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Teletherapy During COVID-19: What the Research Says

When COVID-19 began, the world had to quickly adapt. Both people seeking mental health care and mental health care providers had to immediately switch to teletherapy despite little (or no) experience with it. Before the pandemic, studies had already shown that teletherapy is effective for many mental health concerns – but with much of health care going virtual in the span of just a few weeks, recent studies have added to what we know about digital therapy.

  1. Adolescents (ages 10-19) have had a more varied reaction to teletherapy than other age demographics. For this age group, online spaces are primarily social, and using the same space for therapy has come naturally to some, while others have found it awkward and anxiety-provoking. Finding a comfortable and private location for the individual to have therapy has proven important – somewhere they feel safe, relaxed, and don’t have to worry about being overheard by other household members. A number of teenagers have responded well to shorter, more frequent sessions (30 minutes, multiple times per week) – they are better able to stay in the present moment and therapists are better able to track mood shifts.[i]
     
  2. Despite theories that people with serious mental health conditions would be less likely to convert to teletherapy due to COVID-19-related treatment barriers, studies found similar conversion rates for both the serious mental health condition population and the general help-seeking population. The serious mental health condition population was identified as those with Schizophrenia-spectrum Disorders, Bipolar Disorder (moderate or severe), Major Depressive Disorders (severe), Substance Use Disorders, Borderline Personality Disorder (BPD), suicidality, and/or Post-Traumatic Stress Disorder. Additionally, this population had a higher teletherapy session attendance rate, suggesting that these individuals remain engaged after transitioning to teletherapy.[ii]
     
  3. While teletherapy is a great tool during emergencies like COVID-19, it shouldn’t permanently replace face-to-face therapy – at least not for everyone. Teletherapy is an effective form of therapy and even has some benefits over in-person therapy, like being able to see a therapist who isn’t local. However, it eliminates the social activity and physical closeness in a trusted relationship, which often plays a role in healing. Permanently replacing traditional therapy with teletherapy beyond COVID-19 could also add to feelings of loneliness and isolation that many people were experiencing before the pandemic.[iii] A combination of online and in-person therapy may be a good long-term solution – one study (conducted before the pandemic) found that a hybrid approach improved how quickly clients could be seen and the likelihood that they would continue regular visits.[iv]
     
  4. When the pandemic began, psychoanalytic therapists in the United States were less prepared to switch to teletherapy than therapists in China. The China American Psychoanalytic Alliance (CAPA) has offered training to Chinese mental health providers online since 2006. Before the pandemic, more U.S. therapists than Chinese therapists felt negatively about teletherapy; throughout the pandemic, U.S. therapists haven’t had a significant change in opinion while Chinese therapists have grown to feel more positive about it. This is likely due to Chinese mental health professionals being more familiar with online therapy before it became necessary.[v]
     
  5. The limitations of teletherapy are especially pronounced when working with children who have been abused, neglected, or otherwise traumatized. Generally, children have not yet fully developed the attention and emotional regulation skills that are needed for effective virtual therapy. It is also more difficult for therapists to identify dissociative symptoms over a digital platform and children may be spending more time with their abusers due to lockdown orders. This may impact the child’s access to a safe therapeutic environment - which can make them reluctant to open up and process their trauma, reducing the effectiveness of teletherapy for the struggles they are facing.[vi]
     
  6. Therapeutic presence (when the therapist is fully in the moment with an individual) is seen as necessary for effective therapeutic relationships but is often compromised in digital settings. When a therapist is fully present, it signals to the client that they are safe and understood. Teletherapy creates physical separation between the therapist and client, which limits non-verbal communication – and part of therapeutic presence is utilizing body language to connect and build trust.[vii]
     
  7. Telehealth makes mental health care more accessible for many people, but not all. While it alleviates barriers like transportation access and time spent commuting, it adds in technology barriers that people don’t have to navigate when doing in-person therapy. Not all households have a computer or smartphone, and among those that do, not all have reliable (or any) internet service. And some people, especially older adults, aren’t familiar with technology, which can make seeking telehealth confusing and intimidating. These barriers tend to impact already marginalized communities like low-income households, people in rural areas, and Black, Indigenous, People of Color (BIPOC).[viii]

Long-term teletherapy isn’t for everyone, but it is a critical resource during the pandemic – and it’s likely we will learn more about the benefits and drawbacks as time goes on. As a health care provider, it’s important to stay updated on best practices as evidence emerges so that you can continue to provide quality care for the individuals you work with. What works well for one client may not be effective for another, so be willing and able to adapt as this new age of telemedicine evolves.

While your focus may be helping others, being a health care worker can wear on your own mental health as well. If you’re considering teletherapy, check out this article for more information on how it works and how you can get started. Not sure if you’re dealing with a mental health condition? Taking a mental health screen is a great way to check in on yourself and can give you a starting point when initiating a conversation about your mental health with family, friends, or doctors.


[i] Burgoyne, N. & Cohn, A.S. (2020). Lessons from the transition to relationship teletherapy during COVID-19. Family Process, 59(3). https://doi.org/10.1111/famp.12589

[ii] Miu, A.S., Vo, H.T., Palka, J.M., Glowacki, C.R., & Robinson, R.J. (2020). Teletherapy with serious mental illness populations during COVID-19: Telehealth conversion and engagement. Counseling Psychology Quarterly. https://doi.org/10.1080/09515070.2020.1791800

[iii] Luiggi-Hernandez, J.G., & Rivera-Amador, A.I. (2020). Reconceptualizing social distancing: Teletherapy and social inequality during the COVID-19 and loneliness pandemics. Journal of Humanistic Psychology, 60(5). https://doi.org/10.1177/0022167820937503

[iv] Hughes, M.C., Gorman, J.M., Ren, Y., Khalid, S., & Clayton, C. (2019). Increasing access to rural mental health care using hybrid care that includes telepsychiatry. Journal of Rural Mental Health, 43(1), 30-37. https://doi.org/10.1037/rmh0000110

[v] Wang, X., Gordon, R.M., & Snyder, E.W. (2020). Comparing Chinese

[vi] Racine, N., Hartwick, C., Collin-Vezina, D., Madigan, S. (2020). Telemental health for child trauma treatment during and post-COVID-19: Limitations and considerations. Child Abuse & Neglect. https://doi.org/10.1016/j.chiabu.2020.104698

[vii] Geller, S. (2020). Cultivating online therapeutic presence: Strengthening therapeutic relationships in teletherapy sessions. Counselling Psychology Quarterly. https://doi.org/10.1080/09515070.2020.1787348

[viii] Velasquez, D. & Mehrotra, A. (2020, May 8). Ensuring the growth of telehealth during COVID-19 does not exacerbate disparities in care. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/