Telepsychotherapy: The New Normal

Passing the 1-year anniversary of the onset of the COVID-19 pandemic, psychotherapy delivery has reached a new normal. COVID-19–related social distancing guidelines and public health exigencies make in-person interactions less feasible and less desirable, and therefore, therapists have rapidly and extensively adopted telepsychotherapy to meet the needs of their patients (1). Although some therapists continue to deliver in-person treatment, a majority of practitioners have moved to virtual platforms (2).

For most therapists, the decision to switch to telepsychotherapy was driven by pandemic-related social forces, including loosened regulations on the practice of telehealth (2–5). Notably, almost no studies test the efficacy of video-based psychotherapy (6, 7). Most studies of remote therapy focus on telephone therapy and typically show equivalence in the efficacy of psychotherapy delivered via telephone compared with in person (8, 9). Almost nothing is known about which patients are most and least likely to benefit from video-based psychotherapy. Thus, therapists rely primarily on uncontrolled reports and anecdotal experience to support their widespread adoption of technology-enabled therapy.

First-person reviews of telepsychotherapy are mixed (6, 10). Some feel that something is lost in translation when therapeutic interactions move from the therapy room to video. Nuanced nonverbal communication cues (e.g., affect, gaze, and facial expression) provide important clues to therapists about patients’ emotions, and it is much easier to see these cues when therapists meet with individuals face to face, rather than over video (6). Technology-enabled alerts (i.e., e-mail messages, text messages) may intrude on remote therapeutic encounters. Technology itself may limit the quality of therapeutic interactions. For instance, video shots with only the tops of patients’ heads in the frame, distorted audio connections, and dropped calls routinely threaten therapeutic processes. Some therapists, especially non–digital natives, struggle with steep learning curves when adopting new technology platforms (11). Other therapists, especially those with young children at home during the pandemic, find it difficult to work from their home offices (or dining room tables) because of frequent interruptions and lack of privacy. Remote therapy may be impractical for patients who lack access to broadband Internet connections or struggle to find a private space for sessions.

By contrast, when both the patient and therapist enjoy good Internet connections, up-to-date computer equipment, and no privacy concerns, telepsychotherapy seems to work well (6, 10). Many patients find it much easier to access care when it is delivered remotely, especially those with high caregiver burdens, lack of reliable transportation, and rural residency (12). In these cases, patients can attend therapy sessions without the associated burdens of obtaining child care, finding rides, or enduring long commutes. Patients seem to appreciate the convenience of speaking with their therapist from home, obviating costs and nuisances associated with travel to sessions. Many therapists also enjoy the freedom of working remotely, relieved of the cost and time demands associated with going to their offices.

On a personal note, glimpses into homes through video have provided me with greater appreciation for aspects of patients’ lives that had hitherto gone unnoticed or undiscussed. No-show rates have declined, and, especially with patients whom I know well, therapeutic alliance is maintained. Although I am occasionally frustrated by poor sound quality, pixilated images, and Zoom fatigue, I mostly enjoy the experience of speaking with patients on video. Equipping oneself with a high-quality webcam, an external microphone/headset, and upgraded Internet service enhances the ability to deliver (mostly) hassle-free telepsychotherapy. Affectively meaningful therapeutic interventions may be more difficult to achieve over video, but I also find that remote sessions allow some patients to discuss sensitive topics that they may have been otherwise reluctant to share. Telepsychotherapy appeals to me because it improves access to care, allows for a new kind of therapeutic intimacy, and facilitates continuity of care during the pandemic.

Despite its allure, telepsychotherapy is not well understood. More data are needed about the comparative effectiveness of remote and in-person psychotherapies so that we can better understand their impacts on treatment outcomes (13). Studies should evaluate which therapy delivery systems work for whom and under what conditions. When systematically evaluating telepsychotherapy, researchers will need to attend to moderators of treatment outcomes, including types of psychotherapy administered, patient preferences, therapist preferences, and patient burden.

As COVID-19 vaccines become widely available and pandemic-related restrictions are lifted, I predict that we will retain the option for remote therapy. Many individuals will continue to prefer telepsychotherapy, especially when transportation, distance, and caregiver responsibilities limit access (14). Of course, others will welcome the opportunity to sit once again with a therapist in a private space, without the distancing effects of glitchy technology and the inevitable distractions of video chats. Psychotherapy will be enriched by including both in-person and remote treatment delivery in our therapeutic repertoire.

When COVID-19 is the rearview mirror, I hope and expect that telepsychotherapy will continue to be part of the new normal but that therapists and patients—rather than a virus—will dictate the decisions about which treatment delivery system is right for whom.