Rebecca D. is a graduate student and single mom in Atlanta. When she sought help for the stress of completing a degree virtually while raising an active preschooler, her search took her to the same place she had spent her days since the pandemic started – her computer screen. “I was relieved to discover virtual counseling,” she says. “I could get my daughter situated in front of her favorite movie, then meet face-to-face with my counselor on my MacBook and get back to my own work without leaving the house.”
Rebecca’s story was a common one during the pandemic. Telemedicine – which had been around in some form for more than half a century – ramped up to meet a range of needs once handled by in-person office visits. It became a valuable tool for urgent care visits, post-surgical follow-ups, and COVID-19 evaluation and monitoring. But the most common use for telemedicine quickly became psychotherapy. According to FAIR Health, the use of virtual therapy rose throughout 2020, and by January of 2021, one-hour psychotherapy sessions had become the most common telehealth service nationwide.
It’s not known if that trend will continue. As vaccination rates increase and more businesses open up, mental health professionals and their clients are starting to consider resuming in-person visits. In this article, we’ll share what some clients and therapists are taking into consideration as they plan their move forward into the post-pandemic world.
While concerns about COVID-19 were what drove most therapists and clients to choose Video Telehealth last year, convenience is the factor that continues to drive its popularity. Like Rebecca, clients can meet with their therapist with minimal disruption to their days and without adding to the stress that might have caused them to seek therapy in the first place.
“When you think about it, if you travel into a therapist’s office once a week, that is not just an hour appointment, that is travel time to and from, wait time, the whole nine yards,” says Kathryn Esquer, Ph.D., a clinical psychologist practicing in rural Pennsylvania. “That is a lot of time off for someone working with the normal sick time or leave time, so it really does eliminate the time barrier to seeking help.”
Convenience is also a factor for people who have difficulty seeing a therapist in person because they don’t have access to a car or, like Rebecca, are caring for young children at home. “It cuts down on child care costs, work loss, transportation costs, the whole thing,” says Esquer, adding that about half of her clients are choosing to continue with telehealth for those reasons.
Telehealth may have some benefits for therapists and the therapy process as well. “For example, some people are more comfortable opening up and sharing vulnerable information if they are in a comfortable environment, such as their home, as opposed to an unfamiliar environment,” Esquer says. “This could actually facilitate good and deep clinical work with some patients who might have trouble opening up.”
Telehealth may also enhance therapy by offering clinicians a valuable glimpse into the client’s home environment, and how they interact with that environment, she says. An example Esquer cites is hoarding. “For people coming to therapy for help with hoarding, the therapist can actually be with them as they go through their items and work through the emotions of attacking that disorder of hoarding.”
For the therapist, telehealth offers the ability to expand their reach beyond the community where they are located to the whole state or province where they are licensed, says Esquer. It also allows therapists to see the occasional client at odd hours without making an early morning or late night trip to the office. In some cases, it eliminates the need for maintaining and paying for an office at all.
Despite its benefits, telehealth is unlikely to replace in-person therapy for a number of reasons, even in some cases, including accessibility, Esquer says. In rural areas, where telehealth has been thought to hold the most promise, people may not have the bandwidth or phone signal for a telehealth connection, she says. And older people, in particular, may lack the equipment or technical knowledge to set up and participate in a virtual visit.
The very factors that make Video Telehealth sessions appealing to some can be drawbacks for others. For those who don’t have a safe or private spot in their home, such as domestic abuse survivors or teenagers afraid of being overheard by parents, Video Telehealth isn’t an option.
Lack of privacy can also be an issue for therapists practicing out of their homes. Maintaining focus or client confidentiality can be a challenge in a place they share with a roommate, a partner, or children.
“I don’t do my sessions at home anymore,” said one mental health professional interviewed for a Journal of Contemporary Psychotherapy study on factors associated with the decision to provide in-person therapy in the age of COVID-19. “I found it too ‘challenging’ in a two-bedroom apartment with my son and husband there to be able to focus on work.”
Burnout and separation of work and personal life also can be issues for therapists working in isolation, says Esquer, who founded a community organization in July of 2020 to support modern mental health therapists in a virtual world. “And staring at a computer screen all day is simply not as rewarding as staring at a live, breathing person,” she says. In the same Journal of Contemporary Psychotherapy study, 70 percent of therapists surveyed said that remote work is more draining than in-person psychotherapy.
And while virtual therapy offers a glimpse into a person’s home environment, it doesn’t allow the therapist to observe body language – wringing hands or a tapping foot, for example – that they might notice in an in-person encounter. Thus, it’s up to therapists to pick up on even more subtle nonverbal communication, such as eye contact or facial expression, Esquer says.
Perhaps the greatest drawback of Video Telehealth is that it deprives both therapists and clients of the benefit of caring acts that can only be done in person. “I don’t think any therapist would hesitate to hand a patient a box of tissue who is crying,” says Esquer. “That gesture in itself has a lot of power and meaning behind it, but something like that is taken away with telehealth.”
All of these factors must be weighed when deciding whether to go back to in-person therapy. The decision will be different for different people. Therapists who go back to an office will face new challenges such as keeping their spaces properly sanitized or reading the facial cues of clients wearing masks.
For clients like Rebecca, the change will mean once again carving time out of the day to travel to her therapist’s office when her daughter’s in school or a family member can watch her.
For most therapists and their clients, the future of therapy will likely lie somewhere between 100 percent in-person and 100 percent virtual. “I think virtual counseling will always be an option,” says Esquer. For some, it may continue to make up a big part of their practice. For others, it might be a backup option if someone gets stuck in traffic or is home sick but still wants to meet, she says. “It all depends on who the therapist is and who they work with,” she says. “Some populations aren’t necessarily appropriate for telehealth, so it’s important to make sure the therapist is a match for telehealth as well as the client.”
Fair Health: “About Us.” “Monthly Telehealth Regional Tracker, Jan. vs. Feb. 2021”
Journal of Contemporary Psychotherapy: “Will We Ever Again Conduct in-Person Psychotherapy Sessions? Factors Associated with the Decision to Provide in-Person Therapy in the Age of COVID-19.”
Kathryn Esquer, Ph.D., clinical psychologist, Pennsylvania; founder of the Teletherapist Network.
MedPage Today: “Psychotherapy Now the Most Common Telehealth Procedure.”
Rebecca D. (last name redacted for privacy), Atlanta, GA.