Kirsten Bradbury Ph.D.

Breathing Room

Teletherapy Tips for Clinicians

3 basic rules for practicing teletherapy.

Posted Mar 26, 2020

Like it or not, telehealth for psychotherapyteletherapy—is here. COVID-19 has forced therapy offices around the country, including mine, to close to visitors for the foreseeable future. So we are offering telehealth services to our clients and patients. I recognize my good fortune in being able to adapt to this crisis with relatively little disruption compared to many businesses, continuing to provide patient services and keeping my job. Nonetheless, I already miss my clients, my office-mates, and the rhythm of our usual practice. If you value the human aspects of practicing in person as much as I do, the transition to telehealth is going to take a little getting used to.

Kirsten Bradbury
Source: Kirsten Bradbury

Whether you are using Zoom, FaceTime, Skype, or any of the many other available video chat technologies, therapeutic communication is more challenging when you and your client aren’t in the same room.

Video chat is clearly superior to talking on the phone for all therapeutic communication and is necessary for some types of interactions—most diagnostic assessments, for example, cannot be done responsibly without interactive video.

Fortunately, interactive video is easy to set up these days, and most types of work you would do at a therapy office can be adapted to it. However, even over video chat, you will notice barriers to full communication and a dampening of your ability to read a client’s cues and responses. Clients’ communication output in a therapy session includes subtleties and nuances, both auditory and physical, that are easily missed—or impossible to discern—in a video chat session.

There are other issues with teletherapy, which is largely unexplored territory in terms of training, supervision, and continuing education for mental health professionals.

Geographic separation between therapist and client has both practical and process implications. For example, video chat therapies will rely even more than in-person therapy on the client's willingness to display or disclose their behaviors, and many aspects of functioning can be hidden or faked more easily on camera than in person.

Kirsten Bradbury
Source: Kirsten Bradbury

Like any fundamental shift in practice dynamics, this one will include many problems we must work through, and we want to minimize the risk of harm while we do so.

That's why, in my book, the first rule of the new teletherapy is: Be Aware of Its Limitations.

That said, and without disregarding the first rule, the second rule of new teletherapy has to be: Go For It. Telehealth is more needed now than ever, and it's not going away. Mental health as a practice can always benefit from motivation to innovate. We can’t stop taking risks if we want to continue to meet our clients’ needs in a changing world. We will need to learn new things and try new things; we will need to do some research on what the particulars are for our individual practices; we will all need to read up on new ethical guidelines and (temporary) relaxations to HIPAA requirements; we will need to talk to our clients about what’s happening and what to expect; we will need to do some exploring and experimenting. We can do it! Remember that teletherapy is still therapy. It is already something you know how to do, and you will get used to it, just like you had to get used to working around the limitations and challenges of in-person therapy when you learned that method. Jump in and serve; we all know the demand is there, and even clumsy teletherapy will be better for clients and patients than no therapy at all.

Take it easy on yourself and accept that this as a multi-step process. At first, keep it simple. Consider your own practice rhythm and specifics and make the smallest changes you can make while still maintaining continuity of care to the greatest extent possible. In terms of technology to handle a fully functioning telehealth practice, there is a variety of business and technical solutions available already and more being offered every day. New ethico-legal-technical standards and tools will be developed, and other supports for clinicians in the field attempting to do our best work will be implemented over time. Once you are set up doing something simple to accommodate your clients now, look into the options for possible longer-term solutions that could provide unexpected benefits relative to traditional practice.

Kirsten Bradbury
Source: Kirsten Bradbury

The third rule of the new teletherapy might be Get Creative. We must all get creative and give some real thought to the best ways to run our practices given this newly restrictive set of circumstances. Practicing in this context will require more creativity than practicing in the context of a pre-COVID world, and we must all endeavor to rise to that occasion. Therapeutic interaction is not immediately transferable to remote methods; we must each give new thought to treatment plan, session organization and goals, and communication for each client. Using telehealth technologies to bridge gaps between in-person sessions is very different than building therapeutic relationships entirely online; nonetheless, we must each work to implement online procedures for intakes, assessments, or whatever version of new client appointments our particular practice context entails.

And these are just some of the many examples of new considerations that have sprung up. Creative adaptation is what’s needed, and we can all throw ourselves at this challenge. What area of practice do you know well? Help the field grow by sharing your best online practices for your context as you develop them.

Kirsten Bradbury
Source: Kirsten Bradbury

We are going to benefit greatly from remaining positive, growth-oriented, and collaborative. Regardless of which technical and business solutions you choose to implement in your practice over time, you will need to get yourself set up with a comfortable video chatting area (what’s behind you?) and attempt to remove and prevent distractions (where are the kids?). Maintaining a holding environment for the client will require deliberate problem-solving. Patients and clients will need to be oriented to the process of teletherapy, even if they are already experienced at in-person therapy. The issues they bring to in-person sessions will also influence how they respond and adapt to teletherapy.

They will still be clients and you will still be a therapist. They will do what they do, and you will do what you do; you will connect and do the work of therapy. And it will be thanks to telehealth technology that you can still make that connection and do that work.

For more tips on how to get the most out of your teletherapy practice, download our free handout at txpsychce.org.