Screen Time: Cost vs. Comfort in the World of Online Therapy

COVID limitations have pushed many mental health services to a digital format, underscoring the challenges of receiving therapy during a national pandemic. 

Adaptation to COVID-19 has dramatically altered the way we conduct our everyday activities. Grocery stores have changed guidelines and started limiting capacity, schools have shifted to an online learning setting, cities have imposed lockdowns, and countries have shut down traveling. Of the many industries affected by the pandemic, though, therapy is certainly one of the most crucially underlooked. 

Online therapy, which has been the only real replacement for the original practice, is an unusual transition for many. There are two perspectives in the online setting: first, a patient’s viewpoint is vital in any medical process, especially in mental health counseling. However, practitioners’ opinions should not be ignored when evaluating the effectiveness of online therapy, as they often are; so, in addition to including anonymous patient testimonials, this article also aims to examine the experience and perspectives of mental health professionals. 

Mental health counseling is, first and foremost, meant to provide a “safe space,” a place to share without judgment. The idea of a safe space has been given an entirely different meaning in the online setting. For some, it’s grown more difficult to feel like there is a truly safe space to mention issues that need to be discussed. Not everyone has the option of privacy in their living space, which makes revealing important information all the more difficult. For instance, some patients don’t even have the ability to do their therapy sessions in their house because of spatial issues. 

Consistency is one of the most important factors in productive therapy, and not having a stable location to do sessions can create anxiety and stress that may impede a patient’s capacity to disclose information and to “come down” (like when rebounding from a panic attack, for example). One patient explains, “Let’s say the session is over, and we hang up, like I’m just left by myself. I’m not left with somebody who is ok with me in that vulnerable state. I’m by myself and I’m feeling naked.” When conducted in-person, there is time to sit and reflect after a potentially intense and open session in close proximity to a trained professional. That transition period disappears when therapy is via computer or phone. 

Another LA-based patient says that they’ve encountered similar spatial issues: “A really huge part of therapy is saying the stuff you need to say and then leaving it in that room.” Physically exiting the space you do therapy in can help leave bad thoughts and energy behind, whereas staying in the same location for both therapy and the rest of everyday life blends the two in a way that some might find uncomfortable. On the opposite end of that spectrum, though, the normalcy of one’s own room may provide a base of confidence to share, as opposed to the emotional barrier that a therapist’s office can feel like for some patients. The same goes for commuting to an office, which was universally disliked by those interviewed: “The process involved to do therapy [in-person] was significantly more complex and had more things to think about than… getting up and opening my computer and pressing a button.”

Another important change to consider is the inherent middleman of online therapy: the screen. Remote work and learning have made us all too familiar with the digital setting; it has become a pretty universal feeling that a screen can create a disconnect in relationships. Speaking to another person over a device is vastly different than face-to-face. It takes away some of the physical, sensory parts of social interaction and can create a depersonalized experience. This lack of intimacy might make it harder to be present, which is necessary in an activity like therapy that requires complete attention and a personal connection between those participating. 

One of the patients echoed this sentiment: “It’s not the quality of the therapy that’s different, but rather that there’s a limit to what can be achieved. I can easily open my phone and zone out… In a session, you have to focus on the person physically in front of you.” However, once again, there are multiple perspectives to every situation — for the other patient, the screen isn’t as limiting: “I feel like I’ve had more breakthroughs, and [the therapist] is able to gauge what’s going on in my life better through virtual than she was before.” For this patient, “it’s easier to be less distracted and therefore more focused,” because it’s hard to see if someone’s fidgeting or moving, which is specifically distracting for them. This suggests that some patients may continue with online therapy even after the pandemic is contained, and hints at the prospect of hybrid therapy (a combination of online and in-person sessions). 

It’s also hard to compare the success of online therapy to its in-person counterpart because the latter is associated with a much different social and economic environment. “I think I get something different out of it, but my life is very different than it was before,” said one patient. Comparably, in education, “Zoom learning” often draws out negative connotations because of its adjacence to isolation and loneliness; online therapy may do the same for patients. These connotations could persist even post-pandemic, which could deter patients from staying or starting digitally. 

Josie Breger is a therapist practicing in Southern California who stopped renting her office space to pivot towards online services. She’s been using Telehealth, a program designed for various health-related resources, to meet with patients. For Breger, the transfer to online sessions was strange at the start, but became a net positive over time: “It’s interesting, because I think I went through a progression. At first I was a little apprehensive… because I had never done it before, but I quickly adapted… and started really enjoying it.” To her, the convenience of online therapy seems to be the largest of its benefits (especially avoiding brutal Los Angeles traffic). She explains that this is true for some patients, too: “Clients have commented on liking the flexibility, so they don’t have to be in traffic or don’t have to worry about getting somewhere, especially with teenagers who can’t drive.” When asked if she feels that there is a difference in the willingness to share amongst clients, Breger offers, “I don’t really think it’s changed that much… again, initially there was a bit of apprehension, but I think with time trust develops and it gets easier to be on the screen.”

For other mental health professionals, the screen has some major, inevitable inconveniences. Laura Friedberg is a therapist and social worker in Lafayette, Louisiana. For Friedberg, the online experience has felt limiting and inaccessible due to factors like body language: “Usually, I can get a lot from their facial expressions, but then, you know, you also have situations where it [sic] freezes and you’re not sure if the client froze because of what you just asked them.” Signs like these can reveal a lot of information about a patient, especially subconscious information that couldn’t otherwise be gathered. These can hinder proper mental health evaluation and response. 

From Friedberg’s perspective, clients have had mixed experiences online: “Some people seem to feel more open and talk about things that are harder to talk about because they’re not having to sit in the same room with me while they discuss something that is, in their mind, embarrassing… At the same time, I have clients that don’t feel like they have as much privacy when they’re at home… some people aren’t talking about the things that they need to talk about because of who might be listening.” Friedberg mentions cases in which sessions were interrupted by the client’s partner coming back home or even entering the room while they were sharing. Some of her clients opted to do sessions in their cars because of privacy and safety concerns, highlighting the unique challenges of seeking therapy in a quarantined America. 

Unlike many other industries that have struggled to find themselves in a digital world, therapy has adjusted to the online format with reasonable comfort. While it is likely that mental health services will largely move back to an in-person setting post-pandemic, COVID-19 has shone light on a method that may work better for the many clients that have difficulty overcoming social stresses or fitting treatment into their schedule. The flexible and familiar hybrid model will certainly make therapy accessible to thousands more people — an unexpected silver lining to a devastating global event.