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A Special Report From the California Association of Marriage and Family Therapists (CAMFT)
The COVID-19 crisis caught us all by surprise, changing almost overnight the ways in which we work, go to school, and interact with our families and friends. In California, the widespread lockdowns begun in March 2020 put most psychotherapists in the position of having to completely revise the way they engaged with clients. Suddenly, the therapist’s couch—a cozy, intimate safe haven for so many—was no longer safely accessible.
Lawmakers in Sacramento and in other states issued emergency orders to loosen restrictions on telehealth compliance, making it easier for therapists to connect with their patients by phone and computer. With legal barriers to widespread telehealth removed, therapists scrambled to educate themselves about the ins and outs of telehealth while implementing new procedures with new technologies to keep their patients physically safe and mentally secure.
Many therapists leaned on the support of the California Association of Marriage and Family Therapists (CAMFT), a professional association that supports more than 31,000 mental health clinicians. CAMFT raced to get needed information to their membership about state and federal regulations regarding safety precautions and telehealth guidelines as CAMFT call lines were bombarded with members worried about how they could continue to safely support their patients and keep their businesses afloat.
In June, CAMFT sent out an email message asking members to participate in a short survey to explore how the forced transition to teletherapy was impacting their practices and how the events of 2020 may change the way they work in the future. The survey comprised fifteen (15) multiple-choice and six (6) open-form questions. Approximately twenty three hundred (2300) mental health providers throughout California submitted responses. Here we present initial results, first from the multiple-choice questions, which were largely quantitative in nature, and then from two open-ended questions, which were coded and analyzed.
Forced Adoption Leads to Adaptation and Acceptance
The survey shows that before the pandemic only a small fraction of therapists (five percent) used teletherapy for most of their clients. The overwhelming majority (~86 percent) reported that pre-COVID they saw clients predominantly in person and used no or almost no teletherapy. Within weeks of the lockdown, however, a whopping 95 percent said they’d moved—or tried to move—all of their practice to telehealth. By the end of April, 75 percent of respondents were using teletherapy with three-quarters or more of their clients, and 45 percent were using teletherapy with all or nearly all clients. By mid-June, when seeing clients in person using social distancing guidelines became more feasible, 85 percent were still using teletherapy with three-quarters or more of their clients while 75 percent were using teletherapy with all or nearly all clients. Not using teletherapy at all was rare (six percent).
This indicates a remarkable reversal of pre-pandemic patterns. Further results show that the smoothness of the transition process varied widely, with the most common response (40 percent) indicating moderate difficulty in transitioning to telehealth (three on a five-point scale, i.e., “a change, but doable”). Yet once they made the decision to transition to teletherapy, it took most clinicians (66 percent) a surprisingly short time to implement, typically a week or less.
As national and state governing agencies moved fast to remove the mandates requiring highly encrypted, secure telehealth platforms, major insurance companies including Medicare and Medi-Cal agreed to reimburse for teletherapy of all kinds at the standard rate for in-person sessions. Therapists suddenly found themselves with an array of telehealth platforms they could use without the usual encryption restrictions or the blocks insurance companies had placed on telehealth.
CAMFT’s survey found that clinicians experimented with a wide variety of teleconferencing and telephone applications. In fact, most respondents (71 percent) said they tried five or more different platforms. The most popular were Zoom or Zoom Healthcare (89 percent), Doxy.me (23 percent), and Simple Practice (16 percent). Responses to open-ended questions suggest that many therapists adjusted the platform to the specific client and context. Additionally, while some clients did not have access to a computer, almost all had access to a phone, so video apps such as FaceTime were employed. For some clients, audio-only was required or preferred.
This survey presents a picture of inspiring resilience from both therapists and clients during a time of upheaval. Even more remarkable is the data that shows how this sudden shift may change the way psychotherapy is provided in California and across the country in the future. CAMFT asked its members what percentage of clients they would prefer to see via teletherapy once the COVID crisis is over and/or a vaccine is available. Recall that 86 percent of respondents had reported using “almost no” teletherapy before the pandemic. In sharp contrast, after using it for three months only 28 percent said they’d prefer to use “almost no” teletherapy after the pandemic is over. In fact, 12 percent said they’d prefer to see three-quarters to all of their clients virtually! Most respondents preferred a hybrid approach: 29 percent indicated they would ideally see up to one-quarter of their caseload via telehealth, 24 percent indicated they would ideally see up to one-half via telehealth, and 20 percent indicated they would ideally see up to three-quarters via telehealth. This data suggests a momentous shift in the way clinicians will structure their practices and in the ways people will engage in psychotherapy moving forward.
Impacts of Teletherapy on the Therapeutic Process
About 70 percent of survey participants answered open-ended questions about the negative and positive impacts of teletherapy on the patient-provider relationship. Of these, the great majority (92 percent) could identify at least one negative and one positive impact. A wide range of responses were given.
Perhaps not surprisingly, when asked to describe negative impacts of teletherapy, respondents often mentioned technological limitations. Almost a third of open-ended negative responses concerned interruptions in the therapeutic process as a result of technical glitches and connection problems. About the same number of respondents cited a diminished ability to observe micro-expressions, body language, and somatic cues, and to communicate nonverbally. As one therapist wrote, “There were too many technical problems (voice and video not syncing, tiled picture, etc.). Even when I was able to get a rather good connection, I felt it prevented my ability to see all nonverbal communication.” Another wrote, “In a recent session with a client, I couldn’t tell if she was crying or not because of the poor video resolution and pixelation. I had to ask, ‘Are you crying?’ Which wasn’t ideal.”
“A screen between client and therapist is not ideal” was a frequent sentiment in the negative responses. Many therapists mentioned concerns about loss of “closeness” and “connectedness” in the therapeutic relationship. As one noted, “There is a level of intimacy and certainly a depth to the work that is lacking.” Difficulty in creating therapeutic alliance and maintaining rapport was the single most commonly reported negative impact of teletherapy—more than 43 percent of respondents mentioned it. Some said teletherapy felt “very distanced and disconnected,” especially at first. Many wrote that this disconnect could be especially problematic with new clients who hadn’t first met the therapist in person to “ground” their “felt sense” of the relationship.
About a third of respondents also mentioned concerns about the negative effects of teletherapy on treatment effectiveness. One wrote, “I feel telehealth has impacted my ability to be as effective and intuitive since it requires different skills and information than in-person meetings, i.e., more verbal, fewer somatic/visual cues since I can only see neck-up on video.” Treatment concerns were especially notable for those practicing modalities such as somatic therapy and EMDR. These practitioners felt they either had to resort to other techniques or make less-than-optimal adaptations to their practices. One clinician wrote, “I am a body-oriented psychotherapist and at times do provide touch bodywork for trauma. I cannot see clients in person and so cannot provide this touch service.” Another shared, “I cannot do EMDR as effectively with clients online, so we are mainly working on distress tolerance skills and building resources.” Other concerns included doubts around the ability to observe and assess clients accurately. One clinician wrote, “Hard to do an effective assessment and get to know new clients via telehealth.”
Respondents also reported less client engagement in therapy, by children in particular and especially after extended periods of screen use, as in the course of online learning. As a result, some therapists reported shortening their sessions with young children or choosing not to see them at all; others were scrambling to develop new approaches. Substantial client distraction was also prevalent, especially with children and youth who were using other online apps, and with adults who were interrupted (or afraid of being overheard) by children, spouses, or pets. Indeed, as one clinician wrote, “For some clients, accessing privacy or a comfortable place for therapy is a problem … clients are using cars/rooftops/going on walks.”
In addition, therapists commonly mentioned “Zoom fatigue” or strain from extended screen use. One respondent wrote, “I’m a lot more exhausted using telehealth, and that limits how many clients I feel capable of seeing. I also have a much harder time remembering what has happened in session, and I feel more disconnected from the process and get less satisfaction from my work. While my clients continue to express that therapy is helpful and they don’t seem adversely affected, it is harder for me.”
Client loss was another negative impact, especially during the beginning of the pandemic. Clinician comments included “some clients stopped therapy due to the switch to telehealth” and “I have lost some newer clients who were not willing to make the transition.” In addition, respondents not infrequently voiced a preference for physical presence over telehealth (e.g., “it’s simply not the same as an in-person visit” and “the ‘vibe’ of in-person cannot be matched”). Outright rejections of telehealth were rare, but some clinicians were adamant. One noted, “I do not consider it a viable way to do psychotherapy.”
When respondents were asked to identify positive impacts of teletherapy, the most commonly cited benefit (48 percent) was simply the ability to continue the therapeutic process safely and “stay connected in this very difficult time.” The importance of continuing therapy even—and perhaps especially—during a pandemic that demands social isolation was palpable in the open-ended responses, e.g., “I can be there for my clients when access to the rest of the world is shut down.”
Approximately 44 percent of respondents applauded the convenience and flexibility of teletherapy for therapists and clients alike. Therapists stated that they could be more available to clients, or in the words of one respondent, “I am able to see clients all week at any time (not being restricted by office hours).” Many mentioned the benefits of avoiding long commutes, traffic jams, and parking tickets. And while some expressed sadness about giving up their offices, they were also happy to save on rent.
The benefits of this newfound flexibility seemed to go beyond logistical concerns to the quality of the therapeutic encounter. Many echoed the sentiments of one clinician, who wrote, “Clients approach therapy more positively because it is convenient, less disruptive of their day.” This convenience and flexibility has also led to a welcome trend of fewer cancellations and no-shows. In addition, teletherapy provided greater access to disabled clients who had difficulty leaving their homes or who relied on public transportation.
Many clinicians appreciated the loosening of geographic boundaries (at least within California) that allowed them to continue care when clients needed to relocate temporarily or move out of town. Some respondents mentioned that they now feel better able to attract new clients who live too far away to come to the office.
One surprising positive impact mentioned by almost one-quarter of respondents was that teletherapy sometimes promoted an improvement in the therapeutic relationship, especially after initial resistance on both sides had worn off and adjustments were made. One therapist observed, “Some clients have been much more open as I see them … via telehealth.” Some offered that this openness may stem from both sides feeling as if they’re “in the same boat” in weathering the crisis and so are grateful to able to do therapy at all. One described the therapeutic benefits of “modeling making the best of a situation that may not be optimal. So my clients and I learn together how this works.”
Respondents surmised that increased feelings of closeness or intimacy within the therapeutic relationship could also stem from therapist and client seeing one another more casually, “from the comfort of home.” Teletherapy was experienced by some as “almost like a home visit,” which allowed the therapist to “enter the client’s home and better understand contextual issues.” At the same time, as one clinician put it, “They see my home—that I’m human too and we are all in this together!” Other benefits cited included the ability to see multiple family members together more easily, perhaps even using multiple devices, and the ability to ask child clients to show off their favorite pets and toys in situ.
Interestingly, some responses suggested that the distance teletherapy imposes may actually provide some clients with a feeling of emotional safety that allows them to risk greater openness and vulnerability. Clinicians wrote, “Some clients have been better able to do deeper work with the safety of the technology barrier between us,” and “for clients with high social anxiety, it has allowed some to have lower levels of anxiety during sessions, leading to fewer cancellations and more emotional tolerance to address deeper issues.” Another therapist observed that a client with Asperger’s is “more open and talkative.” Yet another felt that being a little disconnected from the process was helpful for relationship therapy, writing, “For couples, I think I might prefer online because I feel like I can observe the dynamics better—I’m not in the dynamic in the room with them.”
Finally, some specific technical features of online therapy platforms were cited as being beneficial. For example, the chat feature has “allowed some clients to express things that they otherwise have difficulty expressing orally,” according to one therapist. Another respondent appreciated the ability to “upload and download homework activities without the demand of additional devices such as printers and ink or the pressure of finding resource(s) during an in-person session.” Some therapists even reported being able to “see and hear better,” thus improving their ability to observe clients’ cues, especially when using high-quality, high-resolution telehealth platforms.
Only a few therapists expressed unconditional enthusiasm for teletherapy, such as one who wrote, “Wow! It is great! I feel it is more intimate than sitting across a room from someone. Even using the phone as well.” Another said simply, “I love it!” Still, many appreciated that teletherapy held a potential they hadn’t seen before the pandemic pushed them to use it. As one respondent put it, “Pre-COVID I had a very dismissive attitude toward telehealth, and now I am very grateful to have it.”
Looking to the Future
The results of this survey suggest a sea change in the way both clinicians and clients are engaging with therapy. Few therapists or clients were attracted to teletherapy prior to the COVID crisis, but only three months into the initial stay-at-home orders in California we saw evidence of increasing adaptation to and acceptance of telehealth. In this survey, therapists reported that some clients who initially refused teletherapy eventually tried it and returned. Some therapists who were initially skeptical of teletherapy reported taking trainings or otherwise learning to make it “good enough.” “It is better than it was in the beginning,” wrote one respondent. Another said, “Even with new clients, it’s been much easier than I anticipated.”
One therapist summed up the experience of many by stating, “Having connection during this uncertain time has been very helpful for both client and therapist. Use of telehealth is demonstrating flexibility, connection, community, and a caring relationship continuing. It has helped clients see options for staying connected to family and friends in a new way. If they can do it with me, they can do it within their community. I get to see a bit of their environment, and they’re not all dressed up looking good for their appointments. It gives me a new perspective to add to the client’s depth.”
No one can predict how long we will be impacted by this pandemic. Meanwhile, the world continues to change rapidly, and the need for mental health care continues to soar. How will these changes impact the working lives of clinicians and the dynamics of psychotherapy? What role will teletherapy play 6, 12, or 18 months from now? These questions can only be answered with future research, but the initial findings are clear: Teletherapy is here to stay—at least for most therapists, some of the time.
This article was co-authored by Diane Schiano, PhD, LMFT, and Holly Daniels, PhD, LMFT on November 1, 2020, for the California Association of Marriage and Family Therapists (CAMFT).