Teletherapy Tips (but mostly rant)

(This is a bit long, and you may want to just skip to the end, where there is a client resource that you can check out!)

I’m not particularly new to teletherapy – I’ve done it for a couple of years, though only at need (for example, with a client who traveled out-of-town but in-state to care for her dying father for several weeks). Like it has for many of us, teletherapy has taken a larger role in my practice in 2020, and – as a result – I’ve solidified my relative distaste for it. It’s taken me some weeks to really get a handle on what bothers me about it, and I think I have.

• It’s just not clinically appropriate for some clients.
  • For some clients, coming into the office is literally part of what is therapeutic – for depressed clients who have difficulty getting out of bed, for social anxiety clients who “feel safe” behind the screen, for clients with autism spectrum disorder whose work involves building social skills, for clients with dependent personality disorder/features
  • For some clients (those above, and those with almost any other kind of anxiety), staying sequestered at home exacerbates their symptoms. Consider how many people will have added a “with panic attacks” or “with agoraphobia” specifier to their diagnoses by the end of this time!
  • Perhaps it goes without saying, but managing potentially dangerous situations (e.g., self or other harm) via telehealth is something very few people have been adequately trained in. I have a feeling we don’t really know if we’ve been adequately trained until we’re in the moment across the screen with our client who has the scissors at their elbow.
• Privacy/confidentiality is our responsibility, and teletherapy makes that much more difficult.
  • Privacy and confidentiality are much easier to manage in our office environments. For therapists who have moved their practice to their homes, unless they live alone, this poses significant challenges (e.g., family members hearing session, Bluetooth devices nearby allowing access to sessions). Also, when records are kept outside of the office, or moved between home and office (e.g., if you use paper records), that adds risk.
  • Probably the larger issue is that we don’t have any control over the environment that the client chooses. We can ask them to provide an optimal environment, but it becomes an ethical dilemma at some point: do we provide (suboptimal!) services when a client is, say, constantly interrupted by their kids, walking through the grocery store, or under the scrutiny of an abusive partner? Where do we draw the line and say it’s not an appropriate environment for therapy? Typically, we honor those boundaries even when clients don’t – when they sit down next to us in a church pew and start to share or even try to continue their session in the waiting room, we actively prevent that and protect their confidentiality even when they don’t.
• We miss out on the benefit of the “sacred space.”
  • Therapy is special. When people choose to come to therapy, we are supposed to offer them something that is different from their normal lives. That’s part of what helps it to bring newness into their lives. There’s a reason that sacred spaces have existed throughout time – why you build an altar in the desert, why you go to your closet to pray, why you climb a mountain to get clarity, why indigenous healers set up holy spaces. If you think that therapy is just telling people your wise thoughts or finding interesting solutions to problems, maybe it doesn’t matter. But if you practice therapy with the intention to heal, the sacredness of the therapeutic space matters.
  • In a more scientific way, we could say that our internal states are tied to the physical spaces in which they are activated. That is the reason that one of the primary sleep hygiene rules is to only use your bed for sleep – because classical conditioning is a real thing. So, our offices – where clients choose to be disclosing and access emotions, where they feel safe, where they can bring themselves to do hard work – those offices allow clients, over time, to feel safe, disclose, access emotions, and do uncomfortable work more readily. When they do therapy from their homes, offices, cars… we lose the benefit of the therapy space.
• For many therapists, it seems like it is more difficult for them to keep their professional boundaries.
  • The teletherapy experience seems to be convincing many therapists that they should be in text-contact with their clients much more often than they typically would be. If this is not part of a therapeutic system that a therapist has been trained in (like a Linehan-style DBT program), there are a lot of risks with extending the session beyond the session time. Beyond the risks for clients in believing that you’re always available, and then sending a crisis text while you’re unavailable, how do you take a shower, sleep restfully, or drive safely without attending constantly to the concern that a client in need might be texting you right now?
  • I’ve also been reading about and hearing about the “increased intimacy” of online therapy that some therapists are suggesting is a good thing. There are many therapists who are sharing things with clients that they never would share in face-to-face counseling, like the state of their homes and allowing clients to see them interact with their family members. Likewise, they are experiencing aspects of their clients’ lives that they wouldn’t otherwise experience. My question about this is whether those clients would choose to share those things, if they were mindful about it. Would therapists? We intentionally don’t join a client’s personal book club or speak to them when they’re at the gym. When we begin to do in-home therapy services, we get training in how to interact in a client’s personal space. While I’m sure everyone has good intentions, there’s no data about whether this is helpful or harmful to clients, and it seems to me to blur the lines that we know are helpful to clients.
  • For both of these issues, how clear are therapists being? Are we honoring our professional, ethical obligations to “clarify professional roles and obligations” and “avoid unwise or unclear commitments” (Ethical Principles of Psychologists and Code of Conduct, General Principles)? To what degree are we even maintaining a professional relationship? And make no mistake, the professional relationship is part of the healing process – we have known for a long time and continue to accumulate data that the therapeutic relationship is the primary factor in positive change (not the physician-patient relationship and not “good friendships” – the therapeutic relationship).
• It’s harder to create a growth-promoting climate because it’s harder to use the basic Rogerian skills.
  • Silence is one of the foundational skills of therapy, and the mediation of the screen and internet connection really diminishes the effectiveness of silence… especially when the client has to ask, “Are you frozen?!” The head nods that we can use to show we’re listening while silent can be problematic; for example, they often seem like agreement to clients, so we don’t want to overuse them. The “mmm-hmming” is often either so quiet that it gets lost or so loud that it breaks the client’s rhythm because they think you want to speak.
  • Eye contact, which is also one of the most basic attending skills, is frankly impossible. If you are watching the client for facial and other non verbal cues, then they can’t see your eyes. If you look at the camera, so that it appears that you’re giving them eye contact, you can’t see them anymore. If you move your camera so far back that you can “fake it,” you’re no longer close enough to see their facial changes well. Not to mention that you need to be monitoring your tiny picture at least some of the time to at least make sure that you’re on screen, clear, and well lit.
  • Pacing is more substantially more difficult online. For one, it’s virtually impossible to see and hear clients’ breathing, which is one of the ways that you know how and when to speak in session, even if you aren’t aware that you’re attending to that. Also, the conversational lag time, even when both parties have a good connection, is unavoidable – that’s why we have to say, “Oh, sorry, you go ahead” so often.
  • Attending to nonverbals is also largely impossible. There are the issues listed above, with clarity of facial expressions and breath, but it’s unusual to be able to see more of the client’s body that you get to see in face-to-face work – wringing hands, tapping feet, holding a pillow across their torso, etc.
  • And it’s less congruent. According to Dr. Marlene Maheu, the leading teletherapy trainer in the country, from the Telebehavioral Health Institute, we need to be about 10% more expressive in order to come across the medium with the same level of engagement. That means that we are either acting (in which case our internal experience will be incongruent) or being perceived as less present (in which case the client’s experience is incongruent with our intention).
• For me, personally, it feels less rich – the same energy isn’t there.
  • Partly, this is because I am more easily distracted and it takes more effort for me to stay fully engaged through the screen (esp in hour seven!). That may not be an issue for everyone.
  • Partly, it’s because my primary theoretical orientation is existential-experiential with a person-centered foundation, so I utilize the here-and-now and the relational process more often than other therapists might.
  • I really like how psychotherapist Erika Shershun said it, in an interview for The Bold Italic: teletherapy lacks the “refreshing and energizing resonance between two people.”

I know this is going to be a controversial thing to say, but in short, I think that teletherapy is the Standard American Diet of psychotherapy: it’s more convenient, it’s cheaper for the people who provide it, and it will keep you going, but it’s less nourishing and is probably causing problems down the line that we don’t even know about yet.

Of course, it’s also certainly better than nothing. For scenarios that are more like coaching, or brief solution-focused work, I think it doesn’t make much difference. If we do it well, I think it can be helpful. And I think that, in some cases, we can use it to our advantage (e.g., using the out-of-office environment to create different exposure scenarios for clients with OCD).

So, I have tried to channel these feelings into something much more productive than just a rant, and created this tip sheet  for clients doing teletherapy our scouring the internet and my professional community and finding nothing like it. Please check it out! Hopefully, you’ll find it useful and not-ranty, and be inspired to use it or make your own!

Thank you so much to my lovely colleague who helped me clarify these thoughts, soften my rantiness, and upgrade the usefulness of the client tip sheet.