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Here is how my therapy appointments usually went. I’d book a late-morning session, so I could go to the gym first. After a workout, shower, and sauna, I’d get in the car and drive to Bedford. I would try to arrive a few minutes early and make a cup of coffee in the waiting room. Then the waiting room door would open, my therapist would greet me, and I’d head into her office, sit by the aquarium, and talk about whatever I needed to discuss that day.
My most recent appointment was March 25. Here’s how that worked. I got an email ahead of time telling me I’d get the option of a phone or video call. The email reminder that went out the week before had some very particular and specific instructions:
It may be helpful to have a paper and pen on hand, as well as a list of topics you’d like to cover with your therapist. Remote sessions can pose unique challenges to the therapist-client connection, and you may not be used to talking on the phone, or video-conferencing. Having something concrete to focus on (such as a list or a paper for taking notes) can help ensure you get the most out of the session. Also be sure you have water, tissue, hand sanitizer, your journal or any relevant worksheets your therapist has given you, and any other supplies on hand that you may need during the session.
Instead of going to the gym on the morning of my appointment, I did chores and hung around in the kitchen chatting with my partner. So by the time I came up to my office I was already late, and found a text from my therapist saying, “Hi Philip are you ready for our session?”
Once I launched the video conferencing software, I saw my therapist in a home office, bookshelves behind her. “How the world has changed since our last appointment,” she said.
Under current emergency regulations, psychologists and counselling therapists in Nova Scotia are only allowed to see clients in person for “emergency or urgent care” says Marla MacInnis, a spokesperson for the province. So, like so many others, they are taking their business online.
Moving therapy online
“I can say with confidence we were doing zero percent video conferencing. No tele-psychology at all,” says psychologist Daniel Chorney, of Dr. Daniel Chorney & Associates. “We went from zero to 100 percent immediately… literally transforming the practice upside-down, closing our doors and saying everyone who is presently booked or booked in the future has to give some thought to whether they’re willing to use a different form of treatment delivery.”
He says his bookings have been down, largely over logistical concerns. “Our numbers in terms of sessions per week are down dramatically, and a lot of the cancellations are due to things like I can’t find a spot in my apartment where I have privacy. Or I don’t want my roommates to know I’m seeing a treatment provider, or I don’t know if my parents are listening in. We’ve had a lot of cancellations and rescheduling due to those concerns,” he says.
Registered counselling therapist Elizabeth Berlasso, who runs a part-time private practice in addition to her counselling work with the Nova Scotia Health Authority’s Integrated Chronic Care Service clinic in Fall River, had never offered therapy online either.
With many of her private clients, she offers a form of therapy called somatic experiencing, which is designed to help overcome the ongoing effects of traumatic events. She says it “starts with “awareness of sensations in the body, and there’s a really nice overlap with mindfulness, which I’ve been doing for decades as a practitioner and counsellor.”
Berlasso says that in the beginning, offering video therapy was “very difficult for me,” because of the connection between somatic experiencing and the body. “It’s difficult doing somatic experiencing because I’m not seeing the whole body. I’m mostly seeing faces. I’m relying more on basic principles of mindfulness and practices encouraging clients to deepen their connection to their body and self-awareness,” she says.
In her work with the NSHA, she can only do phone therapy, which has its own challenges. “I can’t see the person, so I have be very attentive to the tone of the voice and their language,” she says. She also finds that silences are harder to tolerate on the phone: “I was saying to one of my colleagues at work that I talk way more on the phone. There is so much more talking compared to seeing people live… People’s attentions span on the phone is challenged.”
Working remotely, either on the phone or with a computer, is also hard on her body, Berlasso says. “My back is sore, my neck is sore, and now I have to spend the evening unwinding myself.”
At the same time, she’s glad to still be able to offer services, especially at a time when so many people are, naturally, feeling more stressed than usual. She generally works with stress-related issues anyway, but over the last month says she’s seeing lots of anxiety. “People are still booking. They want help and support. Sometimes it doesn’t have to be Big T therapy. It’s that ability to share something with someone else who is there for you, who gives you attention, and affirms and validates you. They feel seen. Especially with this pandemic. Everyone is hived away, isolated, insular,” she says. “Mostly I’m working with anxiety. Clients’ anxiety about being alone. About having elderly family members they can’t see. They worry, they’re not sleeping, and for some it’s this paranoia of getting sick. So there’s a lot of calming strategies, building structure into their day-to-day, limiting online viewing, making sure they do online social connecting if they can.”
Chorney’s practice is largely focused on children, teens, and young adults. “The kids are funny, because they use this technology all day, but it’s different for some of them to see me or another provider online. Kids are still kids,” he says. “I was doing a session a week or two ago, and the child was more interested in seeing themselves on the screen and making faces. We’re trying to talk about serious issues and they’re sticking their tongue out. So we had a talk and turned off the Zoom feature where they could see themselves.”
It’s not just the appointments, it’s the rituals
Even when he is working from home, Chorney dresses up and puts on a tie because “that’s what I do — I wear a tie.” There have been a few surprises during sessions though. “I’m happy that a lot of people feel comfortable at home, but it does change the feeling a bit,” he says. “I’m used to seeing people dressed up in their outside clothes, and now they are having their sessions in sweatpants.” On the other hand, “if my dog wanders in, people are understanding.”
Chorney also says he misses some of the daily rituals of his practice, now that he is working from home. “Personally, I like the routine of walking to work, getting a coffee, and going up the elevator. It breaks up my day and I get a bit of exercise.”
Writer and Concordia graduate student Brennan McCracken can understand that. He returned to Nova Scotia to be with his family the day the state of emergency was declared here. In Montreal, McCracken had been seeing a therapist regularly, and said he enjoyed the routine he’d built around his appointments: “Honestly, it felt sort of like like an adventure. Something felt very purposeful about calling, making the appointment, waking up that day, getting ready and taking myself to this office in Little Italy, not too far from where I live.”
Before McCracken left Montreal, his therapist had already transitioned to online sessions. McCracken was skeptical. He worried about feeling disconnected, and said he’s “not the most comfortable on video chat.” Still, he went ahead with a Skype session from his Montreal apartment.
But even though the appointment itself was better than he expected, McCracken said it felt odd once the session was over: “The thing that I noticed the most was how strange I felt after the session, because I had gotten quite used to going to a session, usually having something of a of an emotional experience, and then giving myself half an hour or so to take a slow walk home, maybe stop for coffee — just have that in-between time between the end of the session and me sort of returning to my day. But at the end of the Skype session, we closed our chat and then I realized I was just staring at my computer screen in my apartment. I think I closed Skype and my email was open or something, and I was immediately reminded of these other things I have to do in my life. And I found that very jarring, to not have the same separation.”
In Montreal, McCracken lived on his own, so he wasn’t worried about privacy. But now that he’s back with his family, he’s not as comfortable with video appointments. He’s had one more therapy appointment since returning to Nova Scotia, and he did it on the phone.
“Both my parents and my brother are here. They all have work to do, and we each have our own space. I don’t think that anybody would be eavesdropping on me. But just that feeling of being in a house with other people — I think I felt less comfortable, I guess, or not as unguarded. So I wanted to do the phone sessions. That way I could go outside and not have to worry about anybody else overhearing something.”
McCracken says he prefers video sessions, but would only go back to them “if I were in an environment that felt totally private. And it’s the same with phone, but it’s easier to get to those spaces on the phone than it is with your laptop.”
Employee assistance programs and distance therapy
While therapy by phone or video conference may be new to many providers, there’s one group who have been doing it for a long time — people who work for employee assistance programs, or EAPs. EAPs are a benefit many workplaces offer. Employees can get access to a certain number of therapy sessions, usually provided by a third party contracted to do the work.
Canada’s largest EAP provider is Morneau Shepell. (Federal finance minister Bill Morneau resigned as the company’s executive chair in 2015, after he was elected to parliament. Two years later, he was the centre of a conflict of interest scandal, when the Globe and Mail revealed he still owned a million shares in the company. Morneau subsequently sold them for $20 million and donated the money to charity.)
Paula Allen, Morneau Shepell’s senior vice president of research, analytics and innovation, says the company was in good shape to make the transition away from in-person therapy, because it had already been offering phone and video options for years. “We were a pioneer for telephonic counselling in the late 90s, and web-based counselling, email, chat-based counselling — that’s been around for years, if not decades. Typically we’ve offered people a range of modalities,” she says. So the company didn’t find itself having to “build anything new… it’s just that we were moving people away from those face-to-face sessions.” She adds, “We have a whole society transitioning from face-to-face to video meetings, and people seem to be adapting quite well — and the same is true for counselling.”
Morneau Shepell EAP counsellors are a mix of staffers and independent providers. Asked how the company sets payment rates for their contractors, Allen said, “We pay them for their clinical skill and expertise” regardless of whether they are providing counselling by phone, video, or in-person.
But an email from a Morneau Shepell recruiter obtained by the Halifax Examiner says that “Our standard rate for telephonic counseling is a flat fee of 40$/session.” The Association of Psychologists of Nova Scotia guidelines for members set a rate of $190 per 50-minute session, and registered counselling therapists in the province typically charge in the range of $100 to $125 an hour.
Elizabeth Berlasso, who has a part-time practice and additionally works with Integrated Chronic Care Service, calls the rates Morneau Shepell pays EAP providers “terrible.” She says she started with Morneau Shepell 17 years ago and was earning $40 an hour back then, for in-person counselling. “I negotiated a higher price for myself after maybe 15 years; I negotiated up to $60 an hour.” She says a regional manager told her she’d likely get few referrals from the company after that, because they’d send them to people willing to work for the lower rate. “It’s ridiculous,” Berlasso says. “It’s just ridiculous, given the amount of money that they make.”
Asked about rates of pay, Morneau Shepell replied with an email from corporate communications manager Heather MacDonald, saying the company’s “fee structures and pay grades align with industry standards and best practises, and are the same now as they were prior to the COVID-19 pandemic.” The statement says independent providers (“affiliate network counsellors”) like Berlasso “handle in-person cases only.” Of course, there are no in-person cases right now, so the company is “offering them to join our digital/virtual assignments.”
Logistics
Daniel Chorney says research shows online therapy is not inferior to in-person, logistical problems aside. (He had the power go out twice in one afternoon in his South End home.) He says, “I think it’s important for people to know tele is just as effective as face to face both in terms of what’s delivered, and efficacy of treatment overall. I don’t want people to think this is a lesser service.” His company’s website, though, does note that “most of us would agree we’d prefer to meet face to face.”
Brennan McCracken falls into that camp. “When I was realizing the severity of what we are experiencing and the like real necessity of social distancing and staying home, one of the first things I kind of worried about was shit, I wonder if I’ll be able to keep going to therapy or if therapy will be helpful in the same way,” he says. “It’s been something I’ve been thinking about a lot so far. Like I said, I’m not totally dissatisfied with this, but it’s definitely not the same as being able to go in person.”
There are, obviously, some key differences. I don’t think I’ve ever made it through a therapy session without crying at least once. I was glad to have a reminder to keep tissues handy.
On his website, Chorney offers a series of tips for both therapists and clients. It suggests not sitting in front of a window, remembering that if you share your screen the other person can see any other tabs or apps you have open, and, if you’re using WiFi, to make sure you have enough bandwidth. “If you’ve got Netflix, Spotify, and something else streaming, the internet might be slow,” Chorney says. “Or if your kid is practicing piano in the next room it might be a distraction.”
He says he’s advising for other therapists too, ensuring they are using secure platforms and that they’ve thought of the privacy implications of their settings. “You can’t just have your partner open a door in the middle of a session. There has to be a clear space, and it has to be secure. Some people are using earbuds, some have a special room in the house.”
For McCracken’s video appointment, his therapist was working from home, and McCracken said the place looked “so spare. And I was wondering if that was what his place always looked like. Did he remove as much identifying, personal decoration to neutralize his background? I wanted to ask him about it, but, of course, that wasn’t my priority in the time that we had together.”
Asked if she thinks about the background her clients can see through her webcam, she says, “Asbolutely. I have set the space up intentionally. They can’t see a lot, but I have artwork up, and I have Christmas lights. People are curious! Who is this therapist? They have a taste of that when they come to the office. They see artwork and a colour scheme and plants, and there is a sense of security in that.”
“Most providers spend a lot of time and thought on their office environment,” Chorney says. The waiting room at his office is bright and inviting, with comic books for people to read while they wait. “It’s where they walk in and we try to make it comfortable and secure and safe — and now people are at home. It’s very different, but people do get comfortable quickly.”
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