Virtual treatment and social distancing
Authors: John Markowitz
Journal: The Lancet Psychiatry (2020)

The coronavirus disease 2019 (COVID-19) pandemic is raising levels of anxiety worldwide: both appropriate anxiety in reaction to real dangers and maladaptive panic. Beyond handwashing, a key public health directive is social distancing, which entails avoiding public gatherings and generally keeping physical distance from others. The economy is shutting down, leaving people at home without the structure of their daily work routine. The closing of theatres, museums, restaurants, and bars has disrupted and diminished social life. Rapid shifts in information (and misinformation) about a previously unknown pathogen amplify ongoing uncertainty and anxiety. Social distancing seems to mean increasing social isolation while worrying about a potentially lethal illness. Isolation can easily translate to loss of social support, particularly for individuals who live alone; and loss of social support often compounds symptom severity. The current crisis is transforming both our society and our practice. This situation has large implications for psychotherapy, and perhaps particularly for interpersonal psychotherapy (IPT).1Weissman MM Markowitz JC Klerman GL The guide to interpersonal psychotherapy. Basic Books, New York2018Google Scholar Overnight, psychotherapy has changed from in-person treatment to teletherapy, which maintains the therapist–patient alliance despite the emotional and hygienic distancing of a computer or smartphone screen. Teletherapy is functional,2Dennis CL Grigoriadis S Zupancic J Kiss A Ravitz P Telephone-based nurse-delivered interpersonal psychotherapy for postpartum depression: nationwide randomised controlled trial.Br J Psychiatry. 2020; (published online Feb 7.)DOI:10.1192/bjp.2019.275Crossref PubMed Scopus (52) Google Scholar, 3Neugebauer R Kline J Markowitz JC et al.Pilot randomized controlled trial of interpersonal counseling for subsyndromal depression following miscarriage.J Clin Psychiatry. 2006; 67: 1299-1304Crossref PubMed Scopus (34) Google Scholar, 4Heckman TG Heckman BD Anderson TI et al.Tele-interpersonal psychotherapy acutely reduces depressive symptoms in depressed HIV-infected rural persons: a randomized clinical trial.Behav Med. 2017; 43: 285-295Crossref PubMed Scopus (27) Google Scholar but is not exactly like being in the same room with another person. In IPT, we generally aspire to have patients look up from their screens to make eye contact, but now we distance. Now talking heads might be the safest substitute for personal encounters. Whereas other treatments like psychodynamic psychotherapy and cognitive behavioral therapy have intrapsychic targets, IPT focuses on the interpersonal arena. IPT therapists usually encourage patients to interact with others. Social contact is already a challenge for depressed and anxious patients, and it has just become far more complicated. It is not a good time to join a social group or meet new individuals. So how should therapists handle the current crisis? Recent virtual supervisions and treatments have offered the following suggestions. Address reality. The first step is to acknowledge the extraordinary situation. To strengthen the therapeutic alliance, therapists can be clear that we would rather meet in person, but that in this public health emergency that is not a good idea. The therapist might want to privately recognise his or her countertransference, which might well include relief at avoiding infection by maintaining a distance. The message to the patient, however, needs to convey that the therapist will stay in touch and continue working to help the patient get better, the crisis notwithstanding. Indeed, isolated patients need a lifeline now more than ever. Try to maintain a regular schedule, and have the patient find a space where he or she will not be overheard or interrupted. It is important to try to use Health Insurance Portability and Accountability Act-approved media to make eye contact through the screen. Give the patient your full empathic attention; do not take notes during sessions. The therapeutic alliance could have particular potency in a time of crisis. Social support. Similarly, the patient's social interaction presents a dilemma. It is important to make the most of social engagement given the limitations of the moment, to maintain social bonds, and to seek interpersonal support even as one must maintain a safe physical distance. Social engagement—attachment—is a basic human need.5Bowlby J Attachment and loss, vol 1. Attachment. Basic Books, New York1969Google Scholar At a time when developing new relationships might be hard, taking a good interpersonal inventory1Weissman MM Markowitz JC Klerman GL The guide to interpersonal psychotherapy. Basic Books, New York2018Google Scholar can identify existing relationships that the patient can use to minimise isolation. The phone, FaceTime, Skype, and the like can help to lessen social isolation and maintain social support. Failing that strategy, more isolated individuals might want to use social media to maintain a sense of connection with others. Because most new therapies require in-person intake visits, a patient you terminate with is unlikely to be able to start new treatment elsewhere. Hence, even if you were planning to terminate a time-limited treatment with a patient, it might be appropriate—depending upon clinical status—to add continuation sessions to a treatment you would normally end, in order to ensure the patient's continuity of care. Every cloud has a silver lining. Objectively, this situation is a terrible moment in world history, and not one to trivialise to patients. From a therapeutic stance, however, bad news can be good news. IPT therapists capitalise on environmental stressors and losses—the death of a significant other (complicated bereavement), a painful interpersonal situation (role dispute), or other major life event (role transition)—as helpful explanations for why patients are feeling the way they do, contextualising those feelings and symptoms in a current personal crisis that the patient can work on and resolve in time-limited treatment.1Weissman MM Markowitz JC Klerman GL The guide to interpersonal psychotherapy. Basic Books, New York2018Google Scholar A pandemic can helpfully be reframed as a role transition in which the patient needs to mourn the (hopefully temporary) loss of old roles and to adaptively restructure activities and relationships in the present. Forty years ago, another frightening and initially untreatable virus with very different course, stigma, and social reverberations struck. Because the news was so bad, IPT proved particularly efficacious in treating HIV-related major depression,6Markowitz JC Kocsis JH Fishman B et al.Treatment of depressive symptoms in human immunodeficiency virus-positive patients.Arch Gen Psychiatry. 1998; 55: 452-457Crossref PubMed Scopus (198) Google Scholar and might have similar potency today. This setting is a painful but powerful moment for psychotherapy. Patients need therapy more than ever, yet are physically distanced from it. Psychotherapy might be harder in some respects to do at a distance, but teletherapy does work, and the basic principles remain the same. The interpersonal, environmental context can provide a useful frame for treating the problems patients now face. JM reports personal fees from Oxford University Press, American Psychiatric Publication, and Basic Books; and support from a grant from the Bob Woodruff Foundation, outside the submitted work. Isolation and inclusionThe COVID-19 crisis will touch the life of everyone in some way. While viral transmission, incubation times, and care of severely affected patients rightly dominate the news, it is heartening that mental health is given plenty of airtime. Symptoms of anxiety and depression are to be expected in times of stress. Concerns more specific to the COVID-19 outbreak that might have more lasting consequences are the features that prevent health-care staff, carers, and families from having personal contact with patients: working from behind a mask, limiting physical interaction, and not being able to visit ill relatives. Full-Text PDF