Week one of lockdown: reflections from the couch

On 16 March President Ramaphosa declared a state of emergency. A full lockdown followed soon after. In South Africa you cannot walk your dog, nor pop out to buy alcohol or cigarettes.

Psychiatrists have responded by being as freaked out as everyone.

For the last 200 years, psychiatrists have used “The Container” as the boundary for their work. It is the committed time and a safe space within which my patients and I explore the hard stuff. A safe space is as important to a psychiatrist’s work, as a sterile environment is to a surgeon. It can be done in other ways, but the risk of contagion is high.

Along comes a nasty little virus, and suddenly it’s not safe to be around other people. Like the rest of the country, I started figuring out how to do my work online.

It has been hard. Like many of my colleagues, I am a bit technophobic. I have had to get educated in Zoom, Face Time and various other platforms. A WhatsApp group called “Psychs and Telemedicine” formed, where we help each other figure out the answers. Rapidly the two hundred and fifty -six group member limit was reached and subgroups were formed. This is unprecedented for psychiatrists! We are used to facing challenges in our own corners.

I have tried to figure out what the best platform is, for reliability and confidentiality. I carefully weighed up the evidence for each one. The reality is, I have ended up using whatever my patient has access to and is comfortable with.

In each session I try to help the patient set up a bit of a private space. This is not always easy, with family members milling around. I try to help the patients set up a good line, which sometimes means booting off a son using up all the bandwidth on Ark.

Another tool of the psychiatrists’ trade is the concept of implicit content. It’s not what the patient says, but how they say it. Its is not in the words, but in the silences. When I’m on top of my game, I can be a bit of a mind reader thanks to implicit content. Implicit content is much easier when the patient is in the room with you. I feel like I have been practising blind by not having my patients in the room with me.

It has not been all miserable. I have had tours of patients homes, I have seen their kids and pets. Some patients really struggle to talk under direct gaze in a consultation, now they freely chat to their phone screen. Previously I resolutely refused to do online consultations, even with my patients abroad. I think that I will have more confidence for it in the future.

At the end of the week, I have a crick in my neck. I am not used to working with computers all the time, so have had to give myself an education in ergonomics. I am exhausted with trying to actively listen with an inter web between me and my patients. It is with some relief that I have next week off (booked pre-Covid) to recalibrate. I am, however, aware of what a privilege it is to be able to continue working in these unstable times.

The Corona Virus is clearly a disrupter. Of the world, and of how psychiatrists have always done things. With a little help from friends and a lot of help from the magic of technology, we will step up to the plate.