How effective is teletherapy? Diving deep into online psychotherapy with Katie Aafjes-van Doorn

In this conversation, Dan talks with Dr. Katie Aafjes van Doorn about the effectiveness of teletherapy. 

Katie shares her perspective on teletherapy and its benefits, as well as the differences between phone and video therapy. They also explore the importance of the therapeutic presence in teletherapy and its potential impact on treatment outcomes. This conversation explores the challenges and benefits of teletherapy, focusing on the concepts of presence, therapeutic alliance, and the real relationship. Additionally, they cover topics such as the impact of teletherapy on therapeutic presence, the informal and conversational nature of teletherapy, the challenges of therapist disclosure, and the lack of boundaries in the therapeutic relationship. In the conversation they also discuss the potential benefits and drawbacks of teletherapy, the need for hybrid treatment approaches, and the impact of teletherapy on therapist fatigue. Additionally, the importance of training in teletherapy skills and the facilitation of interpersonal connection in teletherapy are explored. This conversation explores the challenges and opportunities of teletherapy, focusing on alliance ruptures, therapeutic skills, technical challenges, adapting approaches, training, client considerations, technical quality, pros and cons, effectiveness, attachment styles, and the importance of flexibility and individualized approaches.

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Transcript

Welcome, welcome, welcome to the second episode of The Applied Psychology Podcast. It's been interesting thus far, having done a couple of these. I feel like I'm learning a lot.
In particular, I'm learning what I need to do differently. One of the things I'm still really struggling with, to be honest, is sort of being present while I have these conversations. It's sort of like when I first started teaching or giving talks in public, there's this sort of dissociation out of body experience.
And it's very weird. I mean, it's just sort of small things. It's having a microphone, having headphones.
So I'm feeling like I'm not as in the moment with the person I'm talking to as I will be. So my hope is I keep doing these and hopefully you still struggle along and listen to them. And that eventually we sort of get more in a groove here and it gets a little more, feeling a little more comfortable.
And now that I'm saying this, I'm realizing that you might be listening to this and not pick up on any of it in our conversation. So maybe I shouldn't have said anything, but whatever. What I told myself that I would do with this is do my best to be as authentic as possible for the folks who are listening.
So that's what I'm doing. And if you don't like it, you can let me know.
So if you do like it, or even if you know, even if you just think it's kind of mediocre and maybe you like want to could stick with me for a little while, do me a favor, hit the subscribe button. Or if you're in Apple Podcast, if you're in Apple Podcast, you hit the follow button, not the subscribe button, because that's something different. Because Apple, you know, Apple just always needs to be different.
So you follow in Apple and you subscribe, I think in every other thing. Okay, so on to today's conversation. So I've known my guest for several years, and actually we met at a pre-conference meeting several years ago for the Conference for the Society of Psychotherapy Research.
And it was one of those situations where there were about a dozen people, maybe a little bit less, in a room for 40 or 50. And everybody's just sort of awkwardly sitting around and only people who already knew each other were talking to each, are talking to each other. It's just one of those awkward things.
And somehow we ended up chatting and yeah, that's how it's been. And it's just been great to get to know her over the years. So my guest today, she's relatively early in her career.
So depending on how you think about it, she's either at the end of her early career or she's at the beginning of the middle of her career. I don't know, depends on how you wanna break these things down. But she's one of these people who, she's sort of a burgeoning rock star in the field, which is, you know, like the trajectory that she is on is quite obvious.
That she's just a budding rock star. And so I feel very fortunate to have met her on this side of her rock stardom, because, you know, in a few years, she might not have time for me, because then she'll actually be a rock star. So it's good to know her now.
But of course, these are just my projections of my own insecurities, not a reflection of her in the least. So today we're going to cover a lot of topics. So generally we're talking about teletherapy.
So we discuss lots of things like what teletherapy is, the differences between phone and video therapy, the effectiveness of teletherapy, the therapeutic alliance in teletherapy, presence in teletherapy, therapist directiveness in teletherapy, the informal conversational nature of teletherapy, therapist and client disclosure in teletherapy, the practicality of teletherapy, hybrid models of in-person and teletherapy, therapist fatigue and distraction in teletherapy, the real relationship in teletherapy, and how we should be doing training in teletherapy and attachment styles in teletherapy. So we cover a lot in this, I don't know, relatively brief conversation. You tell me.
So anyway, I'm thrilled to have one of the world's foremost experts in teletherapy. She's an associate professor at Yeshiva University in New York and a visiting associate professor at New York University in Shanghai, saying hi, Dr. Katie Aafjes-van Doorn.
This is something that you've written about, and I think isn't clear, and I think is something that we should just sort of hit on right at the outset, which is when you're talking about teletherapy, and you even call it telesycotherapy in some places, like, what is that and what isn't that?
Yeah, exactly. No, I think it's even in our writings, we've changed names depending on the paper and the call for papers or the journal that required the use of teletherapy or telesycotherapy or telehealth or online therapy via video conferencing or phone or like, they're all these different terms. But I guess what I've been trying to research is therapy that's conducted via video conferencing.
So you can see your patients live. So it's a live synchronous interaction with the patient and the therapist, but it's happening via video conferencing. And then a lot of our studies have also included the questions about phone, just so that we could compare phone and video.
And I know a lot of research studies have included phone as well. A lot of meta-analysis on the effect of teletherapy have included video and phone. So in that sense, it can be any synchronous interaction with your patient and therapist that's happening, either via video conferencing or phone.
That would be it.
Okay, so let's say, so probably for most of this conversation, we're gonna talk about synchronous with video, right? That's mostly what we'll talk about and sort of mostly the work that you've done.
Yeah.
But before we leave it, if you're thinking about like the clinician out there who's listening, are there any takeaways in terms of like the differences between phone and video? Besides the obvious, but like the meaningful differences that clinicians might want to be aware of?
There is, but I don't have that at all in my head. Actually, a student is looking at that now.
I guess in terms of, I'm trying to think like, you know, so like a lot of clinicians are out there sort of having to make these decisions about, should I be doing this or that? Is it as therapeutically beneficial? All that sort of stuff, you know, so like, I guess you're sort of thinking about like, and I think most people who are doing teletherapy are doing video, you know, are including video.
But I guess just if you had any insights or any thoughts about, you know, telephone.
Well, I know that within the psycholithic psychotherapy world where I've conducted lots of my surveys, therapy via the phone was much more popular even before the pandemic and has stayed very popular because it's far more similar to your patient being on the couch and not have an eye contact. And so the idea is that actually you can, you know, regress much more and get much deeper when you're not, when you're sort of not distracted by someone's surrounding and sort of eye contact and interactions. So in that sense, I think it's, it has remained popular in that sample or sub sample of therapists.
Do you buy that?
Can see if you're a traditional psychoanalyst and you value the patient being on the couch, and I know as a patient having been on the couch, there's something about not having to worry about the way I look or the way you look at me or whether you smile or sigh or look away or not have to worry about that part of the interaction so that I can actually turn more internal. So in that sense, I think it's true. But I've also been a patient, as a patient, done these phone sessions while I was walking in the park or something because I appreciated that more than laying on the sofa somewhere.
And I'm not sure if that's actually more therapeutic or if it just was me trying to be a little bit more rebellious, you know.
Yeah.
Okay. So do you think that there's any, like, do you see any downside to doing telephone?
Well, you can argue that, like, the lack of emotional expression isn't this difficult, right? But then I think if you're an analyst and you're not, that's not part of your work anyway, or at least it's more intellectual or more insight focused anyway. But I think for any experiential work or any work that is more, like, affect focused, having some nonverbal information is quite crucial.
So I wouldn't see how you could do more experiential type therapy without having the patient, like be able to actually see the patient and for the patient to see you.
Right. So sort of just depending on what you're like as a therapist, what do you want to work with? Right.
So, all right, so let's shift to sort of just getting to the teletherapy stuff. So, you know, I've had several people ask me, you know, they're like, you're a researcher, what is teletherapy as effective as in-person therapy? And what, so just where, based on your understanding, where are we with that?
So from my understanding, from both the efficacy trials, so the controlled randomized trial, but also the effectiveness of real life application research shows that the teletherapy is just as effective as in-person therapy with regards to symptom change, with regards to dropout rates, with regards to sort of general outcomes, I guess. That said, I know that the perception of a specialist is different. So even though this research is building and building, I think showing this picture quite clearly, therapists are not so convinced still.
I think a lot of therapists still see teletherapy as a second best. If you can't do anything else, then it's great to do teletherapy is better than nothing. But if you can see a patient in person, I think that's still the perception that's laying around.
And I've just concluded a meta-analysis looking at the relationship between alliance and outcome in teletherapies. And it actually showed that there was a significant relationship between alliance and outcome just as there is in person, but it was quite a bit smaller than the in-person literature. So it seems like maybe there is something else that might play an important part in predicting outcome that is not the alliance, or the alliance might still be a little bit important, but maybe not as important.
So what other variables are there? And I think in that sense, it's not the same as what we know about in person.
Right. So what do you think is going on there?
I wonder if, for example, the variable that has come up in a lot of my survey studies so far is the therapeutic presence as an important variable. So far we've shown that the working alliance and the real relationship to an assistant is very similar in person and teletherapy, or at least the quality of it is perceived as similar by patients and therapists. But there seems to be something about the therapeutic presence in that therapists and patients both feel they're less in the moment, less present, more distracted, less really experientially there in a teletherapy session.
So I guess I'm wondering if there's something about that, that is possibly not captured by a working alliance infantry, but it's like different aspects of the therapeutic relationship of actually the presence together. If that might play an important role in treatment outcome.
So when you say presence, what do you mean? Because I think most people think about, but imagine alliance and presence are kind of the same thing.
Well, I guess the alliance, or at least how it's been measured in a lot of these studies, is talking about the agreement between the task and the goal, and how much the therapist and patient work together. But the therapeutic presence is really about how you are aware, focused on the other in the moment. So not thinking about something else, not distracted by something else, really focused on that moment, what's happening.
So it's sort of more of a, it's very attention based, conceptually, and then is it like, so then would it be that the therapist is saying their presence towards the client, or are they saying their client's presence towards me?
No, so the client and the therapist are both reporting that their own presence is less, is less good in teletherapy as it is in person. So there's something there I think that is hard to achieve in a teletherapy session. That is a little, you know, that would be really important to work on when you have a teletherapy session.
And I think that might have an impact on outcome. We have to test that, but that would be my thinking that there's something, there's something about that aspect of the relationship. And of course, the therapeutic relationship is much more than only the working alliance.
So there could be other aspects about it, too. And yeah, another thing that I think is interesting with regards to what's happening in the therapy process between patients and therapists in the teletherapy, is that the therapist is becoming much more directive. It's like providing more like support, but also more conversational support.
So it's like being more active, but actually using fewer techniques. And I think that's interesting. So jumping in quicker, it's hard to leave a silence and to let things emerge.
So there's something about the therapist's stance in the teletherapy session that is different, maybe to counteract the lack of a real emotional connection, maybe, or some other things that are difficult in teletherapy. But in that sense, the process is not the same. The outcome might be very similar, but actually what happens in the session is not the exact same.
Right. Yeah. So when you say that, so you said using less techniques.
So what does that mean?
So if you think about, I guess more leaning on the common factors, rather than on specific techniques that you would otherwise apply in, whether you're a psychodynamic therapist or a CVT therapist. So it seems like it's a little bit more informal, more conversational than you would expect in an in-person session. And I don't know whether that is because you have your home surroundings, or it feels a little bit more fluent.
There's not this boundary of a room that is specifically set for you. I don't know whether that plays a part, but it seems like it's a little bit more informal. And therapists disclose more about themselves.
So not only by showing a picture of something in the background, but also just saying more, telling more. As a result, the patients say a little bit more too. But at least what we found so far is that it might actually not be that therapeutic, because it's also creating a stress for the patient that the therapist is disclosing more.
So we'll see if it's actually seen as positive by the patient. But the patients do report those more.
So it's kind of like the idea that, conceptually, so if I'm a therapist and I'm just walking into my office in my house or whatever, that because there's sort of less distance and the space is sort of different. But if I have to go to my therapy office to do therapy, that's like a process. And I have to get in my car and drive to that place, and this is the place where I do therapy.
But in my house, this is a place where I do a million things and therapy is now one of them. And also, I mean, frankly, just the fact that you can see what's behind me, I almost might feel obligated to explain stuff. Oh, that's my kid's drawing or like, oh, that's a mess because of this reason or whatever it happens to be.
So they're disclosing more, but that's actually maybe not super helpful for clients.
Yeah, at least that's what the patient report told us is that they might see that as more, perceive that as more stressful that they have to worry about their therapist in a way, but then they do disclose more themselves. So when that happens, so you could argue like as a therapist, maybe that's good because then if you disclose more, then maybe patients disclose more.
But it's probably not so good if they're feeling like a pressure to do it. Like, oh, my therapist is telling me about what's in her background, so I should tell her what's in my background or I need to explain. Like, that's probably that's not necessarily particularly therapeutic disclosure.
Right, right, right.
Huh, interesting. So like if you were to talk to a therapist who is doing online therapy, what like would you tell them to sort of think more about what they're disclosing to their clients when they're doing teletherapy?
Well, definitely the reason why you're disclosing, right? Is this meant to be a therapeutic intervention or is this disclosing because of your discomfort or because there's something going on in your own surrounding, which I guess is more likely when you're doing teletherapy from your own home. So I yeah, I mean, there's some I think there's some benefit in the hierarchy being being less clear, right?
And in teletherapy, when you have two people joining a Zoom room rather than an office that you visit. But it just yeah, I think we need to think about the effect of the patient and whether it's actually just creating a genuine and real relationship that we would value or is this actually something that is more to do with the therapist overcompensating?
Right. And I mean, it totally makes sense. I mean, even before this interaction right now, I had to get some stuff out of my background and do some of those sorts of things.
And I'm still like, is it okay? But you could see how, especially if you're doing teletherapy and you have stuff at home, that you would feel uncomfortable. And you would feel a little bit like, oh, am I presenting as professionally as I should be or as put together as I should be or whatever.
And so I sort of do, I mean, it would seem reasonable to feel insecure about that.
Yeah. Yeah. It's sort of paradoxical, right?
Because you would think teletherapy is far more distant, but you can argue that it's actually far more close because it gets closer to your personal surroundings, which is also, I think, one of the strengths therapeutically is that as a therapist, you might be able to see much more and understand much better, even when a partner walks in and has a certain type of interaction or just seeing the home a little bit more, that you understand the context of the patient actually much more than if the patient would have tried to explain that in words. So I think if you read these benefits, that's great, but it also comes with the challenges of maybe overcompensating a bit as a therapist.
But it seems like, I mean, there's also, in a way, there's an argument here for doing occasional teletherapy, right? That I can get a sense of what's going on in my client's life, in her house and whatever, and that sort of thing, which could be really therapeutically beneficial. But if I'm doing it all of the time, I might lose some of those other in-person aspects.
Yeah, and that would definitely be a next step in research, I think. All the research so far is comparing one or the other, right? As if they're that distant.
And I think many therapists and patients also have said that actually what they prefer is a combination of both. Maybe starting off with in-person sessions to get a stronger relationship, but then be more flexible. And so I think that the next direction in research would be to really understand how these hybrid treatments work and whether they are more effective than one or the other in full.
Right, no, I mean, I think that makes a lot of sense. And I mean, you know, I always think that, you know, with teletherapy, I mean, there is something to be said about it, because if I'm doing in-person therapy, if I'm a client and I'm doing in-person therapy, and I have an 11 a.m. appointment, that means I have to leave my job, you know, depending on what your, you know, where your therapy is, you might have to leave a half an hour ahead of time, you know, where I live, most likely you're gonna have to go pay for parking somewhere, which is just the worst, and then or find parking or whatever.
So you might actually have to leave 45 minutes ahead of time or whatever it is. And then you have to, you know, after therapy, then it's going to take you 30 minutes to come back. So your 50 minute therapy session becomes a, you know, a two and a half or three hour endeavor.
And then depending on your job, you know, what am I going to say to my boss? You know, how am I going to explain these absences? And in some case, you know, you just can't or you're like, do I lie or do I tell them the truth?
And what are the implications of that? And so the idea of being able to, you know, like for me, I could close my door and do therapy. And for other people, they could just go walk and sit in their car, or go, you know, find a bench somewhere and do it on their phone.
And it could literally be 50 minutes out of their day. And that's just so much more practical for people in certain circumstances.
No, exactly. I think a lot of you could argue that even if teletherapy wouldn't have been similarly effective, you could say, well, actually, maybe it's fine, even if it just touches on this gap of people who would not be able to go to an in-person office, right, would be able to take three hours out of their day or take such a long lunch break or being able to actually really make use of in-person therapies. But they would be able to zoom in for 50 minutes in between meetings.
Or, you know, if that would be a way to get you the partner involved or a family member involved, or actually, I think that even if it would be less effective, it would still be very important to be able to offer that. So yes, I think that in itself is important for the people who otherwise would not access therapy for all sorts of different reasons. But definitely, I think it's a, you know, it's a large investment.
It's really hard. I think the downside, though, or the difficulty also is that therapists seem to be very tired, far more tired doing teletherapy than in person. So I think there's also something about this room and the breaks in between.
And there's something about, I think, the lack of boundaries, I guess, in all these teletherapy sessions that makes it far more tiring. And it's easier to book in more sessions. So it might not also always be that great that we want to be more efficient in our time, in a way.
Right, yeah. One of the things that I've wondered about too is, whenever I do a Zoom meeting with somebody, I always turn off the self view so I can't see myself, because I just find I'm constantly looking at myself. And I did it because it was so distracting.
And I was like, I just cannot be present with whomever I'm talking with, with my video showing. But I've also heard that that will, that, I don't know if this is true, but that that is depleting. Like having yourself, you having the picture of yourself, that that is sort of tiring.
I don't know, do you have any sense of that?
Yeah, that's definitely my understanding too, that it's one of these projects that is still in my mind, but I haven't actually done yet. But I think that's my understanding from outside the psychotherapy world that actually looking at your own image is distracting, is tiring. And I think actually having to monitor the patient and yourself so actively is, it must take more attention and more time than actually really being focused.
And just like we were talking earlier about the therapeutic presence, or how can you be that attentive and that present when you're seeing yourself or you're thinking like, hey, well, I should have dressed differently, or just you're so aware. It's actually hard to be present.
Yeah. So for anybody who's listening, so turn off yourself. But one of the things that I've done also is like in some software, I can't.
And so what I'll do is I'll like take a little sticky note and put it on my monitor where my self-view is. Because I find it's just like at this point, since I'm seriously just turning it off, I find it incredibly distracting. And it's helpful.
I mean, you know, it just like it just goes away and I can actually be there with you and talking with you and focused on you. Yeah. So one of the things that you've said, and this is, so you talked about the real relationship.
So this is a construct that frankly, I've always had trouble with. Like, I don't really get it. So just, you know, generally speaking, what is the real relationship in psychotherapy?
So it's the way a patient and a therapist are interacting that is genuine, that is sincere, that is real. So that means it's two human beings. So I don't see you as a therapist, you professional, the person I idolize, but it's actually you as another human being.
You're doing your work, you're trying to do your best. We're both in this together. So in a way, it's far more the realistic relationship.
So if you compare it to the transference and the counter transference, the real relationship would be the real human connection of two human beings. So I can see you as a human being trying to do your best to help me. And I see the patient as a human being who's trying to seek for help and not just as a patient.
Okay, but that's different than like genuineness or authenticity.
Well, so those two are part of the real relationship, the realness and the genuineness and sincere relationship that you have. So whether you can communicate that you are actually genuinely in your responses to the patient or the patient is just genuinely in the responses to you. So I think these constructs are related, so it complements the working alliance, which is far more focused on actually task, what you're working on as if you're a good team player, you can work on it collaboratively, which is different from the real relationship, which is more about the two human beings together.
I still think I don't completely get it, but I think I'm sort of getting closer. I need like an analogy or something to totally drive it home.
Let me see.
So I think if you think about a relationship with a patient and a therapist, you have what we consciously are working on together, whether we are good at working together, would be the working alliance. Then we have the transference, counter transference, whatever we project into each other that comes from our own baggage, I guess. And then we have the real relationship, which is actually us trying to connect as two human beings.
So me seeing you as maybe not just as a therapist, but also as someone who has a family at home, who made it in time for me to be here, who also needs to do shopping, who is when you communicate to me, you mean what you say, you're not patronizing me in a therapist tone, you're treating me as a fellow human being.
Right, so it's almost like you're more than just your role, so like your role as client. I mean, I think about this, it's like when you meet people, whether they're famous people, or sort of famous to you people, and you meet them and it's like, oh my god, this is this person, blah, blah, blah. And then if you actually develop a real relationship with that person, you're like, oh, okay, yeah, they've done all these things, so they're well known for whatever, or I aspire to do a lot of the things like they've done because they're so impressive.
But over time, they become like that moves to the side and you develop a real relationship with them, which is that this is this person who's, you know, I know about their struggles with their wife and their job and their kids and their pets and their, you know, their mom or their dad or whatever it is. And like that, those other roles or those other ways I see that person sort of like fall into the background, at least when we're hanging out or whatever. Is that sort of?
Yeah, I think that that's sort of the realness aspect and then you have to genuine and sincere or whether you have a sense of the other person is sincere and genuine, and so you would hope that a therapist can actually be sincere and genuine in saying things to the patient and not saying like, oh, you've done so well, whereas actually that is not really coming across. That's sort of a patronizing tone. So I think patients pick up on that.
And similar to patients when they please a therapist or something, but it's actually not genuine. So that's in a way not helpful.
Right. Yeah, yeah. It's like moving away from that authenticity.
And as an aside, this is something, so like for when I'm teaching people like first doing counseling stuff or therapy stuff, this is one of the things that's the hardest for them to let go of because they like when they're doing, you know, sort of mock therapy with people that they're, you know, they always want to say, oh, that's so great. Oh, that's, you know, so whatever. And it's sort of like, oh, that's okay.
You know, there's just this real cheerleading kind of aspect to it. And but it's like, but it's, it's, it's, you know, and so it's, I understand, you know, their intuition is coming from a very good place, which they want to be supporting and caring and positive and all that sort of stuff. But it isn't, you know, it sort of it's not authentic.
It's interesting that you say that.
No, it's interesting because one of the findings that I couldn't make sense of, or maybe you can, is that so the Working Alliance seems to be similar to in person and in teletherapy, but the real relationship seems to be judged, at least sometimes a little lower in teletherapy, but actually that seems to be explained by clinical experience. So it seems that junior therapists have more trouble creating a real relationship in teletherapy than more senior therapists. But maybe that might be part of what you're saying, is that junior therapists want to be more in the therapist role in a way, so that they have something to offer rather than being more comfortable, being genuine and more real.
Right, and I mean, yeah, I think that to be real as a therapist is vulnerable.
And to do it therapeutically, to experience your intuition, to experience whatever it is I'm experiencing right now, and be willing to communicate that to you, but to be skilled enough to know how to communicate that to you in a therapeutic way, right? Because I mean, there are times when you're sitting there with a client, and you're really getting frustrated with them. So, but you would be very thought, and so there would certainly be times where you would communicate that to your client, but it would run through your therapy filter in your head about knowing this client, where they are right now, where our relationship is, what's helpful.
I'm going to give that to them in a very specific way. And I think it's vulnerable and it takes courage to do that.
Yeah. And what we found, at least in the patient and therapist surveys, is that the professional doubt of therapists and sort of the sense of competency and skill seem to be lower in teletherapy than it is in person. And especially so for junior therapists.
So it seems like as long as you have clinical expertise and you've seen all different patients and you've seen different how sessions can turn out and feel a little bit more comfortable, you can also deal with the adaptation to teletherapy. The way you're relatively new, this makes a lot of junior therapists very insecure about their capabilities and their competency.
Which is interesting because in a way, one could make the argument that, and I'm substituting age here for experience, but the two are correlated, although not perfectly, that there could be an argument, newer therapists who are typically younger people are going to feel more comfortable on screens and having remote conversations and that sort of thing. Which just by and large has to be true that younger folks on average are more comfortable.
Well, they have more positive attitudes towards technology. So towards video conferencing technology, young people seem more positive about it than especially the older people. And there were some really senior analysts as part of our respondents.
And so these people were a little less excited about technology and using video conferencing. But these attitudes changed when they used teletherapy. But the competency issues remained for therapists.
So across the board, but even more so for more junior therapists.
That they were more, they felt less competent.
Exactly, yeah.
And so, and I know you wrote about this, that so we had this interesting experience with COVID. And I know that I can say I found it fascinating, which was that a lot of my colleagues pre-pandemic were just like, teletherapy, no, like that is a no-go. Like there is just, there's no way.
Forget even, forget training in it. Like, I mean, even just doing it. Like that was anathema, you know, to doing good therapy.
And then COVID hit, and then it was like, it took about 15 minutes for us all to get and, you know, doing Zoom therapy or whatever it was. Which was just, I mean, it was, and here we are now, where we sort of have now everybody, you know, now it's much more acceptable and people do seem, I would say the average person is much more willing to do some, and there are some people who do all teletherapy. But that we had this interesting experience where everybody was very much like, if you want to continue doing therapy, you have to do it online.
And so you did some work looking at this sort of like, in that context where folks had the metaphorical gun to their head, they were forced online. And so like, what was that like? How did that, you know, in your data, how did that sort of play out?
So even though the experience was forced, which definitely it was, otherwise people would not have tried teletherapy. But even so, the experience of providing teletherapy made patients and therapists far more positive about the use of teletherapy, video conferencing, about their effectiveness and whether they would use it in the future. So definitely I think having sort of a forced exposure to it has helped people to get more comfortable with doing it.
That said, there are some sort of four areas of challenges that we've identified. Those actually remained even though people have gained lots of experience. So there were challenges that were identified at the beginning of the pandemic with regards to the technical difficulties of videoconferencing, with regards to emotional disconnection or how hard it actually is to feel connected and to express your emotions via videoconferencing.
A lot of distraction of both patient and therapist, of messages coming in and people walking in, and also the issue of safety and confidentiality. So actually the boundaries of the videoconferencing. So those four elements of challenges, I thought that maybe has to do with just the start-up of videoconferencing, the very start, first few months.
But those remained over time. It seems like those challenges remain challenges. So similar to the lack of competence that many therapists still feel in providing teletherapy.
So I think that really highlights the need for training. So to just experience itself is not going to solve these challenges and solve your sense of skill. So that is why the most recent part of my research program on teletherapy has focused on developing skills trainings for therapists.
Because actually most trainings that do exist focus more on practicalities and on ethical issues of how to use a platform or how to do it according to the state laws, but not so much on actually therapeutic skills, like how do you engage with your patient. So this is something that we try to do in developing teletherapy skills training based on Tim Anderson's paradigm of sedative interpersonal skills. So where we showed participants different examples of mock patients in these scenarios of teletherapy and asked therapists to respond and to learn from other people's responses.
So a lot of deliberate practice elements in this training. So this, I think, is very important for us to develop an active experiential training that targets these skills. And so we're just writing up the RCT data for that now.
So we've developed a training. We've run it. So this was a webinar version of the training, live interaction with the facilitator and different participants and trainees and licensed clinicians.
And we've been assessing their therapeutic skills before the training afterwards and at follow up. And we compared the training group with the waitlist group. And we found that actually, even though the training itself was only two hours, it has had a significant effect on therapist skills as measured by observers, as well as measured by self-report.
So it seems that actually, you know, it's possible to feel more capable and also be more capable with reverse geotherapeutic skills in response to teletherapy scenarios.
And so, okay, so earlier you said facilitative and personal skills. So what is that?
So those are sort of common factor skills that are known to be important across the board, whatever therapy modality you practice. So for example, providing hope and positive expectations about treatment or emotional expression or empathy or rupture repair, whether someone's actually able to capture when there's an interpersonal rupture and do something about it. So these are things that are known to be important across the board.
Sorry, go ahead.
Yeah, no, no, sorry. And so this training was using that paradigm for those skills specifically for teletherapy scenarios. So based on those four challenges that I mentioned earlier, we developed like stimulus clips of patients that were in those, expressing those challenges.
So there was like a disruption in the connection. So there was a technical issue or the patient was saying, I don't feel connected with you. I don't see whether you actually feel anything when I'm with you.
Or the patient was worried about boundaries or whether someone else was going to walk into the room or something like that. So these kind of scenarios we use to practice therapeutic skills. So that we could be more comfortable specifically in a therapeutic context of teletherapy.
So I guess that's what I was going to ask was like, so something like feeling disconnected from a therapist, right? That being able to, for a therapist to facilitate that sort of interpersonal connection is important across, right? So whether you're in person or you're doing teletherapy.
So I would have guessed that a therapist just general ability to do that would then extend to when they were doing teletherapy. But it sounds like that's not necessarily the case. And there are specific ways that you're going to train, you know, how to facilitate that interpersonal connection in a remote, you know, in teletherapy specifically.
So like, what would like, how would that be different than me teaching, you know, a graduate student, us doing scenarios, working on facilitating connection with a client in person when the client's not feeling connected versus, you know, what would that look like if we were doing it in the teletherapeutic context? Does that make sense?
Yeah, yeah. So I think that the skills in a way would be very similar. But the scenarios that a patient might bring up have to do with the teletherapy context.
So I think the way a good therapist would respond to a rupture in trying to identify the interpersonal need or what the patient is actually trying to say and the opens of that and explore. And that would be the same, I think, whether you're in person or in teletherapy. But the scenarios that will come up in teletherapy will be different.
So that's at least what we've been practicing with in this training is to see, okay, so what kind of unique scenarios can you expect in teletherapy that might put you off? You feel that you're unskilled and actually practice with those using these general therapeutic skills.
Got it. So just to clarify, so when you're talking about a rupture, you're talking about an alliance rupture. And so this is a time when the therapist either overtly will state it or not, but they might say something like, I don't feel like you understand what I'm saying.
So they might get pissed off to the therapist and be like, you don't get what I'm saying. Or they might say, you know, we've been at this, we've been hammering, we've been banging on this for the last three sessions, and this is just not helpful. Right.
So like, that would be another example of an alliance rupture.
Yeah, exactly. Exactly. And rather than maybe in teletherapy that might say, well, teletherapy is not working for me.
Right. And so maybe one of the responses people might say, well, let's refer you on to in person. Like, that will be one solution that may be not the most therapeutic.
Right. So maybe we can think together about what it's like to be in teletherapy or where, you know, how do you see me? How is that different from what you expected and explore that?
And maybe that means that I, as a therapist, need to do something slightly different or be more expressive or say things more when I do them. Or maybe it's just the patient getting used to it, too, or feeling that it's not effective and they're paying too much for it or whatever is underneath that sort of grumpiness, the teletherapy context.
So, I mean, it sort of sounds like there would be a similar sort of thing you would do in teletherapy as in person, which is, you know, often we might say, like, bring it into the room, like bring it into the here and now, right? So, like, when you say, like, okay, help me understand this, right, like, let me understand what's going on. But so you're, like, actually processing it with the client.
So it would be so part of this would be encouraging therapists to feel comfortable doing that in a teletherapy context.
Yeah, exactly. Exactly.
So now that what about the example you said about, like, the technical snafu? So, like, where does that come in in terms of because, like, to me, that doesn't seem like a facilitative interpersonal skill, like we would typically. So, like, but these technical challenges are very, so I guess, help me understand that.
Yeah, so if the patient, for example, or if the connection breaks and you're trying to patient is trying to say something, but doesn't feel like doesn't get something across or you can't hear what the patient's saying. So then it would be a very similar facility of interpersonal skills of trying to see what it's like for the patient to actually have to express something and it's being disconnected. Whereas actually, you know, there's something really important there and I can't hear what you're saying.
So to bear with the frustration, I guess, of the teletherapy context. So obviously, you can't always solve the technical issues, which, you know, if you can, you will. But still being able to be attuned to that sort of frustration and be able to make space for that in the teletherapy session.
Rather than say, oh, let's stop the teletherapy session, or it doesn't work, or something like that.
So it seems like a lot of the skills that you're suggesting that teletherapy training should be focusing on, it's sort of like the same common factors, if you will, therapeutic common factors, but bringing them into this sort of digital context, how it's going to be conveyed, experienced, what that's going to look like is going to be different. So being able to surface some of those and have therapists practice that for this specific context.
Responding therapy, because I could see that. Frankly, if I'm a therapist and we're having technical problems, I'm thinking about it as a technical problem, and I might be thinking about it as embarrassing. I might be thinking about it as myself feeling helpless or whatever it is, and I wouldn't really conceptualize that as something that I should bring into the room, you know, that I should process with the client because it's like, oh, no, no, this is just a hurdle I have to figure out or push through or throw up my hands or whatever.
So I mean, I would see how like you can have really skilled therapists who just having a couple of hours to help them reconceptualize and do a bit of practice, how they could quickly start to see these problems very differently or how they respond to them very differently.
Yeah, and I think something about like practicing and seeing some examples of, you know, OK responses and great responses from other therapists and seeing what might come up in a teletherapy session with regards to patients' dilemmas or scenarios and how therapists might respond. I think that in itself gives therapists more comfort and knowing what to expect and feeling prepared for what might come. Yeah.
Yeah, that's interesting. OK. So I mean, it's also, I mean, I do think that, you know, because I think there is sort of this question of now programs are doing more teletherapy in terms of their training.
But what does the, you know, other than just seeing clients in this context, what is the specific training? What are the specific skills that these folks need to learn above and beyond what they normally, I think there's a big question about that for programs.
Yeah. Yeah, exactly. And I think so far it seems more focused on guidelines or knowing what your state requires or something like that, or, you know, technicalities of video conferencing platform or how to log in or something like that, but not actually the therapeutic work per se or what kind of scenarios might come up and might be challenging that we worry about as therapists, but that we can actually practice and be more confident with and comfortable with.
Yeah. Is there anything on like the I sort of wonder about like the like the like the technical quality, like how much does it matter? You know, like how much does it matter the microphone that a therapist has or like the video quality or those sorts of things in terms of the experience of the client?
I was going to say, probably if you would have asked me this five years ago, I would have said like it makes a lot of difference. But to be honest now, I think every basic Zoom account or Teams account or whatever software you're using is fine. It's good quality.
And so it's more depending on the Wi-Fi connection that might make a difference if there's an issue there with where the patient is or the therapist is. But there's no real reason why the quality should be bad nowadays, I think.
So as long as it like meets a certain threshold of not being terrible, then it's probably fine.
Then it's probably fine. It's probably fine. Well, and then I guess, you know, ruptures might still occur or when there's a delay in speech or something, it might be little things happening, but I think those should be more exceptional or than normal nowadays.
Right. Yeah, that makes sense. So getting back to what you were saying earlier.
So like, I mean, it seems like there are... Alright, so there's data to suggest that it's just as effective.
There's all these kind of hedges, these sort of like, but folks tend to have trouble being, or more difficulty being present or in the moment, and sort of that real relationship doesn't seem to be quite as strong. And there are some specific skills that seem to matter, or some ways of framing the experience that seem to matter, that aren't part of traditional programs, and that good therapists might struggle with without getting a little bit of training on. People are a little bit less confident.
So, I mean, it does seem like they're equally as effective, but then there's all this stuff that sort of suggests that like, well, I don't know, there are some concerns that a therapist should have, or things to be mindful of if they are doing teletherapy. I mean, it seems to me. So it sort of gets to, I don't know, like, I'm in no way am I questioning the folks that have done this work and said that these things are equally effective.
I buy that that's what they found. But it also seems like, but in the real world, you know, in nature, is it, it seems like it shouldn't be. It seems like it shouldn't be as effective.
Even if it's only slightly less effective, it seems like it shouldn't be as effective, considering all these limitations, or all these, you know, all these concerns.
I literally feel it's a combination of pros and cons to get together. So yes, it comes with therapeutic challenges, or like those four elements that I was just talking about, but it's also over quite amazing opportunities, not only practically to be able to see patients much more easily than otherwise, but also to be able to get the context of the patient's surrounding and being able to see their home and see their family or see their context, get a bit more of a sense. I think it's literally like an added opportunity, but also added challenge.
So I would not be able to say confidently whether one is, in that sense, better than the other. It really offers different types of opportunities that I think, at least that's what the survey results have been showing, is that as long as therapists are adapting and not just doing exactly what they did as in person, because that doesn't seem to be effective, that doesn't seem to help the working alliance in teletherapy or the outcomes in teletherapy, don't just copy paste what you do in person, but know it's different and take the opportunities from it. So the idea is that you would be more expressive, for example, in your emotions and try to communicate how you feel about your patient or patient's story and you can't just assume that your non-verbals will do all that for you.
So you might be able to sort of subtitle more of what you're trying to say, to be more explicit in that way. But you can definitely also ask your patient to show more or to bring their world to you a little more. And I know we were talking about different therapeutic approaches earlier.
But for example, what we found is that for CBT therapists, they made actually the Alliance higher in teletherapy than they do in person. So for all the CBT therapists who have done both. And that seems interesting to me.
So actually, maybe because it's a different format, that you might work harder as a CBT therapist or to actually rebuild a relationship, whereas you might just assume it's already there when you're in person. I don't know, but it doesn't necessarily need to be any lower. So I definitely think it's a mixed bag with regards to pros and cons and challenges and opportunities.
So do you feel like... Some of this might be based on data. Some of this might be based on your own experience or even inferences.
But do you feel like there are certain... Whether it's types of clients, personalities, struggles they're having, types of therapists, approaches, whatever. Are there any of these sort of factors that you sort of think that folks should consider when they're thinking about, yeah, maybe not so much for this person in this particular situation or this therapist, or maybe, yeah, this could be good for this person.
Are there any of those sort of variables that folks should consider?
Yeah, I think as far as I'm aware, based on the research, we're not that sure yet, I think. I think the most worries that have been expressed are, for example, about suicidal patients, or so risk, you know, how to manage risk when you're not there, and how do you know where the other person is? How can you be sure that that's indeed the case?
How do you handle when there's immediate risk? I think that that's a worry. But then, at least from what I've been asking, a therapist is similar question, do you think that for some people you should never ever do teletherapy?
People have such contradictory answers. You know, some people think of with people with autism, Asperger or something, you should not use teletherapy. Others say, well, actually, this is the best way to reach people with autism because it's a little easier to show around your personal surroundings or not be too close.
So people have different, I think, fears and experiences. And it seems that actually, as far as I can understand, most people who have experience with working with people then become more confident that it's actually possible. Just like some people say, oh, with kids, it's like never ever do it.
And other people say, well, this is the best way to engage kids. And you can play, almost make it into a game and actually use the language that kids use, use the technology that kids use. And so I feel like people have such contradictory opinions.
Yeah, we need to wait until the research actually backs up any strong decision either way, I think for a patient group.
Yeah, okay, that's interesting. Yeah, as soon as you were talking about the risk part, so client is suicidal, for example, sort of immediately my reaction was, I could total, I see the argument, and I could also see a therapist reasonably saying, I'm concerned about my own risk, so I'm not going to see this client online. But what that could mean is that this client doesn't get as much therapy because they're suicidal, because they don't have as much access to it.
And then I'm thinking like, oh my God, this is a problem. You know, the sort of like cover your own self, which is a very reasonable, I mean, this is not a critique of folks who have that intuition. That's a totally reasonable intuition.
But thinking about it in terms of sort of, you know, systematically withholding or providing less opportunities for therapy for folks who are at risk, it's like, oh no, this is not, this is an unintended consequence.
Exactly, exactly. Yeah, yeah. Yeah, you asked about a particular type of therapist too, right?
And I, so I previously always thought like psychodynamic or psychoanalytic therapist would never ever do this. And so I think that's definitely changed over time. And so, for example, I can imagine with a CBT therapist or behavioral, doing a behavioral exposure, for example, that that might be far more fruitful actually, when you have a context of the patient's home and actually know what are, what are going to be the challenges that come up, right?
When you're in a therapy session in an office, you might not understand really how hard it is to go through different steps of an exposure because you don't understand what's, what's the context of where the patient is trying to do this. So I think if you like develop particular like homework tasks or, or these exposure hierarchies or to actually have a better sense of the patient's context might really be quite fruitful. But when you're, for example, a process-oriented therapist and it's, you know, it's all about more experiential work, then maybe it's, it's harder to do it to do it in person because the therapeutic presence is weaker, right?
It's hard to be so in the moment is so present for both patient and therapist. So I think, you know, then maybe you could argue, well, in person sessions would be important to do that kind of work.
Yeah, no, I mean, it's fascinating to think about, like to think about, and to an extent, maybe this gets back to the technique thing that we almost started with, which is like, you know, doing less techniques. So I'm thinking about, you know, what would a person be less likely to do, you know, to apply certain techniques like an empty chair technique or to be doing certain, I thought about this too, in terms of like, you know, the, you know, sort of someone who's very behavioral that, yeah, I mean, it's, it's two sides of the coin, right? Like, or both sides of the coin, because you could actually have them do some of those exposure exercises, you know, actually in the real context, you know, like it's like in vivo in vivo, like actually in, you know, in the kitchen where you had the panic attack, you know, at the same time, it's sort of, you know, having done a lot of, you know, exposure stuff with clients, it's, you know, it can be pretty intense and that you have, I would feel less control, you know, less, but like less like I could ensure that this is therapeutic.
Yeah.
Right. If I wasn't there.
Well, then might explain why, why therapists tend to be more supportive rather than actually doing their, like challenging their, their patients in teletherapy. That it seems like you have a little less control on what's, what's going on. But yeah, I think one of the things that I definitely find harder with teletherapy, for example, is the use of silences, right?
Where I think in, in person you can definitely sit and the tension can build and it's actually, it can be fruitful to have some, some time to not actually say something. Whereas I think in teletherapy or for like, do you hear me? Are you okay?
No, it's, it's hard to actually really roll with the, with the silences, I think.
So, okay. So I'm really appreciative that you brought that up. Cause I, so in my head, that was one of the things that popped into my, that was one of the things that popped in my head and I didn't say it.
Cause I thought you would like, I thought it would be like a naive and stupid thing to say. So, but that was totally what I, that was one of these things I was thinking about, which is, you know, cause like silence is, can be so incredibly powerful for all sorts of different reasons. But one, the very practical thing of like, are you frozen?
Like that could, you know, cause a lot of times silence comes along with not moving very much. Right. But then, yeah, just like, will it have that same, will it have that sort of intended therapeutic effect?
If it's, if it's a road, yeah.
Yeah. Yeah. So it definitely, I think it makes some things more challenging, but it opens up other opportunities.
And that's on us to be able to work with that, I think, to be able to navigate what we can get from in-person work and what we can get from teletherapy work.
And sort of thinking, sort of talking about these very practical things, it's like I could see what would be cool would be like talking to a whole bunch of different therapists from a whole bunch of different orientations who have done a lot of teletherapy and been like, how have you, you know, to talk to like a hardcore behaviorist and sort of say, you know, what initially didn't work that you figured out how to make it work, you know, and then what initially didn't work, and it's still you've given up on doing it until a therapy. So either you've shifted to something else to meet that ends, or you just, you know, when working with this type of situation, you have to do it in person, you know, like to sort of see to really get experts in those different, you know, there's different approaches using those different interventions, sort of to really get from them, you know, what has worked, where are the limits of this thing? But then, but also sort of that, you know, again, for the person who does empty chair all the time or something like that, that how have you figured out how to make this work?
Because I'm sure that many of them have.
Right, right. Yeah, yeah, many therapists have given up their offices. So, you know, I think nowadays it's, I mean, maybe that's just because I'm in New York and New York's offices are expensive, you know, but I think many people have seen it.
It's possible.
Yeah. Also, and I'm thinking about, like, work with clients who are dealing with hoarding. You know, was there a really great opportunity there?
I don't know. Yeah, it's interesting. It's fascinating.
Well, this is great. So is there anything before we end that you want to make sure to hit that we haven't hit yet?
No, a good question.
That wasn't that good of a question.
Yeah, no, no, I don't know. Yeah, yeah, yeah, I don't. I don't know.
I don't know anything. I know that we did some research on the attachment of patient attachments and teletherapy, but it seems to be such a mixed bag in results that it's maybe not such a clear picture, but it's.
So yeah, let's spend a couple minutes on that, because I know that there are so many people who clinically, they really attend to attachment as really, you know, emphasized. So we should probably just really briefly hit on, you know, what's avoidant attachment, what's anxious attachment, and then what you guys found.
Yes. So it seems like the avoidantly attached patients, so people who are less depending on other people and wanting to do things independently, I guess, are usually not so keen to seek out therapy to start with, but seem more open to trying teletherapy. But people who were more anxiously attached, so people who were actually clinging on to other people to be able to feel secure, really needed this therapeutic alliance to be high in teletherapy, to be able to get benefit from it.
Whereas people who were more securely attached and didn't need the therapeutic alliance so much or they didn't matter, but there were more, for them, it was more important that they had some agency in the teletherapy session, so that they felt that they could actually contribute themselves and that they were actively participating in the teletherapy process. So those seems like some of the nuances. But yeah, there is definitely, I think, room for more research on exactly like, for example, if people who are avoidantly attached, they might prefer teletherapy over in-person, but then is it actually better for them or not?
Of course, preferences and outcomes don't necessarily relate. So I don't think we know, at least I don't know enough about what then actually would result in better outcomes.
So let's just hit on the avoidantly attached person. The underlying idea here is that because they're more avoidant, that this teletherapy thing seems safer, because they don't actually have to go into therapy and be in that more, what they might at least at the outset, perceive in more intense context. So they can have more distance, literally, figuratively, which is more consistent with that avoidant style.
Yes, yes, exactly. So there's an argument that that would create an opportunity for entry into therapy that they might not take if they didn't have that remote, that teletherapy.
Yeah, yeah, yeah. But I don't know at this moment whether that's actually fruitful. Would it not be better to actually push them a little and say, no, you need to come in person just because they are?
So I think there's something different about preferences and outcomes for sure.
Right, because the idea that it might, because they're avoidant, that sort of coming in person and having that more likely be challenging experience could be more therapeutic for them, because it could sort of push them more in ways that will be beneficial for them, but they don't want to do.
Right, that's the story for the whole teletherapy research I feel like. What is the one, and you can say, for which populations do you think it will be more effective, but also who's willing to participate in what? And do what people want, does that necessarily translate to better treatment outcomes?
And I doubt it. Maybe I prefer to work with a male because it's easier, but actually I have a lot of mother issues, so I need to actually have a female therapist, you know, but I'm trying to avoid that because it's too hard. So, yeah, so I think that we don't know yet about the outcomes.
What I think, though, that I think, like, clinically, like, it seems to me like there are some implications here, which are, as a therapist, to think about, like, are there certain things, are there certain, I might say defenses, or are there certain things that are uncomfortable for the client that teletherapy isn't facilitating addressing? And so that for this, particularly as you continue to work with a client, that it could be very reasonable to say, oh, this, you know, as you get working with, you know, that it would be valuable for us to transition and to do four weeks in person and see how it goes, or four sessions in person, or whatever, and see how it goes. That it, yeah, that this sort of does get, you know, so I think there is a reasonable argument that for that more avoidantly attached person or for the many avoidantly attached people, this might help to get them treatment, you know, teletherapy, which is a great thing.
And then, you know, after they establish a little bit of a relationship with you and you start to conceptualize and understand what's going on for them, that the therapist would do well to think about, all right, so now they're here, which is great, would there be therapeutic value in us moving to in-person song, right?
So wouldn't that be true for all patients? That, you know, if for whatever reason teletherapy is an easier way in, let's start there, and then there's something to be gained and something that you also lose or don't have. So let's see then if in-person offers some additional elements that you didn't gain from teletherapy.
I think ideally we would go to a world like that, right, where we would consider both and see where the patient might be more comfortable starting off with and starting there.
Right, and I think that what this, I mean, and this does put, you know, this does put some more onus on the therapist to be more flexible because just like you said, you know, for the therapist in Manhattan who it's like, you know, I don't feel like spending an obscene amount of money for this little corner office, you know, this little office. I'm going to do it remotely. Well, if I only do it remotely and I don't have any other options, then like I'm not flexible now as a therapist, which I mean, I mean, it's a, I say this very sympathetically because like it's a very difficult situation for the therapist to be in, you know, but I mean, it is something to think about though in terms of if I want to be the most effective therapist that I can, how can I be flexible?
Yeah, and then you could sort of say the same thing with the anxious. Well, that would there be value in doing online therapy for some people? Yeah, it's interesting.
Yeah. Yeah. Yeah, I mean, maybe that would be other research study, right?
To find out if maybe it would be helpful for most people to have a little bit of both to see what you can gain. This might be hard to understand at this moment, what kind of gains you might get from either type of therapy. Right.
Yeah. No, I think that one of the take homes here is for, I mean, it's hard and there's no perfect answer, but that for the therapist to really be thinking about their individual client, the individual needs of their client, their own experiences, and to be flexible and proactive in terms of thinking about how is this affecting my client and their experience, bringing it into the room to talk to them about it, and then moving forward based on that. But the teletherapy part, it does become a character in the story.
It does become an aspect of this that we should consider in what we're doing with each of our clients.
Yeah. And I'm hoping that at least the outcome literature that is now more and more established, that that gives therapists some confidence to say, well, actually, whatever we do, it's going to help you in some way, or not for everyone, but the outcomes are similar. So in that sense, it's not about that.
It's about what we can, different elements of the process that we can focus on and that are stronger in one way or the other, but it's both valuable options. I think you can lay on the table quite openly. Totally.
Great. Well, this is great. I really appreciate it.
I feel like I've learned a lot.
No, thank you.
There's always more questions than answers. So let's do a fake goodbye right now, and then I can stop recording, and then we can do a real goodbye, a real catch up or whatever. Thanks, Katie.
Thank you so much. That was really great.
I want to thank Dr. Katie Aafjes-van Doorn for joining me on this week's podcast. And for those of you listening, we want your feedback. So please hit us up on Twitter at the APPod.
That's the A-P-P-O-D. Email us at theappliedpsychologypodcast.gmail.com or if you're watching this on YouTube, leave a comment below. Thank you so much for joining me.
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