I first met Rebecca A. Eldredge, PhD a little less than a year ago. She was moving to Traverse City, MI and she contacted me. I always love meeting with new clinicians. It’s great to welcome them to our beautiful area and find ways to connect. I never know how our skills and interests will overlap. Some people see new clinicians as competition, for me I just like getting to know new people in the field. More times than not, we both end up strengthening one another.
As I have said in past guest-blogger posts, I invite people to write for Practice of the Practice when I believe that they have skills, experience, or expertise that are beyond my areas of knowledge. Rebecca A. Eldredge, PhD is one such example. Her background in teletherapy is something I have yet to dive into.
She told me that once she started writing, she just kept going. That’s why I’ve divided her posts into three separate blog posts. Since this is such a new topic, devoting time and writing to it is important. Also, keep in mind that Rebecca A. Eldredge, PhD is not a lawyer, accountant and is offering her point of view. Make sure you check with your own state regarding teletherapy and what is allowed. With that said, take it away, Rebecca!
Evidence in support of teletherapy
By: Rebecca A. Eldredge, PhD
First, I was surprised by the presence and support teletherapy had already garnered. There was a lot of information out there, and beyond the fears and cautions of some, there was a wealth of research and examples about how teletherapy has been used, successfully. Many medical professions have been using electronic means of communication, treatment, and training for years.
There is a surprising amount of data within mental health as well, including some studies showing a lack of statistical difference in the effectiveness of face-to-face therapy from both video-therapy and even text/email therapy! Even the government seems to have embraced teletherapy, at least for specific circumstances, as they both provide it and reimburse for it within some federal systems (e.g. VA) and programs (e.g. Medicare).
Fear of Teletherapy
Despite all this data, experience, and circumstances of seeming need for teletherapy, there is an abundance of fear and mistrust of teletherapy in the mental health field. This is evident from the surprised expressions I get, particularly from colleagues in mental health, when I mention my use of teletherapy (the general public, however, seems to react with much more interest and enthusiasm). Many listservs appear to multiply professionals’ anxieties about teletherapy. What does it mean for traditional therapy? What are the legal pitfalls? Does it work? How does one do teletherapy? For whom is it appropriate?
We should decide
While there are some valid concerns and appropriate limitations regarding the uses and appropriateness of teletherapy, the amount of fear and mystery around it may inhibit the complex thinking and decision-making that we, as mental health professionals, use regularly in “traditional” therapy decisions. For example, as the therapist, we determine the modalities and settings of treatment with which we are comfortable, accept or refer clients based on our areas of competence and availability, and continuously assess and evaluate whether or not treatment is working effectively for the client’s needs, or, if not, what other changes might be appropriate. It is much the same with the assessment and evaluation process of teletherapy modalities.
Limitations to appropriateness of teletherapy
There is some general information out there on what’s been studied and what is or is not considered appropriate material for teletherapy. I found this to fall mostly into categories of common sense and thoughtful decision-making. For example, I did not, and do not, accept clients for teletherapy for whom there is a known or likely risk of danger to self or others. I communicate this with clients, I include it in a separate informed consent I require for teletherapy clients, and I ask clients to identify, in advance, their local emergency resources for any unforeseen circumstances. I also am clear with clients that their well being is the priority; if, at any time, we do not feel the teletherapy can meet their needs or provide the most benefit for them, I emphasize in advance that I will work with them to find a more suitable alternative.
In addition, I have declined to provide teletherapy for clients that wanted to continue to work together for whom trauma was a current and ongoing focus of therapy. For the work that I do, I believe that the interpersonal connection and personal presence is a crucial part of the healing required for trauma. As much as I cared about and felt a strong connection to these clients, I felt that their long-term benefits would be greater from working with someone who could be physically present with them, in the same room, as they encountered and faced the deep pain and memories of past trauma. This was not always a popular decision with these clients, particularly when we had established a safe connection, and yet, ethically and out of my concern for them, it was the one I came to accept and confirm again and again (and again, and again as I continued to struggle with and re-assess their preferences in combination with my professional expertise and perspective).
Trust, trust, trust
Similarly, I did not agree to provide teletherapy services for those with whom a strong alliance and or trust had not been established. If I am gathering self-reports from clients via video and across a distance, I need to be able to trust whether they are telling me the truth about how they are feeling, whether the therapy is effective, and whether they are a danger to themselves or others. Granted, there is no guarantee of this, even within the same room. However, for my own comfort and competence in providing teletherapy effectively, I felt the risks outweighed the potential benefits if a strong alliance had not been established. Consequently, I hoped it was also likely these clients would be able to make a smooth transition to a new therapist with whom they could work in-person.
It’s not for everyone
Lastly, teletherapy was not an option that all my clients requested or desired. There was one circumstance in which none of the above concerns were present; we had a strong alliance, she was not a risk to herself or others, and trauma was not a focus of the therapy work. However, as we explored options for transition related to my upcoming move and discussed pros and cons, the client identified the benefit she gained from coming to a physical location. It gave her a place to be and a reason to get ready and leave her home as well as providing a sense of emotional safety to let down her guard and know “this was the time and place” to be vulnerable and do the emotional work she had come into therapy to do. This was a valuable realization for the client, and one I completely supported. Her being able to identify it, I believe, may have also helped her to take an active role and come to peace with me leaving, a reality she had been struggling with previously.
The above are a sampling of the types of circumstances and issues for which I feel the potential limitations outweigh the potential benefits as assessed on an individual basis. As a result of this careful evaluation, I believe, I have had exceptionally positive self-reports from clients who have utilized teletherapy about their comfort and benefit from the format, reaffirming that for those for whom teletherapy is a good match, it is a valuable modality for providing therapy.
Rebecca Eldredge, PhD is a licensed psychologist currently residing and practicing in Traverse City, Michigan. She graduated with her doctorate in counseling psychology from Southern Illinois University at Carbondale, completed her predoctoral internship at University of Oregon’s counseling center, and finished her post-doctoral fellowship at University of Houston’s counseling center prior to beginning her independent practice in Houston, Texas. Her professional passions include offering individual and couples therapy to adults, working with and facilitating trainings for cultural competency and diversity, and providing clinical supervision. Based on these interests, Rebecca has also enjoyed working with refugee support programs, teaching applied clinical courses, and engaging in local volunteer and advocacy opportunities. Rebecca’s personal passions include the outdoors, travel, and connections with family and friends.
Photo from Creative Commons, thank you dgbury