In early 2020, I was a research assistant at the Child and Adolescent Psychiatry Outpatient Clinic at Sheba Medical Center in central Israel. Typically, our clinic was busy and bustling, with over a hundred young patients visiting each day to meet with their doctor or therapist for various neuropsychiatric conditions, from ADHD, anxiety, and depression, to autism, personality disorders, and psychosis. However, in March 2020 our focus was drawn to a new medical issue that we initially believed was separate from mental health.
When Covid-19 struck Israel, our once tumultuous and busy clinic became unfamiliarly quiet. I recall coming to work three days after the lockdown was announced (as public hospital employees, we continued working on-site), only to find the clinic disturbingly peaceful. Knowing that our patients needed our support more than ever, our first mission was to transform ourselves into online providers of psychological services. We set up the infrastructure for telepsychiatry and teletherapy overnight. Instead of children waiting in the lobby and sounds emanating from therapy rooms, we had doctors and therapists sitting alone in front of their computers, inviting patients to join through emailed links instead of calling them from the waiting area. Dollhouses and board games once used for play-therapy were abandoned and replaced by online games and virtual Zoom whiteboards. Patients who previously would have resisted therapy by arriving late instead refused to turn on their cameras. Remote sessions were a serious shift from traditional psychotherapy and raised questions among our staff and many professionals beyond our clinic. Most notably: can virtual meetings provide the intimacy necessary for psychotherapy, especially as most therapists lacked experience in this form of digital work? But also: could remote psychotherapy not only disrupt the therapeutic process, but perhaps advance it?
A few months later, I became a therapist myself. In my first week as a clinical psychology student, I prepared for my first-ever meeting with a patient who, for the next ten months, would be my patient. Meeting a patient for the first time is a terrifying experience. The most shocking aspect of it, I found, is that there is no one in the room to guide or supervise you; just the patient and you, inexperienced, unsupervised, and insecure, sitting in front of this person in need and declaring “I’ll be your therapist.” Despite my therapist-version of imposter syndrome, I believed that I could trust my intuition. I knew that even if I would not always say the right words, communication is more than that. Communication is also tone, pace, and rhythm, along with eye contact and small gestures. Most of all, it is body language, and I knew I could trust my ability to read my patient’s non-verbal gestures and offer some of my own. Unfortunately, my first patient had no body, at least none that I could see. My first-ever meeting with my first-ever patient was through a Zoom call.
It was hard. I felt that one of the most precious things in therapy, the setting, was taken away from us. One of the basic principles of psychotherapy, dating back over 100 years, is the room, which keeps the drama of therapy in and the rest of the world out. We just didn’t have it. Not only did the external world penetrate into our setting, it was our setting. My patient would log in every week from a different location around her house, sometimes the kitchen, sometimes the living room, sometimes the bedroom. My colleagues would have even worse stories, about patients attending sessions from a noisy, crowded bus. Those who treated children would have to deal with parents entering the room at the peak of meaningful moments, taking away the privacy of meetings. The therapeutic relationship between a patient and a therapist is intimate in the sense that it requires trust and vulnerability from both parties. In order for therapy to be effective, the patient must feel that they are in a safe and private space, where they can share their innermost thoughts and feelings without distractions or restraints. How can a therapist create intimacy under such conditions? And how can any gain arise from therapy without intimacy?
"Could remote psychotherapy not only disrupt the therapeutic process, but perhaps advance it?"
The moment Covid restrictions eased, most of my colleagues tried their best to bring their patients back to the clinic, but they often faced resistance. Since I had good rapport with my patient, I also offered to meet her in person. We were both excited to finally meet face to face. However, my patient was an undergraduate student and exam season had just started. She was stressed and overwhelmed, and the idea of commuting one hour to the clinic and back was nearly impossible for her then. She asked if we could be flexible and meet on Zoom from time to time. I thought that was a bad idea.
To explain my hesitancy, I must stress the importance of the setting in psychotherapy. The setting refers to the physical, social, and psychological environment in which therapy takes place. In other words: it is the time and place of sessions, their length, the sitting arrangement, the way the room is organised, and even the furniture. It is all crucial for building trust and forming a therapeutic alliance. A stable and unchanging setting enables the patient to feel that no matter how stormy it is outside, the boat which is our therapy cannot be rocked. In short, the setting should stay as stable and reliable as possible. Agreeing to my patient’s request would have been very unorthodox and meant breaking the setting in a way that I was sure would disrupt whatever therapeutic process we were achieving.
But I agreed and was surprised by what came next. Able to stay at home and avoid time-wasting traffic, my patient became more peaceful. Seeing that I was flexible and respecting her wishes, she trusted me more. Our sessions became hybrid. Sometimes we met in person, and sometimes through Zoom. We also often changed the meeting times. We broke the setting completely, but my patient got better. With online meetings, I got a rare opportunity to not only hear about her daily experiences, but to experience them with her. I got a peek into her “natural habitat” and could understand more about her life by observing the small details that do not always come up in the tidy and neutral setting of the clinic. I could witness how she dealt with frustration when small things like the audio settings did not go smoothly. I realised that virtual psychotherapy is not necessarily bad and can enable new therapeutic tools and precious insights into our patients’ lives.
When looking at the ways the pandemic affected mental healthcare, I believe we need to consider the broader picture of access to treatment. In most countries, accessibility (and lack thereof) is a problem. Private practice is usually very expensive, and public services are hampered by an overwhelming demand. This leads to long waiting lists for treatment—which in Israel can reach one to two years—and a limited number of sessions. Just think of the last time you felt like you needed some help; could you wait 18 months? Rural living exacerbates these problems; people who wish to meet with a therapist may need to commute for hours every week to receive a 50-minute session. Many just choose no care. Others don’t get to choose; they just don’t have access to therapy where they live, and they cannot commute. In simple terms, mental health services are inaccessible for those who don’t have the financial means or live too far. Remote psychotherapy is a powerful option to alleviate these problems.
"With online meetings, I got a rare opportunity to not only hear about her daily experiences, but to experience them with her. I got a peek into her “natural habitat” and could understand more about her life by observing the small details that do not always come up in the tidy and neutral setting of the clinic."
During the first year of the pandemic, with lockdowns and social distancing orders, mental health professionals gained valuable experience with remote psychotherapy and became proficient with this new setting. Hospitals—where such changes can take years to implement—adapted to the new reality within a few weeks, and virtual sessions became the norm. Medical filing systems now even have a built-in option to report on virtual appointments. This crucial and necessary change has been facilitated not only technically, but also perceptually, as psychological barriers held by traditional Freudians who could not imagine the “setting” going online have gradually eroded. Even though professionals can and do argue over the effectiveness of virtual psychotherapy compared to traditional practice, pointing out the pros and cons of each platform, there is no longer doubt that e-therapy can be done.
This shift is especially relevant to people who live far away from hospitals and public clinics. If they previously had to choose between commuting for half a day or giving up mental help, they now have a third option. This is also relevant for immigrants, refugees, or people who relocate far away from their old home—when physical distance is no longer a barrier, you can meet with your therapist, in your language, no matter where you live. All you need is an internet connection and a suitable device. Psychotherapy is now more global. I believe that interacting through computers has specific merits when treating children, as this is a central mode of communication in their daily interactions. It is also an opportunity to learn more about family dynamics (remember the session-intruding parents from before). Does it mean that virtual sessions should replace physical ones? Absolutely not. But I believe that this can—and should—become another tool in the therapist’s toolbox.
Since my first patient, I’ve had several others who I’ve met virtually. I now feel as comfortable with online therapy as I do with traditional in-person sessions. Devastating events like pandemics, wars, or natural disasters usually result in a heightened need for emotional support and, at the same time, less ability to access it in person. However, crises can also be a gateway for necessary revolutions. Remote psychotherapy can bring help to the people who need it most. Last year, I saw the parents of a 12-year-old patient through Zoom when they were quarantined. They sat peacefully on their living room couch, comfortable and serene, while I was at the clinic. It felt more intimate than ever. On a personal note, I can share that I experienced online therapy as a patient both during the pandemic and, recently, when I moved to Cambridge. The fact that I could keep seeing my therapist during a major life change was very reassuring.
Covid significantly challenged our traditional conceptions of therapy. But, like every good therapeutic process, it has led us to adapt and evolve. In the words of existential psychiatrist and psychotherapist Viktor Frankl: "When we are no longer able to change a situation, we are challenged to change ourselves."
Nimrod Hertz [2022] is a clinical psychologist, studying the cognitive underpinnings of psychological interventions for post-traumatic stress disorder. He trained in Tel Aviv and has worked with children and adults.