How my patients and I struggle with remote mental health treatment during circuit breaker

The Ministry of Health’s (MOH’s) decision to classify face-to-face psychological outpatient treatment as non-essential care that is not allowed during the circuit breaker period has led to some concerns being raised that this could adversely affect the well-being of patients in need of such treatment.

There are merits to both the Government’s move and of the arguments made by those who feel that outpatient mental health services should remain open.

As a psychologist in private practice, I have come to accept MOH’s decision but would like to share my experience in how it has affected me and my patients.

Before I begin to address the topic of online psychotherapy and its usefulness or failings against a backdrop of some of my personal experiences, perhaps it may be pertinent to shed light on the nature of psychotherapy and illuminate the role psychologists perform, traditionally.

A session with a psychologist is an intimate one, wherein a patient is encouraged to share some of his deepest fears and struggles.

Collaboratively, he works with this trusted person toward resolving some of these issues. This can work only when there is trust. Where does this trust come from?

It is precisely the “therapeutic alliance” TODAY reader Jonathan Kuek referred to in his recent letter to Voices.

He said: “Therapeutic alliance, the single strongest predictor of therapy success, can be challenging to build or maintain via online means. Not everyone can form such an alliance in this manner”.

Indeed, a strong therapeutic alliance requires the consolidation of various factors, including obtaining a sensing of the person, which is largely visceral and usually happens in a face-to-face setting where both are in the same physical space.

With virtual care, it can be difficult to assess a person’s physical and psychological state, and this is compounded by the secretive nature of certain mental illnesses which causes patients to at times be untruthful or to downplay their symptoms and behaviours.

Psychologists have to rely heavily on patients’ self-report measures during the circuit breaker, or the (again, not always accurate) feedback of a loved one living with the patient, and so a patient’s decline may not be easily picked up on and some may fall through the cracks.

In my online sessions, I’ve found myself squinting at the screen tirelessly, so as to catch (as best I can, over a screen) my patients' body language, which would prove to be clinically informative for me. Things I look out for: An uncomfortable shift, raised eyebrows, tear-stained cheeks, an empty gaze or a feeble smile.

I sure hope I did not miss anything or made any wrong assessments.

Certain skills which psychotherapists are equipped with in their training also involve the use of the physical space, which cannot be easily replicated over a screen.

Child psychologists use play-therapy, along with other tools of sensory nature.

Some use diagrams and handouts, where both therapist and patient work collaboratively on a piece, in real time. There is the use of chair-work (the classic Gestalt “empty chair” technique) during which a patient faces a chair and speaks emotively of his thoughts and feelings toward a person he perceives conflict with, as a means to promote healing.

The physical space is indeed powerful in the process of healing and recovery.

Many patients only feel safe within the confines of their psychotherapist’s consultation room, which is why many therapists go to great lengths to make it as private, comfortable and conducive as possible.

In this circuit breaker period, patients may also be confined to their homes with the very family members who may have abused them or been a source of distress to them at some point or another.

For those who share rooms with family members, where would there be a safe place to participate in a consultation, away from the prying ears of their family members? There may be no such safe place in the house.

In addition, some may feel uncomfortable or embarrassed even, to have their home surroundings or conditions viewable via video consults.

Just the other day, during a video consultation, one of my patients had to stifle her cries as she did not want her mother to overhear her in distress, resulting in her being unable to fully let out her pain through the cathartic act of crying.

Another had to lower her voice to a hushed whisper as she elaborated on a sensitive topic as she was worried that her father, whose room was next to hers, would be privy to the content discussed.

While for those comprehensible reasons I could not ask her to raise her voice, I struggled to make sense of what she was trying to tell me.

There are also privacy and technical issues associated with tele-consultations that could similarly result in  crucial therapeutic moments being lost.

Having said all of that, there have been studies that show that online forms of therapy prove just as effective as face-to-face sessions, and during times like this, some access to your therapist (albeit in a less-than-ideal manner), is better than none.

I say this, too, because online therapy is not entirely new to me — pre-coronavirus days have seen me taking to this platform for pre-existing patients who subsequently re-located.

Having already developed a good relationship with me, they preferred the option of converting sessions with me to online consultations versus starting over with a new therapist.

In some cases, there were no viable alternative options at their physical location.

During this circuit breaker period, one of my patients shared that she had found it “awkward speaking about such intimate feelings to an ‘inanimate object’, even if someone was sitting across the other side”.

But toward the end of the session, she felt “rejuvenated” and “recognised that this was only possible because I already had that established relationship with my therapist and trusted her fully”.

Also, some of my patients who are predominantly introverts and homebodies have welcomed this, as they can now connect with me from the comfort of their homes.

On a personal level, I have struggled with the transition to online platforms for the delivering of my services.

I have found it both disconcerting in that I may be providing a less-than-ideal service, and also exhausting in that video and phone consultations require a lot more focus and attunement to non-verbal cues and nuances that would be much more easily picked up in a face-to-face setting.

Emotionally, I struggle to really be present for each patient. What had previously helped in face-to-face sessions was my physical presence.

The use of my body language and facial expressions to display empathy and warmth which had previously been effortless, was now an effortful undertaking.

The sense of helplessness when I saw my patients painfully bawl their eyes out was difficult to swallow — I could not be there for them; I could not offer them a tissue, a pat, or in some instances, a hug.

In essence, what has been ultimately exhausting and disconcerting for me is battling the dissonance I feel between the overwhelmingly emotional work that I do and the presently-necessary cold and impersonal nature of delivering it.

Given that the circuit breaker period has been extended to June 1 and there is a possibility that online consultations will be necessary for some time, I, alongside my peers, will have to make the best of what we have.

ABOUT THE AUTHOR:

Dr Kim Lian Rolles-Abraham is Senior Clinical Psychologist at Better Life Psychological Medicine Clinic.