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Virtual Therapy: 9 New Lessons for Patients and Therapists

What can we learn from therapy's sudden pivot to teletherapy?

There is a war being waged over whether the human relationship will remain central to therapy (that battle is well-articulated by psychologist Todd Essig). Virtual therapy is a potential step toward dehumanization. There is no argument—physical co-presence and all that goes along with it, subtle visual cues, scents, chemistry—just isn't the same as an image or a voice on the line.

We can imagine high-tech VR therapy, hyperreal, augmented, and transcending physicality. Why not jack into the brain and conjure something more-than—but today’s technology is a dim forerunner of that science-fiction reality.

Pragmatically, teletherapy is useful, was arriving regardless, and, courtesy of coronavirus, is now suddenly here. As the potential for distress from COVID-19 increases, the effect of isolation, failure of trust in authority, as-yet-unrealized consequences, the sense of fear from vulnerability—in spite of resilience, people need support and therapy.

With this in mind, as a practicing therapist and co-founder of Neighborhood Psychiatry, where our staff has quickly shifted to telepsychiatry, here are observations about teletherapy from both decades of practice as well as recent events:

1. Teletherapy can be more intimate than regular therapy. Therapy, especially long-term insight-oriented therapy, creates a deep bond. Sharing and opening up fosters closeness. Therapists generally keep professional boundaries, so even the most open therapist is relatively anonymous compared to people in therapy, creating an intimacy difference (or gradient).

Teletherapy feels closer for many. Speaking on the telephone can be very personal. Cradling a telephone engages the sense of touch, typically minimized in therapy. It makes a difference whether via cellphone, a personal extension of the self, a hunched-up laptop, or a big screen with a comfortable desk. The embodied experience is different with each as is the meaning.

2. You get to see people in their natural habitat. This is something you can’t get with in-person therapy. While we always say to find a quiet, private space where you won’t be interrupted, life happens. As with talking, where we censor what we say and don't say, it's important to note what we show on video—and what we don't.

Kids barge in, people walk around, holding their phones up for a virtual tour, giving glimpses of beloved pets formerly only the subject of tales, call from intimate locations in casual mode, and all kinds of things.

The “experiment” of therapy is less controlled than in an office just talking, but it is more alive and rich in important ways. This is true for both patient and therapist, varying depending on how their respective spaces are set-up.

3. Patients may feel more secure. There can be a greater sense of control. You are on your own turf, leveling the playing field compared with going to a clinician’s office. The power dynamic feels evened-out.

Compared with past traditional therapy, patients may express feelings differently—ending the session by tapping that beautiful red hang-up icon first. While some patients track the time and end the session, more often than not therapists say when it’s time to stop.

The patient’s experience toward the therapist and therapy, the “transference,” is very different with teletherapy.

4. Countertransference is a double-edged sword. With a situation like COVID-19, where therapists and patients are likely to share adversity and prospects for resilience, there are risks and benefits to teletherapy which aren’t there when virtual meetings are for other reasons.

On one hand, being in it together can enhance the bond and the sharing, bringing things up which are very important which otherwise might not have ever surfaced, for example around mutual empathy and caregiving. Patients have a chance to show concern for the therapist they usually suppress. In moderation, mutual vulnerability can spur therapeutic growth.

On the other hand, therapists may get drawn into treatment-interfering or destructive enactments because of difficulty keeping boundaries during crisis. Boundaries may be too permeable, too rigid, or both. Therapists may over-identify, sharing too much, trying too hard, playing out their own fears, or withholding excessively.

5. You can move around. Research shows that moving around while thinking improves creativity and problem-solving. This seems to be because motor systems, the nervous and muscular activity which allows us to move, is tied closely with thinking and feeling. You can do that with teletherapy, within reason.

Some patients may also find they think more clearly while doing something else, though that can also be a distraction. These factors should be explicitly addressed. People may also be reminded of things in their homes that are important to discuss, whereas in the office they may have trouble remembering what to talk about.

6. It may be easier to talk about difficult subjects. For people who have experienced abuse at the hands of another person, being in physical proximity may sound the alarm as PTSD is from betrayal in an intimate relationship. This complicates the therapeutic relationship.

For patients with difficulty being close for any reason, whether personality-based, the result of trauma, abuse or bullying, or for other reasons, virtual therapy often feels safer. The increased detachment can both help and hinder therapy, depending on where in the process it comes up.

From a safe physical remove, patients may be able to take risks they wouldn't in person, including bringing up painful memories and complicated feelings about the therapist and therapy.

7. Teletherapy facilitates care. Many people don’t have therapists in their area or psychiatric treatment. Telemedicine addresses this problem. Teletherapy may also be cost-effective with lower overhead—no rent or commuting expenses, for instance.

For both, teletherapy may be more convenient. Many therapists, however, prefer to keep personal and professional spaces and identities more distinct—this can be an issue in a small city apartment without room for a home office.

8. Clinician burnout may be reduced. For many practitioners, teletherapy allows for a better quality of life. Reduced costs, more time, the ability to take breaks between sessions, control one’s schedule, and manage home responsibilities more easily make telemedicine appealing. If the therapist is in a good frame of mind, the therapy is likely to go better. However, many therapists report teletherapy is more draining without the invigorating human in-person interaction.

9. You can have breakthroughs you didn't before. Multiple people have remarked that being cut off from others, and knowing others are in the same situation, makes them feel better understood. There is a powerful sense that others can now relate to being isolated and rejected.

This can be a relief and can also open the door for insight and epiphany. The sense of urgent and immediate need, the sense of danger, can mobilize survival instincts, heightening the sense of day-to-day meaning and purpose. A threat to mortality can make the need for change more pressing. Also, having a concrete, real-and-present reason for all that anxiety can be a profound, transformative experience.

For these reasons and more, teletherapy may be an important factor in precipitating developmental leaps.

Will therapy ever be the same?

Time will tell whether coronavirus permanently alters the therapy landscape, or accelerates the inevitable—or whether all of life will ever return to how it was, or whether we learn anything from this experience. And, what will it be like when we start meeting in-person again?

In the meantime, a lot of folks are experiencing teletherapy immersion, motivated to make it work regardless of their opinion—as long as the internet and phones keep us virtually connected.


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