Which is better: Psychotherapy using video or in-person while wearing masks?

At the very start of the pandemic last year, I met with a couple of patients in the office while we wore masks. Based on that limited experience, I quickly concluded that seeing each other’s faces was of paramount importance, even if over video. That, plus the infection risk, led me to close my office to in-person appointments. For more than a year, I exclusively conducted my practice by video (mostly) and over the phone (occasionally). Even though phone calls preclude seeing faces, they seemed no worse in that respect than a masked office visit.

A few months ago, I reopened my office to vaccinated patients, and saw them without masks. Most of those who were eligible returned to the office; a minority did not. I didn’t conduct a survey, but it seemed clear that those who remained online did so for practical reasons, i.e., time or distance, not because they felt it was more clinically beneficial.

For me, meeting again with patients in the office felt like the good old days. I sometimes joked that it was “3-D,” not on a screen. Indeed, I was occasionally struck by how much “presence in the room” mattered. Being with another person in the same space is a different experience. Among other things, it connotes intimacy and privacy. My hybrid (in-person and online) practice persisted out of necessity — not because the options were interchangeable.

Unfortunately, the coronavirus Delta variant recently added another twist.

These switches — from a year of video to a few months of in-person unmasked, and now to in-person masked — create a natural experiment, allowing my patients and me to compare these situations.

Face to face is better, even masked

Somewhat to my surprise, and in contrast to my quick impression back in March 2020, I find masked, in-person encounters more engaging, real, and human than the video alternative. Even with masks, it is still “3-D.” There are no technical glitches. We are still in a room together. I also asked those who came to the office whether, given the masks, they’d rather return to video. The results were nearly unanimous: they preferred meeting in person with masks to mask-free video sessions.

The only possible exceptions were two patients who refused to don masks last week despite the new law and my advice. (I wore one, but they didn’t. I didn’t insist, as it didn’t feel acutely dangerous to either of us, and I considered their refusal a clinical issue, perhaps to resolve with time.) One such patient had met with me by phone only this past year; the other shunned remote sessions and had not met with me at all. It thus seems fair to conclude that not a single vaccinated person who opted to see me in the office would choose video instead, simply to avoid masks.

This was all something of a revelation. I had assumed that seeing a person’s face is a central ingredient of psychotherapy: I read my patient’s subtle emotional expressions, he or she reads my attention and caring. This may be less crucial than I thought. Instead, physical presence is more important.

Being with each other in therapy

Being with each other is a subtle but crucial matter in psychotherapy. In the traditional office setting, being with goes well beyond simple physical proximity. It also includes attentional focus, emotional attunement, mirroring, empathy, and other relational nuances. But physical presence is foundational.

Granted, there is also a sense of presence (“telepresence”) over video or telephone when the medium falls away ( i.e., when we can ignore it). At such times our attention, attunement, and similar factors determine whether we are being with the patient. But telepresence is transient. As soon as the video lags, the audio is garbled, or we simply become aware of missing information we would have had in person, we become conscious of separation. Our attention momentarily turns to the technology, or to the intellectual challenge of inferring from limited, noisy data. We are no longer with the patient.

As technology improves, telepresence presumably will as well. Perhaps someday, there will be no distinction between being with someone in the same room or halfway around the world. However, for now, and for most of the patients in my practice, in-person presence is even more significant than seeing each other’s faces. That says a lot.