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, a closed door, a comfortable chair, the sense of having entered a 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 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 part of what separates therapy from talking to a friend.

That space isn't created by the room, though. 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, sure, the closed door and the consistent setting support what's forming. But the actual work is being done by the attention each person brings, and by what accumulates between them as it 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 focused attention, the willingness to sit with what's hard, the 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 keeps 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, my own steadiness, my focus, my sense that this hour is serious and protected, and that becomes what holds the session together in the room's absence.

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 too. Something about the office is hard to give up. Pretending otherwise would be 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 a way that doesn't quite travel through a screen. The room itself, which has held previous sessions, where dreams have been told and grief has been spoken. There's a threshold to crossing into a doorway that exists only for this purpose, and that's a real loss. Acknowledging it is part of working with it rather than around it.

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

Take disruption. The office is a place without it, no phone calls, no notifications interrupting. That much can actually be recreated at home: mute the phone, close email, find a space where others won't walk in. For some clients that means a parked car, or a closet, or a corner of the yard. It isn't the same as a soundproofed office. But the protection it offers is real enough to matter.

The office also signals that this hour is different from the rest of life, in a way that's easy to underestimate. A person goes somewhere specifically for it. They sit on a couch used only for this. 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. I've had clients put on a particular sweater, or sit in one specific chair, only for therapy. Small rituals like that do more than they look like they would, because they mark the time as belonging to something other than ordinary life.

The bookends of a session, the drive to the office and the drive home, are another real loss when the work moves remote. That transitional time lets a person shift into the work, and then shift back out of it before re-entering ordinary life. Without it, sessions can collide with what surrounds them, the meeting that ended two minutes before, the child who needs lunch immediately after. Those bookends can be partly rebuilt, though, a short walk before signing on, a cup of tea made slowly in the kitchen, a few minutes in the car before going inside. Anything that lets a person arrive at the session, and later leave it, rather than just falling straight in and out of it.

So the loss is real, and it's also workable. Some of what the office holds can be brought into a home or 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 becomes part of what we're working with, not a distraction from it.

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 that matters. It can also help earlier in therapy, when having a sense of the therapist as a real, embodied person is part of how trust develops.

Phone removes that visual register entirely, and that has its own quality. The voice comes forward. Silences feel different. A client will often close their eyes, or look out a window, and drop into a more interior space than they might otherwise reach. Some find this freeing, especially with material that feels too exposing to bring under a gaze.

Neither is better across the board. Some clients prefer one consistently. Some move between them depending on what's being worked on, or just how the day is going. What matters is whichever format lets the client actually be present.

What clients sometimes worry about

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

Will silences feel awkward? They can, at first. Silences over video sometimes land differently than silences in a room, since there's an added awareness of being watched watching. Over time, this usually softens, and the silences become part of the work rather than something to manage.

What about privacy at home? This one's real. Plenty of clients don't have a quiet, private space to take a session from. We work it out together, a parked car, a closet, a corner of a yard, sessions scheduled around when housemates are out. Being able to speak freely matters, and it's worth talking about directly rather than assuming it'll sort itself out.

Can we really do deep work this way? Yes, in my experience. The work I've done with telehealth clients goes just as deep as the work I do in person. What changes the depth of therapy isn't the medium, it's whether both people keep showing up and keep going further.

What gets created between us

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

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

-Catherine Comiskey, LCSW