Source: Image by Pexels from Pixabay
During the COVID-19 pandemic, therapists pivoted quickly to providing on-line, remote psychotherapy to patients, using a variety of software programs and systems. Many therapists were offered exemption from various rules in order to make these transitions easier. Many of those exemptions have now expired, including the relaxation of requirements to use software and devices that are compliant with state and federal confidentiality. But many therapists learned the convenience and economic benefits of offering full remote practices, where they saved themselves the cost of having a professional office space.
Unfortunately, this leaves many therapists providing remote psychotherapy from a space in their personal home. In my opinion, this is risky, and potentially problematic for therapy. During the pandemic, all bets were off. We worked with what we had available. I saw patients who sat in their cars in their driveways, where they could still connect to Wi-Fi at their house, but they had some privacy from their family.
There were times I was seeing patients while sitting in my backyard, while my wife was doing remote teaching from our living room, and our children were doing remote schooling from the kitchen table. We did what we had to do, amidst cataclysmic shifts in industry and society. But those times have passed and it’s time to professionalize.
Unfortunately, I still see a great many therapists who are providing remote telehealth services from rooms in their homes which are not dedicated to their therapy practice. (I’m not going to get into the tax issues of home office space, but it does require the space be dedicated exclusively to business use). Oftentimes, this space is a spare bedroom.
Let’s consider how this looks from your patient’s perspective. They are seeing their therapist, and seeing their therapist’s home and living space behind and around them. What are the messages this might send? First, it simply sends a less than professional impression that the therapist can’t afford or care enough to have a space dedicated to their clinical practice.
Second, seeing a bed in the background can and does impact a patient’s thinking about their therapist. It doesn’t necessarily go right to sex, but that’s in the mix, as that bed in the background might start a patient’s mind wandering: “Does my therapist sleep in that bed?” “Is that their guest room?” “Does my therapist sleep in the same bed as their spouse?” And don’t get me started when the bed is unmade – yes, I’ve seen therapists where the bed in the background was unmade, looking like someone literally just crawled out of it from a nap. “Was my therapist just asleep in the bed before our session?”
Source: Image by Anna Lisa from Pixabay
You might think I’m being a bit old-fashioned here, stroking my ego and channeling Dr. Freud, but psychotherapy is about our patient, not about us the therapist. We are responsible for being mindful of anything we bring into the therapy space that our patients must react to. Sometimes, that’s intentional on the part of a therapist, who might have a “Safe Space” sign, or display information on 988. But, when it invites the patient to begin speculating about their therapist’s private life and life away from the therapy office, this can get in the way of the work a patient is in therapy to do. Therapists are allowed to have private and personal lives. But, at the same time, we must be mindful of what we bring into therapy from those aspects of ourselves.
Things in your background may also give away clues to the therapist’s identity and location that you might not want to give away unthinkingly. Those of us who work with patients with boundary problems or histories of criminal stalking behavior should take this into very careful consideration. There have been cases where stalkers identified a person’s location by the reflection in their eyes in a photo, or by the stars in the sky in the background.
So, what about blurring the background, or using one of those slick smart backgrounds that replaces our background with a photo of some office or generic space? I guess that’s better than your spare room with an unmade bed in the background. But in my experience, those approaches also raise questions in our patients, even prompting them to wonder, “Gee, what’s my therapist hiding?” It also can potentially lead your patient to wonder if you are in a space that is confidential. Can other people in the therapist’s environment potentially hear or see them?
Recommendations
So, if you’re a therapist doing remote counseling, here are some easy recommendations:
- Have a dedicated space for doing therapy. An office is ideal.
- If the room you’re using is multipurpose, use a critical eye to see what your patients will see. Perhaps position the camera so there’s just wall behind you, and not any furniture or other parts of the room.
- Make sure the space you’re using is private and confidential. I saw a patient once who reported that during remote therapy, a hand suddenly came into the camera view, bringing their therapist a cup of coffee! The hand belonged to the therapist’s husband. The patient was left wondering what had the husband heard? To be clear, this is a potential ethical violation by the therapist. If you’re a single parent working from home, it’s very important you figure out ways to supervise your children without them having any ability to hear or see your patients.
- If you’re using your spare bedroom as an office, consider investing in a bed that can be put away, into a couch or a credenza or a murphy bed — anything that will keep the room looking more professional.
- Include in your informed consent paperwork that you do psychotherapy remotely and assure your patients that you provide confidentiality in your remote practice.
- In the rare circumstances that you’re traveling, like me, and you have to see a patient remotely from a hotel room, or space other than your office, talk to your patient about it, ensure they are comfortable, and be prepared to reschedule if they’re not.
Remote psychotherapy has been a tremendous gift for many, allowing access to behavioral health for many persons who couldn’t obtain these services otherwise. It’s also created a highly flexible opportunity for many therapists to work independently. However, in these new and evolving times, it’s our duty to define what ethical and responsible practice involves. Otherwise, it will be defined and mandated for us.
