Home Health Care Shattering the fourth wall: The shared behavioral health experiences

Shattering the fourth wall: The shared behavioral health experiences


Behavioral health care providers are on the front lines of the Covid-19 pandemic, even if that front line is on the other side of a phone or computer screen. The rapid adoption of telehealth for mental health and substance use disorders has been a lifeline for many of the almost half of U.S. adults reporting high levels of anxiety, and distress and fears about the future.

The therapists, counselors, and psychiatrists providing these critical behavioral health services are trained to skillfully treat their patients’ pain, trauma and uncertainty while acknowledging and managing their own reactions and personal issues. However, this current crisis poses an added layer of complexity for behavioral health providers as many are experiencing similar challenges to their patients – breaking down the invisible barrier between doctor and patient.

New Challenges and Breakthroughs in Mental Health Treatment
In previous crises, like 9/11 or Hurricane Katrina, behavioral health providers played a critical role in the immediate and long-term responses. However, the widespread impact of Covid-19, the uncertainty of its course, and physical distancing have forced providers to drastically alter the ways they communicate with and treat patients.

The virus is sending many new patients in search of help. In turn, government agencies and insurers have jumped into warp speed to expand access to health care, waiving HIPAA enforcement, changing Medicare and Medicaid regulations, and expanding medical policy to promote access to telehealth, including behavioral health services.

Beyond convenience, telehealth sessions have additional benefits including efficiency, flexibility, reduced costs and increased show rates. Although not everyone has easy access to the technology (computers, dependable WIFI, reliable phone coverage) or the privacy needed for virtual sessions, providers and patients alike are implementing creative solutions to make treatment work.

Shifting Treatment Leads to Shattering of the Fourth Wall
With the global nature of this pandemic and the reliance on telemental health strategies, providers and patients may now have a more literal view into one another’s personal space, including their homes and families. This increased intimacy can shatter the “fourth wall” between provider and patient. Taken from acting, this concept has been written about in psychoanalysis to reference the creation of a treatment framework that seeks to minimize interference from the outside world. The therapy session is seen as sacrosanct and therapists attempt to maintain strict boundaries, keeping their own experiences outside of the treatment room.

With the fourth wall broken, behavioral health providers and their patients gain a sense that “we are in this together.” This can be comforting to some patients and allow them to see providers as more human. It may also instill a greater sense of trust in a provider, as someone who will understand them. For providers, knowledge of a shared experience with patients has the potential to increase patience, compassion, emphasis on strengths and an increased ability to be vulnerable, self-aware and attend to one’s own self-care.

However, providers should be aware that knowledge of a shared experience can pose challenges for some patients. Some patients may become reluctant to seek help or voice their own concerns if they believe their provider is having similar experiences. They may downplay their own needs or feel as if their problems may pose a burden to others. These patients may require additional encouragement to validate and focus on their own issues.

Behavioral health providers are accustomed to being able to tap into their own reserves after seeing patients, but the shared nature of this health crisis makes this more difficult as their own reserves may be low. Providers must remain vigilant and rely on colleagues or supervisors to help them monitor their own experiences in the context of these shifts in the therapeutic relationship so they may continue to be a source of comfort and support to their patients, not the other way around.

Making the New Relationship Between Providers and Patients Work
Health care providers on the front lines of Covid-19 have been likened to superheroes, but even Superman has his kryptonite. As the demand for behavioral health care inevitably increases, so will the risk for providers to experience burnout, secondary trauma, depression, and anxiety in response to their patients – and also their own experiences in this pandemic.

Caregivers are often told, “When the oxygen mask deploys on an airplane, you put it on yourself before helping others” – which means practice self-care, so you can be there for people who need you. With the line between provider and patient now blurred, behavioral health professionals need to be in tune with their own psychological and physical state and seek support from colleagues, a supervisor, or their own therapist. Today, online therapeutic and psycho-educational programs are available to help providers to relax, destress and carve out time for coping.

With cases of Covid-19 — along with mental health concerns — continuing to rise across the country, it’s important to step back and appreciate the behavioral health superheroes on the front line of this pandemic. With that appreciation comes the recognition that therapists, counselors, psychiatrists and others are facing tremendous professional and personal strain themselves, as the fourth wall between their patients’ crumbles. New technology is leading to challenges and breakthroughs of treatment, creating a truly shared experience between providers and patients. More than ever, we are all truly in the battle for mental health together.

Photo: SIphotography, Getty Images





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