When the coronavirus pandemic first began in March 2020, Through the Woods Therapy was a group practice, with five clinicians working here. And so, like every business owner, I had some tough decisions to make. I believe in collaborative leadership, so I discussed with my staff how we should handle it.
Initially, the therapists at Through the Woods wanted to keep coming into the office and seeing clients in person. I think our first instinct is always to be there for our clients. Plus, we are medical providers, and we have a duty to continue supporting people during this difficult time. Thus, our initial decision, three Fridays ago, was to keep operating as usual, and to offer video sessions to clients who requested them.
But that weekend, everything changed. The situation seemed to be evolving by the hour. By the following Monday, it had become clear that in order to keep everyone safe and healthy, we needed to fully convert the way we provide services.
We spent the next few days getting a crash course in how to provide telehealth ethically. We all watched a webinar on the subject, and I called on my previous experience of doing video sessions when I moved to LA from Boston, so I could keep working with my Massachusetts-based clients. So, one phone call at a time, we contacted all of our clients and converted our entire practice of over 100 clients to video sessions.
Truly, there’s nothing like face-to-face therapy. But a lot of clients expressed that being able to meet by video helps them feel supported in this challenging time.
I have learned a lot about telehealth since March 2020 – how it’s different than in-person sessions, how it’s the same, and some of the unique considerations. Following is a partial list of those findings. I wanted to share them with you in order to answer any questions you might have about how this whole thing works.
1. Telehealth is effective.
Here’s the first question people ask about converting their therapy to video sessions: Does it work?
The good news is that there have been a lot of studies investigating this. Even before COVID-19 hit, telehealth was widely used. It helped therapists support people who live in rural areas, people with agoraphobia (an anxiety disorder in which a person is afraid to leave their home), people with mobility-related disabilities, and people who wanted more flexibility. So this research was approved and funded to make sure those services were up to muster.
And the findings, generally, are positive. Yes, people feel better after seeing a therapist online. Yes, those benefits are sustained over time in a way that’s comparable to what you would expect from seeing an in-person therapist. And yes, therapists can feel good about delivering services in this way, because it does, indeed, work as well as in-person therapy.
2. But telehealth feels different than in-person sessions.
I’m glad telehealth is available to us, and I’m glad it helps us help people. But there’s nothing quite like meeting in person. I’m not very woo-woo, but people bring an energy into the physical spaces they inhabit. On many, many occasions, I’ve walked into our waiting room and thought, “whoa, this person is really sad today” or “what’s making them feel so anxious?” And that “something in the air” energy is lacking in video sessions.
Also lacking in video sessions: body language cues. In person, I’ll frequently say to someone, “your fists clenched when you said that” or “I noticed your foot started tapping when I mentioned your ex-husband”. In telehealth, all you get is a “headshot” view, so a lot of those cues go unseen.
The good news is that there are 43 muscles in your face, so an attuned therapist can often still get a lot of important information through video sessions. A great example is that recently, when I ask “are you hanging in there?” a lot of people say “yes” or “as well as anyone”… but their head is shaking no. So there’s still plenty of grist for the therapy mill.
Another way that telehealth feels different is that looking at a screen feels inherently different than an in-person interaction. Within a few days of converting to telehealth services, every therapist I know – both at Through the Woods and elsewhere – was asking, “why do I feel so much more drained than when I’m doing in-person sessions?”
The answer is that it takes a lot of effort for your eyes to digest the brightness of a screen. (See this post about how to protect your online therapy sessions from contributing to your Zoom Fatigue.) So here’s what we did – and what you can do too. We downloaded an extension called Flux that decreases the blue light in our screens. It’s helped a lot, and I highly recommend it, not only for therapy, but also if you’re spending a lot of time on Zoom chats these days.
3. Eye contact is a quirky thing.
In person, if I look at your eyes and you look at my eyes, we are making eye contact. In a video session, if I look at your eyes, it will appear to you that I’m looking down. After a few sessions, therapists learn to look at the camera, then look at the client, and back and forth throughout the session. But if you’re meeting with your therapist and it seems like they’re looking down rather than at you, that’s why.
And also, if you’re looking at your therapist, it will appear to them like you are looking down.
It’s not bad – just something to adjust to and learn to expect.
4. It matters where you are, physically, when you meet with your therapist.
I am only licensed in the state of California, as were all of the therapists who worked for Through the Woods during this transition.
For in-person sessions, that means that if I’m in California, I can legally practice therapy. If I travel to Florida and meet with a client in person while I’m there, I would be practicing without a license in Florida.
But telehealth is more complicated – who defines where therapy “happens”? The answer is that therapy is defined as happening where the client is physically located at the time of service. If my client is in Los Angeles or Bakersfield or San Francisco, my license says I can serve them – even if I’m physically in a different state. If my client is in Manhattan or Nashville or Cleveland and I do a session with them – whether I’m in California or not – I am considered to be practicing without a license in New York or Tennessee or Ohio.
This is particularly relevant right now because a lot of people have decided to go to their home states to be with their families and wait out coronavirus. If this is your situation, and you have an ongoing relationship with a therapist, ask the therapist to contact the licensure board of the state you’re in. Some states are making blanket exceptions to state-by-state telehealth restrictions under current circumstances. Other states will waive the state licensure requirement if your therapist advocates for you. It doesn’t hurt to ask.
And honestly, some therapists (though not ours) are just ignoring these restrictions. But as a client of therapy, it’s good for you to know what your therapist is and is not legally allowed to do.
5. Privacy is an important consideration.
When you attend therapy at a physical office, there are walls and white noise machines set up to ensure your privacy. (In my new outdoor space, which I’ve begun to see clients in, you’re in a private yard.) It’s not 100% perfect, but it’s intentional.
But with telehealth, privacy is a two-way street. I do my part by making sure that I’m in a private space where I can’t be overheard, and that the video interface they’re using is confidential and HIPAA compliant. But there are also considerations on your end. You may live with your spouse, or parents, or roommates. You may have childcare barriers that prevent you from having total privacy while also making sure your children are attended to.
Most of our in-person clients decided to keep seeing their therapists by telehealth. But of those who chose not to, the most frequent concern they cited was privacy. A client who is processing relationship problems doesn’t want to be overheard by their spouse. A client who is trying to set better boundaries with their parents doesn’t want to be overheard by their parents. And, on a whole, people feel less free to talk candidly when they’re worried they’re being overheard.
The good news is that we were able to help some of these clients find imperfect but workable solutions. Some clients are doing video sessions from their car. Others are doing phone sessions while taking safe, socially distant walks around their neighborhood.
If you have concerns about this, please reach out and ask for problem-solving support. I would be happy to help you find a creative solution.
6. Telehealth can give your therapist a different kind of insight into your life.
I mentioned in #2 that video sessions omit a lot of information that is often available – the “vibe” you bring into the room, your body language beyond your face, etc. But telehealth sessions can also provide a rich array of information that isn’t usually available during in-person sessions.
Depending on where your camera is pointed during the sessions, your therapist may learn about your living situation, the way you have your home decorated, the kind of art you’re drawn to, even your pets. You can even be deliberate about this and use the video medium to show your therapist something you’ve referenced in the past.
Final thoughts on telehealth
On a whole, I’m so glad that this technology is available to us. I miss seeing my clients in person. (Update: I am now offering outdoor, in-person sessions to fully vaccinated clients – more info here.) But if something like this had happened 20 years ago, we therapists would have been so much less equipped to keep supporting our clients during this time.
Anxiety is running very high. Existential questions are coming a mile a minute. And people are downright scared. In a time like this, I’m grateful these tools are available to allow me to keep supporting my clients.