Dispatch from the Covid-Mandate Frontlines: The Pitfalls of Remotization

A clinical social worker in NYC shares her account of how Covid mitigation-at-all-costs policies have harmed the most vulnerable among us.

This story comes from a NYC-based social worker who has seen first-hand how remote psychiatry and mental health services simply do not work for everyone.

She even offers a solution or two.

Policymakers - take note.

REMOTIZATION

by Ilana Horowitz

The harms from prolonged school closures are now well documented.

In this piece in The Atlantic,  you can read about how high-poverty schools on average stayed closed even longer, and widened racial achievement gaps. Learning loss is real and hit vulnerable communities the hardest. Harvard University tweeted that remote school widened racial gaps in education. This is backed up by recent federal data revealing how this has affected nine year olds with reading and math scores declining significantly. 

Schools also struggled last year to deal with worsening student emotional and behavioral issues.  After all, schools are not just places where children learn academics, but where they learn how to interact socially, and what is acceptable.  They learn from watching peers and other adults.  This simply was not available to many kids who lived in areas with prolonged school closures.  Books and articles have been trickling out over the past year about the importance about the impacts of school closures, but there is resistance to assigning blame or even examining how this was allowed to happen. 

Of course, it is not over and done with.  Kids in many liberal areas are still contending with mask and vaccine mandates for extracurricular activities including sports.  Additionally, we still have a mountain of work to do to catch children up and provide for their emotional needs as well.  Do we trust the people who encouraged these closures with that task? Certainly not, if we know that will not be held accountable, either way.

Late last year, the US Surgeon General Vivek H. Murthy released a report showing the extent of the pediatric mental health crisis and called for urgent action.  Dr. Murthy highlighted increased ER visits due to suicidal ideation by adolescent girls as well as across-the-board increases in depression and anxiety.  This paragraph stood out to me:

“Repeated lockdowns designed to curb the spread of the virus also meant that many youths’ social networks collapsed, according to Murthy. Children and teens, he pointed out, were cut off from friends who could have provided social support and from seeing pediatricians who might detect mental health issues. They were also isolated from adults outside the home, such as teachers, who could have been lifelines for children affected by the uptick in domestic abuse during this period.”

He calls for investment in stakeholders but what does that mean? Mental health services for children are already in high demand.  Actual therapists as well as more comprehensive mental health programs are tough to find and too many are still only providing services remotely, which has been another hardship not only on children and families but on other vulnerable populations.  

I work in an inpatient psychiatry unit in a public hospital in NYC.  The people we serve typically are struggling with many socioeconomic issues on top of their mental illness, such as poverty, homelessness, substance abuse, and lack of social support.  There is typically poor adherence to treatment for mental illness, which predates COVID.  Many people come in and out of hospitals to stabilize, only to be readmitted a few months later.  Many also cycle through the criminal justice system, which is an enormous issue aside from this.  

I don’t know if you’ve ever attempted to speak via zoom with someone with schizophrenia but most do not like it.  The issues are numerous.  The image changes easily as different people speak, and the connection gets easily interrupted.  Paranoid patients might speak too low for anyone to hear them.  Many older clients are not computer literate and the entire process does little for building rapport and trust.  These are all things I’ve experienced with my clients as I’ve attempted to assist them from the unit. I can just imagine what happens when they are on their own, in a bustling shelter, on the subway, if they are lucky enough to have a working device with consistent WIFI access.  And if it is just a phone call, you are getting even less information.  How do you know if your client has been showering? Can you see bruises? Have they been abused? Are they wearing a winter coat in July? Are they experiencing visible side effects of their medications? There are many limitations to this modality.  

Long after vaccines were available and mental health professionals were prioritized, a young woman was admitted to our unit who was having a hard time staying out of the hospital.  I’ll call her Patricia.  Patricia lost all connection to her family after years of living with schizophrenia.  She was lucky enough to be living in a supportive housing facility and she had an ACT team.  ACT teams are technically the highest level of mental health care.  It is a team of mental health clinicians including a psychiatrist who visits people at home at least six times per month to provide medication, mental health support, substance abuse counseling, vocational help, and general wellness checks.  In New York, the teams are all over the city and state and have a set amount of clients they see every month.  This modality exists in many states.  The patients who have an ACT team are people who would never otherwise keep appointments at clinics.  When Covid began, many ACT teams went remote.  They would attempt to call their clients, or the facilities that house them, including shelters, in order to make contact.  This went on not just during the first wave, not just until vaccines were available, but some continue to this in some form right now.  

Patricia was on our unit and her ACT team had not seen her at all in 9 months.  During that time, she was alone in her room at her supportive housing facility.  The ACT team would call them to check in and they’d say that she was escalating, getting into fights with people on the street, at one point brandishing a knife at someone on the train who she perceived to be laughing at her.  The ACT team still did not come to assess her.  Ultimately, she had to be admitted to our unit for treatment as she was no longer safe in the community.  She had to be brought in by police, by force.  When it came time to discuss Patricia’s treatment, the ACT team insisted that community living was not working for her and that she should be transferred to a state psychiatric hospital.  It was obvious to me and the treatment team that it wasn’t her that failed the ACT modality, but the ACT team failed her.  Speaking with other in-person clinicians in hospitals and facilities like where Patricia lives, we are all thinking the same thing.  It’s no longer spring 2020, although many of us were working then too.  We have vaccines and plentiful PPE, high-quality masks.  Why are so many agencies still allowed to only offer remote treatment? It is obvious that we are hurting our most vulnerable.  They are billing for a service that people are truly not getting, and then gaslighting them into thinking they are failing if it doesn’t work.  

This brings me back to the pediatric mental health crisis.  If we are to truly treat this as a moral obligation, children must be prioritized for in-person, comprehensive mental health treatment.  In my hospital, the amount of kids waiting to be transferred to a pediatric psych hospital has tripled with wait times going from 2-3 days to sometimes 2-3 weeks.  These are suicidal children, waiting on medical floors of acute hospitals, some with behavioral issues, and not receiving the care they need.  Parents with children with less acute needs are waiting the better part of a year for neuropsychological evaluations that would answer so many questions, and help direct their child’s care and education, only to be told it is still remote.  These evaluations hold a lot of weight for children.  Getting them wrong or incomplete can be quite consequential.  In a city where everything is wide open, why is this allowed to happen? Sadly, the only way this will stop is if insurance companies stop reimbursing for it, or at least provide some penalty for offering it exclusively.

Many other services for kids remain remote also.  If your child happens to require OT, PT, or speech therapy, oftentimes, this is remote as well, adding stress to a parent who may not be able to navigate this or do the treatment properly.  A parent may not speak English, or they may not understand the instructions.  Are we really saying that a parent copying a therapist on the screen is the same as in-person therapy? Can these therapists not see that in the future, their insurance companies will simply offer PT/OT YouTube videos and call it a day? All the while, these same therapists work in hospitals, nursing homes, and rehabs in person treating sick and elderly people.  They were in hospitals even during Covid and treating them at bedside.  But they cannot provide the same care to a healthy three year old? Why is this allowed? 

Thinking back to social work school, I remember the phrase, “Meet the clients where they’re at,” which mostly refers to the belief that you cannot impose your will on people.  You should work with people on their goals at their own pace, and attempt to empower them through it. We also addressed the uneven relationship between client and worker.  Mental healthcare providers are often in positions of power and it behooves us to be aware of this, and try to minimize the potential harms of this dynamic.  One way to do this now is to leave the comfort of our homes and actually be with the clients.  Don’t force them to figure out WIFI or how to pay for their phones while you easily jump online.  I belong to an NYC social worker group on Facebook where so many posts are from people inquiring about remote jobs. I understand it.  Many of my friends are living more comfortable lives, not spending on commuting and excessive childcare costs, and dealing with the rush hour hustle when they have a remote job.  People can buy homes in less expensive areas because they don’t need to be close to their jobs.  Did anyone not think that essential workers wouldn’t want in on this as well?   It’s problematic.       

Remote therapy for some people is fine, and can have benefits.  People in rural areas, without traditional access to mental health care can now log on and speak to a therapist from their homes.  People with many obligations who normally wouldn’t take the time to go see a therapist can now dial in from wherever and work on their issues.  It also allows the therapist to have more flexibility for their families and not have to pay for office space.  People cancel less frequently as the therapy session now demands less sacrifice of other responsibilities.  

However, there is also real harm being done by not seeing people in person, and another way in which Covid mitigations have benefitted the more comfortable among us while ignoring the needs of the vulnerable, including children.  If the surgeon general is serious, he may want to press the administration to give incentives to treatment providers of children to see them in person, and to hire more therapists at competitive rates.  Make it cost families less; insist private insurers cover it, or create a Medicaid carve out for all minors while providing acceptable reimbursement.  Lower the reimbursement rate for remote therapy. I’m open to suggestions.  But without concrete guidance, it is all talk.

About the Author:

Ilana Horowitz is a licensed clinical social worker based in NYC specializing in psychiatric social work.  She is one of the earliest advocates for open schools and restoring normal childhood, and is passionate about bringing back in-person mental health and other related therapies for children and other vulnerable populations. You can find her on Twitter @NYC_essentialSW

Our Take:

Thank you, Ilana, for sharing your story and speaking up against misguided policy.

Yours is yet another illuminating story of the little-discussed downsides of the Covid-mitigation-at-all-costs mindset that has wreaked havoc throughout America - especially in Blue-State America.

Let’s hope that policymakers take note.

What’s Next:

A) Follow Ilana on Twitter at @NYC_essentialSW

B) If you would like to tell your own story through our Substack — anonymous or not then — please reach out to us at restorechildhood@substack.com or @Rstorechildhood on Twitter and we’ll do what we can to make that happen.

and

C) Share Ilana’s story with the heroes in your life who are also fighting back