Before the pandemic, Haley Walker was going to in-person talk therapy up to four times a week. Then, in March 2021, when she was six months pregnant, she moved across the country and decided to try a new therapist online. But as the months went on, she found it challenging to connect.
“I go to therapy to have my heart cracked open, and it’s been way harder for me to do that on video,” said Ms. Walker, 33, a freelance communications consultant. “When my therapist’s eyes drift off, I wonder whether she’s on Facebook while I’m talking about my postpartum hemorrhage.”
The disconnect made Ms. Walker consider returning to in-person therapy. “Covid’s essentially narrowed my priorities to: Do I need to leave the house? Is therapy worth the risk with a baby? I think it is,” she said.
In an American Psychological Association survey published in June 2020, just 1 percent of the psychologists polled said they were seeing all of their patients remotely before the pandemic. In a subsequent survey, published later that year in November, 64 percent said they were doing so, and 32 percent said they were offering a mix of in-person and remote treatment. (The association said it would not likely have updated figures for 2021 until November.)
Experts say that if you’re in need of mental health services, getting them remotely — via technologies like audio or video call — is unquestionably better than getting no therapy at all. But is teletherapy as good as seeing a therapist in person?
“In the literature I’ve seen, the data is pretty clear that you can have just as effective outcomes with telehealth as with in-person therapy,” said Lynn Bufka, a licensed psychologist who worked on the A.P.A.’s most recent telepsychology guidelines.
A 2019 review of 24 studies, for example, found that in nearly all cases, phone and video therapies were just as effective at treating certain conditions like anxiety, depression and post-traumatic stress disorder as in-person therapy. In another review published in February, this time of 27 studies, the authors concluded that compared with in-person services, phone and video therapy were similarly successful in treating trauma, depression and other mental health conditions in veterans.
But there are limitations to what we know, said Dr. John C. Markowitz, a professor of clinical psychiatry at the Columbia University Vagelos College of Physicians and Surgeons, and the lead author of a teletherapy report published in the March 2021 issue of the American Journal of Psychiatry. It’s not clear which type of remote therapy, like video versus telephone, is best, for example. And many teletherapy trials enroll patients with less severe symptoms, who are more likely to respond to treatment.
And while the data suggest the outcomes of in-person versus remote therapy may be equal, the experience itself is not the same. For instance, teletherapy can be exhausting for providers. “If I’m virtual, 50 minutes seems like an eternity,” said Antonieta Contreras, a psychotherapist in New York City. (In the March report, Dr. Markowitz and his colleagues wrote that providers can “feel rigidly locked before the camera, tensing different muscles.” They likened a string of back-to-back seated therapy sessions to a long-haul airline flight.)
Ms. Contreras said she worries that therapists (like Ms. Walker’s) are also more easily distracted when delivering care remotely. “I had one client who said her therapist was clipping her toenails in session,” she said. This can significantly affect the quality of care therapists are able to offer.
Patients can get distracted during virtual care, too. Alex Kattamis, 42, an electrical engineer in New York City who switched from in-person to audio-only telephone therapy when the pandemic began, said that doing teletherapy is “kind of like having a conversation when you’re driving.” You’re half-focused on diversions — in his case, phone alerts and a messy house — and half-focused “on the person you’re talking to.”
Though “for some people, distance works better,” Ms. Contreras said. “I work with a lot of men, and they have opened up online much better than in person. It’s like the screen gives them permission to be more transparent.”
Lea Adams, 51, a manager with the Army Corps of Engineers in Davis, Calif., recently did family therapy with her brothers to help their mother through a major depressive episode. Ms. Adams said that meeting remotely not only allowed her middle brother to be more vulnerable, it made therapy possible in the first place.
“We had six people in very diverse locations with time restraints,” she said. “To commute would have added an hour to an already hourlong session. With video, I finished work at 4:55 and was on our Zoom call at 5.”
“Virtual therapy has some real strengths — principally access,” Dr. Markowitz said. It’s lowered the barrier to entry for people with schedules that wouldn’t allow for commuting to a therapist’s office or who live in an area with a therapist shortage. (As of this month, 22 states allow psychologists to practice across state lines.)
How to decide which format is right for you
Having the option to choose between remote and in-person therapy is, of course, a privilege, since not everyone has access to the same resources. But if your therapist is offering in-person appointments and you’re considering a switch, here are some questions to ask yourself.
What’s your comfort level with Covid risk? If you, your therapist or a family member are at high risk of complications from contracting Covid-19, virtual is almost certainly your best bet, Dr. Bufka said.
“Obviously a big factor is whether you’re vaccinated or not, because if you’re not, the risk of going in person is greater for yourself and the therapist,” said David Mohr, a professor at Northwestern University’s Feinberg School of Medicine. You should also check if your therapist is vaccinated. Beyond that, Dr. Mohr said, it’s all about your comfort level. “If it’s extremely anxiety-producing to meet in person, it may not be productive.”
Is your provider taking precautions? The A.P.A. has recommended that providers take certain steps to reduce the spread of the coronavirus, including spacing out appointments, increasing ventilation, encouraging physical distancing and enforcing masking for everyone.
Don’t be afraid to ask your therapist about the measures they have in place, said Camilo Ortiz, a clinical psychologist and a professor at Long Island University Post in New York. “I would personally never be offended if someone asked me a whole lot of questions,” he added.
Who and what is being treated? Certain conditions may actually benefit from being treated remotely. Patients with autism, for example, may feel that virtual therapy gives them more control over their environment, Dr. Bufka said. Virtual sessions may also be better for exposure therapy, a psychological treatment that helps patients with conditions like obsessive-compulsive disorder or anxiety confront their fears. Instead of assigning exposure as homework, a therapist can observe it happening in real time. And teletherapy can be a good bridge to in-person sessions for people with severe anxiety or agoraphobia, or who are prone to panic attacks.
On the other hand, people with symptoms like paranoia may do better with in-person therapy because it allows for more nonverbal communication, which can help them manage any suspicion they might feel toward their therapist. Hoarders who are ashamed of their home may also feel uncomfortable doing video therapy. And when it comes to treating kids, face-to-face is usually better too, Dr. Ortiz said. In his experience, children tend to look at some other part of the screen or slowly tilt their camera up until it’s facing the ceiling when he’s meeting with them virtually. “I see a lot of kids with attentional problems, and this is the worst possible way to do therapy,” he said.
Do you have privacy? If you don’t live alone, can you close yourself in a bedroom or bathroom? Can you drown out your conversation with white noise?
“If people can overhear you or there are a lot of distracting sounds, that may decrease your ability to engage,” Dr. Mohr said. “A lot of times when people are distressed, the source of the distress can be the people that they live with. If you’re married or have a partner or have difficulty with your kids, are you able to talk without being overheard? The ability to have privacy in the home is really critical.”
Are you feeling connected to your therapist? This is an important one, Dr. Ortiz said, so if not, start by ensuring you’re making the most of the medium. Silence all phone and computer notifications, and close out of any unnecessary applications on the device you’re using for therapy, he advised. If you’re using a computer, sit far enough away from it so that you’re not tempted to check social media or catch up on the news, and put your phone in another room. If your own image on a video call is distracting you, hide it.
Still dissatisfied? Consider doing at least a few in-person sessions, especially if you’re struggling to build rapport with your therapist or if there’s been a rupture in your bond. In fact, Dr. Ortiz recommends scheduling in-person sessions once every month or two, even if virtual is going well. “It’s not always an either/or,” Dr. Mohr said. “A lot of times the question may not be one or the other, but how remote versus in-person is mixed.”
Juno DeMelo is a journalist, essayist and editor in Portland, Ore.
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