June 03rd, 2020

4 Things We Lose, When We Don't See Our Clients In Person

Video and phone counseling has been gaining in popularity in recent years. There is research to suggest that these forms of counseling are just as effective as in person counseling. While I am a believer in science, I struggle to square the results of that research with realities of video and phone counseling discussed below. As a result, I find myself thinking that this research must be flawed, though I acknowledge I do not have experiments to refute it, only the thoughts that follow and the feeling in my gut.

This issue has become even more important during the time of the COVID-19 pandemic. The vast majority of counseling is now taking place by video or phone, and understandably so. As the health crisis continues, and economies begin to slowly re-open, many discussions are occurring between therapists about when to go back to in-person therapy. Understandably, most of the discussion has centered-around the importance of keeping each other safe from and slowing the spread of infections.

I present this list, not as an argument for therapists to ignore risk and go back to in-person therapy, but to give voice to concerns I have about the effectiveness of video and phone therapy. Of course, reasonable precautions during a health crisis must be assessed. Additionally, as a reasonable level of safety is approached, so too should the effectiveness of the treatment be a part of the decision making process. I do not know when therapists should go back to seeing clients in-person.* The circumstances individual to each client and therapist are so varied that there cannot be a universal answer. Even during the heart of this pandemic, there are clients whose circumstances make video and phone counseling unrealistic, who are in great need of treatment, and whose therapists have calculated the risk involved and determined to see them in person. I don’t fault anyone, therapist or client, for choosing to be careful during this difficult health crisis. I’m not even sure myself what the best course of action is yet. I only want to acknowledge a part of the equation which seems to me to be lacking in the discussion of when to go back to seeing clients in person again. These are four important things lost, when we don’t see our clients in person:
    
1. Non Verbal Communication

The lion’s share of communication is non-verbal, and a great deal of that is lost over video and phone. Over the phone, volume and tone of voice are the only non-verbal cues that are transmitted, and only as well as the sound quality of the call allows. Over video, you can only see the portion of the body which is within the frame of the camera. Many people will chose to sit close to the camera, because to sit far away (and therefore have more of the body visible) is to see each other less clearly. It would take very large screens, expensive, high-quality equipment, and excellent internet speed, to be able to have both parties fully visible in each other’s screens with high resolution, to come close to the visibility of one another that is achieved in a face-to-face meeting. This just isn’t reasonable for the majority of therapists and clients, and so people often choose to sit in such a way as to be visible approximately from the chest-up. As a result, all of the non-verbal communication that is left out to the screen, such as posture and movement, is not visible to therapist or client. When one or both parties sits far enough away to see the full body of the other, their nonverbal communication is still limited by the size and quality of the video coming through.

Non-verbal communication is vital to the process of psychotherapy. Posture, movement, and how a client chooses to physically arrange themselves in relation to the therapist tell the story of the client’s struggle in ways that they often can’t, and may not even be aware of. The therapist’s posture, movement, and arrangement in relation to the client give the client vital information about who the person is that they are attempting to open their hearts to. The coming together of hearts and minds for the purpose of healing is hindered by the communicative limitations inherent in phone and video counseling.

2. Eye-Contact

Eye-contact, which could also fall under non-verbal communication, is a real problem over-video, and impossible over phone. You can look at each other’s eyes on the screen, but you can’t look into each others eyes. When you look down at the screen, to see the eyes of the other person, you are not looking directly into the camera, and when they do the same, they aren’t either. Obviously, looking at the camera is no solution to this problem. Each person is looking at the other’s eyes looking slightly down towards a screen. What is lost, if the eyes  are the window to the soul?

3. The Work of Being With An Other

People who come to therapy usually have difficulties in their relationships with others. Many therapists, including myself, would argue that client’s relational difficulties are most often core to what brought them to therapy in the first place. People’s difficulties in relating to others manifest themselves in their relationship to the therapist. The therapist’s job is to become aware of this and, largely through the therapeutic relationship, help the client repair their relational capacities so that they can be utilized by the client to form and maintain healthy and satisfying relationships in their life.

The relationship between the client and the therapist is not lost over phone and video, but it is significantly altered. The impact of that alteration depends upon the particular relational difficulties of the client. In many cases, the client may feel safer talking to the therapist over phone or video, but this is a barrier to the person getting better in the long-term. By avoiding the anxiety that is brought about by being in the physical presence of the other, the working through of that anxiety so that healthy closeness can be achieved when desired in other relationships, is also avoided. You cannot work through that which is  not evoked.

4. The Sacred Space of the Therapeutic Milieu

Where we do something influences how we do it. Sleep experts advise us to keep the bedroom for sleeping and not to use it for TV watching, studying, working, etc., so that we know deep down that this space is for sleeping. Working from home creates challenges around the boundaries of work and relaxation. Some who work from home struggle with getting enough done, while others can’t seem to put work away. For certain parts of life, mixing spaces causes confusion and difficulty.

Just as the bedroom is the space for sleeping, the therapy office is the space for therapy. The office provides safety, privacy, and comfort for the difficult task of working through one’s problems with the help of an other. The hour in that office provides a boundary around an important part of the client’s process in becoming a happier, healthier person. The therapist assists in creating this boundary with the way that they furnish and arrange the space to encourage a therapeutic environment. Over video and phone, the client misses out on this sacred space.

* I recognize that there are clients whose life circumstances and difficulties make in person therapy impractical or impossible and that for these clients, video or phone therapy is a great option. This is a subject for a different paper and is not relevant here.

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