In the era of COVID-19, therapy moves online

Patients can no longer travel to see their therapists. AA members can’t go to meetings. So the use of e-therapy has surged.

Patients usually lie down on this couch when they come to talk to Berkeley psychologist and psychoanalyst Marian Joycechild. It sits empty as she has shifted to online therapy. Photo: Marian Joycechild

U.J., 81, misses the handshakes, hugs and small talk that brightened her AA meetings on University Avenue in Berkeley until early last month.

Now the gatherings are on Zoom, and there are lots of new attendees whom U.J. has never met. Making matters worse, she says, someone “Zoom-bombed” a recent meeting with a pornographic video – not the first time trolls have done this – raising fears that high tech may be taking the “anonymous” out of Alcoholics Anonymous.

“AA becomes a family for alcoholics, but I feel like I’m losing that part,” U.J. said.

With COVID-19 deaths still on the rise, and the worst news still ahead, Americans, unsurprisingly, are suffering high anxiety.  In a recent survey by the American Psychiatric Association, more than 36% of the respondents said the pandemic is having a “serious effect” on their mental health. Crisis hotlines are struggling to meet surging demand.


In a sad irony, the stress is making people crave connection just when they need to stay apart. East Bay therapists are responding, remaining engaged with their patients even as they connect remotely rather than face-to-face. Being able to talk to clients by phone and by video provides a workaround to the shelter-in-place order, but it brings its own complications, according to interviews with patients and therapists.

“It has been a mixed experience,” said Leah Kaizer, a Berkeley licensed clinical social worker with a practice in Oakland. After more than 30 years of seeing clients in person, Kaizer now meets with them on phone calls or in video conferences.

Kaizer is a digital novice – she only recently started to use email with her clients. Yet despite some initial reluctance, she said her clients have readily adapted to the virtual therapy.

Her clients – individuals and couples, running the gamut of mental health issues — have been resilient, she said. Very few have dropped out, while a few who are sheltering in place with young children take their computers and phones out to their parked cars so they can talk without interruptions.


And Kaizer sees some personal advantages to e-therapy. She doesn’t have to drive to her office and can wear sweatpants throughout the day – although when using Zoom, she dons a scarf to make her feel as if she’s really at work.

Video-conferencing can reveal some useful surprises, therapists said. One psychiatrist, who asked not to be named, said he had been seeing a client in person for years without being aware that she smoked cigarettes until he saw her by video, in her home. That led to a fruitful discussion about self-care, he said.

Cynthia Peterson, a pediatric neuropsychologist, has started to do online therapy. Photo: Courtesy Cynthia Peterson

Pediatric neuropsychologist Cynthia Peterson, who runs a practice on Ashby Avenue, is another therapist who had to get savvier about technology in a hurry. While conducting a trial session of doxy.me, a cloud-based platform that complies with HIPAA federal privacy regulations, with her 21-year-old son in Boulder, Colorado, she learned, among other things, that she needed to light up her face.

“He was saying, ‘Mom, you gotta turn on the lights; I can barely see you,’ and I was saying, ‘I can see you fine!’,” she recalled, laughing. She has also found screen-based conversations distracting, Peterson said. During the trial run, her son was looking all over the place, and I’d be saying, ‘What are you looking at?’” she recounted.

“Technology was never my thing,” Peterson acknowledged. Beyond the logistical problems, she fears video-conferencing diminishes the quality of communication. For the time being, at least, she is using it only to give clients feedback on diagnostic tests they have already taken. There is still no effective way to give the tests themselves online, she said, in part because visual clues outside of the monitor frame can tell a therapist so much about a client.

“When I conduct an assessment, I start by noticing how a child enters the room,” she said. “There is so much that gets lost when you just use a screen.”

Kaizer expressed a similar concern. “There are so many little nuances that happen in the room that can be really rich material to work with,” she says. “Where someone decides to sit in your office. How the session ends, those last lingering words upon exiting the office…. It’s really just not the same.”

“Now I can’t tell if someone is crying or not; they have to tell me.” — Marian Joycechild

For the past few weeks, Berkeley psychologist and psychoanalyst Marian Joycechild has been “seeing” her clients by phone and iPad from her converted garage office on Cedar Street, with its now-unused custom-designed vermillion couch. Normally, Joycechild said, the ritual and structure of an office session provides a kind of container for the painful feelings her patients express. “Now I can’t tell if someone is crying or not; they have to tell me,” she said, adding that some clients worry when they can’t see her, whether she is really listening to them.

The pandemic has led to a boom of all sorts of digital mental health services, whether they are ready or not for primetime. These include not only platforms that let established therapists, like Kaizer and Joycechild, and their patients move online, but also fledgling e-therapy apps such as BetterHelp and Talkspace, which sell subscriptions to text-based and video-chat therapy, and related chatbots such as Woebot and Wysa. All have reported major increases in users in the past month.

The White House recently helped speed the trend by expanding “telehealth” benefits for Americans receiving Medicare payments while suspending some parts of HIPAA, which previously strictly regulated providers of remote care.

Neil Leibowitz, the chief medical officer at Talkspace, recently told the Washington Post that the current combination of rising stress and travel restrictions might overcome potential patients’ fear of the unknown, which he said had been a major barrier to greater adoption of text-based therapies. Once the crisis subsides, he predicted, “some people will go back to face-to-face therapy, but I think a large number will be converted.”

At a time when fewer than half of all Americans with mental illness are receiving treatment, some remote technologies may help cut costs and increase access. Yet even as high-quality research supports the efficacy of video-conference sessions, experts warn there is little to no published evidence to date that therapy by text or chatbot yields significant benefits. The absence of those studies risks turning “patients into guinea pigs with downscaled services,” said John Torous, a Harvard Medical School researcher, chair of the Smartphone App Evaluation Task Force for the American Psychiatric Association and a longtime critic of text-based and chatbox therapy services.

The kind of therapy Kaizer and Joycechild are providing, with clients they’ve sometimes known for years, is a far cry from the programmed bromides of a chatbot.  But they and other therapists say they’re still looking forward to the time when they can meet in person once again.

“I don’t think anything compares to the relational experience of sitting and thinking in the same room together,” said Kaizer.

Katherine Ellison is a journalist and author whose most recent book is Mothers & Murderers: A True Story of Love, Lies, Obsession…and Second Chances.