Online Therapy with Couples 2/5: Reading the Virtual Room

The focus of this post will be on the ‘remote’ component of doing online couples therapy while Covid-19 based social-distancing recommendations remain in place. 

Most clinicians have been understandably wary of engaging in online therapy because of the obvious limitations of virtual engagement. Because we were all trained to treat patients face-to-face, perhaps the most significant obstacle is being deprived of the interpersonal cues that, as therapists, we have come to rely upon when it comes to understanding our patients’ struggles and how to most effectively empathise with and address them. 

A sensory-deprivation tank?

There is simply no substitute for physical presence. So, for many of us, engaging in virtual psychotherapy is akin to floating in a sensory-deprivation tank, disoriented by the absence of perceptual indicators that signal emotional states. “It is hard to read the room,” I have often mused to myself during a remote consultation, “when not everybody is in the room.”

This difficulty can reveal itself in a range of problematic ways. For example, when I am sitting with a patient, I do not direct an unwavering gaze in his or her direction, but often stare at the ceiling or out the window as I’m listening or thinking. But because we are still in physical proximity, it does not necessarily feel like I am mentally adrift or distracted. However, when the same shift-of-gaze occurred during a recent online session, my patient wondered if I had lost focus: “Are you still listening to me?” was her worried query.

Similarly, it is much easier for therapist and patient to sit through silent moments when they are with each other in the same room. But when silence occurs during virtual sessions, it may be harder to tolerate, to find and inhabit the collaborative ‘rhythm’ associated with quiet stillness – or, that ‘quiet stillness’ may simply be the result of a temporarily-frozen screen due to an unstable Internet connection.

Five unexpected benefits for couples work

But despite its disadvantages, online therapy is here to stay, and, let’s face it, if the pandemic had occurred as recently as 5-10 years ago, before so many individuals had access to networked technology, far fewer individuals would be able to engage in treatment. Some recent research has in fact suggested that video-enabled teletherapy is as effective as in-person therapy, and that the therapeutic relationship does not, in fact, suffer at all.

Plus, there may be some unexpected clinical benefits to online consulting, particularly with couples:

1. We are able to obtain a glimpse of the couple’s home environment (furnishings, wall hangings, lighting, etc.) that might illuminate aspects of their relational environment.
2. We may be privy, even briefly, to their interactions with other family members (children or grandparents, for example) whom we might not otherwise have the opportunity to see
3. In order to ‘fit into the screen’, couples may seat themselves much closer to each other than they could in an office setting, so we are offered a different view of the “geography” of their interaction 
4. Individuals may behave in less guarded ways when they are in the safety of their home and behind the ‘safety’ of a screen, so relational behaviors may be revealed that might have otherwise been censored in our consultation room.
5. There are fewer missed sessions due to logistical issues such as weather, scheduling and traffic.

Redefining the ‘room’

Of course, hesitancy when it comes to online therapy is not the exclusive province of the clinician – our patients may have their own concerns about such a significant shift in therapeutic platform. But they will take their cues from us, and if we envision online therapy as a potential asset rather than as a certain liability, they will be more likely to do so, as well.

So while there are clearly some limitations to doing online therapy as opposed to face-to-face therapy with couples, it still behooves us to look for creative ways to explore this tool and to flexibly deploy it in the service of effective treatment. 

‘Reading the room’ without everyone being in the room is a challenge, indeed. But if we expand and elasticise our definition of a ‘room’, we are well on our way to innovatively meeting that challenge.