What Can and Cannot Be Seen During Online Therapy

When a person contacts me to initiate online therapy, they will receive a short consultation that helps both of us determine whether we’re a good “fit” to work together. I believe there are some good reasons to refer some people to see a counselor, psychologist, or psychiatrist who has a brick-and-mortar office, depending on their specific needs and the outcomes they seek.

For all others, online counseling can help bridge one of the most important gaps in healthcare: timely access. Getting people the help they need when they need it has been one of my lifetime goals for my mental health practice, now going entering its 19th year.

What I want every person to know, unequivocally, is what a licensed mental health professional can and cannot see in an online therapy session, based on the nature of the technology. While this appears plain, I’ve noticed that a brief discussion about the nature of online counseling — whether they will become my client or someone else’s — helps every person make better decisions regarding their health needs and the options they have to meet those needs.

What You Can See During An Online Therapy Session

Here’s is what I am able to see (and hear) during an online therapy session under the conditions of bright lighting, good audio, a video camera trained on head, shoulders, chest, and arm movements, robust Internet speed, and a quiet room where the session takes place:

  1. Facial expressions, which helps to reveal mood and changing emotions related to the content being discussed
  2. Body language, such as shoulder shrugs, hand wringing or rotating, posture, and body motions (i.e. rocking, shaking, trembling)
  3. Eyes: blinking, tears, darting, rolling, attentive, sleepy
  4. Breathing patterns, such as shallow, deep, rapid, slow, etc

Part of the reason online therapy can be helpful for people seeking mental health help is that the various measures of pain and progress can still be seen, heard, and felt through an online counseling session through your computer or smart device.

In terms of insight-oriented counseling, the same elements that you would experience in a F2F session can be transmitted and experienced in an online session. But there are exceptions.

What You Can’t See in an Online Session

  1. Just like F2F sessions, I can’t see what someone is hiding. I can, however, see the indicators that would lead me to believe someone is hiding something. Another way to say this: if you are seeking therapy to end your ability to manipulate and lie to the people you love (and you’re good at it), a good therapist may detect the lie in both an online and a F2F session, and both may not be able to determine what exactly the lie is.
  2. I can’t see what you’re doing off-camera. I can only see the reaction of your body and mind to what is happening outside of your camera’s view. For example, if you broke your foot and you were on a pain medication that produces sedation, I would not see the foot cast, but I might see the effects of the sedation in your eyes and facial movement, or the slur or slowness of your speech and cognitive functions.
  3. I also can’t use my other senses, like my sense of smell. This is important for therapists treating someone for depression, as a depressed person might not have the energy or will to attend to their own personal hygiene or wear clean clothes.
  4. Energy levels take longer for me to feel through the lens of the camera, putting together such clues as body posture, vocal quality, alertness of the eyes, and extraneous movement cues, such as “happy feet” and nervous finger movement off camera.

Would Online Counseling Work for You?

So, would online counseling work for you? The answer, like so many other answers contingent on multiple points of concern: it depends.

The best way to determine if online counseling would work for you is have a brief consultation with a licensed therapist to discuss your needs. Next, host a brief time on a HIPAA compatible online counseling platform, such as the one I use, Doxy.me. 

Take a moment to make direct eye contact during the video chat. Ask yourself if you sense your emotions and expressions can be easily read, even if you didn’t explicitly name them. You can also see how we bridge the physical gap by using the text box to write things down, send a resource link, or even give you a virtual high five.

If you feel you have your own bias against online counseling, I think it’s important to just say that upfront. I call this, “Putting your cards on the table.” When you do this, you’re acknowledging your bias. That acknowledgement can be helpful to know if you have some openness to experiencing something other than what you are “certain” you know; that is, that your experience might be different than your feelings.

For example, it might help to talk about your skepticism and negative feelings about talking about difficult things on a video chatting platform. At the same time, I might ask you if you like pets, such as a cat. If the answer is yes, and my cat obliges us, she may poke her head on the camera, and you can interact with her while you experience your real emotions about seeing my fluffy cat as she head butts the laptop and purrs into the microphone.

The reverse is true as well. You may be eager to try online counseling, only to be told that what you are wishing to address in your life needs more support and hands-on or sensory input than an online counseling experience can deliver.

You may have heard in the news that a man with a terminal illness received the bad news of his prognosis through a teleheath robot using a live video connection to his provider. The man died from his illness, and the family was so upset by the delivery method — a robot and a video chat instead of an in-person visit to the man’s bedside in hospital – that they complained to the hospital.

I personally don’t believe we as humans are ready for receiving bad news in this way, whether it is for the end of a relationship (an email), the end of a job (a group email or a recorded video message from the CEO), or an health prognosis. In the case of the latter, a patient may need their hand held, or to feel a presence in the room that speaks to the unspoken — “I’m still here, and my life has value because of the respect being paid to it by someone taking the time to be here.”

It is a subtle shift in thinking to understand that your online therapist has taken time to meet with you over an Internet connection, and the time has as much value as time that passes in the same room. It may help to ask an online counselor what they do to prepare, minimize distraction, and apply the steps of attending during a session.

In the end, a good first online counseling consult should leave you feeling like you made a good connection with the therapist, enough so that you would want to meet again to discuss more complex or difficult subjects.

During the time that the Greater Puget Sound area received a record number of snow days, school closures, and dangerous road conditions, I received an increase in calls inquiring about online counseling. You should know that I used the same elements in this post to help each person make their own decision about online counseling, and that not every call meant that online counseling was the best fit. Sometimes, it’s just not.

But when it is the right fit, we’re ready for you.

    What Will You Do

    When you’re at a loss for words, something disruptive happened. Something disruptive DID happen. Something disruptive has been happening for a long time.

    We write, “No words,” hashtag it under a photo of something we don’t agree with, despise, find unacceptable, or wish to point out its flaws.

    In the first week of Black History Month as well as the first days of the Lunar New Year celebrated by Asian peoples worldwide, my mouth is agape. While I’m not surprised by the examples of racism that has made America’s headlines recently, I find myself wondering right along with the greater community about how I — and we — want to respond.

    We’re not just talking about one example in one field, such as Northam and American politics. There’s Ehrenreich’s tweet about Marie Kondo, the Japanese home organization “tidying guru”, and there’s also Rep. Steve King’s long-standing history of proclaiming western white supremacy as a “superior civilization” (he was most recently stripped of his House committee seats). If that wasn’t enough, fashion design house Gucci removed a sweater with a built-in blackface design with red lips, leaving the world wondering how an expensive sweater design could have made it through the design process without someone flagging it with a, “Wait a minute”.

    What would you do?

    What would you do if you, your child, your colleague at work, your friend at the local coffee shop that you love spending time with, represents one of these people upon whom the nuanced and the not-so-nuanced effects of racism, bias, and discrimination lands?

    What happens after the apologies — that is, the “sorry-for-any-offense” version of apologies — are demanded and given? For governing officials, do we also demand that there be any follow up, or even any kind of workplace bias and diversity training similar to what employees are expected to complete?

    It was pointed out to me recently that the typical formula for “making nice” after an offense is to accept the apology first, and then to offer forgiveness. However, many people interpret forgiveness as the end of the apology transaction; that is, the act of forgiveness signals that nothing more need be done. It also may represent the offended person’s discomfort and pain, even if it does not represent the person’s experience. If I just forgive, we can all forget about what just happened, and go about our lives.

    What would you do?

    I don’t have answers for you. I leave it to the scholars, the researchers and the social scientists who are working on recommending real solutions regarding what we do to not only shape public discourse, but to expose the harm of the racial gaze and the socio-economic and gendered bubble. This isn’t an easy way out of the debacle; rather, I’m highlighting how this is so complex. To this date, we fire people, we lay public charges against those who display the most heinous of racist beliefs and actions, and then — in the silence that follows, what do we do, even in our own neighborhoods, to change the minds that seem so unchangeable?

    I don’t have answers, yet I have many questions.

    What will you do?

    I can say that one of the better responses I have come across was found in a Social Media post from a black woman responding to a white friend from high school who asked about what white privilege is, and what effects of institutional bias she had experienced. Her response was published more broadly in Yes magazine. Ms. Hutcherson’s response involves a decision to take time and care to educate, even beyond the transaction between two people, when she didn’t have to, when it’s often tiring to share the same stories, when it seems like no one cares or listens, when the examples of racism are so numerous, there is no possible way to retell them all.

    She took the time.

    What will you do? 

      On Being Alone

      Solitary woman running towards a forest with mountains in the background.
      Photo credit by Light and Lea, Alberta Canada, August 2018,. Used by permission.

      In a time when nearly half of Americans report sometimes feeling alone or left out, it may surprise you to hear that others work hard to spend time alone.

      Really?

      Yes, really.

      According to a Cigna Study in 2018 that used the UCLA Loneliness Scale (a scale on the subject of measuring loneliness, known for its accuracy and statistical significance), 20,000 adults surveyed showed an alarming trend of isolation and feelings of loneliness and lack of meaningful connection that have sparked conversations around such topics as depression, suicide, and the future of communication in a world of advance technological access.

      With a high indication of a loneliness epidemic, why are there those who are working hard to be alone? And where are they going?

      Loneliness expresses the pain of being alone, and Solitude expresses the glory of being alone.

      Paul Tillich

      As my gal friends were chatting it up on the way to a snowshoe trip, the topic turned to safety. Several of us had been scolded and lectured about not hiking, running, or camping alone, even though there were several among us who had experience doing so during all of the above activities, with the exception of mountain climbing. We packed out “Ten essentials”; we told a friend or spouse where we’d be, and what time we were expected back. We studied weather forecasts, read trip reports, and paid attention to road conditions and closures. We are intelligent, informed women. We do our homework and our due diligence in managing risk.

      Even with precautions taken, many of us were still discouraged – and in some cases shamed – by others who did not understand our desire to be alone in nature. Why, wasn’t being alone for loners, oddball hermits, and recluses who did not know how to have close relationships with people? Aren’t we crazy for daring to be alone in a dangerous world? And if you wanted to be alone, couldn’t you just find a quiet corner in a Starbuck’s, put on your Beats headphones and a pair of dark sunglasses, and tune the world out?

      Shouldn’t that be enough aloneness?

      I only went out for a walk and finally concluded to stay out till sundown, for going out, I found, was really going in.

      John Muir

      For over ten year, I’ve found a certain strength in seeking to be alone in nature for periods of time: a few hours, a day, or a long weekend. From these experiences, here are just a few personal reasons why being alone on purpose and in nature might be a transformative experience that you might just want to turn into a habit and ritual as a part of your own personal development

      Four Reasons for Being Alone in Nature

      • Going out. When you travel to more remote parks, forests, reserves, and trails, you physically leave your home and your city behind. Instead a news, music, TV shows, and work meetings, you hear birds, insects, rivers, and wind rustling through tall grasses or trees. Time is measured by the movement of the sun and the moon, by light and shade, not by the clock. You directly connect your legs, arms, lungs, and mind to the beauty of what nature unrolls before your eyes.

      • Going in. If you give yourself a chance to unplug from the digital world, you don’t just see what is in front of you. You also go inward, attending to your own thoughts that arise when you have no one and nothing else to attend to but yourself in nature. If you experience fear and anxiety, sadness, anger or frustration, your inner eye is often awakened without the distraction of other voices or needs. Like hunger, you may only become aware of it if you stop eating by the clock and actually allow yourself to feel your rumbling tummy or your sluggish mind. Similarly, by being alone with little distraction, the slower world of nature is a setting that allows inward processing and awareness without closing your eyes in meditation. It is a moving meditation, just at a slower pace.
      • Self-reliance. I personally learn more about who I am and what I need when I’m alone and there’s no one to hand me what I’ve forgotten. This requires me to be methodical about planning, to be flexible and creative when things don’t work out quite the way I had hoped, and to learn from my mistakes. One time while camping alone in the summertime, the weather turned unusually chilly overnight. I ended up making a tent within a tent, trapping warm air around my body. Another time, I was grateful to have remembered to pack a set of Yaktrax in my day pack after encountering deeper than expected snowfall, preventing my trail hike from becoming a lengthy hour of postholing. If I was with someone else who brought full gear, I might have an easy way out. Instead, going alone teaches me to rely on myself and own my decisions and experiences.

      • Changing your pace. When I go out in nature alone, my pace is often different than if I were in a race or with a group of people. I take whatever time I want to truly enjoy the time. I might stop for longer breaks, spread out a picnic of foods, jump in a lake and sunbathe to dry off, or take it easy in order to make sure I can “go long” and not run into trouble. Because I am not beholden to anyone’s schedule but my own, I can let go of any pressure to hurry, with only the weather, the terrain, and the amount of daylight as the boundaries of what I am doing. As a therapist who has learned how to measure off a 50 minute interval in her head, it’s a refreshing change of pace in all respects.

      Adopt the pace of nature: her secret is Patience.

      Ralph Waldo Emerson

      Your Turn

      If you are interested in exploring what being alone in nature could do for you, consider reading a few articles to help you prepare, and use available resources, such as local trail conditions and trip reports, which often include tips on what to bring regarding gear, food and water.

      You can also join a Facebook group on climbing and hiking, and see if there is local group that is open to fielding questions from new hikers.

      If you are concerned about safety as a solo hiker, runner, climber, etc., take the time to read safety recommendations on solo activities, and don’t be shy about asking what others do to take precautions.