In a context of social distancing, isolation and implementation of strategies to contain the virus the introduction of telepsychiatry via videoconference was in a unique position to maintain psychiatric services on the frontline amid efforts to offer effective healthcare to patients. The challenge is around harmonising the advantages offered by telepsychiatry and online support provision while keeping the helping relationship focused on its core: human connection.
The ongoing pandemic has been exposing us all to a sense of vulnerability and uncertainty. This sense of vulnerability that both doctors and patients feel during the pandemic is a new form of proximity and an equal starting point for their relationship. This was the introduction to the lecture of Glen O. Gabbard- the American psychotherapist and psychiatrist, and Professor at the Baylor College of Medicine in Houston- that he conducted remotely at the last National Conference of the Italian Society of Psychiatric Disorders [1,2].
COVID-19 somehow equalised everything by putting doctors and patients on the same level. “We are all facing uncertainty at an existential level,” explains Gabbard. “As therapists we try to contain our patients’ anxiety meanwhile we become increasingly aware of a similar vulnerability of our own. Sometimes it’s the patients who contain their therapists’ anxiety.” There is indeed a sense of pervasive anxiety in all of us: both patients and therapists are facing uncertainty each day and the meaning of the simple “How is it going?” question suddenly implies, “I feel like we’re both in the same uncertain and catastrophic situation”.
While each of our daily lives changed the context that the patient-therapist relationship takes place in did as well. The crucial aspect of this change was switching from meeting in person to conducting online therapy remotely. Gabbard adds, “The use of the phone and Skype or Zoom has been approved for some time and there is different scientific literature on that. However, right now we are learning the best way to utilise these tools”.
The helping relationship from a distance
Some therapists are very critical around the inevitable physical distance between patients and doctors. Others believe that in any therapy either party might experience emotional distance from the other due to internal conflicts and that this can happen regardless of them being in the same room or using tools such as telepsychiatry.
“A patient of mine used to tell me how much easier it was for her cry when I could not see her,” tells Gabbard. “She told me, ‘I felt you would judge me if you saw me cry’”. Patients can feel very scrutinised or judged and some might feel more comfortable if therapists cannot see them so that they can have a guaranteed space for intimacy, reflection and contemplation. Others might prefer using the telephone instead of video-calls during sessions.
Gabbard sees a form of continuity with the in-person interaction in the therapist’s attempt not to invade the patient’s space and in the need to let both the therapist and the patient have a space to be free. “Often in recent years I’ve been telling my students to avoid frontal settings where both people are sitting in front of each other as staring at patients directly might make them uncomfortable. For this reason I prefer to place the chair at a forty-five degree angle to the patient, as if you were two people sitting by the fireplace in the winter season”. Screen to screen contact can be distracting, both for in-person relationships and for those taking place in front of a display.
Entering the patient’s home
As the psychiatrist emphasises, “The therapist is invited into the patient’s home”. This aspect redefines the type of empathic relationship one can establish but this shift is not unambiguous. Having access to someone’s private space might be an advantage with some patients as they feel more comfortable and talk more. Nonetheless, as Gabbard states, this might not necessarily be the case, “The therapist is invited into the patient’s home who might feel inhibited around what to say”. When conducting a session remotely sometimes it can be harder to find a balance around concentrating on the various details as these can say a lot about the patient but might also be a distraction. Therapists get to see the relationships that take place in the patient’s home with dogs, cats and partners appearing in the background. They get to see settings that might raise questions about their patients, such as some inappropriate background that patients might choose to utilise to protect their privacy.
The details of somebody’s facial expressions can also say a lot about them, but they can be extremely difficult to observe at the same time. The use of Zoom- and video-calls in general- reduces a vital space: the distance. It’s as though we were inside a crowded lift. “Seeing a face up so close, which is what you see on the screen, makes you get a physical reaction whereby you jump backwards. Being so close to one another makes you react physically,” Gabbard adds. “On one hand watching the other person through a screen enables you to get more details of their facial expression and position. On the other hand you also get information you are not used to and that is different from what you would normally get to see during the relationship with patients when you share a physical space with them.” It might be harder to process the non-verbal cues that hide behind changes in facial expressions, tone of voice and all the elements that define body language. Our bodies are distant while our minds are united and sometimes that creates a tiring dissonance.
Eyes never meet
As anyone with a bit of experience on video-calling platforms can guess, maintaining eye contact with the patient means that the therapist has to stare at the camera rather than at the person on the screen so that the patient can feel as though they are being looked at. However, doing this means that the therapist is not actually looking at the patient.
Gabbard adds, “Many of us feel like we are glued to the screen”. The anxiety around maintaining online contact with the other party on the screen is something new compared to in-person therapy. Nevertheless, the attempt to keep this illusion where one tries to recreate the in-person experience through the screen is one of the reasons why it’s necessary to keep refining these IT tools.
Therapy during COVID-19
When faced with uncertainty and with a weaker sense of meaning around what is happening, the challenge for psychiatrists and psychotherapists is to find a balance between being aware of one’s vulnerability and the ability to stay alert and vigilant. On one hand it is important to remember that patients are in a particular context- “It feels like life is on pause, you get a sense of impotence and stagnation where you loose that sense of control over your life”. On the other hand there are people whose symptoms are not just a response to the pandemic but are part of a pre-existing condition and they might need therapy and psychotherapy. “Telepsychiatry’s use in the COVID-19 pandemic was distinctive,” Jay Shore and his psychiatrist colleagues, from the University of Colorado in Aurora (USA), wrote in the Jama Psychiatry Journal , “and will have long-lasting and wide-ranging effects on the field of psychiatry, including mental health care delivery and configuration and patient experience and expectations”.
“Will doctor’s offices disappear from New York after the pandemic? Will some patients decide to carry on with remote sessions- no need to look for parking, drive through traffic or ask for leave at work?” wonders Gabbard. “We don’t know when the pandemic will end or whether we will be able to fully overcome it, but we do know that technology is here to stay and offers some positive benefits. The pandemic gave us the opportunity to look at certain tools and broadened our horizons”.
What will happen to telepsychiatry after COVID-19? How will people decide what should be done in person or through telepsychiatry? Where should the limit be? Is there a saturation point for the use of online tools where the benefits of an online relationship decrease or where patients ask for more in-person interactions? What data need to be collected in order to answer these questions and focus on the lessons from COVID-19? The rapid switch to online tools, the change of legislation and to the system which the pandemic required provide the opportunity to collect and categorise the experiences acquired by patients, doctors and executive managers in order to shape strategically the post-COVID-19 world of psychiatry and telepsychiatry. “We might be on the verge of a necessary change,” concludes Gabbard. “The pandemic offers an x-ray of the malfunctioning pieces. When faced with such a clear scenario you might decide to take action or not, but you can only get a chance to find a solution if you truly look at what failed”.
Norina Di Blasio
 Gabbard GO. Telepsychiatry and online psychotherapy. Lettura magistrale al XXV Congresso nazionale Sopsi, 24-27 febbraio 2021, live virtual edition.
 Gabbard GO. The analyst and the virus. J Am Psychoanal Assoc 2020;68:1089-99.
 Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the coronavirus disease 2019 pandemic—current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry 2020;77:1211-2.
Telepsychoanalysis: Gabbard’s strategies
Every narrative has at least the capacity to suggest a metanarrative.
• There is no such thing as a general patient profile, particularly in the current vortex we are all in.
• Be more careful and explicit with patients when explaining the difference between in-person therapy and Zoom-based therapy.
• Discuss the meaning of looking away- both applied to the patient and the therapist- with transparency.
• Consider telephone-based therapy as an alternative and in situations where the patient might feel more comfortable.
• Remember that both the patient and the therapist are facing uncertainty and this common ground might be a starting point.
• Reassure the patient around the confidentiality of the setting that the relationship is taking place in.
• Create a similar setting to that of the in-person sessions.
• Wear appropriate clothing.
• Continue to educate healthcare professionals around new technologies.
• Continue to build the therapeutic alliance through telemedicine.