Therapy From the Living Room

The pandemic forced Czech therapists to curtail their services, but when mental health needs kept growing they moved their sessions online. Might this method be here to stay? From Seznam Zpravy.

When Michaela started regular therapy sessions a year ago, before the coronavirus pandemic began, the therapist told her she could email her if she had concerns outside the office. When the coronavirus crisis struck, they agreed on video meetings via Skype.

“I always sat in the same place; it was important to me to feel that no one could hear me and that I was ‘safe,’ in a calm, familiar environment,” Michaela said. “The therapy then happened the same way as when it was live.”

This kind of temporary arrangement, when psychologists and therapists had to curtail or temporarily stop their services during the spring state of emergency, didn’t affect just her. Marek, in therapy for more than three years, was in the same situation. “After the lockdown started, this was basically the only way to continue therapy,” he explained. The sessions went more or less as normal: At the agreed time he and the therapist called each other over Skype. “In terms of topics, intimacy, or intensity of therapy, I didn’t feel a significant difference. But you can hide or not reveal some emotions behind a screen.”

Making Connections at a Distance

Many mental health services moved online since limits on social contact were first imposed last spring. And people who hadn’t sought out this kind of care before but now needed to talk to an expert because of problems arising from the pandemic began asking for help. Some doctors started offering their services free of charge. The Czech Association for Psychotherapy set up a hot line staffed by volunteers in the early, most disruptive weeks of the pandemic.

Although online therapy boomed during those first weeks, the idea is not new. So-called telemedicine has been in use for years, not only in mental health care but also in other areas of medicine, most often in the form of consultations. The beginnings of telemedicine date back to the American Civil War, when a telegraph was used to share information about the number of wounded and to order medical supplies.

Telemedicine is not just a way to maintain care during crises like the current one; it can offer remedies for systemic health problems. The number of psychologists in the Czech Republic is well below that in other developed countries. According to World Health Organization (WHO) data for 2015–2016, the Czech Republic had 12 psychologists per 100,000 inhabitants compared to 29 in the United States, 49 in Germany, and up to 123 in the Netherlands. Moreover, according to the Czech Association of Clinical Psychologists, their distribution in the Czech Republic favors Prague and other large cities.

A further impediment is the very small number of pediatric psychiatrists, only 60 to 70 in the entire country. The regional distribution of pediatric mental health facilities is unbalanced: the Liberec region, for instance has among the fewest mental health facilities of any region, yet in 2017 it had the most hospitalized pediatric psychiatric patients per capita.

Most mental illnesses develop before the age of 24; and untreated anxiety, for example, increases the risk of depression, which in turn increases the risk of substance abuse and suicide.

Australia has employed telemedicine for several decades as a way to distribute medical consultations across its thinly-peopled territory. It is gradually being introduced in the United States, and in Europe the service is widespread in Norway, for example. Early efforts in the Czech Republic include the company Terap.io, which started delivering services to adult patients more than a year ago. In September, the Czech investment group Miton said it planned a large investment in the company.

Terap.io “was born out of our personal needs, when [co-founder Jan Sasinek] and I went through the demise of our marriages a few years ago and got help from a psychotherapist,” Sasinek’s business partner Chadi El-Moussawi said. Until then he’d had little to do with psychotherapy. After graduating from the University of Economics in Prague he went into finance.

“We discovered that there are many obstacles in a person’s path while in therapy,” he said. “Clients sometimes travel across the country to see a therapist in Prague, not because they don’t have help available where they live but because they don’t want to be seen visiting a therapist.”

Terap.io’s online sessions start with the clients choosing an available date. After logging in for their time slot, they enter a virtual room where they meet the therapist and agree on a method of communication – video call, audio call, or chat. “The therapist has to be careful to not interrupt the client, and has to watch the client more closely than when they’re facing each other,” El-Moussawi noted.

The internet environment has other pitfalls. “Patients do lose out on physical contact with the therapist,” Michaela told us. “I’m used to sitting across from my therapist, noticing her facial expressions, body language, her movements in general. It was harder with video, and mostly I only saw her face. I didn’t mind to the point of it making me less open, but I did see it as a disadvantage.” A suitable environment is another important factor, she added. “Once I couldn’t be at home; I was at some friends’ house and this was not ideal. I heard them talking in the next room. At that moment I was less open because I didn’t want them to hear me.”

Barbora, in her third year of therapy, said she puts the highest value on personal contact with her therapist. Although she was offered phone therapy after the pandemic broke out, Barbora turned it down. “I miss therapy very much at the moment, but subconsciously I felt that over the phone I couldn’t be as honest as I try to be during a normal session,” she said.

Martina Cerna, one of Terap.io’s therapists, moved to a small town and began offering online therapy even before the pandemic struck.

“One advantage is the ability to work from home,” she explained. “I don’t lose time traveling to an office, and I don’t have to rent space. Clients sit at home in their safe space, they don’t have to commute anywhere. … Clients are glad that no one sees them in the therapist’s waiting room. Some clients show up on camera only after a while, when they become comfortable with it; others never do.”

Communication can be hampered if the quality of the internet connection is low. But neither patients nor therapists considered this to be a major obstacle. Much more tricky is payment for an online version of service that in person would routinely be covered by insurance. This was a complicated issue even before the pandemic, said Marie Salomonova, founder of the nonprofit Nevypust Dusi (Don’t Release the Soul) and a co-author of the National Mental Health Action Plan 2020–2030. “Insurance companies refused to reimburse these services [before the pandemic], and the professional community had doubts whether remote care would offer sufficient quality,” she said.

During the first pandemic state of emergency in the spring, insurance companies reimbursed online therapy, but this was meant as a temporary solution, according to Jana Sixtova, spokeswoman for VZP, the largest Czech health insurer.

Klara Dolakova, a spokeswoman for the Ministry of Health, said earlier this year that negotiations were under way with insurance companies on the definition of remote care services. Salomonova noted that if insurance coverage weren’t just temporary, online care would significantly benefit people in places where therapists are few. According to Dhara Meghani, an assistant professor of clinical psychology at the University of San Francisco, remote delivery of services allows therapists to reach more people and helps relieve the anxiety some clients feel about seeking psychological services.

“In general, however, there are so few child psychiatrists, for example, that they wouldn’t have time for it anyway. They can’t even handle the clientele they normally have, let alone remote clients,” Salomonova said. Although online care proved its effectiveness during the pandemic, it has its limits and is intended more for “simpler therapy,” she said. The Health Ministry’s view is that telemedicine brings the greatest benefit in countries with long travel distances, but its use in the Czech Republic would make mental health care more available and help patients stick to their treatment regimes and actively participate in therapy.

The advantages and disadvantages of online therapy also are being discussed among experts at the international level. A 2017 publication by the American Academy of Child and Adolescent Psychiatry on telepsychiatry with children and adolescents recommended considering several factors when it comes to therapy for young people. Psychiatrists should assess whether the patient has an appropriate space for remote therapy, privacy, and trained personnel should advise on whether the child can safely engage with the therapist alone or if a parent should be present. “If an appropriate site is not available, then the patient might need to be referred to in-person services, recognizing that might mean no psychiatric care,” the publication stated.

A split took place at the spring meeting of the European Federation for Psychoanalytic Psychotherapy in Berlin, according to psychoanalytic psychotherapist Halina Cermakova. About half of the attendees were using online sessions; others resisted, pointing out, for example, one major risk: “The medium [internet or phone line] belongs to or may be influenced by a third party. A very private, intimate, and therefore safe environment is a basic prerequisite for psychotherapy. You can probably imagine that when you deal with your personal problems, you need to know that no one else will know.”

Nikol Mudrova is a journalism student at Charles University in Prague and a reporter with the Czech news site Seznam Zpravy. Tereza Dornakova is a journalism student at Charles University and a past intern at Seznam Zpravy.

A version of this article ran on Seznam Zpravy. Translated by Dasa Obereigner.

The names of therapy clients in this article have been changed to protect their privacy.