“Hello? Hello? Can you hear me?”
“I can, but your head is cut off. I just see your neck. Can you hear me?”
“Yeah, yeah, I hear you. There, is that better? Can you see me now?”
“Yes, that’s good.”
“Ok, good. I’m glad I have a head.”
“Me, too–it makes things much easier. How have things been for you?”
Such is the awkward start to many a teletherapy session I have conducted with clients over the past 16 months, since the world turned inside out. Before the pandemic, I had only held the odd telephone session with a client stuck at work during session time; I had never used teletherapy as a regular mode of engagement. I even, I admit, had some snobbery about the idea: that’s not real therapy, I always thought. With the arrival of COVID, however, everything changed.
The COVID-19 pandemic is unlike anything we have experienced in our lifetimes. Characterized by widespread fear, uncertainty, grief, and loss, the COVID crisis is not just a medical one but a mental one, ushering in a convergence of increased mental health needs and decreased in-person capabilities. As school and work closures, social distancing guidelines, and stay-at-home orders became the stuff of everyday life, millions of Americans found themselves suddenly at home, isolated, with disrupted routines, living with fear and uncertainty, and with enormous amounts of stress. Those who had mental health supports in place before the pandemic could no longer access them the same way, and many of those who didn’t suddenly needed them as they struggled to adjust to a radically changed present and the possibility of a new normal to come.
In the wake of the crisis, the Centers for Disease Control, the National Mental Health Association, the American Psychiatric Association, the National Alliance on Mental Illness and others have offered tips on how to cope with the mental health challenges that may arise during this time. For those who need additional support, experts generally recommend teletherapy, or psychotherapy conducted via a secure online video platform. An emergent (if still relatively small) industry before the COVID-19 pandemic, teletherapy suddenly catapulted to the forefront of the mental and behavioral health industry, becoming the primary (if not the sole) modality of care for millions of Americans in need.
The changes have been monumental. Teledoc reports that virtual mental health care visits are up 79% for men and 75% for women since the pandemic began. Ginger, which offers text-based psychotherapy and psychiatry services, reports that usage has increased up 50% per month compared to pre-COVID averages. Amwell found that 62% of consumers would prefer a virtual visit, even after restrictions are lifted. These shifts go hand in hand with a growing body of research that indicatesthat virtual visits are as effective as in-person visits and carry a convenience that both clients and therapists alike find appealing.
As an anthropologist and licensed clinical social worker (LCSW) with a private psychotherapy practice, I have tracked (and lived) this teletherapy boom with much interest, as it both reflects and facilitates something of a sea change in American responses to mental and emotional distress. Not only has teletherapy fundamentally shifted how mental health services are provided in the U.S.; it also seems to have a hand in reshaping American attitudes toward mental health and illness and views about getting help. Specifically, data suggests that telehealth is making mental health services more accessible, more comfortable, and less intimidating to individuals from all walks of life, although some important disparities remain in terms of digital access and therapists trained to work responsibly with diverse clientele.
This reconfiguration of perspectives on mental health and teletherapy is true of clinicians as much as anyone else. It is certainly true of me. Sixteen months ago, I discounted the entire idea of teletherapy. Now, over a year into the pandemic, I see all of my clients virtually. A number of them I have only known through teletherapy: I have never sat in a room with them in person. Some I have never even seen on video, communicating only through text. This transformation has radically changed how I engage with my clients, and has led me to question my own understandings about the process of therapy, the meanings of intimacy, and the nature of connection.
The opportunities and challenges of technologically mediated connection stretch far beyond just teletherapy, or even telemedicine more broadly. From Zoom cocktail hours, to online family game nights, to virtual birthday parties, to dissertation defenses and graduations, and even date nights, so much of sociality has become technologically mediated since the beginning of the pandemic. As a result, new forms of intimacy are emerging as geographical distances collapse, yet we remain physically separated and technologically mediated.
Here, I want to reflect on teletherapy as one of these new forms of technologically mediated intimacy and care. For the purposes of this piece, I will focus on three specific elements that have unique import in teletherapy: (1) embodiment, disembodiment, and presencing; (2) space, place, and setting (3) relational dynamics. First, however, brief sketch of the teletherapeutic landscape.
Teletherapy in a Time of Crisis
Telehealth as a form of healthcare has been around for decades, but began to see more public uptake with the arrival of services such as Teladoc, Amwell and Doctor on Demand in the early 2000s. In recent years, these innovations have expanded to the psy- fields as well. Although telepsychiatry (remote visits with a medical doctor specializing in psychiatric care who is able to prescribe medications) has been around for some time, teletherapy (remote talk therapy or counseling) is relatively new, at least for the general population (it has been used in the military in some form for about 20 years). While some therapists did offer teletherapy options before the pandemic, it was quite rare and by no means mainstream. Face-to-face therapy was (and still is) almost unanimously considered “better” than telephonic or virtual therapyfor reasons I’ll discuss more below, although it is important to note that face-to-face therapy is and always has been mediated and distanced in a variety of ways (see Zeavin’s forthcoming book The Distance Cure as well as her piece in this series for more on this point).
A number of teletherapy platforms have emerged or gained steam in the past sixteen months, becoming the primary means for ethically conducting therapy over the internet. From a platform standpoint, there are two broad options: (1) a therapist can engage with her own clients via a secure video connection through a service like Simple Practicer Therapyappointment.com (I call these “portal platforms”), or (2) they can register as a therapist with a company like BetterHelp or Talk Space, to which clients subscribe for a monthly fee and then are assigned a clinician (what I will call “subscription platforms”). Many clinicians use both kinds of platforms, and there is no limit to how many a clinician may utilize as part of her practice. Since I use one platform of each of these two categories in my own work, I’ll offer some of my own experiences as a way of illustrating their relative benefits and limitations.
Portal platforms like Simple Practice and Therapyappointment.com simply provide a portal through which clinicians can see their own private clients virtually and through which they can process payments and maintain psychotherapy records. They are relatively inexpensive: as a clinician, I pay a monthly fee of $69 for Simple Practice (it was the same when I used Therapyappointment.com), and my clients use the platform for free. In addition to accessing sessions through the Simple Practice platform, clients can also check my online calendar to see my availability and schedule their own appointments. The platform also has a messaging feature so we can communicate outside of session in HIPAA-protected ways. It stores secured, encrypted copies of therapy notes, and the site also provides a great deal of resources for therapists, like therapy worksheets, treatment plan templates, a website builder, webinars, and workshops.
Subscription sites like Talk Space and BetterHelp (which is the one I use) operate on a different business model than the portal ones. On these sites, it is free for clinicians to sign up and offer their services as independent contractors under the company’s umbrella, and they are subject to the company’s rules and pay structure for any clients gained through the site. Clients pay a monthly fee, and the subscription level they choose determines the number of sessions they can have per month (which generally run between $40-$60 per session). Once clients sign up, an algorithm assigns them to a clinician based on their stated preferences and needs. On the clinician side, when a new client is assigned to you, you then have the option to either accept the match or decline to work with a client for any reason; likewise, clients can change therapists at any time. Clinicians receive a check once a month from the subscription site to compensate them for any sessions or other client interactions they had during that time.
As a clinician, signing up for BetterHelp was quite an involved process. I had to provide documentation of my education and licensure,as well as fill out an extensive questionnaire about my specialtiesand experience and the kinds of clients I prefer to work with. Before being officially on-boarded to BetterHelp, I had to undergo a live virtual interview with two clinical coordinators at the organization and to demonstrate my understanding of both clinical ethics and BetterHelp policies.
I’m not sure what the pay structure is like at Talk Space, but BetterHelp uses a graduated pay scale to encourage clinicians to take on more clients. Therapists are paid $30 per hour for working 0-5 hours, $35 per hour for 5-10 hours, $40 per hour for 10-15 hours, and so forth up to $70 per hour for 35+ hours. While not insubstantial, these rates are significantly less what most therapists usually charge (as a comparison, my full fee for a private-pay client with financial means is $100 per session, which is still considered quite reasonable). BetterHelp also only pays for time spent in sessions—there is no compensation for the time it takes to document visits, which is significant. However, with BetterHelp, therapists don’t have to pay office overhead, and the clients come to you. You don’t have to advertise or worry that you won’t have enough clients to fill your schedule. In fact, I have had to toggle the “not accepting new clients” button because otherwise, I get inundated. I often get emails from BetterHelp with subject lines like “You missed 14 potential clients this week!” and BetterHelp at times has offered financial incentives to therapists to take on additional clients because demand is so high.
The Practice of Teletherapy
So, what does the practice of teletherapy look like? Whether using a portal platform or subscription platform, the actual therapy looks the same. Picture your last one-on-one Zoom meeting with a colleague or friend. On the surface, teletherapy looks very much the same: at the appointed time, each person clicks a link and then they engage with each other, mediated by a third-party virtual platform that includes capabilities such as screen sharing.
Aside from this superficial similarity, however, teletherapy is not at all like meeting with a colleague or chatting with a friend. Like “regular” psychotherapy, teletherapy is guided by a set of principles and ethics about relational boundaries and dynamics and what is thought to bring about change. Unlike in-person therapy, however, some of these ethics and principles stand at direct odds with the medium through which teletherapy is delivered, and additional ethical considerations come into play in the virtual environment. For example, therapists are trained to assess and respond to urgent concerns about a client’s wellbeing or the wellbeing of others. This can mean getting the client to an emergency room if they are suicidal or at high risk of self-harm, reporting suspicions of child or elder abuse to social services, or even (in rare cases) warning a third party of a specific threat. In regular psychotherapy, the physical presence of the therapist is key in facilitating these interventions, and physically remaining with the client until the danger has passed (or. making sure they are with another responsible adult) is a central part of doing ethical work. A therapist should never leave a client alone when they are unsafe or in the midst of a psychiatric emergency. Yet in the digital environment, therapists have no way of doing this. A client may simply push a button and be gone, leaving the therapist few options. In private practice, therapists know a client’s address and maintain a record of emergency contacts for each client, so they can enlist additional supports for helping to ensure the client’s safety. On the portal platforms, therapists don’t have access to this information and have to go through some degree of bureaucracy to get the portal administrators to take action.
Even as a seasoned therapist, I have encountered situations where I felt unsure how to proceed. Just last week, a client experienced a full-blown, hour-long panic attack during session. I utilized all my training and skills the same way I would do in person, but the physiological co-regulation that one can facilitate in the office (breathing together, putting a hand on the client’s arm if this feels safe to them, etc.) was largely unavailable. By the end of session, the client was still panicking and unable to stop shaking. Concerned for her, I told her I didn’t want to get off the call until her sister arrived with her anti-anxiety medication. But, feeling guilty for going over time, the client thanked me, and disconnected communication (she is doing better this week so far).
How, then, to manage such ethical challenges in the virtual environment? Given this kind of unchartered territory, the teletherapy explosion has brought in its wake a number of secondary phenomena, such as specialized training programs and credentialing bodies oriented specifically to virtual therapy, such as IBCCES, the Zur Institute, PESI, and TBHI. While such certifications are not required for practicing teletherapy, in the new marketplace of competition created by the virtual environment such qualifications can potentially make one therapist more attractive than another to a prospective client.
The last issue I want to address before moving on to my three points is the role of intimacy in therapy. Intimacy in colloquial usage is generally associated with proximity, either physical, emotional, or both. Anthropologists and other social scientists have written about transformations of intimacy with the rise of new social forms, particularly those mediated by technology. While some decry these changes as problematic, others argue that these forms can actually facilitate or enhance intimacies.
Teletherapy is one place where such renegotiations of intimacies become foregrounded. Data suggests that this intimacy in a therapeutic relationship—the therapeutic bond—is the primary vehicle for transformation. Therapeutic relationship predicated on this intimacy has been shown to have more of an effect on patient outcome than the specific treatment modality used. It is, perhaps, the number one concern of clinicians and clients alike. Without intimacy, there is no trust and there is no progress.
Intimacy, then, is both a requirement and a result of therapy, which is as paradoxical as it sounds. For therapy to work, clients must share things with their therapists that are deeply, deeply personal and vulnerable, like their worst fears or their most private desires. It can take many months, if not years, to get to a point where a client feels safe enough to share this kind of information. As the therapist takes in these disclosures, holds them non-judgmentally, continues to view the client with unconditional positive regard and accompanies them through experiences of shame, grief, fear, loss, etc., new forms of intimacy are forged. But it is a particular kind of intimacy, because the client does not receive similar kinds of details from the therapist, a fact considered to be central to the “work” of therapy. Different schools of thought maintain different opinions about how much of a “blank screen” the therapist ought to be, but all agree that the therapist should be extremely careful about what information about themselves is shared. This is part of why the physical space of the therapist’s office is so carefully curated, as I discuss below.
The change from in-person to virtual psychotherapy, then, is in many ways an existential one for the field. It has required me, along with millions of other therapists, to radically retool our skills and to improvise new ways of connecting with and relating to clients in the absence of physical presence. What does it mean to be intimate in these new ways? What is gained and what is lost? And what does this mean for the future of mental healthcare?
Embodiment, Disembodiment, and Presencing
The first time I saw a therapy client over video, I was not expecting much. In my training, the physical co-presence of therapist and client was always emphasized as a central and indispensable component, and it is certainly something I have depended upon heavily in my work. Much of what I do as a therapist goes on under the skin, and has to do with attuning carefully not only to the client’s words and actions, but also to their affective “vibe” and how they are inhabiting their bodies and the space around them. This, in turn, affects my own physiological and emotional responses in session, and something of an affective loop emerges between therapist and client. While a significant amount of thinking, analyzing, speculating, and questioning goes on in my mind during a session, much of the therapy work I do is about feeling my way, as best I can, into the experience of the client. I access this at least as much through non-verbal cues as what they actually say: how they sit, how they hold their hands, the way their eyes move around the room, the energy they give off, the vibe between us, how the affect circulates in the room, and how it settles, or sticks, or is denied.
Sitting down in front of a screen to talk with a 2-dimensional image of a client is a very different sort of experience. I can still “feel” my clients’ affect, but through means that rely much more on the visual and verbal than other senses. I can see when they’re crying, or fidgeting, or sitting rigidly, and I can hear it when they tell me they are sad or angry or despondent, but that’s a far cry from feeling it in the room, and from them feeling me feeling it with them.
I also continually struggle with the issue of monitors and cameras. When I began doing teletherapy regularly, I got a big 27” monitor and a fancy high-quality video camera. Both work wonderfully—except that the monitor is so big that, with the camera clipped to the top of it, it looks like I’m not making eye contact when I look at the client on the screen. My gaze looks a bit off, like I’m looking a little bit down. I can shift my gaze to the camera, but then I’m talking to a piece of equipment rather than a person.
In these ways, teletherapy is a profoundly disembodying sort of experience. This is amplified by the fact that a video camera only captures so much of a person in its view. I may see a client’s face, but not their hands or how they’re sitting. Viewing angles may be strange or awkward depending on a client’s computer set-up or it they’re using their phones. I have spent entire sessions looking up someone’s nose or trying to do couple’s therapy when one partner’s face is half way out of the picture. Sometimes someone’s microphone isn’t working, or either the client or I become frozen and we have to hang up the call and reconnect. Such events are a radical rupture of the therapeutic holding environment considered to be so critical for successful therapy, and they are especially problematic when the client is at a point of vulnerability or in the midst of expressing difficult emotions. Sometimes when an internet connection is poor, either the client or I show up to the other as a cartoon silhouette of a man.
As disorienting as teletherapy can be in these ways, at the same time it gives an opportunity for new kinds of embodiment. Clients have taken me on walks around their neighborhoods with them. I have talked with them while they were making coffee or feeding their babies. With teletherapy, I get more of a sense of clients using their bodies to do things in the world rather than simply sitting in my office.
In terms of my own body: with my hands mostly out of the view of the camera, I find myself fidgeting during sessions, often playing with an elastic hair tie or sometimes doodling on my notes as I listen (it helps me focus). I would never,ever do those things with a client in person because it would be distracting to me and to them, and could potentially be very hurtful depending on how they interpreted it. But with teletherapy, because a different kind of attention and attunement is required of me that is less fully embodied, I find my hands need something to do when I’m not taking notes. I don’t know that it makes the quality of my engagement better or worse—it’s just different.
Space, Place, and Setting
Space, place, and setting have very special meanings in psychotherapy and are profoundly important to marking and holding the therapeutic encounter as something special, unlike what happens elsewhere. A therapist’s office is very carefully curated, from the magazines and music in the waiting room, to the wall art in the bathroom, to the furniture arrangements and knick-knacks in the office. The furniture should be soft and inviting, but not too soft. Colors should be soothing and not jarring. Pictures of family members should not be present. Lighting should be sufficient but not too glaring. Clients (especially trauma clients) should be offered the seat closest to the door so they don’t feel trapped. Tissues are a must. Pillows are fine but can be pulled into laps as a defensive or hiding gesture, so they too are liable to become recruits in the therapy. Depending on your particular specialty, you might have to make other decisions: I shared my last office with a woman who liked to keep caramels in a bowl for her clients to take if they wanted to. Since I work with a number of eating-disorder clients, I was careful to tuck this away before session.
Teletherapy blows all of this out of the water. I am still mindful to curate the area behind me in view of the camera (including a sign on the wall that says “Everything is Figureoutable” that many clients have commented on), but this is still a very far cry from curating and entire sensorial experience for the client in the therapy space.
Instead, inthe land of teletherapy, the computer screen becomes the therapeutic “holding environment.” But unlike in-person therapy, this space is not marked as distinct from the rest of the client’s life. During pre-COVID times, clients would often tell me, “I would never talk about this outside this room,” or “I feel a sense of calm [or anxiety, or whatever] as soon as I walk through the door.” Now they are in their own spaces when they talk to me: kitchens, bedrooms, cars, patios, balconies. And the therapeutic space is not bounded in the same way: I have met children, pets, siblings, and partners who pass through a client’s space during a session.
The effects of this are likely both positive and negative. Certainly, it seems to eliminate the kind of “safe space” as both a physical and emotional experience we traditionally try to create and hold for clients in therapy. At the same time, it means that they are accessing and working through their difficulties in the very place where they live, in the “real world,” in ways that may potentially be helpful.
Teletherapy has also shifted the relational dynamics between therapists and clients significantly. In traditional therapy, a client enters into the therapist’s space, which, as I’ve said, has been carefully curated to offer a safe, welcoming, supportive environment. The client can certainly deduce things about a therapist depending on how their office is decorated, but it is still a place of work. Teletherapy has introduced a new kind of relational intimacy into sessions with clients that I could never have imagined. We are in each other’s homes, have access to each other’s lives in ways we never did before.
Most significantly, teletherapy equalizes some of the traditional power differentials in the therapeutic relationship. Some things remain the same: I am still the “expert,” and they are still the person in need seeking help. As the therapist, I am the only one who can begin a video session. But they are not on “my turf” in telemedicine, like in in-person therapy, and they could, if they wanted to, leave a therapy session at any time simply by clicking a button, never having to face me again. I haven’t had anyone leave a session, but on BetterHelp it’s not uncommon for clients to disappear after a few sessions without explanation, and I have had this happen more than once. This happens at times in traditional therapy, too, but with a platform like BetterHelp I don’t have their direct contact information, so I can’t follow up.
At the same time, many clients have noted that they really appreciate the ease and convenience of teletherapy and they have come to prefer it to in-person sessions. One might reasonably explore whether there is something else going on here about vulnerability or attachment that makes the distancing aspects of teletherapy more appealing than the physical copresence of traditional therapy to some clients more than others. But we should be careful not to overinterpret here. People have busy, active lives, and not having to drive across town, find parking, and sit in a waiting room with other clients can be a significant relief. And part of this response is likely generational. Many people under 30 have grown up having relationships mediated by technology in ways that others of us have not. Teletherapy seems like a logical extension of these kinds of interactions. Does this mean that the quality of emotional connection is worse than in in-person sessions? Or is it simply different? It depends on whom you ask. What I do know is that my teletherapy clients do seem to improve, and the virtual platform increases accessibility and convenience for many.
The explosion of teletherapy over the past 16 months has revolutionized therapeutic practice and challenged some of the field’s most basic, dominant assumptions about what enables connection, what facilitates change, and what the therapeutic relationship means and does. It has demanded new skill sets from therapists as well as new vulnerabilities, as the therapy enters our homes and clients can literally carry us – on a laptop or phone – along with them as they go about their daily activities.
The future of teletherapy seems clear: it’s not going away. In fact, it will continue to expand. As an anthropologist, I remain attuned to this tidal shift in therapeutic culture and practices, how this transformation reflects broader societal shifts toward an a la carte service sector characterized by gig work and digital marketplaces, and how understandings of mental health and illness are deeply shaped by available strategies and technologies of care. As a therapist, I continue to adapt to the new virtual therapeutic marketplace through ongoing trainings, workshops, and everyday practice, and I remain especially sensitized to how virtual modalities of embodiment, relationship, and intimacy can affect emotional and psychological healing. The long-term effects of these changes– for clients, for therapists, and for our understandings of mental health and healing — remain to be seen. As for me and my initial snobbery and skepticism? In September 2020,I stopped renting my physical office space and moved my practice entirely online.
Rebecca Lester is a Professor of Anthropology at Washington University in St. Louis and a practicing psychotherapist. Her anthropological research centers on questions of embodiment, intersubjectivity, and cultural practices of self-cultivation. Her work is deeply interdisciplinary, drawing on anthropology, psychology, and gender and sexuality studies to engage questions of materiality, relationality, and (inter)subjectivity. As a clinician, Dr. Lester specializes in treating eating disorders, trauma, personality disorders, mood disorders, and gender/sexuality issues. Her most recent book, Famished: Eating Disorders and Failed Care in America (2019) was awarded a Victor Turner Prize for Ethnographic Writing. She is currently Editor-in-Chief of the journal Culture, Medicine, and Psychiatry and president of the Society for Psychological Anthropology.
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