Seen and Heard

A pandemic jolted therapists and clients into a move that now feels inevitable: going online. Given what therapists now know about impactful online exchanges, others may want to take note.

By Matt Huston, published June 19, 2020 - last reviewed on July 17, 2020

Mike McQuade, used with permission.
Mike McQuade, used with permission.

Around the time the number of COVID-19 cases in the United States exploded and stay-at-home orders spread, in March, Sira was offered the chance to move her meetings with her therapist online. “I wasn’t really onboard,” she says—until she had no choice.

As therapy continued over video calls, though, the 24-year-old client discovered some upsides. She has found that getting a glimpse of the therapist’s home life, as when her doorbell rings in the background, “makes her more human.” They can examine worksheets and watch videos together on screen, even if connectivity is sometimes a challenge. Sira prefers in-person sessions, but she’d like to be able to choose either option in the future.

The pandemic made therapy by video call, phone, or text an overnight necessity for therapists and clients across the U.S. and the world, including many who had never held a remote session before. In a time of crisis, the opportunity to seek out or continue working with a therapist was mission critical.

The practice of therapy using telecommunications technology, often called teletherapy or telepsychology, had gained steam before COVID—showing growth in the 2000s and 2010s—but the sudden taste that so many people received this year may cement it as a standard way to seek sustained help. “I don’t think there’s putting the genie back in the bottle,” says clinical psychologist Eve-Lynn Nelson, statewide director of the Kansas Telebehavioral Health Network.

The therapist-client relationship is a special kind of dance, and how practitioners and clients handle the transition to remote work may offer lessons for anyone seeking to make the most of high-stakes encounters at a distance, from remote schooling to virtual job interviews. Building a therapist-client alliance without sitting in an office together may involve some stumbles for both parties. Yet therapy over phone or video, experts say, can be as effective as therapy in person, and it comes with its own advantages—ranging from the logistical to the deeply personal. Therapists, both newcomers to teletherapy and long-time practitioners, have been developing a variety of skills and sensitivities to deliver their best care at a distance.

••• MEETING PEOPLE WHERE THEY ARE

Plenty of people simply don’t live close to many—or any—therapists. “There are just not enough of us to go around, and often we’re based in more urban areas,” Nelson says. Tens of millions of Americans live in regions with shortages of mental health professionals. For them, a therapist on screen or on the phone may be an urgently needed lifeline. “It allows us to reach people who would have gone without services—and maybe would have taken their own lives,” says Carly McCord, director of the Telebehavioral Care program at Texas A&M University, which delivers services throughout the state. “Almost half of our clients come in with severe suicidal ideation.”

Even if someone lives within driving distance of therapists, having access to one through the smartphone in one’s pocket or the computer in the next room may make it easier to cross the threshold into treatment: Online therapy can help alleviate concerns about privacy and stigma, experts suggest. “Especially if you live in a small town, if you feel weird about sitting in a waiting room and having people you know see you there, this can ease that,” says Shannon Sauer-Zavala, a clinical psychologist and assistant professor at the University of Kentucky.

Others face physical obstacles to attending sessions in person due to an illness or disability; seeing a therapist from home is a way around that. A person’s reason for consulting a therapist could itself be a hurdle. “There are some who have experienced trauma caused by other people, and they don’t feel safe leaving home during certain phases of treatment,” says psychiatrist Grant Brenner, who conducted remote therapy sessions prior to COVID.

While teletherapy sessions were foreign terrain for many before the pandemic, reports suggest that usage had in fact been steadily growing for years. A paper in the Journal of the American Medical Association reported that between 2005 and 2017, mental health televisits grew an average of 56 percent each year among enrollees of a large private health insurance plan. A report in Health Affairs found a comparable growth rate between 2004 and 2014 among rural Medicare enrollees. “The technologies have gotten better, faster, cheaper,” says Nelson, who has worked in telehealth for about two decades.

The growing landscape can also increase choice. Finding a therapist often requires finding a provider with the right clinical toolbox, sensibility, or cultural background.

Some problems call out for specific, tested solutions. Greg Gardner, a therapist in Australia who has provided video and phone sessions, recalls a client who had suffered from insomnia for most of her adult life: “She wanted cognitive behavioral therapy (CBT) for insomnia, and I don’t think there was anyone locally who was trained well enough.” She took seriously her remotely conducted therapy with Gardner, including learning about the condition and keeping sleep diaries, and “we just knocked the problem on the head in four sessions,” he says. “That really sold it to me.”

Remote access to a therapist, McCord notes, could similarly help people with borderline personality disorder seek treatment from a clinician specially trained in dialectical behavioral therapy, the treatment modality of choice. People with post-traumatic stress disorder (PTSD) may have a better chance at receiving a highly rated treatment such as prolonged exposure therapy.

Nathan Brandon, a therapist in Georgia who has provided therapy sessions remotely for three years, says he has also served clients seeking a specific, evidence-supported treatment, such as CBT for anxiety. And he has seen other upsides emerge due to the long-distance reach of his practice. “I had a client from a rural area who, as a young gay person, had a really hard time looking for a therapist—and also just not having anybody around who was gay whom he could talk to.” He started working with Brandon, who is also gay and brought an understanding of LGBTQ issues to their sessions. Brandon credits online therapy for this outcome.

Mike McQuade, used with permission.
Mike McQuade, used with permission.

••• THE SAME BUT DIFFERENT

Therapy through a video calling app or over the phone is therapy, couch or no couch. Though, as many people found out when birthday parties and staff meetings went online during the pandemic and as therapists and clients attested, a change of medium can influence the nature and possibilities of conversations in nuanced ways.

Fifteen years’ worth of research suggests that remote sessions can be as effective as in-person ones for common mental health conditions. In a 2018 paper in the journal Psychological Services, University of Melbourne psychologist Tracey Varker and colleagues corralled the evidence on teletherapy’s efficacy in treating anxiety disorders, major depressive disorder, PTSD, and adjustment disorder.

For therapy via telephone, overall, “the evidence suggested that it’s as effective as face-to-face treatment—and certainly better than doing nothing,” Varker says. Although a major portion of the video-based therapy studies focused on veteran samples, and therefore may not be perfectly representative of the population at large, researchers drew a similarly positive conclusion about video as a platform. Due to a lack of quality evidence on real-time online chat, its effectiveness was deemed “unknown.” The researchers did not examine asynchronous (or delayed) messaging as a therapeutic tool, which some practitioners and teletherapy companies also employ.

Teletherapy holds promise for treating other conditions, too, research finds. A recent review of studies on teletherapy for substance use disorders indicates that video-based treatment may be an effective alternative to in-person treatment (though it flagged methodological limitations such as small sample sizes).

In practice, experts acknowledge, therapy may be less tidy than it is in randomized controlled trials. Therapists have to make their own judgments about whether teletherapy is suitable for a given patient. And meeting with clients remotely can involve its own stumbling blocks—from technical hiccups and dodgy internet connection to behaviors that test the norms of therapy.

For one man with PTSD, Gardner recalls, “the boundary creep that happened over the course of the episode of care became a really big problem. We had sessions while he was in his office, and it soon got to the point where people were coming in and having conversations with him during sessions. He started answering emails.” Another client called in for sessions from his car: “I could barely see him,” Gardner says.

Setting the stage for a time and space dedicated to the work of therapy is important, he says. “People bring their own personal assumptions about private video chat. You must set very clear boundaries, like: ‘You actually need to attend on time’; ‘You need to be respectfully dressed’; and ‘You need to be in a quiet space away from other people.’” The implicit precepts of face-to-face therapy have to be made explicit. Then there’s prep unique to this experience. It’s crucial for therapists to obtain consent for remote practice and to ensure that they know exactly where the client is during sessions and that there’s a plan in case of an emergency, such as an imminent risk of self-harm.

Online or phone sessions limit (or eliminate) the visibility of body gestures and facial expressions from which a therapist can infer feelings or reactions—a concern therapists and clients alike mentioned in recent surveys. “Sometimes, I’m not even seeing a whole face. It’s harder to see nuances in breathing,” says Jennifer Frary, a therapist who switched to remote sessions during the pandemic. Pointing to an example she calls “shoulder-earing,” she says, “A lot of times when clients are feeling tense or emotionally triggered, their shoulders naturally rise. And, depending on where they’re sitting, in telehealth you can’t necessarily observe the shoulders quite like that.”

Staying mindful of what might fail to come across visually—and being more verbally explicit—may help bridge the gap. On phone calls, “you don’t know if someone is totally distracted and playing solitaire or is thinking really deeply,” McCord says. “And you think, How do I know what’s going on here? Well, you ask them: ‘Hey, I noticed there are a whole bunch of pauses in these sessions. I can’t tell if those are working pauses or if you’re distracted.’” She also suggests that with experience, it’s possible for therapists to develop “something of a sixth sense” for invisible cues. “Once you build a relationship, you can better feel the pulse of the person’s tone and pacing.”

It can be challenging to develop rapport without first seeing a client in person, but it gets easier over time, according to Brandon. He suggests asking open-ended questions to help clients go into greater depth in their responses. “Silence isn’t really as helpful when you’re on a telehealth session, especially if it’s over the phone,” he says. Trying to mirror a client’s tone and energy level is useful for rapport-building, he says, as is deploying a sense of humor.

One 17-year-old client, Bea, suspected the fidgets and other motions that conveyed how she was feeling weren’t coming across to her therapist once they moved to FaceTime. But eventually, they started communicating more openly about what was or wasn’t helping in sessions, Bea says. “Every time my therapist says something, she asks me straight up, ‘How do you feel about that?’”

Teletherapy doesn’t only subtract information, however. It can also provide a window into a client’s typical surroundings and way of being. “You can see their cats running around in the background or their kids. However they choose to create that boundary—or not—becomes apparent,” says Brandon. A client with depression, he explains, may “just be lying in bed to do the session on the phone, and it’s kind of showing you some of the desperation, the mood, when the person wasn’t motivated enough to get out of bed and get dressed. So that’s also telling you something.”

Mike McQuade, used with permission.
Mike McQuade, used with permission.

••• THE NEXT CHAPTER

Therapists and clients have adapted differently to meeting each other remotely, and their reception to the mode shift doesn’t necessarily break down in stereotypic ways. While Varker says she has run into technology-related frustrations with clinical study participants in their 70s and 80s, she observes that younger cohorts seem to manage better. Anna, 61, says it took her a couple of video sessions to get comfortable, but now she doesn’t feel that anything critical is missing. “I can see my therapist’s facial expressions, I can see her smile, I can tell when someone is really listening, so in that respect I feel it hasn’t taken anything away.”

Some clinicians have been pleasantly surprised. Like so many others, Sauer-Zavala, who has been conducting therapy sessions as part of a research study, had to take them online. “I think that before this, a lot of people, myself included, would have said, ‘It’s not the same. There’s so much that would be lost.’ But even with people I’ve seen only online, the first session was a little bit weird, but since then it’s been fine. It’s clear to me that they feel heard.”

Many full-time therapists, having transferred most or all of their cases to video or phone, reported feeling exhausted as the pandemic-related shutdowns wore on. Some attributed the fatigue to the extra work required to monitor a client’s expressions or having to stare at a screen for many hours.

A day full of appointments on video can feel “kind of like watching television all day—you feel a little bit spacey afterwards if you have back-to-back sessions,” says Brandon. That’s why, he suggests, it’s important to have downtime to ground oneself between calls.

Speaking about her experience in April, Frary describes the sessions as “exhausting,” but offers that it may have been difficult for therapists to completely disentangle COVID-related stresses from those caused by an obligatory transition to teletherapy. “It’s hard to judge bigger-picture how we would’ve felt about this if it weren’t happening in a pandemic.”  

The extent to which teletherapy expands will depend partly on how regulations and insurance reimbursement policies shift in the near future. During the pandemic, states and the U.S. government temporarily relaxed some of the limits that would usually give therapists and clients reasons not to use teletherapy—rules requiring that a therapist is licensed in the state where the client lives, for example, or fines for noncompliance with the law that governs patient information use. The extent to which insurers reimburse clients for remote sessions varies across the U.S.

“The question is, do we go back to where we were pre-COVID-19? Nobody quite knows the answer to that now,” says Mei Wa Kwong, executive director of the nonprofit Center for Connected Health Policy. “I think certain changes will stay. This pandemic has brought to the forefront of people’s minds that this is a valuable tool in our healthcare system. It’s been a huge exposure to consumers.”

For McCord, the abrupt transition that was required to keep therapy afloat during an emergency highlighted a need for therapists to take teletherapy more seriously going forward.

“One of the reasons this has been such a scramble is that we have a whole generation of providers who had never done telehealth before, who needed to log in immediately and take care of their patients,” she says. “We’ve got to keep this going so that we’re all ready the next time.”

Disastrous events provided a sudden opportunity for therapists and clients to innovate. But in this era of remotely mediated connections, the lessons they have learned—including the value of an expanded range of potential collaborators, the need to speak up when visual signals are lost in translation, and the importance of setting boundaries to keep meetings productive—are worth spreading outside the virtual therapist’s office.

Mike McQuade, used with permission.
Mike McQuade, used with permission.

A Therapist’s Guide To Serious Talks—at a Distance

After many hours of weighty conversations on webcams, therapists have learned plenty about how to make the most of the medium. Here are some of their recommendations—which may elevate the quality of important exchanges whether you’re in therapy or not.

•••Set boundaries.

If the chat is more than casual, establish your expectations and set the tone for the kind of conversation you want. It may be as simple as asking the other person to show up on time, not sit near potential eavesdroppers, and not eat during the call.

•••Limit distractions.

Find as quiet a place as you can and try to minimize potential distractions from your device. Clinical psychologist Seth Gillihan suggests closing other apps or programs that could hurt video quality and silencing notifications that could pop up mid-conversation.

•••Get comfortable.

Any in-depth conversation can run long—so make sure you’re comfortably situated. And think about where you set up your screen. Therapist Anney Snyder started placing hers far enough away that clients could see her as they would if they were sitting across from her. It’s familiar, allows for gesturing, and “you are able to naturally look away, above, and to the side of the clients’ face” rather than staring them down.

•••Take a break before you start.

Dedicating some time just before a session to gather thoughts or consider what to talk about can help clients get in the right headspace, therapist Nathan Brandon says—as they might while driving or sitting in the waiting room before an in-person session. If you’re gearing up for any kind of serious talk, consider giving yourself a buffer period after whatever you were doing before.

•••If it can’t be seen, say it.

Since certain nonverbal signals—a fidgeting leg, a sigh—may be harder to see during a call, verbalizing more than usual can help, Brandon says. This may be especially the case for audio-only calls: “If something’s upsetting, I can’t just look upset. I have to say, ‘That sounds upsetting. That makes me feel upset for you.’” If your head is bowed because you’re taking notes, make it clear you’re not simply ignoring the other person.

•••Make “eye contact.”

If you’re close to your device, keep the top of your head near the top of the screen, Gillihan suggests: “When they’re looking at your face, they’ll be looking more or less into their camera (assuming it’s at the top of their computer), so it will feel as if they’re looking at you.”

•••Consider your background.

When clients walk into your office for the first time, they may see humanizing clues about who you are—a family photo, a poster, books on your shelf. If you’re meeting a remote conversation partner for the first time with only a blank wall behind you, “you’re not really giving them much to go on,” says Brandon. “If you were in your office space, what would you want people to see?”

•••Ask: Is more better?

Psychiatrist Grant Brenner has held many audio-only sessions. In some ways, he says, going without video “is preferable because it more closely approximates the psychoanalytic ideal of lying on a couch. It frees the brain up from the need to monitor social information. It helps people to not get tied up wondering what the other person thinks about them.”

•••Keep the connection going between talks.

The conversation doesn’t necessarily have to end when your call does—even if you’re a therapist. “Maybe you suggest a book on what you talked about,” Brandon says, “or any other resources that could be helpful in making them feel that you’re interested in how they’re doing outside of sessions.”

Make a Lasting Impression In Just 15 Seconds

A few moments and a comforting presence may be enough to help someone take the next step toward starting therapy. In response to the increased demand for teletherapy this year, and to help therapists better connect with those seeking services, Psychology Today invited the therapists in its directory to introduce themselves, by video, in 15 seconds or less. Thousands of professionals have since created and uploaded these personal videos.

What’s the secret to an effective introduction? Therapists are given a few tips: Speak as you naturally would, dress professionally, face a light source, use a neutral background, and hold the phone above eye level—so as not to stare imposingly downward at viewers.

With these tips, clinicians have found ways to convey their individuality and commitment to their metier in a snap. To reach the clients most likely to benefit from their help, many therapists share their specialties in specific and concise terms, such as an interest in “women’s mental and reproductive health” or “adolescents and adults with anxiety and depression.” Many also offer a glimpse of their surroundings that is inviting (a calm painting or minimalist sculpture) but not cluttered.

First impressions are critical in any important alliance and resonate especially for those seeking a good therapist-client fit. So in the absence of a face-to-face meeting, Directory therapists offer diverse examples of how to initiate a strong connection.

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