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Telepresence: Managing Teletherapy “Surprises”


December 7, 2020 | Reading Time: 6 Minutes

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Darin is participating in his teletherapy session with you, but he clearly isn’t focused. His eyes are pointed in your general direction, but he seems to be looking off to the side as if he is watching another screen. Given how he has adjusted his camera, you can only see his upper chest and head, but cannot see lower than his mid-chest. You may realize that he is snacking on popcorn while working with you, but you may wonder if he is quietly playing a video game at the same time. How do you best respond?

A recent study of 1,000 telehealth consumers found that clients and patients are indulging in a variety of non-treatment related activities during video visits with healthcare providers. At the heart of the issue is multi-tasking – doing more than one thing at a time. From the perspective of the person who is multi-tasking, a world of readily-available distractions at one’s fingertips can be compelling for a variety of reasons during telebehavioral health, not the least of which is the avoidance of difficult feelings and/or discussions. And that’s just what might be happening on the client’s/patient’s side. What about the super-busy professional who multi-tasks as a way of life?

From the perspective of the person dealing with someone who is multi-tasking during telehealth to-the-home, these experiences can lead to a wide range of “teletherapy surprises” that are leaving many therapists and clients/patients alike at a loss for what to say or do.

Which teletherapy surprises are being reported?

In a DrFirst survey of 1,000 consumers, the Maryland-based digital health company found that while 44% percent of their respondents recently tried virtual visits, many are indulging in telehealth distractions while meeting with their healthcare professional – including indulging in a cocktail. These are the activities reported:

  • Checking social media or eating a meal or snack – 21%
  • Playing a video game 19%
  • Exercising – 18%
  • Smoking a cigarette – 11%
  • Driving a car – 10%
  • Having a “quarantini” cocktail or other alcoholic beverage – 9%
  • Men seemed to be the worst offending multi-taskers, (73%) as opposed to women (39%).

The DrFirst study also commented that few providers seem to take the time to lay ground rules for their telehealth visits. “While healthcare providers and telehealth companies have developed ‘webside manner’ guidelines for doctors and nurses engaged in virtual visits, few take the time to lay out ground rules for patients on the other end of the phone or video link.”

Other Teletherapy Surprises

Teletherapy surprises have to do with either one or both parties not being fully prepared to be on camera and available for a telehealth encounter. They can involve being in various states of dress or undress, as the case may be. They can involve being in a moving vehicle, in a room with invited or uninvited guest(s), on the toilet or in bed. Guests can be invited, or un-invited, in which case they would be considered intruders. These intruders can be either hostile to the encounter or believe they are needed to lend a helping hand, by providing “necessary” information, whether or not it is solicited. Atypical commentary may surface, from another room, intending to be overheard. Naked children can come screaming across a screen, or grab a laptop and run through the house, careening the other person’s view from one wall to another.

Here are a few of the many teletherapy surprise scenarios that have been reported in the COVID Telehealth Clinical Best Practices, the Telebehavioral Health Institute’s advanced clinical training class that has been taken by more than 3,450 psychotherapists to date:

  • Eating
  • Smoking a cigarette, vaping
  • Drinking beer, wine, cocktail
  • Presenting while intoxicated
  • Brushing teeth
  • Appearing semi-clothed
  • Sitting on the toilet
  • Sitting/lying on the bed
  • Accompanied by others in the session
  • Masturbating during session
  • Fainting
  • Taking a walk
  • Driving a car
  • Riding in an Uber with the driver “not listening”
  • Cleaning person in the background
  • Unmanaged children in the background
  • Unmanaged children hijacking the laptop
  • Unmanaged partners engaging in questionable behavior in the background

Just Call Me Doctor

As most professionals know, patients aren’t the only ones who can be easily distracted during telehealth sessions. Some of us may be guilty of checking text messaging and email during a telephone conversation. Multi-tasking during therapy with a person’s voice most certainly creates a diminished experience when compared to sitting in a room with a client or patient. Rarely do we hear that a therapist sits with their eyes closed during telephone therapy, focused on their client’s every word, breathing patterns, hesitancies, the lowering or raising of voice pitch and tone. If not keenly focused on these factors, where does the therapist’s attention go? Is it getting diverted or diminished appropriately or inappropriately?

Video calls can also easily be hijacked by incoming texts, for example. They can populate our video screens, or provides beeps, buzzes, and chirps alerting us to pre-set alarms and messages. Then again, alerts are not the only distractions or surprises for the recipients of our professional care.

Clients and patients report relatively hair-raising complaints of their therapists, too. Professionals have been reported in telehealth surveys for decades, for showing up dressed in a bathrobe, with chest hair protruding. Behavioral professionals reportedly twirl or rock in their seats, audibly tap pencils on the desktops, file their nails, and answer text-messages while on camera. An exercise bicycle might be off to the side of the screen, next to a laundry basket of dirty clothes. A professional’s hair might be uncombed and messy, shirts or blouses buttoned out of sequence or the bookcase in the background might be stuffed with papers, knickknacks, or a large family picture taken during summer vacation. They reportedly appear for their sessions eating salads or sandwiches, filling 1/2 of the recipient’s monitor with lip-smacking, teeth-cleaning goodness.

These therapists don’t know how to position themselves on a screen, and appear in the bottom 1/4 of their recipients’ monitor, creating an annoying visual display that most patients don’t mention, but most certainly find bizarre. These clinicians may be facing another monitor, only occasionally glancing over their shoulders at the patient. Or they may pour over their keyboard, showing only the tops of their heads, rarely coming up for air — or eye contact. Speaking of eye-contact, they might fail to be fully on camera, giving their audience what is known as the “one-eye-ball effect”, that is, having only half one’s face on the camera, apparently unaware of their appearance, for the entire session (Luxton, Nelson & Maheu, 2016; Maheu, Drude, Merril, Callan & Hilty, 2020).

What’s going on?

Since COVID catapulted telehealth to the forefront of healthcare, many previously untrained professionals were thrust into video conferencing without understanding well-established, evidence-based, telehealth clinical models, competencies, workflows, or even basic boundary enforcement strategies. Many are now likely to have niggling questions about how they should be operating when using telehealth. Such questions are so common, new studies calling for more training are being published weekly, such as last week’s report by Pierce and colleagues (2020), which concluded, “Additional telepsychology training and information for psychologists may increase its use … “

At issue is telepresence, which was defined as “how participants experience the technology system: how it makes them feel and think, in general, and how it enables them to feel present and respond to others” (Hilty, Randhawa, Maheu, McKean, Pantera, & Mishkind, 2020).  In the scoping review,  titled A Review of Telepresence, Virtual Reality, and Augmented Reality Applied to Clinical Care, teletherapy distractions were identified as the single most significant impediment to good telepresence.

How to manage teletherapy distractions?

While both patients and providers are vulnerable to distractions during telehealth sessions, it falls on the clinician to set the tone and manage the experience for the professional encounter to be well, professional. The first order of business is to get the training needed to learn how to manage advanced clinical skills, particularly with people who present with complex issues. Many professionals have taken training since the beginning of COVID-19, but those training won’t likely teach the type of skills to know and integrate correct response sets. Professional Training and Modeling

If you’ve taken more than one telehealth training, you probably have realized by now that all telehealth training is not created equal. offers training that is specific to telebehavioral health, taught by industry leaders, and available 24/7 in a multi-media environment accessible through tablets as well as computers. In January, it is offering a 4-hour live, highly-interactive training experience to address these advanced clinical issues, including how to prevent and handle complex clinical cases.

Until December 31, you can register for this popular training at 50% off by using the “Holiday50” coupon code in the cart: COVID Telehealth Clinical Best Practices.

And feel free to leave questions or comments below. Happy Holidays!


DrFirst article: Telehealth Faces New Challenges: Surfing, Snacking and Social Hour.

Hilty, D. M., Randhawa, K., Maheu, M. M., McKean, A. J., Pantera, R., & Mishkind, M. C. (2020). A Review of Telepresence, Virtual Reality, and Augmented Reality Applied to Clinical Care. Journal of Technology in Behavioral Science, 1-28.

Luxton, D. D., Nelson, E. L., & Maheu, M. M. (2016). A practitioner’s guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. American Psychological Association.

Maheu, M. M., Drude, K., Merrill, C., Callan, J. E., & Hilty, D. M. (2020). Telebehavioral health foundations in theory & practice for graduate learners. San Diego, CA: Cognella.

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Alice Ward
Alice Ward
2 years ago

What date and time in January 2021 will the COVID Best Practices take place

2 years ago

My therapist obviously is eating as I can hear the munch munching right in my ear as he either eats cereal or is munching on iceberg lettuce. I often hear him emptying his dishwasher, washing his dishes by hand or turning pages of the newspaper. Sometimes I simply stop speaking and wait to see how long it takes for him to realize nothing is being said. It is very discouraging and disappointing. You would think the opposite would be the case….since he is unable to see my non-verbals one might expect the therapist to get into a recliner, put his feet up, close his eyes and pay attention to what is happening with the least amount of distractions.

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