The Psychiatrist Will See You Online Now
Doctors and patients see gains and losses as psychotherapy goes virtual.
By Benedict Carey
years, Michael Raymos made the drive from Modesto, Calif., to Sacramento and back for therapy, and for the therapist, who could listen to stories of childhood abuse and gently unwind their hold on the present. Those regular office sessions, at a clinic at the University of California, Davis, created a strong bond, and Mr. Raymos came to rely on them to manage symptoms of post-traumatic stress and the emotional weight of a neurodegenerative disorder.
But this routine ended abruptly when the clinic went almost entirely virtual in response to the Covid-19 outbreak. Since then, Mr. Raymos has engaged in twice-a-month sessions on his computer or phone.
“There is a drop of social contact, not being able to always see his expression,” said Mr. Raymos, 49. “There’s more of an intimacy level when you’re one on one and that office door is closed. But there’s a comfort level at home. I’ll sit there in bed with my dog, Bug, on my lap, and that comfort allows me to talk about things I maybe wouldn’t have in the office, because of how painful they are.”
The coronavirus pandemic has forced medical centers around the world to partially adopt telemedicine, with varying results.
Psychiatry is a special case.
Experts had said for years that the field’s most intimate treatment — psychotherapy — was poised to go largely virtual, for many or most patients, forever altering day-to-day practice. In the extraordinary year of 2020, they were proved right.
Last March, federal health officials loosened restrictions on practicing across state lines, and began to expand reimbursement. Clinics across the country went virtual. The number of virtual mental health visits in the sprawling V.A. Health System jumped more than sevenfold, from 7,500 to 52,600, in just the first two months of the U.S. epidemic.
“Overnight, everyone began practicing telepsychiatry, with physicians in New York, Texas, California able to reach their patients, wherever they were,” said Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center, a Harvard affiliate.
Many Freudian-based therapists have been skeptical, concerned that going virtual might weaken a therapeutic bond built through the shared physical space of analysis. Others worry that a rich dimension of body language is lost in video interactions.
“In terms of trauma, one of the things many of us track is micro-expressions, these flickers of emotional tone, when people are talking,” said Dr. Andres Sciolla, a psychiatrist in the U.C. Davis clinic. “I cannot tell you how many times I have noticed a flicker of tears or fear in the gaze of a patient, perceived a shift in feeling, and explored that — and found a lot behind that change.”
Not everyone who could benefit from psychiatric care is a candidate for the virtual variety. For people who are deeply delusional, who are scared, paranoid and alone, for instance, a video call in these situations can be an invitation to confusion, or much worse.
But for now, in this moment of shared anxiety and uncertainty, the seal on telepsychiatry has broken.
Dr. Peter Yellowlees, the senior psychiatrist at the
U.C. Davis clinic, said: “Your home is your space. It’s more egalitarian, less stressful. And potentially you can turn the device off and end the session, if you really wanted.”