“Going to therapy,” once meant quite literally, going, or leaving the house and traveling to the therapist’s office, which was endowed with a certain cultural cache as a socially sanctioned place for people to go to share their most troubling and troublesome thoughts and feelings. Therapy started when you left the house, which is reflected in the oft-uttered phrase I hear clients use: “On the way here I was zeroing in on what I wanted to talk about during today’s session.” A Gen Z client of mine aptly refers to this as “dropping in,” or cutting beneath his distracted, overstimulated, externalized existence to tap into wellsprings of genuine inner experience. Dropping in speaks to his need to enter the same physical space as me, which allows him to more thoroughly drop into his inner world of experience.
In-person sessions involve the ritual of sitting in the waiting room, walking back to the therapist’s office, leaving the outside world behind, and entering a physical space demarcated for honest self-exploration, inwardness, and experiential immersion.
It is the bedrock privacy afforded by crossing the threshold into the inner sanctum of the therapist’s office that frees clients up to abandon social pretense and be boldly honest. Now that online therapy, or its synonyms—teletherapy, behavioral telehealth, virtual therapy, internet therapy—is widespread in the mental health field, the treatment frame is often inverted such that instead of clients visiting the therapist’s room, the therapist is visiting the client’s room, or car, or favorite neighborhood walking route.
What are the privacy implications of this? How inwardly honest and honestly inward—in a sustained, engrossed way—can clients get when there is fear of random breaches in privacy? Last week the following events occurred while I was conducting virtual therapy sessions with clients:
I conducted an internet session with a client who was in his car on a busy street (he assured me he was comfortable with this arrangement) using his phone. He ranted over the fact that his wife seems to treat him as another child in the house whose needs exhaust her. Unbeknown to him his phone paired with that of his wife’s via Bluetooth and she listened in briefly before my client caught on and ended the call.
During a virtual session with a male client who could not attend in person because his two young sons were home sick from school, he mentioned that his wife was having difficulty corralling them and keeping them entertained. They were yelling “dadda, dadda” outside his door desperately trying to capture his attention.
When virtual therapy spaces are not hermetic and there is the random possibility of intrusions upon privacy, how deeply into matters of emotional concern can clients venture?
On the therapist’s end, what about the ritual of commuting to the office, gathering one’s thoughts, “getting in the zone,” gearing up for the workday? Of being at the office where the ambient associations are largely, if not exclusively, related to “doing therapy?” This is in contrast to the ambient domestic associations therapists encounter doing virtual sessions at home, steps away from places and spaces where you dine, defecate, pee, watch TV, sleep, and have sex. How does a therapist effectively tune out domestic matters when therapy is provided in a domestic sphere?
What about the aesthetic needs of therapists, to be in an office of their design, that puts them at ease, the predictability and constancy of the imagery allowing for a real settling in experience with clients—a zone of comfort that emboldens them to constructively engage with clients’ emotional discomfort? This is in contradistinction to not knowing when you jump on the screen what type of background imagery you will encounter that may put you off kilter, no matter how slightly.
What are the implications for the changed ritual of session endings? The absence of friendly handshakes, hugs, pats on the back, walking out into the waiting room together—the small reassuring gestures of rapport and affirmation before clients returns to the “real world,” where keeping up social pretense, tolerating the intolerable, and assaults on their everyday coping skills reenter the picture?
A body of literature is emerging on therapists’ telepresence—their ability to be empathetic, caring, and fully engaged void of sharing the same physical space as clients. For effective therapy to unfold it is commonly accepted in the field that a strong alliance be formed, where therapists are adept at tuning into clients’ moment-to-moment shifting feelings and responding in attuned ways that leave clients feeling recognized and understood. Facial communication is important in this endeavor. Especially the well-timed, well-synchronized head nods, grimaces, eye rolls, furrowed brows, smirks, and grins on the part of therapists—the microexpressions of attunement—that add that special quotient of approval and felt-connection for clients. Can two-dimensional facial communication ever provide what the three-dimensional variety offers? What if the therapist’s face is washed out, darkened, or opaque due to bad lighting or an unstable internet connection? Not surprisingly, some research exists substantiating how the rapport and alliance building formed during teletherapy sessions falls short of that achieved when clients attend psychotherapy in person.
There is also the fact that virtual therapy omits therapists’ and clients’ full embodied presence. Bodies communicate with bodies during in-person sessions. As odd as it sounds, when I am conducting therapy, I listen and respond not just with my ears and mouth, but my eyes, hands, fingers, feet, legs, torso, and lungs. In the therapy literature this is called “dyadic synchrony.” The pre-conscious and unconscious ways I breathe deeply or shallowly, shift from a closed to open body posture, clasp and unclasp my hands, lean forward or backward in my seat, fold or unfold my arms, tap my foot or keep it still, stretch or bend my legs—all in response to how I am experiencing what is going on with a client. We are learning that these forms of non-verbal communication spontaneously expressed by therapists—mostly covertly—are fundamentally important to cement a feeling of true rapport with clients.
In fact, when these bodily forms of subliminally relating to clients are missing there is some evidence to suggest that clients drop out of therapy prematurely because they feel their therapist is not relating to their problems in deep ways. Therefore, it should not surprise us that in the emerging post-Covid delivery of mental health care the vast majority of clients prefer in-person psychotherapy. A 2024 Psychotherapy Action Network (PsiAN) survey revealed that 78 percent of clients prefer in-person psychotherapy, while only one-in-three believed that virtual therapy was as effective as an in-person arrangement. Since one of the core features of ethically minded, evidence-based, provision of psychotherapy in the mental health field is client preference, providers may have a professional obligation to offer in-person care to those that desire it.
More far-reaching ethical concerns need to be considered. Insofar as society adopts a two-dimensional, virtual approach to psychotherapy, are we unwittingly playing into the platformization and deprofessionalization of the field where psychotherapy is simplified, genericized, automated, framed as a reprogramming experience that is managed and overseen using algorithmic procedures curated and overseen by large corporations and health management companies, where psychotherapists are expected to function like gig workers offering therapy as a side-hustle, alongside or competing with Chatbots that supposedly offer evidence-based care?
If psychotherapists and their clients are too overzealous in adopting virtual therapy for convenience-based reasons—saving time on commutes, opening up access by overcoming the geographical constraints to seeing therapists in person—are we contributing to the depersonalization and loneliness that has hollowed out social life in our culture in general? Is one of the antidotes to Zoom fatigue, Chatbot cynicism, virtual dating, cancel culture due to unfiltered honesty, a private in-person relationship with a flesh-and-blood therapist?
Now that virtual therapy is here to stay, a social reckoning is required to reach beyond the issues of broader access to psychotherapy brought about internet-based care. We need to address quality control concerns that, perhaps, will always favor in-person psychotherapy. I, for one, take the position that online psychotherapy, at best, can be adequate, but not optimal. Along these lines, I endorse that we label it distance therapy, because this simultaneously captures how it is delivered in a format where therapist and client do not share the same physical space, and concedes that telepresence is a lesser form of embodied presence.
One day love affairs, seductions, flirting, ongoing relationships and splitting up will be conducted over the net. In fact they a ready are.
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Downright creepy article.
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Virtual therapy can come in handy but I agree that virtual therapy cannot compare to the overall ambience of being in-person. The same is true of any social interactions, i.e. chatting with friends or family virtually vs getting together in person. It just doesn’t feel quite the same.
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The same with online classes. I got more out of in-person classroom school settings than online classes.
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“Is Virtual Psychotherapy of Lesser Quality Than In-Person?” The common sense answer would, of course, be yes.
… not that I’m a big fan of our current DSM deluded psychological industries’ systemic crimes, nor methods … quite the opposite.
But I do hope, we may confess to the reality that industries that believe it is their right to psych op innocent others, or the entire world, have chosen to use their knowledge for evil … and to be merely trying to protect themselves and their scientifically “invalid” industries, for profit.
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Maybe less effective for people who might benefit from a real connection to another person….
Maybe also less dangerous for the client/patient?
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More concerning are the psychologists who would prefer distant therapy. Nowadays universities select candidates for Masters and PhD programs based on academic performance and not on their interest in other people, their ability to relate to other human beings, facilitate conversations, have some innate wisdom or whether they actually care about others.
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Covid forced a lot of therapy on line. All my reading and research suggests that overall it seemed to work quite well. In some cases, outcomes were considered to be as good or better than one-on-one. For example there was less “no shows”. It seems that benefits and disadvantages more or less balanced each other out.
My group is currently experimenting with online (zoom) support groups. When enough people are located in an area that makes physical meet ups possible, group participants are free and welcome to make such arrangements.
The alternative to the sort of online support groups that we are putting together is often long waiting lists of many months or no support at all.
Online arrangements obviously don’t suit everybody but for those it does, it looks to us like a convenient and workable option. It is also more cost effective because there is no bricks and mortar rent to pay and it overcomes the problems of distance particularly for those living in remote or regional areas.
Those participating in our trials seem to agree that online support works quite well. Once you settle into that way of interacting there seems to be very little difference between online with zoom and personal interaction.
As with any sort of therapeutic situation, the skill of the therapist(s)/facilitator(s) is probably far more important than the method of delivery.
We are a voluntary run, not for profit peer to peer organisation. If we could come up with a better way of providing support for those of us who have been subjected to the horrors of the Australian mental health system we would be doing it that way. The reality is that quality affordable support is in short supply despite millions of dollars of public money being spent to try and provide it.
Time will tell if we can do better with our online approach.
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I am a psychotherapist, I have provided telehealth psychotherapy since the pandemic and intend to continue. I’ve also been receiving my own telehealth psychotherapy since the pandemic and intend to continue that as well. So this article rubs me the wrong way for both professional and personal reasons.
The writing style is to just ask a hundred intensely judgmental rhetorical questions and then provide 2 links that vaguely support the assertions he is making implicitly. I’m very familiar with this communication strategy in many contexts, which allows the person to throw up their hands and say “what? I was JUST asking questions! Why are YOU getting mad?” when people try to argue with them.
Everyone would PREFER in person psychotherapy, in the same way we would all PREFER 20 hour work weeks, free childcare, organic and ethically produced food, economic and political systems and give ordinary people meaningful control over their own lives, etc. So what? The world we actually exist in, and the people we actually care about, are horrifically overworked and under-resourced. They often lack the necessary time, transportation, or childcare to engage in the luxury of travelling across town in the middle of the day to someone’s fancy office. So their choice isn’t ‘in person therapy or telehealth’, it’s ‘telehealth or nothing’. Therapists are also being driven into poverty by the same cost of living issues as everyone else, in addition to insurance companies lowering reimbursement rates and denying claims at every possible opportunity. Renting and maintaining office space is MASSIVELY expensive, and many therapists, especially those providing for families of their own, are forced to either change careers entirely or stop taking insurance and only serve the rich, just so they can make a decent living. Telehealth reduces those overhead costs and allows some therapists to actually continue serving ordinary people while still being able to pay their own rent.
This whole article is incredibly ignorant, classist, and tone-deaf. If this guy doesn’t want to lower himself to providing “sub-optimal” therapy to people working two jobs who have to take therapy sessions in their cars while their kids nap, he doesn’t have to. The rest of us will carry on the work without him.
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I have no specific objection to therapy at a distance. I used to be very successful with phone counseling at a crisis line many years back. There are some advantages to NOT being able to see one’s client – visual biases are virtually eliminated, for instance – I have no idea if I’m counseling a fat person or a black person or an old or young person.
The real question is, of course, effectiveness. I’m betting that has a lot more to do with WHO is the counselor and HOW they relate to their clients than it does with WHERE the counselor or client are during the process. In-person therapy certainly hasn’t got a fantastic record to beat!
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Yes! The myriad therapies out there are decidedly unsuccessful. I do think that a meaningful connection with a human being who cares and offers valuable insight could potentially be helpful even long term…
But those situations are rare and they seem to be less and less common now than say 20 years ago.
My personal misadventures in psychotherapy have resulted in disillusionment and frustration with a system that seems to reward self important and greedy people over those who actually want to be a force for good. This leads me to the rather obvious conclusion that the system should be avoided.
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There is now substantial evidence that meaningful connection with a human being who cares and simply listens can make a huge difference.
Unfortunately, as you say, such facilities are relatively uncommon and when those few caring environments get taken over or infiltrated by institutions, as they often do, they usually degenerate quickly.
In my experience it is also difficult to get people interested in independent self care a.k.a. peer support which I believe could provide at least a much better partial solution if it caught on in any significant way.
I also agree with you that in the mean time, the best strategy is probably to try and avoid the mainstream systems as far as possible but that is not always easy to do and when people are desperate…
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I definitely agree about peer support and the central importance of basic human connection. When I’ve seen people really get a lot of benefit out of therapy, it has rarely been because of some particularly clever technique, but just because the person they were interacting with (sometimes me!) actually listened to them, cared about them, and offered them the space and support to take themselves seriously and see their own lives clearly. And that skillset can be taught to any reasonably compassionate/open-minded person without years of fancy education and debt, and without getting embedded in the medicalized mental health industry.
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I agree 100%. Techniques are secondary, handy “tricks” that can help smooth the path sometimes. But what is really healing is having someone care enough to be open to hearing and listening deeply to what is happening for another person. It requires courage, empathy, and an ability to hold others’ pain without reaction or withdrawing or advising. These things can be learned but not “trained” in the sense of classroom instruction. And a person can spend decades “studying” human psychology and yet be completely clueless as a therapist.
I used to work managing a volunteer crisis line. Some of my best counselors were computer programmers. Some of the worst had doctorates in psychology. I can find literally no correlation between “training” and competence as a therapist.
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Agree 100%. The “mental health” system should be avoided at all costs.
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i quit therapy for good after the three-time master’s attained therapist continued to croquet while I was having a breakdown as I was explaining how I felt like what I was experiencing was a lifelong breakdown of growing up and marrying into families that are sneaky good at keeping me gaslit. I don’t care if they’re in person or online now. However, she was via video. There’s enough information online and I’ve endured enough forced psychiatry that I’ve learned the game. I needed boundaries and self-care. Good riddance.
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Finding good support for mental health can be a difficult business. There is certainly no one size fits all. I’m a very old survivor of the mental health system and I am still trying to better manage my delusions, hallucinations, trauma etc as well as trying to help others as best I can.
I have experienced therapists who were downright destructive, others who were a waste of time and money and a few, very carefully chosen, who have been very helpful. I have also found that the more I learn about mental health and my own problems and issues, the easier it has been to find a worthwhile therapist because you know what to look for and what to avoid. If you are now managing to get by without expert or professional help I can only say well done. I wish you all the best from hereon.
As for online or in person my current therapist offers both and says some people prefer online. Particularly busy execs etc. I’m retired and need to force myself out of the house so once a month I drive half way across town to his consulting rooms. It is a day’s outing for me which I have the luxury of time to look forward to.
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“There’s enough information online…”. Damn right.
Knowing the game, setting boundaries, and doing a hell of a lot of self-care ARE really what’s it’s all about. Let professional bloodsuckers take a hike.
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Hi Birdsong,
You say there is enough information online. There is also a huge amount of false and misleading information online. Those that I call Conservative Vested Interests (CVIs) have, for many years, flooded the market with false and misleading information. These CVI’s include pharmaceutical companies, the psychiatric fraternities, text book and journal publishing companies, universities, mainstream media, bureaucrats, politicians and more. The entire rort has been described as the greatest criminal fraud in recorded history. Despite criminal convictions and billion dollar fines in the US it goes on regardless.
This means that any young person experiencing for example first episode psychosis and going online looking for useful information is likely to to find bullshit and in many cases this bullshit can be extremely damaging.
In Australia, the same happens if they go to government MH advisory services or many of the government funded NGO’s.
I am just saying the it is not easy to get good helpful information online or anywhere else unless you have a lot of experience and know what to look for.
In my experience, even many well meaning so called professionals are clueless. Australia’s metal health services are more than a mess. They are a disaster.
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Tim, you are preaching to the choir, except for one thing: I grew up before the internet, which meant there was absolutely no easy access to information on alternatives; it was like living in the Dark Ages. So, which would you choose? Besides that, I think young people these days are a lot savvier than you seem to think.
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So true Birdsong! Though your Dark Ages reference gave me a good laugh, it later struck me as rather true! I wonder what kind of choices, in the early 80’s and on, I would have made surrounding my childhood trauma, had there been the internet (or plethora of books now available!) and the breath of available information and knowledge there is today! I mean, PTSD wasn’t even a thing back then, much less terms like narcissistic abuse, C-PTSD, betrayal trauma, betrayal blindness, and many more, from which to objectify and navigate internalizations of abuse. So ‘we’ went to therapist’s, who told us nothing happened to leave us feeling the way we did, and then, offered pills, judgements, and pep talks for how to orient our dissonant inner world to the ever availed bourgeoise utopia before me/us. So, yea…it was the Dark Ages.
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Hi Birdsong,
I remember the Dark Ages well. I was born in 1948. The first time I was hospitalised (1971) I recall a small group of us patients crawling under a barbwire fence and going across to the medical library at Latrobe Uni to look up text books to try and figure out what was wrong with us. Needless to say we didn’t learn much. Today it is hard to realise how we even coped without the internet so your point is well taken in that respect. It has made a huge difference and it is now possible to do research in hours that would have taken months or perhaps years back then.
I talk with quite a few young people with significant MH problems and what concerns me is how many believe the brain disease and medication story and seem to have little or no awareness of other options. From what I’m told, many of these people finish up overmedicated and dumped on the human scrap heap. This, as far as I can tell it is not universal. It seems to depend on which state mental health region they finish up in. Attitudes in some regions seem to be much more enlightened than others.
From memory my understanding is that you are in WA. I’m in Vic and I’m able to track goings on on the east coast pretty well but WA and SA are a bit of a mystery.
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It seems to me that the distinction between “psychotherapy” and counseling is a long overdue conversation. Most of what passes for psychotherapy today, at least in my personal experience, as well as a troubling abundant- array of others shared experiences-save incalculable critiques and books I’ve read, is little more than counselling. At best counseling amounts to life coaching, at worst, forms of harm (from passive incompetence to outright victimization-ergo power tripping and virtue hoarding). And let’s be honest, todays “psychotherapist” likely hasn’t received an adequately robust undergrad or graduate level education. What they receive, instead-and are generally oblivious to, is a decades in the making water-downed democratized (i.e., mediocrity producing) technocratic vocational education, from which far too many-if not majority-of therapist tend to operate from a [s]pace of copious ignorance surrounding literature, philosophy, critical theory, anthropology, education, psychiatry, the humanities, and all things “critical” in these and other disciplines. In this respect I regard much of the psychotherapy over the past 20 or more years already “virtual” before COVID
Case and point the above psychotherapists’ whose comment that Enrique’s blog “is ignorant”. FWIW, this old broken-down mover thinks Enrique made several astute observations surrounding the inherent psycho-social and emotional dynamics that operate and influence “psychotherapy”, save recommendations for how to address. But, then, I’m inclined to think Enrique is providing psychotherapy, not counselling or life coaching…As for classist, I paid top dollar for a Ph.D. “psychotherapist” fully educated at America’s at 3 top 10% universities. What I received then, I understand now, was ‘counseling”, shitty counseling at that. Though class factors significantly with ones access to ‘psychotherapy, it does so only by shrinking the haystack of those who actually practice “psychotherapy”.
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I disagree. I think most people are ready to cut the cord with the notion of “psychotherapy”.
And one more thing: you keep mentioning “psychotherapy” as opposed to counseling, but you neglect to clarify what you think the difference between them is and why you think one is better than the other. But come to think of it, I don’t think anyone can do that.
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I could very well be wrong? But, then, I’m a bit confused as to what you disagree with?
As for the difference between counseling and psychotherapy, I pretty much agree with Google’s description! Counseling is a short term solutions oriented process, psychotherapy a longer term process whereby one makes changes to their person (unconscious patterns, etc., ad nauseum.). I could continue on about the differences for quite awhile, but no need to drone on. And “I do not think one is better than the other”, only substantively different in ways that benefit one or another’s needs at a particular point in time in their lives-or doesn’t due to those same differences in modalities; as I alluded to in my personal example above (however poorly articulated!). Ergo I desperately ‘needed” and sought “psychotherapy, and I got, instead, a solutions oriented process (“fix”)-and was too uneducated and ignorant at the time to understand this. I hope this helps!
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I’m sorry Kevin. I’m so confused between your and Tim’s comments to the point I’m not sure I agree 100% with either of you.
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Well, as a rule, its good to never agree with 100% of anything I say! I would only add to my tepid comments above-to more accurately capture my sentiments on the matter: I wouldn’t get within the distance of a restraining order to that of a professional mental health therapist. There, nuff said!
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☺️☺️☺️
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My humble apologies to Enrico for my misspelling and misrepresentation of his name.
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Hi Kevin,
I’m not sure why I have gotten so caught up in this conversation. Probably the result of a lot of disappointing results from many different mental health professionals including of course psychiatrists over many years.
There are many labels inevitably trying to classify people. Psychotherapist, councillor, support worker etc etc. In my experience most of these labels are meaningless. I can really only speak with any authority about the situation in Australia where the “top rung” are university trained PhD psychologists while the bottom rung may have little or no formal training or qualifications at all. The qualification mainly determines what they charge and the government rebate the client is entitled to if anything.
There is nothing here to stop anyone calling themselves a councillor and charging for their services but even if there was, it would hardly make any difference. I have talked with PhD qualified psychologists who have told me their training provided nothing more than an entry into a well paid position. They say they didn’t really learn anything useful until they started working with clients under supervision, The skills they then acquired seem to depend a lot on natural empathy and ability to connect with people as well as the skills and ability of their supervisor and the particular treatment stream they follow.
As I said in an earlier post, finding good psychologists, therapists etc can be a very tricky business. Labels, qualifications etc can have a significant bearing on what they charge but very little on their skills and competence or how much help they are to any particular individual. I also think a good match can be very important. There is no one size fits all and qualifications or fees charged seem to be a very poor indication of how useful any mental health professional will be to someone.
Let the buyer beware.
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Agree 100%.
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ChatGPT > 80% of mental health industry folk. Hopefully the day comes when it doles out pills when required too. That should eliminate most of the profession.
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JustMe- You said
I definitely agree about peer support and the central importance of basic human connection…
Steve McCrea-You said
But what is really healing is having someone care enough to be open to hearing and listening deeply…
I find both these comments very helpful and supportive. I have been trying for many months to establish some sort of peer support network in Australia. So far there has been little progress and a lot of scepticism. Many of the people I was hoping would embrace this idea are acting like frightened rabbits in the spotlight. They seem to believe that lots of qualifications from expensive and often unattainable courses are essential. They also appear to be frightened of stepping away from the re-assuring but often counter productive voices of the “professionals”. Even entertaining the idea of functioning without or with reduced medication fills them with dread. Horror of horrors is the thought of learning to live in the world without depending on government financial handouts.
The reality is that no one needs to abandon all these things and take a giant leap of faith into the unknown. One small step at a time is all that is required but fear is often an irrational and all powerful emotional driver that defies logic or even common sense.
As for psychology vs psychiatry vs counselling etc, these days I prefer to think in terms of “support” as needed, wanted and chosen by the person concerned using the apparently very successful Open Dialogue facilitation approach. I believe a considerable amount of this support can be provided by peers or as we usually call them here, Lived Experience Workers (LEWs). Many probably only need a little bit of practical hands on training and their own ongoing support.
In due course I hope to be able to report my efforts in a Mad In America article but at the moment I am still on the slippery slope making very little progress despite quite a lot of effort.
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