Translating In-Person Therapy to Telehealth

Behavior, whether problematic or advantageous, is activated by an environment, is influenced by personality, and results in consequences. Some treatment addresses the environment, such as changing parenting techniques (i.e., the child’s environment) to change a child’s behavior or avoiding gatherings where alcohol is served to help manage the consumption of it. Some treatment addresses consequences, as when anxiety and depression are treated with techniques like mindfulness or exercise.

During the pandemic, patients old and new are bound to have emotional reactions to death, disease, unemployment, and so on. Therapists might be guided by Freud’s maxim, that the purpose of therapy is to replace “neurotic suffering” with “common unhappiness.” Freud meant that it is natural to be unhappy and upset, but the therapist’s job is typically to address neurotic reactions, such as thoughts of deserving or having caused the misery. “Common unhappiness” lends itself to direct strategies for symptom reduction.

Real psychotherapy addresses the tendency to respond to activating environments in ways that produce problematic consequences. It changes, or tries to change, the patient’s personality—i.e., the patient’s response tendencies, patterns of expectations, organizing principles, cognitive schemas, or relational paradigms. Deadly therapy involves discussions about the patient’s personality. Lively therapy evokes the patient’s problematic personality functioning in the context of the therapy relationship and responds to it differently in real-time. Some forms of lively therapy do not translate to telehealth, but some do.

A quick take on the advantage of lively therapy involves the family therapy practice of enactment. A family with discipline problems is told to discipline the child during the family session, or a couple is told to argue about something during the session, or parents are told to get their anorexic child to eat lunch during a session. These enactments put the therapist in a position to see what happens rather than merely hear reports about the problem, and they put the therapist in a position to intervene within the problematic pattern as it unfolds. Lively therapy depends on the patient messing up the therapy like they mess up other relationships and other situations.

These are nine potential ways that real therapy can help (from my book, What Every Therapist Needs to Know).

1. Intimacy Exposure

The most powerful lively therapy takes the form of intimacy exposure. People who have been hurt in close relationships may react oddly in romance, in close friendships, and around children. Like people who have been hurt in an elevator and need to get used to being in one, many people benefit from therapy by being in a close, personal relationship where nothing too scary happens.

Intimacy exposure does not translate well to telehealth. Unusually engrossed and relationally-oriented patients can still derive this benefit of self-revelation, but generally, exposure through screens doesn’t work any better for intimacy or for stigmatized identity elements than it does for, say, a fear of dogs. A patient afraid of dogs can get some initial benefits from pictures of dogs, but eventually, an actual dog must be confronted.

2. “I Know What to Do, But I’m Not That Type of Person.”

One reason advice often fails is that people already know what to do, and the problem is that they can’t see themselves doing it. Therapist and patient put their heads together to understand what kind of person the patient actually is. Invariably, they find, among other things, that the patient is delightfully ordinary and not, in Albert Ellis’s phrasing, either subhuman or superhuman. The gathering of evidence and drawing inferences from it about the patient’s essential humanity, both by report and by observation, translates well to telehealth.

3. Misreading Situations

One way of relating to any situation is to construe it as being like some other situation that the person has encountered. When that construction is unrealistic—i.e., when it distorts the current situation—resulting behaviors are likely to be clumsy and ineffective. Therapists help by exploring moments when the patient misconstrues the therapy itself. Online, it’s much harder to construe situations accurately, especially subtle emotions, and therefore it is much more common for patients to make errors that turn out to be meaningless and much harder for therapists to know when a significant error is occurring. Conversely, the therapist is much more likely to misconstrue the patient online.

4. Conflict Resolution

Good therapy teaches patients the advantages of approaching conflicts, of considering conflicts in a reflective rather than problem-solving mindset, and of valuing potential solutions for their benefits to the relationship and not just to one individual or the other. All of these can occur online if the therapist can engage the patient in identifying conflicts. The physical distance can even make it easier for patients to acknowledge that there is a conflict in the relationship. (There is always a conflict in the relationship because humans have so many contradictory agendas.)

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5. Reparenting

People invariably hide aspects of themselves that would undermine the definition of the self they are promoting, such as men who hide their vulnerability or narcissists who hide their insecurity. Lively therapy evokes these aspects of the self and relates to them differently, welcoming them into the mainstream identity of the patient. Much therapy can be analogized to a child with a sore or a pimple who thinks it is too disgusting to be revealed and a parent who says, “Let me see.” That’s a far cry from a parent who says, “Let me see a picture of it while I’m in another building.”

6. Changing Narratives

Much of our behavior follows from the stories we tell ourselves about who we are, what the world is like, and what other people are up to. In adolescence, we are often confronted, because of the relationships we form with friends, with disruptive changes to our narratives. Superficially, we discover, by exposure to friends’ families, which of our own family’s practices are idiosyncratic or just plain weird. More deeply, we may find in our friend group that we are not brilliant, gorgeous, hideous, unreliable, or selfish as we came to believe we were. Therapy provides both someone to help patients consider and revise their narratives and a new relationship that generates new information that requires a narrative change. The former of these translates easily to telehealth.

7. Collaboration

Many life problems stem from collaboration deficiencies. Patients may not know how to collaborate on dates. They may not know how to make a relationship a team or how to maintain romances or friendships. They may not know that true love is built, not found. They may not know how to collaborate with co-workers or bosses and may have trouble finding or maintaining rewarding employment. In these cases, the therapeutic working alliance is not only the key to successful treatment, it is the window into the problem. Patients screw up the therapeutic collaboration just as they screw up other collaborations; establishing and repairing the therapeutic alliance changes patients in ways that will enable them to establish and repair other relationships. This can be done online.

8. Self-Exposure

As Jung said, every identity casts a shadow; every “I am” implies an “I am not.” People waste a lot of energy on keeping the shadow hidden, especially from themselves, and they sacrifice a lot of satisfaction by shunning the shadow, which often contains virtuous aggression, sexual gratification, and unmet needs. To Horney, the very definition of neurosis is the energy spent on polishing one’s identity claims instead of embracing the real self. Therapy can be a place not only to introduce the real self to the therapist, which as noted above is less effective online, but also a place to introduce the real self to the patient, which telehealth need not diminish. A consequent decrease in self-avoidance channels energy into getting one’s needs met rather than pretending those needs don’t exist.

9. Play

Many life problems reflect an incapacity to play, which is the opposite, not of work, but of depression (Sutton-Smith, 1997). Play means taking things seriously while they last, and then moving on. Play also means, as Janna Goodwin explains, the loose but secure coupling—the give—between train cars that keeps them connected but not so tightly that they can’t take a bend in the road. Therapists promote play by setting the therapy apart from life, by drawing out and honoring fantasies, by following the rules of the interaction, and by taking the occasion seriously while it lasts—much as adults teach children to play. This can be done online if special care is taken to demarcate the playspace of therapy from the rest of life.

Intimacy exposure, reparenting, and analysis of framing and perceptual errors do not translate well to working online (except with particularly relational and engrossed patients). Play and self-exposure require adaptations to work on screens. Telehealth is well-suited to changing narratives, accepting one’s humanity, appreciating conflict, and exploring disruptions in collaboration. Telehealth also supports techniques for direct symptom reduction, although these, as always, are often like muting the burglar alarm instead of dealing with the burglar.