Virtual Therapy in the Post-Pandemic Era
Since the onset of the COVID-19 pandemic in 2020, therapists have been part of the rapid expansion of online or virtual therapy (which for this article refers to synchronous video or telephone sessions, such as on the platform Zoom). Online therapy has become a valuable tool for clients who face barriers to attending in-person sessions, such as those with disabilities, those living in rural areas, or individuals with demanding work and childcare schedules. Research shows that many therapists and clients report high levels of satisfaction with online sessions, often finding them nearly as effective as traditional in-person therapy (MacKenzie et al., 2023; Brouzos et al., 2021). However, some therapists note the limitations of the online format, including the loss of physical presence, reduced access to non-verbal cues, and the absence of certain therapeutic techniques. For example, those who use experiential methods like psychodrama or spatial enactments—such as repositioning clients to represent emotional distance—often find online therapy insufficient for their practice.
Regarding logistics, therapists find that clients who move or travel frequently across the country and around the world present a challenge regarding licensure. Psychologists in some states who are part of PSYPACT are often covered, though most find that their license does not permit practice out of state or in other countries without researching the statutes in those areas and receiving permission for temporary practice. Locating laws and obtaining permission in many foreign countries becomes especially perplexing, leaving therapists to either deny continuing treatment to those in need or to practice surreptitiously and risk sanctions.
This article will illustrate the dilemmas posed by the proliferation of online therapy, not only for therapists in general, but particularly for those whose practice models are limited by the logistics and regulations of online therapy. The cases illustrated below all have some unique features, but the limitations and advantages indicated are relevant to most cases.
Clinical Example: Virtual Therapy from a Provider’s Perspective
Dr. Dilessio, a veteran of the first Gulf War, obtained his doctorate in counseling psychology with assistance from the Department of Veterans Affairs (VA) after being honorably discharged due to a service-related injury that resulted in permanent paralysis of his lower limbs. Following his injury, he received care through the Wounded Warrior program, participating in group therapy sessions three times per week for one month. Although the program incorporated online reality simulations to recreate experiences in Afghanistan, Dr. Dilessio found the in-person interactions with other wounded veterans—individuals with whom he could closely identify—significantly more meaningful. These sessions also facilitated engagement with individuals from diverse backgrounds, allowing him to connect across differences in personality, ethnicity, and worldview.
As his clinical training and professional experience progressed, Dr. Dilessio became increasingly accepting of his condition and more comfortable working with individuals from varied backgrounds. Motivated by both personal experience and professional interest, he pursued specialized training in trauma treatment and later obtained board certification (ABPP) in rehabilitation psychology. After 15 years of practice, however, he has observed a shift in VA mental health services toward predominantly online delivery.
While Dr. Dilessio values the expanded reach of telehealth—particularly its ability to serve veterans in remote or underserved areas—he also notes several limitations. Specifically, he finds it difficult to assess the full extent of a client’s disability without being able to view assistive devices or observe posture and mobility. Likewise, clients are often unaware of his own physical condition due to the limited frame of video communication, reducing opportunities for identification and mutual understanding. Important nonverbal cues such as body language and micro-expressions may be obscured, and the absence of physical gestures such as handshakes or embraces limits the development of camaraderie often shared among veterans.
Based on his experience, Dr. Dilessio estimates that online therapy is approximately 80% as effective as in-person sessions for his clients. It remains beneficial particularly for clients who would otherwise go without treatment. However, when strong personal identification and shared experience are critical to the therapeutic alliance, the lack of physical presence may diminish effectiveness. For many veterans and others, interpersonal connection is especially important due to factors such as social isolation, cognitive impairment, and cultural and individual preferences that prioritize direct, face-to-face interaction.
Virtual Therapy with Distracted and Overwhelmed Clients
Most therapists have experienced sessions in which clients are late, become interrupted by children, pets, doorbells, or texts, or are constantly busy to the point where they find it difficult to be fully present. At first glance it might seem best for these clients to be seen remotely to allow them to minimize travel time and manage their time more efficiently. Experience indicates, however, that many clients who multitask, or are impulsive or easily distractible, tend to be late, check their phones, or stop to talk to someone nearby in online sessions. It can happen so quickly that the therapist cannot comment and ask them to delay what they are doing before the screen goes blank or the audio cuts off. This can easily happen with clients with ADHD, impulse control disorders, or with those who simply cannot manage their time effectively (Grant & Potenza, 2006; Yadav et al., 2023).
Despite the advantages of telehealth, urging these clients to come to the office removes many of the distractions that occur at home or at work (or their car). When they are inclined to answer the phone or check texts in the therapist’s office, it is easier to have a conversation and immediately request that such distractions be postponed until after the session. As Kofmehl (2017) states, citing Dowell & Berman (2013): “Through in-person interactions, both the psychologist and the client can communicate through signals of eye contact, trunk leans, pauses, silence, vocal tones, and other proprioceptive stimuli to enhance the overall therapeutic process.” This is also applicable to young children, who are easily distracted while staring at a screen and benefit more from the ability to move around, play, draw, or even receive an occasional hug from a caring therapist (Hagyari-Donaldson & Scott, 2024).
Clinical Example: The Distracted Client
Manny, 27 is single and living in a new city far from his family after accepting a new job in technology. He has always found it easy to immerse himself in his work, though he reports that since moving across the country he is busy with new friends, has joined a cycling club and a chess club, and keeps up with high school and college friends online. Thus, he has become a multitasker and sometimes finds it difficult to get his remote work done on time since his friends are always texting him, his mother sends him frequent emails, and he’s often more interested in his hobbies than his work. In online sessions he appears distracted and his therapist, Dr. Martinez, who is board-certified in Clinical Psychology, has commented on his distractibility and frequent looking at his phone. Dr. Martinez wonders whether she should switch to in-person sessions or continue to treat Manny online since she believes the remote sessions are minimally effective.
Peripatetic Clients and Jurisdictional Ambiguity
On some occasions the therapist signs on to a session expecting a client to be in their usual location, only to find them in a completely unexpected place. This raises several dilemmas for the therapist. If the psychologist is a member of PSYPACT, which allows therapists in certain states to practice across jurisdictional lines, requirements regarding licensure may be easily met. However, since the statutes concerning child and elder abuse reporting and duty to protect or warn vary from state to state, the psychologist must be aware of relevant statutes where the client is residing. It is essential for the psychologist to know where the client can be located for sessions; this can be made clear at the time of informed consent and updated when needed. When we see that the client is currently outside the United States, the situation becomes even murkier. Some Western countries have codes of ethics and legal requirements like those in the United States, but the process for obtaining permission to treat a client temporarily in that country may be unclear or cumbersome. Other countries may not have a procedure for licensure comparable to the United States, with authority to practice only authorized for those who graduate from university programs with a licentiate.
The dilemma comes to the fore when a client who has been engaged in intensive treatment or may be in crisis suddenly appears online in another state or country without notice. What do we do—go ahead and conduct the session or defer it until we obtain permission from that jurisdiction? Do we do it once under the premise “act first and ask later” or not at all? While the statutes may be clear, the ethical, legal, and logistical issues leave therapists in the grey area of deciding whether to strictly adhere to the letter of the law or to adhere to the clinical mandate to serve the best interests of clients. Telehealth presents these challenges to psychologists in ways that have never been previously encountered.
Clinical Example: The Peripatetic Client
Martina and her husband and two children are avid skiers and wanted an opportunity to be able to teach their children to be proficient. They recently moved from California to a ski town in Colorado. The parents had been consulting with Dr. Wilson, a specialist in Couple and Family Psychology in California for conduct disorder of their 7-year-old son, who was suspended from second grade in his new school. The parents gave Dr. Wilson two weeks’ notice before their next session before moving , during which he researched the regulations in Colorado and discovered he needed to obtain permission from the Colorado Board of Psychology to practice there temporarily. It was unclear if he could begin therapy initially without permission, and he had not heard back from the Board when the session was scheduled. As the parents felt that the family therapy was urgent, Dr. Wilson wondered whether he should see them with the situation being unclear.
A Clinician’s Perspective on Effectiveness and Engagement
While online therapy has opened vital pathways to care—especially for clients in remote areas, those with disabilities, and those balancing demanding schedules—there remains a palpable difference between virtual sessions and those conducted in person. From my experience as a Couple and Family Psychologist, I “just know” that therapy is often more effective when practiced face-to-face.
My clinical foundation is rooted in scientific evidence and what’s sometimes called practice-based evidence—learning from what works in real time. I integrate existential perspectives and draw on pragmatic, philosophical, and experiential methods to meet clients where they are. Many of these approaches, especially those from humanistic traditions such as Gestalt therapy, play therapy, and psychodrama, rely on physical presence and immediacy – factors that cannot be replicated through a screen.
Consider, for example, tactile and somatic techniques once used by Virginia Satir. Though rarely imitated today, her deeply physical, emotionally resonant methods cannot translate online. I regularly employ sculpting, role-playing, and doubling—techniques that depend on spatial awareness, body language, and in-the-room energy. In virtual sessions, I find myself constrained, particularly when guiding couples to face one another, maintain eye contact, and engage in emotionally corrective interactions while I observe and intervene based on nuanced nonverbal cues.
This isn’t simply nostalgia or resistance to technology. I am aware that research in kinesiology, neurobiology, and indigenous healing practices often supports what many therapists intuitively feel: that embodied, visceral experiences contribute substantially to therapeutic depth and change. Moreover, clients themselves often express a preference for in-person work and frequently request it—further supporting this sense that something essential is often lost online.
As recommended by Kanani & Regehr (2003), clinicians are urged to thoughtfully consider the clinical, ethical, and legal limitations of telehealth by reviewing carefully:
- Do clients tend to be distracted, late, or otherwise less engaged in online sessions? Do these issues improve in person?
- Are certain therapeutic methods (e.g., somatic or experiential techniques) more impactful or only possible in person?
- Do you, as the therapist, notice your own engagement, focus, or emotional attunement diminishing over long hours on screen?
- Are you able to meet regulatory and ethical responsibilities—such as mandated reporting or emergency response protocols—given the client’s physical location?
- When virtual therapy is the only option, what clinical, ethical, and legal guidelines are available to ensure the highest quality of care?
There’s no denying the advantages of telehealth, including increased access, flexible scheduling, and reduced overhead for clinicians (Gros et al., 2013). Psychologists can review teletherapy modalities that have been evaluated from numerous orientations, including CBT (Anderson, 2024) in making decisions. Along with the advantages, our primary ethical mandate remains: to do no harm and to serve our clients’ best interests. That means continuing to assess the clinical appropriateness of virtual care—not just its convenience or reach.
As technology reshapes the field of mental health, let’s keep in mind what happens in the room: the presence, the visceral connection, the emotional attunement, and the nonverbal cues. For many therapeutic modalities, these elements aren’t just helpful—they’re essential. (Kanani & Regehr, 2003).
References
Andersson, G. (2024). Internet-delivered CBT: Distinctive features. Taylor & Francis. https://doi.org/10.4324/9781003453444
Brous, A., Vassilopoulos, S. P., Stavrou, V., Baourda, V. C., Tassi, C., & Brouzou, K. O. (2021). Therapeutic factors and member satisfaction in an online group intervention during the COVID-19 pandemic. Journal of Technology in Behavioral Science, 6(4), 609–619. https://doi.org/10.1007/s41347-021-00216-4
Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E., Tuerk, P. W., Myrick, H., & Frueh, B. C. (2013). Delivery of evidence-based psychotherapy via video telehealth. Journal of Psychopathology and Behavioral Assessment, 35(4), 506–521.
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Grant, J. E., & Potenza, M. N. (2006). Compulsive aspects of impulse-control disorders. Psychiatric Clinics, 29(2), 539–551.
Hagyari-Donaldson, P., & Scott, N. (2024, November). Online therapy for children: Yay or nay? Clinicians’ insights from the COVID-19 era. In Child & Youth Care Forum (pp. 1–28). Springer US. https://doi.org/10.1007/s10566-024-09835-3
Kanani, K., & Regehr, C. (2003). Clinical, ethical, and legal issues in e-therapy. Families in Society, 84(2), 155–162.
Kofmehl, J. J. (2017). Online versus in-person therapy: Effect of client demographics and personality characteristics [Doctoral dissertation, Walden University]. ProQuest Dissertations Publishing. https://doi.org/10.1037/a0031421
MacKenzie, A., Papadopolous, E., Lisandrelli, G., Abutalib, Z., & Eannucci, E. F. (2023). Patient satisfaction with telehealth vs in-person hand therapy: A retrospective review of results of an online satisfaction survey. Journal of Hand Therapy, 36(4), 974–981. https://doi.org/10.1016/j.jht.2022.11.003
Yadav, N., Yadav, K., Khare, A., Goel, O., & Goel, P. (2023). Dynamic self-regulation: A key to effective time management. International Journal of Novel Research and Development, 8(11), d854–d876.
Terence Patterson, EdD, ABPP
Board Certified in Couple and Family Psychology
Correspondence: pattersont@usfca.edu