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.
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.
I am teaching a Psych 492 R Field Study of Addiction class at a University (currently online) and I relate to this phenomenon significantly. I have 16 students in this section and do an hour and a half Zoom class per week and it is astonishingly tiring. In the regular face to face setting of a classroom I am usually invigorated but not this. Thanks so very much for your suggestions.
This was helpful, however I would have to add a few things:
For group settings or individual use the “share screen” icon, this helps the client’s to be involved in the session. I have participants read the slides or take turns with me. Additionally, I’ve played Q & A type games similar to those in the Family Talk Game. I have used TedTalks video’s as well, had to use the CC for my participants to hear as the sound did not work well enough. We also take 10 min. breaks since our Group therapy is typically in-person 3 hours; being online as mentioned in your clip is stressful and people still need a break though I’ve reduced the session to 2 hours.
Hope this helps!
Difficult to feel as connected and as in the moment – especially with video where can see oneself too.
Excellent!!!! I liked the non eye ball to eyeball approach and perhaps sending worksheets to the client and filling out together eg from Mind Over Mood. Thank you very helpful. Gordon St. Mary PSYD
Thanks! Great video… Most of my clients are adults who grew up with one or both parents with a serious mental illness which is based on my research. My clients have a strong preference for face-to-face work and so most will resume in 12mths or so when things become safer. I find that being in the same room for the type of work I do cannot be replaced with Telehealth sessions as I miss many nuances, e.g., the client’s breathing. I also have an issue with the risk that confidentiality cannot be guaranteed. So I’m turning my attention now to writing for mental health practitioners. If people are interested in my research on an unacknowledged trauma and grief or the brief articles I’m invited to write on complex trauma and grief by a Sydney psychiatrist, they just need to Google my name: Suzette Misrachi. After my articles get published in the psychiatrists’ e-publication, I offer them for free on medium.com
The points raised in this video was worth listening to. Thank you…
That was really helpful. Knowing that others are experiencing the same feeling of exhaustion is in itself very comforting.
The suggestions re distance from the screen and eye to eye contact were also very valuable.
For all of us it has been a steep learning curve over the last few weeks/months with so many new things to consider in our ways of working .
Thanks for the ideas!
Working in a rural mountain area with many disabled and elderly patients, I have had phone sessions for some time. I have never found it difficult or tiring. In fact I find it the opposite. So I was surprised to see that there are colleagues who find remote sessions stressful
Now that I must see all clients on the phone, I”m even more relaxed and have more free time, not having to put together outfits every morning, put on make-up, pay careful attention to styling of my hair. I just dress casually and comfortably.
It is somewhat different now though. I lost 2 clients who do not want to talk on the phone and, only one is interested in video – Facebook Instant Messaging. But I gained one who is delighted that no one will see her car at my office. I also lost 2 minors because I don’t see pre-teen children on the phone. I have found them too distracted and unaccustomed to long, focused phone conversations. I also lost one couple who doesn’t want to Face Time or otherwise not be here in my office.
I’ve never done intake by phone before, though, and the logistics of this has been challenging. I’m emailing the forms to new clients but only one had returned them so far.
So why don’t I find phone sessions tiring or more difficult? My best guess is that I interact the same with them as if they are here. I would prefer to see my Intakes in person at least once so I know what they look like of course, but the 3 new client and I are developing a good rapport so far at about the same rate as when in person.
My only suggestion to those who are new to this mode of therapy is trite but true. Just be yourself. Listen intently for voice tone and mood, pauses, quick subject changes, tears, etc. And be sure to consciously use you vagal tone since they won’t be able to see your face if you’re on the phone. Hopefully you’ll find yourself enjoying you tele-work as much as ever as it becomes more familiar.
PS – My therapy dog Snow is having more of a problem than i am. He misses people coming in all day, getting treats , getting strokes, etc. He seems bored and mainly just sleeps through all my sessions. Sometimes on my lap for comfort and company. I try to squeeze in brief walks into the day.
thank you…..i’ve done phone sessions when necessary over the 35 yrs i’ve been doing this work. i always offer folks a free consult before an appt…which i guess would be an intake, but it’s more for checking what the needs are and can i help. i would say that i usually end up booking an appt for them at least 80% of the time. so, that gives me confidence that it works. as yet, i’m still in bafflement about how to create the space for couple’s to really benefit when not in person…..we’ll see how that goes as it comes up
i’ve been resisting “telementalhealth” for years for a variety of reasons and am not so interested to jump on the band wagon now, just because it’s “in”.
for sure, it’s not the same as in person. i’m realizing how much i enjoy creating a healing environment….my office is in my home…feed back of appreciation for that has been consistent over the years. i also miss the energy exchange that comes with person to person, the hug at the end…. the a reassuring hand on the shoulder as i remind them to “breathe”…which has become our joke.
i’m happy to hear that someone else has a positive experience on the phone, as well, now that we have fewer options. it is painful to realize i may never be able to see folks in my office again…it was a safe place for everybody
I see a lot of children of divorce, so a child or adolescent may be with one parent one week and the other the parent the next. I’m almost positive while conducting telehealth therapy with one of my adolescents that one of the parents was recording the session. I’ve decided that while my client is with that particular parent that I won’t see them again until they can come to my office and the clients confidentiality and mine can be ensured.
I’m glad to realize that the fatigue I feel is a thing and I’m not the only one! What I’ve found interesting with some of my virtual sessions is that my clients move around more. They may be eating, move outdoors, say something to someone in another part of the house and be less inclined to “dress” for the occasion. I’ve been wondering if this a sign of discomfort or perhaps even more comfort. I’d like to hear some comments about this.
Hi, me as a therapist find difficult to establish therapeutic connection and space over video call.
And I certainly agree with being exhausted from being preoccupied by technical and irrelevant staff. Maybes not calling it irrelevant but less relevant, am I seen properly, how much of the background I should show ( from where I am coming from we were told simplicity in the office)?
Do I stare at the screen and where do I look while I’m listening?
Phone as sort of psychoanalytic tool suits me better both ways, listening and talking.
And as a client I am not a fan at all of Skype sessions, find them boundary fluid and as a trauma being part of my journey very distancing and difficulty for DID client to stay within present moment.
Thank you
Katarina
I am grateful to have telehealth video sessions available to support clients & It is more tiring for me. I find that I feel anxious when the technology doesn’t work because I am a bit of a technophobe & have no knowledge of how to fix things. Invariably it seems to happen @ critical moments so the momentum is pretty much lost. This video helped me to realize that I need to check in with my clients about it more.
I can so relate! I too am a technophobe and I decided that prior to working with my telehealth clients I would inform them of my back-up plan. I inform them at the beginning of our session that should we experience unexpected tech issues on my end or theirs that we could continue our session over the telephone. I would inform them that I would be responsible for contacting them via telephone to complete the session.
Tele conference for decent longer term therapy is inefficient since Therapeutic Alliance is very hard to maintain( Dr. Stephen Porges’s social engagement System + Body Language).
Most patients use Avoidance as the major Defense and along with Eye-gaze aversion ,
the quality of therapeutic process starts to
‘ garble up’
Very Exhausting and dissatisfying
Must say absolutely true in my experience.
Thank you
Katarina
I work with a predominantly male, military population. It soon became apparent they speak more freely by phone and seem more open to using interventions as well. For that reason, I am being careful about transitioning to video chat and probably won’t use it with all of my clients. One or two want to try EMDR via video for specific issues, of course. I like the idea of trying earbuds and plan to try it.
This was super helpful! I have a better understanding of why phone sessions are so much easier for me & my clients. I’ve noticed that the narrow focus on a computer screen can actually be activating to the amygdala, so bringing in these options is a great idea. Thank you.
Very helpful information but l realized in person is more comfortable and reliable for both the client and the practitioner in that some clients will not be able to share all their problems with a practitioner on a phone due to their environment and people around them.. and as a practitioner you can read a client body language in person than on a phone.
These comments were very useful and raised some points I hadn’t considered. I have attributed my increased fatigue to the absence of shared physical connection. I know that I learn about my client from more than their spoken words or their movement from the shoulders up. I miss seeing their whole body as it shifts and moves in space, or even as we both shift and move in synchrony or awkward dyssynchrony. That difficult to quantify “energy” is more elusive in tele-therapy and I sense myself work harder to find the ineffable connection that moves therapy forward,
i do phone sessions only now, for a variety of reasons…..not having one to one personal change is different and can be tiring, in my experience….not that we are entertainers by any means…however, listening to stephen colbert and jake gyllenhall talk about how much they miss the feed back from an audience…it find that doing therapy in person has always been energizing for me as the best style for me is interactive and the exchange of energy in that form is wonderful.
I think in therapy as in crisis work it is often much more comfortable to feel invisible while speaking of things that embarrass or humiliate or what the person may feel that way about and I appreciate the movement of gaze and working together information presented in this video. Thanks vey much
First, let me say that I appreciate all the help I get from your group. I would take all your seminars if I could afford it. Many thanks. I am so glad to hear these topics on telemental health addressed. They are helpful. No wonder we’re exhausted. I am sublimely happy that I can use telebehavioral health practices generally. However, I would like to have my sayso about what makes me chronically angry at telebehavioral health regulations or the lack thereof, especially considering video-counseling and e-mail counseling, and why that anger exhausts me. We should have and could have been prepared to respond to the demands of this pandemic, but we weren’t allowed by the regulators of telebehavioral health.
Although I like very much for myriad reasons telebehavioral health, and I have been certified for years to do it, my underlying anger about the controls and regulations at state and federal levels exhausts me. These regulations are made by people who know nothing about the medium. It’s similar to the way legislators continually override the opinions of physicians, scientists, and experts and legalize whatever they “feel” is best for us and our clients. I am angry about Medicare and insurance companies holding back reimbursement for telebehavioral health for so long. We could have been using it for years. We could have saved millions of lives and improved the quality of life for many people. My anger at harmful regulations that make service delivery impossible for the majority of persons who need it saps my energy at times.
Part of my two-volume dissertation many years ago was my attempt to measure the efficacy of Literary Arts in psychotherapy, eg. Biblio and Poetry Therapy, and that was successful. Although my University thought it was a grand idea, and the Psychology Department was excited about it, I could get no recognition from my Board for this endeavor, although these therapies were already being recognized, legitimized, and used in various forms of psychotherapy and the arts all over the country. Especially, I am angry at regulators who wouldn’t recognize that knowledge of literary psychotherapeutics was especially important to justify the practice of e-mail therapy, and I consider that a wasteful and even dangerous lapse in behavioral healthcare.
I have taken great pains to create and follow continually changing privacy practice regulations from HIPAA over the years as a licensed Clinical Counselor (Ph.D) and certified Telebehavioral practitioner (TBHI). But now with the pandemic, all regulations are off and electronic service delivery no longer protects the privacy of people’s mental health records! How irresponsible! And all practitioners are thrown on their own creative efforts to deal with it without any support! It exhausts me whenever I have to think about all the people who could have been helped over the years when this help was denied them because of irresponsible regulations.
My clients prefer e-mail therapy, actually. My clients do not like video-counseling for all the reasons mentioned in your group. I find it very easy to use e-mail therapy for myself and my clients, partly because of my training in literary psychotherapeutics. I know how to protect the privacy of the client’s e-mail responses. And that’s another thing! I have legitimate ways to protect my clients’ telebehavioral health records, but in this pandemic, this privacy protection is no longer required. Thanks for recognizing that clients may not like video counseling. As you say, many don’t have the technological expertise and equipment to use it and it isn’t available in many areas of the country, rural or city, anyway. Thanks for saying that, too. Thanks for everything you do. Marlene Talbott-Green Ph.D.
Wow! Thank you! I couldn’t agree more with your ideas. I’d like to extend my professional admiration and praise to you for your more than scholarly and worthy dissertation(s)! I find clients have gained from the written back and forth processes. I will share this, one client said, “I find I go back and reread our emails, when I’m anxious or feel disorganized, it helps me a lot and I feel grounded”. I believe this to be a healthy outcome. Tammy Croy McMillian PhD
I wanted to share with you, my dissertation was based on the writings of Ellen West. I was fortunate at Loyola University in Chicago where clinical emphasis and qualitative research were embraced. I hope I can locate your dissertation online, would like to read!
Thank you for sharing your experience with alternate therapy forms. Yours is deeper than mine by a lot. What I’ve seen is confusion all the way through the handling of the pandemic. And that has been quite frustrating to me.
As much as I value the in person session, it is clear to me that my clients in their twenties tend to do much better, are freer and more open, by phone. Now that I’ve experienced that I am definitely open to using technology. However, as a person with a strong visual orientation, I think that if I were a new therapist, I’d be lost right now. My years of face-to-face experience are serving me very well right now.
These were very helpful suggestions; I have found the tele therapy work to be exhausting; the audio is usually the problem. Thanks, Patricia Lindquist
I have found that my cat loves to join in on my video sessions which is a pain for me. However, my clients don’t seem to mind at all and are now asking where my cat is. Her entrance on the screen adds some humor and humanity to the sessions which is sometimes an occasional distraction from the topic at hand.
I also have cut back on sessions to be 50-55 minutes so I have time to get up, go to the washroom or just walk about. I now book no more than 4 sessions in a row so I am not overtiring myself instead of the 6-7 sessions that I used to do.
I do find that looking around and checking in with the client about the closeness of the screen for both myself and them feels comfortable for all.
I have the same issue, and thankfully my clients are also entertained by my cats photo/audiobombing our sessions. One of them is super vocal and interactive with the clients. The other girl is quiet and mostly just sleeps beside me… I think she’s therapeutic for me!!
I will definitely be taking back the points on averting gaze occasionally from the screen, and on checking with them how close or how far from the screen they want me to be.
Thank you so much for this video. It validated my own experience using telehealth. I’ve been working this way since mid March and noticed right away that it is more tiring. I thought it was just me!
I have also experienced that a few of my clients are actually prospering with this method. There a couple of people who have avoidant personality issues and they are doing very well with telephone sessions. And, I admit I prefer telephone over video. They eyeball to eyeball situation is something that I wasn’t consciously aware of so thank you!
Can you do something about keeping clients motivated with teletherapy and life in general? It seems like social distancing is here to stay and we will not be going back to life the way it was? Maybe a video about grief in terms of our own lives would be good!
I now leave 30 minutes between clients so I can relax, do something different, walk around the house, go out into the garden, smell the fresh air and listen to the birds. I need to be replenished.
Wow. Wonderful self-care. Love it.
This was incredibly helpful as I was feeling desperate because I thought I must be a really bad therapist because I was so exhausted… I never thought but of course I’m struggling to hear as I have a hearing problem and I also really found not looking at clients eyeball to eyeball all the time most helpful.
however the top tip for me was discussing it with my clients… I suppose I felt a uncomfortable that I don’t seem to know what I’m doing when they are struggling so much with the knock-on effects of lockdown… and toxic stress… so the first thing I’m going to do tomorrow is discuss with them about how it is them and how to make it work thank you
Very helpful suggestions on how to manage telehealth in partnership with clients…what is freeing about it and what is problematic…in order to problem solve together. I appreciated ways to relieve staring at the screen.
And, I have found that the phone or screen has been freeing for some.
I have been doing telehealth for at least 6 years. I do think that the pandemic has something to do with the exhaustion. There was a different feeling before the pandemic when I did telehealth. Crisis work tells us that for many, maintaining the previous level of function is what we can hope for at difficult times. I appreciate the helpful tools especially the topic of shoulder to shoulder versus eyeball to eyeball.
One of the most effective demonstration I do is the ACT tug of war with my clients. Very difficult to do it on line with them pretending to pull on a rope. I also find it difficult to keep the attention of the children I work with.
One of the funniest things that happened doing telehealth was with a 7 year old. His mom went to attend to a sibling, and after a few minutes, he decided he was done with me, put the device down and walked away. I figure it was really empowering for him, and I noticed I was feeling a bit abandoned….and whenever I tell the story I just laugh!
I have been offering Telehealth sessions for about 6 weeks now. I have noticed that many people prefer the in-person counseling over Telehealth which impacts their willingness to try virtual counseling. It is also more challenging to keep focus of children and teens when engaging in virtual sessions where as you might have included activities in the session prior. Definitely a learning adjustment for us all.
Very helpful information from skilled, as well as compassionately “practical” clinicians thank you
I knew I was exhausted more so after starting Telehealth, which paralleled the processes of helping clients cope with a novel pandemic. This was helpful And affirmed that Telehealth uses different energies for the client and myself as the therapist. I have not used Telehealth prior, and I surly would not want to draw any conclusions on the effectiveness after 6 weeks—although a thumbnail observation, the “relationship” either with new clients or established is different. I’m clear that tending behavior is a wash… cannot offer coffee, or water, the environment, what holds? Cannot offer tissue when a person is tearful… as a therapist grounded in object relations theory it’s an exhausting environment. Tammy Croy McMilllian PhD
very supportive. thank u.
Thank you for this post! I need to add in a grounding exercise at first. I think that will be helpful. My office is on my three acres home property in the oak filled hills of Texas. It’s very serene except for my rooster. Most clients drive at least 30 minutes to see me. They find the scenic drive & nature as a way to relax & reflect at the beginning & end of their session. A grounding belly breathing exercise will help! Most of my clients are teens though early 40’s. Maybe because we are rural & many work online from home or attend school online, they are like ducks in water with being online. This is normal for them! I have realized if I do over 5 sessions a day I’m still exhausted the next day. My sessions run about 1.5 hours & that’s just too much for me. I am also doing more emergency sessions. I have clients married to Narcissistic Personality Disordered spouses. These spouses have enjoyed reigning their power, control & manipulation over the family & feel trapped in their homes. However, it’s been nice to be able to meet my clients needs more when they’re in crisis & also to view them from their home. I also have a much greater appreciation of my clients who are working on the computer all day. I am going to start asking my clients where they want me to sit so they feel more comfortable. I think that will give them the sense of more control of the session. I will also be using more worksheets. That’s a brilliant suggestion to help change the feeling of being eyeball to eyeball with my clients. I think because of the distance to see me, more clients are going to request more online sessions. I’m continuing to learn to be accepting & resilient in all of life’s changes & will learn to adapt. Thank you so much for sharing all this info. It all resonated with what I’m feeling.
Nicole Ditz, psychotherapist specializing in complex trauma in professional Adults:
The transition was much easier than I expected. I already carry many phone and Telehealth virtual clients. When they move away most have elected to stay on with me.
Given the fact that I tend to see clients long term for years, the intimate and secure attachment bond has already been well established for most, and they have internalized deeply my every gesture, physical idiosyncrasies, and facial expressions so they are able to have meaningful sessions even by phone.
If I had to have a full time practice with frequent turn over and new clients, I think the telehealth sessions would be a significant challenge.
I am a very warm and engaged relational person with rich prosody in my voice and that seems to come through for my clients and sustain the holding environment. Stephen Porges has addressed the importance of prosody many times in working with trauma.
I have managed to conduct very deep and emotionally experientially moving two hour couples sessions as well so am really pleasantly surprised.
Of course we miss seeing each other in person.
Clients see me in a lovely home based space filled with personal art, symbolic objects, warm blankets and soothing surround sound music. Many spend time before the sessions wandering and meditating in my gardens so in this fine weather this is sadly missed by them.
My biggest grievance is the touchiness in fairly rare moments of the technology when pictures fuzz and freeze.
I feel profoundly blessed to have the great privilege of being in service to such beautiful human beings.
I do not feel drained but rather inspired, energized, uplifted, challenged and personally transformed by my work and this has been consistent for 25 years. I am beyond grateful!!
Thank you. I could relate to so much of what you wrote. I, too, feel privileged to be able to continue with my long term clients using telehealth. While it isn’t perfect, our relationships are intact and meaningful as we continue the journeys in whatever medium we can continue to utilize. Only one other time in my life did I work with a traumatized client who moved away to attend college and wanted to continue with me. Those sessions helped keep her successful away from home. Now, although I prefer in person sessions I look forward to these sessions and I am no more exhausted than usual. The pandemic exhausts me, not my clients.
thank you Ilene for sharing your similar experience.
I was beginning to feel like the odd woman out here.
But then again, I have never felt burned out by my work even while I watch colleagues feel drained.
I think because I engage in deep relational attachment based work, it is consistently nourishing for me as well accessing robustly my ventral vagus social engagement system.
This was great, Thank you. I relate with 3 items. I appreciate & relate with the discussion points about audio. I actually have hearing issues & through this switch to online sessions I inadvertently discovered how joyful it is to have the power to turn up the volume of my clients in teletherapy! What a difference it is to hear some of my quieter or timid/hesitant clients. Also I found that writing my notes looking away from camera is when clients open up. In addition, I have a client that averts the camera to look at the ceiling & he has opened up & explores topics about family of origin that he hadn’t been able to before. Teletherapy is a fascinating medium to work in! Thanks again, Lynn Talmon LMFT
Thank you both – this is really helpful. I also appreciate everyone commenting about how different working online is. My practice has been entirely online for the last six weeks. Prior to that I started working online with some of my clients who left Oxford after finishing their degree courses or temporary contracts. I find that the volume of online work is an important factor when it comes to fatigue and also whether we have had time to prepare for transitioning online beforehand. With the restrictions that came with Covid19 this hasn’t been possible, so the first online session had to be the transition. Some of my clients found it really hard and missed the gradual transition (via the downstairs waiting room and the three flights of stairs to my office on the top of the building) between the world outside the therapy room and the therapeutic space – physical and symbolic. With some experimentation what appears to be helpful is taking a few minutes at the beginning of each online session to ground ourselves together in our respective spaces – feet on the floor, breathing consciously, but without forcing the breath, noticing what it feels like to be in each other’s presence in this way. This feels like taking the time to enter the online space.
Great topic- some clients have a disorganized attachment style and the virtual presence instead of physical presence seems to, on one hand create some safety/distance- they are literally out of reach and can say things without the acute shame of “feeling seen”. Some clients say in the office, I don’t want you to look at me. With phone, there is some freedom to say more what they want. I notice it also creates some anger/ resentment at themselves because in a deeper way they long to be seen and heard and known and understood, and they seem to depend on subtle nuances of facial expression, voice tone, to gauge if they are being heard. The garbled picture or audio can interfere with that. And the client doesn’t seem to know for sure if she wants to be invisible or not, seen or not. It recreates the anxiety many had in interactions with parents- do you hear me? What’s going to happen if you do hear me? And to give the client a new experience requires they see you when they share something vulnerable and your face shows compassion, acceptance, not scorn or indifference.
comparing in-person session with video or phone session, I find
that I cannot read body language nor the energy field during video
or phone session.
I had not been aware of the fact that therapeutic work entails energetically sensing that person and tuning into the energy field.
And what I notice also is the pausing for reflection is short cut – client feeling observed cuts short on the processing, reflecting on what he or she said.
What I am now learning is to catch that moment where the short cut happens and ask them to repeat what they have said – to highlight their insight gained.
I Concur with Billur Ugursal that I have great difficulty reading the Body language as well as the Energy field during the Tele conference e.g.
Poor visualization of Social engagement System
( as referred to by Dr. Stephen Porgess),
Patient’s Equipment could be faulty,
Lack of Privacy in their home,and Lastly,
Using ‘Avoidace’ as their most efficient Defense
leaves me at a disadvantage to engage with
my patient’s , maintaining a good therapeutic alliance and difficulty of sustaining
a balanced eye- gaze contact
It is exhausting and interactively inefficient because
” The Presence is Absent. “
Thank you for this short video. Like many of the comments I read below, I too miss the in person sessions. Our client’s body language tells us so much. You gave us some great tips that I will implement this week.
My colleague and I both have found that we don’t need as much time discussing issues. I also don’t feel as emotionally connected and I miss the intimacy of our sessions.
Very helpful to hear how to reduce the fatigue factor – just by having good audio aids.
Good advise about not staring at video all day.
Thank you for those videos, I found them very gratifying and supportive.
I’ve been doing phone sessions for 40 years and I’m very comfortable with them. Your comment about sound quality mirrored my experience: When it’s poor I get much more tired trying to decipher what’s being said.
I refuse to do video sessions for all the reasons mentioned, as well as the constant scrutiny inherent in all that up close screen time. Paradoxically, I think it impedes intimacy. I fully agreed with your comment about the old psychoanalytic model allowing people to more freely express themselves with less shame and self-consciousnesses.
I have also thought and talked with my patients about eyeball to eyeball or shoulder to shoulder talks. (As a mother, I realized my children would be much more self-divulging if we were taking a walk or sitting in the car than if we were face-to-face.)
Listening to you made me realize how beneficial it’s been that my office chairs swivel. This enables both of us to shift our gaze and postural orientation during the session.
Many years ago, after taking a seminar with Jerry Edelwich, who wrote the first book on burn out, I realized I wanted to stay in this field ‘till I drop the body as they say in India. To do that I would have to limit the number of sessions I had on any given day or week. I have assiduously done that for the past 40+ years and have very rarely felt burned out. Naturally, it meant making less money, but since I wanted to be a therapist more than anything else, it was worth it.
Thank you, it is exhausting. I have been using a lot of mindfulness and guided imagery work with my clients. They are responding well to it and in addition, it has created a great deal of peace in my life as we walk this path together. I have also used a number of strategies lately from the most recent workshop, “Working with Core Beliefs of “Never Good Enough”.
The challenge for me has been my group ACT supervision/consultation has ended and I really miss it. It would be valuable if you could set up something that would be interactive and supportive for therapists/counselors during this time. Thank you for all the important work you share with us.
I invite my clients to do a short mindfulness- or breathing- or even stretching exercise. It helps both of us to bring the awareness back to the body and help the body to feel just a little bit more comfortable and have a more qualitative presence.
That’s a really good idea, thank you.
I always start by asking people if they’re somewhere private and comfortable where they can talk freely.
I find it helpful to take notes during phone (especially) and Telehealth sessions as a way of staying focused which I rarely do in in person sessions. Sadly, some need to speak from their cars for privacy, while I wish some others could to save frequent interruptions from-especially children.
All my sessions are online. I am A Licensed Independent Social Worker who is in private practice. I have wondered why I find teletherapy so exhausting. I think it is because there is no space for the natural quiet times of thought and reflection that occurs during an in person session. With teletherapy every void needs to be filled. Then there is anxiety about will the screen suddenly go blank due to a technical glitch? I feel pressured to talk more in teletherapy. All in all, it is a very distant second in terms of connecting with a client. I look forward to returning to in person sessions. And I miss my business office. It is a more professional atmosphere.
The thing I most miss about face to face interactions with clients is picking up on the body language, the energy, and feeling attuned (or sometimes not) to the client. There is so much subtlety in our interactions that just cant be picked up on screen, and I also think it is harder for clients to feel really met and good contact to happen, or be experienced and embodied.
I find the flat screen tiring – I think I am missing the nourishment of good interaction, and having to work so much harder to try and get the more subtler cues and exchanges. I also find it much harder (being an introvert) to bring some clients long deflective speeches to their attention than I would in person.
I’ve found that many of my clients simply can’t find the privacy for online or telephone sessions at the moment. They have houses full of people who wouldn’t normally be at home and that makes it very challenging to have a confidential conversation. I work from home and have a separate office to the house, but my husband and two kids are also at home – when I do have to work from the main house I find it very difficult. I’ve done teletherapy on and off for a long time and have always found it more tiring – I find I need much greater levels of concentration to compensate for what I’m not seeing, and sometimes not hearing. Also I work in a very practical and solution focused way, so the therapy that I provide over the telephone and online is different to my usual approach and we both have to work much harder for the same gains!
Some of my clients request phone rather than video sessions and I believe this is because they feel freer in that way. Also highlights the benefit of a walking session, perhaps at a social distance in current time.
I have experienced a reduction in tiredness over time as working online. I always take a break and go outside or walk between sessions. I find it helpful to be a little more relaxed online and to name some of the issues with the online experience so being really transparent about any difficulties with it. Useful also to discuss distance from the screen with the client, I sometimes use a short meditation and allow the client to go off screen if they want while doing it. thank you Christine
Some really good thoughts there!
I left brick and mortar and went online completely two years ago. I had my calendaring and automated messaging all set up and proved out when Covid came around and the whole world seemed to discover Zoom all at once.
The additional Joy has been helping other therapists smooth their on ramp. Some of them the ones who told me they couldn’t imagine how I would get enough people willing to do tele-counseling.
I would have loved for it not to happen in this way!
Many of the elements Christine and Ron point out really resonated with me. Yes!
Many clients will not initially select an appropriate space in their home from which to conduct their session. I find setting some initial guidelines helps avoid interruptions/distractions.