Practical Practice: The dynamics of returning to in-person sessions

The pandemic suddenly changed the provision of psychotherapy—with no opportunity to process the shift in treatment delivery in advance. Maintaining access to care was the priority. Interruption of care is disruptive in any case, however, the psychological impact of the pandemic and the related uncertainties created significant increases in mental health concerns making access to care even more time sensitive.

We tolerate uncertainty and adapt to changing circumstances at home and at work. The concern for the health and welfare of our patients and our own health is legitimate. The pandemic revealed the variable nature of the perception of risk which affects the decision to resume in person services.

A virtual platform for psychotherapy challenged the traditional frame of psychotherapy. A frame for psychotherapy, and maintaining that frame, is clinically and logistically justified. It provides boundaries, clear expectations, predictability, and safety.

Miraculously, telehealth platforms were generated quickly and surprisingly, effectively. Maintaining the frame in a virtual environment proved challenging because it creates a perception of informality, convenience, flexibility, and more availability.

The guidance regarding resuming in-person activities is changing. If people are resuming attending school in person, sports activities, etc., when might it be appropriate to return to in- person psychotherapy sessions?

That answer may not be so clear. The same factors that have contributed to the culture of telework are related to therapists. Some therapists may enjoy the conveniences of home office work, more flexibility, no commute, and less overhead expenses.

The pandemic provoked rapid development of technology, everything from HIPAA secure video teleconferencing to electronic health records, making practicing telehealth practical and cost-effective.

Some patients may resist returning to the office whereas others feel disconnected or struggle using technology. Some patients may prefer sessions in their own space feeling more comfortable. Being able to meet virtually may create access for patients who may have difficulty arranging childcare or whose work obligations make going to a therapist’s office for regular sessions prohibitive.

There are few reasons for lateness or missing a telehealth appointment. Conversely, working from home may not be conducive for everyone because of environmental factors or preference to separate work and home life. Some patients may prefer the containment of the therapist’s office and may also have environmental factors that would make participating in therapy from home, work, or even their car, less conducive to fully engaging in the therapy session.

When considering a return to in-person sessions, updating your informed consent document is important to include precautions, cleaning procedures, and social distancing measures. There are ethical and clinical considerations.

While it may not be illegal to deny a patient in-person services if they are not vaccinated, is it ethical? Is the psychologist obligated to disclose his or her vaccination status?

If the psychologist or the patient becomes COVID positive or exposed, are they obligated to inform one another? Could the therapist be considered liable if there is any indication that the patient contracted coronavirus from being in their office? Should there be different considerations if the therapist is working with populations who may be susceptible to severe illness?

How a decision is approached regarding returning to the office should be reflective of the patient’s treatment goals, the needs of the therapist, and within recommended safety protocols.

Processing the transition sufficiently before changing the treatment venue is clinically valuable. What would it mean to return to sitting face to face, without a screen in between? What shift in defenses might occur? Might there be more or less avoidance? What losses might be experienced?

Had the therapeutic relationship begun virtually, and will this be the first-time meeting in person? While there has been awareness that a virtual experience is altered from an in-person experience, what might the effects be on the dynamics of wearing a mask in psychotherapy? Seeing one’s facial expressions is a core element of any interpersonal interaction, and certainly for psychotherapy. Can a therapist get a better sense of the patient sitting with him or her in person while both wearing masks or by a virtual interaction without masks?

There may be clinical implications of wearing a mask for certain populations. For example, a patient with borderline personality disorder may struggle with the ambiguity of not being able to read the therapist’s facial expressions.

Asking trauma patients to wear a mask might create enactments of their trauma or unconsciously communicate that they should not share their trauma.

Patients with attachment disorders may struggle with even subtle shifts in how they experience the therapeutic relationship that may arise when changing how psychotherapy is delivered.

Teletherapy could remain an option if the frame of psychotherapy is maintained. Therapists have permission not to be a “blank screen” because their personal circumstances are directly related to the decision to return to in-person sessions.

Logistics need to be managed in the transition to the return to in-office sessions. If the therapist has been seeing the patient through telehealth, can the therapist require that sessions will return to in-person, even if the patient prefers telehealth appointments?

Similarly, what if an existing patient prefers to meet in-person and the therapist prefers to continue working through telehealth?

How would a hybrid option affect the treatment frame? Could the patient, or the therapist, request in person or telehealth visits from session to session? Suppose the therapist requests that a session that was in-person last week, be virtual this week? Would the patient wonder if he or she had said or done something to “make” the therapist “not want to” meet with them in person?

Could there be countertransference on the therapist’s part, or might the therapist have a logistical need or a preference for telehealth work that week? It would be important to outline what the expectations will be for how and when it is determined about whether sessions will be held in the office or via telehealth and to discuss the feelings that may arise while making those decisions.

An all or nothing approach is unlikely to be effective. Clinical judgment is necessary to synthesize these dialectics.

Guidance evolves related to responding to the pandemic and psychotherapy can be delivered effectively through telehealth. We routinely work through the dynamics of the psychotherapy process and the issues related to telehealth versus in-person sessions, is one more dynamic.

Countertransference and transference, maintaining the frame of psychotherapy, and processing the dynamics are “grist for the mill” helping patients work through the enactments and dynamics which brought them into the consulting “room.” The therapeutic relationship transcends walls and screens and endures.