How Perfectionism Quietly Fuels Anxiety

Perfectionism has a marketing problem.

It's the flaw people are most willing to admit in a job interview. The trait we secretly consider a strength. The thing parents quietly hope their kids develop.

We've collectively agreed that perfectionism is, at worst, a slightly inconvenient feature of being driven and capable.

In clinical practice, it looks very different.

Perfectionism is one of the most consistent drivers of anxiety I see in my Los Angeles therapy practice. Not because perfectionists are anxious people who happen to have high standards—but because the underlying engine of perfectionism is anxiety.

The standards are the visible part. What's underneath is what's actually running the system.

This piece is about that engine.

What Perfectionism Actually Is

In therapy, we use the term perfectionism to mean something specific—and it gets misunderstood a lot.

It's not about caring about quality. People with healthy high standards can finish work, accept feedback, feel proud, and move on. The internal experience is generative.

Perfectionism is something else entirely. It's using performance to manage internal threat.

The threat is usually some version of: if I am not excellent, I will not be safe, valued, or okay. The performance is the strategy. The point is the feeling the strategy is trying to outrun.

This is why perfectionism is so closely tied to anxiety. The standards aren't the point. The standards are the armor.

High Standards vs. Perfectionism

A few distinctions that matter clinically:

• High standards are flexible. Perfectionism is rigid.

• High standards allow for completion. Perfectionism makes finishing feel dangerous.

• High standards treat mistakes as information. Perfectionism treats them as evidence of inadequacy.

• High standards produce satisfaction. Perfectionism produces relief that quickly fades.

• High standards are about the work. Perfectionism is about the self.

The internal experience is the giveaway. If your standards feel like an expression of caring, they probably are. If they feel like a threat you're managing, you're looking at perfectionism.

Why Perfectionism Produces Anxiety

The mechanics are direct.

Perfectionism asks you to control something that can't be fully controlled—how you're perceived, whether you've done enough, whether your work is good enough, whether you are.

Your nervous system responds to this impossible standard the same way it would respond to any chronic, unresolvable threat: with sustained activation.

This is why perfectionists often describe a baseline of low-grade anxiety that doesn't have an obvious cause. There's no single thing they're worried about. There's a system they're trying to maintain, and the maintenance is constant.

The Bar That Keeps Moving

One of the most exhausting features of perfectionism is that it's self-correcting in the wrong direction.

Once a goal is met, it stops counting. The achievement that would've felt enormous six months ago barely registers now. The threshold for "good" recedes faster than you can chase it.

Many of my clients describe this as the strangest part of their experience: they've achieved things their younger selves would have considered impossible, and they cannot feel the achievement.

Perfectionism has eaten the satisfaction in advance.

Procrastination as a Perfectionism Symptom

This one surprises people.

A lot of perfectionists also struggle with procrastination. They interpret it as a contradiction—shouldn't perfectionists be the productive ones?

Sometimes. But more often, perfectionism and procrastination are two sides of the same mechanism.

If finishing something means exposing it to judgment, and judgment feels existentially threatening, the nervous system delays. The procrastination isn't laziness. It's protection. The work doesn't get done because doing it imperfectly feels worse than not doing it at all.

The Hidden Costs

The visible cost of perfectionism is exhaustion. The hidden costs are harder to name and often more significant:

• An adversarial relationship with your own work rather than a generative one

• Achievements that don't feel like yours — you can list them but can't feel them

• Difficulty receiving praise, because it doesn't match the internal standard

• A persistent sense of being a few steps behind, regardless of evidence

• Erosion of intrinsic motivation, as performance becomes about threat-management instead of meaning

• Self-criticism so constant it sounds like the voice of reason

The last one is worth sitting with. Most perfectionists don't recognize their self-talk as cruel because it's been the soundtrack so long it sounds like fact. One of the moments that often shifts something in therapy is hearing yourself describe how you speak to yourself and realizing you would never speak to anyone else that way.

Why "Just Lower Your Standards" Doesn't Work

Most perfectionism advice amounts to: try not to be such a perfectionist.

It rarely lands, for an obvious reason: the perfectionism isn't about the standards. It's about the threat the standards are managing.

Telling a perfectionist to relax is like telling someone to take off their seatbelt during a crash they're convinced is coming.

Real change involves working with what's underneath—usually some combination of early experiences in which approval, attention, or safety felt contingent on performance. This isn't about blaming anyone. Perfectionism was, at one point, a reasonable adaptation. The work is updating the adaptation now that the environment has changed.

What Therapy for Perfectionism Actually Involves

Effective therapy for perfectionism doesn't try to convince you to care less. It works with the underlying anxiety and identity structure that makes perfectionism feel necessary.

A few of the threads:

• Examining the early relational templates that taught you what you had to be in order to be loved or accepted

• Building tolerance for "good enough," which initially feels intolerable

• Working with the inner critic — not silencing it, but understanding what it's protecting and developing a different relationship with it

• Separating self-worth from performance, which is harder and slower than it sounds and is the actual project

• Nervous system work, because perfectionism lives in the body too—the chronic muscular tension, the held breath, the inability to settle

This kind of work tends to be slower than people expect. Perfectionism isn't just a thinking pattern. It's an identity structure. The shifts are often subtle from the outside—the people in your life may not notice anything different for a while—but they reshape how you exist inside your own life.

A Final Note

If you're reading this and recognizing yourself, you're not broken and you don't need to be less ambitious.

Many of the most thoughtful, accomplished, contributive people I know are recovering perfectionists. The recovery doesn't take your edge away. It returns you to yourself.

Working with a therapist in Los Angeles who understands perfectionism as an anxiety pattern—not a personality trait to be tolerated—can shift the engine, not just the symptoms. The version of you that gets to make things without first having to survive them.

If you're considering modern therapy in Los Angeles, or virtual therapy across California, Nevada, or Oregon, I'd love to talk.

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Frequently Asked Questions

Is perfectionism the same as having high standards? No. High standards are flexible, allow for completion, and produce genuine satisfaction. Perfectionism is rigid, makes finishing feel risky, and produces brief relief rather than lasting fulfillment. The internal experience is the clearest tell: high standards feel like care; perfectionism feels like threat.

Can perfectionism cause anxiety, or do they just often appear together? Perfectionism is one of the most reliable drivers of anxiety I see clinically. The mechanism is direct: perfectionism asks the nervous system to maintain an unachievable standard indefinitely, which produces sustained activation. Treating the underlying perfectionism often resolves much of the anxiety.

Is procrastination a sign of perfectionism? Often, yes. When finishing something means exposing it to evaluation, and evaluation feels existentially risky, perfectionists frequently delay. It looks like avoidance. It's usually self-protection. This is why "stop procrastinating" advice rarely helps people whose procrastination is rooted in perfectionism.

How long does therapy for perfectionism take? It depends on how entrenched the pattern is and what's underneath it. Many clients notice early shifts in awareness within the first couple of months. Deeper identity-level change—where perfectionism stops feeling like who you are—tends to unfold over a longer arc, often a year or more.

Do you work with high achievers and professionals in Los Angeles? Yes. A significant portion of my practice is high-functioning, ambitious professionals whose perfectionism has become both a driver of their success and a quiet source of their suffering.

Why Overthinking Can Feel Impossible to Turn Off

It usually starts small.

A text you sent that didn't get a response. A comment from your manager you can't quite read. A decision you made last Tuesday that you're now turning over for the fourth time today.

Overthinking doesn't announce itself. It just becomes the background of your mental life until you realize you haven't been fully present in your own day for weeks.

If you've tried to stop and the strategies don't quite work—if "just let it go" feels like advice from someone who's never lived inside your head—there's a reason.

Overthinking isn't a character flaw. It isn't a discipline problem. It's a coping mechanism, and a sophisticated one. Understanding what it's actually doing for you is the first move toward real relief.

As an anxiety therapist in Los Angeles, I work with a lot of clients whose minds don't stop. Smart, capable, often deeply self-aware people who have read the books, downloaded the apps, and still find themselves at 1 a.m. rehearsing a conversation that hasn't happened yet.

This is for them.

What Overthinking Actually Is

In therapy, we talk about overthinking as two related but distinct patterns:

• Rumination — looping over things that have already happened (conversations, decisions, mistakes, perceived missteps)

• Anticipatory anxiety — rehearsing things that haven't happened yet (future conversations, hypothetical conflicts, decisions you might have to make)

Both share the same underlying mechanism: the mind is trying to use thought to manage discomfort.

The discomfort might be uncertainty, vulnerability, the fear of being misunderstood, or the fear of making the wrong call. Thinking feels like doing something about it.

The catch: the thinking rarely resolves anything. It produces the sensation of progress without the substance of it. You can spend two hours analyzing a situation and arrive exactly where you started—except more depleted.

Why Your Brain Won't Stop

Here's what surface-level advice misses: overthinking is rewarded by the nervous system.

The brain experiences uncertainty as threat. Thinking creates the illusion of control. Control quiets the threat signal for a moment. The brain learns that thinking = safety, even when the thinking is going in circles.

This is why telling yourself to stop doesn't work. You're not battling a habit. You're battling a regulation strategy your nervous system has come to rely on.

The Illusion of Productive Worry

A lot of overthinkers carry a quiet belief that worrying is responsible. That if they stop running through scenarios, something will catch them off guard. That vigilance is what's kept them safe so far.

There's usually some truth to that. Many people who overthink grew up in environments where being prepared—anticipating other people's moods, staying ahead of problems—was genuinely necessary. The strategy worked.

The problem is that your nervous system doesn't know the environment has changed. It's still running the old software in a context that no longer requires it.

When Overthinking Is Really Avoidance

This is the one that catches my clients off guard.

Overthinking often functions as a form of avoidance—of feelings, of decisions, of action.

If you've been "thinking about" leaving a job, ending a relationship, having a hard conversation, or making a change for months or years without movement—the overthinking isn't preparation. It's the substitute for the discomfort of actually doing the thing.

The mental loop feels productive, which protects you from confronting that you're afraid, ambivalent, or grieving. This isn't a moral failing. It's deeply human.

But it's worth naming, because no amount of additional thinking will resolve a situation that requires feeling.

What Overthinking Is Quietly Costing You

The price isn't paid in one big payment. It accrues:

• Decision fatigue — small choices feel disproportionately heavy

• Difficulty being present in conversations, meals, intimacy, your own life

• Sleep that gets thinner as the mind uses bedtime as processing hours

• An adversarial relationship with your own mind — you've started to fear your own thoughts

• Erosion of trust in your instincts, because analysis has replaced them

• A sense of running, even when you're sitting still

Most people don't realize how much cognitive bandwidth is being absorbed by background processing until something interrupts it—a vacation, a meditation retreat, a moment of unexpected stillness—and they feel the contrast.

Why Common Advice Misses

Most overthinking content offers tools: thought-stopping, journaling, breathwork, the 5-4-3-2-1 grounding technique.

These can be useful in moments. There's nothing wrong with them.

But for chronic overthinkers, they often fail for one specific reason: they treat overthinking as a habit to interrupt rather than a signal worth listening to.

If your overthinking is your nervous system trying to manage something real—unresolved relational dynamics, identity questions, ambivalence about a major life choice, old patterns of hypervigilance—suppressing it with a worksheet won't hold. The system will route the energy somewhere else. Usually into the body.

This is why real therapy for overthinking isn't about thinking less. It's about needing to think less.

What Actually Helps

A few of the threads that move the needle.

Distinguishing Productive Thought from Looping

Productive thought moves toward a decision, an insight, or an action.

Looping returns you to the same place with diminishing returns.

Learning to feel the difference—not intellectually, but in your body—is foundational. Most overthinkers don't realize they've crossed from one to the other until they're hours in.

Working with the Underlying Emotion

Underneath most overthinking is an emotion that hasn't been fully felt. Anxiety, yes—but often also grief, anger, hurt, longing, or fear.

When the emotion is named and metabolized, the thinking quiets on its own.

This is where therapy does work that self-help can't reach. Not because the techniques are exotic. Because emotion needs another nervous system present to be processed.

Nervous System Regulation

Overthinking lives partly in the body. A nervous system stuck in low-grade activation will keep generating mental content to match its physiological state.

Learning what activation feels like, and how to come down from it—through breath, movement, and grounded presence—gives the mind less fuel to burn.

Building Tolerance for Uncertainty

Most overthinking is, at its core, an intolerance of uncertainty.

The work isn't to eliminate uncertainty. It can't be done. The work is to expand your capacity to be in it without needing to think your way out.

This is often the most quietly transformative piece. And the hardest to do alone.

A Note on When to Reach Out

If overthinking is affecting your sleep, your relationships, your ability to make decisions, or your sense of yourself, it's worth taking seriously.

Not because something is wrong with you. Because the longer the loop runs, the more entrenched it becomes—and the more it shapes who you are when you're not paying attention.

Working with an anxiety therapist in Los Angeles who understands how overthinking actually functions—not as a quirk, but as a coping system—can change the relationship you have with your own mind. The goal isn't a quiet head. It's a head that doesn't have to work this hard.

If you're considering modern therapy in Los Angeles, or virtual therapy across California, Nevada, or Oregon, I'd love to talk.

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Frequently Asked Questions

Is overthinking a sign of anxiety? Often, yes. Overthinking is one of the most common cognitive expressions of anxiety—particularly generalized anxiety and high functioning anxiety. It can also appear alongside perfectionism, trauma responses, or chronic stress. The pattern matters more than the label.

Why does overthinking get worse at night? At night, the external demands that absorb your cognitive bandwidth fall away, and the nervous system's unprocessed material rises. Many overthinkers function during the day by staying busy. Nighttime removes the buffer—which is why your mind feels loudest right when you're trying to sleep.

Can therapy actually help with overthinking, or is this something I just have to manage forever? It can genuinely help. The goal isn't to eliminate thinking—obviously—but to address what's driving the loop. When the underlying emotional and physiological patterns shift, the overthinking quiets substantially. Many clients describe it as having their bandwidth back.

What's the difference between overthinking and being thoughtful? Thoughtfulness moves you toward clarity, decision, or insight. Overthinking circles without resolution and leaves you more depleted than when you started. The internal experience is the tell: thoughtfulness feels generative; overthinking feels like static.

Do you work with clients whose main concern is overthinking? Yes. A significant portion of my practice is working with overthinkers—often high achievers and professionals whose minds have become both their greatest asset and their greatest source of exhaustion.

High Functioning Anxiety: When Success Doesn't Feel Like Success

From the outside, it looks like competence.

Deadlines met early. Inbox at zero. You're the friend who remembers the birthday, the colleague who absorbs the overflow, the partner who keeps the logistics running.

From the inside, it looks like something else.

You're awake at 2 a.m. rehearsing a conversation from three days ago. You haven't taken a real breath since Tuesday. Your achievements don't feel like yours—they feel like things you barely escaped failing at.

That's high functioning anxiety.

As an anxiety therapist in Los Angeles, I work with a specific kind of client. Young professionals. Creatives. Founders. Graduate students. People whose résumés say everything is fine.

They're not in crisis. They're not falling apart. They're exhausted in a way that doesn't yet have language.

Let's give it one.

What High Functioning Anxiety Actually Is

A note first: high functioning anxiety isn't a formal diagnosis. You won't find it in the DSM. But clinically, it describes something real—and the people living inside it deserve a more honest conversation than wellness content usually offers.

Here's what it tends to look like:

• A mental loop of planning, anticipating, and reviewing that rarely shuts off

• Difficulty resting without guilt or a low hum of unease

• Over-preparing for situations other people move through casually

• Saying yes when your body is clearly saying no

• Overfunctioning at work, in your family, in your relationships

• A racing mind that only quiets when you're producing

• Sleep that comes hard or breaks early

• A faint, persistent feeling that something is about to go wrong

The signature isn't dysfunction. It's the cost of the function.

People with high functioning anxiety often look like they're thriving by every external measure—and they may be—while privately running on a steady current of low-grade dread.

Why Achievement Becomes the Coping Mechanism

Here's the part most people don't talk about: anxiety and ambition are often two sides of the same coin.

For many high achievers, productivity is how the nervous system regulates itself. The brief relief of crossing something off the list. The promotion. The A. Being called "the responsible one." These don't just feel good—they temporarily quiet an older signal underneath:

If you stop, something bad will happen.

That signal isn't conscious. It usually got installed early—in a family where approval was contingent on performance, a school where being gifted hardened into identity, a culture that conflates worth with output. Los Angeles, for many of my clients, is a particularly fluent dialect of that culture.

The Perfectionism Feedback Loop

Perfectionism is one of the most reliable engines of high functioning anxiety. And it gets misunderstood a lot.

In therapy, we use the term perfectionism to describe something specific—not high standards, but using performance to manage internal threat. The fear that being less than excellent will expose something unacceptable about who you are.

People with genuinely high standards can finish, rest, and feel proud. Perfectionism doesn't allow that. The loop runs predictably: anxiety drives effort → effort produces results → results bring temporary relief → the bar quietly rises.

The threshold for "enough" recedes faster than you can chase it.

When Productivity Becomes Regulation

I describe this in session as productivity-as-regulation. The work isn't only work. It's how you stay okay.

Which is why rest—real rest, not the performative kind—can feel destabilizing. When the doing stops, the feelings the doing was managing tend to surface.

Most people, understandably, get busy again.

The Cost Most People Don't See

Some of what I see most often in my Los Angeles practice:

• Chronic emotional exhaustion that doesn't resolve with a weekend away

• Difficulty being present in your own relationships, even the ones you love

• Resentment that surprises you—at work, at the people who ask things of you, at yourself

• Physical signals: tension headaches, jaw clenching, GI issues, disrupted sleep

• A sense of being further from yourself than you were a few years ago

• The strange grief of having achieved what you wanted and feeling somehow worse

Burnout lives in this territory too. Anxiety drives over-effort. Over-effort depletes you. Depletion sharpens the anxiety. The loop tightens.

Why This Is So Hard to Recognize

A few reasons, all of them stubborn.

It works. Sort of. The strategies that fuel it—planning, controlling, achieving—do produce results. The people around you reward them. Letting them soften can feel less like healing and more like losing your edge.

It's quiet. There may be no panic attacks, no obvious avoidance, no clear "incident." Just a persistent hum that's become so familiar it reads as personality.

You're good at performing wellness. People with high functioning anxiety can describe their patterns lucidly in a first session and still be entirely identified with them. Insight isn't the same as change.

What Therapy for High Functioning Anxiety Actually Involves

If you're considering anxiety therapy in Los Angeles, the work for high functioning anxiety looks different from generic anxiety management.

The goal isn't to make you less ambitious. It's to separate your competence from your compulsion.

Beyond Symptom Management

Most short-form anxiety advice targets symptoms—breathing, grounding, reframing thoughts. These tools have their place, but for high functioning anxiety, they tend to become another item on the to-do list. You can optimize your way through them and feel no different at the core.

Deeper work tends to include:

• Examining the early relational templates that taught you achievement equals safety

• Distinguishing your nervous system's actual signals from your habitual responses

• Building tolerance for the discomfort of not performing—rest, receiving, being seen without producing

• Developing a sense of self-worth that doesn't require continuous output

• Naming the costs you've been quietly absorbing as the price of being who you are

Nervous System Work

Much of high functioning anxiety lives in the body. The mind is the last to know.

Working with the nervous system—learning what activation actually feels like, what regulation feels like, what real rest is and isn't—is often a meaningful part of recovery. Not a wellness trend. A clinical one.

A Final Note

One of the harder truths about high functioning anxiety is that it can persist for years before someone decides it's worth addressing. There's no obvious bottom. The career keeps progressing. The relationships keep functioning. The internal experience quietly gets worse.

If you're recognizing yourself here, you haven't failed at anything. You've built a life on strategies that worked—right up until they started costing more than they returned.

Working with an anxiety therapist in Los Angeles who understands high functioning anxiety isn't about dismantling what you've built. It's about giving you a different relationship with the engine underneath it. The version of you that doesn't have to earn rest. The one that gets to actually inhabit the life you've worked this hard to create.

If you're considering modern therapy in Los Angeles—or virtual therapy across California, Nevada, or Oregon—I'd love to talk.

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Frequently Asked Questions

Is high functioning anxiety a real diagnosis? Not formally. You won't find high functioning anxiety in the DSM, but it describes a recognizable clinical pattern: significant internal anxiety paired with strong external functioning. It overlaps with generalized anxiety, perfectionism, and chronic stress—and it captures something specific about how anxiety shows up in high achievers.

Can therapy help if I'm still functioning well? Yes—and this is often the most useful time to start. People who wait until they're in crisis face a steeper climb. Early work tends to be more nuanced and more identity-focused. Functioning well doesn't mean nothing is wrong. It usually means you've built effective compensations.

How is therapy for high functioning anxiety different from generic anxiety treatment? It focuses less on basic symptom management and more on the underlying relationship between achievement, identity, and self-worth. The work typically includes nervous system awareness, attention to early relational patterns, and steady examination of the beliefs that make rest feel unsafe.

Do you offer virtual therapy outside of Los Angeles? Yes. I offer virtual therapy across California, Nevada, and Oregon, which makes consistent work possible for busy professionals, frequent travelers, and people in areas with fewer specialized therapists.

How long does it usually take to feel different? It varies, but many clients notice meaningful shifts within the first couple of months—not the disappearance of anxiety, but a different relationship to it. Deeper change in patterns like perfectionism and overfunctioning generally unfolds over a longer arc, often six months to a year or more.

Does online therapy work?

One of the biggest concerns about online therapy is that therapists don't have an opportunity to observe the patient—something that is usually integral to an assessment and diagnosis. The tone of voice, body language, and overall demeanor provide insight into an individual's well-being.

A major component of effective therapy involves the relationship between the therapist and the patient. As online therapy is impersonal (often, it's completely anonymous), many people have raised concerns about whether digital communication can provide skills, tools, and healing power to individuals staring at a screen.

Despite the concerns, research consistently shows that online treatment can be very effective for many mental health issues. Here are the results of a few studies:

• A 2014 study published in the Journal of Affective Disorders found that online treatment was just as effective as face-to-face treatment for depression.

• A 2018 study published in the Journal of Psychological Disorders found that online cognitive behavioral therapy is, "effective, acceptable, and practical health care." The study found the online cognitive behavioral therapy was equally as effective as face-to-face treatment for major depression, panic disorder, social anxiety disorder, and generalized anxiety disorder.

• A 2014 study published in Behaviour Research and Therapy found that online cognitive behavioral therapy was effective in treating anxiety disorders. Treatment was cost-effective and the positive improvements were sustained at the one-year follow-up.

The Potential Benefits of Online Treatment

Online therapy offers some benefits over traditional face-to-face treatment:

• People in rural areas or those with transportation difficulties may have easier access.

• Many online therapy sites allow users to sign up with "nicknames" which can entice people who are embarrassed about getting services under their real names.

• Most online therapy services cost less than face-to-face treatment.

• Scheduling is more convenient for many people.

• Studies show online therapy requires 7.8 times less of a therapist's time than face-to-face treatment—meaning therapists can often treat more people online than they can in-person.

• Clients don't have to worry about seeing people they know in the waiting room.

• It can be easier for some people to reveal private information when they're sharing it online.

• Individuals with anxiety, especially social anxiety, are more likely to reach out to an online therapist.

The Potential Drawbacks

Online therapy isn't for everyone. Here are some potential risks and drawbacks:    

• Online therapy isn't meant for people with certain problems or conditions (such as suicidal intent or psychosis).

• Without being able to interact face-to-face, therapists miss out on body language and other cues that can help them arrive at an appropriate diagnosis.

• Technological issues can become a barrier. Dropped calls, frozen videos, and trouble accessing chats aren't conducive to treatment.

• Some people who advertise themselves as online therapists might not be licensed mental health treatment providers.

• Sites that aren't reputable may not keep client information safe.

• It can be difficult to form a therapeutic alliance with someone when meetings aren't face-to-face.

• It can be difficult for therapists to intervene in the event of a crisis.

How to Find an Online Therapist

If you are interested in online therapy, there are many options to choose from. Think about what type of services you want most—phone therapy, video chats, live chats, audio messaging, or text messaging.

You may find a local therapist who offers online services, or you might find you prefer a large organization that offers a substantial directory of therapists to choose from.

But do your homework and shop around for the service and price plan that best suits your needs.

Find the full article here.

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If you're looking for a therapist who provides online sessions, I invite you to contact me to schedule your free phone consultation today! Contact Me Here

COVID 19 & Teletherapy

Seeing a therapist used to imply being in the same room with them, but not any longer. Teleconferencing has made it possible to see a mental health professional from a distance.

With recent requirements for social distancing, many therapists and clients have had to either pause their work or make other arrangements, including meeting by video conference. 

I've been providing teletherapy services for a few years now. Here are some common questions and issues that come up when thinking about making the transition. 

Will My Therapist Agree to Online Sessions?

Some therapists (myself included) are enthusiastic about using teletherapy, some won't use it at all, and a large number of therapists approach it with some reservations. I've been surprised how many therapists are now moving to it with the COVID-19 outbreak and resulting social distancing. Most therapists generally seem to find that it's a very beneficial approach. 

Even among therapists I know who were skeptical about online sessions in the past, the majority have opened to the idea. They seem to recognize it as a good option to avoid an untimely break in the therapy relationship, and to provide continuity of care. 

Will It Be Weird? 

If you're generally comfortable with communicating through a screen (e.g., Skype, FaceTime), you'll probably be comfortable moving to online therapy. If you can't stand this form of communication, you'll likely have a harder time with it. Of the dozens of clients I've treated through teletherapy, most seem to find the transition to be smoother than they expected. Therapy tends to be intense, and quickly enough you're likely to forget about the medium and focus on the work. 

That said, expect some differences with teletherapy. It's different when you're not in the same room with someone, and you're experiencing them in two spatial dimensions instead of three. It can also be harder to pick up on body language through a video. And while most of my clients seemed to be comfortable with making the switch, a few were not, or found the transition to be quite challenging. Occasional tech issues come up (like a delay in the audio and video), but typically can be handled with a little patience and humor.  

Is It Effective? 

Research suggests that therapy by video conference can be very effective, which has also been my clinical experience. It depends on you and your therapist, of course, but in general you should expect it to be helpful if you were finding in-person therapy helpful. 

Personally, some of the most powerful clinical experiences I've witnessed have occurred through teletherapy. In my own practice, I've seen it work for people dealing with things like depression, anxiety, obsessive-compulsive disorder, insomnia, relationship issues, grief, and trauma. 

Will Insurance Reimburse Me? 

A growing number of insurance providers seem to be willing to cover online therapy sessions. They'll probably require the standard things for reimbursement: your identifying information, the provider's license and so forth, a diagnostic code, and a session (CPT) code. Check with your insurance provider before starting your sessions if you'll depend on reimbursement to cover the sessions.  

How Does It Work?

You and your therapist will agree on a platform to use (or in some cases may decide to forego video and simply speak by phone). Some rely on Skype or FaceTime, although those options are not HIPAA compliant. More secure platforms include VSee, Zoom, and Doxy, among others. There may be a fee for your therapist to use the technology depending on the service, but it should be free for you (aside from your therapist's session fee, of course).  

How Should I Prepare for My Sessions?

Some important and finer points about the logistics of teletherapy:

• Do a test of the software beforehand for your own peace of mind and to be sure it will work, and verify that you have your therapist's contact information (e.g., VSee username).

• Find a place in your home where you'll have as much privacy as possible. This could be a challenge if kids are out of school or other family members are always home (or work from home).

• Along those lines, I recommend ear buds for privacy and also better sound quality. That way your therapist's voice won't feed back into your microphone and out their speakers.

• Make sure you're sitting somewhere you'll be comfortable for the length of your session.

• Have your screen on a stable surface, since excessive movement can create a feeling of seasickness for your therapist. If they're new to teletherapy and their screen is bouncing around, ask them to do the same.

• A finer point: try to have the top of your head near the top of your video screen, rather than in the bottom half of the screen. That way when they're looking at your face they'll be looking more or less into their camera (assuming it's at the top of their computer), so it will feel like they're looking at you.  

• Be sure to close email and turn off notifications that could be distracting and dilute the experience for you. You'll want to have your full attention focused on your session.

• Also close programs that could slow down your computer's processing ability and interfere with the quality of the video. 

• You may also need to work out payment arrangements with your therapist if you generally pay in person. Some therapists will keep a credit card on file for you; others will ask that you mail a check. Find out what they prefer. 

Are There Other Advantages to Online Therapy?

One plus of online therapy you'll notice right away is that there's no travel time involved, so your sessions will probably take up much less of your day. With that in mind, you may want to build in some transition time into and out of therapy, since travel time often provides a buffer before and after your session. It might be challenging, for example, to return directly to childcare after an emotional session. Even a 10-minute break to process and digest the session can make a big difference. 

You'll also never have to cancel for weather (assuming you have electricity and Internet), and there are no concerns about whether you could pass along a sickness to your therapist (or vice versa) if you're well enough to meet but possibly contagious. It's also possible to see your therapist when you're traveling, just as I've been able to see clients when I've been on the road. 

What If My Therapist Won't Do Online Sessions? 

If your current therapist isn't open to doing teletherapy, you might consider speaking with a new therapist who does offer online sessions. Obviously it's not ideal to have to start over with someone new, especially if you've been seeing your therapist for a while. But it may be your only option if you're committed to continuing therapy with as little interruption as possible.

If you don't want to start with a new person, consider other resources during the hiatus from seeing your therapist (and work with them on the plan, if possible). For example, there may be books, brief online courses, or other resources that will help you to continue the work. Your therapist might be open to having brief phone check-ins during this time. 

Seek out additional support from loved ones, as well, and be sure to take care of your basic needs like sleep, nutrition, and movement to keep your body and mind healthy. You might find journaling to be helpful during this time, as it's been shown to be an effective way to process thoughts and emotions.

Keep in mind that there could be unexpected benefits to taking a therapy vacation. While it may not be ideal, an unplanned break from therapy can lead to surprising growth, as the work you've done settles in and takes hold.  

The Bottom Line

If you're considering teletherapy, talk it over with your therapist and see if it's worth giving a try. You don't have to know in advance if it's the right decision for you—you can always plan to do a limited number of sessions to see how it goes. If it works well, it could be a convenient and time-saving way to continue the important work of therapy.  

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