Clinical Impact Statement: Providing psychotherapy via videoconferencing in the midst of a pandemic can be very beneficial for patients. However, this opportunity can also go hand-in-hand with challenges to certain aspects that can be central for the provision of treatment, such as the therapeutic space, boundaries, and presence. The discussion of these issues and the implications for individual and group therapy is central, as it will allow therapists to prepare for possible difficulties that might arise when engaging in telepsychology.
Online psychotherapy is not new. Group therapy using videoconferencing is not new. What is new, however, is having to start online treatment for the first time in the midst of a global pandemic.
Usually, before COVID-19, therapists who provided telehealth services had gone through a planned and thoughtful process of figuring out online work, including using HIPAA compliant platforms, creating consent forms for online treatment, and considering the physical space where they would provide such work (e.g., from their home office).
Now, in the time of COVID-19, those of us who are just jumping on the telehealth bandwagon have benefited from the knowledge of pioneers who started this journey before us. However, in this pandemic, many (if not most) psychologists (1) have had to quickly adjust and start providing treatment from home, (2) might not have a previously planned space to engage in online services (e.g., an office), and (3) might be sharing spaces at the same time with many other members of their household. Additionally, therapists might be dividing their time between working from home with other responsibilities (e.g., helping their children with online schooling). Such fast adjustment is happening at the same time that we are holding several reactions and feelings related to this pandemic, such as various concerns, anxieties, griefs, and fears.
Just like us as psychotherapists, patients are also facing challenges related to the uncertainties and physical distance of this pandemic. Thus, online treatment can become a necessary way of providing care for them. Furthermore, online therapy groups can become a uniquely valuable virtual space that provides connection, where there can be shared emotional experiences, growth, and the possibility of receiving and providing support. Such opportunities for treatment can also go hand-in-hand with some challenges for psychotherapy providers. First, state licensing requirements set boundaries regarding who psychologists can work with. Thus, it might not be possible to continue providing care to some of our patients (e.g., students who were seen at a university counseling center who returned to their home states). Additionally, working remotely can have added challenges when risk-related issues arise.
Many authors have discussed and provided helpful guidelines for the delivery of online psychotherapy, including technical, ethical, and legal considerations (e.g., Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013; Maheu, 2019). Anyone who decides to offer psychotherapy using videoconferencing should engage in appropriate training (e.g., webinars, readings) before providing such services. In addition to addressing the practical, ethical, and legal considerations of telepsychology, it is important to ponder other aspects that relate to providing these services. In the following paragraphs, I present a brief discussion regarding the concepts of space, boundaries, and presence that are unique to the provision of individual or group psychotherapy via videoconferencing. These concepts might be useful when engaging in such services.
Space, Boundaries, and Presence When Providing Online Psychotherapy
Before COVID-19, many psychotherapists devoted significant efforts in designing a therapeutic space (e.g., through the choice of furniture, lighting, personal items displayed) that would reflect us and our work, and that would be conducive to the treatment process. Now, in the time of COVID-19, many of us practice therapy from our home, where we might not have been able to create a therapeutic space as intentionally as we previously had. Additionally, many patients are attending therapy via videoconferencing from their homes. As a consequence, we psychotherapists enter into a patient’s physical personal space; we have a visual window into aspects of a patient’s experience, which before we had only heard about in therapy sessions. In that way, the patient also enters our personal space (which for many providers might have been considered a “private” space before). Therefore, we are faced with the task of creating virtual spaces that do not feel intrusive to the physical spaces we live in.
This issue of space brings up the interconnected issue of boundaries. Setting a specific space from where we can work privately and confidentially is central for the maintenance of boundaries in our work. Before COVID-19, many therapists considered their office as the only space where therapy could take place. Currently, many patients are connecting online from their bedrooms, which could be the only private space in their homes where they might be able to connect with a therapy provider safely. How about therapists? Which spaces in our homes are we using to connect with our patients? How does that choice influence us, our patients, and our work?
Also, space and boundaries are central for our self-care as we provide remote therapy during a pandemic. How can we create separation between work and other aspects of our life when we are working online from home? Some therapists might not have any challenges with this transition, but others might need to have a physical space for work that is separate from other areas.
Recently, an intern I work with pointed out the following: while providing therapy using videoconferencing from our homes, there is a unique experience of having to separate ourselves or disconnect from our own space at home in order to join, connect, and stay present with what is going on with the patient. As therapists, we need to filter what we are paying attention to (e.g., what if, while providing therapy, your dog is scratching the door, or you hear one of your children crying?). In a way, in order to connect with the patient’s experience, we must create some distance from our own bodily experience of our surroundings. Some of our patients might be facing a similar experience. Of note is that when therapist and patient are in the same physical space, disruptions during a therapy session (e.g., a knock on the door) become a joint experience and can be easily addressed. However, while providing treatment online, two physical and separate spaces are bridged through a shared virtual space, and in order for us therapists to be present and join our patients, we might need to distance from some aspects of our own space.
Another issue that needs to be considered when providing online treatment is this: How can we, as therapists, convey presence when we are bounded by the limitations of virtual space? Interestingly, online treatment using videoconferencing raises a unique paradox: In order to convey the perception of connecting to the patient, in a way, there is disconnection that takes places. Specifically, to show visual connection through a direct gaze, psychotherapists need to look directly towards the camera. While doing so, we might miss seeing the reactions that the patient is having to what we are saying. This online process is a different type of experience in comparison to the one we might have while in person, a few feet apart. Fortunately, several authors have proposed factors that might allow us to increase our presence beyond the virtual distance, such as focusing on facial expressions and using self-disclosure (Weinberg, 2020), and adjusting the body’s distance from the camera (Ogden & Goldstein, 2020).
Space, Boundaries, and Presence When Providing Group Therapy via Videoconferencing
During online group therapy, group leaders are no longer in control of the group space as they are when engaging in in-person treatment (Weinberg, 2020). Additionally, as Weinberg (2020) highlights, when engaging in online group psychotherapy, the traditional format of the circle changes, as we appear as rectangles on a screen, and the configuration of such rectangles on the screen will vary from member to member. Therefore, unless we verbalize who we are looking at or identify to whom we are speaking to, other group members will not know with whom we are trying to connect. Thus, this change of space affects even the way in which the group leader and the group members can convey their presence to others and non-verbally relate to one another. Using video conferencing to provide group therapy also brings up the possibility of having parallel streams of communication if group members engage in using the chat option while others are talking. A group leader needs to establish clear boundaries related to ways of communicating (e.g., “use the chat option only to convey that you are having issues with connectivity”) so that the virtual space can be established as a space shared by all group members.
When working with an online group, there are potential challenges that may prohibit or affect one’s ability to be virtually present and engaged during the session. Some of these difficulties relate to technical issues (e.g., not being able to join the session due to internet problems). One way of establishing clear boundaries and procedures is to state in the informed consent, the steps to take if a group member gets disconnected. However, besides the technical aspects related to connectivity issues, we can have disconnections that mask intrapersonal (individual group member) and/or interpersonal (among the group members) dynamics, and then, the connectivity challenges relate to a challenge in connections.
Just like with in-person groups, when leading an online group, a therapist needs to remain curious. For example, if a group member sends a message that he/she cannot join the session due to internet issues, or if a group member gets disconnected, it is central for the group therapist to ponder whether this connectivity issue is masking a desire to disconnect. Exploration with group members continues to be a key aspect of group treatment, especially in interpersonal process (IP) groups, where such challenges in connectivity can become grist for the mill. Questions that IP group leaders can ask the group member who got disconnected include: How was it to not be able to join the group? Can you explain what feelings arose when you got disconnected? Exploration of the reactions that came up for those who remained in the group is also essential. Weinberg (2020) also raises an important point when he shares a vignette in which a group leader asks a group member to leave a session (e.g., due to confidentiality issues related to the space the group member was using when connecting to the session), and group therapists that provide treatment using video conferencing have to ponder ahead of time how they would manage such cases with the group if such situations arise.
Additionally, due to intense reactions or difficulties in the moment, a group member might decide to leave the shared space (including “storming out”) by choosing to virtually disconnect. If this were to happen in person, usually there is a process of getting up and going to the door, which allows others to react, whereas online it can be a simple click that might occur unexpectedly. Group leader(s) have to be especially attuned to the group’s reaction to this and process the experience and implications (which might include exploration of fantasies) that this might bring for group members, including how it feels to no longer to have the presence of that group member in the virtual space.
Finally, another key aspect to consider during online group treatment is the possibility for the group leader to have connectivity issues. This is not as challenging if the group is co-led, because if one of the group leaders gets disconnected, the other might remain present and can continue leading. However, if this disconnection were to happen in a group where there is only one group leader, we have the potential of having different group members in a shared space that is “leaderless.” How should that be addressed if this happens? Thus, it seems central for therapists to learn about the characteristics of the video conference platform that they are using (e.g., if the host of the meeting gets disconnected, does the group still proceed?) and to plan for how to address possible challenges that might arise during treatment.
The considerations of space, boundaries, and presence are important aspects of psychotherapy work. As we face this pandemic and as therapists are increasingly engaging in providing therapy via video conferencing, the previous experience of shared space, boundaries, and presence in the therapy hour is somewhat shifting. Telepsychology providers need to be aware of the different aspects that relate to the previously mentioned concepts, in order to better plan and also better address challenges when they arise. However, in spite of the adjustments that COVID-19 has brought, the basics of psychotherapy (e.g., being empathic, remaining curious, engaging in exploration, processing any relational challenges that come up) continue to be central in the provision of therapy.
Cite This Article
Palma, B. (2020). Space, boundaries, and presence: Considerations for individual and group therapy using videoconferencing in the time of COVID-19. Psychotherapy Bulletin, 55(2), 18-22.
Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. (2013). Guidelines for the practice of telepsychology. American Psychologist, 68(9), 791-800. https://doi.org/10.1037/a0035001
Maheu, M. M. (2019). Telepsychology best practice 101 series [Webinar]. American Psychological Association. https://apa.content.online/catalog/product.xhtml?eid=15132
Ogden, P. & Goldstein, B. (2020). Sensorimotor psychotherapy from a distance: Engaging the body, creating presence, and building relationships in online therapy [Webinar]. Sensorimotor Psychotherapy Institute. https://sensorimotor.pages.ontraport.net/online-therapy-resources
Weinberg, H. (2020). From the circle to the screen: On conducting group therapy online [Webinar]. Group Analytic Society International.