Self-Care in the Age of Telepsychology

The practice of psychotherapy has changed dramatically in response to the COVID-19 pandemic. Some changes may be seen as positive for both psychotherapists and their clients. For clients there is the convenience of online psychotherapy, such as no longer needing to take as much time off from work due to the time needed to get to and from appointments. Some clients now have access to psychotherapists with specialized expertise that best meets their treatment needs and that could not be met in their local geographic area. Further, those who are homebound for any reason may now be able to receive needed psychotherapy that was previously inaccessible to them. 

Benefits and Challenges for Psychotherapists

Psychotherapists may be providing telepsychology services from their home, saving time by no longer having a commute to work and saving money if they no longer need to rent an office or have the myriad associated expenses such as office utilities and transportation costs to include fuel and vehicle maintenance. Working from home also makes it possible to check on one’s family between treatment sessions and to do quick household chores such as throwing in a load of laundry, paying a few bills, and the like. 

At the same time, several potential drawbacks may be experienced. Working from home can be quite challenging, especially if one has children at home who need to be cared for or supervised. The downside of no longer having a commute can be the loss of time to transition between work and home, both to gather one’s thoughts and prepare for work, as well as to decompress from a busy workday as one prepares to re-engage with their home life (Shklarski et al., 2021). There may be less separation between work and home, with home possibly now being on the other side of one’s office door. Thoughts, concerns, and even noises from one’s home may now intrude on the psychotherapist and possibly interfere with their ability to remain focused on their clients during virtual treatment sessions. 

One significant challenge concerns the shift from interacting with clients in-person to meeting with them online. Beyond the loss of in-person contact with clients there are multiple potential adjustments to online treatment that psychotherapists must make. The loss of in-person interactions with clients and staring at a computer screen for many hours each day results in “Zoom fatigue” for many psychotherapists (Wiederhold, 2020). Shklarski and colleagues noted that this fatigue is exacerbated by a psychotherapists’ inability to observe the client’s entire body, resulting in the need to “compensate by paying especially close attention to what was in their view” (p. 60). 

Technology-Related Challenges

Psychotherapists must address multiple technology-related issues such as selecting a HIPAA-compliant videoconferencing platform and using it effectively. For some, this can be a stressful and challenging situation. Additionally, some clients may not be familiar or comfortable with the technologies being used and may need additional support and assistance in making this transition. Beyond one’s necessary clinical competence, one must now add the need for technological competence (Godine & Barnett, 2013). Many clients will need to be instructed in the use of the applicable technologies and psychotherapists will need to assist clients should any difficulties be experienced. Concerns about technological difficulties and internet connectivity failures may add an additional layer of stress and anxiety beyond that which is already present in one’s life. 

Transitioning to Online Psychotherapy

Many psychotherapists have no previous education or training about telepsychology and have felt ill-prepared for the rapid transition to the provision of online psychotherapy and lack confidence in their online psychotherapy skills (Glueckauf et al., 2018). Further, many psychotherapists report perceiving their ability to apply their psychotherapy skills less effectively when doing so online (Lin et al., 2021). The onset of the pandemic has resulted in rapidly changing laws and regulations regarding the practice of telepsychology as some states have temporarily loosened restrictions on interjurisdictional practice (practicing across state borders) while others have not. Additionally, when engaging in interjurisdictional practice, it may not be clear to psychotherapists which state’s laws to follow when considering mandatory reporting requirements, for example (Younggren et al., 2022). Glueckauf and colleagues (2018) found that a significant portion of psychotherapists report confusion and misunderstandings about changing laws relevant to the provision of telepsychology services, potentially adding further to the level of stress and anxiety many psychotherapists may be experiencing. 

Impact on the Psychotherapist

Psychotherapists are finding themselves impacted by many of the same challenges, stresses, worries, and anxieties that their clients are experiencing and that are the reasons many of these clients are seeking treatment. Shklarski and colleagues (2021) found that many psychotherapists report difficulties assisting clients with coping with pandemic-related trauma due to struggles coping with their own trauma; many psychotherapists have lost family, friends, or colleagues to COVID and many live with concerns about COVID transmission for themselves and loved ones. In fact, these authors report that, “The levels of stress and anxiety that participants experienced as a result of the pandemic have impacted their ability to offer the best care possible to their clients” (p. 58). Phillips and colleagues (2021) found psychotherapists to report their greatest stressors during this time as the fear of COVID infection, childcare challenges, and caring for family members. Rosen and colleagues (2020) describe the pandemic as “a traumatic stressor” (p. 175) because of the on-going and pervasive experiences of “persistent fear; illness; social isolation; economic stress; resource loss; or the death of a family member, friend, or patient” (p. 174). 

Additionally, psychotherapists must consider how the practice of telepsychology has increased the amount of professional and social isolation they experience. Perhaps one of the greatest challenges for psychotherapists is the loss of both planned and unplanned in-person interaction with colleagues. Gone are the brief chats when walking down the hallway between sessions, meeting at the photocopier, or having a quick lunch together in shared spaces. Increased isolation, fewer social contacts with colleagues, and hour after hour each day of communicating with clients through video conferencing (think “Zoom fatigue” and staring at a computer monitor for many hours each day), may impact our wellness and clinical effectiveness. 

Psychotherapists may be at increased risk of developing burnout, finding themselves experiencing increased amounts of emotional exhaustion, depersonalization, and loss of feelings or professional accomplishment. Significant contributing factors include the loss of in-person interactions with clients and colleagues alike (Webster, 2020). While many psychotherapists have been resilient in the face of these losses, these circumstances have become a more chronic situation as new variants are discovered and new waves of infection are experienced, adding to the risk of symptoms of burnout developing for even the most resilient individuals. Wright (2022) has written of the significant impact the loss of predictable routines and interpersonal connections in our lives can have on us. Feelings of loss and isolation may be especially challenging for psychotherapists who are attempting to care for their clients, their loved ones, and themselves during such unpredictable and challenging times. 

In addition to the usual life stresses each psychotherapist experiences and life during a pandemic, many psychotherapists are contending with the impact of world events, long wait lists, and the pressure to treat more clients. The need for intentional self-care practices is perhaps now greater than ever. These practices are best broadly described as an adoption of attitudes and values and the use of a range of activities employed to help prevent burnout, mitigate distress, and maintain our professional competence. How we practice self-care in this age of telepsychology (and the pandemic, partisan politics, political unrest and increased conflict, war, climate change, etc.) has direct implications for our personal and professional functioning, to include our clinical competence. 

Self-Care Needs and Responses

Perhaps more than ever before, psychotherapists must reassess their self-care needs and practices, being intentional and proactive about instituting both personal and interpersonal self-care activities. In their survey of independent practitioner psychologists during the early months of the pandemic, Phillips and colleagues (2021) found the most frequently reported sources of support during their transition to online service delivery included close colleagues, informal groups of colleagues, and professional associations. These authors also found psychologists engaging in multiple self-care strategies, such as exercise, connecting with others, and meditation, while not relying on any one strategy in isolation. 

Shklarski and colleagues (2021) found that the majority of psychotherapists surveyed reported their self-care activities during the pandemic included: “having the support of their peers,
supervision groups, families, and friends—as well as engaging in self-care practices, such as
yoga and exercise,” describing these activities as “extremely helpful in coping with the emotional and psychological effects of the pandemic, including Zoom fatigue.” Further, they report that “some of the participants became involved in therapy groups online, which provided them with support and ideas and allowed them to connect with other clinicians” (p. 60).

The variety of self-care practices endorsed by clinicians during the pandemic underscores the necessity of intentional, individualized self-care. A well-rounded self-care routine ought to address a clinician’s functioning in both the personal and professional spheres, and attend to one’s wellness across social, emotional, spiritual, and physical realms. Further, it is essential that psychotherapists accept that self-care is not a solitary endeavor. 

Communitarianism and the Role of Peers

During times of increased and on-going challenges and stressors, the inclusion of peers and colleagues becomes all the more important when practicing self-care. We must be open and transparent with our peer networks to receive the support needed to maintain our best functioning as clinicians. When our experiences are shared amongst trusted colleagues, exchange of varied strategies, stories of success and failure, and on-going frustrations offer the opportunity to address the new challenges posed by telehealth services, together. 

Additional benefits of accessing one’s community of peers include enhanced social and emotional well-being, additional protection from anxiety and stressful events, increased cognitive functioning, and opportunities for personal growth (Liu et al., 2022). Wise and Reuman (2019) add that peer support networks are essential in promoting on-going wellness and flourishing that are associated with continued maintenance of high levels of competence. Beyond having colleagues to confide in and our colleagues’ roles in combatting isolation lies the fact that there is significant ethical risk associated with operating in isolation, and relying on self-assessment to both acknowledge problems and monitor the solutions one may employ. Past research has revealed the general ineffectiveness of self-assessment of competence by health professionals (including psychotherapists) and that self-assessment is even further degraded in the presence of increased and on-going distress such as what has been encountered during the COVID-19 pandemic (Dunning et al., 2004; Dunning et al., 2003). 

Knowing that self-assessment is both flawed and insufficient, we must be willing to shift the ways in which we choose to monitor our competence and well-being to include colleagues within the framework of our self-care routines, even if this inclusion must occur virtually. A communitarian approach to engaging with colleagues provides a strong framework for this outreach, encouraging values of reciprocity, trust, and support both during times of decreased functioning and times of celebrated success. Especially during times of forced isolation and uncertain adjustment, communitarianism lifts the burden of self-assessment from clinicians and distributes the responsibility of monitoring one’s well-being to their community of colleagues and peers (Johnson et al., 2014). This means that a psychotherapist grieving the loss of a loved one, struggling with telehealth transitions, or regaining their own health has a community of colleagues supporting both their work and their independent well-being as they process the additional challenges that are present. 

Early Career Psychotherapist Needs

This support may be especially relevant for certain populations of clinicians. As Aafjes-van Doorn and colleagues (2020) found, younger psychotherapists with less clinical experience and those who had past negative experiences with remote treatment are more likely to experience higher levels of secondary trauma and compassion fatigue while working remotely with clients during the pandemic. Communitarian support offers these individuals an additional source for monitoring their well-being, the presence of these difficulties, and addressing symptoms as they may arise. Additionally, more experienced colleagues (regarding telehealth or practice in general) may have invaluable advice or insight from which less experienced clinicians may benefit. 

Self-Care Implementation Moving Forward

Engaging with one’s communitarian network is an activity that may look different for each clinician. For some, video conferences arranged weekly or bi-weekly are most feasible, while for others, in-person meetings (when pandemic conditions allow) with similar regularity are possible and preferred. The style, location, and content of these meetings may change with each occasion. The most important part of this engagement is that it is routine, ongoing, and actively used to bolster one’s competence-monitoring and coping strategies. Of course, this is only one facet of self-care as it pertains to practicing during the exceptionally difficult circumstances posed by the COVID-19 pandemic. Other elements of self-care routines must also be maintained and integrated in sustainable ways. For example, incorporating a short walk or time outside into one’s daily routine, taking five minutes for mindful meditation between clients, or using time that was once spent commuting to prepare well-balanced meals. As previously mentioned, self-care will look different for each clinician, and self-care activities many need to be modified as needs change over the course of one’s career. The impact of a strong self-care routine will likely have similarly beneficial effects for all clinicians at any stage in their career, reducing stress, burnout, and secondary trauma and compassion fatigue especially in the ever-evolving age of pandemic-era practice. 

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Jeffrey E. Barnett, Psy.D., ABPP

Jeffrey E. Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola University Maryland and a licensed psychologist who is board certified by the American Board of Professional Psychology in Clinical Psychology and in Clinical Child and Adolescent Psychology. Additionally, he is a Distinguished Practitioner in Psychology of the National Academies of Practice. Among his many professional activities, Dr. Barnett is a past chair of the ethics committees of the American Psychological Association, the American Board of Professional Psychology, and the Maryland Psychological Association. He previously served on the Maryland Board of Examiners of Psychologists and has been a consultant to licensing boards across a range of health professions. His numerous publications and presentations focus on ethics, legal, and professional practice issues in psychology. Dr. Barnett is a recipient of the APA’s outstanding ethics educator award.