Post-pandemic psychotherapy

May 26, 2020

The outlines of post-pandemic psychotherapy are taking shape. Fortunately, the light at the end of the tunnel is getting closer, and it doesn’t look like a train. 

Let me start by highlighting what seems to me to be the most substantial factors shaping the future of psychotherapy. 

Macro-trends that shape the US mental health environment

Money for Payroll Protection Program is in business’s accounts

Almost 4.5 million businesses have received stimulus money through the Payroll Protection Program administered by the federal government’s Small Business Administration. Interestingly, the average “loan” size is $115,533. Therefore, the SBA must be giving out a massive number of smaller loans to balance the huge ones we read about in the newspapers. Fascinating.

For many owners, this was not a painless process with many anxious moments. Predictably, banks took care of their big clients first and eventually got around to truly smaller enterprises. By then, there was no more money from the first round of funding. So the program’s high demand required a second round of Congressional funding—crazy times.

Despite the trials, the PPP is helping. Most mental health practices are finding ways to meet the requirements, so the funds do not become a loan obligation. Whew!! Quite a ride.

For more data on the PPP, see the SBA Website: Paycheck Protection Program. The data reported in this post was as of May 23, 2020.

Unemployment will come down but still painful for some

Right now, the US is getting close to the Depression-era unemployment rates. And as you know, we got here with unimaginable speed. Nearly 38 million people are out of work. Additionally, it looks like many who kept their jobs are experiencing salary reductions. (See Salaries Get Chopped for Many Americans Who Manage to Keep Jobs in Bloomberg.com.) 

And of course, those who had employer-sponsored health care coverage are seeing those benefits go away–an estimated 16.2 million to 27 million people. While Congress agreed to pay hospitals for COVID treatment, they made no provision for a broader coverage for those who lost their jobs. Instead, they are immediately eligible to purchase coverage via the Affordable Care Act, i.e., ObamaCare. And yet, when one is without work, finding the money for a new expense becomes especially challenging.

But is this level of unemployment temporary?

The one significant difference that everyone highlights is the hope that many of the layoffs are temporary. About 80% of the unemployed think that as our society opens up, their jobs will return. And yet many economists are less sure how temporary the layoffs will be. They cite the reluctance of employers to rehire after the 2008 recession. It took nearly ten years to get to the same levels of employment after the 2008 recession. Let’s hope for a quick employment recovery.

I made the argument that even massive unemployment will not overpower the demand for mental health services. I look at the history of how mental health organizations have survived similar situations in the past to inform my views. Read that post here:

And here is a sampling of some predictions about where the unemployment trends will go:

Marriages are doing surprisingly well

When “sheltering in place” became the norm across the US, most therapists, including myself, thought that marriages would suffer. That seems to be true for some. For example, here is a medical newsletter using data from previous pandemics to predict an increase in domestic violence cases:

And here is some early data suggesting that domestic violence is following the predicted pattern:

Furthermore, while domestic violence calls are diminishing, that could be bad news. Why? As teachers and other mandated reports have less contact with children and families, abuse could be rising without detection.

The bigger marital picture

But a broader study is adding other dimensions to the picture. 

Monmouth University Polling Institute surveyed 808 adults age 18 and older in a national random sample from April 30 to May 4, 2020. Here is the report:

The most astonishing finding? Most couples are doing just fine. Some are even thriving. The best predictor? You can guess. It is how the couple was doing before the shutdown. Couples that were doing well continue to. 

Couples doing well is good news for our society and, I believe, for therapists as well. One of our fears is that the shutdown would generate a massive setback for couples and families. Therapists’ work would be even more challenging than it already is. Perhaps, instead, clients will come back having learned some skills they did not know they had. Maybe post-pandemic psychotherapy will not be as challenging as we thought. Wouldn’t that be a blessing for all? 

Insurance companies are supporting teletherapy, for now

As expected, insurance companies are extending the deadlines for accepting and paying for teletherapy. (See some of my previous predictions here.) Some have moved their endpoint to the end of 2020. And interestingly, I am hearing rumors that some state professional associations are going for a legislative push. They want to require insurance companies to pay for teletherapy at the same levels as face-to-face therapy permanently. Interesting times. 

Of course, the outcome of these efforts may dramatically change many aspects of the provision of mental health services. For example, without a doubt, Since it is clear that post-pandemic psychotherapy will include teletherapy, graduate schools will incorporate teletherapy into their curriculums. Accreditation bodies are already struggling with how to manage their practicum requirements under our current societal restrictions. 

Additionally, complaints about the current restrictions on licensure portability will grow. And of course, as teletherapy becomes commonplace, jurisdictional and disciplinary issues will rise to the surface more frequently. Yes, the prospect of permanently incorporating teletherapy into mainstream psychotherapy will have many ramifications. 

Our responses

So this is our new world. Some help from the Feds; high unemployment for a while; some clients coping surprisingly well; and lots of teletherapy, for now. And post-pandemic psychotherapy will be different in response.

The challenge I keep hearing is, “it is so hard to make plans. When will we get to the new normal?” 

Plans for opening-up

Despite the uncertainties, most practices are making preliminary plans to reopen to the public. Of course, some were never completely closed in the first place. However the past was handled, reopening means more careful cleaning and scheduling protocols. 

The goal is to keep the public spaces cleaner and to stagger appointments to minimize waiting room use. Some practices will use texting to inform clients when to enter the building. This approach allows clients to have zero time in the waiting room. Furthermore, some offices are rethinking the check-in window if they had them. 

Undoubtedly, not all clients will be willing to reenter the offices. Therefore, most will also continue with teletherapy. 

Managing risk

The truth is that any increased contact between people, increases some risk. And not all regions have the same infection rates and, therefore, risk. See this statistical analysis.

And this explanation for why these regional differences.

So far, a state’s population density—measured by the share of residents living within five miles (8km) of each other—has been a stronger predictor of its COVID-19 death rate than the presidential vote in 2016. And red states tend to be more sparsely inhabited than blue ones, which might hamper the transmission of the virus.

Covid-19 is hitting Democratic states harder than Republican ones. May 22, 2020. The Economist.

I forecast that at a local level, we will open up, monitor, and respond as cases of COVID-19 either increase or decrease. Are there risks in this approach? Inevitably. But no society can stay closed forever. 

So each practice owner will try to calculate the reasonable risks as the local situation warrants. Most are deciding that we cannot wait for a vaccine or herd immunity. Waiting has risks too. So we make our judgments and live with the consequences. 

What does post-pandemic psychotherapy look like?

Are we doing therapy in masks? Every practitioner I talk with cannot imagine dong post-pandemic psychotherapy behind a mask. Many have said to me that they anticipate clients would prefer teletherapy to masked treatment. I agree. 

Some practices are envisioning heavy-duty air-filtration equipment in each office. But the sound is an issue. And getting these machines is not easy. 

How about walk-about therapy? It works fine as long as the weather holds, and one has sparsely traveled paths nearby. The challenges are enormous. 

And of course, some clients and therapists are more risk-averse than others. For the most risk-averse, post-pandemic psychotherapy looks like teletherapy.

I believe that once people come to the office, therapy will look much like it ever did. Yes, we will do everything we can to make it safer to get to our office. And we will do our best to make the office environment as safe as we can. But once the session begins, the process will be similar to what it ever was. Of course, the topics, at first, will include how the Coronavirus has changed life. But therapy will feel like therapy. 

May our society’s recovery come quickly. 

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To look at some other posts on managing setback see these posts:

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