The Covid-19 pandemic threw us all into a new era of virtual life. With a sudden, unexpected need, we were all hurled into isolation with only a screen connecting us to a society of bubbles more voluminous than a case of Prosecco on a hen do. We created an online world, one that existed before but not to the extent in which “cyber space” became an extension of our living room, the office and the pub. We all have our views about this. Some love the freedom it allows, the flexibility with time and place which means life can be expanded, connected or balanced in new efficient ways from before. Some feel there is loss involved- loss of the tangible and the “human touch” that characterizes our best memories of socializing in our pasts. The world is changing, and we are all doing our best to keep up with the adjustments. So, what about the new world that is quickly coming our way with all of its pros and cons- the world of virtual medicine?
Virtual medicine, or telehealth, is not new. As a grad student completing a pre-doctoral residence in 2008 on the plains of Denver, Colorado in the great American Midwest, Psychology lecturers spoke to us about the practicalities and ethics of reaching residents in far off counties, and I mean far off, where a trip to the supermarket means a good 90-minute journey for milk and bacon. Access to healthcare would always be problematic with these not-so-uncommon communities. We were taught not only of the possibilities of technology to bridge the gap, but also the art of bartering, what a 50-minute Psychology session would be worth in eggs and fresh chicken thighs. The point was access. Providing services to those limited by boundaries that could be overcome with a little out-of-the box thinking, which of course led to some in-the-box thinking: use of both the telephone box or the internet box. We were trained in this modality of service delivery, and for years onward, it was an option that was occasionally used in unconventional situations. And the bottom line, deserving people with barriers to access got good help.
One pandemic later, and now remote therapy is everywhere. The positive of the pandemic is the spotlight that was placed on mental health and human adaptation, including how prevalent psychological struggles are and the needlessness to suffer without support to avoid prejudice. Naturally, the push for seeking mental health treatment with the new acceptance of online connection led to many therapy practices and companies promoting psychological treatment that solved the problem of access- via online platforms, on a much wider scale, with greater public agreement. Needs must, but now that masks are sparse, the online therapy fad continues. This is because of one very important reason: it works.
Literature has long reviewed effectiveness of telehealth protocols for the populations and reasons described above. The lockdown provided an incentive and a push to study this delivery method in much greater detail, and the results are satisfying, if not even surprising. Some of the more recent metanalyses (reviewing the combined studies of many individual studies on a similar topic) show the benefits of virtual therapy for a number of populations and disorders using a range of therapeutic treatment types. Some of these include one showing no difference for therapeutic success with anxiety resolution (Novella, Ng, & Samuolis, 2021), another supporting the effectiveness of online EMDR as an effective technique, and another finding online CBT as effective as offline for anxiety and depression in young adults (Howes, Gorey & Charron, 2021), amongst many, many more. One metanalysis of 17 studies of virtual therapy delivery to patients with depression concluded an increased effectiveness of virtual treatment over traditional face-to-face treatment with conclusions that online treatment was “at least as effective” if not superior to face to face treatment; and with increased cost effectiveness, it “should be offered if preferred by patients and therapists” (Luo, Sanger, Singhal… et al, 2020). Now, there’s even literature predicting the normalized use of virtual reality space to be the next frontier location for therapy- with specialized virtual spaces made fit-for-purpose for therapy and with all the benefits of cost-effectiveness and accessibility (Sampaio, Haro, De Sousa, 2021).
As a provider of both online and in-person therapy, I noticed my own trend developing with the clients who enquired for help. Many were insistent on face-to-face treatment only, yet after just a session or two, they opted to try a virtual appointment (mostly because our schedules matched more quickly that way). I then enjoyed long relationships with these clients, but never in-person again! This trend seems to suggest the difference between the perceived ideas that clients presented with versus the hidden benefits of treatment from afar. Of course, I’m curious. So I sought to find out from both my clients and my colleagues what were their actual experiences with both types of therapy delivery methods, and what were the hidden experiences/lessons that people were not considering when choosing with whom and where to begin treatment.
Time and Location
This is the most obvious benefit of remote treatment. Clearly the whole point is that remote services are available for anyone anywhere with an internet signal. Practically, this can mean a lot. By freeing up an hour session to only the actual hour (maybe an extra minute [or ten] signing on and faffing around with the technology), a huge amount is saved from the totality of time needed to set aside to attend an in-person session. With that time also reduces the frustrations of travel. Traffic, weather, crowded waiting rooms, trekking out on cold, dark days when you know the M4 is busy and you have to be back for child pick-up by 3. The ease of keeping an hour to an hour is a primary reason why many people choose this option, because it can be confidently scheduled around life without the uncertainties of unpredictability. And with many clinicians, it can be slipped into unpopular hours of the day. Many clinicians are willing to make that 8:30 PM session after the kids are in bed or the 9:00 am Saturday morning before your Crossfit class. This is much less likely available when clinicians are using a clinic room with strict clinic times that are being charged by block. It also means the possibility of some leeway on both sides for greater flexibility with small alterations in schedule when the hiccups of life are thrown at you both.
It should be noted that location freedom isn’t without restriction. There are complications crossing international borders between clinician and client. Clinicians have certain localities in which they are allowed to practice to follow the conditions of their insurances, professional bodies, or legal expectations. The rules imposed here are mostly around keeping the patient safe. However, with so many geographical boundaries seeming to melt away, these rules may be forced to be reviewed- watch this space. In the meantime, it means sticking to a clinician in your country at least, and if you end up moving countries, it is possible you will need a new clinician.
Environment and Comfort
The next thing to consider is what kind of environment will you feel most comfortable to adopt the openness required for successful therapy? Some people may value the idea of going to the doctor. There’s something that may feel proactive about physically moving oneself towards a space reserved only for therapy. Walking into that space may remind someone why they are there, and therefore focus on the treatment may be stronger. Particularly with treatments that are more didactic or protocol driven, the clinic room may be associated with teaching authority or health and wellness, which can all positively impact outcome.
However, for others, the clinic room can be just that: clinical. If the room is too sterile, there is a possibility of discomfort that interferes with the openness and safety required for deeper emotional work. Some people knock around the chairs in my clinic room, trying to find something more comfortable than an upright, plastic seat that may or may not be too small for them. Others have commented on the weird eye machine in the corner that could “see into their soul” or the awful green wallpaper which doesn’t match up with each new sheet. These distractions can derail the process of getting into the work or create distance which must first be overcome before the session can move forward. And then there is, of course, coming and going into/from the clinic room. Walking through a crowded hospital or wait room can be disconcerting for some and removes some of the anonymity promised in therapy. For those who do access tough memories or traumas, it can be tricky to wrap these emotions up and compose oneself to leave the room towards their mode of transportation. After a particularly sad session, one red-faced, tear-stained patient asked me whether she could cut eye holes in her Covid mask to get through the wait room unrecognised! Still lastly, with the world now more aware than ever of transmissible illnesses, many steer clear of hospitals or doctors’ offices. Those with autoimmune disorders, health anxiety, long-term conditions, or those too busy to get ill may prefer the guaranteed protection that online work offers from spreading of germs or illnesses- a risk just not needed!
The benefits of online treatment mean that some people can face the therapy work better when surrounded by the safety of their own environments. Their creature comforts and objects of attachment surround them in their safe spaces as they navigate the challenges that bring them to therapy to begin with. Being anchored by safety, some feel better able to reach more dark and difficult subject matter.
Perceived Distance
Others may feel better able to create connection, paradoxically, when feeling some safety in a little distance behind the screen. The irony there is that with technology, social contact rules are eased, so the camera can allow much closer interaction than what would be appropriate in-person. Some treatments may encourage greater closeness of the faces within the camera to better read the non-verbal movements of the face and eyes and to create closer connection within the relationship. The reverse can be true also, though. One patient described the screen distance as a way to “hide” from the emotional work needed. She felt that physical distance protected her from the vulnerability of exposure when in-person and therefore knew she gained more help when in clinic. These are personal preferences that often stem from the specific difficulties that bring the person to treatment to begin with and therefore may be unclear which is better when starting out but may be elucidated as the treatment process continues. Sometimes one may just need to try different things out and see what works for them!
Privacy
Privacy will always be a major concern, however; and some living arrangements may be better suited for in-person therapy over online. Those with busy households, flat mates, children, or work-from-home partners may find private space challenging when at home, and therefore there’s comfort knowing nobody else will disturb when in a clinic room. There are always solutions around this problem too, however. The places with which I’ve given (or even held!) treatment sessions are diverse and liberating! I’ve had clients in their car, in the park, in a loft, in their gardens, taking walks in the woods, away on holiday. We clinicians don’t mind. We are after your focus and commitment, and if you provide that, we can provide you a service. The freedom with which treatment boundaries have expanded have led to research into other non-traditional environments for therapy. Walk-and-talks, where patient and clinician go out into nature to have sessions, became popular during social distancing times but maintain popularity as a great way to combine the health benefits of exercise and nature with therapeutic processes. These can be done both in-person or virtually.
Symptoms
Besides practical issues of timing and location, another essential factor to consider when choosing therapy style is how are your symptoms presenting? If you are seeking therapy for the treatment of mental health conditions (and by the way, therapy is for anyone willing to be open to self-improvement, not just those with treatable diagnoses), the nature and severity of your symptoms must be considered. Many people struggling with anxiety or depression may struggle to leave the house to attend a treatment session. Therapy is only effective for those that go to therapy. Therapists understand that you are not your symptoms; symptoms may interfere with you wanting to achieve the things you want to do, and more severe symptoms can really impact your ability to help yourself or seek help. It’s therefore relevant to consider, “Where am I most likely to actually get to therapy?” If the effort involved with getting up and dressed, leaving the house, going to a clinic, seeing other people all seems potentially overwhelming, or the threat response is on high alert making it all unmanageable, online treatment may be the door to at least reliably attend sessions- the demands are naturally less. As symptoms subside or treatment takes effect, the possibility of then attending in-person sessions may become a goal of treatment, as well as engaging in the wider community in general.
Making Choices
At the end of the day, therapy is about a relationship. It is the relationship that will have the meaning that creates change or relief. Though there may be many topics to consider here, the intention is not to create too many choices that feel overwhelming. Instead it is to highlight that finding the best fit for you may go beyond your initial reservations regarding the therapeutic space. I hope that reviewing these considerations will help broaden your scope to finding the person best fit to help you make meaningful change, which includes accessing the right clinician even if they are many miles away. I always reassure people that there aren’t mistakes in this process. Each decision provides new information that helps you make the next decision. So when choosing a clinician, call around. Identify those with a background or specialism that is similar to the things you want to address. Get a feel for the relationship that may form. Find that sense of connection with the person on the other end, and then rest assured knowing with some openness, whether close or far, you can work together to manage the practical to make the treatment successful.
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