to afford phones, tablets, computers or the monthly cost of an internet service provider. For others, particularly older people, it manifests in a lack of internet skills. For these reasons, Dr. Clark said, many of her patients had decided to wait out the pandemic and return when in person therapy was possible.
Cultural contexts and experiences vary, but the need for good, consistent mental healthcare remains constant. Even without the complications of the pandemic, therapy still remains a sensitive, and in some cases even taboo, topic. Now it’s become a double edged sword—need is increasing, but access and availability are more complicated than ever.
Dr. Clark said that her experiences with online therapy has varied greatly from patient to patient. An additional challenge for those in the United States is the constantly changing and often confusing status of federal and state regulations governing teletherapy. This has been an issue for people who had been seeing a therapist in one state but were sheltering in place in another.
Angela, a recent high school graduate in Canada, was one of those who managed to continue with her therapy sessions, but she says online therapy came with its own challenges—chiefly, a loss of privacy and fear of being overheard. This, she said “…significantly impacted the quality” of her sessions.
For those who are in therapy to deal with domestic problems, a therapist’s office can be a safe haven. Switching to home sessions often means that young people like Angela find themselves self censoring for fear of being overheard. According to digital privacy expert Jo O’Reilly, “this type of environmental privacy concern is something that patients and therapists must discuss to ensure that sessions are carried out in as much seclusion and privacy as possible, using headphones, or code words when required.”
But these adjustments are not always sufficient for many, particularly for those in the most difficult and precarious domestic situations.
Palwasha lives in the city of Peshawar in Pakistan. She has been in therapy for both depression and grief counselling for more than four years and was already familiar with online sessions, since her therapist is based in Islamabad, which is over two-and-a-half hours away by car. But being unable to visit Islamabad at all during lockdown— previously she had visited as frequently as once a week when needed—made therapy that much more difficult. “In person [therapy] is much better because it allows you to leave home and come out of your shell. This is especially important for someone like me who feels trapped by her circumstances and is a survivor of domestic abuse. COVID has been particularly hard for me,” she said.
Therapists have also suffered. According to Dr. Clark, many of her colleagues chose to close their practice, while those who stuck it out, as she did, have been paying full rent for empty clinics. The reliance on digital communication has also had a negative impact on her own mental health. “Extended meetings can cause physical and mental fatigue from sitting and working on a computer screen for five to eight hours per day with patients,” she said. She misses the intimacy of in-person therapy, adding: “Nonverbal cues are [more] limited online than in person.”
Unsurprisingly, patients and therapists in countries where the pandemic has subsided somewhat have celebrated the return to in-person sessions. After six months of teletherapy, Angela was in her comfort zone, opening up and connecting in her therapist’s office in ways she hadn’t been able to online.
Others have observed an upside to online therapy. Dr. Graham of Growing Hope explained that certain children, particularly those with special needs, have actually responded better to remote therapy sessions from home. For these children, “online therapy meant they were in their home environment which made them feel safer and more comfortable.” While they still prefer in-person sessions, she and her fellow therapists are now planning to be more flexible, adjusting to the use of online therapy for those who prefer it, even as their clinics have started re-opening.
Jen, whose autistic son is non-verbal, decided for his safety to continue with at-home therapy through Growing Hope. “Although this was the right decision, it was really hard for Jen having to care for her son 24/7 without any support,” said Dr. Graham. But it was during those online sessions that her son learned to eat with a spoon unaided. Growing Hope stayed in touch virtually with the young boy’s school as it reopened, which made his transition back to the classroom much easier. By managing the boy’s therapy and relationship with his school online, Jen and Growing Hope opened productive new avenues to help him.
The past 15 months have provided some positive lessons. “We have seen that digital support can be beneficial, but we also know it doesn’t work for everybody. We want to first and foremost tailor our therapy to what the individual and their family needs,” said Dr. Graham. As patients return to in-office sessions, it’s important that these more flexible arrangements become better defined and that patients are kept informed of their options, whether they be in-person or remote. Now they must begin the work of healing from the trauma of the pandemic year.
*All the patients’ names have been changed to protect their privacy.