Online therapy revisited, thanks to COVID-19

It was 2013. Hi-tech entrepreneurs were excitedly “disrupting” industries, bringing goods and services closer to users. Uber replaced cabs, Kickstarter replaced investors, and telehealth companies offered convenient, at-home medical care over smartphone video. Why waste time going to an office or clinic, especially if you’re not feeling well? Why spend so much money? The physician’s physical examination had been oversold. It wasn’t really needed.

Psychotherapy never required a physical exam in the first place, and so was even more ripe for disruption. Therapy, after all, is just talk. A phone call will do, although that lacks cutting-edge tech and huge potential profitability. Proprietary video channels solve those drawbacks. Therapy could be mass-marketed as a commodity more than a professional relationship, always available and as close as your phone. It was sold to the public with a fresh, slightly subversive undertone: fire your shrink and use our app. Have therapy at home, in your pajamas if you like. It’s even “evidence-based,” a sleight-of-hand that substitutes symptomatic improvement for truly feeling well.

In 2013 I was skeptical of the burgeoning popularity of online therapy:

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious.  Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or highly contagious with an infectious disease…. It is more potentially problematic to choose online therapy over in-person treatment when both are practical options.

Back then, choosing online therapy over face-to-face struck me as corner-cutting: opting for fast food over fine dining. Yes, it was easy to imagine implausible conditions where the former was the best available or the only practical option. But that wasn’t the reality. Instead, online therapists and their patients chose convenience, the innate attractions of tech, and sometimes a lower fee, while settling for a substandard experience.

It’s 2020 now, and times have certainly changed. In the midst of the COVID-19 pandemic, it hardly ever makes sense to risk infection in the psychotherapy office. Conducting sessions by video, or simply over the phone, is much closer to standard therapy than it is to nothing — close enough that holding out for the real thing is recklessly rigid. Other things being equal, in-person therapy is still superior to the online variety. However, it isn’t so much better that it’s worth the risk of a potentially fatal disease.

This March, I offered all patients the option of telephone or video sessions instead of meeting in person. Most readily accepted. One or two had no private place to speak with me other than my office, so I continued to see them in person. Even our strict Shelter in Place order in San Francisco allows supermarket shopping, picking up take-out food, and visiting the dry cleaner or hardware store. Sharing my office for 50 minutes with one person quietly sitting eight feet away, when both of us are asymptomatic and I handle the doorknobs, didn’t seem out of line with these other common exposures; it was also permitted under the law. This week I decided to wear a cloth mask when seeing the rare such patient in the office.

Most patients opted for video. I tried FaceTime and Zoom before settling on I found the three services essentially interchangeable, despite raging debates about HIPAA compliance and privacy. Audio and video quality varied a lot, though, depending on internet bandwidth. The calls improved substantially when I replaced wifi with wired ethernet at my end. But there were still occasional frozen video feeds and garbled audio. Once or twice it was so bad we switched to telephones mid-session. Conversely, when everything was going well, which was usually, the technology receded into the background.

Well, except that I was, and am, still conscious of positioning myself correctly in the camera frame, modulating my voice, attending to my facial feedback, confirming the novel payment arrangements, and asking about the transmission quality at the other end. I imagine all that improves with practice.

I considered charging less for phone and video sessions, maybe even less for phone than video. To my mind, I wasn’t offering as much virtually as I do in a “real” session. But I ended up keeping my usual fee, on the theory that my time and expertise are equally valuable no matter how it’s delivered. Of note, many insurers don’t see it that way. As of this writing, Medicare just started covering video therapy, but not telephone therapy (yet).

When the crisis is over, I plan to resume in-person services and retire the remote options. I fear others will not — that therapists and patients will have learned to accept glitchy transmissions and the other distractions of tech as normal. I worry, too, that therapists will no longer value the subtleties lost online: the quiet sighs, sly glances, and fleeting hesitations that add music and meaning to the words.

To my surprise, even the American Psychoanalytic Association blog argues that “online therapy can be just as effective as being in the same room with your therapist.” (This is not APsaA’s official position.) I wonder if this is a counterphobic reaction to psychoanalysis suffering a behind-the-times reputation for generations. Curiously, their argument is based on online music being emotionally moving. However, as noted by the general manager of New York’s Metropolitan Opera, the fact that online music is moving doesn’t mean it equals a live performance. The interaction between artist and audience animates the latter.

So it is with psychotherapy. If we reduce therapy to mere information transfer — complaints, feelings, and recollections in one direction, reframing, support, and/or interpretation in the other — then virtual therapy does a pretty good job. But if we see therapy as co-constructed, it’s more than information transfer. It’s “being with” each other in relationship. It’s intimacy. It’s closeness and trust.

Can this be approximated online? Sure. At a time when the viral risks of in-person treatment almost always outweigh its benefits, we should use the technology available to us. And third party payers should cover such sessions, which currently many don’t.

But when the dust settles, we’d be shortchanging our patients and ourselves if we settled for what we’re forced to champion now. The inconvenient truth is that physical exams are often important in medical diagnosis, and can’t be replicated online. Likewise, in-person psychotherapy enjoys advantages that distance therapies can’t touch. There’s no shame in admitting that, while advocating for a little less right now.

Image courtesy of Ambro at

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