Myself, My Patients,
and COVID-19
Several patients of mine, as well as friends and associates,
have been asking how others I treat are reacting and responding to the current
COVID-19 pandemic. This is what I see.
To gain perspective, this is being written five weeks into
the stay-at-home orders of the state governments. Only workers deemed essential
are allowed to leave home for places of work; all others are either working
from home on-line or they are temporarily or permanently unemployed.
Unemployment rates are soaring quickly, the economy is headed for a major
recession if not a full blown depression, and many here in Pittsburgh are
frightened by the mismanagement crisis in Washington. We
are still early in the game. It appears we will be dealing with massive
disruptions for months if not years to come, until and beyond the date of an effective
vaccination against the coronavirus. To most of us, this is the greatest
national crisis we have ever experienced.
That said, we have mostly been coping surprisingly well.
Myself, I've had to switch my outpatient practice from in office "personal
and personable" care to online virtual care through a HIPPA-compliant
telepsychiatry platform. This was done literally overnight, but has required a
great deal of effort to contact and instruct my patients on the change. I have
been surprised at my own reactions to doing virtual treatment. I was surprised
that I sort of like this platform to connect to patients. While I would prefer
the in-person connections, I find a different and pleasant intimacy in working
on screen with my patients. For one, their faces are closer to me. and mine to
them. I can appreciate their facial expressions up close, and they, I figure,
are doing the same with me. Up close, my patients look strikingly handsome on
the monitor. I also find myself automatically leaning into the screen when i
need an issue clarified or a question answered. I wonder how my patients take
to this "leaning in." Also, I am seeing my patients mostly in their
cloistered homes. I get to be a little bit more of an ethologist, observing my
patients in their natural habitats rather than my office. I see some
decorations, wall pictures, some furniture, There is a greater informality in
this forum. Patients dress in sweatshirts, recline a bit, muse, walk around the
house, or excuse themselves to deal briefly with their kids' noise or their
on-line homework. I get to watch some
interactions I would not otherwise have been privy to. On one occasion, my
psychotherapy patient and I agreed to invite his wife to join us on video for
her input into their marital tensions. After all, she was right thee and going
nowhere. It proved to be a fruitful
session. One patient came wrapped in her bathrobe; another woman, who had
forgotten her appointment time, did her telepsychiatry while fishing alone at a
rural stream. I never knew she enjoyed fishing. Several were able to show their
crafts. One woman was spending her alone time sewing face masks for Magee
Hospital. Many a cat walked across their keyboards and onto my screen.
What of the patients' responses to the coronavirus crisis? Does diagnosis play a role in the response of
these patients? Absolutely it does. Individuals diagnosed with Social Phobia,
as well as those with Agoraphobia, are
routinely relieved to be at home. They do not have to face the anxieties
of meeting new people or being away from the safety of home(respectively), nor
the anticipatory anxiety which accompanies both conditions. These are arguably
the most contented patients of all. Lack of exposure to their anxieties may not
be the best treatment for them, but given the stress of the crisis, a welcome
reprieve from anxiety and tension.
Surprisingly, a number of patients diagnosed with Obsessive Compulsive
Disorder with germ phobia were uncharacteristically nonchalant about the
possibility of they or their children getting infected. I've been even more so
struck by patients with Panic Disorder, who characteristically manifest the
symptom of hypochondriasis, a severe
exaggeration of the negative significance of medical problems, physical
symptoms, and medication side effects. They, too, have been surprisingly blase
about the epidemic. One patient, whose friend had a germ phobia but was
currently relaxed, surmised that these otherwise anxious persons were feeling
something like, "Hey! Now everybody is just as anxious as I am! I"m
no different than everyone else!"
I've yet seen no significant change in symptoms in my
depressed and Bipolar patients, at least no intensifications above what might
have occurred were there no crisis at hand.
For sure, nearly all patients acknowledge an increase in
mild chronic baseline tension attendant to the possibility of infection in
themselves or close ones, and to the unknowns in their futures. A number of
patients feel sad and anxious in reaction to the isolation, especially those
who live alone. Patients who own their own small businesses are hit hardest.
Many will not survive the financial crisis and the inability to generate income
in this depressed economic environment. Likewise, a number have been furloughed
or laid off permanently. They are anxious, but not nearly so much as the
business owners who feel the even greater pressures of large bills due and
mounting debts, and employee layoffs. Some individuals are having more tension
with their spouses or significant others due to the close quarters. However,
for the most part there exists an unexpected equanimity among my patients when
it comes to this crisis. Could it be that my outpatients are actually mentally
inoculated against the effects of this pandemic? Are they perhaps more resilient to the behavioral effects of this
epidemic than many others?
I
was curious as to why this might be the case, so I went on an ethological
inquiry of my own. All patients understood that the whole country, nay, the
whole world, was undergoing the same stressors. All were sequestered, staying
six feet apart at minimum, isolated from loved ones. All have to rely on
connecting via video chat, or, at best, conversing with the neighbors or family
members on the porch or on the street. No one is different or odd. Secondly,
many patients are finding silver linings in the current stay-at-home
sequestration, often multiple such linings. They no longer have to get dressed
for work. They no longer have to spend anxious time commuting or paying for parking.
They can spend precious time with their "home-schooled" children.
Many are devoting themselves to home projects they have put off for years.
Others are getting into past or new hobbies. One young female patient built
three desks for her children, then a stone wall outside her home. I myself have
been using my free time cleaning out a cluttered basement, something I had put
off for a retirement I suspected will never come.
Perhaps another dynamic comes into play to explain, at least
partially, my patients' equanimity in this crisis(aside, of course, from their
symptomatic improvements due to treatment). I have no definition for this
phenomenon nor any facile psychological explanation for this. though I believe
one exists. Many years ago, when state psychiatric hospitals were being emptied
of their patients due to the advent of Thorazine and related anti-psychotic
medications, there was a period of time when chronically psychotic patients
were being housed in nursing homes. Medicare picked up the tab for these
quasi-hospitalizations of severely debilitated, "back ward" patients.
Even medicated, many continued to hear voices, see visions, and be paranoid or
otherwise delusional. They were often detached from one another, in their own
worlds. On several occasions, however, a fire broke out in a number of these
facilities. These otherwise psychotic patients reportedly lined up quietly and
cooperatively, followed all directions, and walked in single file outside the
facility. No fuss, no muss; as if, faced with
real external threat, the mind focuses acutely on the immediate danger
at hand and puts other, "lesser" symptoms, aside. Could such a
phenomenon also be at play in the current disaster?
Mostly though, I sense an equanimity in my patients borne of
a return to a kind of simpler life long
past. They are forced to be at home, to exert themselves less, to spend more
time with immediate family; sometimes to scrounge for supplies. They are called
upon perforce to find new, more resilient ways to cope, to be innovative, to
self-entertain. They feel it more necessary to connect whenever and however
possible, and to appreciate and address the pain others are also suffering.
They grieve the loss of the Federal buffer we once took for granted, and
instead fall back on supporting and buffering one another.
It may sound perverse and counter-intuitive that my
outpatient cohort is taking this massive crisis in relative stride, when much
of the news screams such pain and suffering. But, taking a step back, a clearer
picture comes into focus.: Consider that half of the population is thought to
bear a diagnosable psychiatric condition. However, only ten percent of the
population benefits from any behavioral treatment, and only three percent ever
seek specific psychiatric care. The bottom line is- my outpatients are being
treated for their symptoms. As such, they are arguably, and likely, more
resilient and calmer in the face of the current overwhelming stressors than are
much of the untreated and still symptomatic population. The psyche, no longer
burdened and overwhelmed by symptoms, is far better equipped to cognitively,
emotionally, and behaviorally adapt to this disaster flexibly and adaptively when liberated from itsprior symptomatic shackles.
So much for stigma.
Comments
Post a Comment