Walking Our Talk: Can Psychology Practice What It Preaches?

At its core, psychotherapy is the business of change. It’s a tough business, because change is hard. Human beings are resistant to change because an easily changeable system is inherently unstable, and the distance from high instability to chaos is short. We do poorly in chaos.

Geographically, most people stay put in the land and culture of their birth even under tenuous, dangerous, and oppressive conditions. Likewise psychologically, our default mode is to keep doing what we’ve been doing. We form lingering attachments and long-term habits, which, to paraphrase St. Augustine, over time become necessities; so much so that we often find ourselves still working for them long after they have ceased working for us.

The process of therapeutic change is thus quite analogous to that of immigration: A person decides to leave the place that they know, having deemed it dangerous, oppressive, or otherwise untenable, and journey toward a new place they believe offers better safety, autonomy, or opportunity. But the journey involves inherent risks and unknowns. What if they veer off course? What if the promised new land proves less plentiful than envisioned? What if their resources are not up to the ardors of travel? And what of the doubt, the nagging notion that had they endured in place a bit longer, their luck might have changed, rendering the whole trip unnecessary?

As psychologists, we are charged with guiding people on their change journeys. We try to help them weigh carefully the decision to move, map out the path, pack well for the trip, stay the course, and learn the language and culture of their new destination. Yet rarely are we asked to become ‘immigrants’ ourselves.

The coronavirus pandemic amounts to one such rare occasion. The pandemic has caused a seismic shift in how most of us work, compelling us, quite literally, to migrate from our previous in-office in-person existence to working at-home and online. For once, as a profession, we are now called to take a dose of our own medicine, to change in earnest, to walk our talk and move to a new place.

True, we are called to travel under less than ideal conditions—but conditions are rarely ideal in this life, as we well know. In the case of this pandemic, we were not given much time to weigh our options nor pack for the trip; signposts along the way are spotty, and we have not yet had time to settle on an idea of what the promised land might look like, let alone get there.

Psychology is changing. And change is hard, particularly when you’re the one who’s asked to make it. Human beings are loss averse, so our attention naturally gravitates toward the losses we have incurred in the process of this pandemic-induced change. And certainly, the losses are real. For one, we are losing access to those clients who are not digitally savvy or who don’t have digital access. In addition, we are also losing the reliability of live face-to-face interaction, insofar as the current online technology often falters, failing to deliver clear and consistent connectivity.

Moreover, the online encounter limits our access to real-time contextual information about the client and the therapy process, because we cannot see our clients or their surroundings in full (and, of course, vice versa). Further, the online platform eliminates the physical dimension of our work—the handshake, the pat on the shoulder, the high five, the hug.

Finally, a less tangible, though no less profound, loss is that of a certain ephemeral-yet-powerful quality we may call ‘presence,’ the soothing effect of which may be traced all the way back to our earliest experiences and to the unique comfort provided by the proximity to a caring, responsive, attentive and competent other.

Even in the absence of direct physical contact, such physical presence matters greatly. This is because, for human beings, it’s not merely the actualities that make the experience, but also the potentialities. What can happen is as powerful in shaping our experience as what does happen. The freedom to leave the house if you wanted to changes dramatically the experience of being in the house, even if you never take advantage of that freedom.

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The visceral effect of physical presence cannot be substituted for via existing technology. That’s why people travel to Venice even though virtual tours and spectacular pictures of Venice are available in abundance and for a fraction of the cost. That’s why we go to concerts and shows even though high quality recordings are available and cheap. Seeing and hearing someone is not the same as being present with them. The comforting sentiment of “I’m here with you” losses much of its power online.

Thus, while we can definitely do therapy online—establish and maintain rapport, provide and receive honest feedback, deliver sound content—few people would deny that something is missing. Few, I would guess, would opt for a future that resembles this present.

Yet if we are to accept the challenge placed before us by this pandemic, then we are called to do what we ask our clients to do—be flexible, check the facts, face fear, frame the issue correctly, practice self-compassion not self pity, tolerate uncertainty, and move forward clear-eyed, with courage and optimism.

To that end, we have to acknowledge several additional truths. First, for all its limitations, the new online format also constitutes a wide-open horizon, offering opportunities that were unimaginable but a short time ago. For one, online therapy is bound to lower the barriers for entry to many clients, both financially and logistically. As psychologists, it may expand our reach greatly, since access to online therapy is (at least in principle) unbounded by geography.

Second, what was seen cannot be unseen, and what we now know we cannot un-know. Just as 9/11 altered permanently the way we fly; just as AIDS altered how we approach sex; just as online shopping has permanently altered the retail landscape, the pandemic has changed the enterprise of psychotherapy. What we’ve seen and learned, what we now know, is that health care delivery online is not merely feasible but also necessary.

The current reality has rendered obsolete the old question, “Does online therapy work?” Instead, we must ask: “How do we make online therapy work?” There is no longer a professional future in front of us that does not include online therapy. Graduate programs, private and community clinics, as well as insurance companies will have to reflect this change in their training, practices, and policies.

This means that there no longer can be a "best practices" notion in mental health care that excludes online services and capabilities. Over time, mental health systems that do not integrate online delivery into their DNA will not survive, neither will they be honoring their obligations to deliver cutting edge, "best practices" level care.

True, it is highly unlikely that digital delivery will replace the clinic office entirely. Yet it is quite likely that telehealth will, sooner rather than later, replace office care as the default, primary option in mental health care. Office visits may become a second level option, reserved for those who cannot access or benefit from online services and for those who are willing and able to pay more for specialty niche services.

Emerging new technologies often follow this kind of trajectory. The evolution of the cellphone is one useful and timely example. The cellphone has morphed, in quite the short order, from fantasy into a novelty, then into a luxury, then into a household fixture, then a habit, and finally into a necessity. Online therapy is moving through these stages as we speak. The pandemic has accelerated the pace of the process, or in the least served as a spoiler, revealing the endgame ahead of schedule. What was once fantasy, novelty, or luxury has become, in the course of this pandemic, a household fixture and a necessity. This change, like every change, comes at a price. But so does the failure to change.

* The full version of this post appeared in The Ohio Psychologist (Vol. 67, p. 8-10), 2020 Edition.