When it’s time for me to see a patient on the teletherapy platform the new coronavirus pandemic has forced me to rely on, a little message pops up on my screen: “Admit from the waiting room.” With a click of my mouse, I admit my psychiatry patients into my house. Not my office—my house. They can’t see my house because I use a Zoom background that blocks the environment behind me and sometimes makes my hands disappear. (Zoom backgrounds are weird like that.) But still.
Every morning I feel like I’m trying to convince myself that seeing patients using Zoom, which is what I have been doing since March, is the same as being in person—all the while knowing full well it isn’t. Don’t get me wrong: I completely understand why teletherapy is a fantastic tool. It magnifies access to mental health resources for many people, which is crucial given how scarce these resources already are. I understand why my socially anxious patients love it because they don’t have to come and socialize with a ton of people just to see—and have to socialize with—me. It’s also great for people who live far away from their therapists. Driving hours to see a therapist for less than an hour doesn’t make sense.
But, like everything, teletherapy is not for everyone. There are people who don’t feel safe talking over the internet, some who have paranoid feelings that are centered around it. Other people can’t afford to have devices that allow for video calls or don’t have access to Wi-Fi. Then there’s me. As great as teletherapy is for certain reasons, these are the very significant things I’ve realized I miss about the way I usually get to practice my job.
1. An intact therapy “frame”
No Zoom background can block out my dog barking. Or a delivery person knocking on my door. Or sounds from my neighbors. Or any of the other many reasons practicing therapy at home is not the same as being in an office.
The entire time I’m in a teletherapy session, I’m anxious that some distraction will cause me to “break the frame.” The frame describes the space therapy creates, where you meet every week (or some other agreed-upon frequency) at the same time, in the same room, and end exactly at 50 minutes. This is done by design to help create an environment and relationship that allows you to feel safe and open in a confidential and trusting way. When my dog barks, for example, the frame doesn’t feel as secure anymore. The therapy session becomes more about me than my patient. As a psychiatrist, my work is never supposed to be about me, so this is not just a small anxiety.
2. No internet interruptions
Because of teletherapy, I have taken to adding an additional step to the usual way I introduce myself to new patients: explaining how often the technology gets interrupted and apologizing upfront. There have been visits during which I have gotten dropped from the call, when the person can’t hear or see me, and when I can’t see or hear them. One time, I explained the side effects of a medication for 10 minutes, only to find out later that my patient had heard none of it. I’ve also had sessions that I have had to give up entirely and had to call the patient from my cell phone as a blocked number because their video couldn’t work or they couldn’t figure out how to get into the room or hear me. The possibility of the internet breaking the frame is another added anxiety for me. I don’t do very well with the “will it or won’t it,” especially with the world full of uncertainty right now.
Teletherapy is especially anxiety-inducing with new patients thanks to the lack of chitchat. I realized quickly that a lot of my ability to make people comfortable came from getting them from the waiting room and talking to them about the weather or the chairs—anything else except their mental health—so they could get a little more ready to divulge things they have never told anyone before to a perfect stranger. It’s a lot harder to do that when someone just pops up on my screen. My humor, which is also a large part of my ice-breaking and overall relationship building, also doesn’t seem to translate as well over the internet. It often feels kind of awkward or like we missed a step.
4. The ability to see body language
I practice in a field that functions in nuance, and this specific nuance is really missing from teletherapy. On Zoom I can usually see patients from about the shoulders up, and sometimes I don’t get to see their hands. I have to really rely on facial expressions to learn about them or see the subtle cues of their behavior. It’s still possible to sense if someone is anxious or depressed or if their words don’t match how they appear, but it’s not as easy over a screen. The complete picture is missing.
5. Everyone’s full and undivided attention
Zoom is nice because my patients can do it from anywhere, but it’s also very odd as a provider because…my patients can do it from anywhere. It’s very common for people to take appointments in their cars because it’s their only option for privacy, and that is totally reasonable. But as someone who is pretty easily distracted, it’s hard to focus if, say, a patient is a passenger in a car someone else is driving, which has happened. I also find myself distracted when patients do things like eat or smoke cigarettes during a visit.