So You have Questions about Online Counselling?

• Concern about a Lack of Connection
• How do I know if a particular therapist is right for me?
• How Do I Know the Technology Used by my Psychotherapist is Safe/Secure?
• Are There Advantages to Online Therapy over In-Person Meetings?
• Virtual Therapy: For you to decide

As the world reacted to the pandemic in March 2020, there was a massive shift in the field of psychotherapy in North America and elsewhere. Up to then, the vast majority of psychotherapists chose to meet only face-to-face with clients. But with the arrival of the health and safety protocols, we rapidly shifted our practices to accommodate telephone and videoconferences. Many of us did not return to in-person meetings, and most of those who have, provide a hybrid model: meeting with some clients in person and others by video.

With the arrival of the pandemic, very suddenly so much shifted for us culturally, and with it a shift in mental health and wellness. The combination of uncertainty and a sudden shift in what day to day life and interpersonal connections looked like contributed. At the same time, there seemed to be an increase in awareness of the importance of mental health and wellness. In both conventional media and social media, there was a lot of discussion about the stress of living through the pandemic and the impact on mental health.

Living through that time, and subsequently political upheaval and conflict in many areas of the world (and it must be said the way the media and social media reports all of this) has also led to a shift in my practice and in the practices of many of my colleagues. Some people decided it was time to work on the painful stories and experiences from the past that were lingering, because if not now, then when? Some people have been triggered and reminded of those previous experiences, so felt some urgency to work through them. Others have acknowledged with gratitude their privilege in living in a safer environment, but have reflected about their own quality of life and the impediments to that.

Even now, where life has returned to a rhythm very close to pre-pandemic times, people are still emerging from their protective, highly vigilant state and asking, what happened there? What happened to me there? And people are wanting to look at their personal histories of hurt and trauma, and how to live a life that feels more grounded and hopeful. As well some people are traumatized by the pandemic itself or by how it continues to affect them emotionally, vocationally, socially and/or physically.

A few months ago as things started to 'return to normal' I was watching an interview of a celebrity on television and the interviewer asked how things had been during the pandemic for the celebrity. Very candidly, the celebrity talked about how before the pandemic, that while she was compassionate about people experiencing mental health difficulties, she realized she underestimated just how powerfully they could affect people until she herself experienced some troubles during the pandemic, and then she disclosed how psychotherapy and an anti-depressant had helped her through a time that felt very dark. And immediately, spontaneously, the interviewer then disclosed that she as well had started medication during the pandemic. (I'm not advocating medication here, by the way – if you think that is something that might help you, speak to a medical professional about that, and if you think it is not something that will help you, trust that.) But I was so surprised, and delighted, that both people found comfort and solidarity in acknowledging to each other their own mental health challenges during these stressful times, and what role models they were in normalizing how common mental health challenges are, especially in these times.

My practice remains virtual. Many psychotherapists and mental health professionals continue to work either entirely or partly by videoconference. You may have some concerns or hesitations about the virtual approach if you have not experienced it before.

Here are some things to consider as you reflect about whether Online Therapy is right for you.

Concern about a Lack of Connection

Client J.: "When I used to meet in person with my psychotherapist, I felt his presence. There was almost an energy in the room that helped me to have the difficult conversation."

Client M: "My therapist seemed to notice nuance when I was in her office. She'd comment about my facial expression or notice a shift in my body. I can't see how that would work by videoconference."

Just about everyone has participated in video meetings of some sort now. Still, even the week I decided to update this article several months after 'returning to normal' two different people commented that they could not imagine how psychotherapy could work when you can't sense the energy or presence of the therapist "like you can in person".

These were also some of my own biggest concerns as a therapist when I switched to virtual sessions in March 2020. It's okay to feel skeptical – in fact that's how I felt too when I first launched into this approach. But I realized right away that there can be a very strong therapeutic connection and that we therapists can do very similar therapeutic work including noticing subtle shifts in a client's response.

Ideally your therapist is doing a variety of things during your therapy session:

1. Listening to your story/situation/problem and providing support, compassion and empathy.
2. Assessing throughout the meeting how they can be helpful to you.
3. Providing grounding and safety to be able to confront difficult issues. Often that feels like a particular energetic presence.
4. Looking for what's behind the words – what emotion, what body sensation, what history of trauma or history of success can help, or is getting in the way, of you moving forward.
5. What one of my non-therapist friends calls my capacity to read other people. We therapists tend to notice subtle changes in facial expression, tone of voice, body language and we're curious about whether those may be clues to what's getting in the way, or what can facilitate moving forward.

Does that feel different by videoconference? Possibly, yes.

Can it still happen by videoconference? Absolutely. Therapists have adapted and have found different ways to engage with their clients.

Can I still feel that sense of energy through a computer screen? It surprised me as I shifted my practice how strong that energetic connection can be virtually.

How do I know if a particular therapist is right for me?

• you can sense the therapist's presence and attention
• the therapist is noticing you enough – your emotion, your discomfort and your success
• you feel supported

Recently I have begun work with new clients who met with other therapists virtually and did not find it worked for them with those other therapists. One therapist was vaping during session, another seemed distracted by their surroundings and checked their phone during session. Clearly not okay. The professionalism of a therapist during a virtual session should be equivalent to the professionalism you would expect in a traditional office environment.

One other factor to consider is the location of the therapist. Each jurisdiction may have different legal or ethical guidelines around the provision of psychotherapy. If the online therapist does not live in your province or region, you may want to check if/how they are professionally regulated to ensure ethical care.

How Do I Know the Technology Used by my Psychotherapist is Safe/Secure?

Each jurisdiction will have guidelines on which videoconference platforms are acceptable for psychotherapy and that may differ from province to province in Canada and may differ again in other countries outside Canada. Many of these platforms quickly adapted and upgraded to accommodate the nuances of psychotherapy and have continued to upgrade. Some of these platforms have been designed specifically for use by psychotherapists or medical professionals with issues of privacy in mind.

• Ask if the videoconference platform meets those standards of security and safety.
• Ask whether your confidentiality will be maintained by the platform so you ensure the privacy of your healthcare.
• Ask whether the platform keeps any of your personal information after the meeting.

Some of the platforms you use to chat with your friends and family will not have the same security measures as these ones designed for psychotherapy do. Your therapist should be using one that ensures your confidentiality and protection from hacks.

The platforms used for these purposes tend to be quite user-friendly. In fact, you have likely already used one or something similar for work or family events and other meet ups with friends. Even if you don't have much experience (or confidence with) new technology, the platform will likely be easy to use. As well, the psychotherapist will provide access to a meeting in an accessible format. Ask the psychotherapist about this.

If you are uncertain, the psychotherapist can phone you at the start of the meeting to help you as you set up the first time.

Are There Advantages to Online Therapy over In-Person Meetings?

What therapists like me with little experience with online therapy prior to the pandemic had not predicted, was how quickly our clients would adapt to this approach, nor all the reasons people would benefit from and prefer this approach. Indeed, most of my clients still prefer virtual. (currently the exception to this is someone whose partner or family is likely to be in the home when they meet for therapy so they don't have enough privacy for meetings. Even then often people find creative solutions to meet – the car in the garage/driveway/parked down the street, an isolated private area of a park where other people are at a distance, are a couple of examples.)

1. The commute. As many of our clients were working from home during the pandemic and tend to still working from home at least part of the time, being able to meet with the therapist between their own virtual work meetings and 'travelling from one room to another' rather than travelling by vehicle or public transit to an office has been very helpful and reduced some stress. I live in a large city, so it was not uncommon for clients to travel an hour each way to meet with me, so this shift is a distinct advantage for many of my clients. Plus several of my clients live in other parts of the province where I live, so they would not be able to meet with me in person if I was not meeting virtually.
2. Childcare. Likewise, during peak times in the pandemic with children doing some or all of their schoolwork virtually, for many parents it was possible to meet without figuring out other childcare. And still, that's an issue if parents are meeting after school hours.
3. Safe, familiar environment. Being surrounded by the familiarity and comfort of home, to wear comfortable casual clothing, to sit in a comfortable spot at home, to have comforting familiar objects within reach – these aspects can all enhance safety and groundedness to facilitate the sometimes difficult work of therapy.
4. Pets. I have been amazed how often pets just knew it was time to join their person in therapy. When my clients have felt sad, fearful or vulnerable, pets have often known it was time to enter the room, to come close and nuzzle, to provide a source of comfort. Some clients anticipate the support their pets provide and bring their pets to session so they can be nearby. Several cats, dogs and rabbits have attended session with my clients since my practice went virtual.
5. The screen may provide a buffer that actually enhances connection. This paradox I did not anticipate. For some clients, the screen actually allows enough psychological safety to take more risk and be more vulnerable. With a few of my clients who are trauma survivors, we (both my client and I) have noticed a greater depth to our work once we started working online, which we both attribute partly to being at a physical distance. Paradoxically this has led to a stronger energetic connection in our work, and more personal/emotional risk-taking for the client to work on their personal issues.

Virtual Therapy: For you to decide

• Have feelings or memories been activated due to how you have been feeling during the ebbs and flows of the pandemic or by media (or personal) stories of political upheaval and world conflict?
• Did you notice difficulties in your family and relationships more acutely while you were living in close quarters? Are you more able to explore those issues now?
• Are you asking quality of life and stage of life questions now that are now emerging?

Virtual therapy may help.

Read my complete article: "So You have Questions about Online Counselling?"

Additional topics include:

• Phone Therapy Versus Video Therapy
• Virtual EMDR Therapy
• Professional guidelines for virtual EMDR Therapy

Jeremy Tomlinson, M.Ed., RSW is a therapist in Toronto. He specializes in EMDR therapy, DBR, trauma therapy, life transitions, and sex therapy. Many of his clients are survivors of childhood sexual abuse or have experienced attachment issues in childhood, are survivors of adult sexual assault, or are living with symptoms of depression or anxiety. He currently has a virtual practice in a home office.