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Like many of you, my work as a BHC moved abruptly to 100% phone and video work in mid-March 2020 due to the COVID-19 pandemic. Personally, there have been some downsides to this. I miss seeing patients in the privacy of an exam room or my office and that irreplaceable connection that can arise between us when we occupy the same space. And: so.much.sitting. However, there is something else that we may come to consider irreplaceable about telehealth as we proceed into the uncertain future: environmental context. The amalgam of experiences below attempts to illustrate the power of the context provided by telehealth services.
I log into the 10 am telehealth visit. By 10:02, the patient has not joined the virtual meeting so I call her phone and she answers. The first thing I hear is a crying baby. The next is a toddler—“no, no, no, NO!” Third is the patient—“Hi Katie, I’m so sorry. Everything exploded right before 10.”
She proceeds to join the video meeting and I can see her bouncing the baby. The toddler is briefly quiet, interested in my face on the screen. Showing me his doll, which he proceeds to bounce just like his mom is bouncing his sister. I provide appreciative feedback to him and he keeps going. They are in a dusky room with light filtering through cracks. A bed that is stripped of blankets and piled with stuffed animals, toy cars and what looks like an enormous open suitcase fills the room. A table is in the corner and holds a percolating coffee machine, an open box of Cheerios, a bag of mandarin oranges and a stack of paper plates. While she bounces baby to sleep she says apologetically and with a bit of a tremble in her voice, “we had to move into my sister’s spare room last week so things are really messy….”
We go on to discuss her partner’s recent job loss, choosing to vacate their apartment rather than face uncertainty of whether they would be able to pay rent, trying to make it work for a family of four living in a single bedroom, the new hopes they are forming for the future. All of this in a roundabout effort to address a worsening case of postpartum depression.
The elements of providing behavioral health services via telehealth that stand out the most to me thus far are the sights and sounds that form the music of our patients’ lives—and of course our own lives for those providing telehealth services from home. That cacophony of howling dogs, brightly painted walls, heavily curtained windows, cooped-up children, endless Netflix and ESPN, backyard trains, crisply made beds and stacked unpacked boxes of which we are completely unaware when we meet in the office.
These sights and sounds paint a deeper and more nuanced picture than the still life of the contextual interview. They disrupt our tidy in-office discussions and explode the reach of our interventions into the realm of real life. We understand without asking the nature of the current stressors and the elements of daily life that are deserving of gratitude. In addition, of course—most of all—these sights and sounds mean access for many people who have never before had access to healthcare with so few barriers. No cross-town or cross-county trek through bus stops and traffic. No expensive childcare arrangements or taking 3 hours off work for a 30 or 40-minute appointment.
At the end of our appointment, this particular patient thanked me. She said she had been looking forward to the appointment for several days—one of very few conversations she has with adults these days. “I never would have made this appointment in person—we just got out of bed 10 minutes ago and the kids haven’t eaten yet.” We had managed to communicate with her medical provider during the visit and they made plans to have her start taking an antidepressant. We tried to identify some small and realistic steps toward feeling better and made plans for our next telehealth visit.
These sights and sounds mean access for many people who have never before had access to healthcare with so few barriers
Before we ended, she was able to lay her baby down in the pack ‘n play (still sleeping—victory!) and sit on the bed to play with her toddler while we talked. There was so much care and strength in those interactions with her children and of course, I pointed that out to her. I could see a tiny smile lift the corners of her mouth as she took in my words, hands busy rolling cars over the open suitcase as she listened.
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