Clinical Impact Statement: Help practitioners balance the positives and negatives of video psychotherapy and comparing them to face-to-face contact in office consulting room.
It has been about two and a half years since the beginning of COVID, which mandated the suspension of in-person psychotherapy contact, forced the rapid closing of offices, and ushered in a mass migration to video psychotherapy. For some colleagues, the change has become permanent, as they have terminated their physical office leases and are now dedicated solely to video practice. They view the change as a positive one, allowing them to practice from home with a greater degree of freedom to create a better work-personal life balance and save the costs of office rental and related expenses.
In focusing on greater freedom and flexibility, it is easy to overlook or minimize some of the adjustments necessary for video psychotherapy to be effective. And it is also easy to lose consideration of what may be sacrificed therapeutically by not meeting patients face-to-face in an office setting, especially for those whose theoretical orientation and practice tools hinge on in-person contact.
After 43 years of doing psychotherapy face-to-face in a private practice office setting, it was an abrupt and unwelcomed adjustment for me—as it was for many—when COVID forced us to rapidly learn to work through video platforms. For those of us who hadn’t been conversant with online video interaction, it required learning new tools, like Zoom, in order to make the transition. Considerations such as contracting with new patients, digital payment, lighting, camera location, beginnings and endings of an hour, family and pet distractions, background screens, personal appearance, and various technical interruptions and glitches that may occur as part of the digital connective process all had to be faced and resolved for the sessions to be productive.
Positive Aspects of Video Psychotherapy
1.Convenience and safety. Some patients, especially those who were already conversant with online video platforms through their work, welcomed meeting this way. They no longer had to drive to my office. This, combined with no longer commuting to their physical office space, made staying safe from COVID easier and work more convenient. The convenience became so pronounced over the last two years that companies of all kinds are now having challenges getting people to come back to the physical office. We hear of cases where some have quit their jobs if their employer refused to let them continue working online from home, at least part of the week.
Some longer-term patients initially missed the direct interaction of meeting in the consulting room. But in the early months of the pandemic, when the initial shock and fear of contracting COVID was at its height, they didn’t have the luxury to think about what may be lost by not meeting in person. Most quickly adjusted to the increased ease of not having to leave their home. Meeting online became welcomed, and most did not complain of any less value in losing the in-person contact between us. The only people who mentioned it were new patients who were forced to have their initial sessions via Zoom. These people were asked to fill out intake forms online and return them, and to pre-pay for the initial session instead of paying by check, as they normally would, after the intake hour in the office.
Another unanticipated convenience of the switch to video psychotherapy has been the method of payment for treatment. Before COVID, I was paid almost exclusively by personal check or cash, as I do not accept credit card or insurance payments. After COVID, I began using Zelle, which is a direct bank-to-bank payment offered by most major banks. Now, my practice is nearly one hundred percent payment through Zelle. While it is faster and more confidential since I no longer have to drive to the bank with hard-copy checks, it does require monitoring to ensure the digital payment is made. Since my standard policy is for patients to pay at the time of service, this was not asking them to pay any differently than usual. It did mean explaining to patients how to pay through Zelle just before or after a session. I do not like to keep track or follow up on who hasn’t paid, and, with occasional reminders, patients have all been compliant in paying in a timely fashion.
2. Greater Geographical Access to Psychotherapy Services. The pandemic acted as a lightning bolt, igniting the geographical broadening of psychotherapy. Suddenly, a much larger pool of licensed psychologists and mental health professionals of all stripes were available to deliver online services. Intra-state and inter-state laws and licensing board guidelines were loosened to address the crisis. Remote areas of the United States that had little or no access to in-person services could now find a psychotherapist from the comfort of their own home. Now that technology has brought everyone with cable or digital phone line access, this “quick and easy delivery” model enabled anyone who wanted services to obtain them.
One of the basic issues now being hashed out by stakeholders is how various mental health providers, state and federal laws, and ethics organizations will try to regulate a technology that I do not believe was meant to be contained by state boundaries. The beauty of the internet is that, with sufficient bandwidth, I can talk to you from your home in Switzerland and see and hear you as if you’re down the street. If ever in human history there was a technology that transcended artificially drawn state, national and international borders, the digital/ethernet world is it.
So, if psychologists—often more careful and overly self-regulating and self-restricting than other professions—try to limit who can see a patient in another state and grant rights only to those who pass their requirements, the profession again risks being left behind, as other professions throw caution to the wind and let the ethical chips fall where they may. This, in fact, is what is already happening. Those designating themselves as coaches, counselors, or various other licensed and unlicensed providers will work with anyone anywhere and not feel restricted by state, national, or ethical concerns.
3. Seeing patients in their “natural habitat.” In the initial sessions following the switch to video therapy, some patients were eager to show me their home surroundings. Using a cell phone for his connection, one walked through his kitchen, which was under renovation and had been a topic of his concern. Some showed off their pets. Seeing how they relate to their dog in real-time is more powerful than just watching a cell phone video of it. In fact, it made me begin to wonder how beneficial it might be to have all patients show me around their house using a cell phone. I would have access to a slice of their life in a way that is more “real” than what they may tell me about how they live and the fantasy I may construct from it. Some worried about whether their office space or wherever they were sitting was clean and orderly and whether I might judge them for being sloppy.
One long-time patient allowed her adolescent children to walk into her office and interrupt the session on a few occasions. Since one of her challenges was in setting and maintaining boundaries in the home for her kids and having them respect those boundaries, she demonstrated in front of my eyes how this was played out by not keeping them out of her office during our sessions. Watching kids come through the door with no regard for interrupting their mother when she was online was far more revealing than being told about it. I then used this interruption to discuss why she wouldn’t lock the door so they did not have access during her work or a session.
Some wanted to show off art objects or furniture in their office or other rooms in the house that they were proud of and wanted me to see. This would have been possible in vivo had we not been doing video therapy.
While I do not allow eating during an in-office session, some would nibble during an online session. While I chose not to comment on their eating, I did make a mental note of it. It became obvious that the level of comfort in their own homes changed some of their habits during our sessions. As was common during the pandemic, most everyone dressed more casually for video sessions, wearing clothes they would not be wearing in an office visit.
4. Viewing my own behavior in real-time. I use a desktop iMac in my home office and fill most of the 27-inch monitor with the Zoom interface. I open two equal-sized windows, either stacked or side-by-side, one showing the patient and one showing myself. What was new for me compared to in-office sessions was the ability to glance at myself and notice my reactions to statements by the patient. For example, I noticed a slight smirk of my mouth when I heard something that sounded questionable. I knew that I made this smirk in the office but was never able to actually see it in action as I could on the screen. I also noticed an occasional tilt of my head when listening. So, immediate visual feedback of oneself while interacting clearly is one of the positives of video contact. One may see on the screen forced smiles, over-emotional reactions, fidgeting, and distractions that would not be visually reflected in real-time in the consulting room.
5. Revealing my personal home office space. I made the decision not to use one of the prefabricated static background privacy screens available on Zoom. The background in my home office is made up of a floor-to-ceiling wall of built-in bookshelves. The shelves are filled with books, rows of journals, and personal memorabilia, including photos. For the first time in my career, I chose to share this home office background. While it still appears professional, it does reveal more personal objects than patients would see in my office consulting room. Almost no one has commented, except to be surprised at what appears to them to be a vast library collection. I would label this personal revelation of my home library a minor positive resulting from video psychotherapy in that it did show patients something about my personal possessions that they otherwise would not have seen. I have no bookshelves in my away-office, so seeing my home office bookshelves may at least leave an impression that I have done some studying and reading in my life.
6. Increased flexibility in location and scheduling. As mentioned, using video therapy offers flexibility for patients. They may choose to connect via desktop, laptop, or phone. They may be sitting in a home office, outside on a patio, in a closet for privacy, or in their car. Because I only use my desktop at home for video sessions, it is not as flexible for me. In fact, because my desktop is in my home office, doing video therapy has now required more careful planning on my part. I must coordinate the scheduling of in-office sessions and the scheduling of video sessions in my home office. Fortunately, my home office is a few minutes away from my outside office, so it is not all that challenging. The positive aspect of this is that I end up with a greater window to schedule patients for video therapy, sometimes meeting earlier in the morning that I normally would in my outside office setting. This results in greater accommodation to patient preferences in scheduling.
7. Recording of sessions for analyzing interaction. With Zoom, it is possible to record sessions. So far, I haven’t used this feature. But as a training tool, having it available is a plus, since it is not as easy to employ in my away-office. For graduate students being supervised, it could surely be a valuable adjunct in the psychotherapy learning process.
8. Paradoxical sense of intimacy and distance. When I asked my wife, also a clinical psychologist, how she experienced the difference between video therapy and being in the office, she said that she felt both a sense of intimacy and distance online. Intimacy, in the direct camera to camera, face-to-face focus, where it is easier to make eye contact with patients because you are looking directly at their face rather than their whole body, as you would in the office. However, the eye contact on the screen is not as direct or penetrating as it would be in person. As mentioned, there is also the intimacy of being invited into their home, where they are sharing something of their personal space. And distance, in the sense that they can’t see how you are dressed from the waist down and you are not “exposed” in the same way you are as in the stimuli in the consulting room. What is lost, of course, are the body movements that would help convey a more complete picture of their reactions to the interaction.
Negative Aspects of Video Psychotherapy
1.Technical glitches. The most obvious and persistent negative of doing video psychotherapy is the interruption caused by audio and video glitches in the online connection. Because of poor signal location, not fast enough computer speed or enough memory, simultaneous over-use of the bandwidth by family members, or other reasons, the lags of speech and freezing of the video picture can compromise the best efforts being made by both patient and therapist.
These interruptions interfere with the focus on the conversation and attenuate the typically smooth back and forth interaction between patient and therapist that occurs in the office consulting room. For example, there have been times when the freezing of audio or video has been bad enough that we had to terminate the connection and resort to speaking on the phone. Too often, short glitches have meant filling in the patient’s words by using context to decipher what has been lost. This requires attention focused on understanding the meaning of what is being said rather than enhancing the quality of contact with the patient.
While these glitches may occur on any platform being used by therapist and patient, they seem to happen more often with patients using a cell phone for their connecting device. For example, wanting privacy, some choose to have our session using their phone from their car. While the use of the phone was convenient for them, it tended to have technical glitches associated with it, as patients would be parked in places with poor cell reception. This meant interruptions in the contact, which made more intense focusing on content problematic. It also meant that every time a call came into them during our session, the picture would go off until the call was ended by the patient. Most seem to value the ease of having the session where they choose more than worrying about technical glitches. But there is no question that interruptions like this—especially when they repeatedly occur throughout a session—limit the patient’s ability to focus attention compared to not having to deal with this in a quiet and undisturbed office setting.
Sounds from the desktop or laptop announcing newly arriving emails, texts, or other kinds of application pop-ups are another distractor for both patient and therapist. These distractions, while not as severe as loss of sound or picture freezing, still limit one’s ability to concentrate. Lighting, shadows on the patient’s face, the focus of the camera, and other details that are part of online interaction all become potential issues that rarely, if ever, become considerations in an office consulting room.
2. Loss of pre-session preparation. Patients tend to mentally prepare for their sessions. One of the reasons for having consistent sessions on the same day and time on a weekly basis is that they can anticipate the session and organize their thoughts around topics of concern. Part of this forethought takes place driving to the session and sitting in the waiting room. This forethought is less likely to happen when they are busy with video-conferencing meetings or household chores prior to our session. Many come to the video session with their attention still on whatever project they had just been working on. Because it may take some time to become fully present, this tends to make for less organized and productive digital sessions.
3. Restriction of therapeutic experimentation. If your theoretical orientation is one in which you help focus the patient’s attention on here-and-now behavioral experimentation, your ability to do this will be hampered by not being in an office face-to-face with the patient. For example, doing Gestalt “empty-chair” work will be difficult and awkward via a video screen compared to being in an office. While the video camera keeps the patient’s face in full view, much of the rest of the body is not viewed. Making comments on nervous gestures, breaks in eye contact, reactions to the therapist, and various suggestions for experiments for the patient to try all will be impossible or at least more difficult to do through a video screen. While the greater number of psychotherapists practice from some form of cognitive-behavioral perspective, those who are more eclectic in approach may find that their bag of therapeutic tools is limited by not being face-to-face in an office setting with the patient. Even simple experimentation, like showing a patient a relaxation breathing technique, will be more trying via a screen.
I have found it useful to notice how the patient glances around the office, looks at the artwork, averts eye contact when uncomfortable, or moves their eyes up to a corner quadrant when deliberating. Due to room lighting, eyeglasses, shadows, glare, or other factors, much of this is not going to be readily visible to me when on video. While some of the information may be noticed, interrupting the flow of dialogue to point it out to the patient is clearly more trying when online. This discourages a therapist with an experimental orientation from utilizing these skills and tools.
4. The healing power of embodied presence is diminished. What I have noticed in the last two years of doing video psychotherapy is that my own embodied presence—the patient’s sense of my physical and mental energy or “vibration” in the room and its impact—simply is nowhere near the same as meeting in person. Some of my presence will come through the video contact, but it just cannot compare to our meeting in the office. Does the convenience to the patient of not leaving the comfort of their home outweigh the impact of my presence? Many would say it does. But this loss is of concern to me, especially for those who are contemplating or have already given up their physical office space and made the switch to doing only video psychotherapy. When you give up your power of embodied presence, you give up one of the important healing tools of the psychotherapy relationship.
Should You Give Up an Outside Office?
There are now a growing number of mental health companies offering “counseling” or “coaching” online via email, video, text, cellphone apps, and phone contact. They appeal to mostly younger generations who grew up online and are comfortable utilizing services in which they never actually meet in person the “service provider” with whom they may be engaged. These services are usually at a low to moderate cost. They all are taking advantage of what is possible when personal problem solving, advice giving, and various techniques and mental, emotional and spiritual tools may be transmitted via telehealth-video rather than in person. Because so much of our lives are now lived digitally in some form, it has lessened the perceived importance and necessity for personally meeting with people in an office setting.
What impact is this having, and will it have on how psychotherapy services are delivered? Is it the wave of the future as young and old psychotherapists alike march inexorably toward the metaverse, in which we spend more of our lives in a digitally created world than we do in the real world? Is it a good idea for people to be investing time and money in the metaverse, where you can actually pay large sums to own a restaurant, gas station, shop, building, or home in a “desirable location” in what is a captivating make-believe world? Teens and young adults are flocking to lose themselves in this digital world, as they tire of the daily challenges, perceived or actual failures, and disappointments in the real world. While it is certainly understandable they may be disgusted by what they see in the real world, why not orient them to try and make it better to live rather than escape it through a headset that whooshes them away into an artificial world? It is one thing to spend some time engaged in “social media,” play games online, or even use the virtual world to help deal with psychological issues. It is another to transition to a greater commitment of time, money, and emotional investment in the realms of virtual and augmented reality than is made in the everyday world.
You can bet your digital dollar that the very same real-world issues that disgust those flocking to the metaverse will raise their ugly head in the metaverse. For example, there are already reports from women that their initial entrance into the virtual world may be threatening. Their avatars are being accosted as soon as they enter a scenario with male avatars. Males offer them liquor and ask them to loosen their self-protection by turning off the physical safe space around their avatar, which then permits them to be accosted by the male. Assault, abuse, and even rape are how they are welcomed into virtual reality.
My point is that if the world we live in is likely to become more digital and less actual, the transition from a physical office to a digital video connection is consistent with this movement.
If you are toward the later part of your practice career or practice in a more rural area, it may make economic and practical sense to eliminate a physical office space. But until there is no further “face validity” in maintaining a physical office, it is premature to make the move simply because the pandemic pushed us into video psychotherapy. One of the ways psychologists may distinguish themselves from the torrent of online providers is by offering a physical office presence to meet in person. Having an office is a sign of integration into the local community, offering a presence that signifies a commitment to practice and to offering the fullest possible array of ways to meet and provide psychotherapy. Up to now, not having a physical office has connoted not being integrated into one’s community. We’ll see how this may change over the next few years, as the pandemic hopefully has less influence on how we meet with patients.
I will not be on the planet long enough to see how much influence the digital world ultimately has on our lives and on the practice of clinical psychology. Perhaps it’s because I’ve been in the full-time private practice trenches for the last 45 years, but I can’t imagine that what comes through a Zoom video screen could ever be as powerful as what happens face-to-face in the office. Maybe virtual and augmented reality will come close to duplicating it as we strap on the headset and take a ride into the wild make-believe made oh-so-real. And the next generation of psychotherapists may never know the wonder of what happens when the chemistry is right in the consulting room.
Steven Hendlin is a clinical psychologist and author in Newport Beach, CA
Cite This Article
Hendlin, S. (2022). Comments on doing video psychotherapy. Psychotherapy Bulletin, 57(3), 20-26.