Will COVID Make Teletherapy the New Normal?

A recent small survey by the American Association for Psychoanalysis in Clinical Social Work, although small in scope, nevertheless had some interesting findings for the future of psychotherapy. Taken in the middle of our rapidly shifting landscape about the safety of resuming in-office therapy, the survey shed light on the future of teletherapy as a mode of service delivery for our field.

Nearly 35 percent of respondents reported that they are unsure if they will return to in-office in the next three months; a full 21 percent have no plan to return to the office at all.

While many of us are currently seeing (or plan to see) clients in person, the rest of us are not so sure. One in five of us may never return to office visits again.

It’s not just our colleagues who are embracing teletherapy; many patients report satisfaction with online therapy or analysis. They are either reluctant to come back to the office or wish to come to some in-person sessions, but not all. (This would be particularly true for patients in intensive therapy, say two or more times per week, and for whom commuting time is a significant deterrent to coming to the office.) This applies to both trainees and veteran colleagues.

It is clear that online practice is here to stay. No longer controversial or “experimental” as a method of delivering therapy, teletherapy has become a way of life. It is not going away once the pandemic recedes — and in any case, that now seems to be no time soon with the advent of the Delta variant, and possibly more variants in our future. We can now see that even when we are fully vaccinated, there will continue to be threats and compromises to our in-person work. For now, that includes unvaccinated children and their families, as well as those who cannot (or will not) be vaccinated. But even if we see those obstacles as temporary, it seems clear to me that the therapy world has changed forever: seeing our patients or clients online is going to be a substantial part of our future.

For those of us who really want to deliver the highest quality psychotherapy and psychoanalysis — and who teach students who want to do serious work — this poses a series of questions: can equivalently valuable sessions take place online? What are the benefits and drawbacks? Any change is bound to have good and bad aspects.

Here are some positive possibilities:

• Therapy can be more convenient, accessible, and affordable.
• More intensive therapy may be possible when practicalities made it impossible before. This is particularly beneficial for clients living with disabilities.
• Many therapists now have lower overhead costs, as they are not paying for permanent office space.
• As more people gain access to therapy, we can expect a decreased stigma around mental health services.
• Online sessions may be more accessible to some disabled or phobic patients, as well as those living far from providers.
• Some patients may actually be more treatable in this modality, but we will have to study which ones.

However, here are some potential problems:

• You may have insufficient training. There is now an urgent need for training to address common issues that arise while working online: everything from technical glitches to time zone issues can affect your clients’ user experience.
• Patients without internet access or who are wary of the internet will not be able to access your services if you move exclusively online.
• For some of us, there may be less ability to read patients’ nonverbal cues. Dedicated online practitioners have spent hundreds of hours honing their craft, but those new to the format may find that this takes some getting used to.
• Beware emotional distancing. Patients may be able to more effectively hide essential elements of their situation. This is particularly worrisome in domestic violence or child abuse cases. Social workers with these populations should continue to make in-person sessions a priority whenever possible. (But some patients will experience online therapy as emotionally closer.)
• Children are probably the hardest group to treat online and will require extensive parental cooperation.
• Patients at risk for self-harm, violence, or psychotic complications will probably be much more difficult to manage.
• Insurance and licensing issues abound here. Each state, each discipline, and each insurance carrier have their own rules, including whether or not they will continue to allow cross-state practice or will reimburse for teletherapy, if they do, they may reimburse at a lower rate. Prepare for a headache as the blanket permission brought on by COVID is rescinded.
• Finally, many online services have started to move into this space, offering cheap alternatives to competent therapy. More on this later, but serious therapists and serious associations will have to be aware of this recent development.

The best way to gear up for using online therapy in your practice is to arm yourself with information: Read the growing literature that studies online practice and watch for webinars that offer tips and tricks for using teletherapy to your advantage. There are plenty of trainings, webinars, and online learning tools available. Take advantage of them.

Finally, explore with your patients if online therapy is really the best option for them, or might it be a way of resisting face-to-face encounters with you and with themselves. No two clients are exactly the same, and the online medium may not work at all for some people. As you consider the contours involved in moving your practice online (or not), you will have adjustments to make no matter what you decide.