Is Virtual Psychotherapy of Lesser Quality Than In-Person?

This article originally appeared at Mad in America on November 23, 2024.

“Going to therapy,” once meant quite literally, going, or leaving the house and traveling to the therapist’s office, which was endowed with a certain cultural cache as a socially sanctioned place for people to go to share their most troubling and troublesome thoughts and feelings. Therapy started when you left the house, which is reflected in the oft-uttered phrase I hear clients use: “On the way here I was zeroing in on what I wanted to talk about during today’s session.” A Gen Z client of mine aptly refers to this as “dropping in,” or cutting beneath his distracted, overstimulated, externalized existence to tap into wellsprings of genuine inner experience. Dropping in speaks to his need to enter the same physical space as me, which allows him to more thoroughly drop into his inner world of experience.

In-person sessions involve the ritual of sitting in the waiting room, walking back to the therapist’s office, leaving the outside world behind, and entering a physical space demarcated for honest self-exploration, inwardness, and experiential immersion.

It is the bedrock privacy afforded by crossing the threshold into the inner sanctum of the therapist’s office that frees clients up to abandon social pretense and be boldly honest. Now that online therapy, or its synonyms—teletherapy, behavioral telehealth, virtual therapy, internet therapy—is widespread in the mental health field, the treatment frame is often inverted such that instead of clients visiting the therapist’s room, the therapist is visiting the client’s room, or car, or favorite neighborhood walking route.

What are the privacy implications of this? How inwardly honest and honestly inward—in a sustained, engrossed way—can clients get when there is fear of random breaches in privacy? Last week the following events occurred while I was conducting virtual therapy sessions with clients:

I conducted an internet session with a client who was in his car on a busy street (he assured me he was comfortable with this arrangement) using his phone. He ranted over the fact that his wife seems to treat him as another child in the house whose needs exhaust her. Unbeknown to him his phone paired with that of his wife’s via Bluetooth and she listened in briefly before my client caught on and ended the call.

During a virtual session with a male client who could not attend in person because his two young sons were home sick from school, he mentioned that his wife was having difficulty corralling them and keeping them entertained. They were yelling “dadda, dadda” outside his door desperately trying to capture his attention.

When virtual therapy spaces are not hermetic and there is the random possibility of intrusions upon privacy, how deeply into matters of emotional concern can clients venture?

On the therapist’s end, what about the ritual of commuting to the office, gathering one’s thoughts, “getting in the zone,” gearing up for the workday? Of being at the office where the ambient associations are largely, if not exclusively, related to “doing therapy?” This is in contrast to the ambient domestic associations therapists encounter doing virtual sessions at home, steps away from places and spaces where you dine, defecate, pee, watch TV, sleep, and have sex. How does a therapist effectively tune out domestic matters when therapy is provided in a domestic sphere?

What about the aesthetic needs of therapists, to be in an office of their design, that puts them at ease, the predictability and constancy of the imagery allowing for a real settling in experience with clients—a zone of comfort that emboldens them to constructively engage with clients’ emotional discomfort? This is in contradistinction to not knowing when you jump on the screen what type of background imagery you will encounter that may put you off kilter, no matter how slightly.

What are the implications for the changed ritual of session endings? The absence of friendly handshakes, hugs, pats on the back, walking out into the waiting room together—the small reassuring gestures of rapport and affirmation before clients returns to the “real world,” where keeping up social pretense, tolerating the intolerable, and assaults on their everyday coping skills reenter the picture?

A body of literature is emerging on therapists’ telepresence—their ability to be empathetic, caring, and fully engaged void of sharing the same physical space as clients. For effective therapy to unfold it is commonly accepted in the field that a strong alliance be formed, where therapists are adept at tuning into clients’ moment-to-moment shifting feelings and responding in attuned ways that leave clients feeling recognized and understood. Facial communication is important in this endeavor. Especially the well-timed, well-synchronized head nods, grimaces, eye rolls, furrowed brows, smirks, and grins on the part of therapists—the microexpressions of attunement—that add that special quotient of approval and felt-connection for clients. Can two-dimensional facial communication ever provide what the three-dimensional variety offers? What if the therapist’s face is washed out, darkened, or opaque due to bad lighting or an unstable internet connection? Not surprisingly, some research exists substantiating how the rapport and alliance building formed during teletherapy sessions falls short of that achieved when clients attend psychotherapy in person.

There is also the fact that virtual therapy omits therapists’ and clients’ full embodied presence. Bodies communicate with bodies during in-person sessions. As odd as it sounds, when I am conducting therapy, I listen and respond not just with my ears and mouth, but my eyes, hands, fingers, feet, legs, torso, and lungs. In the therapy literature this is called “dyadic synchrony.” The pre-conscious and unconscious ways I breathe deeply or shallowly, shift from a closed to open body posture, clasp and unclasp my hands, lean forward or backward in my seat, fold or unfold my arms, tap my foot or keep it still, stretch or bend my legs—all in response to how I am experiencing what is going on with a client. We are learning that these forms of non-verbal communication spontaneously expressed by therapists—mostly covertly—are fundamentally important to cement a feeling of true rapport with clients.

In fact, when these bodily forms of subliminally relating to clients are missing there is some evidence to suggest that clients drop out of therapy prematurely because they feel their therapist is not relating to their problems in deep ways. Therefore, it should not surprise us that in the emerging post-Covid delivery of mental health care the vast majority of clients prefer in-person psychotherapy. A 2024 Psychotherapy Action Network (PsiAN) survey revealed that 78 percent of clients prefer in-person psychotherapy, while only one-in-three believed that virtual therapy was as effective as an in-person arrangement. Since one of the core features of ethically minded, evidence-based, provision of psychotherapy in the mental health field is client preference, providers may have a professional obligation to offer in-person care to those that desire it.

More far-reaching ethical concerns need to be considered. Insofar as society adopts a two-dimensional, virtual approach to psychotherapy, are we unwittingly playing into the platformization and deprofessionalization of the field where psychotherapy is simplified, genericized, automated, framed as a reprogramming experience that is managed and overseen using algorithmic procedures curated and overseen by large corporations and health management companies, where psychotherapists are expected to function like gig workers offering therapy as a side-hustle, alongside or competing with Chatbots that supposedly offer evidence-based care?

If psychotherapists and their clients are too overzealous in adopting virtual therapy for convenience-based reasons—saving time on commutes, opening up access by overcoming the geographical constraints to seeing therapists in person—are we contributing to the depersonalization and loneliness that has hollowed out social life in our culture in general? Is one of the antidotes to Zoom fatigue, Chatbot cynicism, virtual dating, cancel culture due to unfiltered honesty, a private in-person relationship with a flesh-and-blood therapist?

Now that virtual therapy is here to stay, a social reckoning is required to reach beyond the issues of broader access to psychotherapy brought about internet-based care. We need to address quality control concerns that, perhaps, will always favor in-person psychotherapy. I, for one, take the position that online psychotherapy, at best, can be adequate, but not optimal. Along these lines, I endorse that we label it distance therapy, because this simultaneously captures how it is delivered in a format where therapist and client do not share the same physical space, and concedes that telepresence is a lesser form of embodied presence.