Telepsychiatry and Teletherapy Versus In-Person Therapy, Which is for Me?

My morning routine was busy and hectic, albeit consistent for a decade. Wake up, do pilates, meditate, wake the kids, make sure they were dressed and groomed, kissed and hugged, and sent to school before commuting to my second home at The Midtown Practice.  After years of practice, I designed my office to be a place I not only love but where others could feel at ease and healing could occur.  I carefully chose the colors and decor to create a peaceful healing atmosphere. My upholstered furniture was selected to be professional yet cozy, the distance between my seat and my patients measured to create closeness without being overbearing, and diplomas and licenses displayed to reassure my clients of my credentials. A place of zen, apart from the hustle and bustle of Midtown Manhattan 11 floors below.  And then everything changed.  

On March 3rd, 2020, New York Governor Andrew Cuomo announced a cluster of COVID cases in New Rochelle, N.Y. By March 9th, Mayor Bill de Blasio followed; there were now 16 confirmed cases of COVID in New York City. The rest we know. Private and public schools closed their doors the following week. Businesses shuttered, and quarantine moved from an arcane notion from the Middle Ages to reality. On March 16th, I opened up my computer and began my new job. No more office. No more commuting.  After practicing medicine in person for 22 years, I was now an online therapist. 

In psychiatry and other mental health disciplines, the physical exam is replaced by the mental status exam: 

• a general assessment of the patient’s level of consciousness
• appearance
• activity
• and emotional state

During the exam, it is essential to pay attention to a patient’s: 

• attire
• speech
• language
• nonverbal clues of affect and mood
• attention level
• thought patterns
• level of gesticulation
• and body movement

A skillful clinician experiences so much more in a therapeutic interaction than what is communicated through spoken language. Although someone might not report anxiety, we are trained to scrutinize for small details that suggest otherwise, such as fidgeting, lack of eye contact, and a sense of unease transmitted through the patient’s unconscious body language. All of this was facilitated through an in-person visit. And then, everything changed. Now we were asked to do our job through video, and telehealth became standard. 

I often reflect that psychiatrists and other mental health clinicians were in a unique position to acclimate to telehealth during COVID. Most of us converted to 100% remote immediately into COVID. We were forced to adapt to work quickly, communicating virtually about emotions and confidential, sensitive issues immediately into the pandemic. At first, it was indeed awkward. Creating an intimate space where confidentiality and trust are paramount was not easy. Learning how to put others at ease while being miles away felt like science fiction. Nevertheless, we had to be flexible and fight what others termed “zoom fatigue” quickly. Thankfully, most of us were able to surmount that hurdle and now feel equally effective virtually as in person. Nevertheless, we acknowledge individuals have particular preferences, and there are pros and cons to each. 

The Pros and Cons of In-Person Therapy

There are several pros of in-person therapy. For some, the neutral location of the therapist’s office provides privacy and a unique escape from the buzz of everyday life. Some might feel distracted at home. Others are emotionally guarded when family members or roommates are close by. Most of us are familiar with the unanticipated interruptions that occur when we are at home. Many find it difficult to return to the therapeutic space after their dog starts barking, their child knocks at the door, or they need to excuse themselves to accept a package. Many do not wish to share their emotional life or that they are in therapy with those at home. They want unquestionable privacy. And of course, virtual therapy relies on the integrity of an internet connection, which can be capricious at best.

In-person therapy makes it easier for both patients and some therapists to pick up on nonverbal information. Even if your practitioner might have completely adjusted to remote work, many clients prefer the one-to-one in-office experience. The physical distance between therapist and patient can make a big difference to certain individuals. This is especially true during intensive work, which requires sustained concentration and vulnerability. Being physically present can be comforting, and for many, that support can only be felt when the therapist and patient are face-to-face. 

While there are several pros of in-person therapy, it is often difficult to find the extra time to commute to your therapist’s office. Consistency is often difficult to maintain secondary to busy schedules, and missed sessions become costly and interfere with effective results.  In addition, for those looking to begin therapy with a new therapist, your choices can be limited when you restrict your search to those that are geographically close. 

Advantages and Disadvantages of Online Appointments

Is Online Therapy Effective 

Several studies have found that remote therapy is just as effective as in-person work.  

A review of 24 studies performed in 2019 by Brand et al found that in almost every case, remote therapy was as effective as in-person therapy. The authors concluded that video teleconference provides a mode to overcome barriers and increase access to psychological services. Similarly,  McClellan et al published a review in 2022, finding telepsychology similarly effective to services providing face-to-face contact. 

What if I Need Emergency Care

For acute, debilitating symptoms that diminish the ability to function, many patients benefit from a visit to the emergency room. If you are having feelings about ending your life or harming yourself or others, an in-person evaluation in an acute setting such as a hospital is crucial for safety and treatment. If you are hearing voices, feel paranoid, or have concerns regarding extreme changes in behavior, again, an emergency room is imperative.

One thing is certain, online therapy is more convenient, supplying psychological support without the hassle of commuting. Furthermore, online options might be advantageous to those with social anxiety, which can be exacerbated by sharing physical space. In addition, many feel that online therapy protects anonymity. No one can see you entering into a therapy session in the privacy of your own home. This reduces stress around social stigma, which can be high in certain communities. 

Limitations of Remote Therapy

Of course, as discussed above, remote therapy has its limitations. Patients might want to discuss with their practitioner how to handle a lost internet connection in order to maintain the continuity of a session. More serious mental health conditions may require in-person work, and certain types of therapy, such as Art Therapy and Play Therapy.  Again, for many, nonverbal communication is not as effective when working virtually. Lastly, online therapy might require you to investigate the HIPAA compliance of your therapist’s platform, and for those who are hesitant to trust the security of the internet, this is an immovable barrier.

Does Insurance Cover Online Sessions?

Currently, most insurance does cover the costs of online sessions. That being said, as we enter a post-COVID world, this might change. Please be sure to call your insurance company to clarify their rates of reimbursement for treatment to receive the most up-to-date information.

Conclusion

Although COVID revolutionized the way Psychiatry and Psychotherapy are performed, there are pros and cons to each. The decision to pursue remote or virtual work with a mental health clinician is unique to each individual.  If you are having difficulty making the decision, our clinicians at The Midtown Practice will work with you to determine the best form of treatment to achieve your therapeutic objectives.