Continue or quit therapeutic treatment? (Covid-19 filter)

July 29, 2020 11:11 AM

My therapist, who I see once every other week for 50 minutes, does not wear a mask.

We'd been doing a couple TeleHealth sessions since the virus hit, but they're really not effective for EMDR, which it turns out is a rousing success for me. I could tell the difference after only a couple sessions (done before Covid-19). I just can't see it clearly on the screen. Phone sessions are OK if I just want to talk, but I want to get in as much EMDR as I can -- it's breathtaking.

Her rationale is,

Social distancing is maintained, office and common areas are sanitized throughout the day, a HEPA 3-filter air purifier runs 24x7 in my office, no groups of people are allowed in the waiting room or my office, and hygiene practices are followed. Ultimately, I feel that wearing a mask interferes with the therapeutic process.

Clients are expected to make their own choices about whether to come in or wear a mask. I do not compel anyone to act in a way that is contrary to their comfort level.

I've only been back in person once, two weeks ago. She does sit across the room from me. Still I don't feel quite safe. What do you think?

posted by intrepid_simpleton to Health & Fitness (27 answers total)

1) how does she feel it interferes with therapy?
2) i think her lack of doing what makes you comfortable is kind of shitty.
posted by misanthropicsarah at 11:20 AM on July 29, 2020 [26 favorites]

Not to discount your experience, but I was taught—in a class on treating trauma—that the effective part of EMDR is the exposure therapy (which is the traditional treatment for trauma), not the eye movement part. Some people find that helpful when they’re so distracted by their trauma they’re unable to focus, but in research it is equivalent to traditional exposure therapy for trauma. I wonder if you’d be open to continuing telehealth even if you can’t see it clearly? Do you feel like it’s not helping as telehealth, or just feel that it must be degraded because you can’t see the movement well (which you understandably assume to be integral)?
posted by brook horse at 11:25 AM on July 29, 2020 [3 favorites]

Clients are expected to make their own choices about whether to come in or wear a mask. I do not compel anyone to act in a way that is contrary to their comfort level.


There you have it. Seems like a reasonable stance. If you are uncomfortable with therapist not having on a mask, do not go. Therapist is very clear that their position is no mask.
posted by AugustWest at 11:38 AM on July 29, 2020 [8 favorites]

I would ask her to wear a mask (not clear if you've specifically requested it), and if she refused, I would not go into her office.
posted by gideonfrog at 11:39 AM on July 29, 2020 [8 favorites]

Your state has guidelines, look them up. Therapist has a professional obligation to follow state guidelines and possibly professional licensing guidelines.

In a closed room for 50 minutes, you are at risk of getting any airborne germs the therapist has. I would not find this acceptable. I just met with a health care professional for @45 mins , we stayed masked. You could consider getting an N95 mask to use and re-use. Open windows are much more effective than any ventilation system. I have Opinions about this therapist, but do whatever you can to stay safer and still get needed therapy.

For tele-sessions, a tablet or larger screen might make a big difference, as well as a headset.
posted by theora55 at 11:42 AM on July 29, 2020 [13 favorites]

IAAT. IANYT. If the therapist seems otherwise helpful, have a conversation with them. Ask them if they would wear a mask for your comfort.

Also, EMDR can be facilitated virtually through video, and safely, but many old school practitioners of EMDR aren't comfortable doing it. Some will be. So it's possible you can find a different provider for the EMDR who will be able to do it through telehealth, if this provider will not wear a mask. I suspect most therapists are struggling with this decision because they want clients to see their facial expressions. But if you need the mask to feel safe, tell them so and see what they say.
posted by crunchy potato at 11:43 AM on July 29, 2020 [2 favorites]

To me, this is the same question as, say: "My new boyfriend, who also dates other people, does not wear a condom, because he feels that it interferes with the sexual process." Substituting genders as necessary, would you feel comfortable with that?

Taking the metaphor further, there are circumstances in which unprotected sex is a very fine idea, but many more in which it is not. Think about where that line is for you.
posted by the_blizz at 11:48 AM on July 29, 2020 [10 favorites]

My therapist who is older is only meeting clients in person outside with masks.

With someone who is around people all day in contact without a mask I wouldn't risk it.

My social work job requires a mask AND face shield for all encounters which are substantially less in length than individual therapy sessions.
posted by AlexiaSky at 12:02 PM on July 29, 2020 [4 favorites]

Still I don't feel quite safe. What do you think?

You are not safe, so it seems perfectly reasonable that you don't feel safe. Your therapist is putting themselves and the clients that do visit them in person at risk. It's unprofessional.

I wouldn't worry so much about another client with COVID-19 being in the room and picking it up from residual droplets on furniture, etc. But if she is exposed to COVID-19 she may very well pass it on to several other patients before she's aware she has it and shows any symptoms (if she does) and tests positive.

I would find a new therapist if this person is unwilling to wear a mask. This is not a matter of personal preference, the science so far seems pretty clear that the conditions she's operating in offer a strong chance of COVID-19 transmission if a person in the room has COVID-19.

The only way I'm going to be in a small room with anyone outside my immediate family bubble is if we are both masked and there's a damn good reason I have to be in that room. Otherwise, I'm out.

Strong -1 on continuing with this therapist or visiting them in person.
posted by jzb at 12:13 PM on July 29, 2020 [11 favorites]

Here's a pretty good summary of the research and theory behind mask-wearing (with citations). As described in that summary, the factors that play into risk include:
1. Proximity
2. Number of people
3. Time
4. Location (indoor vs. outdoor)
5. Air exchange
6. Masks

Your therapist is proposing to spend time in an enclosed space for an hour without wearing a mask (risky on #3, 4, and 6) while using a 6-foot distance, low density of people, and an air purifier (risk mitigation on #1, 2, and 5) as justification. Personally, I wouldn't be too happy with that solution -- though I am personally quite risk-averse.

Another question you might ask yourself: is there community transmission (aka, spreading by asymptomatic carriers) in your area? If so, I think your therapist's solution is a no-go -- health checks don't do much good against asymptomatic transmission. For further info, check the WHO's guidance -- in areas where there is known or suspected community transmission, they recommend 100% masking for all health care providers, including outpatient & community providers.
posted by ourobouros at 1:08 PM on July 29, 2020 [2 favorites]

Have you asked her if she is willing to wear a mask during your session to make you feel more comfortable? That seems like a very reasonable request. If she is wearing a mask, it will significant reduce the chances that if she is positive, she will transmit to you. Obviously her risk of being positive is higher given that she is unmasked with others but the guidelines are based on the assumption of assuming other is positive anyway.

There are some options the therapist could consider that could be better than a traditional mask in terms of not interfering with therapy - eg. face shield with cloth around the openings or a mask with window for people who are lip read. But I don't think it is up to you to solve this for her.
posted by metahawk at 1:11 PM on July 29, 2020 [1 favorite]

I can't fathom how HER* wearing a mask interferes with the therapeutic process (aside from the ordinary inconveniences, like speaking requiring more effort, with which we're all coping.) If I were you, I would ask her directly how her wearing a mask would interfere. And unless she can give you a VERY good and specific reason why you need to see her mouth, I would tell her straight out that her position is undermining the trust you need to continue EDMR with her.

*I can imagine how it's perhaps harder for her when her patients wear a mask, but she is wise enough to realize that she cannot and should not require her patients to go maskless.
posted by desuetude at 1:11 PM on July 29, 2020 [1 favorite]

Where are you located?

I'm a therapist in Portland, OR and almost all of my colleagues are only doing video and phone sessions. I have heard of some therapists who are trying outdoor sessions. I have not heard of any therapists who are meeting people in person in their offices.
posted by overglow at 1:19 PM on July 29, 2020

I’d accept the conditions but only outdoors. Airflow is too strange for me to be comfortable that all of the air was going through the air filter on a regular basis.
posted by Tell Me No Lies at 1:22 PM on July 29, 2020

Best answer: Ask the therapist which malpractice insurance they have, and have they approved the safety protocol in place?
posted by Sophont at 2:07 PM on July 29, 2020 [8 favorites]

Response by poster: OK, it sounds like my instincts were right. Appreciate the input.

(Unfortunately our state kind of sucks with a mini-T governor who is out of his mind anyway -- but I'll look up the guidelines.)
posted by intrepid_simpleton at 2:08 PM on July 29, 2020

Your therapist is being terrifyingly unprofessional.

You're in the United States. You're in a high-risk group. If your therapist won't take precautions to protect you, I think you need a better therapist.

This made me think of some recent news involving a "therapist" in B.C. with fake degrees -- the prof who figured it out became suspicious after the therapist allegedly instructed the prof's student, who was doing a practical placement, to continue seeing patients face-to-face during the COVID-19 pandemic.
posted by heatherlogan at 2:13 PM on July 29, 2020 [2 favorites]

FWIW I and my therapist both agree wearing masks interferes with our therapeutic connection. I don't do EMDR, but it is still very important to us both to see each other's faces. But that is why we are continuing with televisits--the discomfort with lack of facial expressions isn't unreasonable, but expecting you to still meet face-to-face without a mask is!
posted by assenav at 2:27 PM on July 29, 2020

Response by poster: I see a few people jumped in. To be clear, I wear a mask. I wear a long scarf tied around my waist, too, so I can open all the doors that should be propped!
Thanks also for the EMDR lit. I'll enjoy reading that. Was not aware one could do the work on themselves!
posted by intrepid_simpleton at 3:17 PM on July 29, 2020

I can't fathom how HER* wearing a mask interferes with the therapeutic process

Clients scrutinize therapists' reactions, both verbal and non-verbal, to everything they say. A therapist wearing a mask would absolutely interfere with the therapeutic process and it's silly to think otherwise. But that interference is less important than not killing one's clients and it shouldn't be the primary concern.
posted by lapis at 9:47 PM on July 29, 2020 [3 favorites]

A mask does limit some cues, but it's not even the whole face! People in general expeess themselves with their entire body, and things like eye contact (which you can see) make a difference! Masks have slightly different limitations than video which generally limit the view of the body.

But getting your clients sick(or dying! ) is definately not ethical or okay either! There is well documented risk in not mask wearing which is why if she wants to make an exception for herself she should not be doing therapy. It is not okay. Far too many people she is the point of highest risk in their day!

Honestly I'd just respectfully bow out and not give her the option. "Since you informed me to you will not be wearing a mask, I will need to continue telehealth Sessions. If you change your mind about masks, I would be willing to concider in person."

Feeling safe is a huge part of EMDR. If you have any lingering thoughts that this idiot might kill me, your EMDR won't be nearly as effective.

There is a possibility your in a community with very low infection rates, which may be part of her rationale but you do not mention where you are. If infection rates are low or zero, the risks are lower, but right now with the US being how it is, I wouldn't.
posted by AlexiaSky at 11:54 PM on July 29, 2020 [2 favorites]

Response by poster: I missed someone, a couple someones, actually.
No, brook horse, I don't think telehealth is effective for EMDR as I can't see her hands clearly to follow them with my eyes.
theora55, both of my jobs went away due to covid-19, so any new toys are out of the question. (Good idea, though.)
posted by intrepid_simpleton at 8:10 AM on July 30, 2020

Therapists concerned about facial cues could wear masks with clear panels designed for the hard-of-hearing and deaf communities.
posted by acridrabbit at 8:51 AM on July 30, 2020 [2 favorites]

I've never heard "I'm using a HEPA air purifier" as an attempted mitigation of risk here, would be interested to hear other perspectives on this. My hunch is it's useless or somewhat ineffective. Agree on EMDR being also likely not great if you don't feel safe. Genius idea about insurance.
posted by lokta at 10:29 AM on July 30, 2020 [2 favorites]

I'm a therapist in a place with very low cases. I'm risk averse, so I'm still not agreeing to meet with people in person. I did try it a couple times, with the stipulation that we both wear a mask. Those two times showed me that I wasn't comfortable with it...people cry in therapy, lift mask to blow their nose, it's an hour in an enclosed unventilated space...doesn't feel safe.

That said, the guidelines we have are what your therapist is doing. As long as you can distance, no mask necessary. It's what many of my colleagues are doing. They are much less risk averse than I.

EMDR is best done with eye movements, but doesn't have to be. You can do any sort of bilateral stimulation. Some people doing tele-EMDR are using tapping (having clients tap on their knees back and forth). Another (expensive) option would be for you to buy your own "buzzers". You hold one in each hand and they buzz in alternation. The therapist would tell you when to turn them off.

EMDR can be done on your own, however we were told it came with the grave warning that if you felt alone and unsupported during, for example, a childhood trauma, then you don't want to replicate that.

It's tough times for therapy with different comfort levels leading to unfortunate situations. Best of luck to you.
posted by EarnestDeer at 3:32 AM on July 31, 2020

Best answer: EMDR can be done alone, but it can also trigger sudden and severe dissociation (which is why some practitioners who have provided it for many years won't do it virtually). I wouldn't recommend trying it alone unless you've had a lot of it through a therapeutic relationship already and already know your risk of dissociation.

As previously stated, eye movements are not the only way to reprocess information being targeted in treatment. There are online apps that can be used for visual or auditory stimulation as well as self-facilitated tactile bilateral stimulation.

Getting Past Your Past is the name of the self-help book written by the progenitor of EMDR. If you want to do self-led stuff, the exercises in that book are designed to be safe for you to do on your own.
posted by crunchy potato at 9:28 AM on July 31, 2020 [1 favorite]

Response by poster: Followup:

I do not intend to wear a mask in sessions at this time. I experienced mask wearing throughout the day while seeing clients, and it was less than ideal for therapy. Therefore, clients who are uncomfortable with being seen in person without a mask are invited to return to video sessions.

Even if "less than ideal" means "it was uncomfortable." Yeah, I could ask her WHY is it less than ideal, yadda yadda, but besides being (self-diagnosed) avoidant personality, this is not the hill I choose to die on. I have neither the time nor the energy to search for another one at this point, so I guess I'll just talk via TeleHealth or Zoom for awhile and schedule just enough sessions to keep me on her radar.

I should tell you she's not nearly as stiff as she sounds in her writing.
posted by intrepid_simpleton at 9:27 AM on August 5, 2020