Clinical Impact Statement: This piece is intended to generate thinking among practitioners about the ways that the switch to telehealth may have changed the ways psychotherapy is practiced.
Driving to the office, parking the car, gathering your belongings, entering the building, saying hello to colleagues, checking messages, setting an intention for the work of the day. This might sound like a familiar sequence of events to many psychotherapists before March 2020. These are just some of the rituals that a psychotherapist might engage in before getting to the work of welcoming a client into the healing space, walking the client across the threshold and into a space that offers comfort, non-judgment, and a listening ear. The door gets pulled shut behind the client and therapist to signify the sanctity of the space that is created with each client, their own space and time.
Clients have their own rituals before therapy. They sit in traffic fearing that they will be late to session while they fume about the argument they just had with their boss. They complete that homework you assigned a week ago or they try to figure out how they want to use their time in session today. When they finally enter your waiting room, maybe make some tea and have a seat, they are doing their own work to prepare to enter your office. Scholars, practitioners, and clients alike can agree that entering into your space of healing is itself a part of the psychotherapy process. For clients and psychotherapists, the work goes beyond the 50 minutes of the session.
Social distancing is intended to keep people physically apart from one another; it is no longer safe to share physical space in the same way from a public health perspective. So, along with many other industries, psychotherapy has gone virtual. The use of phone or video mechanisms for psychotherapists was an emerging trend across the various disciplines of mental health care providers over the past several years. The rise of the COVID-19 pandemic in the early parts of 2020 have necessitated the switch to telehealth platforms for large swaths of the psychotherapy community. Providers were either encouraged or forced to shut down in-person operations and had to opt for other means of delivering psychotherapy services. In the aftermath of the early days, some providers have gone back to in-person services employing PPE, social distancing, outdoor services, and other creative means to limit the possibility of spreading the virus. Some have adopted hybrid models, while others remain online for the foreseeable future.
Research has suggested for several years now that building rapport is by and large not affected by the use of telehealth (Botaitas & Southern, 2020). Remote offerings of psychotherapy have long now been considered effective and provide numerous benefits for a variety of populations, effectively increasing the accessibility of psychotherapy (Silver et al., 2020). It seems to be the case that the larger body of research indicates that teletherapy is as effective as in-person psychotherapy and that it comes with some added benefits of accessibility in a variety of different areas (travel time, geography, childcare, social anxieties, etc.). It also appears that in some cases, psychotherapists who have moved 100% online are reducing their expenses by no longer maintaining costly leases and other associated expenses.
The pandemic has accelerated the shift that may have already been taking place in the field towards an increasingly virtual administration of psychotherapy services. With multiple vaccine candidates on the horizon, many are considering the implications of these past months on the future of their practice of psychotherapy. Some will resist this change and look to get back in person as soon as possible and kick their virtual platforms to the curb. Others might see this as a way to evolve their practice into one that is entirely virtual. Still, some will be looking towards a hybrid model of some amount of in-person and virtual offerings. Just as there remains little in the way of consensus around the best way to practice psychotherapy, one can speculate the thinking about ways forward in the digital age will vary widely.
So, if virtual psychotherapy is here to stay in one way or another, how does the psychotherapist adapt and what guidance can the psychotherapist give to clients for engaging in virtual treatment? The wonderful thing about this advice is that it applies to both the client and the psychotherapist, as the needs are parallel.
This might vary among practitioners as some continue to work in their office spaces while others are working from home or other spaces not purposefully built as psychotherapy offices. For clients, this might be their home, office, car, or some private area. Whatever the case, to replicate what was available pre-COVID, try to be intentional about creating a space that is for healing. Light a candle, turn on the right amount of light, grab a warm drink, sit somewhere comfortable. This practice of creating a space allows for both client and therapist to cross the threshold together into a space that is intended for healing, growth, and change. This might mean organizing your space to be clear of distracting things (phones, email, etc.), creating a soothing backdrop, and to begin thinking about the next step: setting intention.
The reasons that bring folks to psychotherapy vary greatly and our treatment modalities and specialties influence how each practitioner and client enter the therapy space, however virtual it may be. Regardless of this, there exist infinite ways for each to create some small moment of quiet to name an intention for the hour ahead. For therapists, this might mean taking a few moments to center yourself in the experience of the client for a moment, take a second to think about what you hope for that client in the coming hour, and how you will make space for them. For clients, consider what you would like to get from the hour and how you will allow yourself to enter the session with that intention in mind.
This is that moment of actually crossing that threshold, the one where one or both enter the call and ask, “can you hear and see me alright?” Invite yourself to be open and patient with the technology as it will likely give you a hard time. Think about how to create an opening to the session that simulates the moment when you open the waiting room door and welcome the client back. That moment of, “I’m so glad you’re here today.”
The session is over, the client is to go back about daily life. Now remember, they probably no longer have that commute home. They might be walking into the next room to continue helping a child with online learning or rushing off to a virtual meeting with a work colleague. You might have your next client in your virtual waiting room. Consider ways for you and the client to ease out of the space that you created together today. For some, this is a simple wave, a nod, a bow, or the classic, “same time next week?” Stand up, walk around the room, write down a few thoughts, attend to your body. Consider what you had done when you were in your physical space.
Virtual psychotherapy can be fulfilling, it can be effective, and it comes with some new ways of developing rituals of practice. You can still be present to your clients, continue to hold space for them, to continue to see them (albeit a pixelated version), and to hear them (perhaps with an audio lag). Consider the impact this new reality has on your practice of psychotherapy and how to engage your clients in new ways. Think about the ways that you can recreate the same healing rituals that you had when your client was in your office. If virtual forms of psychotherapy are here to stay or might just be part of your practice moving forward, consider the ways to integrate this in a sustainable way to ultimately get the best parts of traditional face-to-face with all of the advantages of virtual practice.
Cite This Article
Jackson-Wolf, J. (2021). Creating new rituals of psychotherapy practice. Psychotherapy Bulletin, 56(1), 8-10.