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Online Therapy

The Teletherapy Frame

The implicit rules of relating change for telehealth.

Key points

  • The popularity of online therapy has risen during the COVID pandemic.
  • Telehealth poses some additional challenges to the patient-therapist connection, including time, place, payment, neutrality, and confidentiality.
  • Recognizing these new obstacles can help both patient and therapist address them promptly and get the most out of the therapeutic relationship. 

Every relationship has a frame, a set of implicit and explicit rules that define the relationship and serve its purpose. The therapeutic frame in individual work is more like the stretcher for a canvas than the frame for the finished painting.

Many therapeutic case formulations take the general form of a conflict between who the patients think or wish they are and who they really are. The typical relational therapy frame is designed to induce patients to take off their social masks and welcome aspects of the self that have been marginalized. The main construction materials of the therapeutic frame are time, place, fee, anonymity (making space for the patient’s unconscious life by not occupying the space with the therapist), neutrality (having no agenda other than resolving psychological conflict and making no judgments besides clinical judgments), and confidentiality (what happens in therapy stays in therapy).

The therapeutic frame also distinguishes therapy from its main competitors in the relational space, socializing and doctoring. The fact that it is two people meeting to talk pulls for a social frame, and care must be taken not to evoke social responding, most especially because society promotes the wearing of masks and makes it rude to inquire what’s behind a mask.

The fact that one person is paying the other to help resolve problems pulls for a professional frame—gathering data and giving advice—and care must be taken to preserve the therapeutic relationship, which involves the resolution of conflicts as they arise in the treatment rather than advice on what to do outside of the treatment. (If the patient seeks advice on external problems, there’s nothing wrong with giving it, but call it something other than psychotherapy. If an athlete seeks coaching or strength training, and there’s no internal problem such as injury, go ahead with coaching or strength training, but don’t call it physical therapy.)

These framing elements are modified in teletherapy.

Time

You can still start and stop on time, but the experience for the patient is different in teletherapy. There is not a period of driving to the office, collecting thoughts in the waiting room, or reflecting after the session built into teletherapy. Consider inviting patients to arrange for these time periods on their own. Also, engrossment in therapy is enhanced when only the therapist knows what time it is (by putting the clock behind the patient), but in teletherapy, the patient typically has the clock on their screen (unless they agree to hide it).

Place

In teletherapy, the patient provides the location and is responsible for soundproofing and preventing interruptions. The therapist’s office is designed to induce engrossment, while teletherapy presents distractions. Notifications of emails and texts can be turned off, but even then, an available search engine and a history of social media posts to show the therapist can take the patient out of the immediate present.

The fact that they are in two different places dulls therapy’s intimacy exposure—the patient’s discovery that someone can get close to them and not harm them. Patients can’t get the benefit of therapists not running out of the room when they are already in a different room.

Fee

Many therapists take a credit card number and bill it after sessions, even for in-person work; I imagine this is even more common for teletherapy. It makes paying the fee invisible and not an affirmative act. It makes things awkward after missed sessions because it forces the therapist to decide what to do rather than starting the discussion after the patient paid or did not pay the fee.

Anonymity

The background of the therapist’s video should be chosen with the same care as office furnishings. Anonymity—not filling the space—also embraces stillness, and it’s a lot harder to sit still in teletherapy than in person because you don’t want the patient to repeatedly ask if the screen froze. Anonymity also provides a kind of psychological embrace, not the rebuking, defensive redirection of “This is about you, not about me,” but the invitation to make the therapy the patient’s scene and not the therapist’s: “This is about you.” The warmth of this sort of embrace is muted on a screen, and therapists might find themselves providing the needed sense of warmth with self-disclosures.

Neutrality

Something about teletherapy makes therapists feel more like giving advice and taking sides in internal conflicts. I think it’s because the alternative to advice is welcoming curiosity, an invitation to explore the psychology of the situation and integrate conflicting agendas. Welcoming curiosity in teletherapy can feel like dead air on the radio.

Confidentiality

Even a perfectly confidential office setting will raise recordkeeping and gossiping fears in patients about the fate of things they say. No one can reasonably guarantee that teletherapy transmissions are safe from outsiders.

My sense is that certain aspects of individual treatment translate well to the teletherapy frame, including case formulation, changing patient narratives, accepting one’s humanity, approaching conflict, and exploring disruptions in collaboration. Other aspects of therapy, such as intimacy exposure and the exploration of perceptual and framing errors, need a frame that is not easily implemented in telehealth, although some patients are especially good at getting collaboratively engrossed, and these patients can overcome the disadvantages.

A version of this post was also published in The Colorado Psychologist.

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