Illustration by Turtel Onli

As the City Reopens, Mental Health Clinics Keep Services at a Distance

A “significant portion” of services could stay remote as clinics permanently adopt telehealth

In March, when the coronavirus pandemic shut down schools and businesses across Chicago, the city’s public mental health clinics also reduced walk-in services wherever possible and largely switched to providing therapy remotely via telephone or video conference. At a press conference on June 22 announcing how Chicago may move to phase four of reopening from the coronavirus shutdown, Dr. Allison Arwady, commissioner of the Chicago Department of Public Health (CDPH), said that clinics will start to move back into seeing patients in person after the city finishes an ongoing buildings assessment and implements upgrades to protect patrons and staff.

On May 21, CDPH announced a suite of mental health initiatives, including partnerships with four community mental health organizations and $1.2 million in new funding to expand access for persons with serious mental illnesses. The expansion of services also includes a new partnership with Doxy.me to provide behavioral health services—including psychotherapy, psychiatry, case management, and group sessions—to patients via online video conferencing. The partnership will cost the city about $35,000 per year, according to an invoice reviewed by the Weekly. In an interview with the Weekly, Matt Richards, the deputy commissioner of behavioral health, said the cost covers one hundred annual user licenses, which will include all the CDPH mental health clinicians.

Arwady said staff and patients have responded positively to tele-services, adding that she expects “a significant portion” of services will continue to be provided remotely even as the department begins bringing back in-person services. Richards said the department hopes to have its Doxy partnership fully rolled out by the end of the summer.

Telehealth removes some barriers to accessing mental health services, but it’s not without its drawbacks: clinicians say remote sessions lack many of the subtleties and nuance in-person therapy affords. When the city’s clinicsin Englewood, Bronzeville, Gage Park, North Lawndale, Roseland, and North Parkinitially shut down, behavioral therapists scrambled to continue treating their patients remotely. Clinicians told the Weekly the transition was challenging. Jay Roth, a clinical social worker at the city’s North River Mental Health Center (MHC) in North Park, said CDPH did not provide very much technical support at first, and therapists adapted as best they could, mostly providing therapy by phone and, in some cases, improvising video-conference sessions with Zoom. 

“When you’re doing face-to-face therapy, you have a certain rapport and way of interacting that is really essential to the therapeutic process,” Roth said. He added that he has been cautious about using video conferencing with clients due to privacy and safety concerns. Roth also worried about the potential for a client to suddenly become distressed during a video call and drop the connection, leaving him unable to intervene.

Angela Sims, a clinical therapist at the Greater Lawn MHC in Gage Park, said that when the clinics stopped offering in-person therapy, she switched to treating clients over the phone. The medium put her clinical skills to the test. “You’re having to infer a lot more by just one mode of communication,” she said. “And there are a lot of people who just don’t emote well over the phone.” Getting a sense of whether a client is really doing as well as they say they are can be tricky. During an in-person therapy session, Sims is able to use multiple senses—visual, smell, and hearing—to assess a client’s condition. Over the phone, it’s harder to make sure she’s not missing anything beyond what the client is telling her.

“And that’s when they answer the phone,” she said. Some clients may not even pick up because they are preoccupied with kids or family. “There are some other folks who tend to just reach out only when they’re in crisis mode,” she said. “They’re not going to answer the phone just because you called.”

An intake—during which a clinician first talks to a new client to figure out their treatment needs—was one of the hardest things to do over the telephone. When the shutdown began, clinics started informing new clients that they were doing intake assessments by phone. “We proceed to the best of our ability in doing that,” Roth said. Clinicians try to quickly assess a client’s medication needs, and consult with a psychiatrist within a week of the intake. But a lot of the intake work involved explaining how the COVID-19 shutdown impacted service delivery and obtaining informed consent. All of that made the intake process slower.

Sims said that during these intake conversations, she finds herself “working very hard to emote” and show concern, as “doing an intake cold with someone you’re not meeting and won’t even see at all for a while” is extremely difficult. Sims said she would prefer to do an intake in person, even if it meant wearing personal protective equipment and sitting more than six feet apart.

One of the biggest challenges to providing therapy during the shutdown is helping clients navigate the loneliness associated with staying home alone. “We normally spend a lot of time discussing connectedness and avoiding isolation as effective ways to cope with mental health problems,” Roth said. “And here we are telling people to isolate for their own good.” 

The quarantine has been particularly difficult for those clients that are more anxiety-prone, especially for those who may be in financially precarious situations, Sims said. “Those two groups sometimes overlap,” she said.

The clinicians have also had to maintain their own health and morale during the crisis. Sims said that one challenge the shift to telehealth brought is the “tedium” that comes from sitting by the phone all day. Roth has continued working from the North River clinic, but aside from the receptionist, he is usually the only person in the office. “That’s one of the weirdest parts,” he said. And where in-person therapy sessions have a rhythm provided by greeting a patient and getting settled, none of that is available in remote therapy. “With Zoom…you click goodbye, and there they go, and you click right into the next meeting,” Roth said. “It gets really difficult to adjust to that, and create real separation mentally for myself between meetings.”  

Any shift to telehealth can present a number of privacy and security concerns. In April, a Mozilla Foundation report flagged security issues with Doxy. The report, which assessed the security of fifteen video-conferencing apps, awarded Doxy just two and a half out of five stars—the lowest rating it gave. The report cited the platform’s weak password requirements, noting that even insecure passwords such as “123” were acceptable. In an email to the Weekly, Liz Savery, a spokesperson for Doxy, said that since the Mozilla report was released, the company has upgraded its password requirements. “A recent Doxy.me update forces (rather than suggests) a strong password,” she said.

CDPH takes security “with the highest degree of seriousness,” Richards said. “We will have an organizational policy about password complexity. Part of the process that we go through whenever we use software is developing a security plan related to that software.”

In a city where only six clinics remain of the original nineteen that existed in the 1990s, a patient’s therapist could be an hours-long CTA ride away. The partnership with Doxy is meant to address that barrier to access, but ensuring every patient can use the platform isn’t straightforward. Web-based telemedicine relies on dependable internet connections, which public mental health clinic patients may not have. Among those who do, it’s not certain that everyone will want to use the platform. “Probably a third of my clients are easily able to shift to” video-conferencing, Roth said. 

Savery said a successful appointment over the platform requires a computer with camera, microphone, speakers, “the latest operating systems,” and an internet connection with at least 2 Mbps upload and download speeds.

Richards said CDPH is currently identifying how many patients might have difficulty using digital interfaces, as well as those who may not have the tools to do so. “The first step for us is wrapping our arms around how many patients we anticipate would want to receive services this way, but for whom there is a current barrier so we can develop a plan to address it,” he said. 

For now, the city clinics are continuing to provide services by phone for most patients. Richards said the department does not yet have a timeline for reopening clinics because most are still waiting for the city to assess them and make recommendations for infection-control upgrades.

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Jim Daley is the Weekly’s politics editor. He last wrote about harassment of Chicago Freedom School during the May 30 protests.

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