The Ups and Downs of Online Therapy

Almost overnight, given the Covid pandemic, therapists were compelled to make the switch to teletherapy to preserve continuity of care with their clients. The urgency of the situation dictated that we snap to it and quickly get up to speed on the latest digital platforms and alternative modes of offering therapy.

There has been precious little time to reflect on the pros and cons of all this on the quality of therapy we offer. Now that the novelty has worn off and we are able to step back and analyze the situation, what does the switch to teletherapy portend for our profession?

Let’s start with some of the presumed positives. Most therapists I talk to enjoy the convenience of offering therapy from their homes, not having to travel to the office, all the while embracing the ensuing work-life-home-life flexibility. There’s even talk that, after Covid, many therapists will forego renting office space, welcoming the cost-savings.

Some clients reference the benefits of omitting the time-intensive commute to the therapy office. Scheduling can be executed more easily, with clients being available for daytime appointments, inasmuch as their own work-from-home arrangement allows. People living in rural areas or those unable to access adequate transportation can now do an end run around this and access care—assuming they can procure a phone, tablet, or computer. Clients who move far from their therapists can continue their therapy online, if they so choose.

This is notwithstanding how it can be easier for some clients to share personal information during an online session, rather than a face-to-face one, almost like a throwback to when clients lay on the couch with an analyst unobtrusively sitting behind them.

What about the downside? In my estimation, the greatest downside to virtual therapy formats is the potential for privacy to be compromised. I have clients who climb into their cars, parked on busy streets, with pedestrians walking past, ready to start virtual sessions. Several clients have set up an area in their backyard with dogs barking, neighbors walking by, and gardeners milling around.

Then there are the bulk of clients who set up in their bedrooms, or living rooms, or other area of their homes. I am surprised by the number of clients who claim they are comfortable with this arrangement, despite family members barging in, Amazon packages arriving, pings from computers and phones, and any number of other everyday distractions.

Most clients seem to dismiss their need for real privacy, even when the signs are obvious in the moment that the teletherapy arrangement they are about to embark on is rife with potential risks. One of the pivotal things I have learned from the switch to online therapy is the importance of asserting the need for a private setting with minimal outside distractions in which to hold the session.

However, even at that, it is hard to imagine how some clients can override the subliminal compromises to privacy associated with speaking frankly in the very bedrooms, living rooms and home offices they are used to speaking discreetly in. The invisible ears and eyes that inhabit these spaces perhaps censor clients more than they imagine.

There’s the obvious risk of family members, friends, or loved ones overhearing sensitive information with unpleasant consequences. I recently had to interrupt a client during a Facetime session who had launched into a verbal diatribe of her wife who was in the next room: “Mary, how thick are the walls in your condominium? Are you 100% sure Debra can’t hear you?” Mary began whispering, not having considered whether her wife might overhear. These intermittent reminders of privacy concerns have become a refrain of mine.

But, more importantly, most conditions virtual therapy are conducted in counteract the quiet states of inwardness many clients need to perpetually tap into, articulate, and elaborate upon dim thoughts and feelings that are a lifeline to reclaiming their muted, or disavowed, emotional self. Of relevance here is a recent comment issued by Susan Johnson EdD, the renowned developer of Emotionally Focused Therapy, regarding what constitutes a good in-person session for her: “the tent of trancelike attention and stepping into deeper levels of experience.”

It is an understatement to say we live in a culture of distraction. The therapy office has become a valued space for clients to tune out the world and tune into their inner lives. What becomes of therapy when it is held in the very world that clients need to tune out? Is there something unique and sacrosanct about in-person meetings in a therapy office designed for the very purpose of bracketing everyday responsibilities and distractions, ensuring privacy, and encouraging inwardness? Do many, if not most, clients need to cross the threshold of the therapist’s office to enter a space that is socially sanctioned for time-intensive emotional disclosure in order for it to be maximally beneficial? These are questions we will all have to ask once the Covid pandemic recedes.

Then there are the distractions therapists themselves have to contend with: calls being dropped with the momentary frenzy of trying to successfully redial; client images blurring and freezing in less-than-flattering ways for an uncertain amount of time; background lighting randomly flashing lighter and darker, rendering the therapist’s facial expressions oddly out of sync; unexpected computer pop-ups that are hard not to glance at—to name but a few.

https://portfolium.com/entry/hd-2107
https://258462.8b.io/
https://newarka.instructure.com/eportfolios/3730/Home/HK_____Justice_League_Snyder_Cut_2021HD_
https://rgvcollege.instructure.com/eportfolios/2060/Home/_2021HD
https://nfte.instructure.com/eportfolios/10310/Home/__Justice_League_Snyder_Cut_2021__

In my view, teletherapy setups favor more left-brain, content-heavy, problem-solving, solution-focused, symptom-reduction type therapies, rather than right-brain, explorative, emotionally-evocative, process-oriented, non-verbal-affirmative-communication ones. Research is starting to accumulate equating the benefits of online cognitive behavior therapy (CBT) to an in-person format. Will any greater shift to delivering psychotherapy online once Covid is behind us add to the already lopsided dominance of CBT in our profession?

If this is the case, more Americans will have restricted access to psychotherapy that is brief (8-12 sessions), focused on reducing symptoms rather than enhancing their expressive mastery of emotion and overall self-worth, or that disallows simply talking open-endedly and at length about the very matters that cause them agony: family disappointments, relationship breakups, unfulfilling marriages/intimate partnerships and careers, and vexing parenting challenges.

As I have co-written about elsewhere, for therapy to be effective with the typical person afflicted with anxiety and depression, it has to be time-intensive, open-ended, and explorative in nature. It is difficult to know how online therapy approaches adequately meet these criteria.

When it comes to teasing apart the pros and cons of in-person versus online therapy, we therapists will have to engage in an honest reckoning, reaching beyond what is convenient for us. There is a real risk that virtual therapy formats will be preferred by therapists for convenience reasons: cost savings from not leasing office space; eliminating any work commute; being at home to blend caregiving and domestic responsibilities along with professional duties in more flexible ways.

Will therapy morph into a “check-in and check-up” experience for efficiency reasons, rather than an “in-depth, personal exploration” experience for real and enduring self-transformation reasons? Time will tell if therapists meet their ethical obligation to respond to client preferences and best hopes for improvement in offering in-person versus online therapy as the Covid pandemic recedes.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.