Telehealth Psychotherapy: A Few Issues

Mosaic depicting theatrical masks of Tragedy and Comedy, 2nd Century C.E., Located at Capitoline Museums, Public domain, via Wikimedia Commons

We know from in-person experience that feelings, whether they be identified as bodily sensations and/or as emotions, are fundamental to each person’s evaluation of any social interaction. Talk-therapy is a social interaction, albeit a special kind, as a psychotherapist told me:

“Much of that is metaphoric to parenting. The parent gives you boundaries and guidance that’s difficult to hear sometimes. And as they know that it comes with caring and compassion, they tell you. They need that energy from you. They need to know that I’m real, that I care, I’m honest. They need to know that I won’t hold back.”

The above comment shows the intersection of feelings and conduct. Another clinician told me about the clinical importance of feelings:

“[What] I’m doing is using a great deal of empathy as I am listening to their narrative, I am establishing a bond. The bond is going to be critical to our work, for as long as it lasts. Now, of course, some patients will not let me do that. They are pushing me away. I can feel that and that’s diagnostic. And here’s how it’s diagnostic. An individual who is pushing me away is not going to let me be very explorative. So I have to stay on the surface with empathy for a while.”

A psychotherapist talked to me about the quality of knowledge:

“Nonjudgmental acceptance, professionalism, being able to hold their issues without imposing my own issues on them. My knowledge and expertise on personality styles and knowing realistic expectations for this person given the way they are wired. Knowing what is the reasonable goal for someone who’s wired the way they are. A consistent presence so they know what they’re going to walk into from one week to another. They probably have enough of not knowing what to expect in their lives with other people.” 

The next story is about Telehealth and psychotherapy for trauma. The sessions were audio-only:

“I can think of a client, a woman who is divorced, mother of an adult child, late 50s. She has been struggling, she’s a Hispanic woman… She had real difficulty with boundaries. with her boss, with her friends. She tended to let herself be manipulated. She was not protective of herself. I had been talking to her for a while. And we do phone. A lot of my clients do phone, not video. It’s their choice. We were working on helping her recognize what she was doing. She had trauma in her past. She started to understand what she was doing, she started to understand how she was allowing people. She had feelings of being less than. She said to me [that] she had made some really significant changes in taking risks… She was challenging herself. Setting clear boundaries.”

“It’s their choice,” mentioned in a story, resonates with my conclusion and my approach to healing through talk-therapy. “It’s their choice” might be a North Star whenever in-person or Telehealth is a choice. In the next story, streaming video calls were described by a clinician:

“[I’m] doing video on their phone, so I can actually see their face, but not as well as I can with video on the computer. In Telehealth, I’m so focused on people’s eyes and their expressions, as much as I can be. I think I’m more reflective with people on Telehealth because I’m watching so closely and so intently, there’s this smaller range to see on the screen. I have worked with a couple of people who are really doing a deep dive into how childhood trauma formed their unhealthy choices. I’m thinking of one person in particular. It seems to have really worked well doing that deeper, deeper, dive. But it could also be because there’s less opportunity to be out and about, they’re doing more writing. And I’m more reflecting. They come really prepared for the session.”

My psychotherapy practice offers in-person and Telehealth options. I continue to be vigilant, because a videoconference presents unique challenges. A clinician said this:

“You see less cues, you cannot see the whole body. On the other side, I can see the home. But I don’t see all of the nonverbal cues that I see from the body. I can’t see them shaking a foot or that nervous tension in the lower part of the body. I can’t see the posture as clearly. And, I can’t smell them. Sometimes smell is important. It could be body odors, perfume or whatever else. There’s therapeutic information from walking up to the waiting room and seeing what they’re doing, the magazine they’re reading, how they’re sitting.” 

The psychotherapist described the useful nonverbal clues and signals from the client that inform ongoing assessment. Other clinicians told me similar stories. The next one talks directly about a Telehealth barrier to perception that can pose a significant challenge.

“I can speak to this especially since this week I just had a client emergency. When there is a person who is withdrawing into depression or is hiding, unable to be honest about the severity of their mood or their risk factors or their use of substances or their suicidal ideations, it’s risky to be on Telehealth. At that point, I need to be able to see them.” 

Safety issues are significant. The next clinician describes other barriers:

“I’ve had more than one session where a client starts crying and I don’t realize that they’re crying because of the quality of the lights in the room where they’re at and the video connection. So I’m talking with a client and we’re going back and forth. At some point I do a reflection, 30 seconds or a minute... not realizing that the client has begun crying. If they were in the room and I saw them crying, probably my tone of voice may change, or something in me may shift to be with the client in a different sort of way. Not even recognizing someone’s crying doesn’t allow that to happen… I don’t think that’s as effective as being able to accurately gauge a client’s emotional state. Crying is one example. In my office, I may notice when the client starts tapping their foot, when they really tense up or when the whole of their body freezes, I may notice changes in breath a bit more acutely. Changes in breath I do notice pretty well over video. But it’s even more noticeable through the in-person.”

The shared physicality of experience is sometimes very important. Telehealth creates sensate distance. Distance can have therapeutic effects as described by this psychotherapist:

“After switching to Telehealth and continuing to build our rapport, this person was able to talk about a childhood experience of being sexually abused and also later sexually abusing someone else... and over 20 years later, the client had never talked about it to anyone. Never talked about it in therapy or with family members or anyone else. It was part of their life that in some ways was important to their sense of self. So being able to discuss it really allowed them to start forgiving themselves. We didn’t talk about it after the two or three sessions focused on it. After that we focused on self-love, self-compassion, self-forgiveness… The client has experienced so much transformation in the relationships in their life and their career, their sense of self and their sense of self-care. Other compulsive behaviors have sharply declined… I don’t know if the client would have been able to share it if we had been in the same room just feet apart from each other. This is a client that chooses to use the phone. It may be that extra space of not having to see my face provided some level of spaciousness. The client didn’t say that themselves. But one thing I noticed about Telehealth is that some people find it much easier to open up when they don’t have to look at anyone.”

Psychosocial distance, I had thought prior to listening to clinicians, was something that would diminish therapeutic efficacy. Now, I think that consideration of “distance” might be a reason to recommend Telehealth for a client. It can provide a form of safety.

If the psychotherapist is good at what they do, they figure out how to do it through Telehealth, whether it is two-way streaming video or audio-only. The stories illustrate that Telehealth is not a decisive for the therapeutic alliance. Often Telehealth is used improved stability or adaptation in a situation, preconditions for personal, transformative change.

The modality, in-person or Telehealth, does not seem to be the fundamental factor. Nor is psychotherapeutic approach (which is noted parenthetically after the clinician’s comment.)

“Here’s another thing to do when you’re in a long-term psychotherapy relationship, it’s not a bad idea when people say, “You know, I think I need a break, I want to apply what I learned.” Developmentally, people need to practice and see how they do, based on where they are now. That’s always a good thing, So maybe in some weird way, Telehealth has thrust itself on the  therapy experience in a very similar way. It’s like that the patient doesn’t have access to me or the process like they used to. It’s still there in a way, but it’s different.” (Psychodynamic)

Sometimes it is best to return to the office when Telehealth becomes less effective. A clinician shared this story:

“In the last year many have expressed feeling less safe than in the office. Their environment isn’t completely confidential. It’s harder for them to open up. It’s harder for them to do the work. That’s especially important if you work with domestic violence folks. I have a client who uses it because she is so lonely. She answers my call, but she doesn’t take it as seriously and isn't as committed. Telehealth allows her to have more freedom in that area. Coming to my office is more of a commitment for her.” (Relational)

Some clinicians talked about access in the context of psychotherapy with an individual. Here what one said:

“The practicality is good for the continuity of therapy… it has actually been beneficial. From attachment theory, proximity, availability, nurturance, so we’re available. Somebody’s right there on their phone or computer, that is therapeutically very powerful.” (Cognitive)

Here-and-now adaptation and transformative change are clearly related to all experienced therapists. What might not be as clear is the fluid connection with in-person and Telehealth modalities. It’s not simply a question about equivalence or efficacy, but rather it is about recognition. A psychotherapist described it:

“A lady patient is having postpartum depression. So first of all, I met her in person. And I listen to her story of the gestation of her baby, and the birth of her baby, 2 to 3 weeks of good health, and then she is socked with a pretty severe postpartum depression.

So we have got to problem-solve. How is she going to manage the baby enough to care for the other child? We end up working together with her husband who is now out of work and at home trying to help her with the children, but pretty depressed himself because he can’t work and bring home an income. They’re in a lot of distress. We’re doing problem-solving for organizing every kind of resource we can think of. We’re just resourcing. What would be helpful, where can she get it?... I’m working very hard to create a bond with her.

So during the course of our Telehealth work, daddy comes into the room with the baby. The new baby was crying and he said, “I cannot handle her,” and so she said to me, “Do you mind if I nurse her?” I said, “Heavens no, go ahead.” So we’re doing direct supportive psychotherapy, coping skills and she’s nursing the baby. And I’m enjoying this beautiful, beautiful child and getting reinforcement from her about how beautiful the baby really is…

She is nursing her baby and I am providing support to her kind of like grandma. We are admiring the baby and thinking about various resources for her so that she has a little more time for herself to do some very basic things like go walking, go to the grocery store, go to the doctor, this sort of thing. Now that is just problem solving.

She has a great deal of insight and so it doesn’t take very long for us once we create a bond to begin to talk about her internal world. And how she’s coping with this much depression, a new baby, and a 3- or 4-year-old, all at the same time. And her husband is so upset about work. And you meld the two together. The problem solving is the scaffolding of the work, for the insight, especially being able to help her with her sense of herself and her depressive orientation. The insight, she has the capability for that, so we can go there.” (Psychodynamic)

The psychotherapist described the connection between problem-solving and forming insight. She described the intersection of maternal experience, complex social relations, economic stress, logistics and client-psychotherapist intersubjectivity.

Telehealth during the pandemic has stirred things up for clinicians themselves:

“Maybe I’m having more trouble with Telehealth [because] my belief systems [are] getting in the way of my insight. How awesome to be able to validate someone who’s had this experience for a long time and now somebody else gets that [sense of isolation]… [Now they are] able to speak to that [whereas before] going to the office wouldn’t have honored that deep feeling of loneliness they’ve always had, because they’ve always been [mostly] homebound and somehow, they get to an office. Maybe I’m feeling more isolated.” (Relational)

Summary of a Few Issues in Telehealth

The pandemic forced me and other clinicians (who had only provided in-person psychotherapy and supervision) to provide Telehealth services (Carter, 2020; Doran & Lawson, 2021). I had become familiar with Telehealth as I participated in the expanded use of Health Information Technology (HIT) after I returned from Peace Corps service (2006-2008). Once I made the personal decision to deploy Telehealth for my own private practice, I wondered, “Is transformative psychotherapy possible via Telehealth?” 

I wondered: Telehealth doesn’t engage the whole of our physicality, so is it as good as in-person? My view doesn’t represent the truth. It’s my worldview, paradigm. I imagine that some of you see things very differently. According to Reese & Overton (1970) cited by Abney & Maddux (2004):

“Theories built upon radically different models are logically independent and cannot be assimilated to each other. They reflect representations of different ways of looking at the world and as such are incompatible in their implications. Different worldviews involve different understanding of what knowledge is and hence the meaning of truth. Therefore, synthesis is, at best, confusing.” (p. 144)

I am using my synthesis of worldviews and the science derived from them. Hopefully I have done this  in a way that does not confuse.

Talk-therapy is a social interaction, albeit a special kind. Feelings, whether they be identified as bodily sensations and/or as emotions, are fundamental to each person’s evaluation of any social interaction. Telehealth presents unique challenges. Nonverbal signals in shared physical space are lessened by Telehealth because it creates sensate distance. Distance can have therapeutic effects. There can be significant safety issues and yet the distance can provide an envelope of psychological safety.

If the psychotherapist is good at what they do, they figure out how to do it through Telehealth, whether it is two-way streaming video or audio-only. The stories illustrate that Telehealth is not a decisive for the therapeutic alliance. Often Telehealth is used improved stability or adaptation in a situation, preconditions for personal, transformative change. In-person or Telehealth, does not seem to be the fundamental factor. Nor is psychotherapeutic approach (i.e., Psychodynamic, Relational or Cognitive.)

Telehealth during the pandemic has stirred things up for clinicians themselves:

“Maybe I’m having more trouble with Telehealth [because] my belief systems [are] getting in the way of my insight.”