Practical Ways to Improve Telehealth Sessions

A lot of practitioners have made the switch to telehealth sessions during the COVID-19 pandemic.

But seeing patients on a computer screen can be surprisingly exhausting.

Beyond that, it can introduce new clinical challenges to the session.

In the video below, Christine Padesky, PhD and Ron Siegel, PsyD will get into some practical ideas to help with the transition to telehealth.

Click here for full transcript

Dr. Siegel: It’s a whole new world being a psychotherapist during this age of social distancing and doing much of our work over the phone or Zoom or some other video application. I’ve been doing supervision and talking to colleagues about this as well as reflecting on my own experience, and two things come to mind that I think are useful to address. One is it can be really exhausting to spend the whole day staring at a computer and talking to people that way. What my colleagues and I have experienced is that, in many ways, we feel as though we’re being observed more carefully through video than we would feel if we were face-to-face in the office. Face-to-face in the office is relaxed, we’re sitting there, but we’re on camera when we’re with our clients through these virtual media and it becomes much more tiring. It also raises the question of, “How do you develop therapeutic presence through this kind of media? Is it by always staring at the client or is it by trying to make it be a little bit more relaxed or laid-back in a way?” And I think it’s quite useful to talk with your colleagues about how they’re managing it, and particularly not to feel that there’s something wrong with you or that you’re doing it wrong because you’re finding it difficult to attend in this way. The other thing, which is interesting, is what it’s like to work by phone because there are many clients who are actually more comfortable doing this by telephone. It strikes me that it’s a little bit like the old psychoanalytic days, where the setup was that a person would be lying on the couch and Freud would be sitting behind them. There was a way in which that made it easier for the therapists, and in some ways, made it freer for the client – or the patient, in those days – to speak freely about what was on their mind. I’ve observed a number of clients who would much rather do it on the phone than do video, as well as clients who are much more free to talk about things that they would have more shame about or more reluctance to discuss because they’re not being seen. They’re freer to just explore the contents of their mind. That becomes interesting also when talking to clients about the option to try to ascertain what might make them favor one or the other options and weave that into the therapeutic decision-making. So, we’re in a brave new world here, there’s so many new things to learn, but it’s useful to talk to our colleagues and our clients about what the experience is, because we’re all learning about it here.

Dr. Padesky: I’ve been also talking with colleagues in the last few weeks about doing teletherapy, and the difference from doing in-person therapy in the office. There are a couple things that have come out in these conversations. The first is, in terms of dealing with the fatigue factor that therapists often feel in the opening weeks of doing teletherapy, that does reduce over time. Some of the things that we can do to reduce it are, when we’re in our office, we’re not constantly just staring at our client’s face. We may be looking over their head, looking out a window, we might be glancing at something that we’re working on on a whiteboard, or something like that. Allowing our gaze to change is one thing that can make a difference. Another practical thing that can make a huge difference is wearing ear buds or some sort of device that allows us to hear more easily and a microphone, so the clients can hear us more easily. It turns out that one of the big fatiguing factors in online conferences is poor sound and poor audio quality. So, things we can do to improve that can make a really profound difference in our fatigue levels. The other thing is, I think it’s important not just to talk to colleagues about how to make teletherapy go better, it’s also really important to collaborate and talk with our clients about it. One of the big differences is we’re kind of a bigger talking head than we typically would be in the office, where there might be six or so feet between us, when we’re doing in-person therapy. One of the things that I think is really important is to ask our clients, “How close should we be to the screen? Would you feel better if I backed up further or would you feel better if I’m up closer?” Also, to not constantly be doing eyeball-to-eyeball work. I’ve done a lot of thinking over the years and have talked to my clients about the difference between eyeball-to-eyeball conversations and what I call shoulder-to-shoulder work, where we’re working on a piece of paper together. One of the things that I find really helpful in telehealth, as well as in in-person work, is not always to expect to be looking at each other because that’s very unsettling for a lot of clients who have intimacy issues, clients who are quite anxious or feel shame or guilt. To have someone looking at them actually makes them feel quite under the spotlight. So, it can be really helpful to break things up in session and say, “Let’s both get out a piece of paper right now and let’s make a list of some of the things we’ve been talking about,” and actually avert your eyes from the screen and write things out and have the client write things out. Of course, in CBT therapy, many therapists use the Mind Over Mood client workbook that Dennis Greenberger and I wrote. We’ve made it possible for therapists to either email or send the PDF copies of these worksheets to their clients so that you could actually get out a worksheet – it doesn’t have to be from that book, any worksheet that you commonly use with clients. If you’re both periodically writing and then talking to each other about what you’ve written, you’re then not doing all eyeball-to-eyeball work and I think it’s relieving to clients, as well as to therapists, to be working together with purpose on something that doesn’t involve just looking at each other constantly.

If you’ve started seeing clients via video, what practices have you found most helpful for telehealth sessions? What has been most challenging about seeing clients virtually?

Please share your experience a comment below.

71 Comments

Kevin Ceckowski, Social Work, Bethesda, MD, USA says

Many of my providers stated that their patients are very frail, have limited dexterity, some with cognition issues, Wi-Fi troubles, and do not have the right equipment at home for Telehealth. Many like FaceTime for they can leave the house and be in a private location away from family. Many also like being safe at home and not having to come into the Medical Center is super fine by them. Kevin Ceckowski, LICSW, Service Chief, Outpatient Clinics, Bethesda, MD

Mandy Stockley, Counseling, GB says

Glad to know others feel so exhausted at times

Patricia Ross, Marriage/Family Therapy, USA says

I’m apparently in the minority here, but I don’t find telehealth exhausting any more than f2f therapy. With both, I’m very focused and attentive to changes in expression, shifts in mood and affect, nuances of communication. A couple of my clients prefer telephone to video, and my take on this preference is that they feel less scrutinized than either f2f OR video, and are able to be freer and more open than they are when they are watching my face for reaction or response (I tend to not be very deadpan, and sometimes my face gives me away).

Debra McSheffery, Social Work, Grove City, OH, USA says

I have found what both therapists have stated about fatigue to be true. I am so mindful of the client looking at me and making eyeball to eyeball connection. It is exhausting. I am relieved to know why there is fatigue and makes so much sense to come from the different focus provided by telehealth. It is, first of all, a foreign way for me to communicate, so lots of learning curves, with laughing at myself along the way. Fumbling through it all, I’ve forged what feels somewhat natural, meaningful sessions. I’ve learned how much I speak with my hands and have had to stop breaking into the screen with my expressions. I now have some understanding and can be mindful of taking pauses from the client, perhaps use a worksheet to draw attention away from technology and working together. I appreciate hearing these two wonderful therapists

Sheila Crothers, Counseling says

I’ve been working with Zoom what’s app video Skype and phone ….clients choice …for 6 weeks now. Initially my experience, and that of my supervisees, was sorting through the logistics. Then came the tiredness…real fatigue. So we chose to make some changes. For example see less clients in any one sitting or day and increase the time intervals between sessions. For coffee/ tea breaks to physically get up and go outside even if it’s only walking in the garden. Always checking in with our clients how they are finding this new mode of communication in the current climate. This has been particularly important when working with trauma in a period of time which can be seen as traumatic in itself. Being creative With various worksheets or visuals even through the use of zoom etc also helps to ease the concentration that goes on when working in these alternate ways constantly. Particularly important if this time is to continue for the foreseeable future.

Joe Casey, Counseling, Eugene, OR, USA says

Been doing phone sessions for years. There is no need for a camera. I listen. Sessions are at least as effective as in person. No fatigue from this. Video is exhausting for everyone.

Louis, Psychotherapy, GB says

Thankyou! A really helpful video.
I also agree with clients how we sit in terms of distance from the screen.
For a few of clients (and I have used it since) there was value in having a couple of things from my practice behind me. This evoked a sense of warmth, familiarity and continuity.
I have also explored with some clients a distinct preference for only being able to see me and not themselves. Clients with attentional issues or trauma history seem to manage much better.
Louis Sydney
Child, Adolescent & Adult Psychotherapist

Brenda Cole, Psychology, Toledo, OH, USA says

This was very informative and offered helpful suggestions. Thanks!

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