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.

Digital Distress In An Age With Less Privacy

Digital Distress In An Age With Less Privacy
by imei Hsu, RN, LMHC, Artist

Recently, I took part in a conference in Seattle addressing the topics of privacy, identity, and innovation as it relates to the technology affecting our world through the advances of a digital age. At no other time in history have we been more enpowered by technology in multiple formats and with such mobility. I was stunned and in awe to watch the transit of Venus across the face of the sun on June 5,2012 — all from the convenience of my iPad. Yet partly due to the  speed in which many software applications are delivered, the people in charge of developing and delivering these systems admit that they do not have all the questions answered, nor the legislation in place to protect the best interests of the consumer. While I initially thought I should share a more information-oriented, clinical description of the affect of privacy issues on psychology and psychological services, I kept asking myself, “What is it that people want to know from me about this topic?” The answer: what is it that I think about privacy and how it affects us? What does any of this have to do with psychology or my well-being? The answer: what you don’t know can hurt you. For now, I’m calling this effect Digital Distress.

Here’s a few things you should know from conversations about Privacy.

photo placeholder. Original ink drawing by Imei Hsu.
photo placeholder. Original ink drawing by Imei Hsu.

1. Consumers are concerned about privacy. It’s not that we know nothing about what it means to have our contact information or images of ourselves violated or exploited. It’s that in general, many of us do not know enough about how to protect ourselves — that is, we are not readily and clearly educated about how to keep our personal data under our control. Terms of Use Agreements (TOUA’s) are often written in legal language that is difficult to interpret, we are subscribed into programs we didn’t select, and many of us do not know how to launch “do not track” programs on our most frequently used Internet browsers.

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