As therapists throughout the country switch to teletherapy, many are just beginning to reflect on the nature of this new therapeutic space. Most therapists know to create a private space for themselves with an appropriately professional background behind them and a level camera angle in front of them. Therapists often intuitively know to check in with patients about their sense of privacy in early sessions and to prepare for technical problems. But there are other issues to consider in this new terrain. Here are some less commonly offered suggestions that therapists may find helpful.  

 

Consider Turning off the Preview

The preview is that little box in the upper right corner of the screen that shows your own image. In many of my initial teletherapy sessions, I found myself looking at my image almost as much as the patient’s. This led me to have more narcissistic preoccupations, more self-consciousness, less engagement, and less empathy—and I suspect it can do the same for many of my patients.

In one session with a patient who struggles with fluctuations in his sense of grandiosity and worthlessness, I noticed us both looking off to the upper right corner of the screen, not so discretely scrutinizing our appearance through the funhouse mirror of the computer camera. It was a poetic reflection of our work, yes, but in most sessions, I’ve found it counterproductive.  

 

Focus on the Audio

When using headphones, the audio can be heightened. The patient’s voice may be louder or experienced more closely or more intimately. This may actually help the patient and therapist feel more connected. For example, I recently saw a female patient who struggles with conflictual feelings about sexuality and intimacy. A phone call enabled her to communicate this conflict through a throaty whisper that would have been impossible in face-to-face treatment.

Though this was an undoubtedly fraught and challenging therapeutic moment, it shows how intensely intimate the audio can be. When therapists are struggling to feel connected, the sound can sometimes carry more feeling than the image.  

 

You Don’t Have to Fixate on the Visual

Video is different from face-to-face interactions. Eye contact is impossible, and looking at the camera can simulate but not replace the intersubjective gaze. Screen angles are sometimes odd. Shared attention can be altered when both parties are in different rooms. The timing of the feed can sputter or delay. All of this can make therapists and patients feel less connected. If the video is distracting or distancing, it may be helpful to focus on the audio instead.

In face-to-face therapy, most therapists don’t look head-on for the entire session. They usually let their gaze wander occasionally. This can happen in video sessions too, as focusing on the screen too rigidly can make sessions feel exhausting and less engaging.

With one patient who tended to evoke sleepier countertransferences in in-person sessions, I found myself utterly exhausted by our telesessions. I struggled to appear like a therapist “should,” listening attentively and looking directly at the screen. Despite my efforts, I was probably just coming across as stiff and depleted. As I relaxed my gaze, I felt less tired and more able to productively engage with my patient and the feelings he evoked in me.  

 

Note the Challenges

Adjusting to the idioms and nuances of nonverbal interactions in teletherapy (e.g., waving at the end of sessions) takes time. Some patients, especially those with personality disorders, may challenge the frame in new ways (e.g., opening browser windows in session, having sessions in bed, not disclosing when others are within earshot, etc.). Some behaviors can be addressed with a tactful prod (“Are you feeling distracted?”; “Is it hard to find a private space?”, etc.), but often it isn’t so simple. Ongoing consultation with colleagues about these issues is essential.

For example, in a recent consultation I was surprised to find that some therapists thought that sessions in bed weren’t especially noteworthy during the coronavirus epidemic, while others felt that they were freighted with meanings that should be explored in session. Discussions with other professionals can help us contextualize these potential meanings and their impact on our work.  

 

Use the Advantages

Teletherapy can help therapists learn more about patients: what their homes look like, how they feel when family/roommates are in closer proximity, how they behave at home. For more behaviorally-oriented therapists, teletherapy can provide new opportunities for patients to learn, practice, and implement skills in the context in which they will be used. For dynamic therapists, teletherapy can generate new home-related associations and a greater sense of intimacy. Patients may feel freer to get lost in their own thoughts, and transference may be heightened by greater leeway to project onto the therapist-on-the-screen.

One patient, after months of treatment that focused on romantic partners, finally discussed her feelings about her mother’s depressive behavior (spending all day in bed). This patient’s associations were stronger in part because her mother was just one room away from our session. This experience-near intensity sometimes emerges more quickly and easily in teletherapy than in face-to-face work.  

 

Notice the New Information

In teletherapy, clinical information is everywhere, from the way patients position their screen (high angle, low angle, wide angle, extreme close-up) to other cinematic elements: lighting, sound, mise-en-scène, entrances and exits, etc. Context matters, but an extreme close-up could reflect a patient’s intense need for closeness. A patient craving dominance may place the therapist underneath him/her, so to speak, whereas more submissive patients may prefer to lean back and let the therapist tower above. Internally preoccupied patients may be oblivious to how they appear, and may even move in and out of the frame. Shier patients may hide parts of their faces at key moments in session.

But there’s more than just cinematic information. Teletherapy may shift therapists’ perceptions of time, both from working at home and from seeing the clock on the computer screen. Bodily countertransferences may be heightened as both parties have a greater unmet need for physical closeness. Therapists may feel pulled to be more active so as to engage patients who feel further away. Fluctuations in these experiences can cue therapists to important dynamics in their treatments. Personally, I have felt more restless in recent telesessions. As much as possible, I have to stretch and move around between sessions. But it’s been notable that when talking to my patients who are health professionals, the restlessness evaporates. The intensity of their work enhances the affect in the room and our connection feels stronger. This intensity more than compensates for the distance often felt in “remote” therapy.

 

The coronavirus pandemic produces a slew of new clinical challenges, not least of which is the drastic shift in the therapeutic frame. Whereas therapeutic space used to be contained within the six sides of our cube-shaped offices, it’s now bordered by the four sides of two computer screens that are connected through the tunnel of cyberspace. This new space is profoundly different at a somatosensory level, shifting our experiences of embodiment and nonverbal communication. There are so many changes, it’s almost mind numbing (another common countertransference in teletherapy). Yet, this is also exhilarating terra nova, with uncharted landscapes waiting to be explored and mapped.  

 

Andrew Hartz, Ph.D., is a clinical psychologist completing his postdoctoral training in private practice in New York City. He completed his Ph.D. at Long Island University (Brooklyn) and did his clinical training at Columbia University Medical Center, Mount Sinai Hospital, Kings County Hospital, and the William Alanson White Institute. His private practice profile is available here.   

 

To contribute to the special series on COVID-19, send blog posts of up to ~1,000 words (read full submission guidelines here) to Analysis Now blog co-editors Justine Duhr at justinetduhr@gmail.com and Robert Levin at rob@robertlevinlcsw.com.

 

 

 

If you enjoyed this post, we recommend:
Special Series on COVID-19 by Justine Duhr, MFA, and Robert Levin, LCSW
Thinking Analytically in the Time of COVID-19 by Sandra Green, LCSW
Minding COVID-19: Re-establishing Communication Through Mentalizing by Troy Becker, Psy.D.
How Can We Wake up From This Bad Dream? by Irina Simidchieva
An Elegy for My Office From a Psychoanalyst Working Remotely by Blair Casdin, LCSW
Psychoanalysis in the Time of Plague: This *Is* Psychoanalysis! by Veronica Csillag, LCSW