Thank you to everyone who responded to our June Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
June Quandary: The transition from in-person to video sessions was a bit bumpy, but I ultimately found my footing because I was still able to make eye contact with my clients, notice their subtle expressions, movements, gestures. Many of my clients, however, have been requesting phone sessions. I want them to feel comfortable, but without those visual cues I feel hindered as the therapist. What are some tips and strategies that might make phone sessions just as effective as video sessions?
1) Dial Up Your Presence
Transitioning to doing therapy remotely—whether through video or phone—has been challenging for all of us. We depend so much on visual cues: the slumped shoulders, little fidgets of the leg, tapping of the fingers, and everything else that’s left unsaid that we pick up in body language. When this happens in person, the energy in the room, or “sacred silence,” as I call it, is so palpable. It’s something I dearly miss about doing therapy in person.
One of the strategies I find particularly useful in helping recapture that magic when doing a session over the phone is to close my eyes as the client is speaking. This helps me better judge inflection, tone, and nuances in the words spoken. I find that cutting out all visual stimulation amplifies my auditory senses. I can focus completely on voice and content, and I find myself better able to respond.
I also think it can be useful for therapists doing phone sessions to ask clarifying questions when they’re confused and to reflect back more than they normally would during an in-person or video session. Doing this reassures our clients that we’re paying attention and they’re being heard. Also, with the absence of visual cues, we need to handle silence differently during phone sessions. More therapists should reassure their clients upfront that if they want to take a pause, they’ll remain present. Once the client is ready to resume talking, they might do something to signify it, like tapping on the receiver.
Personally, when I finish a phone session, I like to follow up with a text message or email that contains a brief summary of the session. This ensures that the client and I are on the same page and nothing important has been overlooked.
Sukanya S., family therapist
2) Dig Deeper
In my 20 years of practice, I've always seen a small portion of my caseload via phone or video, so this transition wasn't drastic for me. But for clients who’d seen me for months or years face to face, this was a major shift. I knew from experience that some clients would prefer the phone and others video, so I offered both. I can't say exactly what it is that draws a person toward one and not the other, but I suspect that more introspective or self-conscious clients gravitate toward the phone, while those wanting the more relational components seek video.
As a psychodynamically trained therapist, working over the phone isn’t so different from working with a client who’s lying on the couch. The principles are similar: the lack of visual and relational cues pulls for a more inward focus and allows the unconscious to make a grand appearance. Because I'm not able to read body language, I find myself asking more questions about emotions. Some clients feel greater freedom to share deep feelings or memories when they don't have to look me in the face, and we can do good work with that material. Some people find freedom speaking into a phone with no one else in the room, and they address subjects they otherwise wouldn’t.
My clients and I acknowledge these moments and talk about what it might feel like to be this vulnerable with someone who’s actually in front of them, because that's what intimacy is really about. I'm not a chaise-lounge Freudian at heart, as much of my work is very collaborative and relational.
If I've worked with a client for years, I have a sense of their facial expressions and posture that I keep in mind as I listen. For newer clients, I try to engage with them more to fill in the gaps. I clarify if a statement was a joke or a jab, because I can't see their face. I ask if they're feeling sad, because I can't see their body. Fortunately, I haven't heard or felt any pushback for these additional questions, and I believe they improve our connection and our work.
I’ll be happy to return to face-to-face sessions when I know they’re a healthy, low-risk option. In the meantime, I'm enjoying learning about my clients and myself as we explore healing through a very different format. To be honest, I won’t be surprised if I romanticize some of this time in the future. Surviving a shared trauma can have a profound impact on any relationship, including our therapeutic ones.
Ryan Howes, PhD
3) Step Outside Comfort Zones
Conducting therapy by phone presents innate challenges, and communication is key. As the therapist, you’ll need to project your voice more and be exceptionally mindful of your tone since, like you, the client won’t have any context clues to use. You’ll also want to describe your reactions, thoughts, and insight, particularly when there’s silence. Perhaps you might even say something like, “I’m thinking right now about how I can help you….” Or, “Since I can’t see you, I’m wondering what facial expression you’re making as you talk about….” I’d recommend asking your clients to do the same and, again, normalize that it may require both you and the client to step outside your respective comfort zones.
In addition, I’d consider carefully what’s motivating your clients to request phone sessions. There are many possibilities, from the logistics of using a video platform to the discomfort of seeing themselves on screen (I’d certainly be uncomfortable watching myself in therapy!). Many clients are uncomfortable sharing their home or would prefer to not see their therapist’s home. There are many possible reasons why the client might prefer phone sessions, and the solution might be as simple as enabling/disabling features on the platform—or, it may require an in-depth discussion. Either way, there’s an exceptional opportunity for growth and alliance building if the therapist can normalize the discomfort and offer their own experiences, too.
Kate Sample, MA, LPC
Eau Claire, WI
4) Prepare for Disruptions in Advance
Right now, tracking the effects of lockdown is considered the world’s biggest psychological experiment, one that deeply impacts clients, therapists, and our collective humanity. Nearly everyone’s mental health been affected by the pandemic. But while some clients and therapists have grown accustomed to doing therapy remotely, it remains a struggle for others. Most of us were never given specialized education about the difference between doing therapy in person and remotely.
Although I just started working as a therapist, I’ve come to realize that the traditional therapy techniques and treatment plans I learned in graduate school play out very differently in virtual settings. More and more, we’re moving toward a “phy-gital” world, an amalgamation of physical and digital spaces. It does us no favors to resist it.
Still, issues surrounding client privacy and confidentiality arise. Over the phone, there’s a lack of insight into the client’s body language. Using mindfulness and experiential techniques also become difficult. We can’t know for sure whether the client is seated in a safe space. We encounter an ethical quandary.
Addressing issues like depression, anxiety, and insomnia can be relatively straightforward. However, when working with individuals who suffer from trauma, self-harm, or suicidal ideations, matters get tricky. How do we handle this? I’ve come across a few strategies that can help us develop a smooth transition into a digital world and create a safe space for these clients.
The first strategy I use is asking. When I first get on the phone with a client, I ask them if they’re seated comfortably, and if they can hear me. I ask them if they feel safe wherever they may be. If they’re at home, I ask questions about that, too. How far away from the door are they? How thin are the walls? Getting a feel for their space allows us to visualise the process.
A second strategy I use is to ensure that the client has a support system wherever they’re doing the session, just in case they get distressed during the work. It’s important for them to have capable people within reach, especially if they’re dealing with trauma or self-harm issues. If the client lives alone, I like to discuss protective factors and for us to develop a plan to reach out someone if the situation escalates.
Last, I like to clearly state the measures I’ve taken as the therapist to maintain the client’s confidentiality. I explain that I’m seated away from any disturbances. I like to give the client a sense of my space too, which provides transparency and facilities a better therapeutic relationship. However, I’m also clear about the disadvantages of doing therapy remotely. For instance, we might experience technical difficulties or one of us could become interrupted.
Archana Raghavan, Clinical Psychology Associate
Bengaluru, Karnataka, India
5) Comfort Like a Caregiver
With all of us a little “Zoomed out,” I welcome sessions using the good old-fashioned telephone. Too much screen time has left us a little drained, and for good reason. Onscreen sessions have so much more intensity than simply sitting across from someone in the room. In person, you can look around, look away, and move freely, but on a screen, clients and I tend to stare each other down for the full 50 minutes. It isn’t natural, and I’ve found it’s harder to pick up nuances and maintain eye contact in video sessions. I’ve also found managing awkward silences to be tougher in video sessions.
Personally, I’ve found this isn’t the case doing sessions by phone. Our voices carry nuance and prosody that give us all the information we need about how our clients are feeling in the moment. When the distractions of the visual world are removed, our hearing becomes more sensitive. The state of our clients’ nervous system is apparent in the speed, inflection, and tone of their voices. We can pick up little pauses, the catch in the throat, the pregnant pause. We can also supply warmth and support through our own voices, much in the way that the lilt in an early caregiver’s voice soothes an infant. Our voices never lose their power to comfort, as anyone familiar with polyvagal theory knows.
To make the most of phone sessions, I like to curl up in the sofa in my office, away from my desk and distractions. I wear a hands-free headset so I can take notes if I so desire. It’s much easier to do this when your clients can’t see you writing, where they might perhaps anxiously wonder what you’re jotting down. I listen for the nuances in their voice much the same way I would watch for telltale cues from the body if I were sitting in the same room with them. I also ask more questions when I can’t see the client. When there’s a long pause or their voice quivers, I might pose a little query such as, “Are you okay?” I try to keep my voice slow, soothing, and calm so the client doesn’t feel pressured to immediately fill in the silences.
I’ve come to enjoy my phone sessions more than my Zoom calls. I find they’re less draining, there’s no tech to fuss over, and I believe both my client and I leave the session feeling more connected, and even refreshed.
Leslie Ellis, Clinical Counselor
North Vancouver, BC, Canada
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