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Virtual Therapy in the Age of the Pandemic

What I have learned from conducting virtual therapy during the pandemic.

Key points

  • We must negotiate both emotional and physical boundaries.
  • The therapist-patient relationship may be a container for trauma and anxiety, as well as a foundation for change and growth.
  • The healing nature of therapy is bidirectional; I feel empathy from my patients.

It’s 7 am. I leave my bedroom, make a cup of espresso, embark on a 10-second commute to my home office in the living room and start another pandemic workday from home. For many mental health providers, conducting psychotherapy during the pandemic has become something like an episode of Black Mirror; we sit in front of a blinking screen, “teleporting” from one meeting to back-to-back individual and group therapy sessions, with little to no transition.

Christina Morillo/Pexels
Source: Christina Morillo/Pexels

How do I build a relationship with a virtual patient?
As a clinician who firmly believes that the therapeutic relationship is the bedrock for change, I was not without doubt when we first transitioned to virtual therapy. I had a million questions: How do I build a relationship with patients I have not met in person? How do I negotiate both emotional and physical boundaries as I process trauma and abuse with my patients in the middle of my living room? How would the disembodying experience of virtual therapy affect patients with a fragile connection to reality? How do I position my camera tactically to protect the therapist’s neutrality without revealing too much about my personal life, and just how much of my patient’s life on the other side of the screen would I be able to take in?

Therapy is fertile ground for change and growth
It turns out the answer to all my questions lays in the very element of therapy that has been misportrayed by media: the relationship. In TV shows, the therapeutic relationship becomes the vessel through which a pompous or an eccentric therapist manipulates a patient. On the contrary, I find the therapist-patient relationship to be the container for trauma and anxiety, the fertile ground for change and growth in the age of virtual therapy. To minimize distraction, I set my home office in the living room facing a blank wall, and it is always endearing when my patients ask whether I am working in the office or from home. I reflect back and wonder if that is their way to get to know me better, and maybe their worry about whether I am safe when a deadly virus is roaming the streets.

I am often surprised when I ask patients about their experience with virtual therapy, as they respond that they appreciate the increased flexibility and accessibility (especially for those with medical difficulties or limited mobility). I am also fascinated by how clinically enriching virtual therapy can be; I may learn about a patient’s relational style and comfort level with me based on what they allow to appear in their background, whether they attend sessions in their bedroom or outside, or if they introduce me to family members and pets.

How to manage the transitions within a session
While in my experience virtual therapy has proven to be as effective as in-person therapy, with increased accessibility for those with a busy schedule or limited mobility, my colleagues and I have also encountered additional challenges as mental health providers during the pandemic. Traditional therapy is filled with meaningful “transitions,” such as verbal pauses in the session that can draw out powerful insight, and physical transitions when the clinician walks a patient to or out of the office. With virtual therapy, natural transitions are often interrupted; the video may freeze while a patient breaks down in tears, and the back-to-back sessions with no physical transition can take a toll on the clinician’s cognitive resources, leading to a new phenomenon coined as “Zoom Fatigue.” When asked how I handle providing therapy during the pandemic, I try to practice what I preach: I squeeze in a 20-30 minute jog during my workday, I allow myself to connect to my emotional pain because it sends important messages about who I am and what I value, and I draw on my friends and colleagues for strength.

The COVID-19 pandemic is not just a viral one; it is also a pandemic of social isolation. The pandemic has allowed clinicians to relate and care for our patients in a deeper way as we traverse a somber chapter of human history. I am unrelentingly humbled by my patients’ strength and resilience. The pandemic has also helped to demystify the idea that therapists are immune to the harsh human condition. In the past year, I have survived a car accident and grieved the loss of an important relationship. I have heard about colleagues who contracted COVID-19 or lost family members to this deadly virus, colleagues who struggled to find childcare, suffered from burnout or social isolation, and so on.

As we collectively face the devastating reality of COVID-19, it is yet another powerful reminder that the healing nature of therapy is bidirectional: My patients’ empathy and capacity to care for me is as powerful as my support for them. Virtual therapy is likely here to stay as a permanent exhibit in the gallery of psychotherapy. Our experience with it in the past year is a story of distance and intimacy, loss and resilience.