by Kent Campbell, LMFT
“ALL INDIVIDUALS LIVING IN THE COUNTY [ARE] TO SHELTER AT THEIR PLACE OF RESIDENCE EXCEPT THAT THEY MAY LEAVE TO PROVIDE OR RECEIVE CERTAIN ESSENTIAL SERVICES." Order of the Health Officer of Santa Clara County, March 16, 2020
In February a creeping tidal wave of news announced that a novel coronavirus was sickening thousands and killing dozens globally. News stories from Asia about limiting travel and increasing fears bubbled up around us. In what seemed an adequate response at the time, my suitemates and I bought hand sanitizer and bleach wipes, and we talked about practicing good cleanliness in the office. By the middle of March, the stock market crashed, citizens were told to shelter in place, and none of my suitemates and I were using our offices at all; everyone had switched to meeting clients through telehealth. Just like that the global economy, global public health, and our businesses radically changed. As a result, healthcare in our country may never return to the way we used to work.
I have been practicing psychotherapy in my suite since 2004. I remember being the first clinician to advocate for internet service to the office, not that many years after discussions about what kind of an ad to run in the Yellow Pages. While the world has changed in many ways, much of our business operates in a tried and true fashion—two minds, two hearts sitting in a room together, talking, thinking and feeling our way through life, and practicing healthy relationship patterns. Theories and approaches shift with changes in the field, but the act of two humans (or more) making time to meet face to face defines how most of us have always done our work. I sit in my chair and my patient sits across on my couch—that’s how this has always worked. For many of us, social distancing and public health requirements drastically changed all that.
As therapists, we hear about the way this disease and its consequences have impacted our clients as well as our individual families and friends. For example, I work with several parents who are balancing varying degrees of home-schooling their children while being asked to work their same full-time tech jobs from home. Some clients are surprisingly thriving amidst the challenges. One man has seen his depressive symptoms fade as increased responsibilities to care for his children gave him reason to be proud of himself for the first time in years. An anxious woman who feared so many things now feels at ease as she cares for her family and enjoys the slower pace of life. Crisis can indeed be a mix of danger and opportunity. Surely many of you reading this article have your own stories of the tribulations and successes everyday life brings our neighbors and clients these days.
While the risk of exposure to COVID 19 is universal, the effects of sheltering in place and getting sick are not. Many in our community are fairly seamlessly able to work from home, maintaining their salaried income. Others were laid off or asked to take a reduction in pay, or see anticipated income slip away as business decreased. Some of our neighbors lost their ability to work entirely: not everyone can work remotely. Discussions grow about how this illness impacts some communities of color more than Caucasian ones.
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This experience also affects clients’ ability to attend sessions and pay for therapy. Several of my patients reduced the frequency or ceased meeting this last month. One of my clients lost all his income as his small business shuttered; another woman had to apply for unemployment insurance benefits for the first time in her life. Many of our neighbors are without adequate income to pay for rent, let alone pay for counseling services. Reports are that domestic violence reports have increased and anecdotes from other countries suggest increases in divorce might follow pressures of sheltering in place.
For my practice, this past month I have offered to meet a few patients in person, but nearly everyone has asked to meet over the phone or computer. I currently work with about half of my clients by voice over the phone and about half on video conferencing using my online practice management software. For long-time clients, I sometimes enjoy using phone calls to do our work. We do not need eye-contact, we know the cadence of each other’s voices. There is space to think and feel—and even stand or move while talking. Video screens share even more detailed glimpses into family homes, sometimes the living room and sometimes the garage. We can learn more about our patients from observing the parts of their world displayed on the screen as well as how they handle these changes and challenges.
Being in my office puts my heart and mind into a mindset, a frame of mind ready to be the therapist. There are times when being at home supports that mindset, and at other times there are distractions that detract from my being present. I have taken to driving to my office to make some voice and video sessions. I spoke with several therapists this week who likewise will go to the office for their work, even though there will not be any clients in the room with them.
The anxiety most of the world is feeling touches our conversations with our patients in several ways. Our clients have some degree of uncertainty and fear that they or someone they care about may fall ill. Our therapeutic frame has shifted from four walls to a video call. Surely there is some concern that either the client or the therapist might be ill and not displaying symptoms, potentially threatening the wellbeing of the other if we are in a room together. Therapists have anxiety about future clients beginning treatment online instead of the office, and many clients have reason to be anxious about their income and our local economy, let alone large global trends. Anxiety abounds. Yet, humans find comfort in sharing this experience with one another.
I started my group practice, Family Matters Counseling Services, two years ago, some 17 years after beginning my work in this same therapy suite on Bascom Avenue. My seven staff members and I strive to provide counseling across the lifespan to children, teens, and adults, as couples, families, and individuals, with an appreciation for psychodynamic thinking. The rapid requirements that citizens avoid social contact led us to decide to meet solely over the phone or computer instead of meeting in person. Some of our clients opted not to meet via telehealth, for various reasons. Referrals began to slow and nearly stop as the news hit and real social distancing began. As the business manager, it is frustrating to not be able to connect patients with my staff of therapists. We are here to help people who are suffering, of which there are many, and yet some of those people are not in a position to reach out to a new therapist at this time. Several of my colleagues saw their caseloads decreasing. That means less income for all, but for marriage and family therapist associates that also means fewer hours earned for their licensure and at a slower rate than they had planned.
I reached out to my colleague Stacy Dever Levy, an associate MFT, who works with adults as well as children and teens. I asked her how she handles providing therapy to children during the age of social distancing. Perhaps like most of us, Stacy finds challenges and opportunities utilizing telehealth. She explained, “the transition to working over video and phone has gone smoother than I would have expected. With adult clients, some prefer video and some prefer a phone call. While I strongly prefer meeting in person, I think that after the initial adjustment period, for most of my adult clients, our work has proceeded along as before.”
Teens of course tend to feel most comfortable using their phones. Stacy says, “with teens, while I miss seeing them in person, it has been beneficial to see them in their own environment, and they seem to be able to make good use of the sessions; they seem comfortable with technology and often seem more relaxed.” She sometimes offers two half-sessions per week or shorter sessions for children and adolescents instead.
“With children, it is quite different working remotely. For the most part, I encourage kids to engage in the same kind of play or art activities we had been doing together in the room. With play, I invite them to use their own toys,” Stacy explains. “We have also been engaging in art activities and adaptations of games like I Spy, Scavenger Hunts, Simon Says, Red Light/Yellow Light/Green Light. There have been some benefits to seeing the kids in their home environment. For example, they can show me their room and items that are important to them. I have invited them to share feelings that they have had during the week and choose items in their home that represent those feelings. It has required us all to be more flexible.”
If children can adjust to telepsychology, how could a couple in conflict work on their dynamics without falling into overwhelming conflicts? I called Holly Osment, MFT, a classmate from Santa Clara University, where Holly now teaches courses in the Counseling Psychology Department.
From Holly’s perspective, working with couples transitions well to telehealth. She currently meets weekly with five couples, four of whom continue to focus on their issues and who are very much able to connect with Holly online. The fifth couple had a preexisting dynamic where one partner was very reluctant to engage in the process; that person was even less interested in working online. Otherwise, couples can sit next to each other to process their experiences and feelings from the comfort of their home. Her clients appear to be managing the transition well; her caseload has even increased as former patients returned to meet with her as the stresses of sheltering in place ratcheted up.
It might have helped that Holly is already comfortable with this video conferencing. She held sessions over video conferences enough before March 2020 that made the transition feel relatively easy. She knew the process and how to manage the experience. Holly told me, “It is not the same as meeting in person, of course, and I do not prefer it. But I am also not eager to resume sitting in a closed room with someone who could be asymptomatic, they blow their nose because of emotional crying, and inadvertently spread the virus around the room. With that in mind I may continue video conferences for a good long while to come.”
Our society may be caught up for a while in this unusual community health situation. With talks of bending the curve, second waves, and a new normal, unknowns are guaranteed. At the same time, mental health work is now recognized as an essential service. Therapists are allowed by law to continue working with their clients and some of our community have been doing just that. Whether to work with children or teens or because of other considerations, some clinicians have met with clients in their office throughout this time.
My colleague Geoff Nugent, Ph.D., LMFT, who manages his own group practice, Nugent Family Therapy, has had a limited number of clients seen in their offices since the beginning of the shelter in place requirements. They have clear guidelines that client and therapist follow. Doors are propped open to enter the suite and distances are kept. It seems that for those therapists interested in continuing their work and clients ready to meet face-to-face, this process works.
Dr. Nugent and his colleagues, like many of us, assumed that the shelter in place order would be brief before a return to “normal.” As the length of time to avoid social contact continued, he and his staff found that office visits and new referrals decreased over time. They had to pivot to be able to offer online sessions and determine best practices for the new arrangements. Now here in May, referrals have increased, processes are in place, and the group moves forward better prepared to support their clients in this new era.
For one last perspective, I spoke with my mother, Carol Campbell, MFT. She served as the president of the Santa Clara Valley Chapter of CAMFT and of the CAMFT state board. She has been practicing psychoanalysis and psychoanalytic psychotherapy in Palo Alto for the last 15 years. She can do a lot of things very well, but to be honest, using technology is not her strong suite.
To our surprise, Carol found that working over Zoom with her analytic and traditional patients turns out to be very effective. Some of her patients state they can focus more while seeing her on the screen, while others even appreciate being able to write on their computer simultaneously to take notes. She and her patients together have adapted to using the computer to communicate. They can still make effective interpersonal connections, although it is clearly not exactly the same as being in the room together. That said, no one has to commute to the office either. For Carol, the benefits outweigh the challenges and the distance. In fact, she is so pleased with the experience that she has moved her entire practice permanently to operate mostly online: she now offers her psychotherapy services and her professional consulting to licensed therapists either online or by phone. Though she will no longer be working with patients on the couch, she is pleased to reach folks through the convenience and flexibility that this technology offers. Opportunity here is found amidst the crisis.
At the time I am writing these words, Governor Newsom is beginning to talk about the steps we will take as a society to return to increased interactions. Marriage and family therapists have a role to play in helping process the traumas and manage the stresses of families remaining cooped up for weeks on end. Many of our neighbors have lost their jobs or significant income. Perhaps this experience of utilizing technology to connect with our clients will make our services more available to the community and more successful in the years ahead. With the challenges our society and our world face, all of us could use assistance.
Kent received his M.A. in Counseling Psychology from Santa Clara University in 2003. His clinical experience has included private practice, schools, and nonprofits. He completed the 2-year Palo Alto Psychoanalytic Psychotherapy Training Program in 2013, which involves working under the close supervision of senior analysts. In 2018 he founded Family Matters Counseling Services, a center for therapists to work in a facilitated private practice setting to meet the varied needs of the community for counseling services. He can be reached at kentcampbell@familymatters.expert.
