Covid-19 has transformed our landscape into an uncanny mixture of quiet streets and plentiful parking on one hand, and pervasive anxiety, fear, and dissociation on the other. This makes therapy and support for our nervous system as critical as ever. Even as the need grows, shelter-in-place orders also mean that much therapy is now happening online. This is referred to variously as telehealth, teletherapy, online therapy, video counseling, among others. Because of this dramatic and sudden change in the therapeutic experience, this blog addresses some of the issues involved in participating as a client or patient in online therapy.
(Note: mental health services are exempted in some shelter-in-place orders, meaning clients and therapists may consider whether it is preferable or permissible to meet in person. There are also other legal and ethical issues specific to telehealth.*)
Yes, therapy is as necessary as ever. But is therapy online as effective as face to face? The answer, not surprisingly, is either: “yes,” or “there’s not enough data in all cases,” or “it depends.” The answer turns on the type of therapy, the client's relationship with the therapist, and the client’s needs and circumstances, among other factors.
So, should you do online therapy? The answer is probably never an unconditional, yes. But given the choice between no therapy and online therapy, the answer is almost certainly yes in most cases. This answer applies whether you and your therapist have an existing relationship or whether you are meeting your therapist for the first time online. There is good evidence that online therapy can be just as effective as in-person therapy. The evidence is limited regarding its comparative efficacy, and studies don't cover all types of therapies or all issues clients are working on. Nonetheless, data do show that both short and long-term therapy, including psychodynamic and cognitive behavioral therapy, can be effective in addressing many of the same issues clients and therapists work on in person—social anxiety, depression, trauma, and others—for both adults and children.
There are obvious differences between online and face-to-face therapy. The technology, though much improved over the years, still makes it difficult to read the subtle body language of the other person. Sound quality, camera position, wireless bandwidth, familiarity with the technology—these are all variables that in-person therapy doesn’t have to deal with. Moreover, there is built-in bias regarding the video medium in particular. Zoom and other platforms are widely used for business meetings. This can affect the way a client views a therapist and whether the relationship feels trusting and intimate or tinged with the caution and distance of the board room.
At the same time, video has interesting advantages. For one, clients (and therapists sometimes) are in their own homes rather than an office. That means we see parts of each others’ intimate lives that are otherwise invisible. Whether that’s good or bad depends on how therapists work with it in sessions. There is also something known as the “online disinhibition effect.” This is what it sounds like: Clients (and, again, maybe therapists, too) can sometimes feel more at ease and comfortable at a digital distance. The informality can provide new material and poignant, and certainly useful relational fodder for the therapeutic process, particularly in the case of psychodynamic therapy. Finally, there may be groups such as trauma survivors and immigrant populations, where the digital distance can facilitate therapy. And given the vast need for mental health services, online therapy may be ethically imperative in some cases.
The World Health Organization (WHO) has conducted mental health surveys in 28 countries and found that during their lifetime, close to half the global population reveals symptoms associated with a [mental health] diagnosis. Is it feasible to supply all these individuals with psychotherapy in a traditional sense? A conclusion that emerges ... is that the great benefits of efficiency in Online therapy make it a very promising approach to complement traditional therapy. -Franz Caspar, University of Bern
All that said, there are some questions and steps to consider:
Is online therapy appropriate for this type of therapy?
Both client and therapist should prepare ahead of time for an online session—making sure everything is set up.
Consider meeting either more or less often in this medium to account for the type of therapy and the kind of relationship that exists between client and therapist. There is evidence suggesting beneifts of more frequent contact in an online context.
Some conditions and issues may not be appropriate for video counseling, if in-person is at all possible. This should be discussed, if possible, before moving from in-person to online.
The unstructured physical circumstances should at least be acknowledged, if not modified, by creating a consistent location for the client to use as their therapy space.
Consider carefully with your therapist whether confidentiality can be preserved depending on your living situation.
This moment is an opportunity to learn and be creative about what makes therapy effective and accessible. Even family therapy is possible and been shown to be as effective online as in person. How can we use this medium to make therapy more effective? And when do we decide that in-person work is preferable? There is no single answer. But it's a remarkable time to be embracing the conversation.
*There are ethical and legal issues specific to doing therapy over the internet or by phone. These depend in part on who is doing the therapy—a psychologist, a marriage and family therapist, a professional clinical counselor, a social worker, or someone else. Various ethics codes by state licensing boards and professional organizations govern how telehealth should be conducted depending on who is doing it and where people are located. Links to some of these ethical guidelines are provided here: