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Online Therapy

9 Questions to Consider Before Choosing Telehealth

A Personal Perspective: Important points about in-person therapy.

Key points

  • Telehealth has been an important survival tool during the pandemic, but it has challenges and limitations.
  • As we come out of the pandemic, we need sound criteria and rationales for continuing with telehealth.
  • One risk of seeing distressed people over a telehealth platform is that many "felt-sense" indicators are missing.

Written by Karen Z. Hyland, Ph.D., Director of Clinical Services

Telehealth has been an important survival tool during the pandemic, but it is not without its significant challenges and limitations.

Matilda Wormwood/Pexels
Source: Matilda Wormwood/Pexels

There may be situations in which telehealth is the best answer, but they may be fewer than some folks think. It has been proposed that telehealth increases access for clients that might not otherwise have access to therapy, though a recent Time Magazine article suggests differently (Ducharme, J., 2021). Telehealth also, perhaps, offers a safer way to enter the realm of psychotherapy. Younger people are comfortable and familiar with online formats, and this may make it easier for them to begin therapy. I also can’t help but remember how recently I sat across from my teenage daughter’s friend who told me she felt more real and more connected at our dinner table discussion than she had felt in all the months she was restricted to being at home during COVID-19.

So, yes, it may be that for people who live in rural areas and have no access to therapists, for whom there are financial barriers to accessing offices, or for young people, this is a much-needed tool that increases access or creates an entry-point to accessing psychological care. Stay tuned. The data and outcomes of this massive experiment are still being determined.

For many of us that work in big cities in private practice, however, our clients were able to get to our offices before the pandemic. The vast majority could still do it if they really understand the value. They will take our lead on this, and it is our ethical duty to help them understand why and when in-person therapy is valuable and how telehealth is very often "therapy lite."

Value of In-Person Therapy Over Telehealth

For example, although telehealth may feel more convenient for clients, what do people miss when they do not have the "required reflection time" on the commute to and from our offices? This transition time is invaluable for preparing the client to engage in therapy and access what they really want to focus on before they walk in the door. The travel home allows for absorption and processing of material from the session. Leaving painful or difficult emotions “at the office” has also been a helpful and supportive tool for clients who want a bit of separation from the difficulty of processing and the day-to-day operations of their lives.

There are also risks in seeing distressed people over a telehealth platform where many "felt-sense" indicators are missing. During the pandemic, we saw many distressed people over telehealth because it was the best alternative we had. However, nearly everyone I know says they are OK with continuing telehealth “if the client is appropriate for telehealth.” How are clinicians making these decisions? Generally, this means people who are “not suicidal or self-harming, not emotionally dysregulated, not addicted to substances, not a victim of trauma or serious grief, not a person who is abusing others, not someone with psychosis or borderline symptoms, not someone with an eating disorder, etc.” Who does this leave? The worried well? The people who feel anxious, socially phobic, mildly depressed, or have an adjustment disorder? Some couples? Some parents? Even anxious, socially phobic, and mildly depressed clients might benefit from having somewhere to go out of their houses and connecting in-person with someone who is wholly focused and present in the room with them.

Questions for Therapists About Telehealth

If you are considering continuing with telehealth indefinitely, I would encourage you to thoughtfully (and honestly) answer these questions about your telehealth experience:

  1. How many times have your clients (or you) been distracted or less focused than they would have been in the office? For example, you looked at something on your computer or your phone in the middle of a telehealth session, or they texted or typed on their computer during a session?
  2. How many times has a client been unable to share something because of fear of being overheard by someone else in the house?
  3. How often has the telehealth platform glitched? How many minutes of productive therapy have been lost? How many glitches have occurred in the middle of an important client story or expression of emotion?
  4. How many sessions have you done from cars, closets, or parks?
  5. How many times has your client jumped from a work call or parenting to your session immediately and/or returned immediately to work or parenting upon concluding the session? How much might they miss when they skip those periods for transition?
  6. How present are your clients with their emotions and reactions via telehealth compared to in person? How in touch are they with what they need to be discussing?
  7. How do you provide a "safe container" for their processing over telehealth?
  8. How have you felt when your client expressed suicidal ideation via telehealth or is at risk? What is your crisis management plan for this?
  9. How well can you get a "felt sense" of what is going on with your client over telehealth? Can you see their fidgeting below the screen? Their shaking legs? Their picked cuticles? Their weight loss or gain? Their lack of care for themselves? What signals are you missing by seeing only their "headshot"?

What is going to be your criteria and rationale for continuing to see someone via telehealth or for starting telehealth with someone new as we come out of the pandemic? For the pandemic, we had to use telehealth. As we come out of the pandemic, we need sound criteria and rationales for continuing with telehealth.

For some therapists, the decision to continue via telehealth is a financial one. There is a demand for telehealth and the world is full of examples of where demand for something produces positive profits but less than positive outcomes for human beings. Is telehealth one of those things that is positive for humans and profitable as well? Or is it like fast food—convenient, profitable, and yet not that good for people?

As we begin to recover from this pandemic, we must remember that we have been in isolation, cut off from in-person interactions and the healing that comes from being around others. Telehealth has been a lifesaving tool. But surely this is not ideal for many situations or clients. It is incumbent upon us as clinicians to see the bigger picture for what it is, and we have a duty to be clear with our clients about the limitations of a survival tool like telehealth.

References

Ducharme, J., (2021, July 21). Do Therapists Still Need Couches? TIME, 78-81.

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