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Virtual therapy, a marvelous tool, but is it the same as being physically present?

Zooming the last supper

Can you all hear me?

I'm sure many therapists have been thinking about the clinical subtleties entailed in doing virtual therapy. I have been doing almost 100 percent virtual sessions now for well over a year. A few months ago I would have said that screen visits do a pretty good job of simulating being in the room with a person. Now I am not so sure. As I move back into the office with more face to face interactions, I am finding the contrast enlightening.

What impresses me in a global sense is that there is energy in a real encounter that is somewhat deflated when patients are on screen. It's subtle, and I have been wondering how to account for the difference.

We therapists are in general new to thinking about the subtleties in online relationships. The pandemic thrust the technology upon us and we have been adapting. There are those in the fields of sociology, and research psychology who have been dwelling on the impact of technology on human relationships for years. Here are some thoughts.

We have a spectrum of technologies to connect with others, from email, phone contact, to texting and finally streaming video such as Zoom. All have their peculiarities. Authors have written about the pseudo intimacy of texting. Texting involves spontaneity of communication in the absence of seeing the other, in some ways it reminds me a bit of a patient on the couch engaging in free association. Texting can at times feel loose and free wheeling, it is disinhibiting. Writing in distinction, is a more measured form of communication where our words are carefully chosen to achieve razor like clarity, grammatical correctness, and style. Virtual video mimics most closely the presence of another and it is this form of communication that I will focus on.

Sherry Turkle, a psychologist at MIT who is affiliated with the computer science department and is an expert on the psychology of online interactions, has noted that in order to make eye contact with a party in a video chat one most look at the camera rather than hold the gaze of the other directly. This creates a paradox, in order to give a person full attention, one must gaze away from him directing ones gaze at the computer's camera. In effect, giving attention to the other lessens ones ability to receive attention from the other.

Another difference between screen and live is that technical issues may create a minute desynchronization between words and facial expressions and body language. These differences may be small enough to be subliminal. Though out of conscious awareness they nevertheless can be significant enough to create a cognitive dissonance that is tiring for parties engaged in virtual conversation.

There is something psychologically 'light' about online interactions. The screen is a kind of filter which attenuates the consequence of real interactions and facilitates disengagement. All too often you will see a patient's attention drifting while virtual at a rate not seen when they are actually present.

A personal observation I have made is that virtual therapy session are easy in the sense that they don't require a lot of energy to transact. Mine are initiated by walking across the hall into my study, often in my sandals not visible to my interviewee, turning on the computer, and pushing connect. It's equally obvious that little effort is required on the patients part either. Little time spent on travel, a few clicks, and the session transpires. Real interactions are more consequential. Imagine a patient showing up late 10 minutes before clinic closing. Does one reschedule? It's much more messy to say no to a person present and reschedule than it is to an image of a person on screen. Human interactions are messy, that is their beauty, that is also their strength.

Virtual engagement has been a blessing during the pandemic. It's a fascinating medium, but different from seeing a patient in the office. It's up to us clinicians to divine these differences so as to better master the subtlety of our interactions with patients. My take in summary is that when we are actually with a patient it is in essence a physical interaction. What I mean by this is that the presence of another person is consequential. While little is understood about the physical nature of people with each other who are not touching, it is easy to imagine the myriad signals that may be exchanged, most of which are likely subliminal. We give off odors, emit pheromones, we even radiate infrared heat between ourselves. The impact that these signals might have on the psychology of the interaction is easy to appreciate, while at the same time extremely difficult to define. Suffice it to say that my global experience of being with a patient versus a virtual interaction is that the former feels more energetic, I have more of a sense of being in contact in a constructive way.

My own opinion, is that virtual is 95 percent of the power of a face to face interactions however I feel that patients deserve 100 pennies on the dollar. So hard as it might be to relinquish the comfort and ease of online interactions, I'll be back in the office as much as possible and will be encouraging patients to join me.

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