“Psychotherapy, when it works, is a really intense experience,” said John Markowitz, M.D., a professor of psychiatry at Columbia University and a psychotherapist in private practice. “You have two people facing each other in a room, and you have each other’s full attention, even if it feels very uncomfortable.”

What becomes of that encounter when neither therapist nor patient is in the room where it typically happens, but at a distance of miles and talking to each other by phone or on a computer screen? Ten months into the COVID-19 global pandemic, psychotherapists and their patients have become subjects in what amounts to an enormous natural experiment in “tele-psychotherapy”—physically distanced psychotherapy using telephone and/or video using Zoom or other platforms. The latter was an innovation for many but is now nearly ubiquitous.

Psychotherapists who spoke with Psychiatric News said the experience is likely to have lasting effects on the practice of therapy and highlights what is so powerful about that intensely close encounter between therapist and patient.

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In a paper in the American Journal of Psychiatry (AJP), Markowitz and colleagues at the New York State Psychiatric Institute and other centers took a critical look at what is being learned on the fly about the effectiveness of psychotherapy using technology, especially Zoom. (Markowitz has done extensive research on the effectiveness of psychotherapy.)

While acknowledging video psychotherapy has allowed access to care that would have been impossible had the pandemic happened 20 years ago, they said that evidence for its effectiveness compared with traditional in-person therapy is scant and that there are some inherent problems with the technology that go to the heart of what psychotherapy is about.

“It is possible to have a productive psychotherapy session by Zoom, but it’s harder, and there are more barriers to doing it well,” Markowitz told Psychiatric News. “Talking to a screen is not the same as talking to each other in a shared space. You lose some of the emotional intensity. It’s often not the same fully engrossing experience.”

‘A Literal Window Into a Patient’s Life’

Markowitz and colleagues said that a few rigorously designed studies have demonstrated the effectiveness of telephone cognitive-behavioral therapy and interpersonal psychotherapy in reducing depressive symptoms. Among these is a study by Timothy Heckman, Ph.D. (a co-author of the AJP paper), showing that telephone interpersonal psychotherapy produced long-term reductions in depressive symptoms, more than usual care, for depressed rural patients living with HIV.

Evidence for the efficacy of videotherapy is less robust. Markowtiz and colleagues cited a meta-analysis from before the pandemic in the Journal of Telemedicine and E-Health (May 30, 2019) that found roughly equivalent outcomes for in-person and video CBT. However, the studies varied widely in quality and involved heterogenous patient groups; less than half of the studies were randomized, and sample sizes ranged from 1 to 243.

With little research evidence to guide the field, Markowitz and colleagues cited their anecdotal observations to highlight some of the challenges associated with video psychotherapy. Chief among these is the potential for distractions, a phenomenon familiar to anyone who has participated in Zoom meetings with colleagues: Your attention begins to drift, you are tempted to check your phone or PC for email and surf the internet, or blank your video while you talk to a child at home who wants your attention.

Then there is the greater ease with which patients or therapists can emotionally distance themselves from a screen and the difficulty of picking up emotional signals from patients that might be more evident in person.

“Reading the emotional state of someone who is emotionally numb and dissociating can be hard even when you are in the same room,” Markowitz said. “It’s really hard to read by video or telephone.”

Too, there is the problem of privacy. “How does a patient talk about an abusive relationship if the abusive partner is in the next room?”

Markowitz and colleagues report anecdotally that patients often prefer the telephone over video. Explaining this somewhat counterintuitive finding in an interview, he said, “We are more visually than aurally focused, so we have a prejudice for vision. We think it is better to see the person than not, but it may actually be less distracting and more engaging to talk by phone.”

Psychotherapy experts who reviewed the Markowitz paper said that it shines a light on issues with which therapists everywhere are dealing and on the dearth of research evidence to guide them.

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“In general, studies support equivalence of psychotherapy delivered via telephone compared with in person,” said Holly Swartz, M.D., a professor of psychiatry at the University of Pittsburgh and editor of APA’s American Journal of Psychotherapy. “There are almost no studies on videotherapy. Based on the telephone literature—and on growing experience with these platforms—it is likely that outcomes with videotherapy are comparable to in-person treatment.”

Swartz said that Markowitz and colleagues do not denigrate technology, but “encourage us to think critically about the process, considering what may be lost in addition to what is gained.”

She described her own experience with psychotherapy by video with a working mother who was home during the pandemic and trying to supervise remote learning for school-age children. “Because I sometimes see her family issues unfold in real time, I have an even greater appreciation for her parenting difficulties,” Swartz said. “Although we lose the privacy and quiet of meetings in my office, video visits provide practical ways to provide treatment to my patient during a time of great need and afford me a literal window into her life—even if the technology is less than ideal.”

Jeffery Smith, M.D., chair of APA’s Caucus on Psychotherapy, also hailed the Markowitz paper and said it will likely spur more rigorous research on physically distanced psychotherapy.

He is more sanguine about technology and the ability of therapists to adapt and make it work for psychotherapy. “There will be plenty of opportunities for gathering ‘practice-based evidence,’ ” he said. Smith echoed Markowitz’s anecdotal comment that patients often prefer the telephone. “For patients I know very well, the telephone is a very sensitive instrument and is often less fatiguing,” he said. “If I am not so familiar with the patient or it is less clear where the therapy is going, then video psychotherapy really helps. Too many video meetings back to back can be hard to sustain, so I appreciate a mix.

“The drive to relate [with patients] finds ways to overcome whatever barriers might be present,” he said. “We are social beings, and that characteristic turns out to be irrepressible.”

Yearning for Normal

To be sure, “Zoom fatigue” is now a well-known phenomenon, a marker of a deeper yearning for a return to “normal.” Markowitz said both therapists and patients need to find ways to safely replicate normalcy when they can, such as physically distanced meetings with friends and family when possible.

He said that he bicycles across New York City to his office, where he conducts remote psychotherapy with patients. “There is a meaningful buffer to commuting, to having a structure to your day,” he said. “We have all lost that to some extent. To have that division between work and private life is quite important.”

The vast natural experiment in physically distanced psychotherapy will likely have lasting effects on therapy practice, whatever a return to “normalcy” looks like.

What lessons can be gleaned from this experience?

“For individuals who lack access to transportation or child care, remote therapy is a gift,” Swartz said. “Many, however, will welcome the opportunity to once again sit with a therapist in a private space.

“Affect, gaze, and facial expression provide important cues to therapists about patients’ emotions, and it is much easier to see them when we meet with individuals face to face than over video,” she said. “Can we do therapy without these cues? Yes. Is it as effective? We don’t know; we need more data. After the pandemic, we need to figure out for whom in-person visits are a necessity and for whom remote therapy will continue to suffice.” ■