Therapy, like everything else, has moved online. And that's a good thing

When my sister, a therapist, began doing teletherapy because of the COVID-19 lockdown, she and I were sharing a rental house near Washington D.C. It was March; D.C. was a hotspot. Our brother had had emergency surgery and we traveled there to help his family as much as we could. After her first session, my sister reported that it was weird—when she tried to look at her client’s face, on the screen, it looked like she was looking down. To look as if she was looking in their eyes, she would have had to look at the camera. Other applications might work better, but this was the highly encrypted one required for therapists. Eventually, she got more accustomed to it and even took on new patients she’d never met in person. The “new normal” had set in.

Since the onset of COVID-19, many therapists who never thought seriously of becoming teletherapists suddenly are. Therapists who set up offices with candles, flowers, books, art, to create a feeling of safe haven, who relied on their personal energy to connect with clients, now have to channel all that through a screen or through the phone. With teletherapy they are stripped of some of the tools they use to connect with people—visual cues, body language, and simply ‘presence.’ For some clients, it may be too uncomfortable to deal with such vulnerable parts of themselves through a screen or on the phone. But in some ways, teletherapy can improve the experience, according to veteran therapist Don Flory, PhD.

In person, he said, many patients look to him for visual cues for how well they’re doing in their therapy. “It’s less with the truth of what they have to say and more with what they think I want….”

Therapists who set up offices with candles, flowers, books, art, to create a feeling of safe haven, who relied on their personal energy to connect with clients, now have to channel all that through a screen or through the phone.

After moving from Berkeley, California to Taos, New Mexico 15 years ago, Dr. Flory discovered that many of his west coast clients wanted to work with him remotely. “People are very comfortable to be in their own homes while talking to me,” he said. “Working by phone in particular, by eliminating the visual cues, it eliminates the social aspect of therapy. Clients are in contact with me, but more into themselves. During phone therapy, I tend to close my eyes and kind of go inside when I work with people,” he said. “It lets me be more in touch with my intuition.”

I chose to interview Dr. Flory to interview for two reasons: One, I knew he’d been doing telehealth for a long time; two, I spent more than a year visiting his office once a week, working on my own issues. I know that being in his presence was a key part of the experience for me. I found him grounding, transparent, harboring a merriment that either fell toward compassion or popped out in some understated, funny comment that drained drama from a moment, leaving behind plain truth. His style of therapy suited me perfectly; the man changed my life profoundly for the better. I’m pretty sure there’s something missing when you’re not in that space, sharing that energy. I was glad to learn something else really good can replace it.

[Related read: How to support your remote team’s mental health]

Therapy and tech—prevalence and effectiveness

Therapy is different for everyone. For most it involves getting in touch with trauma, pain, fear, or shame around which people have built psychological fortresses—ways to avoid feeling those feelings. Reopening them in order to heal, to live differently, requires vulnerability. People often form intense bonds with their therapists. The question is, how does having a technology as an intermediary impact that relationship and ability to be effective? A study by the Veterans Administration Synthesis Program, published by the National Institutes of Health in 2019 concluded among other things that:

• Video delivery of mental health treatments are likely similar to in-person treatments in terms of patient satisfaction (for both Major Depressive Disorder [MDD] and Post-Traumatic Stress Disorder [PTSD]), number of sessions completed (PTSD), quality of life (both MDD and PTSD), response (MDD), and remission rates (both MDD and PTSD).

• Video delivery of mental health treatments are associated with lower or similar implementation costs (PTSD and MDD) and health care utilization costs (MDD only) compared to in-person treatments.

• Evidence is emerging on the use of video for diagnosis of mental health conditions as well as the use of video for treatment of chronic pain.

One online platform, BetterHealth.com, found that 60 percent of its users in 2019 were in their mid-20s; many used it because of the burnout created by their extended work hours. But the American Psychological Association noted that more than a dozen mental health sites and apps had emerged prior to the COVID-19 outbreak. The Anxiety and Depression Association of America, for example, has posted a list of apps designed to help people with anxiety and depression-related issues, including cognitive distortions, social anxiety, and obsessive-compulsive disorder. There are also options in virtual reality.

The question is, how does having a technology as an intermediary impact that relationship and ability to be effective?

Other studies have shown that teletherapy has many benefits, including making people feel safe because they’re at home, making therapy more accessible—given that accessibility to a therapist is challenging even when there’s not a lockdown—reducing costs, since therapists don’t need an office, and more. Whether seeing a therapist in the office or starting with some form of telehealth, though, people need the experience to make them feel safe in order to do the vulnerable work they must do. Fortunately, our own bodies can tell us whether we feel safe with someone. That’s a message we need to listen to.

Some research shows that people find videoconferencing exhausting because they require so much more brain work than an in-person conversation where cues are sent and received almost automatically. Dr. Flory works with one severely traumatized patient who prefers that they sit side-by-side during sessions—so he’s not looking at her. For her, the distance created by technology seems to help her anxiety; for him, he worries it makes it more difficult to be as sensitive as he needs to be.

[Related read: Talking about mental health at work, now part of the employee experience]

Trade-offs and gains

Dr. Flory insists on meeting all new patients in person at least once. And many people feel like having the opportunity to get a sense for the other person is key.

“I think it would make a difference if we had never met,” said my friend John Egan, a journalist and marketer who is working with his long-time psychiatrist via phone since the coronavirus lockdown. “There’s a level of trust and familiarity there that I think would be hard to establish if we didn’t know each other…. You do need a level of in-person feedback. There’s so much that goes on with body language and you miss some of that if the therapist, psychiatrist, psychologist isn’t seeing you in their office.”

Other studies have shown that teletherapy has many benefits, including making people feel safe because they’re at home, making therapy more accessible…reducing costs…and more.

For another friend, Andrea Genevieve Townson, it wasn’t that she didn’t feel safe. It was that the environment of the therapist’s office gave her a certain freedom. For her, it didn’t seem she could get that from telehealth.

“It wasn’t that I was super tied to a therapist’s office,” said Townson, a digital marketer who works from home and has three young kids. “I always looked forward to going. But it was more that I knew, mentally, when I walked through the door I would be focusing on nothing but myself for that hour. I was not confident enough I would be able to do that here in my home setting.”

The important thing, as Egan pointed out, is if you need help, get it. And many people these days could use some extra help. Fortunately, the COVID legislation waived long-standing rules against using teletherapy unless it was specifically in someone’s plan. With people sequestered in their houses to avoid the spread of a virus that kills in unexpected ways, many of whom have lost their jobs, in the midst of a lot of political bickering over the response, even those who hadn’t thought they struggled with mental health issues before, now definitely are.

[Related read: How to ask for a mental health day from work—because we all need one]

The important thing, as Egan pointed out, is if you need help, get it. And many people these days could use some extra help.

“(Teletherapy) is definitely better than nothing,” he said. “When you’re having a session their key skill is listening and they can do that over the phone; they can do that over video conference,” he said. “They can probably tell whether something is upsetting somebody or bothering somebody. They’d be able to pick it up. For anybody who wonders whether that kind of therapy session would work for them, I’d say give it a try.”

[Related read: One-minute meditations to help you reset]