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?
• Virtual EMDR Therapy
• Are There Advantages to Online Therapy over In-Person Meetings?
• Phone Therapy Versus Video Therapy
• 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 have not returned 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 stress of sharing a space with others 24/7, the uncertainty of what the pandemic meant, the impact of illness and loss, unemployment and underemployment, all contributed to people's moods. Worry, fear, bereavement, hopelessness, lack of motivation, fatigue, isolation, boredom all became common.

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. In fact, most of my colleagues have spoken about an increase in requests for meetings, and full practices. We found both that our former clients, folks we'd met with 2 or 5 or 7 years ago, and new clients, were reaching out for support during the confusing times and also to work through challenges that were arising. We found that with more time to reflect about their lives, some people were reminded of past hurts and traumas and decided it was time to work on those. Others were reflecting about their quality of life and how they preferred to live post-pandemic and wanted to talk about transitions from relationships or jobs that were no longer satisfying.

At this stage of the pandemic, our lives in most communities have returned to something more similar to pre-pandemic times. People are returning to in-person work at least a few days a week, sports and arts events have resumed in person, more people are using public transit, and courses and classes are being held in-person.

But there seems to be a different kind of mental health impact currently. People are 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 affected them emotionally, vocationally, socially and/or physically.

Recently 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."

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 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. It's up to the therapist to adapt and find 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.

At this point, most people have the experience themselves through work meetings and social events, so noticing those subtleties probably feels familiar to most of us.

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

How you will assess this for yourself for virtual counselling, will be similar to how you assess if the person is the right therapist to meet in person. For more about this see How do I know I'm seeing the right psychotherapist.

• 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

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 throughout the pandemic. 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 do. Your therapist should be using one that ensures your confidentiality.

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.

Virtual EMDR Therapy

Many of my clients meet with me for EMDR Therapy. It's an approach that is helpful to manage traumatic experiences or other upsetting experiences that are lingering in the body, or when anxiety is troubling. The therapist helps the client to process the difficult memories using eye movements, ear tones or self-tapping. As well, we use EMDR Therapy to increase strength and resilience. All of that can happen, and happen well, through videoconference.

• you feel safe and comfortable doing difficult therapeutic work with them. Trust your intuitive responses, ask them questions to reassure yourself if you have doubts.
• that you are attending therapy in an environment where you can feel comfortable if you have a strong emotional or physiological reaction during processing as this can sometimes happen during an EMDR session
• that they do a thorough process of preparation and history-taking before beginning any processing. This should take 3 to 5 sessions (or maybe more).
• that during those initial few sessions the therapist has helped you develop strategies for self-care, and also resources to use should you feel upset between sessions

A short time after the first lockdown in North America, EMDRIA, the EMDR International Association, released guidelines for virtual therapy

They hastened the release of the document to address our rapid shift to virtual work at the start of the pandemic. The upshot is that the organization feels that while in general it is preferable to do EMDR therapy in person, that under certain circumstances it is acceptable to provide the therapy virtually. They emphasize the importance of the EMDR therapist being especially mindful of creating a safe infrastructure to do the work and to monitor grounding and self-care even more robustly when working virtually.

As well, EMDR therapists will make decisions on a case-by-case basis how to use the approach, especially with new clients we have not before met in person. We may conceptualize a little differently with virtual clients than we would have in-person, but the experience of therapy should be equally robust.

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.

1. The commute. As many of our clients were working from home during the pandemic and tend to still be 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 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.
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.

Phone Therapy Versus Video Therapy

• Being watched on a screen may feel intrusive.
• Seeing your own image on screen may feel difficult.
• You may have a difficult issue to discuss and you are concerned about feeling judged or ashamed, and working just by voice may make that issue easier to speak about.
• You may be a person who gets distracted when too much is going on, so working just by voice may reduce the amount of stimulation.

While working by phone, the therapist will not have all the same cues to assess your situation, he/she will tune in differently to your voice tone, breathing, pace of speech and so on. In the absence of visual cues, the therapist will ask questions differently to understand how you are feeling.

Virtual Therapy: For you to decide

• You notice memories have been activated or feelings have risen to the surface during the ebbs and flows of the pandemic? (This is common. Some of our usual ways of keeping those things tucked away tend to be harder to access in times of crisis.)
• You noticed difficulties in your family and relationships more acutely while you were living in close quarters. Are you more able to explore those issues now?
• You are asking quality of life and stage of life questions now that we are emerging into a more hopeful situation where there seem to be more possibilities

Virtual therapy may help.

Download this article as a PDF

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.

To read more about professional guidelines for virtual EMDR Therapy:

Rollins, Sharon et al. (2020). Guidelines for Virtual EMDR Therapy.

Watson Wong, Joanna. (2013). EMDR Internet Therapy.