Through the Lens: Telepsychotherapy and the Working Alliance

The provision of tele–mental health services was initiated in the early 2000s as a means of providing treatment access for individuals, primarily in rural and remote areas, or those for whom disabilities rendered travel to the clinician’s office a serious hardship. Research has expanded on the technical, legal, and effectiveness outcomes of telepsychiatry since that time (1, 2). Historically, psychotherapists considered video therapy to be a less optimal modality for therapeutic alliance and outcomes (3, 4) and it was predominantly used for those who had no other way to obtain treatment. The onset of the COVID-19 pandemic brought a rapid transition to almost exclusive care through teleconferencing. In-person treatment was provided only for the seriously medically ill, as families isolated to prevent illness and viral spread. The psychological distress associated with the virus, as well as the reduced access to in-person mental health services, accelerated acceptance of videoconferencing as the modality by which psychotherapeutic services were delivered. Videoconferencing became the new norm for the provision of psychotherapy and other mental health services (5–7).

According to Mental Health America (8), the number of people seeking help for anxiety and depression has skyrocketed since March 2020, the month that marked the initiation of the COVID-19 pandemic shutdown in the United States. Loneliness and isolation are frequently identified stressors affecting emotional well-being. Although rates of anxiety, depression, and suicidal ideation are increasing across the United States, Black or African American youths have experienced the highest increases in anxiety and depression, and Native American and LGBTQ+ youths have experienced the highest rates of suicidal ideation (8). Emergency department visits for teens have increased by almost one-third, compared with prepandemic rates. Among adults, racial-ethnic minority populations, essential workers, and unpaid adult caregivers have experienced disproportionately poor mental health outcomes since the pandemic’s onset, with increases in suicidal ideation and substance use disorders most commonly reported (9). With this crisis comes an ethical imperative to improve access and to optimize effectiveness of psychotherapeutic treatment.

One of the strongest components of psychotherapy and mental health treatment efficacy is the therapeutic alliance. The therapeutic alliance has been consistently linked to positive treatment outcomes and to patient satisfaction, irrespective of psychotherapy modality (10–12). The widespread use of telehealth psychotherapy necessitates investigation into the following question: Is telehealth psychotherapy as effective as in-person psychotherapy?

A review of the literature (13) suggests that telehealth psychotherapy has generally shown effectiveness and patient satisfaction levels comparable with those of in-person psychotherapy. Results of a systematic review (14) have shown that, in general, patient ratings of satisfaction with psychotherapeutic interventions and therapeutic alliance in treatment are comparable between remote telehealth and in-person delivery. Interestingly, although patients rated alliance comparably between telehealth and in-person psychotherapy, their psychotherapists rated their own levels of therapeutic alliance with patients as lower for sessions conducted via videoconferencing compared with sessions conducted in person (15).

Some researchers have suggested that video therapy may provide enhanced opportunities for self-expression, connection, and intimacy, as compared with in-person sessions. According to Simpson et al. (16), “the more neutral therapeutic ‘space’ provides clients with multifarious opportunities for self-awareness, creative experience, and collaboration, with potentially a greater sense of agency over their own experience.” Patients with mood disorders and anxiety-based disorders, such as social phobia, agoraphobia, obsessive-compulsive disorder, and other groups of patients may find the online environment more comfortable and less threatening than the in-person setting (16, 17).

Clinical Vignette

Dr. Becker sauntered into her living room and sat at her desk in front of the computer. She donned a well-pressed blouse and jacket, along with sweatpants and sneakers—her usual work attire these days. It was time for her first appointment with Jaina, an 18-year-old college freshman who was home for spring break. Jaina had experienced anxiety and depression intermittently throughout her adolescence, but she and her family had never sought treatment. She found the academic and social demands of college difficult to negotiate. She experienced a panic attack during her science midterm exam in the fall semester and was mortified when she received a D grade as a result. She self-harmed by cutting herself superficially that night—something she had never contemplated previously. She had sought extra help from the professor, but he had merely advised her to put more time and effort into learning the material. She was sleeping poorly and found herself ruminating about the possibility of another panic attack during the final examination. Her boyfriend of several months had been supportive at the time. Last week, however, he confided that he was not ready to commit to a relationship and wanted to “just be friends.”

Jaina was distraught and began to wonder if life was worth living. She sought out her dormitory resident assistant (RA) and voiced this thought. The RA let administrators know of the concern, Jaina’s parents were called, and they picked her up from the State college that same day—the week prior to her 2-week spring break. Dr. Becker had agreed to provide a telepsychiatric evaluation and recommendations for Jaina and her family.

Dr. Becker logged onto Zoom, an online videoconferencing program, and soon Jaina’s face popped onto the screen. Jaina was an attractive young woman, casually dressed in her college sweatshirt. She sat perched on her bed, using a cell phone for the video call. Dr. Becker smiled warmly.

“Hello. Good to virtually meet you, Jaina. My name is Dr. Marcy Becker.”

“Hi,” Jaina replied. “I’m Jaina.”

She moved her cell phone behind her and took a “selfie” before returning to look at the screen.

“I just want to show my friends that I actually finally saw a shrink,” Jaina said flippantly. “It’s my first time. Should I lie down and free associate on the couch?” she inquired, as she flopped backward onto her bed.

“So, you haven’t met with a psychiatrist or therapist before,” Dr. Becker said. “Perhaps it feels uncomfortable. I can tell you a bit about who I am and about the video session.”

After receiving permission to conduct the session through videoconferencing, reassurance that the session was not being recorded, and ensuring that Jaina was in a safe and private space, but that a parent was at home to ensure safety, Dr. Becker proceeded.

“I understand that college has had its challenges. I’m interested to hear about your experience and how I can be helpful,” Dr. Becker began.

“Well,” Jaina began in a dramatic tone, “here’s what happened.”

Dr. Becker was perplexed by Jaina’s theatrical presentation. She patiently nodded as Jaina began to speak of the events leading to her despair. As Jaina spoke, her voice became more serious, and her eyes moistened with tears.

“You see, doctor,” she proceeded, “my senior year of high school was really disappointing. My grandmother lives with us, and she has diabetes, so we had to be super, super careful so she wouldn’t get COVID-19. Almost all of my junior year of high school had to be virtual. And my dad had to close his business. My mom doesn’t work, so all of a sudden, there wasn’t enough money. I hate to admit it, but I’m a spoiled only child, and I’m used to getting what I want.”

Jaina paused briefly and left to get a tissue.

She continued, “I have been so lonely with the COVID-19 pandemic and all. We couldn’t even have senior prom. So, when I got a really good scholarship to go to State, it was a relief, because we could afford it.”

“The pandemic has been devastating for you and your family,” Dr. Becker reflected.

“It really has,” Jaina nodded as tears began to roll down her cheeks, “but I was doing okay, except for science. It was hard, and the professor didn’t really help. He basically said to work harder. But I was working hard. I stayed up at night studying to do better. But I couldn’t really concentrate. You see, if I panic again and get a D in the class, I lose my scholarship. Then I can’t keep going to college.”

“You have been under enormous stress. And you began to feel hopeless? Like you wanted to end your life?” Dr. Becker queried.

“Well, I hadn’t really thought it out. But when my boyfriend broke up with me, it felt like the last straw. I’m a burden to everyone!” Jaina sobbed.

Dr. Becker leaned in toward the screen. She didn’t feel she could provide comfort as she would in the office—by getting tissues and being physically present. She exaggerated her head nod instinctively to convey her empathy. When Jaina’s crying stopped, Jaina peered into the screen, appearing embarrassed. She turned the camera to the ceiling, so as not to show her face.

“You must hear this all the time,” Jaina said, again with a feigned, dismissive tone.

“You have really difficult things to deal with. You don’t need to feel alone with your pain. Thank you for helping me understand,” Dr. Becker said, looking directly at the camera on her laptop.

Jaina’s eyes met hers.

“So, are we ready to make a safety plan and a therapy plan going forward?” Dr. Becker asked. “Sometimes psychiatrists provide medication therapy, and sometimes psychotherapy and medication, if needed. Would you like me to find another therapist for you, or do you feel comfortable working with me?” Dr. Becker inquired.

“Uh—are you ok seeing me? I think you understand me,” Jaina said.

“Deal!” Dr. Becker replied with a warm smile. “But remember, honesty is really important. You are a kind person and don’t like to hurt anyone’s feelings. But we can be honest here.”

They reviewed the Columbia-Suicide Severity Rating Scale. Jaina had intermittent suicidal thoughts, but no plans to act on these thoughts, and was motivated for treatment.

Jaina called her parents in, and they reviewed a safety plan, including ensuring there were no weapons in the home and locking up medications. They reviewed hotline and emergency numbers, how to reach Dr. Becker, and how to set up another appointment.

“See you soon!” Jaina said, as she waved at the camera and turned it off.

Considerations for Telepsychiatric Sessions

The differences between psychotherapy via videoconferencing and psychotherapy in person may have an impact on how the therapeutic alliance is developed. Both the patient and the therapist can typically see themselves on a videoconference. This view provides an opportunity for receiving feedback on nonverbal facial cues (e.g., one can check to see if one’s facial expression demonstrates empathy) but also may be distracting and detrimental to therapeutic communication (18). Direct eye contact, tone of voice, and ability to use posture and body movements to convey attunement and openness may be hampered by video (19). An unstable Internet connection, a frozen screen, delayed audio, or poor lighting are some of the difficulties that can impair engagement in therapy (20). Other distractions that are less obvious via video than in person, but that may impair therapeutic engagement, include cell phone use, others in the home, simultaneous medical record documentation, pets, outside noise, and other disruptions that may sidetrack the patient and/or the therapist. Despite these potential hinderances, results of multiple studies (21) have concluded that a therapeutic alliance can be successfully formed via teleconferencing. Lopez and colleagues (22) concluded that videoconferencing psychotherapy “…is a viable modality with the potential to improve access to care with a low impact on therapeutic alliance.” Establishing a collaborative mutual partnership, in which the therapist and patient work together to set realistic goals, reach agreement on the specific tasks of therapy, and form a trusting therapeutic bond, is a vital component of psychotherapy that may be forged in person or via videoconferencing (12). See Table 1 for a summary of the advantages and disadvantages of telehealth psychotherapy. The next section provides suggestions for conducting remote tele–mental health sessions (16, 22).

Tips for Conducting Sessions Via Videoconferencing

1. Therapeutic alliance: Highlight from the first interactions the importance of forming a strong working alliance consisting of shared decision making, agreement on the tasks and goals of the therapy, and development of mutual trust.

2. Introduction to teletherapy: Provide the rationale and technology being used for teletherapy (including directions for accessing the platform if needed).

3. Orientation and information about teletherapy: Provide written information and consent forms to explain the process and ensure agreement with the videoconferencing platform. Ensure the patient has good Internet connectivity. Specify whether the sessions will be recorded (typically only relevant for trainees receiving supervision).

4. Risk management: Develop a collaborative risk-management plan to ensure patient safety, including steps to take for acute safety concerns, securing the living space from dangerous items, and assuring the patient is in a confidential location for the appointment. The safety plan should include mobile crisis service contacts, specify when an emergency department evaluation is required, and clarify the plan for communication outside of appointments. Ensure that communication is possible for emergencies but set appropriate limits to decrease dependence.

5. Technology enhancements: Ensure appropriate lighting, good Internet connection, and a HIPAA-secure videoconferencing platform. Headphones may improve privacy and decrease external sounds.

6. Interpersonal communication enhancements: The therapist will need to move in toward the screen more actively, check in with patients, and move the patient’s image toward the top of the screen and closer to the camera lens to demonstrate eye contact. Gestures may need to be exaggerated (especially if the patient is using a cell phone).

7. Boundary maintenance: Establish a therapeutic contract that clarifies time and financial and confidentiality commitments; dress as professionally as in the in-person sessions; ensure sessions take place in a private space; use a separate workspace when possible and/or use the background blur feature on the videoconferencing platform or other means of maintaining home privacy; do not accept social media invitations from patients; clarify methods of communication for nonemergent questions or concerns when not in session.

8. Self-care: Build in breaks to avoid “Zoom fatigue,” also called virtual fatigue, which is the mental exhaustion caused by frequent videoconferencing.