I have found that establishing and maintaining a sense of relatedness and emotional presence in the therapeutic interaction can be a major task. This can become an even greater challenge in an online video counselling session for mental therapy.
Venturing into the new clinical territory, particularly with technology, offers many possibilities and opportunities. This venue allows counselors to provide counseling services to a much larger pool of clients and their families, unhindered by geography, time zone and other limitations inherent by the counselor’s local office and community. The overall challenge of video counselling is to acknowledge it as more than a technological novelty. As the newest tool to one’s service offering, it is here to stay. Our challenge is to make use of it, while respecting that wisdom rests with the counselor by how effectively it is used. The success of this initiative is evidenced by the ability to offer video counseling to all clients, both as the main modality and as an adjunct to the face-to-face approach.
The technological infrastructure that makes video counselling possible, usable and worthwhile, is greatly acknowledged, but will not be expanded upon here. However, I would like to mention that without this technology, counselors would not have the clinical flexibility to expand the ways we can support and benefit our clients with increasing confidence.
The majority of the clients in my mental health video counselling caseload consist of adult females ranging from 20 to 60 years old, with couples making up the remainder with an even smaller representation of male adult clients. Almost all clients have demonstrated a significant comfort level with computer technology, as a way of receiving video counselling. To date, I have had only one client switch out of video counselling and to the face-to-face modality because they felt uncomfortable mixing technology with the traditional face-to-face mode of relating.
In articulating some of my initial thoughts about video counseling, the venue of the Newsletter became an opportunity to share observations and impressions I gathered from my video counselling caseload. A case example is used to illustrate some of the observations. Compared to face-to-face therapeutic interactions, video counseling offers interesting possibilities and opportunities. Factors that can influence the video counselling interaction between the counselor and the client include:
- The fixed and stationary position of the computer screen.
- The relative narrowed visual field captured by the video camera.
- The narrowed view of the individual, limited mostly to their head and upper torso. This can limit the view of whole and partial body movement, behavioral cues and response patterns.
- The difference between the upper location of the video camera and the lower location of the viewed image on the screen minimizes eye contact.
- The approach to and ease of use of technology and video mode of counselling may manifest itself in emotional issues expressed through anger, frustration, anxiety, rejection and feelings of inadequacy. These can create and perpetuate triggers for other issues.
- The struggle for greater connection or inability to engage in more fully connected ways.
- The issue with the technical aspects of the video counselling may be an indicator of issues in other areas.
- All aspects, roles, functions and dynamics of the video counselling technology useful in providing the service can be used as representations of the therapeutic experience conveyed through stories, anecdote, analogies and parallels toward a solution to the client’s presenting problem and ongoing challenges.
The fundamental challenge presented by video counselling for mental health therapy—and all forms of therapy—is how to transfer therapeutic (emotionally corrective) relational experiences with the purpose of enabling the client to learn how to manifest such corrective experiences by their own choice outside and beyond the counselling context. With video counselling, there is the obvious inherent absence of the mutual presence in the same physical room. Connectedness is technically facilitated through the aid of a computer and phone to access the visual and auditory components of the interaction.
I have found that establishing and maintaining a sense of relatedness and emotional presence in the therapeutic interaction can be a major task. This can become an even greater challenge in a video counselling session. Effective use of the physical proximity to the computer screen, attaining the desired visual experience captured by the observer, and reducing the distance between the video capture and video display for maximum eye contact, can maximize the sense of that relatedness and emotional presence.
The process of establishing, maintaining and interrupting eye contact in a video session can be experienced both as a relational and a therapeutic limitation. This is particularly evident when clients present with feelings of disconnectedness. Literally, coming face-to-face with it in the context of seeking and obtaining support is a recurring issue for some clients. The therapeutic challenge of make counselling even more useful and beneficial in a video session rests with the “the look”—the dynamic of looking at being looked at. Attaining and sustaining eye contact initially involves guiding and teaching the client to either look directly at the video camera or to resize and move the window with the counselor’s video image positioned on the screen just below the video camera. The client will experience a greater connection when the counselor looks directly at them. The counselor might also also gage his effectiveness based on the client’s eye contact.
Face to Face Vs Online Counselling Sessions
Being close in face-to-face encounters creates and supports a direct and likely intense interaction between individuals. Moving further away from each other likely diminishes the intensity of the interaction. Video counseling allows the counselor similar yet unique access to the client’s personal space within their home (or other location) compared to what occurs in face-to-face interactions in the counselor’s office. The inherent limitations and restrictions of position, proximity and movement are in terms of flexibility and range of movement within and outside the computer screen. Some influence can be exerted in terms of closeness to the screen, emphasizing facial features, partial or full body movements and what the client and the counselor can view in the background behind and around their respective computer screens.
As with face-to-face sessions, the number of individuals in the video session increases the level of complexity and dynamics. The difficulty in capturing these relevant levels of dynamics increases proportionally with the number of participants in the session; from one counselor and one individual client at one end of the spectrum, to a couple, then to a family or group of individuals (as in a case conference) at the other end of the spectrum. A wide-angle lens on the video camera would improve the video capture, and thereby enhance the experience of the session with couples, families and groups. On the other hand, by visually capture an increasing number of participants, you forgo proximity, increase distance from the screen—and the individuals on the other side of the screen—and thus reduce the resulting interactional intensity in the session.
Additional technological opportunities using video counselling include:
- Eliminates geographical distance between client and counselor, as well as transportation arrangements and cost, inaccessibility for the disabled; can reduce number of missed appointments or late arrival due to traffic and/or unfavorable weather conditions
- Allows greater flexibility in scheduling, access to clients living in remote areas, the elderly, the disabled, and adds additional modality current counselling services
- Increased focus of attention to the limited visual field on the computer screen
- Greater ready-at-hand computer access to digital information of varied formats and media during counselling session • Adds computerized control and specific digital access to visual and audio characteristics to enhance and limit the multi-media counselling experience
- Can regulate and control information flow
- Opportunities for additional collaborative therapeutic work, such as saving chat sessions for future reference, accessing and sharing videos, audio recordings and text files
- Flexibility for cognitive-behavioral therapeutic techniques using the visual field—modifying the visual characteristics of the screen image—by altering the size, brightness, focus, position, movement, etc.; and using the auditory channel—by modifying the pitch, tonality, timbre, volume, and other audio characteristics
Potential therapeutic opportunities available through video counselling:
- Can provide vital visual and auditory information about the client’s personal environment, lifestyle and symbolic validation for what is meaningful to them
- Can facilitate transference issues of attachment, “felt presence”, trust, care, earlier in therapy
- Can offer a sense of safety when addressing emotionally charged and intense experiences, memories and encounters, such as abuse and trauma • Can provide transitional phase to future face-to-face sessions for such issues as social isolation, phobias, anxieties, depression, etc.
- Can maintain therapeutic continuity and minimize cancellations and interruptions
- Can add variety and flexibility to providing and receiving counselling services
- Can facilitate and encourage other forms of digital communication and information exchange
Potential therapeutic concerns resulting from video counselling:
- Greater time needed to develop rapport and trust
- Reinforcing or intensifying client’s sense of feeling ‘disconnected’, being impersonal or objectified
- May elicit feelings of intrusion to the client’s personal space and home environment
Case Example For online counselling session
I recently saw a couple who requested video counselling to help them solidify their marriage following a two-year separation. Their main issue was that the wife wanted her husband to become more involved in the family and to take more initiative in co-parenting their two children, ages 6 and 8.
During the third video counselling session with the couple, I noticed the wife sitting close to the screen and leaning forward, while the husband was sitting behind and back, in a reclined and more relaxed position. This had been consistent with their sitting arrangement in the previous two sessions. Their sitting arrangement was viewed as an elegant metaphor for their respective roles in their marriage and their need for greater balance. Their challenge was that they had become comfortable with their previous roles during the separation, while also recognizing that they needed to become more flexible about switching and sharing their familial and parental responsibilities and responsibilities.
Their consistent sitting arrangement over the three sessions was brought to their attention. This maneuver was used as a therapeutic opportunity to gage their willingness to reverse their physical and symbolic sitting positions. They were encouraged and supported in assessing their level of comfort occupying their respective spouse’s preferred positions. I assisted the couple to choreograph their new sitting positions and discussed the necessary adjustments to succeed in making the switch. The parallel between their sitting arrangement and their marital relationship was then discussed with greater emphasis on their need greater flexibility and jointly deciding when and who was going to be “on duty” and “off duty”.
Video counselling, as a newer modality of therapy, provides many opportunities to deliver counselling services and do effective therapeutic work. It can be a useful metaphor for both the counselor and the client. This can be in the form of training a client to use video counselling effectively or in how to enhance the therapeutic encounter through the use of its varied aspects of video technology. The therapeutic process can parallel the teaching process of familiarizing the client with new technical or technological skills. Through the use of video counselling, clients can be supported to attain context-specific insights, skills and perspectives. This mode of counselling greatly adds to the counselor’s toolbox. It allows one to guide the client on how to use video counselling to enhance their experience and relationships, and to attain their goals.