Remote Therapy in a Post-COVID World 

I recently found myself in my therapy client’s car as he drove home from an errand. I requested that we wait to start the session until he was no longer driving, and rather than pulling into a parking space, he pulled into the drive-thru of a restaurant and ordered a coffee. I observed this behavior from the cupholder of his car, watching from his phone screen while I sat miles away in front of a computer in the clinic I worked in, contemplating how to address an issue that was not part of my initial clinical training.  

Long before the COVID-19 pandemic, scientists and practitioners were interested in the effectiveness of teletherapy for numerous psychological concerns (Lim & Penn, 2018; Swalwell et al., 2018; Tse et al., 2015). Providing mental and physical healthcare remotely was typically considered in exceptional circumstances where clients may have limited mobility or transportation. It was lauded for its ability to increase accessibility of services (Adler et al., 2014; Polinski et al., 2016). Stay-at-home mandates in response to COVID-19 demonstrated an intense need for widespread remote services, facilitating a “good enough” mentality while clients and practitioners scrambled to adapt to unpredictably changing circumstances. Numerous studies and opinion pieces published in the first year of the pandemic highlight the limits of our understanding of teletherapy's efficacy (Markowitz et al., 2021) and the barriers that arise when in-person contact is wholly eliminated (Oesterle et al., 2020). However, the prevailing perspective was that given the rise in mental health concerns, providing care with a weaker evidence base was better than leaving people without care at all (Malapani 2020; Nealon 2021).  

Restrictions have lifted and we have returned to something resembling “normal”, but in many ways, this “good enough” mentality regarding teletherapy has endured. In the early years of the pandemic, providers treated any kind of service, whether it was change-based therapeutic work or simply supportive listening, as better than nothing. Now our clients have options, and it falls on both clients and providers to decide whether the benefits of remote services outweigh the drawbacks. The benefits of offering teletherapy are numerous, including reducing the financial burden and providing greater accessibility for clients with tight or unpredictable schedules (Bulkes et al., 2022). However, let us turn a critical eye to an insidious consequence of defaulting to a remote therapy space: shifting boundaries.  

A mixed methods study published by James and colleagues in 2022 examined how boundaries have shifted due to telehealth options. Themes that emerged from their qualitative work included changes in the formality of sessions, increased self-disclosure by the therapist, and distractions in the client’s environment (James et al., 2022). Other groups have found that therapists view themselves as less skillful when conducting remote sessions (Lin et al., 2021). Findings like these contribute to the “good enough” mentality, as they encourage us to view teletherapy as a necessary but temporary replacement for traditional face-to-face services rather than an additional and permanent option for therapists and clients alike. They also raise questions of what boundaries are necessary, ethical, and therapeutic to set. 

In 2013, a joint task force between the American Psychological Association, the Association of State and Provincial Psychology Boards, and the APA Insurance Trust published guidelines for the practice of telepsychology, currently under revision as they expired in 2023 (Joint Task Force, 2013). These guidelines address areas of consideration in the provision of remote services, including appropriate informed consent practices, ensuring confidentiality, and compliance with interjurisdictional laws and standards. Boundary concerns that are addressed include the therapist’s competence to utilize technology effectively in their practice and the translation of ethical and professional standards of care from in-person to virtual spaces.  

Clinical judgment, a key tool for mental health providers, becomes essential for navigating the nuances of boundary-related questions. Is a boundary being crossed if the therapist conducts a remote session from their home rather than their office? If a remote session is held at a time the therapist would not typically have an in-person session? If a client is in a private space (their car) in a public area (a drive-thru)? Questions like these open the discussion of how to move the pendulum from “good enough” (better than being unable to access care) to “good” (actively benefiting the client and effecting change). In early 2024, Ekeleme and colleagues published a set of guidelines based on research from 40 different studies conducted in high-income countries since 2010. Their suggestions, summarized in the figure below, fell into four primary themes: improving patient experience, improving population health, reducing healthcare costs, and improving provider satisfaction.  

With these suggestions in mind, therapists might consider questions they need to ask themselves, their clients, and their institutions before engaging in telehealth services. Below are some suggestions.  

Self:  

• Will I communicate with remote clients (scheduling, holding sessions, handling crises) outside of the times that I typically communicate with face-to-face clients?  
• Will I hold sessions from a home office or solely in a professional office space?  
• Will I conduct therapy over the phone or with a client who is having technical problems with their device’s camera?  

Client:  

• Do you have a private space in which to engage with these sessions?  
• Are you able to minimize distractions in your environment during our scheduled session time?  
• Can we appropriately address your concerns without meeting face-to-face?  

Institution:  

• Is there additional training available regarding the use of telehealth services?  
• What are the rules and regulations regarding interjurisdictional practice (e.g., if I am or the client is on a trip out of the state in which I’m licensed)?  
• What are the documentation needs when conducting an initial remote session? An ongoing remote therapeutic relationship?  

There are few straightforward answers to questions of what makes teletherapy “good” and what boundaries should be set in virtual spaces. However, continuing to discuss improvements in access, boundary-setting, and clinical standards of care will help us to push past the status quo and offer virtual therapy services that are better than “good enough.” 

References 

Adler, G., Pritchett, L. R., Kauth, M. R., & Nadorff, D. (2014). A pilot project to improve access to telepsychotherapy at rural clinics. Telemedicine and e-Health, 20(1), 83-85.  

Ekeleme, N., Yusuf, A., Kastner, M., Waite, K., Montesanti, S., Atherton, H., ... & O'Neill, B. (2024). Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review. BMJ Open, 14(2), e079244.  

James, G., Schröder, T., & De Boos, D. (2022). Changing to remote psychological therapy during COVID‐19: Psychological therapists' experience of the working alliance, therapeutic boundaries and work involvement. Psychology and Psychotherapy: Theory, Research and Practice, 95(4), 970-989.  

Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013). Guidelines for the practice of telepsychology. The American Psychologist, 68(9), 791–800.  

Lim, M. H., & Penn, D. L. (2018). Using digital technology in the treatment of schizophrenia. Schizophrenia Bulletin, 44(5), 937-938.  

Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58(4), 449.  

Malapani, C. (2020, May 25). COVID-19 and the Need for Action on Mental Health. Columbia University Department of Psychiatry. https://www.columbiapsychiatry.org/news/covid-19-and-need-action-mental… 

Markowitz, J. C., Milrod, B., Heckman, T. G., Bergman, M., Amsalem, D., Zalman, H., ... & Neria, Y. (2021). Psychotherapy at a distance. American Journal of Psychiatry, 178(3), 240-246.  

Nealon, M. (2021, October 9). The Pandemic Accelerant: How COVID-19 Advanced Our Mental Health Priorities. United Nations Chronicle. https://www.un.org/en/un-chronicle/pandemic-accelerant-how-covid-19-adv… 

Oesterle, T. S., Kolla, B., Risma, C. J., Breitinger, S. A., Rakocevic, D. B., Loukianova, L. L., ... & Gold, M. S. (2020). Substance use disorders and telehealth in the COVID-19 pandemic era: A new outlook. Mayo Clinic Proceedings, 95(12), 2709-2718.  

Polinski, J. M., Barker, T., Gagliano, N., Sussman, A., Brennan, T. A., & Shrank, W. H. (2016). Patients’ satisfaction with and preference for telehealth visits. Journal of General Internal Medicine, 31(3), 269-275.  

Swalwell, C., Pachana, N. A., & Dissanayaka, N. N. (2018). Remote delivery of psychological interventions for Parkinson's disease. International Psychogeriatrics, 30(12), 1783-1795.  

Tse, Y. J., McCarty, C. A., Stoep, A. V., & Myers, K. M. (2015). Teletherapy delivery of caregiver behavior training for children with attention-deficit hyperactivity disorder. Telemedicine and e-Health, 21(6), 451-458.