Reflections On Telehealth and In-Between Spaces

Transitioning from in-person counseling to online counseling, sometimes referred to as telehealth, has been one of the biggest adjustments I’ve had to make as a therapist, and perhaps just as big of an adjustment for my clients, as well.

If you’ve ever seen a therapist in-person, you probably noticed that there is a certain amount of attention that has been given to decorating the space. Most therapists admittedly over-think this and can spend a considerable amount of time debating colors, pillows, the appropriate amount of personal items to include, and the perfect chair or couch with which to furnish the office. The office is designed with a certain intention – and hopefully, that’s to make a client feel comfortable and at ease. Over time, this carefully-curated space becomes familiar and comfortable to both the client and the therapist; in fact, the space can be almost as therapeutic as the conversation that takes place inside of it.

When I received word of the stay-at-home order that was issued in Denver, I struggled with the decision whether to close the office or continue to see people in-person. In retrospect, I was probably four days behind in making the decision that many therapists had already made – to move their practices online immediately. But the context was different even two months ago. We didn’t know exactly what was happening, and the executive orders issued by Governor Polis didn’t require behavioral health practitioners to close their practices, as we were technically classified as essential workers. Over time, the guidance issued by the state indicated that unless there was an unusual circumstance that could absolutely not be handled except for in-person meetings, therapists should close their practices. But this wasn’t clear at the beginning – nothing was.

I remember the day that I realized it wasn’t an option to continue meeting in-person. It was Friday, March 13th, 2020. Since Wednesday, I had given clients the option to meet in-person or online, and perhaps only 25% had chosen to participate in telehealth sessions. Two days later, the national conversation was different, and I began notifying clients that all sessions had been moved to telehealth.

I remember gathering my personal belongings from my office, wiping down my credenza and seating areas with anti-microbial wipes, and making my way to the waiting area where I collected the remaining coffee mugs and put them in the dirty dishes tub for washing. I unplugged the white noise machine, designed to keep conversations private while clients waited for their session to begin. I glanced at the water cooler and realized that I should probably unplug that, too.

Part of me felt like I was overreacting to the whole situation. After all, Colorado’s stay-at-home order was scheduled to expire in just two weeks. But something told me that it was much more likely that it would last much longer.

I turned out the light and looked around my office. I had a brief reflection about times when I had shared with my clients the importance of having in-between spaces – or what depth psychologists refer to as liminal space. It’s that space that has a primary intention of helping us to transition from one space to the next. Waiting rooms are a good example of these spaces. We come from the outside world, and the pace slows down just a bit as we sit in a waiting room. Even the waiting room had a therapeutic intent – to help clients ease in from the outside to a place where they could slow down and give their psyche a place to speak its truth.

I looked toward my consulting room, noticing the waiting room chairs that I had moved into the space in the past few days since I had temporarily closed the waiting room and had instead encouraged clients to wait in their cars for their appointment start time. They looked out of place. And yet, it seemed appropriate that they should be in the room where healing takes place, somehow.

As I glanced around my entire office, from the consulting room to the waiting room, I felt tears well up in my eyes. My hands were full, as I was carrying my backpack that had my MacBook computer and folders full of student assignments that still needed grading; my other hand carrying the bin of mugs to take home and wash. In a way, I felt like I was abandoning dear friends. We had gotten to know one another, these fixtures and I, over the last several years. And I felt sad.

I said out loud (fortunately with the suite door still closed), I love you. It’s all going to be okay. I promise I’ll be back, and it won’t be long. And in my heart, I thought I really don’t know how long it will be.

I opened the suite door, juggling to hold keys in my already full hands, turned the lock, and began walking to my car.

And I cried.

I didn’t know what was ahead. What I did know was I was just thrust into a new kind of liminal space–but this type of in-between space wasn’t soothing or comforting at all. This in-between space was full of uncertainty and devoid of intent. I felt melodramatic, too. Was I being more dramatic about what was happening than I needed to be? If it really was only going to be two weeks that we were closed, that wasn’t such a big deal. I had been away from my office for longer periods of time a couple of years before when I traveled abroad. But something was different.

I’m fortunate in that all of my clients continued to engage in therapy when I moved online. They have truly been some of the most resilient people I have ever known. None of them argued with me or put up a fight, or complained. Yet we did know it was strange – instead of meeting in my small office with cozy furnishings, we were now meeting through a computer screen. I was in their space, and they were in mine as we met one another online. They were literal guests at my kitchen table, and I was a guest at theirs – but more often than not, I was a guest in their bedroom since it was the only private place in their house. The truth of it was, however, that we were in a sort of in-between space together. I was both at my home and in theirs; they were at their homes, and yet they were also in mine. We were in the uncertainty together. Digital and physical liminal space.

Eventually, I constructed a small telehealth studio in my basement, in an attempt to show my clients some professional respect – but also to have a space that was our own, and not quite so in-between feeling. We’ve been meeting via telehealth in that space for the duration of the stay-at-home (now safer-at-home) order.

It’s been difficult to stay grounded and focused at times. In-between spaces don’t have a clear intention. I’ve experienced that with my clients, and in some ways, it’s changed the quality and the content of our sessions, often for the better. Clients seem to trust themselves more to talk about whatever comes to mind. The in-between space doesn’t have an agenda. And sometimes not having an agenda for therapy is ideal, rather than having ego run the show all the time.

Even now, we are in a sort of in-between space. Businesses are reopening, but they’re requiring face masks. Can we do therapy with face masks? It seems like that might be even stranger than meeting online. And is it safe to come out? We aren’t fully open, and we aren’t fully closed. Liminal space.

Being in these spaces isn’t easy. And it does feel like we are in a sort of holding pattern, waiting for some clear sign that it’s safe to be out in the world again. And that clear sign may never come.

What I’m learning most of all right now, is that the world is not black and white. It’s a concept I often discuss with clients. Nothing is all good or all bad. There’s a middle ground. The in-between space is fertile ground to develop mindfulness. Perhaps no decisions are to be made right now. Perhaps the best thing to do is to S.T.O.P. That is, Stop, Take a step back, Observe, and Proceed mindfully.

This in-between space won’t last forever. We will meet in-person again, and probably soon. And then, we will be in another transition period, and probably won’t be any more certain about the world than we were before. But if mindfulness does have a personality, it is patient. It isn’t demanding. It is compassionate and allows us to be exactly who and where we are.

Soon our task will no longer be saying goodbye to the world as we have known it, to the changes that will inevitably become permanent. Instead, our task will be to say hello to the familiar things, to welcome them back, to reunite.

Soon the goodbye that I said at my office door will be a hello. The waiting room chairs will be returned to their appointed places. The water cooler will produce its bubbles of welcome, and the white noise machine will again whisper its protective hush over the waiting room. The liminal space we are used to.

And we will once again say hello.

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