A Therapy for Today: Telepsychology in the Coronavirus Age

When the world is stressed, people think of therapy. But what do you do if a therapist’s waiting room makes it impossible to maintain social distance or the office has closed?

Anxiety is understandable. The nation and the world are in self-isolation. We are lonely, apprehensive about our health, and worried about the well-being of our families. Don’t be ashamed of being scared amid this new but temporary situation.

The idea of psychotherapy intimidates many people even when coughs and sneezes aren’t more dangerous than usual. The only safe therapeutic option is now online. Not only is this a change for the vast majority of current patients, but daunting to contemplate for many coming to counseling for the first time.

Welcome to membership in the largest club ever, the unusual human condition of the day. To the good, the therapist wants you to tell him of any hesitations or worries about this unfamiliar, remote method of care. He will try to calm you and work within your limits. 

Even before you seek counseling, the following often helps:

Ask yourself what other challenges you’ve had in your life. Make a list. Remember the qualities inside of you that enabled you to endure and triumph. They are still present.

Here is information to consider if you are seeking live video treatment:

  • While telepsychology or teletherapy can include phone calls, this introduction is limited to simultaneous videoconferencing in real-time.
  • Imagine yourself sitting in front of your computer in a well-lit space. The therapist sees you above the waist, and you can see only as much of him. He hears you and vice versa.
  • Although there is a bit of a time-delay in the discussion, this is an as-it-happens experience, just as in a doctor’s office. Thus, appropriate dress is required. No pajamas! 
  • Some therapists are adept at providing counseling this way. Others are new to it due to our Coronavirus emergency moment. Ask the counselor about his experience with this medium when you reach out for an appointment.
  • The provider will talk about several more things before booking your first session. Among those topics are the following:
    1. You will need a computer that includes a webcam and audio for both talking and listening. He may ask for a few more details of your setup. A phone nearby is essential; headphones are helpful. This person will try to use words you understand if you aren’t computer savvy.
    2. He needs to be acquainted with your reason for calling him. A clinical psychologist considers whether he possesses the skills to treat you for the condition you describe.
    3. Questions related to your physical and emotional history should be anticipated, as well.

Further steps follow once an appointment is made:

    1. The therapist will send you a Telehealth Informed Consent Form and go over it with you. This will include potential benefits and risks of treatment.
    2. Payment arrangements will be made. Be assured that Medicare has agreed to pay for telehealth sessions during this emergency.
    3. If you are not covered by Medicare, check with your own insurance company to determine reimbursement for such services and what portion of the fee is your responsibility.
    4. The counselor will ask you to sign a release/permission allowing him to speak with an individual designated by you in an emergency.

The professional who treats you needs the competence to provide teletherapy. Technical expertise is necessary to address an unexpected failure of the audio or video connection. Ask about this.

FaceTime and Skype are not secure platforms for the delivery of videotherapy, meaning your protected health information in a session might be compromised and your confidentiality breached. Nonetheless, during the Coronavirus emergency, HHS (the US Department of Health and Human Services) is permitting the use of insecure platforms to meet the demand for psychological assistance.

The doctor will discuss potential privacy concerns within your residence. Will anyone try to hear what you are talking about? Might another person enter the room? Will a pet or child show up?

White noise machines may reduce the chance someone else will overhear you. You will be encouraged to minimize distractions to the extent possible.

Your telephone is used as a backup in case of temporary loss of video or audio, not as the primary source of communication.

Visual cues such as your facial expressions, tears in your eyes, or tremulousness in your movements are indications of your emotional state. He must know that you are not engaging in harmful activities within his sight, etc. None of these indicators are knowable if he speaks with you on the phone.

Research suggests that teletherapy patients are about as satisfied as those who participate in traditional office visits. Most dissatisfactions come from technical problems in the course of the sessions.

Consider this an introduction to the treatment closest to an in-person office visit. You can expect other matters to be brought up, too.

Do not take what you have read here as a complete overview of the field. As the virus peril continues, federal and state laws may well change rules to adapt to changing circumstances. These might impact the delivery of psychological assistance.

Know that help is available to respond to the heightened stress of our situation. Talented psychologists, psychiatric social workers, psychiatrists, and other license counselors will continue to render the comfort they provide every day.

All these health professionals work with you, not on you. If you embrace the idea of partnership, both of you will work to create a bridge to a better time for everyone.

—–

The photos above come courtesy of Laura Hedien, a gifted and generous photographer. They are Crossing Chicago River at Michigan Avenue on March 21, 2020, and Crazy Luminescence. Much more of her work can be found at: https://laura-hedien.pixels.com/

19 thoughts on “A Therapy for Today: Telepsychology in the Coronavirus Age

  1. Timely helpful information. Thank you. I reposted on Facebook. I experienced twinges of sadness and hope with the Michigan Ave photo—sad because my old neighborhood is so empty, but hope because folks are staying home for the common good.

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  2. Thank you Dr. Stein as this is very informative. The previous provider I saw for two visits, and did not know how to treat my condition (psychiatrist) offered this to me when I cancelled with him. Zoom is the platform they used, but I turned it down because he was unable to help me in person. Our home is semi-open and I would not feel comfortable using this and would prefer to see someone in person. The person I found after the psychiatrist, practices psychodynamic and psychoanalytic therapy and I feel he would be helpful. He has knowledge of my symptom, and explained it to me and the manifestation (burning pins and needles due to anxiety) and feels he can help me. He is experienced and is a lot younger than me. (Good) He did not offer video therapy to me, but at the time when we spoke the world was just starting to be turned upside down so I was placed on hold until everything calms down.

    I am aware Chicago’s cases and hospitalizations are increasing and I hope you and your family will be ok. Please be safe.

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    • All the big cities are targets, as you know. I’m glad the psychiatrist seems a good fit for you, once we pass through the pandemic. Your good wishes are much appreciated. Hope you and your husband stay safe.

      Liked by 1 person

  3. Hi Dr G – I’m in lockdown in SA and being able to chat to my therapy team via Zoom and WhatsApp is a life saver but what I miss so much is being in their office in my safe space having all my senses activated being able to see all of them and their office being able to huggz my therapists dog before and after a session seeing the mess or not in their office none of this can be conveyed through video and I soul achingly miss it but I am blessed to be able to talk to them even if it is through a computer screen – the worst thing about lockdown is the silence and the look of utter bewilderment on my dog Brambles furry face cause we can’t go on our usual walks and beach and forest runs doggy depression is heart shredding but we’ve had to change things invent new doggy games to play in the backyard which helps me to cope with my mental health wobblies so yes I am scared and my anxiety is through the roof and I’m dissociating badly but seeing doggy smiles on Brambles face gives me joy and I am blessed incarcerated by a virus but blessed – badly quoting Brene Brown – it is the broken hearted that will rise the strongest – stay safe and go looking for those blessings – huggz n blessings

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  4. Thank you, Rosie. Yes, I’ve heard SA doesn’t let you get very far into the human world. At least, for the moment, we have that around here. A dog is one of the most terrific creatures on the planet. Brambles sounds great. Teletherapy clearly has its limits, and you’ve described the most important ones. Zoom is a remarkable invention, but not the genuine article. Be well.

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  5. gb fragmented gumdrops

    Before the stay-home orders began, I sequestered myself. It wasn’t hard for me to do since I have chronic fatigue syndrome, which slows down my energy and causes post-exertional malaise every single day. I’ve spent the last few years primarily at home since my condition worsened. However, when I moved to a different state, I stayed indoors most of the time. Prior to this pandemic, I wasn’t afraid to smoke cigarettes, go outside to meet smoking buddies (neighbors) I had met, check the mail, dump the trash, walk to the nearest Bodega, get my hair done down the street, visit the bank a block away, or spend time with three of my female neighborrs who enjoyed meeting in each others’ apartments or going out for an occasional drive. I was barely getting acclimated to my new surroundings. I hadn’t even lived in my new place a year yet – and then, wham! – the pandemic hit. The pandemic was slow at first. I honestly thought it would be contained in China with only a few cases here and there throughout the world of travelers. I honestly thought the researchers and scientists would have it figured out, given their exchanges of information internationally regarding pandemics. I had no idea that our own government, including the CDC, reduced funding and/or science for China’s epidemiology research, among other necessities such as pandemic detection, prevention, and response. I trusted that we were ahead of the game in funding, science, and education. Little did I know that our country was in a state of “brain drain” in these regards, maybe more. I last saw my therapist and doctors in early February. I decided on my own to get a jump start – which many people considered traits of OCD, but I knew that I am not fully OCD because I can let some things go and weigh the risks, only, I am extra careful because of my PTSD and past medical traumas. Come mid-February, I sequestered myself and resolved to quit smoking soon. I was not as careful as I should have been, but I was more careful than most, considering the statistics being revealed on a near daily basis. Those statistics, in exponential form, told me – an educated person – that this pandemic was here and will double or triple every week, given the lack of testing and time lag with test results. I requested early on to speak to my therapist solely by phone. She honored my request and helped me to process some things. She usually spends time validating my concerns, but in this day and age, she is also trying to help me to adjust my coping. I feared the worst, and I struggled to quit smoking. Nowadays, my therapist primarily only sees her clients via phone, which assured me because I told her that I also feared for her safety, and that I’d miss her so much if she had gone. I also told her that she is one of the best therapists I’ve ever had (I’ve only had one other therapist who was great with me, out of the many I’ve seen throughout the decades past). Although I prefer face-to-face contact with my therapist, I also feel better knowing that she and I are relatively safe conversing this way. I can still process, and I trust her enough to know my voice and what I’m feeling. I tend to explain a lot anyway, so I don’t have to worry about leaving something out, as I hope and pray we are both well enough to meet the following week. What has challenged me is the fear of either of us getting sick with this. She’s older than I am, and I have underlying conditions. Although I’ve quit smoking for about 5 days now (with the patch, and without even an ounce of ever wanting to smoke again, because I love my lungs even more now), I am still at-risk, according to an ER Doctor, whom I visited a few days ago due to shortness of breath. They ran all these tests prior to the Covid-19 test. All came back negative, so my condition is most likely bronchitis. There’s not enough staff right now to check for other factors, such as a growth or tumor that I may have, due to someting I feel inside my throat every time I swallow, or the tickle in my throat on occasion, due to allergies and smoking cessation, etc. The emergency room at the VA prescribed me Azithromycin (500 mg first day, 250 mg each day for four days – total of 5 days; I’m currently on my 4th day and feeling a little better and can breathe better, but my throat is still sore and my swallow is still unusual). I’ve spent the last couple of days after my ER visit cleaning my home, since paramedics walked inside and since I spent some time at the VA’s ER. Just in case they tracked any SARS-COV-2 into my home, I want to make sure that I cleaned and killed the coronavirus residue. Because I have chronic fatigue syndrome, it takes me longer than usual to find enough energy to finish cleaning tasks. Thankfully, I live alone, which is such a blessing – and, in my mind, has been a blessing since 2006, when I became completely independent. I’ve survived homelessness, pneumonia in my early 20s (when I thought I’d be safe without the flu vaccination – I couldn’t have been more wrong), many different bouts of acute bronchits (prior to my smoking, and even thereafter), etc. I don’t have chronic bronchitis, but who knows what I have now. I don’t have shortness of breath anymore, but I do have bronchial pains and tickled coughs every now and then – most likely from the poor air circulation through the uncleaned filters in our central air, which won’t get cleaned for a while, unfortunately. I keep my apartment at 80 degrees in the living room, since that will help to reduce the probability of increased virus loads and trace, especially while I clean with non-EPA cleansers (not disinfectants, because I cannot find any available for me to buy). Whenever a package from a friendly neighbor or my own shopping delivery shows up, I wait at least a day to open it. I use scissors that I now disinfect after each use, and I clean every single item that I bring inside. I leave the emptied boxes and bags outside my front door for later disposal, when I am fully prepared with gloves to dump all the trash in one sitting, so as to reduce my exposure to the stale air in hallways and the only elevator in our apartment building. I explain some of my procedures to my therapist, who understands and helps me to process all of this. My energy is only heightened when I’m in panic mode, or when my PTSD shows up. My therapist reminds me that what I’m feeling is part of my PTSD. I feel betrayed. I feel that people don’t take this seriously enough. I feel fear. I feel like I’m going to die any day. I feel like I’ve not done enough to prepare for death. I feel doomed, helpless, alone. I have never been afraid to check the mail, dump the trash, ride in an elevator, open commonly used doors, push buttons, or deal with my hair falling on my face – especially when outside of my apartment or upon returning to my apartment before I had a chance to shower. I rarely showered that much before – maybe about once a week or so – due to my chronic fatigue syndrome. I’d wash my hands profusely before this pandemic, but now I’ve leared to wash it for 20 seconds, as opposed to maybe 10. This exacerbates my chronic fatigue syndrome. I wonder if I’ll ever be able to handle the fatigue-producing gasping of air right before I “tire out” and need a ventilator. I wonder if I can do the ventilator, since I cannot even handle a C-PAP machine. I wonder if I’ll panic and feel chocked, intruded upon with flashbacks, while the ventilator breathes for me. I wonder if I won’t get a ventilator or any real treatment because some doctors will deem me as not valuable enough to save, especially when younger people or professionals with means flood emergency rooms and compete to survive with me, only, we’re not individually competing, but that is the protocols of hospitals when they’ve been overloaded and lack PPEs. I never thought I’d have to worry about the time I spend on the internet reading current events, because it was consuming me. My entire world became Corona – that ball with spikes staring me in the face on the screen, as if saying, “I’m coming after you. I will rape you, too!” – though not with those exact words, but the feelings were similar to being threatened with sexual abuse. This is a thing that invades your body and threatens your health – so the PTSD kicks in, which is NOT good for our immune systems at all. The CDC’s list should include evidence-based research on mental illnesses, but the doctors’ protocols when choosing who lives or dies already includes the exclusion of those with TBI, intellectual disabilities, cognitive disorders, among other mental illnesses. I wonder if PTSD is on the list, which I hope not (though this is a selfish statement, but one of survival). I wonder if I’ll ever get to say good-bye to my therapist, or if she will get to say the same to me, should something happen to either of us. I wonder how long it will be for me to feel safe enough to see her in person again. I don’t want to lose her. She’s my personal hero – on many levels, including being an officer of the Armed Forces with a doctoral degree in psychology. She knows, in part, the medical stuff, and she’s so brave. She may be older than I, but she’s so brave. I imagine her smile and her concerned face on the other end of our phones. I imagine her taking notes and genuinely seeing what treatments I will need when we both survive this. I imagine the good future we may have, as I progress through treatments. I don’t want to imagine the worst. My therapist is my rock, and I hope she will still be there for me throughout this and a few more phases of the pandemic. We’re not even at the spike, which a New York physician at a prestigious ICU predicts will occur in May. This is only the first phase, according to his reflection of epidemiologists. We will have two ore more phases with spikes here and there, until all people take this seriously and “follow the rules” (don’t touch your face, always wash your hands and use hand sanitizer after touching public things or packages, maintain your distance, keep your home clean). This is the “new normal” for now – there is no societal homeostasis right now. The allostatic load is too high. Mental health is truly important to help with the psychosocial aspects of this pandemic. There’s a lot of trauma, loss, fear, panic, anxiety, depression, and more. Therapists are sometimes on the front lines when they still see their clients in person. But many nurses and doctors are now finding that sustained time with clients or patients without both parties wearing protective masks could spread the virus. It may not be pleasant for some people to go to telehealth or phone sessions with their therapists, but it will save both therapists’ and clients’ lives to do so. I don’t want to lose my therapist. I don’t want to die and have my therapist deal with that either. I don’t want to die, period, even though I’ve had thoughts of “dying with dignity.” The good news is that most people recover on a ventilator within about 10 days. You may be awake and freaked out about a machine breathing for you, if it comes to that, but it has helped out a lot of people. Even then, some people have survived without a ventilator and only respirators. The majority have survived with Covid-19 without any hospitalization or with minimal hospitalization. Although our country has the most Covid-19 cases in the world at the moment, we do statistically have the fewest deaths. We may be mediocre in social control and resulting compliance with social distancing, hygiene, and obedience to stay-home rules, but we are doing the best we can, given our ideologies, xenophobias, and individualism. Balance is key to everything, and I’m learning to balance my fears with balanced information. If these are my last days, I want to enjoy as much as I can at home, like shows and conversing with others through Facebook. If these are not my last days, I know that it is due to my persistence in following the rules, staying indoors, maintaining hygiene, making sure I’m hydrated (which is of utmost importance to survive any disease), making sure I have enough nutrition (not too much, not too little), and keeping my mental health in check by therapists who care and sacrifice their time and even safety (if still meeting in person) with their clients. It’s an adjustment, a new normal, but not impossible to overcome. Our military is beginning to help our other heroes – the doctors, the nurses, the delivery personnel, the police, and more. Telehealth is an excellent option, and it should be available going forward when there are any clients who request it during times they have the flu or any other communicable disease, including Covid-19. Covid-19 will eventually mutate into milder forms every year, especially after they find a vaccination about 18 months to 2 years down the line, but we’re not there yet since the virus is slow to mutate. It’s best to get used to the new normal of telehealth now and for our future. It saves lives.

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  6. Thank you, glb. In the course of your comment, you began to talk back to the worst-case scenario you described at the start. That is one of the keys to getting through this. I’m glad your therapist is there for you. You are doing everything you can to control what you can. This is the best that any of us can do. Remember, the vast majority of people will survive this difficult moment.

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  7. Dr. Stein, thanks for this timely and informative post. While telepsychology or teletherapy may be an invaluable resource for those in need of such services during this time of social isolation, I fear that more of our personal lives would become accessible to those who seek to manipulate the general population for their own ends.

    As you point out: “FaceTime and Skype are not secure platforms for the delivery of videotherapy, meaning your protected health information in a session might be compromised and your confidentiality breached. Nonetheless, during the Coronavirus emergency, HHS (the US Department of Health and Human Services) is permitting the use of insecure platforms to meet the demand for psychological assistance.” Once we become accustomed to accepting this new reality, we may fail to take the necessary precautions of securing our personal data when conditions are normalized.

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    • For anyone interested, VSee is supposed to be a secure and confidential platform for medical and therapy use and I believe it is HIPAA compliant though I’m not sure if there are fees associated with it.

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    • Your point cannot be dismissed, Rosaliene. Much of life depends on choices. At present, not all therapists have performed teletherapy, not nearly as many as might be required to serve their current patients, not to mention those who are seeking treatment because of the emotional effects of the pandemic. Thus, we have many people who might need to choose between therapy that creates the possibility of compromise or no therapy at all.

      Others will hope to get telephone treatment. If they call from smartphones, I imagine such arrangements are also insecure, and are less like an office visit than a video session would be. This conundrum will be up to the individual to solve.

      There are always those whos will take advantage of a bad situation, but the helping professionals do want to help and are prepared to provide it in a way no one would have imagined when they entered the profession. The best we can do as citizens is to be vigilant about governmental encroachment beyond the boundaries of the democratic republic in which we live and hope to live.

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  8. Thank you, Brewdun. The therapist is the person who determines the platform. It is his to arrange, though I imagine a counselor not used to doing telehealth might appreciate the suggestion.

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  9. gb fragmented gumdrops

    Oh, and about the actual topic… I think there are risks with either phone and telehealth, especially on unsecured lines. But, until the Vet Center has funding for telehealth, I am content with phone calls. I would prefer telehealth though. Some therapy in any platform is better than none. I also trust the laws about our privacy, including the institutions that catch identity thieves. But even then, we are all a bit anxious and dealing with something. Empathy has grown to the point where people would understand and offer help. Some may be jerks to those who do not quite fit into the paradigm of survivorship when Social Darwinism is their unconscious or deliberate end game. But like you said, the majority do survive. Prayers that we all make it!

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    • The idea of phone therapy, in my opinion, loses its value with those who the therapist has never met, never seen even once. There is so much communicated by a person’s presence, I’d be hesitant to take on a new client without first establishing a relationship in the office. The person on the other end of the phone line can be drinking, taking drugs, cutting themselves, etc. The counselor can’t tell directly.

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  10. I started in-person therapy sessions with my previous therapist and then had to move to another city. We both felt that it would be in my best interests to stick with her, and so we started having our sessions via video. At first I thought it wouldn’t work well, and I felt awkward the first time, but then I realized that it was still pretty much the same thing. We did online therapy for almost 2 years, and I don’t feel that it hindered anything. It was super helpful. When I went into the clinic about 2 years ago I saw a therapist in-person during my stay there, and while it was a hard decision, I decided to start seeing her exclusively instead. I still have contact with my previous therapist, which is really nice. So when my current therapist and I were talking about having to do video sessions during the lockdown, it wasn’t such a big deal for me. I’ve done it before, and am therefore comfortable with it. I still can’t wait to see my therapist in-person again, but this is good enough for now. 🙂 Just thought I’d share this for anyone reading the comments who may need some reassurance.

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  11. Very helpful, Rayne, and very reassuring. Thank you!

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