Teletherapy: One Step Removed

By Gabriella Dishy

For the past few months, both globally and locally, therapists have had to make major shifts in the way they treat their patients. While therapists are acclimating to the “new normal” of meeting with their patients virtually, they may not always be having the best experiences. We spoke with Kathy Sommerich, a licensed clinical social worker at the Center of Prevention and Evaluation (COPE), to discuss what her experience with teletherapy has been like.

Since 1984, Kathy has been a practicing Social Worker meeting with patients face-to-face. She began practicing with teletherapy as an option for homebound patients in her private practice a year ago during inclement weather. Since the pandemic began, however, teletherapy and virtual settings have been her sole medium for communicating with patients for both COPE and her private practice. 

In theory, teletherapy should be like any regular session, except it isn’t. Rather than the ritual of traveling to the therapist’s office, patients can be home, lounging in their beds, or even taking a stroll. For those who live with others, there’s the added challenge of finding a private space to talk, with some people reporting having to sit in a car to be alone. 

To schedule appointments, therapists use whatever secure, virtual platform they have access to – whether it be Doximity, Zoom, or Webex (with some even using FaceTime, the security of which is questionable). 

Research has shown that, overall, patients and practitioners are generally satisfied with teletherapy, and findings suggest that it produces outcomes statistically equivalent to face-to-face treatment. In fact, several studies found no differences between in-person and virtual medication treatment or psychotherapy. Despite this, studies have also found that generally, therapists report significantly more concerns than patients. 

The COVID-19 crisis has provided a glimpse into the future, where digital has become central to every interaction, and we are still learning to adjust to these changes. If you’re a clinician struggling with transitioning to teletherapy, you are not alone. For a clinician, Kathy said, teletherapy can feel like it’s “one step removed.”

For one, it can be more exhausting than in-person therapy. As all mental health practitioners know, eye contact is key. However, establishing eye contact in a virtual setting has presented some unique challenges. As a clinician, Kathy said, you want to be as present as possible – and even more so virtually – but knowing where to look on the screen can be difficult. Not only can maintaining eye contact over video be challenging, it’s also sometimes difficult to know if your patient is actually looking at you (or perhaps perusing websites).

When looking out the window or off to the side during an in-person session, it’s clear to the patient that you’re thinking. During teletherapy, however, it can seem like you’re distracted by something off-screen or even uninterested. Ultimately, this results in having to be “on” all the time, which can become exhausting hour after hour of therapy. There can also be more off-screen interruptions, such as a ringing phone or losing your internet connection.

Notably, socioeconomic status can have a significant and negative impact on teletherapy. Patients with no or limited computer access resort to their phones or outdated iPads, which no longer receive the security updates or aren’t compatible with newer video-chat applications. 

Periods of silence are now much more uncomfortable. In person, silence serves a therapeutic purpose. But, over a camera, it just feels like something is missing, and can make the conversation feel disjointed. Because the therapist might not see what’s happening with the rest of the body, gestures, postures, and behaviors may be missed (e.g., if there’s any anxiety being physically expressed).

Without the six feet of social distancing that would be required in an office, teletherapy can feel “more intimate” in some ways, perhaps uncomfortably so. As Kathy described it, the session sometimes ends up feeling a bit less like a shared experience and can feel more invasive and intrusive.

The biggest issue Kathy’s faced with teletherapy, though, is that she just misses her patients! Those she’d been seeing before COVID-19 also agreed that it will be great to be in the same space again once the pandemic is over, though they reported being less bothered by the screen than she is. 

But, not everything about teletherapy is negative. Kathy polled clients in her private practice about how their experience has been. She found that they actually prefer therapy like this, so, despite her difficulties with it, she will likely cutback on office hours in the future. And business is brisk with increased referrals, especially for patients who live outside the city.

Teletherapy also offers a lack of formality that in-person therapy would never be able to replicate. It allows for the clinician to get a deeper glimpse into the lives of patients. As Kathy described it, this glimpse can be both instructive and diagnostic. Patients even get the opportunity to see a bit into the therapist’s life (like meeting Lenny, Kathy’s cat, who will occasionally pop in during a session). When asked if the familiarity can make patients uncomfortable, Kathy said that most seem to enjoy seeing her home. She said that for most, the informality has actually made disclosure a lot easier.

Shifting to teletherapy requires both patients and therapists to get creative. For example, one of Kathy’s patients changed where she sits during her session, repositioning her chair so she could center her energy andsit in a different location for therapy than she does when just browsing her computer. Similarly, Kathy has been using different platforms with telehealth capabilities, allowing her to separate work video sessions from her personal video calls.

Now that it seems teletherapy is here to stay in some capacity, Kathy has taken some practical steps to cope with these changes and successfully merge teletherapy into her life and practice. In addition to doing lots of yoga and more meditation (20 minutes per day!), she has ensured that her background for the session still looks professional, as close to her office as possible, allowing her to maintain her privacy and diminish distractions. She’s also recommended that her patients take the same measures – putting their phones on do not disturb, trying to be in the same space each session (if possible), etc. Kathy also checks-in periodically with her patients about their experience – asking them what they think of it, how the shift has been going for them. Checking in not only benefits them, it can also provide therapists with a peace of mind.

As a society, we’ve had to make many changes because of our extraordinary circumstances, but humans are adaptable and therapists and patients are no exception. The transition to teletherapy has gone more smoothly than most would have predicted. It’s unclear how long virtual sessions will need to continue as the primary means of mental health care, but as we look forward to a future where we are no longer quarantined, what will become of teletherapy – will it continue to be ubiquitous? Will we revert back to primarily in-person treatment or will tele-therapy prevail as the Uber-like disruption we’ve seen in so many industries? Stay tuned.

Gabriella Dishy, MA is a Research Assistant for Dr. Jeffrey Lieberman and the COPE Clinic and a contributor to Columbia Psychiatry News.