Table 1.

Theme 1: It is a “much more remote experience”

Sub-theme 1: There are “Untangible [sic]” losses	It is effective but in-person treatment has an untangible [sic] quality that telehealth does not …new patients I work with online don't seem to take the therapy as seriously when they're in their own home and/or surrounded by people and the things of their home life. It's therefore a much more remote experience I think in every way Working mostly in a telehealth capacity has made the work less rich, and less satisfying overall. Although many of my patients I have had for years and have an established rapport, there's still that fullness of the in-person session that is lost and can't be thoroughly replicated online
Sub-theme 2: Specific losses can be identified
Body language cues	The encounter is intensified, in the focus on facial expression, and enervating. At the same time, information that can be gleaned from posture, attitude, even fidgeting, is lost I miss the immediacy of the in person, whole body encounter Missing body language. Difficult to perform initial evaluation
Eye contact	I cannot look person in the eyes and do not feel presence in the same way as in person The biggest impact is being unable to see clients face to face. There is something lost having a session virtually
Nuance	It's impossible to pick up the nuances of body language and emotional shifts from clients. Some sessions are more like "life coach" than therapy. That's not my thing Video “smooths” out detail making nuances of facial expression indiscernible
Focus (due to distractions)	More distractions and interruptions Client is more focused in person Some challenges with clients being distracted or multitasking during sessions
Subtheme 3: There are therapeutic frame and therapeutic relationship changes
The therapeutic frame is disrupted: office rituals and sense of safe space are lost	One of the most impactful ways COVID19 has interrupted services is by disrupting the framework of therapy. There is a stronger need to reestablish the therapeutic frame virtually and continue to monitor it. Clients also have vocalized the impact of the absence of the physical office space which ensured privacy ...lost ritual of coming to the office for sessions Providing teletherapy from home is much harder than you would think. Just finding privacy is difficult with kids/spouses/pets. And it is for clients, also Some clients have to be in their cars because family members are home
Technology impacts the therapeutic relationship	Tele-health platforms take away from the practice of psychotherapy, as each session time is spent on how to connect, rather than in connecting You can’t see the whole person, there is buffering and technology glitches and it’s easy for the client to be interrupted
It’s harder to build relationships with new clients	And taking new patients is definitely not the same—it's harder to get to know a new patient and vice versa, AND I think there's less staying power in it I think the most difficult issue is creating a therapeutic alliance with new clients As long as we already have a relationship it is just as good. If it’s a new client, it’s difficult to connect
“The screen is a barrier”: Emotional connection and embodied use of self are impaired	More difficult to make emotional connection for therapeutic alliance I also realize how often I shift my posture to bring people in for greater intimacy or to calm someone, so this has hurt my ability to be more direct and confront clients. They are already struggling and there isn't a way to use my whole self to bring calm to sessions It's more difficult to attend to a client's emotional needs remotely. The screen is a barrier