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Clinical News

Zooming in the Pandemic

When the COVID-19 pandemic hit, we had to adapt quickly. Both the virus and our adaptations to it shook the foundations of the Riggs community. The virus turns every person into a potential hazard to every other person; anyone could be a silent unwitting conduit. So many people already harbor anxiety about being harmed by others or about accidentally harming them–this harm is now perilously close to becoming real. The virus becomes a symbol for the dangers of other people.
Our necessary adaptations in the name of safety also threaten community–specifically the openness needed to foster autonomy and to support the random meaningful connections that are such a central, though often overlooked, part of its benefits. Just a few months ago I spoke at the Riggs Centennial Conference about the regular practice of gathering together that sustained us during the crisis of 9/11. In the present crisis, gathering together is exactly what we cannot do. Even smaller meetings must be more distant and more controlled. Freedom of movement on and off campus is curtailed; relationships are disrupted and blocked. People can’t see the people they rely on most.
The cornerstone of our pandemic adaptation is Zoom, the videoconferencing app. At Riggs we have had Zoom meetings with geographically distant family members for a few years. Our nimble IT department quickly scaled up, and within a week we could Zoom most meetings. The on-campus population thinned dramatically, making physical distancing easier for those of us remaining. Patients living off campus began to receive services remotely, and many staff worked from home, Zooming in for clinical and administrative meetings.
Zoom helps us to stay connected in the face of danger. It has enabled us to preserve a residential treatment setting while diminishing the risks of contagion. However, Zoom cannot replicate actual physical presence and, less conspicuously, it constrains interactions to the more deliberate and intentional, filtering out vitally important accidental parts of social life in the name of efficiency and expediency. It becomes more difficult to make space for the unexpected. We compensate for this by paying close attention to its impact, in much the same way as we attend to the effects of other aspects of the social environment.
Zoom proved to be remarkably easy to use for one-on-one and small group meetings, and even for formal gatherings of dozens of people (our All Center meeting, a family town hall, a regional conference for residents). We have kept our daily larger meetings–clinical staff meetings and patient-led community meetings–mixed, with a limited number of people physically together (but spaced apart) in a large room, and others present via Zoom. These are not primarily information-sharing meetings; they are places to work together with the emotional dynamics of the system. Being present via Zoom, of course, is a way of being present even though absent; a way of being both present and absent at the same time. As the pandemic wears on and we settle into what people are calling the “new normal,” the absence within this presence is becoming more evident.
Humans, like other animals, seek proximity to others, particularly in times of danger. Young children turn to caregivers when threatened; we find safety in numbers. The Riggs environment is designed to provide a broad and flexible safety net. Formal relationships like psychotherapy are a big part of it, but as important is the ambient community, the network of working groups and informal relationships that offer places to experiment and explore. So much of what happens here is delightfully unscripted and unpredictable.
To the extent that the treatment is “insight oriented,” rooted in speech, and fostering reflection, Zoom works well enough. While children need physical proximity for safety and security, adults can usually manage with emotional closeness. However, this is more difficult for emotionally vulnerable people or for anyone in times of heightened stress. The virtual connection afforded by Zoom offers verbal and visual contact across physical distance; it is somewhere between reality and virtual reality. The other person is really there, not imagined, but they cannot be touched. They can seem very present, but they can disappear with the flick of a mouse or a glitch in the Wi-Fi. (Much has been written lately about the differences between in-person and remote contact–for instance Kate Murphy’s New York Times article, “Why Zoom Is Terrible” and a lecture for clinicians by the psychoanalyst Todd Essig, “Emergency Conversion to Tele-treatment: Making it Work.”)
Maintaining a shared space when physically separate requires effortful focused attention (hence, the familiar exhaustion at the end of a day of Zooming). Information is both limited and amplified–slight time lags, imperceptible auditory filters, and constriction of the visual field, all distort the many subtle cues that human interaction relies on. On Zoom the face is large and in focus, “in your face” in a way that can feel mandatory. To look away, to gaze out the window and allow space for reverie, risks breaking the connection. There is a lot of information on a face; but online, detached from a part of its context, it is more easily misread. There is no eye contact: you can never look at someone looking at you. You cannot tell if the person is looking at you or at something else on their screen.
Many people who become patients, like many people who become clinicians, are highly sensitive to emotional micro-expressions that are muted on Zoom. The absence of the body, the demand for focused attention, and the lack of a shared surround constrain what can be felt. Sometimes, and for some people, the greater distance can itself be a respite from the overwhelming presence of others. However, to the extent that the work of therapy is about linking–body and mind, emotion and reason, experience and reflection–the added gap of Zoom over the long term can be counterproductive.
Even if Zoom psychotherapy, psychiatry, and family meetings work well enough, there is a lot that cannot be done remotely. As we began discussing work-from-home options at Riggs, one of the kitchen staff joked that he could have the dirty dishes sent to his home to clean. This is most obvious: people who look after the physical environment, like people who look after the physical body, are an essential part of the “holding environment”–the quiet, often overlooked background of social support that the patients rely on. Here, like in other hospitals, our nursing and community staff are the up-front, in-person, sometimes hands-on, 24-hour-a-day clinical presence that holds and stabilizes, enduring emotional eruptions, as well as looking after any physical need that might arise. For this too, full presence is required. Many people come to Riggs to be amongst others, because their previous lives were too isolated, chaotic, or distracting; the community is somewhere between a hospital and a family.
I Zoomed from my office into the patient-led community meetings for the first month or so of the pandemic, to leave space for others to attend in person. When I returned in person, in response to an open request from patients to staff, I noticed a different emotional experience of the meetings–they seemed more stirring and more immediate. People shared complex and vulnerable feelings and reactions to one another spontaneously and courageously. Upon reflection, I realized that the meetings I attended by Zoom also had these moments, but I did not feel them in the same way. Working remotely, there is less information—less of the implicit, unconsciously registered information that fuels empathic resonance.
Physical absence is a clear limitation of the Zoom encounter; less clear but as crucial is the loss of the essential randomness of real-life relationships. In a therapeutic community so much that is important is unintentional—unscripted, unplanned, undirected. Like free association in psychoanalysis, you really don’t know in advance exactly what is going to happen. Sometimes people just sit around, ignoring each other or maybe chatting idly, informally, playfully, or seriously; finding comfort, managing irritation, expressing appreciation, playing games, watching things, making things. The milieu is a playground and a workspace for skill development–not the kind that is taught in workbooks, but the kind that is learned in practice. Perhaps Zoom is better suited to workbook instruction, which is planned, organized, deliberately joined, and turned off and on–better suited, in other words, to a more controlled environment.
The staff, too, rely on the hallway chats, the informal joking around or swapping stories coming into and leaving a meeting, the ten minutes between our 50-minute sessions, the huddles. A few years ago, we were thinking of trying to formalize the huddle, to designate a meeting time for people to not-meet, to grab one another for 5- or 10-minute conversations they otherwise didn’t have time for. But we realized that to formalize it would have turned it into something else; trying to merge the spontaneity of the random huddle with the mandate of the scheduled meeting would have meant losing the advantages of both. Zoom requires that sort of formality. You have to plan and intend to meet.
In a Zoom group meeting, you can’t share a glance with someone, a surreptitious smile of recognition or an eye roll–any expression is for anyone who might be looking, and you can’t tell who is looking. People can watch specific others very closely without being seen to be watching; or they can ignore everyone. In our staff meetings with some people in the room and others on the screen, sometimes the ones on the screen (some of whom object to being referred to as “on the screen” or “in the computer”) seem to be doing something else. When physically present some people may furtively check their phones. But at a distance, alone with a computer (except not entirely alone, because they’ve also Zoomed into a meeting), the temptation seems so much greater to finish a note, check an email, look something up online. So, in larger Zoom meetings some people are only a quarter there–physically absent and mentally distracted. For the Zoomers, part-Zoom meetings are harder than all-Zoom meetings because the in-person participants are all on one view, rather than appearing as separate faces-in-boxes. Speaking from afar feels different. The timing of turn taking has to adjust to the Zoom micro-lag.
To the extent that a Zoomer maintains the effortful focus required to feel “in” the virtual space of the meeting, we are not-in–that is, not attending to—our own physical environment. When I lived in Asia, I sometimes went to American movies, and even after I had been there a long time, whenever I came out of a theater back into the streets of the city, I felt shocked to find myself where I was, rather than in the more deeply familiar places depicted on the screen. You can feel very much “in” the space on screen–and in a meeting it can be a virtual space created between or among the participants. However, this necessarily detaches you from the actual physical environment. On Zoom the effort to stay connected takes you away from where you are.
This difference is most obvious in silence, and silence is such an important part of serious reflective work. In silence you can be together, but also allow freedom for minds to roam, for reverie, for making the connections that require time and space to develop. In a virtual meeting a silence feels more solitary; the shift of attention can feel like a shift to being alone.
As I write this in mid-May of 2020, the long-term effects of the virus and our global adaptations to it remain a very large unknown. Zoom and its technological kin enable us to maintain a remarkable degree of connection while safely distancing. Protection from this threat, and the anxiety that comes with it, requires that we limit the unpredictable; in doing so we also limit the ineffable, serendipitous benefits of being together.