At a glance
The difficult part of an online session is almost never the equipment. It is finding an hour, in a home you share, where you are not half listening for somebody else. This article helps you build that hour before the call opens.
Clinical insights from 22 years in psychotherapy
I am Mark Colclough, MA, psychotherapist in Copenhagen. Qualified at the Psychosynthesis Education Trust and the University of East London. 22 years of full-time, face-to-face clinical practice.
- The session taken from a shared room. People who call from a room somebody else might enter speak more carefully than they intend to, and tell me so weeks later.
- The last 2 minutes. At home people step straight out of something difficult into the rest of the evening, with nothing in between.
- What the camera leaves out. I can see a face and very little else, so I ask about the breath and the hands rather than reading them.
Clinical notes: My observations are anonymised and compounded from my session notes since 2004.
Where in my home can I actually speak freely?
Privacy is the whole question, and it is a practical problem long before it is an emotional one.
Many people book online precisely because the flat they live in is the only room available, and then find they cannot say the thing they booked to say. A partner is working next door. A flatmate is back at six. The walls are thin and you already know how much carries. So the voice drops, the softer word gets chosen, and an hour you paid for becomes a performance for whoever might be within earshot.
Solve it before the first session rather than discovering it halfway through the second. A bedroom with the door shut and something playing in the hallway is usually enough. A parked car works better than people expect. If you travel for work, a hotel room is more private than any office. If nothing where you live works at all, that is information rather than a failure, and it changes what we arrange rather than whether we start.
What is worth setting up before the call opens?
Set up for your own comfort rather than for how you look, which is the opposite of what most people do.
- Light in front of you. A window behind you turns you into a silhouette and I lose your face for the whole hour.
- The device on something solid. Held in your hand the picture moves with your breathing, and you spend the session managing it.
- Headphones. They keep your end private and they bring my voice closer than a speaker across the room does.
- Everything else closed. Messages arriving in the corner of the screen pull you out, and you rarely notice that they did.
- Water, and somewhere to put your feet. Small things, and they are what let you stay in a hard conversation for a full hour. How I work is set out on my page about online therapy in English.
One more thing, which is not a setting. Sit so that you can see me without also watching yourself. Most people spend the early sessions half monitoring their own face, which is a reasonable response to feeling exposed, and it keeps you a step outside the conversation. Almost every program lets you hide your own image, and it is worth doing.
What does a screen take out of the hour?
It takes the body, and that is the part worth preparing for.
In a survey of 479 therapists across 25 countries, the one area where almost nobody found an advantage was the bodily one: 216 responses named something lost in nonverbal and physical contact, and none named a gain.1 Those answers came from therapists rather than clients, and they were given during the first months of 2020, when the change was forced on everyone at once, so they describe a particular moment as much as the medium. On the relationship itself the same therapists were split roughly down the middle.
In my own experience the loss is real and it is workable, provided you fill it in out loud. I cannot see your shoulders drop or your hands stop. You can tell me. Saying that your chest has gone tight, or that you have just gone somewhere else for a moment, takes three seconds and gives the session back what the camera removed. In a room I would notice it. Online you and I do that part together.
What if the connection drops in the middle of something?
Agree what happens before it happens, because the moment it goes is a poor time to improvise.
The usual arrangement is simple. If the call fails, rejoin once, and if that does not work the session continues by telephone. What matters more than the arrangement is knowing there is one. A call that cuts out in the middle of something painful can feel like being dropped by me rather than by a connection, and with no agreement to fall back on that feeling has nowhere to go.
The same goes for interruptions at your end. If somebody knocks, say so and deal with it rather than freezing and hoping I did not notice. What you do with an interruption is often more interesting than the interruption.
How do I land afterwards, and when is online the wrong setting?
At home there is no walk back from the room, so build one.
- Keep 15 minutes afterwards. Not for anything in particular. The gap is the point.
- Change the room. Open a window, push the chair back, make tea. Something that marks the end of the hour for your body as well as your diary.
- Go outside if you can. Even a short walk does what the stairs down from a consulting room would have done.
- Write nothing down immediately. What is still with you by the evening is usually the part worth returning to next time.
Online is not the right setting for everything. Where there is nowhere you can speak freely, the work keeps bending around that, and a block of sessions in one place is the better answer. Where what you want to work on lives mostly in the body, in what happens to your breathing and your posture when a subject arrives, a screen makes that slower. And if you share a home with someone and part of what you need to say is about them, online is not as private as it looks. A free 30-minute call is enough to work out which setting suits what you are bringing, and the way I work is described under online psychotherapy.
Questions people ask
What do I need at my end?
A device with a camera, headphones, a reliable connection and a door you can shut. Nothing else is required, and nothing else makes much difference.
Can I take the session from a car, a hotel or an office?
A car and a hotel room are usually private, and an office usually is not. The test is whether you could say the difficult sentence out loud where you are sitting.
Does a big time difference matter?
Less than the hour you pick within your own day. A session at the end of a working day tends to get whatever is left, which is rarely much.
What if someone walks in?
Say what has happened, deal with it, and come back. Pretending it did not happen costs more of the session than the interruption does.
Can I mix online sessions with a visit in person?
Yes, and people living abroad often do exactly that. A few consecutive sessions in one visit does something that weekly calls cannot, and the calls then carry it.
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Sources
How this article was written: I choose the subject and the angle. An AI assistant researches and drafts. I read the draft, correct and improve it and stand behind every clinical statement. The professional and clinical judgement is mine.
