11 Lessons from Telehealth
When moving to Telehealth in March 2020, I did not predict that in September 2021 I would still be doing Telehealth with most clients. Now, as I survey how the field of counseling and my work have accommodated the needs of clients in the pandemic, I see a forever changed landscape. National licensure is on the horizon or, at least, an interstate agreement that allows professionals to see clients across multiple state lines is in the works. We have installed Telehealth in client consciousness as a viable alternative to in-person sessions at least some of the time. And professionals will continue to unlock the potentials of the internet in delivering services and help to clients in new and creative ways. Although the last year and a half have been difficult, I am excited for the future of psychotherapy.
Telehealth has changed me personally and professionally. I have learned much from experimenting with it, and I want to share some of my thoughts with the community.
1. There is no substitute for physical presence
As hard as I have tried, I have found it difficult, perhaps impossible, to translate “presence” via Telehealth. Most psychotherapists will understand what I mean. Good psychotherapy sessions require a certain feel that is hard to explain – a kind of warm acceptance of anything and everything the client has to offer. It is often palpable to my clients when meeting in person, but many said, particularly toward the beginning of the pandemic and the switch to Telehealth, that they could not feel it via Telehealth.
I have adapted some techniques to communicate more emotion, more acceptance, and more focused attention, but for clients who are easily dysregulated, physical presence is still the best modality to help them regulate.
2. Because presence is missing, disconnects are easier and more prevalent
In the beginning, I was having frequent conversations about disconnected moments. Clients would say they felt disconnected from me, or I would feel disconnected and bring it up. I have gotten better and bolder with these conversations, more often discussing my intentions and hopes for any given conversation or interaction. For example, I have found myself prefacing statements more often with things like “I don’t want this to sound harsh…” or “This isn’t a flippant but a genuine question…” or “Tell me if you think this is wrong…” etc. I also seek to make sure the client feels heard and understood with more questions like “Did I get that right?” or “Does what I said make sense?” It is possible that this adjustment is more about my own anxiety about feeling misunderstood or coming off as critical when I am being curious, inquisitory, or evocative. But I also think these clarifications are needed via Telehealth more often, especially for those clients who are new to psychotherapy with me as their therapist, never having had the alternate experience of how I express care and compassion through “presence.”
Now, I am having fewer of these conversations. I think this reduction is mostly due to my clients and me becoming more familiar with how Telehealth feels. We have normed our experience, so we compare it less to in person sessions. Also, I have made some other adjustments designed to show the client more engagement via Telehealth.
3. Demonstrating emotion with the face is more important
The difficulty communicating felt presence via Telehealth can be helped through some basic tweaks. Understanding cannot be communicated through passive, “listening” faces via Telehealth. In person, my listening face is meant to communicate warmth, calm acceptance, a gentle strength through unflappable care. I often communicated emotion, cried, laughed, and cringed, but I always returned to placid listening.
Via Telehealth, more emotion is needed to communicate that I hear, understand, and accept the client. As silly as it may sound, I have practiced my faces in the mirror. I smile more when listening actively. I use my whole body less and move my hands more when trying to convey understanding. I widen and narrow my eyes to convey understanding or skepticism. I move my head more, both nodding when I understand and cocking my head in one direction or another to show I am listening. I interrupt more, sometimes using my hands to get clients attention by waving or gently tapping on the camera. Perhaps, most importantly, I talk more passionately about what I think and feel. This is a strategic shift that has helped more people feel connected to me in the absence of physical “presence.”
4. Via Telehealth, it is easier to focus on solutions rather than process
Clients tell me that these tweaks have helped them feel more connected to me. But although talking more about what I think and feel is working, it is also a slippery slope that I have had to manage carefully.
Because I am talking more about what I think and feel to help people feel more connected, I also find myself talking too much, sometimes struggling to help the client redirect toward their own experience. It is a delicate balance. My redirects are less silent than they used to be. I ask clients what they feel more. I ask clients to stop focusing on solutions and more on their emotions. And I encourage couples to talk more to each other than to me. In sessions, I lean on prescriptive techniques like guided imagery, mindful breathing, and evocative questioning.
When I notice myself outside of my client’s experience, I compassionately remind myself how easy it is to feel disconnected via Telehealth, remember that I think too much when I feel disconnected, and redirect myself and the client back to our felt experience.
5.) A family of therapists is more important than ever
Shifts in the emotional processing around the work have emphasized my need for a family of therapists. Toward the beginning of the pandemic, I started a consultation group for sex therapists. Feeling adrift, I reminded myself that sex therapy via Telehealth was asking me to learn new skills. Having the opportunity to speak with others facing similar struggles about their myriad ideas for how to adjust was invaluable and highlighted for me my tendency to isolate professionally.
6.) Couples Therapy and Marriage Counseling are more adaptable to Telehealth due to the physical presence of a partner
The redirection to clients’ felt experience is definitively easier when there is a partner involved. I have always relied on partner interaction in Dallas marriage counseling, but I find myself using it for different reasons and with more frequency.
For couple’s sessions, whenever possible, I encourage couples to be physically in the same room looking at the same screen with the same camera. Before the pandemic, I would use my body to interrupt arguments, leaning forward in my chair, holding my hand in between them to get their attention, or even standing up from my chair. When arguments start to spiral in Telehealth, I might encourage clients to stand up, face each other, and take a few deep breaths together.
7.) Having couples touch to interact is the key to de-escalation and to creating more experiential moments of connection
I often encourage couples to hold hands or to place a hand on the heart when expressing empathy. Before the pandemic, I would often leave the room to foster moments of gentle intimacy between couples. Now I do similar things, but I do them in more structured ways. Pulling from the Imago and Emotionally Focused Therapy models of connection and communication, I have couples face each other and repeat what they heard the other say. During these exercises, I encourage clients to touch in some way.
I have been and will continue to experiment with more movement in marriage counseling sessions. Asking clients to stand up and face each other is often a strong encourager of healthy confrontation, anger simply communicated without escalating. When expressing emotion, I also encourage clients to stop looking at the camera or screen, make more eye contact with their partner, or to physically represent “giving” the emotion to the partner by offering a hand.
None of these techniques are new to me or unique to Telehealth, but they have grown in importance over Telehealth. And they have highlighted for me that sex therapy remains a powerful mode for stuck couples – offering structured and safe programs for touch. These programs are often radically different than the negative and disconnected cycles that keep them stuck.
8.) Preparation before and decompression after sessions are essential for positive client outcomes
How clients prepare themselves for therapy and take care of themselves after therapy is a great example of why Telehealth will not be right for everyone.
One of the first changes I noticed after switching to Telehealth is that people were showing up to their appointments more flustered and distracted. At first, I attributed this to the stress of the times and awkwardness of the transition to Telehealth. But it kept happening. I realized that clients were not preparing themselves for Telehealth sessions as they did for in-person appointments. When I asked, clients reported that they were not doing anything overtly different than before. Some clients took rigorous notes before sessions, while many others just showed up with the thoughts and feelings they mentally catalogued to discuss.
As I continued to investigate the difference, I realized that it was simple. Clients were not driving to and from appointments, and they were missing this crucial time to reflect on what they wanted to do in session and how they felt after session. Now, I encourage clients to build in time before and after sessions, at least 5 minutes, to collect their thoughts and process their feelings. This shift has greatly increased client preparedness for sessions and seems to help people retain the learnings from within the session.
9.) Telehealth requires more communication about how therapy works
Discussing the costs and benefits of Telehealth with clients has offered me a new and better way to engage clients in discussions about general informed consent and the therapy process. In my experience, clients ask more questions about how therapy can benefit them via Telehealth, creating better avenues for continued engagement around the efficacy of therapy. I ask clients more often how they perceive the benefits of therapy, and these conversations have made me find new ways to articulate therapy’s benefits and my fit as a therapist for the client.
10.) How we schedule appointments is changing
The traditional model of psychotherapy indicates that frequent and consistent psychotherapy sessions are needed to make significant progress on any issue. Researchers have found that less frequent and less consistent sessions are less immediately helpful (Erekson et al., 2015). But client’s lives are more hectic than ever. This was already true before the pandemic, but the pandemic and the political upheaval have seemingly increased the frenetic nature of our lives.
I used to insist that people schedule regular, recurring appointments. I still encourage it, often citing the research on the importance of consistency and regularity. But I have moved to allowing clients to schedule online whenever they want. This change has opened a new avenue for discussions around their engagement. When I see that they are scheduling less, I ask them about it, and it becomes a sort of test. I have found that highly motivated clients either choose to schedule a recurring appointment, or they have no problem scheduling online regularly. Offering motivated clients the freedom to schedule online allows them to manage their time more efficiently – they can move appointments and schedule additional ones easily without needing to interact with me.
11.) Telehealth, like all psychotherapy, is a mixed bag of costs and benefits, and each client deserves a personalized cost/benefit analysis
Because de-escalation can be difficult via Telehealth due to the lack of counselor “presence,” Telehealth will not be right for everyone.
There was a time in my life when I would have been hard pressed to identify any pros of Telehealth. But they are varied. The convenience of meeting without leaving home or work, the time saved in travel, the ability to work with the best fitted counselor without worrying about geography – are just a few pros. But each client deserves their own cost/benefit analysis with honest accounts about their need for de-escalations Telehealth may not be able to facilitate.
Some Personal Thoughts & Feelings
Telehealth and 2020 have changed how I experience therapy with clients
Personally, I have noticed several differences within myself related to Telehealth practice. I can’t as easily tell what people are feeling, so I ask more questions. I experience more doubt about the efficacy of my work, so I check in more to make sure clients feel helped. I feel less control over the client experience in therapy, and thus I experience more powerlessness. Before Telehealth, I served clients water and tea. I offered blankets. Sometimes, very rarely, I even offered a hug. Now, all I have are words and faces of my emotion, and they often feel insufficient, particularly when I am tired, overwhelmed with the struggles of the times.
This powerlessness has forced me to change my relationship to therapy. I have always had a bad habit of relying on it too much to feel good about myself, to feel like I am making a difference. Like all therapists, I got into the profession to help, so this habit is not surprising or terribly problematic. But the events of 2020, the pandemic, the flaring of racial injustice, the political upheaval, was like watching the death of the power of compassionate listening. The very thing I have always relied on as the center of my power to make change is being rejected by a culture and political climate that is angry and at war with itself.
In many ways, since I started Telehealth, I feel like I have been at war with myself. I want to help, but therapy feels hyper-focused on the individual and powerless to change the larger contexts of oppression and upheaval in society. The switch to Telehealth exacerbated this feeling of puniness. Sometimes I struggled to even see a clear face on an occasionally blurry screen with spotty connection. Does it work? Is it worth it? Am I good enough to help? These questions have been unrelenting, shaking me to the core.
Telehealth has forced me to examine my core beliefs about myself, others, and the world
I have always believed fervently, almost religiously, in the power of therapy. I did not always feel good at it, but I knew I was “meant” to do it. I saw my struggles as meaningful and important obstacles that helped me grow and get better. I had, in a phrase, an entrepreneurial spirit about therapy. I would find a way. In this belief, I avoided a confrontation with larger spiritual questions about the meaning of my work. So, the questions that Telehealth and 2020 made me ask turned into questions I could no longer easily answer. What do I really believe about the power of relationships?
I could write a book and maybe I will, but the short story and answer is – I still believe that relationships hurt and heal. And I still believe that therapy has an important place in restoring the relationships people need to heal and thrive. But Telehealth changed how that relationship felt to me, and this “loss” made me confront anew the abandonment and trauma of my past.
After I came out in 2006, at the tender age of 20, I suddenly lost a family, a community, and a meaning making belief system. I had to reinvent myself. Telehealth and 2020 brought up these themes again. And I think they have brought up these themes for many of us, therapists and clients alike. Loss. Grief. Change. Upheaval. Fear. I feared that Telehealth was a precursor to more changes that I could not control. I was right, but the changes were and are good for clients and for me.
Telehealth has made me a better therapist overall
Telehealth has reminded me that when I let go of the things I fear losing, I allow them to transform themselves and me. In this context, I am letting go of my closely held model of therapy and my self-protective need to feel good at it. In doing so, I have literally expanded my horizons and, I believe, helped my clients expand theirs as well.
As I examine all these lessons from Telehealth, I realize that many of them are the continuation of my growth story. I have always struggled to balance my raw experience of clients with my intellectual knowledge and understanding of their experience. The struggle is not unique to me; it is indicative of the never-ending complexity, difficulty, and importance of this work. As I express compassion to and for myself, I remember my intention – “I want to be open to connection, kind in my assessments, and bold in my ability to speak truth with purpose and love.”
In reflection on the truth of my intent, I see that not much has changed. Technology and the challenges of the times may move us into new and different modes of delivery, but the mission to help will always be rooted in the trust between people who listen and dare to care.
In addition to offering cutting edge sex therapy services, Dr. Kinsey provides Dallas marriage counseling services to those who wish to broaden intimacy and/or deal with general marriage concerns. Schedule online today!