Presence and Vulnerability: Team in a Virtual World (Part 2)

April 27, 2021

This feature by Ronda Oswalt Reitz, PhD is Part 2 of 2 in a series about communication tips to make a DBT consultation team effective in a virtual world. In the first part (read here), Ronda begins by looking at communication and coping ahead. Here in part 2, we examine the impact of the pandemic as it relates to presence and vulnerability and what to watch for to maintain the health of the therapists in the team.

In early March of 2020, despite some misgivings, I went to a film festival.  Over a span of four days, 15,000 people from all over the globe descended on our medium sized mid-western town to see a line-up of independent films.  There were no masks or hand sanitizer, no social distancing, and no mention of a pandemic.  It was emblematic of the planet’s response to this virus.  The following Monday I felt ill, worried I had contracted the virus, and began the first of what would be several periods of quarantine.  A week later COVID-19 was declared a pandemic and a national state of emergency was called.  And just like that, the “old normal” was gone. 

In describing the experience of those first weeks, words like apocalyptic and cataclysmic don’t seem too strong.  The streets were empty.  So many people were sick and dying.  It was hard to find basic supplies and food.  There was contradictory information about how to stay safe.  And in the midst of it, already full therapy caseloads burgeoned.  Therapists, as if shot from a cannon, suddenly had to become adept at using online platforms to access records, clients, and each other.  Barely out of its infancy, tele-mental health wasn’t considered a first line treatment by many providers, and now they were expected to do it full time.  This “stop-gap” strategy stretched from a few weeks to months.  There were no curricula, no training programs, no online CEU’s to teach us how to do it.  Just a new-found freedom to use platforms previously considered taboo for therapy, increased access to insurance and Medicaid/Medicare funding, and permission to do the work unobserved from home.  What could possibly go wrong?!   Thankfully, much of it went better than we would ever have guessed due in no small part to collaboration among therapists and the strength of consultation teams as we navigated this process. 

On the DBT list-serve, we feared the worst for our clients, then cautiously marveled at their strength and skill.  While an online platform didn’t work well for all clients, it worked better than we expected for most.  Many benefits became apparent.  We realized that we were no longer bound by geographic limits in the traditional way.  Clients from anywhere in the state could be treated, just as easily as those who lived nearby.  This opened up treatment for rural, disabled, and clients with no transportation.  Attendance for clients improved in the absence of transportation difficulties and costs.  Therapists could join distant teams.  Therapists also benefited from decreased transportation costs.  Employers realized cost savings by having employees work from home.  In fact, these benefits are so compelling, many companies, agencies, and private practitioners are planning to continue with expanded remote work and virtual treatment beyond the pandemic.   

It may have been the single most dramatic change in our history of health care delivery.  In the face of unimaginable loss and fear, and essentially over-night, we changed our system of care from face-to-face treatment to one that was almost 100% virtual.  And we did it admirably well, with few costs to clients as far as we’re aware.   As research evaluates clinical outcomes of virtual treatment as compared to face-to-face therapy, we will understand more about the benefits and drawbacks of this shift and of online treatment for clients, in general. 

But what of the health of the therapists?  In DBT, we place as much importance on the provider as we do the client, thus our research into outcomes of virtual treatment will need to include the health of members of the consultation team.  There may be important differences in the type and amount of support the consultation team might best provide to each team member.   Online work over the course of many hours is a substantially different demand than in-person work.  First, with meals close at hand, no commute, and fewer cancellations or no-shows, many therapists find that they can hold more sessions and attend more meetings in a single day.  Harvard Business School researcher Ashley Whillans found that people overscheduled themselves during the pandemic in order to make up for a decrease in social contact, leaving them stressed and unavailable for connection with friends and family.  During the pandemic, more individuals presented for treatment, and some private practitioners found that they had to draw a hard line on scheduling or they might work around the clock.  Teams may need to expand the time given for consultation in order to accommodate larger caseloads.   In addition, monitoring for burnout becomes more important with longer clinical hours and fewer breaks in between. 

Second, symptoms of fatigue, blurred vision, and emotional overwhelm have become common in therapists working online.  This has been labeled “zoom-fatigue,” although of course it can occur on any platform.  Stanford University researchers theorize that “non-verbal overload” causes these symptoms: close up eye contact, seeing ourselves on the screen continuously, decreased mobility, and constant close attention to non-verbal behavior of everyone on the small screen (Bailenson, 2021).  The researchers developed a 15-item questionnaire that has been administered to 500 individuals over the course of the last year.  The questionnaire measures exhaustion in the following areas:  physical, eye, social, emotional, and motivational.  This research instrument can be accessed at the following link:

We simply do not know the cumulative consequences of extended periods of social behavior on screen.  The potential that it can cause lasting harm to therapists is concerning.   Solutions for each area of fatigue are offered, but are not entirely viable in the context of a therapy session (e.g., turning off the camera when not speaking).  The goal of the research is to improve the technology but it is in the very early stages.  Teams may want to consider meeting in person as soon as it is safe to do so, in order to decrease screen time, and to increase support that is not accessed via a screen. 

And finally, in order to remain healthy, human beings have a high need for social contact.  It is not clear that interactions on a screen compensate for long hours of isolation.  Certainly, long hours on screen delivering treatment are not the same as in-person contact with friends, family, colleagues, or even “weak ties”-a reference to acquaintances in daily life.  Loneliness has significant health consequences equal in mortality risk to smoking 15 cigarettes a day, being an alcoholic, or obesity (Holt-Lunstad, 2010).  Marsha Linehan frequently admonished teams to remember to socialize together—to have a party or dinner together periodically.   A strong consultation team would do well to understand the implications of loneliness and to make active attempts to help each member stay engaged—even if that is mostly with other team members.  

Much has been written about the recurrent and long-standing stress caused by this pandemic.  Over the course of the last 14 months, we have experienced changes that our minds, emotions, and bodies will continue to process.  Ongoing and new vulnerabilities will be present for each team member and may interfere in optimal or even effective treatment.  The team may find collective wise mind wavering in the face of many challenges and skillful means lagging behind an emotional response.  Stay mindful of each other.  Be mindful of signs of overscheduling, fatigue, or loneliness in yourself or others, hold tight to the consultation agreements, validate each other and target these behaviors as you would any other therapy interfering behavior.  Remember that even as many of us are vaccinated, the impact of the pandemic will reverberate for some time to come. 

The annual film festival is happening again next week, on outdoor screens at a local park, and three months later than usual to allow time for vaccinations.  There will be socially distanced seating, many hand sanitizing stations, and all in attendance will wear masks.  Like the rest of this year, it will be a familiar but different experience than it has ever been before.  After 14 months of near total isolation, it will be both strange and wonderful to be in the company of so many other human beings.  Re-entering the world will hold its own implications for stress, so let’s be gentle with each other as we come back together. 

For more on how to maintain equilibrium and avoid burnout during the pandemic, click here for this feature on “Observing Limits During the Time of Pandemic by Cedar Koons.

Ronda Oswalt Reitz, PhD is the Coordinator for Dialectical Behavior Therapy (DBT) services for the Missouri Department of Mental Health. Dr. Reitz specializes in large-scale implementation of DBT and has developed comprehensive DBT programming in community mental health systems, inpatient hospitals, and in juvenile and adult forensic settings. Read her full bio here.


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