Times are propelling forward at rocket speed and clinical spaces are no exception. My experience illustrates this rapid shift. I am a doctoral candidate in counseling psychology and was transitioning to my fourth year of training when the COVID-19 pandemic hit. Since March 2020, I have had the opportunity to engage in telehealth therapy (once considered a fringe practice), the primary approach to therapeutic work that has catapulted since the start of the pandemic.
Anecdotally, prior to the pandemic, I noticed that telehealth was not prioritized in our courses. In practice-based classes, telehealth might have gotten an hour of discussion, with most people (myself included) stating that the connection that occurs in-person cannot be replicated via a computer screen. Now that we have been forced into a world of telehealth therapy, I find myself wondering if that assertion is true. While it is nice to be in-person with a client, I wonder if this notion was more based on what we as clinicians liked to tell ourselves about the “magic of the therapeutic relationship in the room.” I am now shifting my perspective and wondering about my client’s experiences engaging in therapy online.
Regardless of whether or not clinicians think that in-person work is “better”, one notion that is irrefutable is that most clinicians are currently engaging in telehealth, and that is unlikely to change in the near future. Even after the pandemic is over, it might be the case that clients do not want to return to the in-person sessions. In fact, a recent study on therapists work during the pandemic suggests that 85 percent are currently doing telehealth, and 35 percent expect to continue to utilize telehealth even after the pandemic is over. For clients, some may have come to appreciate the lack of commute, and ease of access embedded in online work. It is understandable, for example, that if someone works an eight-hour day, they may not be keen on traveling to a therapist’s office, particularly after becoming accustomed to telehealth. If telehealth is here to stay, it is my belief that counseling psychologists need to think about how to engage in telehealth ethically and safely.
Prior to the rapid growth of COVID-19 in the United States, researchers were beginning to consider the ethics of telehealth. One article on telepsychology highlights competencies clinicians should address in telehealth. These include competencies like:
- maintaining privacy and limits of confidentiality
- being aware of interjurisdictional practice
- becoming technologically competent
- being aware of resources in the area
- making a case-by-case decision about utilizing telehealth with clients
Guidelines for telepsychology or telehealth are also provided by a joint task force for the development of telepsychology guidelines for psychologists. Such guidelines include:
- competence with technologies and the impact of technologies
- standards of care in delivery
- informed consent
- maintaining confidentiality, security, disposal and transmission of data and information
The aforementioned guidelines are an essential first step to understanding the nuances of engaging in telehealth. They provide an outline for which to effectively work within. Such guidelines also exist under the assumption that we have a choice in whether or not to engage in telehealth. For example, the idea of making a “case by case analyses” regarding telehealth looks very different than it did six months ago. Instead of asking “can I meet with this client in-person or via telehealth” a clinician may be asking “can I meet with this client via telehealth or not at all”?
Several recent articles have detailed optimal practices for how to effectively utilize telehealth in the midst of the COVID-19 pandemic. These include the following:
- Environment: try to mimic in-person therapy to the degree possible. Scholars recommend upholding therapeutic interventions to the best of one’s ability, monitoring behavioral change, maintaining boundaries and a variety of other practices that therapists uphold during in-person work.
- Technology: therapists turn off alerts, turn off assistants like Siri, and streamline the technological aspects of telehealth.
- Specialty Areas: optimize their work with people who present with eating disorders, alcohol use disorders and with people in an intensive outpatient unit (IOP).
- Regarding IOPs, recommendations include utilizing breakout rooms for ease of accessing to different appointments,
- After an initial dip in participants at the beginning of the pandemic, telehealth services were effectively utilized to deliver IOPs.
- For those with substance abuse disorders, it is suggested that telehealth may be an effective way to continue groups and therapy along with medication management and to provide an increase in treatment. The potential barriers to this medium include SES and technological access.
- Regarding eating disorders, recommendations include strategies like engaging virtual exposures, promoting adequate food intake, and considering the pros and cons of weighing and linking it to eating.
Even though existing studies, recommendations, and articles are timely and incredibly valuable, the aforementioned articles are not rigorous in terms of methodology. These articles vary from using suggestions from an online form, a presentation of relevant literature, and descriptive data regarding the number of clients using services. This level of analysis makes sense given that little time has passed since the pandemic began and completing rigorous quantitative and qualitative analyses on telehealth and COVID-19 will undoubtedly take time. One perceived barrier for researchers may be that the pandemic will likely end in a few years, however, as I outlined above, it is likely that telehealth is here to stay.
Given my strong suspicion about the permanence of teletherapy, it may be beneficial to prioritize counseling psychology research and training on how to most effectively, and ethically, deliver telehealth services. Here are some areas where further research and exploration are needed:
- How should therapists intentionally work from home and present on screen? For example, what are the best ways to light the room in order for client’s to best read their therapist’s facial expression and cues, while also creating a warm space?
- How do you go about involuntarily hospitalizing a client who may be a danger to themselves or others when you are in two different locations?
- The location of therapy. For example, is it considered boundary violation for a therapist to sit in bed and deliver therapy? I would argue that it is, however, there are no current standards to discourage such a practice.
- How do you effectively conduct therapy with a client who may be in danger at home if they disclosed certain information (e.g., domestic violence case)?
- What guidelines should be recommended for clients in order to maintain privacy in their homes, particularly as clients may want to process relationships with those in their household?
- How do you effectively track a client’s nonverbals and body language (e.g., shaking legs), when only the upper half of their body is visible via Zoom or other telehealth platforms?
- How can you support clients who may have limitations related to Wi-Fi and technology?
In setting up the space, clinicians also need to be aware of the ethical complexities partners or roommates who may be home during sessions. For those who work in apartments, which is likely the case particularly for those living in big cities, or who are in training programs, other people being in their space is an indisputable reality. If a person lives in New York City, and has four roommates, it will be unlikely they can use a common space, and will be confined to their bedroom, creating other challenges if this room is small and walls are thin. As a field, we need recommendations, for example, on how to best set up a space so that it is private and soundproof. If walls are thin, there is the very real possibility of an ethical breech. It may be that devices like soundboards and noisemakers should be required for telehealth. These requirements, however, are not currently in place. Such considerations have implications for the provision of care with BIPOC clients who often live in multigenerational households and for individuals from impoverished communities.
Beyond examinations of setting, inquiry into the ability of telethealth to foster therapeutically effective work that improves wellbeing for clients is needed. For example, how do the common factors (the alliance, empathy, expectations, therapist effects and cultural adaptations) manifest via telehealth? How do we foster a strong therapeutic alliance via zoom? There may be factors online that facilitate therapeutic alliance that are similar, or different from “in-person” therapy. Differences may also occur in how we communicate empathy, how we set up expectations for therapy, and how we deliver culturally appropriate interventions. Just as we pay close attention to our head nods, body language and tone, there may be distinctions of online intervention that require further consideration. Through research into practices that can enhance, and not hinder the relationship online, therapists can deliver more effective care.
Engaging in telehealth, it is also important for therapists to think about their caseload. Staring at a screen for five or more hours at a time engaging in therapeutic work is for some, exhausting physically and mentally. Beyond that, working back to back with clients while staring at a screen may cause headaches or visual impairment. Therapists need to take care of themselves in order to work effectively with clients and research into how to best maintain attention while staring at a screen is an important step. This may involve using a larger desktop, scheduling clients differently, shorter sessions, and a variety of other methods not yet considered. Telehealth may be taxing to some clinicians in a way that in-person sessions are not, making inquiry into maximizing clinician wellbeing during telehealth an area for further investigation.
While telehealth can be difficult to engage in with clients, there are undeniable benefits to engaging in online therapy with clients. One such benefit can be access for those in rural communities. Telehealth may allow those without clinicians in a nearby area the opportunity to access therapeutic services, an irrefutable positive. Likewise, telehealth is traditionally (and hopefully remains) less expensive than therapy that takes place in-person. As therapists, trained to consider marginalization and its adverse impacts on mental health, we should work to integrate solutions that allow more people to access therapy. Telehelath has the potential to increase access to services, and inquiry into the impact of telehealth on access is another area for further research.
The world has changed immensely in the last ten months, upending all aspects of life, including the role of a therapist. The parameters of clinical work have changed, with clients and clinicians engaging in new ways. Potentially sharing a workplace with partners, roommates, children and pets creates additional difficulties and potential ethical pitfalls that necessitate exploration. Further, how to work with clients most effectively via telehealth, establishing and maintaining rapport requires inquiry. I believe that academics who submit to Professional Psychology: Research and Practice should consider conducting research on the efficacy of telehealth, both in the technological and therapeutic domains. Such research could include quantitatively measuring outcomes of therapy, and qualitatively exploring the experience of telehealth therapy for both clients and clinicians.
Rachel Chickerella is a 4th-year doctoral candidate at the University of Massachusetts Boston. Rachel is originally from Ohio and got her bachelor’s degree at Xavier University and completed her masters degree at UMass Boston in mental health counseling. Following getting her masters degree, she worked in community mental health before returning to UMass to get her doctoral degree in Counseling Psychology. Rachel’s research interests include minority stress for those with bisexual and other marginalized identities, and early interventions to engage in trauma informed practice.