Posted on: March 5, 2021
By Haim Weinberg, PhD & Arnon Rolnick, PhD, Editors of Theory and Practice of Online Therapy
The COVID-19 pandemic abruptly changed the world-including the therapy world. Clinicians who had never thought about teletherapy had to move online quickly and without enough preparation. Two years later, we have learned a lot and improved our skills, but telemental health still presents challenges. This article offers creative yet practical solutions to help therapists overcome the main obstacles that exist with online therapy.
First, we must consider the legal and ethical guidelines for teletherapy: The boundaries on the Internet are loose and confidentiality and privacy are never guaranteed. Never assume that you can keep the same confidentiality as in your office or agency and you must take measures to protect your client. You should know the law and ethical considerations about telehealth for the country (or State) in which you practice.
A teletherapy session is not the same as a session in the therapist's office; however, this does not mean that we cannot provide quality mental health services. We can reach good results through teletherapy, and contemporary research is finding positive therapeutic outcomes of online mental health treatment (Dunstan & Tooth, 2012). What are the main obstacles that we should take into consideration and compensate for when we shift therapy to the screen? We can count four main difficulties:
1. Losing control of the setting;
2. The disembodied environment;
3. The question of presence; and
4. The Dialogue of the patient with technology and the digital world.
Losing Control of the Setting
The setting is a crucial aspect in dynamic and process-oriented therapy. Usually, the therapist has control over the setting: s/he chooses the decoration and furniture in the office, puts a tissue box in the middle of the circle, arranges for a calm music in the waiting room, etc. Taking care of the environment sends the message that we take care of the patients' needs. It creates a holding environment. However, when we move the therapy session online, therapists cannot take care of the environment anymore, as we do not control the environments from which the patients connect. How do we compensate for this shortcoming?
The easiest solution is to instruct the patients to prepare a holding environment for themselves during their teletherapy appointment. It can be addressed simply by adding some items to your standard agreement. For example: "Please connect from a quiet room, with no interruptions, where your privacy is guaranteed." One possible result of shifting the responsibility to the client might be that we encourage more adult coping skills and less regression. It can be an advantage or a disadvantage.
The Disembodied Environment
The body-to-body interaction is important in any close relationship, including the therapeutic one. The Interpersonal Neuro-Biological approach (IPNB) claims that we regulate one another through our body interactions: The therapist's warm gaze, their calming tone of voice, and many other aspects of their body, help the group members to feel held and to regulate their affect. Theoreticians talk about right brain to right brain communication and the unconscious influence that our bodies have on one another. Affective, relational, and regulation change mechanisms are central to psychotherapy. Much of this can be lost with teletherapy: We lose the eye-to-eye contact. We lose the smell, the pheromones that affect our feeling intimate and attached. How do we regulate the other online?
One part of our body is seen more clearly online: the face. We can see and identify facial expressions much better online than in-person because we see people close-up. If we train ourselves to be sensitive to facial expressions, we can get more information about patients through their faces in a teletherapy session than in traditional therapy.
Contrary to the common belief, the body is not absent in video therapy. We still sense and feel our body, and the patients still sense theirs. It's the body-to-body communication that is missing. We can ask the patients to report their body sensations and in requesting that they move in the room (distance themselves from the screen or get closer to it) according to the changing circumstances and needs. As they use the sensorimotor approach, which focuses on the body and sensations, they offer many creative ways to overcome the absence of body interaction in teletherapy.
The Question of Presence
The therapist's presence is understood as the ultimate state of moment-by-moment receptivity and deep relational contact. It involves a being with the client rather than a doing to the client. For many reasons, it is much more difficult to stay present online. There are too many distractions, and the screen barrier might decrease and dilute the presence of the therapist. However, just as some television presenters can pass the screen and transmit their presence through the ether, therapists can learn to do so as well.
One way of increasing your presence in teletherapy sessions is to use yourself more. More self-disclosure is helpful in creating presence. The appropriate kind of self-disclosure and transparency is about the here-and-now. Taking responsibilities for mistakes and for empathic failures is another way of increasing the presence of the therapist. You can also use your imagination and invite the patients to use theirs.
The Dialogue of the Patient with Technology
Meeting with patients via online video conference illuminates the way they handle technology. The dialogue of therapists and patients with online advantages (and hazards) is characteristic of how we cope with modern life. The therapist should listen to the way the patient reacts to the new therapeutic setting from a wider angle: Fear of changes? Enjoying new adventures?
In Conclusion: Practical Considerations for Online Video Therapy
-Integrate f2f and online meetings (not often possible in the current crisis)
-Take into consideration the meeting frequency due to “diluting” the therapeutic alliance online
-Think about the appropriate distance from screen for you and your patient
-Be keenly focused on the conversation
-Prepare the patient to arrange the holding environment
-Add suitable items to the agreement
-Prepare adequate measures for emergency
-Do not ignore what is happening in the patient’s room
-Acquire some technological skills
-Give the patient technical instructions
-Have a backup plan when technology fails
-Pay attention to your countertransference when connection is lost
-Create a virtual background
-Consider the place of the camera
-Pay attention to your self-screen-image
-Do not dismiss the dress code
-Remember the ethical and legal requirements for practicing telehealth in your country or state
Two dialectical messages for conclusion: agility, flexibility, and resilience are essential skills in the 21st-century, particularly when unforeseen disruptive viruses and devastating events driven by climate change are likely to be increasingly common (Blumenstyk, 2020). At the same time practitioners should remember that technology will never replace human touch.