Almost one year ago, mental health practices throughout the United States faced a difficult reality. They would have to transition their practice to a telehealth platform or close down. Most mental health professionals, myself included, had not widely practiced telehealth before. Occasionally, I would have clients out of town on business who would want to do a video session, or college students who would want to do check-in’s. But it was certainly not the norm, and it wasn’t something that most of us planned on doing regularly. So, when governors began announcing widespread, 14 day quarantines to “flatten the curve“ as the coronavirus began to infect more people, we had to think on our feet and respond quickly so the continuity of our patients' care would not be disrupted.
Clinicians like myself, who work with younger children and teens as well as adults, scrambled to find creative ways to engage clients over the virtual platform for the first time. Some clients connected with it right away, willingly cooperating and adjusting quickly. Others were reluctant, but gave it a chance with some coaching from me. I had to adjust my own expectations of what it would entail, and modified my home environment accordingly to have proper boundaries and to successfully focus on the screen. This is not to say there weren’t any distractions. Sometimes my cat visited unexpectedly, demanding attention, or a child client wandered away from the screen to get a toy they wanted to show me. Overall, though, it was a surprisingly successful endeavor which most people assimilated to easily.
We are now approaching the first year anniversary of this experiment in psychotherapy. Our practice receives daily calls from new clients who insist on being seen in person. We also continue to receive a number of calls requesting that therapy be conducted virtually for the foreseeable future. As a clinician, I believe that I bear some responsibility for setting a good example. When it became clear that COVID-19 was going to be a pandemic and there were major safety risks with meeting in person, it was my responsibility to take the lead when clients were resistant to trying virtual therapy. But now, as we have the opportunity to get vaccinated, we know more about how the illness is spread, and we are capable of taking extensive precautions to keep people safe, it’s also my responsibility to lead those for whom it is most appropriate back into a more traditional clinical setting. At the moment, we are allowing clients to choose which format they prefer. My associates and I have gotten vaccinated, and we continue to take extensive precautions to keep everyone safe for those who choose to come in person.
But let’s be honest, there are definite perks to working virtually. It can be tempting to remain at home, for convenience, or to continue to reap the benefits of virtual therapy: clients generally don’t run late; I’ve had fewer cancellations; and I’m more more physically comfortable. I can start dinner and let it cook while I am in a video session. So if there are reasons that I am hesitant to return to in-person therapy, I must ask myself what they are and how I should deal with them.
It seems clear that there are some clients who should be seen in person so long as it is safe to do so. In particular, clients with severe social anxiety who may avoid in person contact, persons struggling with agoraphobia (fear of going out into public places), or clients who struggle with nonverbal, social interactions that makes therapy less productive. Continuing to see these clients virtually may hinder their progress because it doesn’t give them exposure to the source of their anxieties or opportunities to practice in-person social interactions.
I’m certainly not suggesting that this is an all or nothing situation. The ability to conduct virtual therapy has indeed broadened the access to mental health, and there are certain individuals who should be able to continue to use the platform. Some of my clients with chronic physical illnesses and disabilities come to mind, for whom attending regular visits in the office can become an obstacle to the continuity of their care. Individuals who live in rural areas, children and teens whose parents are juggling work and cannot commute to bring them consistently are other examples for whom the prospect of ongoing virtual work is worth considering. It also provides continuity to clients such as college students who have gone back to campus.
My message to clinicians and clients alike is that we must be thoughtful about this decision. We cannot allow modern conveniences to take precedence over the client’s best interest, nor can we allow virtual therapy to enable patterns that will hinder clients from making progress in areas for which they are seeking our therapeutic support. Clinicians may have to become more assertive in guiding clients back to the therapy office by educating them about the risks of continuing virtual therapy. An honest discussion should be held with each client to determine what is best for them and for your therapeutic relationship. This could be a positive experience for therapists and their clients because the clients will know that you genuinely care about their progress, and therapists can explore their own potential anxieties about going back into the office. No matter what is decided, the conversation is a win-win for both parties.
As we move out of the pandemic, we will have to consider whether teletherapy should be a standard fixture of mental health care or if it should be a solution we turn to only in contexts where in-person therapy is not a valid option.