Time to Take a Closer Look
Adapting and Expanding Psychotherapy Process in Telemental Health
Clinical Impact Statement: Many therapists are now doing video psychotherapy and will continue to do so even when in-person therapy becomes safe and possible. It is quite possible that many clients will prefer video psychotherapy because of the ease and accessibility. As therapists, we need to begin to tease out the differences between in-person and video psychotherapy and adapt and for these differences to optimize our effectiveness.
In March of 2020, therapists faced an unprecedented challenge and, in many ways, a glorious opportunity. COVID-19 and lockdowns meant that it was no longer possible or safe to provide psychotherapy in a “business as usual” way. Video psychotherapy, or telemental health, which had been considered by many as the lesser cousin of in-person therapy, became the new business as usual. Although there has been some research on the effectiveness of telemental health, it has not been extensively studied, especially in terms of how the psychotherapy process might differ from traditional in-person therapy.
Pre-COVID, we (the first two authors) found ourselves doing video psychotherapy or telemental health regularly. We were both, as were most of our clients, surprised at how natural it felt and how effective it seemed. We wondered about some of the intuitive and more systematic changes we were making to accommodate the special characteristics inherent when doing video therapy. We wondered not so much about the practical and ethical aspects of doing telehealth (e.g., HIPPA compliance, secure platforms, informed consent) but about how therapists changed what they did in therapy.
Over the past 100 years, we have seen many changes in the way psychotherapy is delivered. Most notably, therapists have adjusted their practices to fewer (per client) sessions per week and typically shorter sessions compared to the session frequency and duration in the early years. Similarly, we wonder what changes “in the room” have been necessitated and inspired by the transfer from the physical room to video? We imagine, especially as many of us begin to negotiate some level of in-person therapy again that many therapists have been thinking about this too. Because of the overwhelming convenience for many clients, it is quite possible that even if we, as therapists, want to return to the office, some of our clients will be reluctant to do so.
For us, the most striking difference between in-person and video psychotherapy is the fact that both client and therapist are disembodied (e.g., we typically only see one another’s faces and in two dimensions). We do not get to see the whole body, which seems to present one of the biggest challenges we face as video-psychotherapists.
But what does this mean exactly? For one thing, most of us have been trained to attend to and use client body language, directly or indirectly. We use it to judge when clients might be anxious, how they are responding to our interventions, whether the client is “with us,” open or closed off, curious or bored. Although the video offers a superior view of the client’s face and allows us to better pick up on facial micro-expressions, it is different from seeing and reading a client’s entire body.
How might one explain to a client a preference for in-person for this reason? “I want to see your whole body because I use it to understand your unconscious and conscious experiences, and in turn, I can help you better.” Sure. However, this might be a hard sell for someone who must commute to your office, pay for parking, and take extra time off of work to get to and from the appointments. Does seeing the whole-body matter that much? Or, better yet, are there ways to compensate for this lack? Of course, one way to compensate is to ask more directly about bodily experiences. Certainly not a bad thing. Or become hyper-alert to other signs of distraction, tapping out of sight of the screen, eye movements, the client moving in a way that you can no longer even see their whole face, all of which can be read by the attentive therapist and processed.
In addition, the therapeutic presence, which has been defined as “bringing one’s whole self into the encounter with the client, being completely in the moment on a multiplicity of levels, physically, emotionally” (Geller & Greenberg, 2002, p. 82-83), may not be the same, especially for some therapists and clients who are visually or spatially oriented (see also Geller, 2020 for an excellent article on developing online therapeutic presence). We all know from our personal lives how different it is to talk on a screen versus sitting in a room with a comforting friend or family member. In the presence of another person, our whole body can let go, we feel safe, nurtured, comforted, at ease. This is not to say that this presence cannot be somewhat replicated through the person of the therapist on a screen, especially if there was an “in-person” relationship built prior to going to video. But we doubt that any of us would say it is “the same.” Attachment researchers and neuroscientists talk about how humans are hard-wired to respond to human connection (Geller & Porges, 2014; Siegel, 2012). Is the connection the same between screens?
Over the years, many clients have asked, half-jokingly at the end of the session, “Can I just stay here for a while.” They feel safe in the office, cocooned from all of the stressors and worries of their outside therapy life. In addition to not being able to sit in a safe space in the physical presence of a caring other, another jarring aspect of video psychotherapy is that there is no gentle ending to the session - a button is pushed, and we are gone, our clients are gone. There is no physical movement or gestures to transition from the psychotherapy space to the rest of clients’ lives. Perhaps some therapists have discovered ways to adjust to this abrupt ending. Some of us find ourselves waving goodbye, something we wouldn’t do in person, but it somehow seems a nicer way to end the video session. Perhaps taking a minute to take a deep breath or two with the client might make for a nicer transition.
Most therapists, we believe, are naturally nurturing people. We likely have many ways we show this to our clients, beyond handing them a tissue box. Much of it is intuitive, developed over years of doing this work. While being on the screen does not preclude nurturing, it does require a more intentional focus, perhaps more verbal reassurance, and perhaps using our bodies to move toward the screen to show concern or move outward to allow space. It might even mean touching the screen. It may mean showing more of our emotions in our facial expressions, a tear in the eye, a shift in our tone of voice. Some colleagues we know have talked about being physically and vocally more expressive when doing video psychotherapy.
Many of us want our clients to know we are humans like them. That is one reason that one of us, after starting video practice, decided to be more intentional about the background during the sessions. Wanting to convey more of her personhood, she makes sure there are fresh flowers behind her and a nice painting on the wall. While barking dogs and noisy family members can be a distraction if they happen too frequently, now and again, it just lets our clients know we are real. We are not some avatars on the screen.
Many therapists are now struggling with the issue of whether to return to seeing clients in person. Some will continue to see at least some of their clients through video. We thus need to know more about the differences. Over the next few years, there will undoubtedly be more research like the qualitative study we are currently working on comparing the in-person to video psychotherapy process. Hopefully, this will include explorations of therapeutic relational processes like working alliance and the real relationship. While we await this research, we plan in our own practices to talk openly and think about ways to optimize therapeutic presence and the real relationship so that we can counteract the limits presented by being disembodied and two-dimensional.
In our discussion with clients who may wish to stay in video psychotherapy, we need to begin fleshing out what really makes a difference and for which clients one modality might be preferred over another. We need to be able to inform clients about the benefits and limitations of each form of therapy for their particular problem and situation. For example, some patients may find video psychotherapy easier because it enables them to work through trauma in a way that feels safer. For others, not having the physicality and presence that facilitates attachment and creates security might make it more difficult to work through trauma.
We encourage therapists, no matter what your ultimate preference will be, to take time to reflect on how to make both modalities as effective as possible. In particular, to become more intentional in video psychotherapy interventions, therapists can consider how to create safety, show nurturing, and become more “real” in a two-dimensional world. In early 2020, most therapists and clients didn’t have a choice about whether or not to use video psychotherapy – it was that or nothing. And we were all grateful. As the world gradually (we hope) returns to normal, let’s think about what and how we are with our clients, maybe opening up to new ways of being and doing therapy.
Video psychotherapy need not be considered ‘less than’ in-person therapy. It is different, just as group therapy or family therapy is different from individual therapy, or cognitive-behavior therapy is different from psychodynamic therapy. We believe that with an open mind, thoughtfulness, and intention, one can find ways to optimize and enhance this modality.
Cite This Article
Thompson, B. J., Norwood, E., Yee, S., & Hill, C. E. (2021). Time to take a closer look: Adapting and expanding psychotherapy process in telemental health. Psychotherapy Bulletin, 56(4), 7-10.
Geller, S. M., & Greenberg, L. S. (2002). Therapeutic presence: Therapists’ experience of presence in the psychotherapy encounter. Person-Centered & Experiential Psychotherapies, 1(1–2), 71–86.
Geller, S.M. (2020). Cultivating online therapeutic presence: Strengthening therapeutic relationships in teletherapy sessions, Counselling Psychology Quarterly, DOI: 10.1080/09515070.2020.1787348
Geller, S. M., & Porges, S. W. (2014). Therapeutic presence: Neurophysiological mechanisms mediating feeling safe in therapeutic relationships. Journal of Psychotherapy Integration, 24(3), 178–192. https://doi.org/10.1037/a0037511
Siegel, D. J. (2012). The developing mind: How relationships and the brain interact to shape who we are (2nd ed.). Guilford Press.
This article resonates with me tremendously. I began doing teletherapy long before Covid partly because I frequently found myself traveling or being outside my State and still wanted to be able to meet with my clients. Because I came into the field from a background of work in social media and video streaming, I wasn’t at all surprised that therapy could be done efficiently and more importantly, effectively through online video.
Initially, I began with client whom I had worked with in-person, but quickly I began seeing clients whom I had never physically met. I found that rapport and therapeutic relationship building was much the same and working virtually had almost no impact on that. There are of course, differences… I might not see a toe tapping or other signs of body language that I might if I were in room with the client. But this seems to not really impact the effectiveness of the work. I do find, like the authors, that the ending of sessions, and particularly the ending of therapy when the work is complete is lacking compared to being in office… and clicking off doesn’t always provide the emotional satisfaction compared to in-person goodbyes. But given the convenience to me and my clients…. I believe the pros of doing work online far outweigh the cons… It is slightly different than in-person work… but not sufficiently different for me to want to go back to the office.