The classic image of a therapy session is a therapist, a patient, perhaps on a couch, in a small room with a box of tissues between them. But COVID-19 changed all of that. Now, more often, therapists and patients are on screens, each logging on from different locations. As COVID-19 restrictions ease in medical environments, it is time to ask if therapists and their patients need to be in the same room for therapy to be beneficial?
Rather than just relying on my personal feelings, I did some research into the effectiveness of remote versus in person therapy. To my surprise, I learned that patients prefer remote sessions more than therapists. As one patient said when I asked her why she prefers remote versus in-person sessions, she commented, “It’s like the difference between TV and live theater. TV is available when I want it, and live theater takes more effort — you have to get the tickets, find parking, etc.”
I appreciated the many benefits of being back in my office but most of my patients chose to stay remote. The convenience outweighed their desire to travel to my office, and they felt no discernible difference in the quality of the work. This created a dilemma for me as I weighed the cost of leasing my office and the ease of working from home against my personal preference for in-person sessions. Recently I made the difficult decision not to renew my office lease for financial reasons. Adapting to remote therapy has meant changing some aspects of how I practice.
In my mind, the greatest deficit of remote therapy is the lack of a physical presence in a shared space. When I was able to watch my patients walk from the waiting room into my office, I noticed how they carried themselves, their attire, and the mood they exuded. No longer having that opportunity online, I learned to be more specific in my questions about how people were feeling, and I look more closely for changes in appearance. Still, the intimacy of a therapy session cannot be replicated on a screen. Watching someone cry is not the same as being in the presence of someone crying. Nonetheless, I have found, to my surprise, some patients prefer sessions to be less intimate and find it easier to open up as a result. This may mean that the availability of remote therapy is capturing a new clientele for therapy.
But some patients are acutely aware of being alone, and thus find it harder to allow themselves to fully express their emotions during a remote session. I miss mirroring someone’s breath and using my steady gaze to offer comfort in person. Instead of being able to offer a tissue, I now wait as they go off-screen to retrieve one. I literally try to lean into my screen to provide a perception of being closer.
Being apart means many patients struggle to find a safe and private space like my office. Often patients are surrounded by distractions from their home, office, car, or wherever they are having their session. They find it is more difficult to shut out the world when we are not together in my office with cell phones off. Encouraging patients to make the effort to create a private space is part of the work of doing remote therapy.
Furthermore, patients tend to squeeze sessions in between other commitments, diluting the work. No longer having to take the time to get to my office, patients fail to prepare for their sessions or give themselves time to think about the session afterward. I encourage patients to build a buffer into their schedules, but realistically it rarely happens. I am guilty of this too; when I turn off my computer, I am home and no longer have my commute to process the day before resuming my personal life. I have changed my routines, so I have a clearer boundary between being at work and being at home.
In my own practice, during the pandemic I began work with a woman in her early 80s with physical limitations who could not access my office. The opportunity to meet with me over Zoom made it possible for her to do some significant grief work after losing her husband to COVID-19. Increased access to psychotherapy for a broader clientele is a plus for everyone.
Continuity of care can also improve when weather or travel are no longer impediments to having a session. Prior to remote work, patients had to cancel sessions when they traveled for business or had to attend to a sick child at home. I have found the ability to offer remote sessions particularly helpful with the new mothers in my practice who were experiencing or at risk for postpartum depression.
Some therapists have required patients to come back in person, while others, like me, have gone fully remote. Increasingly, therapists are working for companies which only provide remote sessions; they never establish an office. It behooves graduate school programs to adapt to this reality in their training of new therapists. It is also important that as a profession we do not create a two-tiered system, preferencing one form of delivery over another based solely on personal opinion.
As we live more of our lives online, the limitations of screens may not be felt as acutely by either therapist or patient going forward. New modalities of therapy may even emerge from this change in venue. But it is critical that the effectiveness and limitations of remote versus in-person therapy be studied. For example, people with social anxiety may request remote sessions when in fact in-person work would be more beneficial. When screening new patients, I take into account why they express a willingness/desire to be remote.
The key to a good therapy relationship has always been about fit. This equation used to be construed as the fit between the therapist and patient, but now perhaps we need to expand that idea to the room(s) where it happens.
File under: Musings and Reflections, Online Therapy
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Changing Perspectives on Teletherapy
Prior to the pandemic, the thought of working remotely never occurred to me. Even if remote work had occurred to me, the fact that insurance only reimbursed for in-person sessions would have provided a significant deterrent. Four years later, I find myself of two minds when it comes to evaluating the pros and cons of remote therapy — for patients as well as for myself.Rather than just relying on my personal feelings, I did some research into the effectiveness of remote versus in person therapy. To my surprise, I learned that patients prefer remote sessions more than therapists. As one patient said when I asked her why she prefers remote versus in-person sessions, she commented, “It’s like the difference between TV and live theater. TV is available when I want it, and live theater takes more effort — you have to get the tickets, find parking, etc.”
I appreciated the many benefits of being back in my office but most of my patients chose to stay remote. The convenience outweighed their desire to travel to my office, and they felt no discernible difference in the quality of the work. This created a dilemma for me as I weighed the cost of leasing my office and the ease of working from home against my personal preference for in-person sessions. Recently I made the difficult decision not to renew my office lease for financial reasons. Adapting to remote therapy has meant changing some aspects of how I practice.
In my mind, the greatest deficit of remote therapy is the lack of a physical presence in a shared space. When I was able to watch my patients walk from the waiting room into my office, I noticed how they carried themselves, their attire, and the mood they exuded. No longer having that opportunity online, I learned to be more specific in my questions about how people were feeling, and I look more closely for changes in appearance. Still, the intimacy of a therapy session cannot be replicated on a screen. Watching someone cry is not the same as being in the presence of someone crying. Nonetheless, I have found, to my surprise, some patients prefer sessions to be less intimate and find it easier to open up as a result. This may mean that the availability of remote therapy is capturing a new clientele for therapy.
But some patients are acutely aware of being alone, and thus find it harder to allow themselves to fully express their emotions during a remote session. I miss mirroring someone’s breath and using my steady gaze to offer comfort in person. Instead of being able to offer a tissue, I now wait as they go off-screen to retrieve one. I literally try to lean into my screen to provide a perception of being closer.
Being apart means many patients struggle to find a safe and private space like my office. Often patients are surrounded by distractions from their home, office, car, or wherever they are having their session. They find it is more difficult to shut out the world when we are not together in my office with cell phones off. Encouraging patients to make the effort to create a private space is part of the work of doing remote therapy.
Furthermore, patients tend to squeeze sessions in between other commitments, diluting the work. No longer having to take the time to get to my office, patients fail to prepare for their sessions or give themselves time to think about the session afterward. I encourage patients to build a buffer into their schedules, but realistically it rarely happens. I am guilty of this too; when I turn off my computer, I am home and no longer have my commute to process the day before resuming my personal life. I have changed my routines, so I have a clearer boundary between being at work and being at home.
Embracing the Future of Teletherapy
Despite these limitations there are important advantages to offering therapy remotely. The most significant gain from the availability of remote therapy is improved access to therapy for more people. Insurance coverage changed during the pandemic to include online sessions, which improved the possibility of finding a therapist. Initially this change suspended the need for the patient and therapist to be in the same state, furthering the potential pool of therapists. (That requirement has since been reinstated.) Finally, patients living in rural areas could find a therapist and have choices similar to those available to people in urban areas. Unfortunately, during the pandemic, demand was so high many people still suffered due to long wait lists. But over time, there is the opportunity for greater access and equity.In my own practice, during the pandemic I began work with a woman in her early 80s with physical limitations who could not access my office. The opportunity to meet with me over Zoom made it possible for her to do some significant grief work after losing her husband to COVID-19. Increased access to psychotherapy for a broader clientele is a plus for everyone.
Continuity of care can also improve when weather or travel are no longer impediments to having a session. Prior to remote work, patients had to cancel sessions when they traveled for business or had to attend to a sick child at home. I have found the ability to offer remote sessions particularly helpful with the new mothers in my practice who were experiencing or at risk for postpartum depression.
Some therapists have required patients to come back in person, while others, like me, have gone fully remote. Increasingly, therapists are working for companies which only provide remote sessions; they never establish an office. It behooves graduate school programs to adapt to this reality in their training of new therapists. It is also important that as a profession we do not create a two-tiered system, preferencing one form of delivery over another based solely on personal opinion.
As we live more of our lives online, the limitations of screens may not be felt as acutely by either therapist or patient going forward. New modalities of therapy may even emerge from this change in venue. But it is critical that the effectiveness and limitations of remote versus in-person therapy be studied. For example, people with social anxiety may request remote sessions when in fact in-person work would be more beneficial. When screening new patients, I take into account why they express a willingness/desire to be remote.
The key to a good therapy relationship has always been about fit. This equation used to be construed as the fit between the therapist and patient, but now perhaps we need to expand that idea to the room(s) where it happens.
File under: Musings and Reflections, Online Therapy