From the Editor

Mental health care has markedly changed since the pandemic began. What is the impact of COVID-19 on psychotherapy?

This week, we have three selections.

In the first, published in The American Journal of Psychiatry, Dr. John C. Markowitz (of Columbia University) and his co-authors write about psychotherapy and virtual care. The paper reviews the literature and also considers practical considerations. They note: “Therapists should acknowledge the crisis, and perhaps that teletherapy is a limited substitute for more direct contact.”


In the second selection, reporter Wency Leung writes about Dr. Vivian Rakoff, who died earlier this month. In the Globe obituary, Leung writes about his various roles, including as psychiatrist-in-chief of the Clarke Institute (now part of CAMH). “To the many he inspired, he is remembered for his extraordinary intellect, kindness, sense of wonder and the agility with which he wove together ideas from a vast range of disciplines, from classic literature and philosophy to politics and pop culture.”

Finally, in our third selection, we consider an essay by Dr. Jillian Horton (of the University of Manitoba). In this LA Times essay, the internist writes about her brother and his mental illness, discussing the emotional and geographic distance of their relationship. “My brother died 40 years ago and he died in April.”



Selection 1: Psychotherapy at a Distance

John C. Markowitz, Barbara Milrod, Timothy G. Heckman,et al.

The American Journal of Psychiatry, 25 September 2020  Online First


COVID-19 has changed the field of psychotherapy overnight from in-person to ‘virtual,’ remote teletherapy. This shift will likely have lasting effects on psychotherapy practice. What had been primarily an adjunctive therapeutic approach for patients in geographically isolated settings who lacked access to in-person care is suddenly, thanks to mandated ‘social distancing,’ the standard mental health care intervention.

Teletherapy can use traditional telephones, smartphones and therapy-related apps, Internet video calls on platforms that are compliant with Health Insurance Portability and Accountability Act rules (e.g., Zoom), or online computer-mediated treatment programs. There seems to be no question that patient access to clinicians is better than no access, and telephone or video therapy seems undoubtedly preferable to more detached media such as texting for a human encounter.

As psychotherapy researchers and therapists, we all had prior experience in conducting telepsychotherapy, but in recent weeks we have rapidly gained a more nuanced appreciation of its strengths and weaknesses through ongoing practice. A brief literature review unearthed several reviews of studies but relatively little discussion of the trade-offs of teletherapy relative to in-person treatment.

So begins a paper by Markowitz et al.

They note a general lack of research done in the area:

  • “Whereas more than a thousand in-person psychotherapy trials have been published for depression alone, the newer field of teletherapy is less developed.”
  • “Much reported ‘teletherapy’ is not tele-psychotherapy. Many teletherapy studies reported in reviews are not traditional efficacy or effectiveness trials, but instead document heterogeneous outcomes, such as reduced travel time for rural patients, psychoeducation, or addition of a video to standard care to reduce depressive symptoms.”
  • “Outcome data are generally encouraging but sparse, and come with caveats. For example, in 2016 Leach and Christensen reviewed 14 studies spanning a range of psychiatric disorders, treatment approaches, and selected populations. They describe mostly positive outcomes of telephone therapy, generally compared with no treatment or with treatment as usual.”
  • “A few rigorous trials have demonstrated the effectiveness of telephone cognitive-behavioral therapy (CBT) and telephone interpersonal psychotherapy in reducing depressive symptoms.”

They note some unique challenges:


“Maintaining a consistent intimate focus is more difficult. The patient is no longer in the room but on a screen (or a telephone). Instead of two human beings fully engaging in a common space, one meets an image of a patient on a computer screen (or a disembodied voice) surrounded by too many distracting stimuli.”

“Distractions abound.”

Physical Discomfort

“We all find remote psychotherapy physically and psychically more exhausting than the in-person variety.”


“Technical difficulties can impede communication or interrupt treatment sessions: difficulty connecting, frozen screens, ‘unstable Internet connection’ warnings, garbled or delayed audio, poor lighting, dropped calls. Videotherapy has turned out to have confidentiality risks.”

Emotional Distancing

“There is a loss of affective nuance on telephone or screen, a factor that seems to bother therapists more than patients. We believe this affective diminution makes the experience less emotionally vibrant, particularly for patients with the psychological tendency to dissociate.”

They note: “Several modalities of teletherapy can preserve the crucially important link of psychotherapy in a highly anxiety-provoking, socially burdened time of quarantine, physical distancing, and deep emotional need and despair. Teletherapy has some empirical backing, but the outcome literature is very limited relative to that of in-person treatment and has unclear generalizability to its broad current use among a wide range of patients with various serious psychiatric problems.”

They also provide recommendations:


A few thoughts:

  1. This is a timely and important paper.
  1. They make very reasonable suggestions. The authors focus on psychotherapy – though many of their comments apply to other aspects of mental health care. For those of us who are spending long hours communicating with our patients, the suggestions are applicable, even outside of psychotherapy.
  1. The authors also discuss psychotherapy during the pandemic. “[Therapists] can attempt to maintain the helpful structure of therapy by maintaining regular sessions and treatment approach. They should encourage patients not to let the physical distancing of ‘social distancing’ impede their existing relationships and cost them protective social support. Many relationships can be preserved either by remote means (Skype, Zoom, or Facetime) or by masked, six-feet-apart, ‘socially distanced’ in-person walks.”

The full paper can be found here:


Selection 2: Psychiatrist Vivian Rakoff believed there was no divide between the brain and the mind”

Wency Leung

The Globe and Mail, 23 September 2020

The Globe and Mail logo (CNW Group/The Globe and Mail)

It has been nearly 20 years, but the words of esteemed Toronto psychiatrist Vivian Rakoff still ring out clearly in Aristotle Voineskos’s memory.

‘I will not tolerate the distinction between psychology and biology. Every thought is a neural event,’ Dr. Voineskos, the incoming vice-president of research at Toronto’s Centre for Addiction and Mental Health (CAMH), recalls his mentor saying.

With this statement, the senior professor staked his position in a long-standing and ongoing disagreement over ‘the soul of psychiatry,’ Dr. Voineskos explained.

‘There’s still these sort of artificial dualities between psychology and biology, the brain and the mind,’ he said. ‘Vivian was sophisticated enough to understand that there’s no such divide, that these things are integrated and they’re really similar representations of the same thing.’

So begins an obituary by Leung.

She notes his various roles: as a past chair of the University of Toronto’s department of psychiatry and a psychiatrist-in-chief at the former Clarke Institute of Psychiatry. Dr. Rakoff was a member of the Order of Canada

“To the many he inspired, he is remembered for his extraordinary intellect, kindness, sense of wonder and the agility with which he wove together ideas from a vast range of disciplines, from classic literature and philosophy to politics and pop culture. If every thought is a neural event, then Dr. Rakoff’s brain composed complex neural symphonies.”

The article talks about his birth in South Africa, his upbringing, and his decision to enter medical school.

One of Dr. Rakoff achievements was opening the Vivian Rakoff Positron Emission Tomography (PET) Centre, the first such centre for research into mental illness. The article quotes Dr. David Goldbloom: “It’s important to bear in mind he was not an imaging researcher. This didn’t meet some selfish need to surround himself with equipment he was going to use. It was much more high-minded than that.” He put the Clarke Institute “on the map globally as one of the world’s leading research imaging centres in psychiatry.”

The article notes his remarkable knowledge of poetry and the arts. “He wrote numerous poems, plays and essays throughout his life, and in his later years, gave lectures on the plays performed at the Stratford Festival.”

A few thoughts:

  1. This is a good obituary.
  1. Leung covers much ground. But Dr. Rakoff had enormous depth. She doesn’t mention his incredible talent as a medical educator. (Residents used to go to his office on Saturday mornings for seminars.)
  1. A longer essay on Dr. Rakoff, written by Drs. David Goldbloom and Pier Bryden, will be featured in a future Reading.

The obituary can be found here:


Selection 3: My mentally ill brother died in the early months of the pandemic. But we lost him long ago

Jillian Horton

Los Angeles Times, 11 October 2020


My brother died in April, in the early months of the pandemic, but that’s not when we lost him. He disappeared from our lives almost 40 years ago, when he was diagnosed with schizophrenia. To say he suffered from schizophrenia is an understatement. Schizophrenia assassinated him, did to him personally what COVID has done to our planet. After he became ill, nothing was ever the same.

My brother had a few good years. He was a quiet boy with a penchant for math, who spent hours assembling model airplane kits. But just before his 15th birthday, illness began dismantling the building blocks of who he was. Within weeks, he became paranoid, endlessly tearful, wildly inappropriate. And then he largely disappeared from my life, hospitalized for treatment that was often worse than the actual disease.

So begins an essay by Dr. Horton.

“There’s no good script when someone in your family becomes severely mentally ill. The underlying thread of many casual conversations is normal milestones – graduations, achievements, weddings – and he had none to share. The milestones I remember were ones I wanted to forget – the time he tried to kill himself by wading into a river, the time he was picked up by the police standing on the railing of a bridge.”

She talks about his physical illness. “About a year ago, he suddenly stopped walking. He was in a group home by then. They sent him to the hospital.” He grows more ill and dies in April.

“His doctor sent me a heartfelt message a few days after he died. She said she would miss his childlike countenance and sense of humor, things I’d never really seen. I wondered with some discomfort if I might have had a deeper well of present-day emotion for my brother if I had been his doctor.”

A few thoughts:

  1. This is a good essay.
  1. Frankly, this is a tough essay to read.
  1. Her tension of being a sister and also a physician is moving. “What does that numbness say about me, a physician recognized for the depth of my compassion? I think it says severe mental illness is brutally hard – hard to watch and hard to understand. It burns everyone down and out, grounding both sufferer and loved ones in the past, leaving us unable to reconcile the person we lost with the one we still have. In some ways it is easier if you never knew that person before because you’re not rowing endlessly toward an image of someone who doesn’t really exist anymore.”

The full LA Times essay can be found here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.