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A therapist on what it’s like to work with patients during the pandemic

Moving clients to virtual counseling was step one.

Two people interact over a laptop screen.
Across the country, mental health services are moving to telehealth.
Getty Images/iStockphoto

In some ways, Mary Firme has never felt closer to her clients. Therapy sessions are traditionally held in grim medical buildings and private offices, but now, as many of our institutions have been offloaded to the internet, Firme gets an opportunity to see how her clients live. She can observe the art on their walls and the books on their nightstands. Sometimes, she meets pets or small children, who wander into the bedroom and stand in the corner of the webcam frame. Virtual therapy isn’t for everyone, but Firme has still found a few small advantages along the way.

Firme is a licensed professional counselor who lives in Austin, Texas. When the city closed its doors on the Friday before spring break in mid-March, her office put a moratorium on in-person counseling services. Since then, she’s conducted the vast majority of her work via Telehealth — a network that offers a variety of different medical services to clients over the phone or internet. Firme isn’t alone; recent surveys estimate that 42 percent of Americans are turning to their phones instead of doctor’s offices during this stay-at-home order. Medical practitioners (and their patients) are converting their bedrooms, garages, and kitchens into makeshift clinics for the time being. Luckily, Firme says nothing has been lost in translation. She can still speak candidly with anyone who seeks her out.

Firme makes it clear that there are a few serious limitations to virtual therapy. If someone is in an unhappy marriage or an abusive living situation, it will compromise their ability to speak openly and freely within earshot of their cohabitants. She also believes that remote treatment is probably limited for children’s therapy as well. That said, Firme hopes that after the pandemic, her clients will continue to take advantage of Telehealth. These days, she routinely goes into a session with a patient during their lunch break — a microdose of therapy before they face the rest of the day — which is just one of the many ways we’re reimagining mental health services during the Covid-19 era. Firme thinks we should hold onto that creativity moving forward. Read our conversation below.

When did the pandemic start to affect your job?

It was March 13. That was the day before spring break, and there was a lot of talk in the universities that spring break might be postponed. What happens in the real world revolves around what happens in schools. When UT called off school that Friday, that was the moment where it was clear that something real was going on.

What was it like breaking the news to your clients that you weren’t going to be able to take in-person sessions for the time being?

Once I informed everyone that we were going to have to do virtual therapy for a while, a lot of them were completely on board with it. People have stuck with it and haven’t batted an eye. Every case is different, but 90 percent of clients are online. It’s been different. People are used to platforms like FaceTime and WhatsApp, so I can say, “Hey, the software I use is similar to FaceTime, it just takes you into an app,” and they’re like, “Okay, great!”

Was it awkward at all at first to do sessions over the internet?

So I’d done some Telehealth prior to this. Some people travel for work, or they can’t make it in, and it’s covered by a lot of insurance companies. It’s well known at this point. But as far as getting used to it, there’s been a learning curve. Some of the technology is tough to guide people through. I never thought I’d be a therapy tech support desk. Another strange byproduct is that when you’re on camera you’re being very mindful to sit up. You don’t want to change positions too much. You start getting these strange aches and pains. But a lot of it has been pretty straightforward. I’m really thrilled and excited that we have the technology to do this now and get people what they need.

Are you still going to the office?

I go to the office. I had three college-aged kids come home from spring break and not return to school, so I use the office so there aren’t any distractions and people aren’t coming through the doors. I’m hoping that we can open up fully again sometime in the near future. I have done some therapy from my house in a pinch when it’s an unexpected session with someone. I don’t have an office, but I do have a bedroom. It works anywhere where you have a good internet connection and a cellphone or an iPad. I can function that way.

Have the sessions themselves been different? Have you been able to reach the same level of intimacy?

For the most part, it mirrors what we’ve been doing in the office. One of the unexpected joys is you get to meet other people’s children and pets, you get to see their home environment, and if they have fun art and stuff. You learn a little bit more about the clients, and I think that’s helpful and important. Ironically, prior to this, the 4 pm to 7 pm therapy hours were the ones everyone wanted because they wanted to go in after the school day or workday. But now, the middle of the day schedule, around someone’s break, are the new hot spots. The level of connectivity is just as good. The clients I had in the past, we still have the same rapport.

Have you taken on any new clients?

I have a very solid continuing client base, but there’s been a few new folks that have come on during the pandemic. A lot of it comes from being alone, and being with their thoughts, and wanting to come to therapy. It’s been an easy transition for people with Zoom and FaceTime. When they sign on with me, I want to make sure that they live in Austin so we can continue in person. I don’t want there to be a situation where someone is like, “Oh great, she takes Telehealth,” and they live in Houston.

That almost sounds advantageous to you, as a therapist, to see how your clients live.

Absolutely. They can hold their dogs, which might make them feel safe. It gives me a sense of what’s going on. It’s a nice glimpse into something we might not otherwise have the privilege to see.

How often do you guys talk about the pandemic? Does that affect the sessions?

Pretty much every session, over Telehealth, it comes up, because we’re doing Telehealth instead of in-person therapy. Almost everyone is bringing it up because their lives are changing, their worlds are changing, their jobs are changing. If there’s a function of society that hasn’t been affected by the pandemic my clients will bring it up, and I’ll be like, “Oh right, that’s changed too.” People are processing other things, but the pandemic is on people’s minds all the time. It’s a huge anxiety for so many clients because they start thinking about their grandparents or their neighbor with diabetes. Everyone is questioning their mortality. It’s a constant reminder of what’s going on.

Do you give your clients advice on how to ensure that they have privacy at home when they’re in a virtual session with you?

I always suggest they go somewhere private if at all possible. This is the caveat. If someone is in a violent situation or an unhappy marriage, that person might not be a good fit for video therapy. But people know to go somewhere private, and I always mention that to those who aren’t doing that. But my goal isn’t to tell you how to handle your stuff. I’m here to help people figure out things for themselves and not dictate anything.

Do you think your clients will continue to use virtual therapy more after the end of this pandemic?

I would hope so. I would hope that this continues to be an option. There is some pushback from insurance companies. If someone is private paying, it doesn’t matter. But there’s some worries that Telehealth might not be equipped for certain situations. And granted, it’s not for everything. From some illnesses, you still need to go into a nurse practitioner’s office. But I hope that they continue to cover it because it gives people so many options. I have people doing therapy during lunch hours at work, which wouldn’t have happened before.

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