What Telehealth Therapy Can Hold (and What It Can't)

A common concern about telehealth therapy is whether the work can go as deep on a screen, or over a phone, as it would in a room. It's a fair question. Most of us carry an image of therapy as two people in a quiet office, with the sense of having entered a particular kind of space set apart from the rest of life. Telehealth seems, at first, to remove all of that.

What I've found is that less is removed than people expect. Some things are, though, and both pieces are worth acknowledging.

The space between us

Therapy works, in part, because something forms between two people over time. Something more than the relationship itself, that develops its own atmosphere, that becomes a place where a client can bring a dream, a confession, a feeling never said out loud, and have it held. This is what makes therapy different from talking to a friend.

The space isn't created by the room. It's created by two people showing up reliably, week after week, paying close attention, returning to what arises, letting it deepen. The room helps. The closed door, the consistent setting, these support what's forming. But the work is being done by the attention each person brings and what accumulates between them as the work continues.

When the work moves to a screen or a phone, the room changes. What's been built between us doesn't have to.

What I bring to a telehealth session

A lot of what holds a session has less to do with the room than with what I'm doing internally. The same focused attention, the same willingness to sit with what's hard, the same listening for what's underneath the words. When I'm with a client over video or phone, I close the other tabs. I'm not multitasking. I'm not somewhere else. The session has the same protected quality it would have in person, the same length, and the same arc.

If anything, I have to be more deliberate about this over telehealth, because I can't lean on the room to do part of the holding for me. I bring more of it myself. The therapist's steadiness, focus, and felt sense of the work as serious and protected become what holds the session together.

What is lost, and what we can attend to

I've been thinking about this question myself, as I move to a primarily telehealth practice. I notice it in my clients, sometimes voiced and sometimes not, and I notice it in myself. Something about the office is hard to give up, and pretending otherwise feels dishonest. So it's worth being clear about what's actually being lost, and where we have some say in shaping what comes in its place.

Some of what the office offers can't be replicated. The shared physical air, two bodies in a room registering each other's presence in ways that don't quite travel through screens. The room itself, which has held previous sessions, where dreams have been told and grief has been spoken. The threshold of crossing into a particular doorway that exists only for this purpose. These are real losses, and acknowledging them is part of working with them rather than around them.

Other parts of what the office provides are more in our control than people often realize.

The office is a place without disruption. No phone calls, no emails, no notifications. This can be recreated. Mute the phone, close email, turn off notifications on the computer. Find a space where others won't walk in. For some clients this means going to a parked car, sitting in a closet, taking the session from a corner of the yard. It isn't the same as a soundproofed office, but the protection it offers is real.

The office also signals that this hour is different from the rest of life. A person goes somewhere specifically for it. A person sits on a couch that is used only for this. The setting itself tells a person something is set apart. At home, that distinction has to be made more deliberately. Some clients find it helpful to take sessions from a space that isn't the most personal room in the house. Some put on a particular sweater or sit in a particular chair only for therapy. Small rituals like these do more than they look like they would, because they mark the time as belonging to something other than ordinary life.

The bookends of session, the drive to the office and the drive home, are another tangible loss when moving to remote work. That transitional time lets a person shift into the work, and then shift out of it before re-entering ordinary life. Without it, sessions can collide with what surrounds them, the meeting that ended two minutes before or the child who needs lunch immediately after. The bookends can be partially rebuilt. A short walk before signing on. A cup of tea made deliberately, slowly, in the kitchen. A few minutes in the car before going inside. A stretch of music between session and whatever comes next. Small markers like these let a person arrive at the session and let a person leave it.

So the loss is real, and it's also workable. Some of what the office holds can be brought into a home, a car, or a quiet corner with intention. Some of it can't, and we acknowledge that together. When clients feel grief about the format, that grief is part of what we work with.

Phone and video are different

Phone and video sessions have different qualities, and which one suits a particular client often depends on what's needed.

Video keeps something of the visual register. We can see each other's faces, register expressions, notice when a client tears up or looks away. For clients who find visual contact grounding, who want to feel met by a face, video preserves something important. It can also help earlier in therapy, where having a sense of the therapist as a real, embodied person is part of how trust develops.

Phone sessions remove the visual register, and that has its own quality. The voice comes forward. Silences feel different. The client often closes the eyes, or looks out a window, and drops into a more interior space. Some clients find this freeing, especially when working with material that feels too exposing to bring under a gaze. Some of the most affecting work I've done has happened over the phone, in moments where the absence of the visual seemed to let something else come through.

Neither format is better. Some clients prefer one consistently. Some move between them depending on what's being worked on, or how the day is going. The format that matters is the one that lets the client be most present.

What clients sometimes worry about

A few specific concerns come up often enough to be worth naming.

Will silences feel awkward? They can, at first. Silences over video sometimes feel different than silences in a room, because we're aware of being watched watching. Over time, this usually softens. The silences become part of the work rather than something to manage.

What about privacy at home? This is real. Many clients don't have a quiet, private space to take a session from. We work this out together. Some clients use a parked car, a closet, a corner of a yard. Some schedule sessions when housemates are out. The sense of being able to speak freely matters, and it's worth talking about directly.

Can we really do deep work this way? Yes, in my experience. The work I've done with telehealth clients goes as deep as the work I do in person. What changes the depth of therapy is the willingness of both people to keep showing up and going further. The medium matters less than what we bring to it.

What gets created between us

The longer two people work together, the less the medium matters. Early on, the format can feel more present, the screen, the phone, the slight strangeness of seeing each other this way. Over time, the format tends to recede, and the work itself comes forward.

The slow building of trust, of understanding, of the capacity to feel and to bear feeling, none of this requires a particular room. It requires two people willing to keep returning to the work.

-Catherine Comiskey, LCSW