Age of COVID: Health, Sensibility, and Rationalization

Ultimately, who we are is shaped by what we know and by our psychology.

I've seen most people for psychotherapy face-to-face at a 10-12-foot distance in Uptown Charlotte, NC, since Governor Cooper imposed lockdown phases. Other sessions in NC are online. Flying from NC to a NY practice is not possible since Governor Cuomo prohibited travel of North Carolinians to New York without quarantine for two weeks in New York. Treatment for all New York patients is via video sessions. I have licenses in both states as well as California.

Where each therapist and patient draws the line of comfortable and appropriate behavior in the era of COVID-19 is often a complicated and contradictory matter, particularly when treating eating disorders.

Decisions about face-to-face contact, in general, are based on adherence to recommendations made by the CDC and state mandates. The individual psychology of both the therapist and the patient also influence the decision. Some patients and therapists are comfortable in person at a distance; some are ardent in their decisions to go completely virtual.

Recommendations made or laws imposed are essential as we face this worldwide pandemic. Social distancing, masks, hand washing, isolating when feeling symptoms or after being exposed to someone who has been sick or exposed help control the spread of the virus. Some therapists have underlying health issues. Most therapists are deeply concerned for the health of many of their patients, particularly those with medical vulnerability; blanket policies to see everyone online control for all physical illness possibilities.

Sometimes, however, superego constraints (fear of being punished or what others think), anxieties of all sorts, shame, concealment, and convenience are hidden motivators. Contact is avoided at all costs in some circumstances, while under other conditions, social contact is rationalized. Someone might attend an awaited gathering on one day but avoid recommended walks on other days under the guise of fear of contracting the illness. Rationalizations to suit our psychological needs are made every day about many things, not just COVID.

What are some of the considerations that determine whether to see patients in-person versus online? How do therapists who treat some of the most vulnerable patients, those with eating disorders, decide what venue is most appropriate?

An increasing number of articles and research about the effectiveness of online versus in-person therapy is available (Stoll, 2020). In one review, the authors cite the pros and cons along a continuum of care issues, including legal, technological, licensing, and cultural variances. They discuss subjective fields: clinical concerns about the illness's nature and patient/therapist dynamic issues.

This post concerns the decision to utilize virtual versus in-person psychotherapy when confronting issues regarding the nature of eating disorder illness and the impact on the therapeutic relationship.

Along therapeutic lines, the pros of online therapy are:

• It affords vulnerable populations—i.e., disabled, low socio-economic, and older individuals, and patients living in remote places—access to care.
• It allows for greater anonymity and privacy, which can increase openness in discussing emotional issues.
• Treatment can be made available for specific psychiatric conditions, like Agoraphobia and severe anxiety.
• Greater access to a clinician who has the specific expertise to match a patient's particular issue is made possible.

The cons to online psychotherapy involve issues related to the severity of illness and the effect on the therapeutic relationship.

Communication issues, which include the absence of non-verbal cues, can lead to misunderstanding and misrepresentation, affecting the assessment, diagnostic, and treatment processes. The expression of feelings like empathy and genuine caring on the part of the therapist and the patient's ability to authentically convey deeper emotions like sadness, anger, and shame can be compromised. Is the "attachment" process, therefore, compromised?

Some physical and psychological characteristics, mainly when patients are severely ill or have conditions that threaten their physical well-being, cannot adequately be assessed online. One of the primary ways to determine a patient's physical stability with Anorexia Nervosa is to be with them in person; their entire body is visible. Layers of clothing cannot mask the emaciation beneath when sitting face-to-face; a slight twist in the sitting position reveals a protruding clavicle or hips. Micro-expressions, paramount in face-to-face psychodynamic treatment, are more difficult to perceive and identify online.

Safety and trust are paramount for all patients; eating disorder patients are no exception. This relational trust will allow a patient to report honestly and openly about their symptoms or allow emotional regression to occur.

Relying on the patient to be rigorously honest implies that the patient trusts and counts on the therapist not to judge or become an alarmist. Does trust build as quickly or similarly when the therapist cannot readily assess the physical appearance, cannot read non-verbal cues, and has a barrier (the computer) interfering in "attachment?"

Eating Disorders Essential Reads

The Quiet Radicalism of Looking After Your Body

Hope and Hesitation in the Journey of Anorexia Recovery

Loss of intimacy between the patient and therapist can occur simply because physical proximity enhances closeness. Attachment issues are further compromised. Looser boundaries more easily occur when there is less control over physical space and parameters. A child knocks on the door, the doorbell rings, the dog barks. These factors are often distracting and can be disruptive when a patient is in the throes of an emotional experience.

Whereas online therapy may allow a patient, for instance, with Agoraphobia, to have access to care, the possibility exists of reinforcing fears further and increasing disability.

Treating Eating Disorders: Pros and Cons to Online vs. In-Person Therapy

Long before COVID, I wrote a post on video sessions in treating patients: "Treating Eating Disorders the New-Fashioned Way." I wrote that it seemed "antithetical to a practitioner who believed and continues to rely heavily on Object Relations and Attachment Theory in understanding why people turn to eating disorders and other self-harm or self-defeating behaviors... How could trust be maximized with a patient if the patient and therapist were in separate places?” I contend that there is no substitute on par with face-to-face treatment for patients with significant eating disorders.

Amidst the pandemic, patients who have recovered from an eating disorder's inexorable symptoms face a relapse. Some middle-aged people are in the throes of an eating disorder for the first time. COVID-19 and life's other relational, psychological, economic, and political challenges are impactive in unprecedented ways.

Mental health experts warn of significant increases in depression, suicide, and other mental health conditions. Socialization and connection to friends and family are the sine qua non of what makes us human, the need for relationships. The loss of connection has left people feeling isolated and reevaluating significant aspects of their lives.

COVID Retreat

Getting adequate treatment is possible but hampered by COVID. Many major eating disorder residential and out-patient programs provide services entirely online, a notion ill-considered before the pandemic but now considered routine. However, the risks of not physically seeing eating disorder patients are worrisome, especially in the early stage of serious illness.

Many psychodynamic therapists practice within what is known as the "analytic field." This field is an environment, space that encompasses physical, metaphysical, verbal, non-verbal cues, including smells, ticking and placement of a clock or proximity of a window, and the dynamic and interpretive interaction between patients and therapists. The essential elements of the "analytic field" cannot be replicated online.

Is it possible that a computer is a tool or vehicle to reduce anxiety and ultimately support relational ease? Yes, it is as I have seen it time and time again. There is a benefit to video sessions for some individuals with eating disorders who present with high anxiety. The computer provides buffers as it creates a barrier; the patient and therapist are not in the same room. Eye contact, often difficult for patients with eating disorders, can be more comfortable and more "natural."

Can virtual sessions be a complete solution for patients with severe eating disorders? Not likely. Can online therapy, even in the early stages of recovery, be useful? Yes.

The bottom line is that some care is better than no care. Expert care for the treatment of eating disorders is essential and ought not ever to be compromised. Seeing an expert online may trump seeing a non-expert face-to-face, despite the potential for missed cues and decreased intimacy. That which may be missed by a non-expert may be worse as limited knowledge and training about etiology could negatively impact treatment and, therefore, patient recovery.

The promise of a vaccine for COVID in the near future is encouraging. Some therapists may continue to choose virtual sessions over in person. Caution is advised when considering online care for patients in the early stages of eating disorder recovery; consider all the decision ramifications.

Every day, practitioners make decisions regarding safety in this pandemic era. Following health protocols is essential; defining other details involves more subjectivity.