Working online with neurodivergent clients

Online counselling is different to face-to-face therapy in many ways, especially when working with neurodivergent clients. I started working with clients online in 2018 and all my sessions were via Zoom during the Pandemic. Some of my autistic or dyspraxic clients don’t drive so online sessions work much better for them. Some neurodivergent clients prefer the comfort and security of their homes. 

One area of online therapy that can cause stress when working is 'telepresence'. It’s as if I was looking directly at the computer but the image coming back makes it look like I was gazing off to the right. The same was happening with some of my clients. It gave me headaches sometimes and eye strain. Eventually, I bought a separate webcam and when in place I was finally seeing clients in the same way I had done face-to-face.

Lighting can also be an issue. I’m autistic/ADHD and notice subtle differences. I don’t like it when half of my face is in shadow with my window casting light from the side so I bought a light ring. It took a while having a light constantly shining down on my face but I adjusted the light to warm and turned down the brightness. It gave my face a decent light, no shadow and it felt better for my clients on the other side of the screen.

When working online with my neurodivergent clients, I want to ensure the background is not too busy. I take care of my environment for neurodivergent clients face-to-face. It’s no different online. I have a plain background and soft lighting. As for me, I tend to wear a plain top and leave out jangly earrings. I don’t want to distract my clients in any way.

When we work face-to-face, we can pick up everything – body language, seeing the whole body and even smell. An example would be working with a problem drinker. Face-to-face I can tell if they are hungover or even under the influence. I’m not being the booze police but ethically, these nuances are important. Online this will be hidden more.
There have been occasions when another person has been in the room with my client while we are working on Zoom. For confidentiality reasons, this is a no, no (unless it has been agreed) and I have had to respectfully ask for the extra body to be removed.

I don’t care what clients wear to therapy. It’s not my business, however, being ready to do therapeutic work and to be serious means some boundaries are necessary. I have had clients turn up on Zoom in their dressing gowns with messy hair, yawning with a coffee mug in hand, obviously having just got out of bed. They would not arrive for a face-to-face like this so I would include a note on my contract under the 'online therapy' section – requesting clients are ready and alert for our sessions. I work 50% face-to-face and 50% online and enjoy both methods of conducting therapy. With online, I don't have to stress so much about the house being tidy and can wear more comfortable clothes, not pyjamas.

Technology-wise, there have been a few bumps in the road. One example was when we were having an issue with the internet. We could see each other on Zoom but not hear each other. To get the full Zoom experience I kept the client on Zoom and then phoned them up and we carried on almost as normal. It was fine.

My clients have told me that they like online counselling. Sometimes we have used WhatsApp video so that a client can be out walking. No problem at all.

Over the past six years, I have learned about the pros and cons of recording sessions, how to share screens and information online and about the psychology of online work. Sometimes people act differently online to how they would face to face, in the same way, a person might write something in a text that they would not say to our face.

There have been times when online clients find it easier to not turn up or quit therapy without letting me know. This has been called the ‘black hole’ effect. At first, I felt imposter syndrome and quite a bit of frustration but now realise it’s just par for the course. I’ve tightened up what I say on my contract for online counselling and this has made a big difference.

Sometimes online clients may share more than they might do face to face. They might say things they wish they hadn’t and feel regret. They might also zone out and it can feel as if we are not ‘connected’. This is called the ‘disinhibition effect’. 

I am training for a Level 6 advanced clinical supervision certificate with online and telephone counselling. This is a great course because it teaches me how important it is to be savvy about GDPR and confidentiality. How we contract and share notes and the many excellent applications available for design and document sharing like Canva. I'm even working on some mind map software that I can support my dyslexic clients with.

With scams, hacking and other nasties arriving through our computers, I am glad that I am learning so much about how to be safe and professional working online. Quite a few of my neurodivergent clients are very tech-aware and can be anxious about security. I can reassure them that I have their safety and needs in place during online counselling.

When autistic clients are non-speaking or are very softly spoken or have auditory processing differences, it is possible to use captions during sessions, and if, I record the session it can be transcribed and sent via an encrypted email. It has been interesting learning how to encrypt and use password-protected applications.

I have worked with tech-savvy clients who have shared new ways of working virtually, and it’s great we can learn from each other and build a trusting and harmonious relationship.

I wonder if, in five years, more counsellors will be using virtual reality as a counselling resource. Exciting times ahead, I reckon.

Online counselling is not for everyone. It may be good to stick with the method we prefer. There is plenty of room for both online (including phone work and email) and face-to-face. Being able to offer alternative methods will bring in more clients.