I’m analytically trained and I’m more conservative in my practice than many. I returned to in-person work relatively early – I gave my patients the option to return two weeks after my second shot, in March 2021. By May 2021, all but two of my patients had returned to my office.
Within a week of my first patient’s first in-person session back, I was confronted by a request to meet virtually (because it was raining). Within two weeks, it was clear that at least some of my patients were using the possibility of switching back and forth at will as a venue for their acting out.
I never liked working virtually, and I found myself resenting these demands, and their logistical consequences for me. I longed to retire my ring light, to reconfigure my chair/sitting situation so it wasn’t bimodal, so it was simply set up to be comfortable for me to sit and face my patients. Sitting in my chair. In my office.
I longed for what I experience as the clinical richness of sharing space with my patients, of hearing and seeing them interact with my waiting room, with my office, even with my bathroom. And, of sharing with them the benefits I perceive of the inconvenience of meeting in person: the time it takes, the separation from the rest of life it demands, the opportunity to devote oneself fully to the session at hand, and of course, the experience of being together – seeing one another’s bodies, smelling one another, etc.
I realized that, to provide my patients the experience I wanted them to have, and to protect myself, I needed to be much clearer about what I was and was not willing to do. Here’s where I landed:
I told all those patients who returned that I am an in-person therapist, that I believe, for me, given how I work, that meeting in person is best. I told them that I’m not, generally, prepared to meet virtually except in very limited situations: those in which a) meeting in person isn’t experienced as safe by one or both of us, and/or b) the physical, geographic circumstances of one’s life make it impossible to meet me – or any therapist – in person – for an extended period of time (not for a day-trip, or a week away). I was open to very limited exceptions to this – I met with people virtually if they were quarantining before travel, or, in one case, if we discussed the reasons to meet virtually on a session-by-session basis, in person, at a session prior to any virtual session we agreed on in advance.
And:
I explained my thinking: given that our project is, ultimately, for us to develop a shared understanding of my patient’s life, there actually is value in, from time to time, our having the experience of missing a session, of feeling the pain or relief or resentment or whatever that may accompany the collision of irreconcilable demands on their time. Feelings that might be directed toward me, a spouse or partner, work, weather, God, the world. I further explained that, when circumstances made meeting in person impossible, I would work hard to find a time to reschedule a session we otherwise would miss at a time that worked to meet in person.
All this was… heightened?… by my expectation that my patients pay for scheduled sessions, period. No twenty-four-hour cancellation policy. When I reserve a recurring hour for my patients, they pay for that hour. Period. (Two exceptions: my vacation and their vacation.)
I should say: all my patients appreciated all of this. None pushed back, initially. Not one.
Over the following months, a couple of patients “forgot” our discussions, what I had said, what they had agreed to, and made last-minute requests to meet virtually. Generally, when this happened, I would try to find a time to meet in person and, if I couldn’t, I would say “yes” to a virtual session, but would say, in doing so, “… but let’s discuss situations like this when we meet,” and I would remind them of our previous discussions, and inform them I wouldn’t be granting such an accommodation again.
For all but one or two patients, all this actually felt good. Containing. Holding. For those others, it brought up familiar, pervasive feelings – transference. What I think of as the bread and butter of our work.
Now, a year after my return to in-person work, I have only two patients with whom I meet virtually – each, for complicated reasons that have nothing to do with anything we’re discussing in this thread.
I don’t make any claims about the utility or right-ness of any of this. It’s just what has been working pretty well for me, given who I am, who my patients are, how I practice…..
