I recently attended a Zoom meeting with 20+ other New York City sex and relationship therapists on the subject of how online counseling, or “TeleHealth,” has transformed their practices. Some of what I heard surprised me.
Many said they missed seeing their clients in person, and that TeleHealth therapy was harder and took more energy. Those were things I’d expected to hear.
Surprisingly, though, many colleagues reported that they actually liked doing TeleHealth therapy. Some said they expected to hate it, but found it unexpectedly interesting and full of creative possibilities.
I’ve been doing TeleHealth somewhat longer than the average sex and relationship therapist. So I felt I understood both the negative feelings and the positive ones.
TeleHealth therapy is different from traditional in-office therapy.
It’s also typically harder to do, at least for the therapist.
But hey, that’s true of lots of innovations in health care. After all, it’s harder to do endoscopic surgery than the traditional kind. But way easier for the patient, and in the long run that’s what counts.
I believe there are at least seven specific advantages to TeleHealth therapy for sex and relationship problems.
Let’s start with the most obvious:
Most obviously, there’s no physical waiting room. There’s no possibility of anyone else seeing you, or gawking at you, or sitting there wondering what your specific problems might be. Big improvement, privacy-wise.
On the other hand, if you’re quarantining at home with others, you might not have as much privacy in the actual session. As my colleague Dr. Daniel Watter notes, “Patients are aware of family members walking around, concerned that they might be overheard, sometimes even not wanting family members to know they’re in therapy.”
During the recent Covid-19 pandemic, both Dr Watter and I spent a fair amount of time with clients phoning in from their cars—which was the only place they could find under the circumstances.
If you don’t have access to a car or an office, air-pods can do a lot to reduce the sounds of therapy. And for ultra-private details, there’s always text-messaging, which is now included on some HIPAA-compliant TeleHealth platforms.
Most places simply don’t have enough fully-trained sex therapists, so seeing a good sex therapist can easily mean having to travel long distances—or its New York City equivalent, expensive parking or multiple subway line transfers. TeleHealth sex and relationship counseling eliminates all these problems with a click of the mouse.
As my colleague Dr. Bat-Sheva Marcus at Maze Women's Sexual Health notes, “On-line therapy offers patients unprecedented access to a wide variety of therapists. You can find specialists in a very focused field and choose a therapist who’s a perfect fit rather than just someone convenient.”
There are downsides to everything, though. And one downside to the spread of TeleHealth is that there are now well-financed “therapy companies” investing large sums to advertise online. Like any business, these companies need to squeeze the most value from every dollar they spend. So they may rely on relatively inexperienced or less successful therapists to do the direct service.
Think of it as the 21st Century equivalent of the doctor’s house call.
TeleHealth counseling means finally getting to see your clients in their natural environment. True, there’s lots of clinical information lost. As a practitioner, you lose access to many non-verbal cues when you only see clients as “talking heads” on a screen. But what you lose in access to body language, you occasionally make up for in greater awareness of the setting.
As a sex and relationship therapist, I find it valuable to see how my clients’ homes are arranged—particularly their bedrooms—and to witness the distractions they have to contend with. Like children and pets.
Children and pets are second only to TV and electronics as obstacles to lovemaking.
In sports this is known as “the home field advantage.”
With TeleHealth, the client has the home field advantage. You’re granting me entrance to your space, rather than the other way around.
The shift in power can be dramatic. When I’ve asked clients in traditional office-based therapy to describe what it felt like when they first arrived at my office, they often tell me that even before we met, when they were just sitting in my waiting room, they felt anxious and worried that I might judge or criticize them.
TeleHealth doesn’t eliminate this kind of anxiety, but it mutes it. The client is more in control. This can be a very positive change, since worrying you’re going to be judged or criticized is as big an impediment to good communication in therapy as it is in real life.
One practical advantage of TeleHealth for couples is that the two of you don't have to be in the same room together. One of you can be in their office in Midtown Manhattan, the other can be on a business trip out-of-town, and I can connect you together from my office on the Upper West Side via 3-way video.
The first time I tried doing this, I was worried there wouldn’t be enough feeling of “togetherness” for it to work. But the session was unexpectedly productive. I struggled to understand why.
In the years that followed, I’ve noted this phenomenon over and over: A couple gets more productive work done in couples therapy when they’re physically separated than when they’re together in the same room.
The answer, as I’ve written elsewhere, is that most couples suffer not from being too separate, but from being too merged together. When couples occupy the same space, they adjust to each other in tiny ways, each sacrificing a bit of their self-hood, and the relationship is diminished as a result.
Three-way TeleHealth sessions can sometimes help a couple “differentiate” more fully. Relieved of the need to adjust to each other, they can speak with greater authority as individuals. This can feel like opening a window to let in fresh air.
TeleHealth, by reducing the power disparity between therapist and patient, can make therapy much more of a collaborative effort. This enhances motivation, reduces dependency, and empowers clients as partners in learning and exploration.
I often encourage clients to audio-record sessions, since many clients have trouble remembering details of what we talked about. But recordings take time to listen to afterwards. If the matter is particularly complicated—as often occurs in sex and relationship therapy—I’ll often spend a few minutes at the end of the session typing out detailed notes, so we can all remember everything.
With TeleHealth, we can take this to the next level: I can create a document on Google Drive, share it with the individual or couple on my screen, and we can make notes together during the session. They can actually see me typing, rather than having to wait to get my notes later.
A few decades ago, so-called Cognitive Therapists would assign clients to fill out worksheets, noting their negative thoughts and critiquing them. On Google Drive, a therapist and client can now do this work on split-screen in real time, working collaboratively online while talking face to face.
Take away the physical constraints of the office, the waiting room, and the need to physically transport yourself to a particular location, and therapy can get much more creative.
With TeleHealth sessions, it’s not necessary to decide in advance whether you’re going to see a couple individually or separately. If I’m conducting a couple’s session and it feels like I need to confer separately with each individual for a few minutes, that’s easily done.
There’s more room in TeleHealth for medical creativity as well. As an MD sex therapist, I often do sexual medicine evaluations for men and women whose sex problems involve a combination of biological and psychological factors. With TeleHealth, I can put everything about a patient on my desktop at once, with their medication list in one window, my cumulative office notes in another, and our live video discussion in a third window.
It’s much easier to be “present” when you’re seeing everything at once, and not wasting time rummaging around in your files for important data.
That being said, there’s something about the seclusion of the traditional office therapy setting, and the reassurance of having a trusted listener physically present in the room, that may be impossible to reproduce online. Only time will tell, though, how much this difference is real—and how much it’s simply the comfort of what’s familiar.
To quote Dr Marcus again, “TeleHealth therapy may not be exactly as helpful or productive as an in-person consult, but with a sensitive and savvy clinician it can be pretty darn close.”
The way we communicate with our healthcare providers has changed dramatically since the advent of broadband and the smartphone. It’s now less authoritarian. More democratic.
Sex and relationship therapy too is becoming more democratic, more collaborative, and less limited by conventional modes of practice. I have decades of experience in my field. But my patients have access to the entire internet, and they frequently find interesting things online that I didn’t know about.
TeleHealth is simply another way for people to take greater responsibility for their health care. These days, the so-called “internet of things” allows patients to take much more charge of the data they share. Blood pressure readings, electrocardiographic rhythms, photos of skin lesions and sore throats, and sleep recordings can now all be up-loaded to your primary care doctor.
As a sex and relationship therapist, I have high hopes for this powerful new technology. And I can’t wait to see what our field will do with it in the years ahead.
© Stephen Snyder MD 2020 New York City