Thoughts on online psychotherapy

Online psychotherapy is indeed a mixed bag of increased and decreased intimacy levels between therapist and client(s). There’s plenty of press to read on the subject, so I won’t bother linking to all of them here.

I will remain working online for the forseeable future, at least until the first vaccine becomes available to patients 65+ and show robust immunity development. This month marks my eighth online exclusively.

The irony of it

online psychotherapy
Credit: The Mighty Tim Inconnu

Ironically, now is a time when many people crave more social life and nearness/togetherness to family and friends. Traditonal office psychotherapy offers a timely antidote to this isolation. But such is not quite the case now. Now is a time for establishing productive collaborative therapy skills (both the therapist’s and the client’s) online.

Increased access

It may well become a much more prominent, established medium in the provision of mental health services worldwide. For many populations, that development frees up access to service.

Online therapy is viable

What should be clear to everyone: there is no full replacement for the experience of physical proximity in a quiet, secure physical office. Yet my experiences, and those of my clients, is that online work is viable and effective. While different, its essentials of good therapy remain.

Increased intimacy

It’s true that online therapy allows the therapist to see clients in their typical settings, rather than the therapist’s office. One school of thought is that this increases the intimacy in the relationship. This may be most true when the client consistently connects from the same room, which then becomes the physical ‘safe space’.

Eyes and ears

The all important client-therapist communication channel of eye contact is diminished in online psychotherapy. A wealth of information is lost via the reduced resolution of the computer or cellphone camera lens. The power of eye-to-eye (brain-to-brain) being diminished means a heavier reliance on all of the other non-verbal channels. Facial muscle striation, a key indicator, remains viable, as do other non-verbals.

online psychotherapy
Credit: cea+

Aural (sound) also suffers loss, including quality drops of various kinds (mostly very brief). However, I do believe that the all important non-verbal vocal tone is preserved online.

Familiar setting

As a Masters program intern and later as a post-graduate, I’ve provided outreach psychotherapy in client’s homes. I also trained foster group home staff – at the homes themselves – all in South Central Los Angeles. My critical incident management services are always delivered in the workplace. So I’m used to practicing where people live, or work.

Separate feeds

For some relationship clients, having partners enter the office on separate video feeds can be advantageous. And not just for clients experiencing severe stress and difficulty tolerating one another. For many non-monogamous and non-cohabiting clients, separate feeds make therapy feasible.


Separate feeds somewhat resembles my prior office of over 20 years. Partners faced each other rather than sit side-by-side (and incur a neck strain they need not suffer.)

Productive conflict

I believe this physical placement helped clients break through their emotional fusion, inside of which they’ve usually lost their clear senses of self. The use of separate video feeds enables a rudimentary form of differentiation. Some might call it creating needed boundaries, or emotional containment.

Opening possibilities

I might say that it opens possibilities for relationships to develop. Helping clients to recognize and contain their emotions while working on specific relationship changes is so often what people really want: productive conflict.

Old school app

Using GoToMeeting, whose popularity has been bypassed by many other streaming video providers, also provides a bit of relief from the Zoom interface. It’s been HIPAA approved for a long time. Its simple interface provides a very clear connection.

Barriers to normalcy

There are numerous barriers to the swift re-opening of the great majority of physical psychotherapy offices (and waiting rooms). Most have not been certified (or retro-fitted ) to have adequate ventilation. Neither is it clear what percentage of clients will wear masks on an ongoing basis.

Speaking of masks

All due credit is given to the professional market masks that provide excellent visibililty for the mouth area. I believe such equipment (as part of an overall prevention approach) will be considered the minimum for office based psychotherapy offices to reopen.

(Here’s the link to my prior post re online psychotherapy, in case you don’t see it in Recent Posts)

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