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Online Therapy

Teletherapy Versus In-Person: Subjective Views and Verdicts

Is teletherapy really the blessing everyone claims it is?

Key points

  • Teletherapy has surged during the COVID pandemic when many are unable to meet in person.
  • Teletherapy is more accessible and convenient, but a lack of body language cues can make it harder to help patients, especially during a crisis.
  • Going forward, therapists will need to adapt to a hybrid model as best suits their and their patients' needs.
 Ravi Chandra, M.D., D.F.A.P.A.
Yours truly in potential Zoom incarnations.
Source: Ravi Chandra, M.D., D.F.A.P.A.

Teletherapy has undoubtedly been a saving grace for mental health care during COVID, for practitioners and patients who required both safety from the pandemic and also continuing care. Of course, there is great inequity in our digital divide and significant shortcomings in therapy conducted through a technological portal. Every person and every situation is different.

Personally, I look forward to returning to a primarily in-person practice, but after much hemming and hawing, I have decided not to do that until cases have dropped into the yellow or green zones per the Brown University School of Public Health-sponsored GlobalPandemics.org. That is between 0-5 cases per 100,000 population in San Francisco. As of today, September 13, 2021, cases are at 13.6 per 100,000, about half of where they were just a few short weeks ago.

Of course, most cases and hospitalizations are among the unvaccinated, but Delta and other variants are causing significant illness in some vaccinated people, and I still have concerns that even vaccinated people can get long COVID. I don’t want to catch or transmit this virus, though current views are that nearly everyone will be exposed to Delta over the next few months. I encourage everyone to get vaccinated, following CDC guidance and FDA approval, and view this as an opportunity to think more deeply about how our safety and well-being depend on other people’s safety and well-being. We can’t keep ourselves safer unless we keep each other safer.

I have occasionally done masked in-person therapy when the patient has needed care, and some of my colleagues have been doing masked care throughout the pandemic, out of their own sense of their patients’ needs or out of institutional necessity (e.g., they work in prisons or hospitals). However, I know therapy goes best when both parties can see each other’s faces and thus better understand each other emotionally.

On rare occasions in the last couple of months, I’ve done unmasked therapy when I feel extremely comfortable with the patient’s level of caution about exposures. Yes, it still made me a bit nervous, and yes, I still interrogated every sniffle and tickle for days afterward. But these occasions reminded me that in-person therapy offers many orders of magnitude more relatedness than a computer screen. While nearly all my video sessions have gone well, there have been occasional miscues when things have gotten off-track. Video therapy creates particular challenges for patients who have been traumatized relationally and culturally because trust is all too easily lost across the Zoom screen, particularly if one is prone to mistrust to begin with.

Weighing the costs and benefits of teletherapy

My verdict: Teletherapy is adequate for patients who are reasonably attuned relationally but can be problematic for those who are prone to mistrust and getting off-track in their relationships, and obviously challenging when a patient is in severe crisis (e.g., psychosis, suicidality and other self-harming behavior, those who are prone to dissociation, those experiencing Intimate Partner Violence, which poses extra challenges in terms of finding privacy in teletherapy). A therapist can also miss a lot on video that they probably wouldn’t miss in-person, and similarly, a patient can miss a lot about their therapist’s intentions online as well. Besides, when we are separated, we are not in the more controlled environment of a therapy office, and this presents potential challenges and discomforts to all parties. Also, it's a bit weird to basically be required to look at each other's faces all the time to feel "contact."

In-person therapy offers a profound and irreplaceable sense of relatedness and companionship. We are interdependent social beings, and we need embodied presence to survive. We should not forget that emotional and physical isolation are forms of torture under the Geneva Conventions for Human Rights. COVID isolation has had a profound impact on the mental health of the entire population, from young to old, and we will need to address these sequelae in more expansive and systemic ways.

What patients are saying about teletherapy

Here’s a sampling of what my colleagues and I have heard about teletherapy during COVID.

"It’s OK, not good, not terrible. I’d give it a B. I feel like I would be more loose in person, more comfortable, instead of wondering about how I look and come across on Zoom. Less self-conscious." (Note: Indeed, what does it mean to be looking at ourselves all the time? Others have noted “Zoom Dysmorphia” or heightened anxiety about physical appearance because of being caught in the camera’s gaze. Personally, I’ve had to up my game of transmitting warmth and empathy through facial expressions. Gah.)

"It’s going well. Because of my physical limitations, it’s easier to do Zoom therapy. I feel connected, and we had met in person in the past. I minimize my own picture because I feel self-conscious about seeing myself."

"It’s easier and more convenient, but I don’t think it’s good for depressed people like me. Before I would have to get out of bed, shower, get out of the house—that’s all inconvenient, but it gave me some feeling of normality too. Right now, I’ve been exhausted because I am not doing all those normal things."

"I don’t like it, but it’s better than nothing. I prefer in-person. The ends of sessions can be abrupt, and I can’t see your whole body, just your face." (My apologies, indeed, lol.)

"It’s convenient. I like taking notes during session, so that’s been good." (Ironically, the patient’s connection dropped right after she says, “It’s convenient!”)

“I still feel unsafe, less so because of COVID but because of the anti-Asian violence. I don’t know if that’ll ever get better... It used to be an excursion, coming to your office, but I would buy groceries and get outside. I guess now I have other excursions, so it’s OK. When it feels safe to travel by public transportation, I would consider coming back to the office.”

"It’s a bit more constrained in tone and subject matter because I live with others, but it is very convenient."

"It feels more comfortable. I can talk to you like I was talking to a friend. I was too embarrassed to talk to you about some things in person. I feel more spontaneous talking this way."

"I feel more spontaneous on Zoom, though there were limitations when I was at home with paper-thin walls and my family in the house. I like having you in a box on my screen (laughs)! I’ve never done in-person therapy, so I can’t compare. I think I might be less open if I saw someone in-person."

"It’s OK. Not as good as in-person, but adequate. I’m a little distracted because I often type what you’re saying so I can remember."

“The relatedness would be better in person. It’s not all-or-nothing.”

“I can build trust through technology just fine. Therapy and med management have been fine, but I feel less connected to you since we are only meeting for med management.”

“Ironically it’s more intimate, because you’re right here on my screen, but also because I’m in my own environment, didn’t have to commute, wait, etc.”

We seem to be headed into an ambidextrous, hybrid world where many therapists will be doing mostly teletherapy, many others will be doing both tele- and in-person therapy, and probably only a minority will be doing solely in-person therapy by choice.

I think we would be wise to remember these two adages: Mileage may vary, and caveat emptor.

References

Chandra R. Teletherapy: Breakthrough or Breakdown?, Psychology Today, September 26, 2011

Chandra R. Coronavirus Anxiety: Should I See My Therapist Face-to-Face?, Psychology Today, March 12, 2020

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