The surprising intimacy of online therapy sessions during the pandemic

(Paige Stampatori for The Washington Post)

Lori Gottlieb is the author of “Maybe You Should Talk to Someone.” She also writes the Atlantic’s “Dear Therapist” column.

If you had asked me what I thought of online therapy sessions before the coronavirus pandemic, I would have said, trying my best not to sound dismissive, “Well, I’m sure they can be helpful in certain ways — but I wouldn’t call them therapy.”

What I meant was that online therapy seemed to go against the core of what I do as a therapist, which is to be present, literally and figuratively, with my patients. It’s not just the words people say or even the visual cues that therapists notice in person — the foot that shakes, the quivering lower lip, the eyes narrowing in anger. Beyond hearing and seeing, there’s the energy in the room, the being together in a shared space with no distractions, the mutual carrying of silences in the few feet between therapist and patient — all of which contribute to the patient’s experience of “feeling felt.” You lose that ineffable dimension when you aren’t sharing the same physical space, which is why a colleague once said that screen-to-screen is like “doing therapy with a condom on.”

But then came covid-19, and with shelter-at-home orders in place, I had no choice but to do remote sessions. I was glad I’d still be able to help to my patients, but I was skeptical that these sessions could go beyond crisis management. I signed up for a HIPAA- or Health Insurance Portability and Accountability Act-compliant platform for therapists, and when I saw the “virtual waiting room” feature, I laughed at the attempt to mirror the real experience. What are they going to have next? I thought. A “hand offering tissues” icon?

As I expected, the first day of sessions was nothing like being in the office. In search of privacy, people were talking to me from closets and cars, laundry rooms and bathrooms. In training, therapists are taught to “meet patients where they are,” but now the phrase took on new meaning. I heard kids arguing about screen time; watched cats jump over patients’ keyboards; saw spouses popping their heads in to ask a question and tried to tune out roommates talking loudly on their own calls in the background. It was the opposite of the sanctuary of the therapy room.

But by the end of the day, instead of feeling distanced from my patients, I was surprised to find that I felt closer to them. Online therapy, it turns out, provides a sense of intimacy I hadn’t anticipated.

Maybe it has to do with a leveling that takes place when we see inside each other’s homes. A typical therapist’s office, no matter how welcoming we try to make it, is still a professional space: couch, therapist chair, diplomas or abstract art on the walls, therapy-related books on the shelf and the conspicuous absence of anything that might reveal a clinician’s personal life. But to me, it seemed almost silly to try to curate a spot like this in what was clearly my bedroom. Even putting a blank wall behind me felt disingenuous, a way of pretending that I wasn’t sitting in my home just like everyone else.

Soon I traded my pressed work blouses for oversized sweaters and comfortable T-shirts. I didn’t try to cover when the washing machine beeped, the neighbor’s dog barked or my son yelled, “Mom, are you done? It’s lunchtime!” I felt freer with my patients, and they seemed to be freer with me, going places we hadn’t ventured before. Letting go might be easier while wrapped in a cozy blanket on your old armchair, sipping tea from your favorite mug. We therapists try to make our offices feel like safe spaces, but the safest space might actually be the one our patients have created for themselves: their turf, not ours.

There’s also the serendipity that happens in a different setting. One man who conducted his sessions from his toilet seat shared that being there reminded him of his childhood, when he would escape to the bathroom to avoid hearing his parents fight. He said he retreats there now when he senses his wife is angry as a way to avoid talking to her about it, something I may never have learned had he not been hiding in the bathroom for our sessions.

Another patient was sitting in her car outside her house when a bird landed on her hood, prompting her to tell me about the harrowing death of her pet parrot. In another patient’s apartment, I noticed a cello in the background and learned that my patient played daily but had never mentioned it in my office. Recently, I’ve watched patients interact with a child, partner or sibling I’ve heard about for months or years but had never seen, and an aspect of that relationship was newly revealed.

Machines of course, have their limitations. More than once I’ve been unsure if a pause in the conversation has meant that the screen froze, or if we were sharing a meaningful silence. When we emerge from the coronavirus, I’ll go back to in-person sessions. But I’m grateful for these remote sessions because they’ve been both an illuminator and an equalizer, breaking down the facades we all construct and highlighting our shared humanity. And in that sense, maybe I’d call them therapy after all.

Watch Opinions videos:

Read more:

Kenneth Paul Rosenberg and Chirlane McCray: The coronavirus is a mental health emergency, too. We must remove barriers to care.

Michael Leonberger: Weathering the coronavirus pandemic with an anxiety disorder

Jason Cherkis: The covid-19 pandemic has shocked the mental-health system out of complacency

Jack Turban: How I am prioritizing my psychiatry patients amid a pandemic

Melinda Gates: How rethinking caregiving could play a crucial role in restarting the economy

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