Due to the spread of coronavirus, much of the world has turned to technology, specifically video conferencing services, to stay connected amidst self-quarantining efforts and shelter-in-place mandates from local and state governments.

As more people are confined to their homes for their safety, and the benefit of the broader community, their work, exercise, social lives, and general daily routines have had to adjust accordingly. For some, this includes going remote for weekly therapy appointments.

On Monday, March 16th, six counties in the Bay Area issued orders to shelter in place, and it has since been extended until May 3rd. Informed by public health guidance and these orders, we shifted our delivery of psychotherapy services from largely in-person care to 100% teletherapy.

While we are heavily focused on the in-person connection whenever possible at Two Chairs, teletherapy is our only lever for access and continuity of care during the COVID-19 situation. Our team’s highest priority is to ensure access to care through this tumultuous and for many, stressful time. The good news is that teletherapy offers a highly effective option for continuity of care.

Below, we will share some of the reasons it’s important to continue in your course of therapy at Two Chairs (or wherever you go to therapy), even if it can’t be in person with your clinician for now. We’ll also explore ways to optimize your teletherapy experience.

The importance of continuity of care

Whether or not you’ve used teletherapy before, it’s helpful to understand why it’s a better alternative to canceling your session in most cases, and it has to do with continuity of care.

Research shows that clinical outcomes are best when clients are engaged in care. So what is client engagement? It’s defined as “efforts that clients make during the course of treatment toward the achievement of changes” (Holdsworth et al., 2014). We also know that the most common indicator of engagement is attendance (Holdsworth et al., 2014).

The dose response model shows that clients see progress (i.e. reduction in symptoms, improvement in quality of life) at the fastest rate with weekly therapy, followed by biweekly, and that if clients are coming in ad-hoc or monthly they can even see a deterioration in symptoms.

Therefore, the greater the attendance, the better the clinical outcomes. Thus, success in therapy is inextricably tied to continuity of care.

At Two Chairs, we have many measures in place that encourage clients to engage in care with us on a consistent basis. From our cancellation policy, to offering teletherapy when applicable, to reaching out to clients who have missed multiple appointments, these efforts are all rooted in knowing that coming to appointments regularly and on time allows clients to make the most out of their time with their therapists. Not only that, it ensures that clients and therapists are set up to do the best work possible together.

Right now, teletherapy is our best tool for bridging any gaps in care that clients might otherwise experience, so let’s dive into the definition, and explore what we know about teletherapy today.

What exactly is teletherapy?

It’s quite simple: teletherapy is providing care to clients digitally, such as video conferencing or phone. It was first introduced 20 years ago and has grown in use over time as technology has evolved, and public perceptions of mental health issues have become less stigmatized.

A recent study found that about 47% of behavioral health providers engage in some form of teletherapy (video, phone, patient monitoring devices, etc)¹. Building a trusting client-therapist relationship can be easier in-person, but many prefer the comfort of their own homes and the convenience of teletherapy options. So that begs the question...

Is teletherapy as effective as in-person care? Or more specifically, how does teletherapy affect the therapeutic alliance?

Teletherapy with a clinician who is a good match for you can be a great alternative when in-person care is not available. As teletherapy usage increases, we’re constantly learning more in the field, and it’s largely good news. Teletherapy (particularly over video) has been shown to be as effective as in-person care for a variety of conditions, including PTSD, General Anxiety Disorder, Insomnia, and Eating Disorders².

In life and in therapy, we’re big believers that in-person connection leads to strong relationships, especially in an increasingly digital world. However, we also know from our own lives, that in this current moment technology is a powerful lever for building and maintaining relationships when we can’t be together in person. At Two Chairs, strong therapeutic alliances are the core of our model. And the research shows that while some of us will always prefer face-to-face, the therapeutic alliances can be developed and maintained through teletherapy. Studies conducted across five different countries confirm that a strong therapeutic alliance can be developed through tele-based sessions3.

There are many things you can do to make sure the therapeutic alliance remains strong as you transition to teletherapy—or if you're just starting therapy, there are many steps you can take to build a strong relationship with your therapist from the start in a digital setting.

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Navigating your first teletherapy session

Whether you are continuing care with a clinician you’ve been working with for years, or partaking in a first therapy session with a clinician over video, here are a few things to consider for your first session:

  • After your initial greeting, use the first few minutes of your session to talk through technology logistics, and any concerns about the use of teletherapy. Your therapist will likely plan on addressing these things, but raise any questions you have right away to establish an open dialogue about it. Make plans for checking in about your teletherapy experience on a consistent basis.

  • Your clinician may ask you for extra information, like your physical address at the time of session or additional emergency contacts. Don’t be alarmed—these are standard procedures for teletherapy sessions, that aren’t always necessary when you are in the room together.

  • Don’t hesitate to turn to your therapist for guidance on how to navigate the dynamic. Although you may be new to the format, your therapist can draw from their experiences and use insights from working with other clients.

  • Finally, you might be unsure about how to navigate teletherapy while working from home with roommates or family members, or taking care of little ones. Use your first session to brainstorm with your therapist. Would a different time of day help? Can you use sound machines, or if you have to, do your session from your parked car or away from other people in a park? Your therapist can help you get creative, but make sure solutions are also safe and effective.

6 tips for getting the most out of your teletherapy sessions

We recently shared some tips for getting the most out of therapy, and many of them apply to teletherapy as well. Here are our suggestions specific to the virtual therapy experience:

1) Find a safe space.

If possible, identify a quiet, enclosed space to protect your privacy while in the session. For your safety and the safety of others, avoid doing therapy sessions while driving.

2) Keep your regular therapy routine.

Maintaining a sense of normalcy applies to many areas of life during COVID-19 lockdowns, including therapy. Since you won’t have a walking, public transit, or driving commute to mentally prepare, consider taking time at home before your session (10-15 minutes) to gather your thoughts. Get out a pen and paper or use your computer to jot down what’s on your mind, and what you hope to get out of your time together.

3) Make sure your face is visible.

For video sessions, be mindful of where you sit in relation to a window or source of light. Try to ensure your face is clearly visible, with no glare. Your visible expressions are equally as important via video as they are in person!

4) Optimize the video experience.

If you can, place your computer on a stable surface (not your lap) and avoid using your phone for video sessions. Check the stability of your internet connection ahead of time by streaming a video or Facetiming with a friend.

5) Avoid distractions.

Turn off notifications for your devices, and minimize sounds that could be distracting. This will allow you to remain present with your therapist for the duration of the session.

6) Be patient with the process.

Especially if you primarily see your therapist in-person, it’s normal for you and your therapist to experience an adjustment period with remote care. As you navigate this together, feel free to use your time in session to talk through any concerns or discomfort you have. You will get better over time!

We care deeply about your wellbeing as you navigate the life changes that accompany COVID-19 safety measures, and are here to support you in your mental health journey.


If you or someone you know is seeking mental health care, you can reach out to our Care Coordination team at [email protected] or by phone at (415) 202-5159.

If you or someone you know is experiencing an emergency or crisis and needs immediate help, call 911 or go to the nearest emergency room. Additional resources can be found here.

¹Mace, H., Boccanelli, A., Dormand, M. (2018). The use of telehealth within behavioral health settings: Utilization, opportunities, and challenges. Behavioral Workforce Research Center, University of Michigan.

²Wagner, Horn, Marcker. (2013). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial.

³Simpson, S.G., Reid, C.L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. Australian Journal of Rural Health, 22, 280-299.