ONLINE PSYCHOTHERAPY: HOW?

Dr. Salih Murat Paker – Clinical Psychologist – Psychotherapist – November 2021

During the pandemic, the use of online psychotherapy has increased unprecedently. Therefore, it is necessary to consider the differences between online therapy and in-office therapy and the main features of online therapy.

Let us first consider therapy in-office. The client comes to the therapist’s office after making a certain journey and spending a certain amount of time on this journey; maybe they spend a few minutes in the waiting room; then they go to the therapist’s office, do their session in a completely private and confidential environment, without any interruption, feel the attention of the therapist, sit on opposite chairs with the therapist or, in some psychoanalytic therapies, lie on a couch, finally pay their fee, leave the office, and this time make the return journey. For a 45-minute session, they spend several hours depending on the round-trip travel time. This cycle, which is repeated at least once a week, soon becomes a kind of ritual for the client. Maybe they come a little early and spend some time every week at the corner cafe, stopping by certain places. This ritual actually offers a suitable environment and time to think about what can be talked about or what has been said in the session before and after the session. We always go to the same office, sit in the same chair, see the same therapist. What we see when we sit in the office is almost the same and three-dimensional, it starts at the agreed time, ends when it should be finished, we pay the same fee (except for annual increases), our relationship with the therapist has certain parameters, etc. All of these constitute the framework of the therapy work, and this framework must be maintained consistently so that the therapeutic relationship can develop on a basis of trust.

Since online therapy is also a type of therapy, the framework is also important there, but there are some difficulties and concerns to be considered compared to in-office therapy. Let us see them in order:

Privacy

It is much easier to maintain privacy in the therapist’s office, since the most private things of the inner world can be shared in therapy sessions, and there is a confidentiality principle that binds the therapist (with certain exceptions, the therapist cannot share what is spoken in the session with anyone). The therapist has taken the necessary precautions. No one can enter the session room, listen to the sessions, record them, telephones cannot ring, there cannot be a noisy environment, etc. However, in online therapy, the therapist cannot control the degree of privacy of the client’s space. The client has to undertake this task and this needs to be discussed from the very beginning. Clients who live alone or have private offices are fine, but those who live with others need to find a place where they can provide privacy for sessions, where they will not be interrupted. If possible, always in the same place. Sometimes it is not possible for various reasons, but it is important to have a private space every time.

Comfort but how much?

When clients come to the therapist’s office, they sit in the place shown to them. In online therapy, the client is much freer. It is good to be comfortable, but since too much comfort in the sessions can make it difficult to focus on the inner world, it should be preferred to sit on a sofa or chair as in the office and to avoid lying on the bed/couch or walking around the house.

Extra material?

In the therapist’s office, there is a box of tissues within reach of the client, so you can cry at times during sessions. In online therapy, the client should set it up from the beginning so that the session is not interrupted each time. According to the therapist’s orientation, they can have a glass of water (or coffee/tea) with them. But during the session, eating, drinking alcohol, smoking or drug use is not allowed. It is possible that clients ask such questions more often or sometimes they attempt without asking in online therapy. Then these rules will need to be discussed.

Clothes?

Clients do not come to therapy offices with comfortable home clothes (e.g., sweatpants, pajamas, shorts, underwear, etc.). This risk increases if online therapy is done from home. The general rule is to choose clothes that can be worn while going to the therapist’s office. This issue is important even when doing a phone session with no video image. Because even if the other party does not see you, you know what you are wearing, and it will inevitably affect your attitude in this session.

Technological Noise

Today, we are very intertwined with technology. We use too many devices and too many programs. Except for the device and program used for the session, all devices and programs must be silenced and should not interrupt the session in any way. Our goal is to create an environment where you can focus only on therapy without any distractions like in the office. It might be preferable to use good headphones to reduce background noise.

Before and After the Session

If we remember that there is a larger, ritualistic package for the in-office therapy, before and after the session, we may think that it will be necessary to create a similar environment for online sessions. It should be preferred not to do any other work for at least 15 minutes before and after the online sessions. It would be very good to relax the mind and focus on the coming session before the session, and then to review what was spoken and felt after the session. We witness that especially those who work online from home can experience their therapy sessions like another meeting from numerous back-to-back meetings. It is never a good idea to join a therapy session as soon as you leave a meeting, and then join another meeting right after it is over. Before and after therapy, pace of life should be slowed down so that people could focus on themselves.

Space

In in-office therapy, the space remains fixed, the ideal situation in online therapy is that the spaces of both parties remain constant, but in our world where mobility has increased, it is not realistic to put this as a strict rule. In cases where the stability of the space cannot be achieved, it would be good to talk about the compulsory changes in the session and turn them into therapy material.

Technology

We can do online therapy thanks to the level reached by technology. Therefore, therapists who will do online sessions need to know the applications that offer this opportunity (Zoom, Skype, etc.), have a strong opinion about the confidentiality restraints of these applications, and follow the developments in this field. Needless to say, both parties need to have as fast and encrypted internet connections as possible. However, there may be short-term interruptions, if such situations occur, it should be added to the end of the session by the therapist. Therapists must take technological measures such as anti-virus, anti-malware, firewall, etc. on their devices used for online sessions.

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