Online v. In-Person Therapy

Because of COVID-19, this year has seen a massive shift in the way that counselling and mental health therapies are happening across the world.  Online therapy is not a new thing by any means – I have been doing it for years – but this year we were all forced to leave our offices and work solely online, for several months.  Now, as we are allowed back in the office for in-person work, many clients and therapists are deciding, in fact, to simply stay with the online work.  I’m sure as we move forward, pretty much every therapist will be doing a mix of both. But how do you decide what is best in any given situation?

In this post I want to explore the pros and cons of online therapy, and I’m going to be fully clear about my biases!  But hopefully, this will be something that can create discussion amongst my colleagues and some thought in potential clients.

A quick Google search about online therapy shows that most of the articles on the first page are heavily promoting online therapy, and are also (not surprisingly) created by companies who specialize in Telehealth services.  I’m going to summarize some of the points I’ve seen and supplement them with my personal experience – since I offer both online and in-person work I hope that you will see that this is less influenced by business strategies, and more by simple experience and information.

 

Pros / Cons

 

Let’s start with the Pros of online counselling, since I’ll spend more time on the Cons.   The general benefits of online counselling are as follows:

  • Convenience
    • Therapy anywhere! I’ve had online sessions with clients in their parked cars, or while they were walking on trails, or while on vacation in Korea.  And this goes for client and therapist!
  • Safety
    • During the time of Covid, this is obviously an important point. Zero risk!

 

Both the convenience and safety factor are relevant to both therapist and patient/ client, which is important to see.  There is an additional point in the PRO column, though, that is for the therapist alone – and this really needs to be emphasized. And that is:

  • Online therapy can save the therapist a huge amount of money!

Ok why am I mentioning this?  This is a really important point to consider because in my experience, it is carrying a little too much weight for therapists and mental health clinics.  Frankly, I am quite dismayed by some of my peers who quote numbers of dollars and minutes saved as being the most important reasons to stay online.  Sure, it is convenient.  Sure, I would save huge amounts of money if I didn’t need to have an actual physical office.  But is this reason enough to emphasize and promote online counselling?  I’m not sold on that.  To me, there is one burning, main question we should be asking.  And really, only ONE important question here:

Is online therapy really as effective as in-person therapy?

Isn’t this the only question that matters in the end?  If the answer is Yes, then fair enough – go ahead and both give and receive your therapy from the cottage or couch.  But if the answer is no, then shouldn’t we all be trying to provide in-person therapy in the safest way possible?

The companies that actively promote online counselling all say “there is good research to show that online therapy is highly effective”.  And that’s true.  But careful here.  From what I can tell, the research only proves that online counselling does something.  That’s like asking how good the coffee is at McDonalds and then finding research done by McDonalds and on their website that says “there is evidence that 1 million people enjoy McDonalds coffee every week”.  Like, what is that really saying?

Online counselling is absolutely way more effective than no therapy at all. And I don’t want to play this down excessively – because online counselling can, in some cases, be truly, extremely and even seamlessly effective.  After personally doing hundreds of hours of online therapy, the important thing to know is that is very much depends on what you are working on, who the client is, and many other factors.  If your focus is, for example, cognitive therapy with a highly functional person who already has an established rapport with the therapist, then honestly there may be zero difference between an online session and an in person one.  But the thing is, in my experience that represents only a small percentage of cases.

Interestingly, just as I write this article, the new edition of Psychology Today (October, 2020) has landed on my doorstep, and in it, lo and behold a new article about online therapy.  I appreciate the article, and part of what I like about it is that it acknowledges that online therapy is a valid alternative to in-person therapy when it is necessary, but that it almost goes without saying that it is merely an alternative to the obviously more useful and effective in-person meeting.    It is poignant that much of the literature about online therapy, if you notice, is really just trying to convince us that it at least has “some effectiveness”.

What I’ve already noticed is that there has been a backlash of people who are a bit ‘done with’ online therapy, and cannot wait to get back in to in-person sessions.  My waitlist in the past 2 months has been bonkers, and most of the people that contact me usually say that though they are willing to start online (as a concession) they really prefer to be in person.  I suspect there is good reason for that.

I would like to point people to the fact that of all the different ways to do therapy – from stuff like DBT and CBT and EMDR and all the other acronyms out there – the single most effective aspect of psychotherapy is always, in every meta-study, the therapeutic relationship.  You learn this in every psychology training program and it is mentioned in pretty much every book about counselling out there.  The relationship itself is the fundamental and indispensable tool of healing.  And are we going to pretend that an online, video or phone relationship is the going to be the same as an in-person one?

If I already have built a relationship with a client, and we are working on higher level, conceptual, CBT or cognitive strategies – then I have had sessions online where I would honestly think that it was just as useful for the client as being in person.  But it would be very, very dangerous to think that this applies to every client and encounter.  There are situations and treatments which just should not be even tried online.  As a trauma-informed and trauma focused therapist, I’m really surprised that some clinicians are trying to do trauma and EMDR work online.  CBT?  Sure.  High functioning clients that just need support and guidance? You bet.  In these cases, I’m going to give a resounding green light for online therapy.  But since when are those the only clients a therapist sees?  When a therapist starts doing ‘only online work’ I worry that that it will start being a bit like that joke that when all you have is a hammer, everything else becomes a nail.  It’s just not a broad enough tool to do everything we can, and want to do.

No.  The whole purpose of our profession is to heal.  To do the highest good we can for another, within the scope of our practice.  And in this way, I want to argue that converting to purely online counselling is actually unethical, based on the mandates of our profession.  No matter how much money and time it saves you, to deliberately not do the highest good we can provide is a disservice to the client, to the  community, and ultimately, for the world.

Perhaps clearly, I am a bit frustrated by this.  Because of COVID-19, I have had to find a new office for myself, and this is directly related to issues of online versus in-person choices being made.  It would be so much easier for me to do online work only.  But who would I be serving?

Far too often, the online counselling platform serves primarily the needs of the therapist.   

I want to be clear that I am not suggesting that we abandon online counselling.  I will personally continue to offer it and defend it in various scenarios.  But that is the key point.  Only in some scenarios!  There is no way that I could do trauma work online. Believe me I have tried, when circumstances (early days of covid!) demanded it.  The whole method and approach and goal has to change.

I realize that I am coming across with obviously strong bias here.  Actually, I will be happy to be proved wrong, and perhaps someday we can develop new ways of doing therapy virtually that will somehow create the intimacy and subtlety and safety that we work so hard to create in-person.  We may have to.  But my guess is technology has some ways to go yet before we get there.

Just yesterday I was doing an online session with a client who was using the wifi in his car to get some privacy.  Midway through the video session, in a very contemplative moment, his internet stopped working and by the time we got it back, via his phone, we tried to resume but we had to acknowledge that he had really lost the point he was trying to make.  We laughed about it, it’s ok, we moved on.  And a few minutes later one of his kids found him and entered the car.  So much for that!

I really wish that online therapy could immerse both patient and clinician in a perfect bubble of connectivity that could enhance the whole experience.  Until then, I will be using it as a necessary fallback and selective tool for some clients, in some circumstances.  I sure hope we don’t have another full lockdown, but if we do I’ll provide counseling in the best way I can.

But also, without lockdown – I am still going to provide counselling the best way I can, and I really hope my colleagues will do the same.  Mental health, and finding peace and balance internally, is arguably the challenge of our times.

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