Saadia Sediqzadah is a psychiatry resident at the University of Toronto and recently completed a master’s degree in health policy at the Harvard T.H. Chan School of Public Health.
“What would Freud say?”
I ask myself this question regularly right now, as my training as a psychiatrist has been suddenly catapulted into the digital age by COVID-19. I am (for the first time ever) providing mental-health care over the phone and the internet. “Seeing” my patients has taken on a whole new meaning in the era of physical distancing.
As a resident, I have completed hundreds of hours of supervised psychotherapy. Thus far, my training has been rooted in the expectation that the patient will “present to clinic” in person. There are a number of reasons for this: One part of psychotherapy consists of behavioural training, or “behavioural activation.” The simple act of a person with a mental illness getting ready, leaving their home and showing up for their appointment has many mental-health benefits.
Another reason is tradition, dating back to Sigmund Freud and other psychoanalysts. We are taught that a significant portion of the work in psychotherapy is in analyzing the relationship between the therapist and the patient. In an interaction with a psychiatrist (or, I would argue, any physician), there is both transference and countertransference between patient and service provider. Transference is the redirection of the patient’s feelings about a person in their life (such as a parent) toward the psychiatrist. Countertransference is the psychiatrist’s feelings toward the patient. Analyzing these processes informs and guides our treatment, and the logic is that these dynamics are best played out in person. As a soon-to-be psychiatrist, I’ve been taught that it’s best for my training to reflect my future practice, which means in-person appointments have been favoured over remote services.
I also suspect an important reason why we have not previously offered appointments virtually is remuneration. Physicians are largely paid via a fee-for-service model, and they can generally only bill for the work they do when a patient is in the room. There have been exceptions, including billing for consults performed over video conferencing for rural communities and certain pilot programs. For the most part, however, the physician has to see the patient in person in order to bill for the service.
Since the pandemic started, things have changed significantly. In an effort to support physical distancing, the Ontario Health Insurance Plan (OHIP) has responded rapidly. For the first time, physicians across specialties can bill OHIP for services provided online and over the phone. This is a welcome change for everyone. It has been a relatively seamless transition for many of us to set up our Ontario Telemedicine Network (OTN) accounts. OTN is an already existing not-for-profit organization funded by the province that has provided secure video conferencing for health care services.
I am relieved to say that my consults and follow-ups through video conferencing and the phone have gone better than I expected. I feel that it is important that I at least “see” any new patients via video conferencing because I need to observe non-verbal communication. However, for follow-ups with patients that I have an established relationship with, I believe talking over the phone works well.
My views on virtual and phone-based provision of mental-health care have changed significantly during the pandemic. I now see great value in it. Cynics may say that we are venturing too far away from tradition and that it may degrade the quality of psychotherapy over time – but only time will tell. For now, I would point to the evidence: We know that no matter what form psychotherapy takes or how it is provided, it is consistently the therapeutic alliance (the relationship between the therapist and patient) that matters the most. By reaching out to my patients and picking up new cases right now, I am indirectly telling my patients, “I am here for you during this difficult time.” They have been more direct in telling me how much they appreciate having their appointments.
What would Freud say? I care less about that as we now contend with a very different world than his. The question I ask now is, how will we go back?
Whether or not we have realized it, the COVID-19 pandemic has changed the way we provide health care across the country. As we grapple with the volume of mental-health concerns and limited resources to meet the demand, psychiatrists moving online might be one way to help ease the burden. We expect that mental-health concerns will increase with the COVID-19 pandemic.
So perhaps the better question is, should we ever go back entirely to the old way? What’s best for patients will likely be a mix of both old and new.
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