Teletherapy

Defining Teletherapy
Teletherapy can be broken down into two components, tele and therapy. The prefix tele means covering distances. Therapy can be defined as treatment of psychological and behavioral disorders. Teletherapy is a branch of Telehealth. Thus, teletherapy itself can be defined as a remote method of treatment for various mental health concerns. Teletherapy uses applications such as Skype, FaceTime, and Zoom for videoconferencing and phone calls between a client(/s) and therapist. Teletherapy is also known as telepsychology, telemental health, or telepsychiatry.

Origins
Teletherapy was first formally introduced in October 1972 at the International Conference on Computers. A counseling session was demonstrated between Stanford and University of California, Los Angeles staff. Since technology was rather limited back then, only a small network of computers had access to online counseling sessions. Before this formal introduction, in the 1960s, mental health support was being conducted via telephone, however, it was not yet understood to be teletherapy. Subsequently, various mental health forums and advice services began to pop up. In 1995, Dr. David Sommers created the first online therapy platform that provided continued conversation. His practice utilized email and a real-time chat platform to provide therapy worldwide. This differed from other mental health forums since it cost money which was similar to traditional therapy sessions. More recently, online therapy platforms have launched new applications that can be utilized such as BetterHelp and Cerebral. Teletherapy began to see a rise in popularity in rural, disabled, and housebound consumers as well as increased access for military veterans. However, due to the fact that many insurance companies did not cover the steep costs of teletherapy, most therapists continued their in-person sessions.

Teletherapy During Covid-19
As a result of the COVID-19 pandemic, psychologists and therapists were forced to move their practice from in-person to virtual. The transition from face-to-face therapy to teletherapy was necessary not only to keep clients safe during this urgent time, but also to maintain the client-therapist relationship. Luckily, we have the technological advancements and access to reliable online platforms where providers can host sessions online. While psychologists moved their practices to virtual video platforms such as Skype and Zoom, there was also a rise in popularity of therapy applications on an individual’s smartphone. The impact of the COVID-19 pandemic caused an increase in mental health concerns and need for therapy. The virus outbreak was associated with an increase in stress, anxiety, fear, post-traumatic stress disorder, substance abuse, and domestic violence​​. Social distancing led to the reduction of social support systems and caused many to feel alone. Additionally, the COVID-19 pandemic resulted in high levels of unemployment which lead to exacerbated stress levels for many individuals and their families. Thus, it became evident that providing continued support virtually, whether that be through computer programming or on a smartphone, was a critical role that therapists needed to take on.

Therapist
Teletherapy requires preparation by the therapist. In teletherapy, the goal is to bring the “office environment” to a virtual platform. The “office environment” implies a setting that maintains professional boundaries. Therapists, in preparation for conducting their practice virtually, are given office and technological guidelines from the American Psychological Association. These guidelines range from client-screening, ensuring that teletherapy will work for their client, to the best way to set up an office environment. From the therapist’s perspective, they are trying to make the most of the therapy session, which may mean creating a distraction-free background. In addition to their new work environment, therapists are also required to learn how to use new technologies in order to accommodate their clients. The checklist from the APA has a technological component which calls for the use of specific types of technology, such as malware, password-protected WiFi, and conferencing platforms that comply with HIPAA. However, this may be confusing for a therapist who is unfamiliar with these technological advances. If therapists feel like they are not skilled in using the technology or online services, they might seek out additional training services, which adds to their already busy workday.

In addition to preparation for the virtual transition, therapists also have to rethink their therapeutic method if it involves reading body language. Therapists now have to alter their approach in order to adapt to video conferencing. This might be difficult for therapists to change if they have relied on body language as a method of analysis for a long period of time. Another prevailing issue that therapists face is burnout. As frontline essential workers during the pandemic, therapists’ work has become more demanding and stressful than ever before. In addition to the therapy sessions they conduct, they now need to ensure their clients are ready for sessions and hold themselves accountable for providing the same, safe and secure environment on the virtual platform as their office. However, overall there have been positive remarks by therapists and many are glad they were able to keep their practice open during tumultuous times.

Clients
The American Psychological Association released a helpful checklist for tele-psychological services that can be used as a guide by psychologists and/or patients. On this guide, there are helpful reminders for patients when starting a teletherapy session including rules and regulations regarding confidentiality. Thus, ensuring both parties keep confidentiality is essential for allowing teletherapy to be a safe and reliable service. Some common practices on the list are verifying the patients' identity each session, confirming the room is isolated and won’t be disturbed, that there are no recording devices in or around the room, and confirming all other devices are silenced and put away. Devices should be up to date on antiviral measures including anti-phishing techniques and parties should not use public WiFi during private sessions. The Office for Civil Rights (OCR) has declared that health care providers (including psychological care) can use any non-public platform to communicate with their patients online. It is important to note that Psychological licenses are state specific and some psychologists cannot practice across their licensed state line, including practicing via telehealth. Many states have loosened or temporarily lifted this rule due to the COVID-19 pandemic. You can verify your state's licensing changes here. Informed consent to patients needs to be ongoing, practitioners need to let them know when anything about their care or their provider changes that may impact them, or limitations of the technologies used in the telehealth sessions.

The client’s age plays a role in the response to teletherapy. For young children, many therapists split their sessions into two thirty minute periods. Thirty minutes are dedicated to speaking with the child and the other thirty is dedicated to play or time with their caregiver that the therapist can observe. This has been found to be effective as children may often lose focus when just staring at a screen. For adolescents, the response to teletherapy varied. While the transition to an online environment was seamless for some, others found it awkward and anxiety provoking, specifically the first session after the transition. However, once adjusted, the location and boundaries of therapy became more important and less anxiety inducing. Researchers note that defining a physical space that is therapy-safe and compatible with the therapeutic process is crucial. Adolescents’ anxiety about the online environment stemmed from concerns of confidentiality, so making sure they felt that their environment was private was the first step for the therapy session. Additionally, many therapists opted to do multiple 30-minute check-ins rather than one session per week so that they could better track their client’s progress.

Conclusion
“What we’ve seen is that telehealth is essentially just as effective as face-to-face psychotherapy—and retention rates are higher,” says David Mohr, PhD, director of the Center for Behavioral Intervention Technologies at Northwestern University’s Feinberg School of Medicine. Clients and therapists, in general, are not seeing significant changes when moving therapy online. Besides some issues like eye contact, internet access, and environmental distractions, the root of the therapy sessions are just as beneficial. With the huge shift from in-person sessions to a virtual environment, psychologists report that they are becoming increasingly more comfortable with running their practice online. The therapists who rated themselves to be more comfortable participated in training, which they believe to be important when considering this change and recommend all teletherapy professionals to undergo it. The response from clients varies based on age, individual versus group therapy, and life status; however, teletherapy serves as a sufficient substitute for in-person therapy at a time when it is most needed. Reports show that teletherapy is viable and, while not necessarily preferred over in-person therapy, is associated with good client and therapist satisfaction.