Shifting the Milieu: Reflections on Converting the Practice to Telehealth

I’m still going into the office, turning on the lights, and plugging in the Keurig but it’s very quiet: Too quiet. Just Alexa and I during the long workdays (she now responds every time I say “celexa because she can hear me.) I could list the many things I miss: Sharon, who is working remotely from home, the quiet chatter in the waiting area, the phone ringing non-stop, and the low hum of activity that has become the comforting background noise of our offices. Even the mailman, who pops up to grab a coffee or hot chocolate (usually without the mail) isn’t coming inside anymore.

Within a week, I went from 5% of the practice being virtual to 100%. My gratitude is toward our practice of telehealth over the past year (how we keep tabs on the college students!) and how we circumvented the angst suffered by our lesser tech savvy colleagues. Because it’s been so quiet here, I’ve had some time to reflect on the recent events, namely, the impact on our practice and delivery of care. I thought I would share the experience, hoping to inspire optimism during this unexpected interlude from our pre- COVID-19 lives.

Milieu is a French word with varied meanings. I learned the word early in my mental health career as an unlicensed paraprofessional or milieu counselor. In psychiatry, the milieu is known as the space in which the treatment takes place, for example, my office is a treatment milieu. Clients are welcomed into my office, entering a space in which we establish a relationship, form collaborative goals, work together toward problem solution, and hopefully, over time, experience relief of the symptoms that prompted treatment. It is within the milieu that we work together toward restoration of mental health: The surroundings are comfortable, my presence and authority essential to treatment. Until two weeks ago.

Across telehealth, I have been graciously welcomed into homes and lives of clients who are adhering to social distance guidelines and in doing so, have been privileged to see people through web cameras that capture much more than what I glean in the office. By moving from behind a desk and into the client’s orbit, I have felt a tilt in balance: I am now in their milieu versus them being in mine. The experience has been humbling.

I have sat at kitchen islands while dinner is prepared. I have met your siblings, spouses, and children. I have met your pets (including a parrot!). I have been to the grocery store (still no toilet paper) and have participated in your quests for creative ways to cope with quarantine. I have sat at dining room tables where families construct puzzles. I have watched children run in and out of the house while parents attempt to work from home. I have seen adolescent girls “re doing” their rooms in beautiful paint colors and Tik Tok lights. I have seen college students making friendship bracelets and painting with watercolors. I have seen enemy siblings making peace and let’s not forget the adolescent males who meet me in between sleeping and gaming. Woodsy hikes, dog walks, and patios have become the new milieu, changing my perception that treatment occurs only in the office.

By shifting the milieu to the client’s social environment, I’ve been able to see people in a new and meaningful way. I’ve been inspired by signs of resilience, creative coping mechanisms, and hope that life will soon return to normal. The past two weeks have reminded me that the most important component required when treating mental heath clients is a trusting relationship; one that is able to nimbly move between settings. I look forward to enduring this crisis together and integrating our work into your own milieu, whatever or wherever that may be.