Online counselling: same, same but different.

I'm writing this article, as it has been a year of changes, most notably the move to online counselling as the new normal way of engaging in therapy.

I realised that there were subtle changes in this new way of working exclusively online, so, I wish to portray the careful considerations that myself and my colleagues have been in discussion about, over the last months.

I had worked online before this COVID year forced myself and other counsellors to establish an online presence, unlike any other time. Usually, this had been a continuation of a more traditional face-to-face relationship, interrupted by travel or moving.

Previously for many years, I had seen the counselling routine, the uninterrupted 50-minute hour, the closed room, the confidential space as a place that is dislocated from the hustle and bustle of the outside world. I would journey to my office and clear my mind of the days' trivialities to prepare for a session

The ritual of appointments, perhaps even the waiting room moment beforehand was time for my clients to gather their thoughts. This had all been an essential part of the ‘theatre’ of counselling.

When I work online, I am aware that some of the above has been diluted or maybe lost in the change of setting. The online world, two people being in their own space, together and apart at the same time is a distinct change in the dynamic. It is not lesser than before, it is simply different.

Practicalities of online counselling

So, now I ask that if you do wish to see me online, that you take care of yourself. By this I mean have some clean time and space that is uninterrupted and feels safe from being overheard. This is not possible for everyone, especially at home with kids or partners.

I will need to do a risk assessment, more thorough than before, specifically if there is a risk of self-harm or an abusive partner in the same house. Safety is of paramount importance, I take this very seriously indeed.

I can see the time flexibility for appointments is less rigid than working from a counselling room. Fine, lives are busy, I only ask that if you need to change the time that we keep to the same day of the week.

Finally, both you and I will require a plan B if the internet connection fails (it does happen),  an email address or mobile phone number will suffice to ensure that we are not left hanging, unresolved.

The above though are relatively minor changes, recognisable from any day to day office demands if you are working at home. This year the chances are that this working from home had seamlessly been part of our changed new normal. Zoom as an Imaginarium.

Minor issues with online therapy 

The original practice of therapy, face to face in person, chairs in a closed room, was often described as a version of Temenos (the sacred space): a safe place where rituals could be performed. 

The confidentiality of the therapist, the ethics of practice being already well established in the lexicon of therapy. Popular culture has reinforced these ideas many times from Frasier to the Sopranos. 

There has been an easy acceptance of this arrangement, the 50-minute hour, the arranged and generally non-moveable time during the working week. A workable solution to the practicalities and ethics of the task of therapy. This has now changed in light of online working. A slight but noticeable alteration in the expectations and reality of the therapeutic relationship.

Put simply the machines get in the way.

The machines are interfering with the basics of the possibilities of how we can relate. The online space is sterile and curiously (it could be me) a little lifeless. The vitality of meeting in person has been replaced with framed faces and shoulders, body language has been minimised somewhat, subtle cues can be missed. 

Instead, these gaps are being filled by our imaginative understanding across cyberspace.  Technical difficulties arise unexpectedly, the video freezes or on a few occasions, the online platform fails. Plan Bs are enacted. The 50-minute session is now flexible as time is now stretched to overcome these problems. There are no more ‘door handle’ conversations or the subtle cues of how we enter and leave the space.

When I trained all those years ago, I was cautioned against ‘diagnosis by dress’ yet here we are showing our homes and spare rooms in a way suggestive of how we would be wished to be seen. Both sides do this, I have a ‘shelfie’ behind me now, I think I hope it suggests I am serious or at least well-read. The stage has been furnished with a personal statement. 

This is a distortion in the relationship already, a reconfirmation of the asymmetry of power in the therapeutic relationship. I can now investigate your space, or what you wish to show me, pictures or photos on the wall, blank walls maybe or cramped rooms. This is a distraction, a distortion of the possibilities of meeting.

Major issues with online therapy

The major issue with working online is that there is a new difficulty in forming a therapeutic relationship. In one-word, trust. This is also called the working alliance. The internet, for all its innovations, has squandered the notion of trust. No amount of paper qualifications, professional documentation, job titles can overcome the one necessity of therapeutic working. Trust.

When I meet someone in person, I have a guiding intuition as to their trustworthiness, this, like everyone else, I have cultivated since I was a child. Sometimes it is an instant judgement, other times it needs to be earned.

This has become harder in a machine-based interaction. There is little to go on, just a talking image on a screen. I would suggest that this alienated presence is at first disorientating. 

This is like just talking to a stranger on the telephone. A voice is there, however, the person on the other end may be doodling, making a cup of coffee, playing with the cat etc. Culturally we have absorbed this notion (we do it ourselves) but the familiar, “so nice to meet you in person,” conversation hints at our anxious reservations of the simple phone call.

Time, space and silences

Time online has a sense of elasticity, the relentless clock in front of our face should keep time straightforward (normally I work with a shared clock in the room) however the constant awareness of the technology, the occasional break up of video or sound, outside random distractions etc have meant that the time boundary has become an elastic concept. The ritual of a constant appointment time is also up for grabs now, appointments can be flexibly rescheduled. This is a new type of arrangement.

The confidential space (Temenos) is always under consideration, at home the world can intrude, moments of therapeutic value can be lost to an incoming call or doorstep delivery. I can now see inside your house. It is natural for the eyes to wander over decorations, paintings etc. Internet disinhibition about your personal space, your boundaries exists.

In your house cups of tea are normal, fiddling with other stuff whilst talking, adjusting blinds etc. These are small thing perhaps, but a distraction from the moments of intimate conversation in a blank room.

I feel that moments of silence, have become foreshortened, the moments of silence with a person in a room are more meaningful. Online, the silence is more ominous. Is it a technical failure? Has the sound gone? Should I move to show I am still there? I suggest this as an important change. In therapy, the moments of silence have a significance beyond that of everyday conversation.

This is mimicked in the notion of internet disinhibition, whereby a video call on the phone or laptop has lost the serious intent of a face-to-face meeting.

This online world is a new space, a place we are not yet entirely at comfort with. 

In therapy, the moments of silence have a significance beyond that of everyday conversation.

Screen fatigue

Lastly, screen work is tiring: the concentrated space, head and shoulders are a compromise to meeting people in real life, body language is minimised, and concentrating on a smallish screen for 50 minutes is fatiguing. 

The screen image does not portray the emotional self-expression through small gestures or tears even clearly. The closeness of face-to-face work has been slightly downgraded.

In conclusion, telehealth has its place. In this COVID-19 world, it has risen to the top of the available safe ways of working. I certainly can and will continue to use it and modify my own practice around the issues. In acknowledging the differences from working face-to-face, I hope we can overcome these small issues and appreciate the value of online counselling.

What I wanted to say here was that all that glistens is not gold. We as humanity can lose our basic connections with this still new technology. However, we have adapted and are adaptable to change.

Peace and good fortune.