I’ve been working remotely since the middle of March. While most of us seem to be using video chat platforms like Zoom and Doxy.Me, I find video so inferior to phone contact that I’m not using it at all in my practice. Surprisingly, all my clients have refused the video option too. Why?
Obvious reasons include not having access to the internet (common in our rural community); not owning a computer, tablet, or smartphone (also common); not having the skills (the elderly, the tech challenged); or simply being too ill to manage being online.
A less obvious reason, but possibly more compelling, could be this: clients make themselves vulnerable enough when they shower and dress to come in and see me in the neutral space of my office. Video chat takes away any sense of safe neutrality by letting me peer into their homes—which violates their privacy and arouses a variety of trust-undermining feelings, such as shame, anxiety, and humiliation.
“It’s a mess! I don’t want you to see the house,” one client admitted. Meanwhile, I can work from my office (I’m the only one there), which means my personal privacy is protected while theirs isn’t. Would seeing me in my personal space level the emotional playing field? Not likely. It would only be a distraction, yet another challenge to keeping the focus of treatment on them.
From my side, video chat destroys the intimacy required to do our sensitive work. The position of the camera rarely allows for reliable eye contact, which makes us both feel unsettled and uneasy. The countless distortions that are a function of the way video images are digitally encoded, decoded, and adjusted cause the image to freeze, blur, and drop, and worst of all, to be out of sync with the audio. These glitches and delays scramble subtle social cues and interfere with perceptual processing. We unceasingly, out of consciousness, strain to fill in the gaps. A full workday of that leaves me exhausted, anxious, and dissatisfied. Rather than feeling connected, I often feel the opposite: isolated and disconnected.
If we must have technology in session with us, the phone approximates live contact better. The rate of speech transmission is closer to live conversation, and the fidelity of sound is far higher, especially from a landline, which is what I use when calling clients. Because I’m deprived of visual cues, my hearing sharpens, and my sensitivity increases to subtle nuances of speech rate, rhythm, tone, and—this is really helpful—the client’s breathing. There are many more moments during the session where all my available senses are fully engaged, and it’s the same for the client.
It’s true that my mind wanders more, but I use the usual self-management techniques to rein it back. That said, there’s a silver lining to phone work. Thinking requires looking in. In a live session, when a client is speaking and looking at me, I maintain eye contact unless they break it. If they do, that releases me to gaze inside to think. But I still have to keep my eyes on them so as not to miss their return. Phone work frees my eyes to do what they want—they tend to wander vaguely around the room—which lets me think while continuing to actively listen and engage with the client.
Here’s an example. Betsy, 65, works as the head of social work at a local nursing home. She’s been in treatment with me for over 25 years, initially to recover from her abusive marriage. As the years passed and layers peeled away, it became clear that the source of all her symptoms and interpersonal problems was childhood trauma. Four years ago, she had a disastrous affair with a man from work.
Breaking from him took two years, and the struggle ripped away her usual defenses, allowing for new insights. Enter the pandemic and remote phone work.
It took a few sessions for the two of us to establish a working rhythm. In a way, it was like being with a new client. Much more frequently than I would in an in-person session, I mirrored, reviewed, and asked for confirmation that I understood what she was telling me. Then we had a real-time aha moment.
“So wait,” I said into the phone, pausing to think as I glanced around the room without seeing it, “are you saying . . .” I leaned forward in my chair, my attention closely tuned to her breathing “. . . that this boyfriend, and the one before, and your ex-husband, are all the same kind of man?”
“Yes!” she said. A long silence ensued. I waited, listening intently to her deep, regular, slow breaths. Then, a little huff, a pause, and—“Oh my god.” Her silence was so active, it was like hearing her think. “Could it be . . .” she whispered.
“They’re all variations of your father?” I offered, feeling the risk run through my body, even as I let the words go.
It’s not like we hadn’t discussed this insight before. We had, many times. But something was going on here that was new, and it was important not to miss the opportunity. How would she react? I couldn’t see her. I couldn’t scan her face or her body language. All I had was the surf-like regularity of her breath in my ear. Then a creak, and a rustling of cloth against cloth. She started chuckling, at first low and soft at the back of her throat, and then building to a full out laugh. I sagged back in my chair with a combination of relief, amazement, and fatigue.
So you see, despite the limitations, it’s possible to do transformative work by phone. I don’t find that to be true for video. Still, it goes without saying (I’ll say it anyway) that contact in any form is better than none. No matter how you “see” your clients these days, do it. They need us more than ever.
PHOTO © ISTOCK / DRAGONIMAGES
Daniela Gitlin, MD, is rural psychiatrist in private practice in upstate New York. Her clinical memoir Practice, Practice, Practice: This Psychiatrist’s Life was selected a Finalist by the 2021 International Book Awards. Her second book, Doorknob Moments: Why Clients Drop Shockers on Their Way Out the Door and Why You Want Them To will be published by WW Norton in 2024. Learn more at danielagitlin.com.