For a century, when we’ve thought of therapy, many of us have thought of the places where it happens: the clinic, the ward, the institution. Most prominent among these spatial associations may be the so-called consulting room and its accoutrements: a box of tissues, a covert clock, chairs and perhaps a couch, the waiting room, buzzers, a white noise machine humming, out-of-date magazines. Beyond the iconicity of the container itself, the office has also offered patient and therapist alike a reflective space seemingly apart from their experience of the world. The office allowed patient and therapist to meet in a confidential, secure location, one ostensibly free from the distractions or sounds of work and family.
But for the last year or so, this de facto and idealized therapeutic place has been unavailable to most mental health care providers and their patients because of mandated social distancing. As a result, FaceTime and Zoom, proprietary medical platforms, and apps have become the dominant spaces of therapy.
Before the pandemic, teletherapy—mental health services delivered via technology—was considered the shadow form of mental health care. It is now the default. But as vaccination rates rise in the United States, therapists and their patients are now increasingly able to consider where they might want to see each other once again. For some, vaccination has marked an end to teletherapy and a return, quite literally, to the physical treatment space.
Given the long-held attachment and import of the therapeutic office, it makes sense that for some therapists, a life of Zoom sessions was an exception, rather than a new rule. These therapists argue for a swift and immediate return to the office—or have already been there, masks on and windows open, sanitizing between sessions. These clinicians are committed to the idea that a certain kind of therapeutic co-presence can only be achieved by two (or more) bodies in the same room. I’ve even heard more than one therapist use the analogy, on listservs and in hushed voices, of sex with condoms (in the negative) to describe video therapy. Remote therapy is posed as a barrier, even as it has diminished other blocks to treatment.
Tech produces medium-specific forms of what I call “distanced intimacy” which, rather than undermining embodied togetherness and attachment, allows for unexpected kinds of human-to-human communication.
But for other practitioners, technology, and the momentarily loosened regulations around it, broke the default of private practice in a private office and exposed its optionality. Being freed from a commute, expensive rents, and the monotony of seated listening was, well, liberating. Now, those practitioners argue, there is no going back—at least not full-time. Perhaps more importantly, other clinicians, who might previously have assumed that the phone or Zoom might thin out the intimate connection to the patient, have discovered instead that not only does teletherapy work for them, but they prefer it for many patients as a clinical tool.
For those mental health clinicians who rely on interpretation-as-method, how to interpret a patient’s unwillingness to attend an appointment in person is a new challenge. Is it resistance or safety seeking? Yet this exposes a new turn in therapy, where power to set the framework of therapy is more equitably held between patient and therapist. Where to practice is not a therapist’s choice alone; even if a clinician moves back to the office, patients must be willing to join them. And while for some patients pandemic teletherapy meant a lack of privacy needed to pursue therapy (or in other cases lack of the means to do, so like a stable internet connection), many long-standing patients found nearly the opposite: that therapy mediated via technology—whether phone, app, or Zoom—can do something extremely useful.
If the pandemic finally made teletherapy ubiquitous, technologies have always played a central role in these caring interactions. As has been true across teletherapy’s long history, some patients feel uniquely free to participate in therapy precisely because the body of the therapist is somewhere else, held at a distance. Tech produces medium-specific forms of what I call “distanced intimacy” which, rather than undermining embodied togetherness and attachment, allows for unexpected kinds of human-to-human communication. For patients who need the shield of anonymity to get in touch with their emotions, for example, or those who find it easier to express anger when they are physically alone, distance can make intimacy more possible.
Teletherapy can be more accessible and add variation to the otherwise punishingly one-size-fits-all model of office-bound care. This has been a revelation for many, especially those marginalized or pathologized in those modes of care. Teletherapy removes some of the power dynamic inherent in expert care. Patients can choose not to be seen or be seen partially; they can show their actual space of living or not, can meet with a practitioner farther away than they could ever travel or otherwise access regularly. Additionally, patients don’t have to commute, which means fewer minutes away from work or other care duties.
Other patients (and therapists) may be anxious about what it means to try, perhaps impossibly, to resume life and work as it was before.
Many report that they have relished the safety of dislocated treatment—and everyday life—especially in the midst of a catastrophic pandemic. Finding their way back out isn’t a simple matter of the vaccine. Though it’s constructed around the exchange of money, therapy is a deeply intimate relationship and a litmus test for coming back together (or staying apart) on the other side of this traumatic year. How we do so is both psychologically as well as materially situated, with immunocompromised people still unable to safely enter the public, many still out of work, schools remote, and childcare difficult to find.
One risk, then, of yet another debate about whether teletherapy is “good” or “bad” (acceptable, better, worse, as intimate, more intimate, or less intimate) is that it can become a conversation that further economically classes presence, embodiment, distance, and access to mental health care only for those already able to purchase this care.
Contemporary teletherapy, like many digital interventions or disruptions, often promises us democratized care. That, by harnessing various tech-enabled therapy models, we will finally be able to send therapy to all who need it. Though corporate teletherapy apps are frequently evangelized as increasing access, they are often only provided via employee insurance or paid for out of pocket and, in some cases, are thus not much more affordable for being tele-. It’s also worth noting that with a sudden move to teletherapy en masse, we risk remediating a whole host of deeply entrenched problems that affect patient and therapist alike—including labor, data privacy, and therapeutic confidentiality concerns—at scale.
And yet, mental health care is so easily enfolded into a technology model in part because there are so few affordances health insurance plans make for therapy in private practice, and too few practitioners to go around. In short, mental healthcare is so broken that we’re desperate for solutions. In a pandemic deeply exacerbated by inequality and disproportionate access, the sudden switch to teletherapy opened some, but certainly not all, barriers to psychological care. This is perhaps most true for historically underserved and ignored communities where purchasing care has been exceedingly difficult. In a nation where health insurance is tied to work and where the system of reimbursement for in-network and out-of-network mental health care providers is exhausting to learn and deal with (for providers and patients alike), suddenly 4 out of 5 of the big insurance companies waived the co-pay for teletherapy in March of last year. New patients were only willing to come into therapy (for psychological reasons) or able to access this form of care (for material ones) because it had been made remote. In tandem, HIPAA enforcement was loosened to allow the use of Zoom and other consumer-friendly tools, precisely because medical-grade communications were failing. Now, those points of access are slowly being withdrawn as insurance deems that we are no longer in an emergency state—just as Delta ramps up in the United States.
When we reduce the clinical debate around teletherapy to the question of its goodness or flatness, the debate, however falsely, centers on a choice and a resulting clash between those clinicians who are eagerly anticipating safe, close contact with patients in the quiet room of yore and those who have adapted and are loath to let go of this new digital way of convening intimacy. And of course, for these practitioners, the stakes are about as huge as they come: what constitutes good care in the 21st century.
Psychoanalysts joke about the impossibility of imagining Freud’s Zoom room. Therapists are now faced with how to adapt to technology and safeguard the legacy of clinical practice (either by preserving it or shifting it), and this solemn question of care. Yet alongside these arguments is also a desire for continuity, borne out of a notion that this is how therapy has “always been done.” Gathering together in the office is a longstanding custom. But this is only a partial view of therapy’s history. Teletherapy may feel “obtrusive” right now to some eager to return to the scene traumatically abandoned in March 2020, but telecare has been with us across the 20th century—long before therapy apps came to dominate the conversation.
Ever since early practitioners of the “talking cure” stopped laying hands on patients as part of hypnosis, some intervening distance between therapist and patient, however minute, has been deeply important in regulating therapeutic intimacy. Teletherapy is as old as psychoanalysis, and Freud himself practiced a version of it through letter-writing. In the intervening century, as therapists have worked to batch-process patients, psychopharmacological and psychoactive drugs, short-term therapies (like CBT), and yes, technology, have each been used— sometimes in concert with one another—to address the problem of therapeutic supply and patient demand that has been a pressing concern since at least World War I.
This too frequently means that when we talk about the paucity of care available, we are always talking about access, affordability, and the availability of mental health workers. In a way, we can reprise the terrain of Freud’s 1918 speech, “Lines of Advance in Psycho-Analytic Therapy,” in which Freud argued for psychoanalysis for all in the aftermath of World War I—even if it meant giving up some of the cherished assumptions about what analytic practice might be like in its schedule, location, modality, and fee. Freud, tellingly by way of a metaphor of precious metal, argued for a “psychotherapy of the people”: “We shall then be faced by the task of adapting our technique to the new conditions … It is very probable, too, that the large-scale application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion.”
“Large-scale” is now a prerequisite for access, but the ability to offer therapy for free is key. Teletherapy, across its longer history, has almost always been offered for free or at a low cost by activist practitioners, community members, and experimenting psychologists. They have “alloyed” the pure gold of psychotherapy, as I argue in my book, The Distance Cure: A History of Teletherapy, with silicon. Technology has expanded the reach of the therapeutic office by dissolving it, and not just because it increases that scene’s material reach over distance. Once one assumption about what therapy must look like goes out the proverbial window, so do other assumptions about where and when and for whom therapy might be made available. If therapy is not constrained by the office, perhaps it may follow that we can both, as individuals and systemically, reimagine a therapy that must only be invested in emotionally rather than economically by its patients. When we insist on in-person treatment, we are perhaps insisting on a kind of purity of genre, of payment, and ultimately—as Freud knew—of the kind of patient who can be seen in the consulting room.
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