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For Nick Cardone, practicing therapy means getting out into the world — meeting clients for activities like hikes, rock climbing, or playing music together.
But during the lockdown, he was forced to practice over the phone and online. Now, getting back to sort-of normal doesn’t mean a return to the office. It means getting out of it.
“Personally, sitting on my arse in an office all day doing phone and video sessions was hard for me and my mental well-being,” he said in an interview.
It was hard on his clients too. “A lot of my teenagers had a really hard time engaging with the virtual therapy,” he said. “I would say a bunch of the young adults that I was working with basically dropped off the map. And most of them would communicate with me saying, you know, Nick, I appreciate your efforts to do virtual stuff, but that’s not why I came to you. So I’ll reconnect with you when we’re able to see each other in person.”
Cardone is a Halifax-based therapist whose practice is called Free Range Therapy. He has long worked in non-traditional spaces.
“Traditional therapy is office based. It’s physically sedentary. How else can we do therapy and where else can we do the therapy?” he said. “Let’s explore. It doesn’t matter really if we go for a walk or hike, or if I’m shooting hoops with someone or doing an activity like geocaching or indoor rock-climbing… The idea really is to find something that resonates with the individual.”
Therapists in the province were forced to take their business online back in March, for public health reasons. In-person visits were only allowed for emergency care — for instance if a therapist considered that a patient might be suicidal.
But as the province opens up more and more, therapists and their governing bodies remain cautious.
Both the Nova Scotia Board of Examiners in Psychology and the Nova Scotia College of Counselling Therapists had their return to work guidelines approved last month, and they are extensive (17 pages long in the case of NSCCT).
But that doesn’t mean therapists are rushing to open their doors.
“We’re allowed to return to in-person elective, non-urgent care,” registered psychologist Daniel Chorney of Dr. Daniel Chorney & Associates said in an interview. “The very first thing the guidelines say is to determine if an in-person visit is necessary. We have the ability to return, but not like it was before.”
Chorney said the office is open “for a very small number of clients who meet this criteria laid out in the guidelines, who, for whatever reason don’t or can’t benefit from the tele-psychology.”
That sounds pretty straightforward, and so does the directive to see clients who are in acute crisis or worsening and seemingly headed to crisis. But there are complications too. One challenge, Chorney said, is “we can see you the in person and then deem it non-acute and go back to tele-health. I don’t know if people are expecting to go back” to online sessions in that circumstance.
He also said he’s had a few people express surprise they can’t book an in-person session.
Some clients, “insist on being seen in person,” Chorney said. “Within the guidelines, insisting is not enough to deem it necessary. Unfortunately, we’ve had some people become upset we’re not willing to see them in person. But we have to follow the guidelines. Some people are amazingly understanding and some find it a bit strange. ‘How come I can go to the bar but I can’t see you in your office?'”
Registered psychologist Judie MacDougall had no interest in using video-conferencing for therapy prior to the pandemic. In the days leading up to the province-wide shutdown, she would check the public health guidance at the end of each day, but she hadn’t done a lot to prepare for a move online and said she was “absolutely” hesitant about the whole idea.
“I don’t know why, but it didn’t occur to me they would stop us [seeing patients in person] because in my space we could do physical distancing and there’s no touching,” she said in an interview. MacDougall described herself as “not very tech savvy” and “a bit of a dinosaur.” She also said she was “pretty stressed out about the whole thing.” And her early sessions did nothing to help her embrace the technology, saying “it was really awkward at the outset.”
But she warmed to it quickly, saying she quickly found online sessions “were effective — video in particular.”
She still prefers the notion of seeing people in person, but said the experience of being online with clients has made her more open to seeing people remotely. She said, “I have had some people, especially people that travel to the city for sessions, or people with various health-related issues or physical differences, ask if they can continue to meet by video and if I am open to that, and of course I said yes. Previously, I would have been less inclined to agree to that.”
Like Chorney, MacDougall notes that “simply because someone would prefer to meet in person doesn’t mean they should be seen in person or they meet the criteria.”
Despite her greater openness to tele-health, she did miss her office though. “I’ve enjoyed the tele-medicine and being at home, but I find I’m much more productive in my office,” she said. “I could do tele-medicine from my office, but that would be ridiculous.”
Chorney said he was feeling “a little tiny bit of anxiety” about returning to his practice in person, even in a limited way. He compared it to when restrictions in general started easing. “I imagine it’s the same type of thing: you feel a bit of anxiety and then it’s normal.”
Masks are not required during in-person therapy, because the office is not a public space. Under the return to work guidelines, therapists do have to have masks available — in particular for use with anyone who has been pre-screened for symptoms but starts to demonstrate them in the office. MacDougall hopes to not have to practice in person while she or clients are masked though. “Part of what makes video so user-friendly is you get all the para-verbal cues and we would miss a lot of that with masks — as well as hearing people clearly,” she said.
For his part, Chorney is less hesitant about working with clients who are wearing masks. “I don’t know if you would lose a lot,” he said. “A lot of treatment is based on feeling physically and emotionally comfortable, so if you don’t feel comfortable that may negatively impact the session. But it’s for everyone’s safety.”
Chorney and MacDougall both have drastically reduced in-person office hours, with buffers between clients to ensure distancing. Some therapists (OK, mine) ask clients to text when they arrive and not enter the waiting room until told to in order to minimize accidental contact with others.
Because a lot of Cardone’s sessions are outdoors, he doesn’t have to worry as much about things like sanitizing a waiting room. He is still required to assess whether an in-person meeting is “necessary or appropriate,” but seeing people in person outdoors is not dramatically different from his pre-pandemic sessions. “I just don’t shake their hand or give high fives or come into close physical contact with them in any way,” he said. “But that’s the beauty of how I do the work. If I go for a hike or a walk, you know, even if it’s a walk on the street or a hike in the woods or something like that, it’s easy to maintain distances.”
Cardone missed the physical aspect of his work so much that he would sometimes go on hikes himself during sessions. He would book all his phone appointments for the same day of the week, and sometimes on that day, “I would load up a backpack with some lunch and some snacks and some water and I’d have an extra battery charger, and I would go into the Nova Scotia backwoods for literally four, five, six hours, hiking around,” he said. “And so, while I was hiking, I was on the phone with my client… I tend to engage and focus better with my clients when I’m doing something else. A couple of clients also started doing this. So they’d be geographically distant to me and some of them started going for walks where they were, and I would go for a walk or hike where I was. And then we’d have a therapy session like that.”
Confidentiality is one of the pillars of the therapist-client relationship. But with the advent of COVID-19, psychologists and registered counselling therapists have to inform their clients that they may need to turn over their information to public health in order to warn about potential exposure to the novel coronavirus.
Chorney said, “Our insurance company wanted us to sign a waiver, but as a profession we’ve pushed back across the country and said it’s more about consent. We’re going to ask clients to sign a consent saying they understand there is risk inherent” in in-person visits. (I can think of a university that could have benefited from this advice before sending out a heavy-handed waiver.)
The Nova Scotia Board of Examiners in Psychology puts it this way in its guidelines:
In order for clients to be able to provide informed consent for face-to-face services, they should be made aware of any changes in clinic procedures that would affect their visit as well as the possibility that their name may need to be disclosed if required by contact tracing.
“People acknowledge that by being seen in person there is a small risk, but a risk of exposure, and contact tracing is part of the process,” MacDougall said.
She added that she doesn’t see the increased sanitation required for an even limited return to the office as a problem, since she was already doing a lot of what’s in the guidelines anyway.
“I haven’t changed my routines a lot because I was always wiping things down. I’ve always had Lysol wipes and wiped the chairs. There is this part of me that thinks, oh right, not everybody does this,” she said.
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