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Is In-Person Therapy Different From Teletherapy?
Understanding how we will deliver therapy in the future.
Posted March 5, 2022 Reviewed by Vanessa Lancaster
Key points
- During the COVID-19 pandemic, therapists shifted to teletherapy almost overnight.
- Some therapists think teletherapy is as good as in-person therapy, while others sense differences.
- Animal models suggest that the presence of another being of the same species enhances well-being.
“OK, we’re out of time for today.” I smile and stand up. The patient stands and crosses towards me. I back up and walk towards the door. I smile again and look at the patient, they look at me, and then they walk out. I have a warm feeling as I close the door.
Nothing unusual about that do-si-do. I’ve done it hundreds if not thousands of times during my career. Except that we’re two years into the COVID pandemic. We spent months—even years—seeing everyone outside of our “pod” via Zoom. That included our therapy patients. So the opportunity to be together in a room seems miraculous. Yes, we’re wearing masks, but I see the patient’s “eye smile,” and they see mine. We move together in space. I see the snow on their boots and the back of their head. We are together.
But is it important for treatment? In March of 2020, teletherapy saved the day. Overnight, mental health providers all over the world began seeing patients online. Treatments continued, and new people were seen. We learned about virtual waiting rooms and blurred backgrounds. We met pets and got house tours. We wore nice tops over sweatpants.
A computer placed at the back of a couch helped approximate the analytic situation. We were happy not to commute and to eat lunch at home. As we watched the numbers of depressed and anxious people soar, we patted ourselves on the back for adapting so quickly and being able to respond to the growing need. We saw patients who lived far away.
Articles in the most prestigious journals predicted that teletherapy would outlive the COVID crisis. Some said we’d never go back. Was this just as good?
Now that I’ve started to see patients face-to-face again, I sense that the answer to that question is no. When I see patients in the office—even when we both wear masks—I sense that they can get deeper into issues and confront more difficult feelings. I sense that my patients and I can tolerate more silence and appreciate more nuance. I have a better sense that we understand each other. I feel more connected to my patients and my work. Since I only have my tiny "n," I asked colleagues if they felt the same way. Those who are back in the office say yes. We are, though, a self-selected group. We all want to be back. But this is just our “sense.” Are we right?
As a therapist and psychoanalyst, it seems intuitive that physically being with another person matters. Harry Harlow demonstrated that even having a terry cloth mother helped baby monkeys, but therapy isn’t about touch. Could just being in a room with someone else make a difference?
I posed this question to a group of neuroscientists. They pointed me in the direction of social buffering, defined by Kiyokawa et al. (2012) as alleviating the acute stress response by “the presence of an affiliative conspecific.”
An affiliative conspecific? What’s that? It turns out it’s a fancy name for a peaceful member of the same species. In this case, it’s a nice rat-mate. In male rats, this effect comes about because of smell and can be blocked when the connection between the brain’s smell and fear centers is surgically cut.
I wonder what would happen if the rats were wearing masks…
But I’m getting ahead of myself. Maybe, I thought, I’m an affiliative conspecific. It wouldn’t be the worst thing in the world. And it isn’t just about touch – a small study showed that two male mice who lived in the same cage with a barrier did moderately better than those who lived alone. Just being near another mouse was enough.
It’s too early for science to give us answers. These studies help us to think of questions. Are in-person and online treatments equal for symptom alleviation? Do they work via the same mechanisms? Are the same things happening in the brain of my patients in the office and over the internet? Does it matter? These questions are critical to understanding how we will deliver therapy in the future. Let’s hope the studies get funded.
The access advantages to teletherapy are clear. Young mothers can get treatment right after delivery. People in remote areas can see psychiatrists. Therapy doesn’t have to be ended by a move – or a pandemic. But it does seem that something is lost.
As for this affiliative conspecific, I’m happy to be back in the office.
With thanks to Daniel Kimmel, M.D., Ph.D., Bradley Miller, M.D., Ph.D., Gaurav Patel M.D., Ph.D., and Alejandro Ramirez M.D., Ph.D.
To find a therapist, visit the Psychology Today Therapy Directory.
References
Harlow, H. F. (1958). The nature of love. American Psychologist, 13(12), 673–685. https://doi.org/10.1037/h0047884
Hohlbaum, K., Frahm, S., Rex, A., Palme, R., Thöne-Reineke, C., & Ullmann, K. (2020). Social enrichment by separated pair housing of male C57BL/6JRj mice. Scientific Reports, 10(1), 1-15.Kiyokawa, Y., Wakabayashi, Y., Takeuchi, Y., & Mori, Y. (2012). The neural pathway underlying social buffering of conditioned fear responses in male rats. European Journal of Neuroscience, 36(10), 3429–3437. https://doi.org/10.1111/j.1460-9568.2012.08257.x
Kiyokawa, Y., Wakabayashi, Y., Takeuchi, Y., & Mori, Y. (2012). The neural pathway underlying social buffering of conditioned fear responses in male rats. European Journal of Neuroscience, 36(10), 3429–3437. https://doi.org/10.1111/j.1460-9568.2012.08257.x
Markowitz, J. C., Milrod, B., Heckman, T. G., Bergman, M., Amsalem, D., Zalman, H., Ballas, T., Neria, Y., (2020, September 25). Psychotherapy at a distance. American Journal of Psychiatry. Retrieved March 5, 2022, from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2020.20050557
