Two years ago, we published a piece with best practices in cultivating therapeutic rapport in telemental health [1]. We reviewed the literature about the role of the therapeutic alliance when using telemental health and offered suggestions for best practices to help maintain this relationship through videoconferencing technology. Little did we know how important these guidelines would be to support providers in the rapid conversion to full-scale telehealth services in response to the COVID-19 pandemic. Looking back at that pre-pandemic advice, we wondered what aspects of our suggestions have held true? What aspects were too simplistic? What needs to be modified given that most of our day-to-day relationships, in addition to therapeutic ones, had to be maintained via technology during widespread community lockdowns? Where do we go from here, given likelihood that there will be increased use of remote relationships moving forward? While many of the suggestions for best practices remain the same, there were two areas that we wanted to explore in and update that are likely unique to the COVID-19 pandemic experience. First, we wanted to know what happens when telemental health is the only choice. Second, we wanted to comment on the idea of self-disclosure when the provider and the patient are experiencing the same stressors, in this case, when both patient and provider are using telemental health from their own homes.

A primary finding from the original paper was that the therapeutic relationship was best developed and maintained when both the provider and the patient were comfortable with technology, and that care via telehealth was the preferred option for both parties. We would argue that given the ubiquity of online relationships in 2020, comfort with technology and preference were no longer the decision point for when telehealth should be used. Rather, due to widespread stay-at-home orders, telehealth became the only option. A survey by the American Psychiatric Association in June of 2020 found that prior to the pandemic, only 35% of psychiatrists were conducting telehealth visits. However, after the pandemic, 85% of those surveyed were seeing their patients via telehealth [2]. As more providers began using telemental health, many found that they liked it, even if they were initially hesitant. A systematic review by Connelly indicates that frequency of use of telemental health increased both comfort levels as well as preference for providing care via technology [3]. A 2020 survey by Steidtmann, McBride, and Mishkind directly related to switching to telehealth during a pandemic found that 85% of mental health providers rated the experience of providing care via telemental health as “somewhat better” or “much better than expected” [4].

Although providers may have begun using telehealth as a necessity rather than a choice, many providers found that not only was it a viable alternative, but a way in which they could contribute towards the response to a global crisis. Rather than harming the therapeutic alliance, many providers report making the switch to telehealth specifically to maintain the therapeutic alliance. It allowed them to provide continuity in care when patients were likely to need it. In a survey of practicing psychiatrists by Uscher-Pines et al, it was found that despite personal discomfort with technology, providers thought it more important to maintain contact with patients than cancelling appointments or discontinuing care [5]. In the aforementioned studies, almost all providers expressed intent to continue with a hybrid model of care, providing some telemental health visits, even when it is safe to return to face-to-face care [4-6]. Patients are also in support of continuing telemental health when available, with one survey of 550 patients reporting 67% of respondents being “very likely” to continue with telemental health services on an ongoing basis [6].

These findings appear to indicate that for both patients and providers, the comfort with technology and telehealth preference in order to maintain the alliance no longer appear to be as important factors as they may have been pre-pandemic. Through this experience, we, along with many providers, have learned that fears of the technology compromising the therapeutic relationship may have been unfounded. Rather, providers and patients have been able to come to formal or informal agreements around how to make it work, especially when the only other choice was no treatment at all. The COVID-19 pandemic demonstrated that alliance can be maintained via technology, even by those who are not as comfortable with technology. Given the number of providers and patients wanting to continue via telehealth when more treatment options become available, it may be that an introduction to telehealth and agreements around use are enough to provide those alliance foundations. This is different from pre-pandemic studies that suggested building alliance happens primarily when both parties demonstrate aptitude and preference for telemental health. Instead, it appears that many of the elements of alliance can still be met, especially when telemental health may be the only choice.

The second issue related to the therapeutic alliance and telemental health is the work-from-home experience, that all of us, patients and providers included, faced in 2020. It is somewhat unique from a therapeutic point-of-view, for the clinician and their patients to be simultaneously experiencing the same stressor. COVID-19 stay-at-home orders forced many clinicians into treating patients remotely from their own homes. The Internet has been awash with light-hearted compilations of newscaster’s children crawling into the frame or interviewees being interrupted by their curious cats mid-quote. As clinicians, we are thoughtful and careful about how we share information about our personal lives and/or stressors. But how does that change when that stress is collective and observable, such as when a kid is belting out their choir song in the background or a dog whining at the office door? As we mentioned in our previous paper, one of the cited benefits of providing telehealth is that it allows providers to see client’s homes, which can provide insight into the client’s life. But what happens to the therapeutic alliance when we let clients into our homes and lives as well?

How much to disclose about shared stressors is not well defined in the literature [7], especially when some of these disclosures may be accidental or unintentional. Broad acknowledgement of the challenges of working from home, home schooling, or maintaining social distancing of toddlers or teenagers may be a helpful way to normalize the experience of our patients, normalize the stress, or normalize the general difficulties of the last year, especially when they can witness the pile of laundry or hear the crying baby in the background. It may be acceptable to share personal experiences with the patient in the context of this highly abnormal time, especially when they can see or hear them as part of the session. While there may be times it is appropriate or even necessary to comment on what a patient may have observed in a provider’s home, this should still be done with thought about the impact to the therapeutic alliance. A patient’s view of a practitioner working from home may provide some normalcy to the stressor, but may also bring up feelings of comparison and judgement that would not normally be considered in the office setting. In discussing these shared experiences, there should be some awareness that although the experiences may be similar, the shared trauma may not be the same for the patient and provider [8].

It is one thing when these decisions to share information about our homes and lives for benefit of normalizing, but it is another when these disclosures are accidental. When clinicians are trying to manage their household life with roommates, partners, children, or pets who may suddenly become audible or visible during the session, the clients may suddenly receive new information about their therapist. Self-disclosure can be a powerful tool in the therapeutic relationship when it is planned with a clear purpose, fits the goals of treatment, and the provider is able to maintain clear boundaries around the depth of the disclosure [9]. Unfortunately, during the pandemic, many clinicians had the experience in which information about themselves or their family were revealed as an unintended consequence of providing telehealth in a shared workspace. Many providers have had to rethink the idea of self-disclosure during this time.

In our initial paper, we proposed that clinicians “acknowledge the awkward” as it pertains to the realities of telemental health. Although in this instance, we framed this from the patient’s experience of awkward – primarily the strange and futuristic idea of talking to someone through a screen. But given the circumstances of the last year, we argue that it is therapeutically appropriate and healthy, for us too to acknowledge our awkward. It is reasonable for us to acknowledge that our child is in the next room but we have headphones to assure their privacy. It is reasonable for us to acknowledge that our cat has jumped on the desk but the door is closed so their image cannot be observed on the screen by anyone else in the household. And when there are times in which work-from-home does interfere with the therapeutic process, such as interruptions by a child or pet, to be open and problem solve with the patient around how these experiences are impacting the work together. In this way, there is a need to “acknowledge the awkward” not only around the differences of telehealth from traditional face-to-face, but also to acknowledge the work-from-home experience, especially when these disruptions may prompt unplanned disclosures from the provider [10].

While much of our guidance from the original paper remains the same, the COVID-19 pandemic forced us to reconsider telemental health as it became the primary way to provide services. We hope that the initial guidance we provided served as a foundation to developing practices to support remote therapeutic relationships when it was not a choice. As explored in our commentary, both patients and providers found they liked telehealth more than expected, so it is likely that moving forward many providers will offer hybrid models. To address this, we want to provide some slightly modified suggestions that will help providers continue to use telehealth as an option, especially if providers continue to work from home (Table 1). We hope that we can take what has been learned during this year to continue to strengthen and grow telehealth practices, especially the best ways to support the therapeutic alliance.