How to keep individual and group sessions running smoothly
This article appeared on Psychology Today in July 2023.
Photo by Windows on Unsplash
Since the COVID pandemic, therapists and researchers have been keen to prove that online therapy can be just as effective as in-person therapy, and that the therapeutic benefits for depression and anxiety are sustained over one-year follow-up. In most situations, where there are no crises, risks, or severe cognitive or sensory impairment, online therapy is often preferable, and just as effective (Wager et al., 2014). This finding is particularly strong if factors such as therapist and equipment positioning, light and contrast are optimised for greater telepresence.
So online sessions can work in exactly the same way as in-person therapy, using the same techniques and strategies. The clinical outcomes can be equally effective, whilst providing a wider choice of therapists for the client (and a more diverse population of clients for the therapist); improving flexibility of scheduling, increasing accessibility and, often, reducing therapy costs for both client and therapist.
Strikingly, a meta-analysis showed we are spending 7.8 times longer on in-person sessions (Andrews et al., 2018). Online therapy might be better for focusing on problem-solving and goal-setting, without the therapeutic drift and strong transference and countertransference that comes from being in the presence of another; not to mention the small talk, deviations from the topic and social pleasantries that ensue in-person.
Online therapy can also be less emotionally intense, because our brains don't have to pick up on as many social cues, maintain as much eye contact, or respond with physical comforts to a client in distress. We can even say goodbye with one click.
We may find online sessions more convenient today, but what if your lifeline to the client—the internet—repeatedly crashes?
You have been in that session, losing the will to go on, because your internet connection is glitchy. Your client is on the brink of tears, recounting the depths of a recently uncovered childhood trauma for the first time. The video is patchy and freezes, at exactly the wrong moment, and you’re asking them to repeat the trauma over and over because you can’t hear.
The person’s voice is robotic in sound; their face and lips are moving at different times, out of sync; and in that moment you want the ground to swallow you up (especially because the client is fee-paying and the delivery of therapy completely loses its professionalism).
Eventually the audio speeds up to catch up with the visual and, if you’re lucky, you can piece together the narrative so that you, too, are up to speed with the conversation.
Here are 8 tips for actively problem-solving a crashing internet connection without switching off and on the router. It’s important to troubleshoot before and during your first session with the connection on both sides. These tips also apply to group sessions with multiple clients/relatives or a spouse:
1. Wifi boosters. This is my personal favourite. Use a wifi booster (sometimes called an “extender”) or two. Assess the height and number of floors in your home and the range of the wifi extenders. Follow the instructions for where would be the best place to plug it in, in order to maximise the signal. Be careful of solid walls, appliances, or other barriers to a consistent signal. Be sure to select your boosted signal and not your original signal on your laptop or device. Consult your internet service provider if you need to.
2. Use the speaker on your phone. Use your phone on loudspeaker whilst on a video call with the client on your laptop or device. When the client is on loudspeaker, mute the microphone icon on your laptop. You can use conference calling on your phone from your network provider to add multiple people in a session to the loudspeaker. Place your phone on your laptop so other people in the session can hear the conversation.
3. Use Do Not Disturb. If you are using your smartphone to deliver online therapy, make sure the phone set on do not disturb for all apps and calls. Remove any scheduled alarms that might interrupt the signal or session. If the client is using their smartphone for sessions, this applies to them, too. Close all the internet pages and apps that are on your phone or laptop, so they don’t slow down the processing speed of your device and internet connection.
4. Move rooms. Assess whose signal is unstable. You or your client can go into alternative rooms to see if it makes a difference. There will likely be a hotspot where the internet connection is faster. Ideally this would have been assessed and located before the session.
5. Use your Hotspot. Use your personal hotspot on your mobile device to see if the signal is better. Have it readily available to switch to if there is maintenance on your home internet, or you need an immediate backup connection you can switch to, when the signal gets patchy.
6. Use visual formulations. At Lifespan Psychology, we are trained to develop tailor-made visual formulations where we use the best available evidence and research to map out any cycles, factors, or patterns that might be maintaining the client’s problems. On the whiteboard on Zoom, or in Word, draw a formulation online to take the pressure of connecting verbally, using still images you can both collaborate on. The recent film Stutz, produced by Jonah Hill, is a testament to how powerful formulated drawing can be in therapy.
7. Innovate with multimedia. Share screen and experiment with making your client the host. Play pre-downloaded multi-media, psychoeducational videos, meditations, photos on a slide show. If you’re working with children, you might want to draw online, play a game, or explore the avatars and apps for fun together instead of talking.
8. Try a different browser. Whether it’s Chrome, Firefox, Safari, or any others, it’s a good idea to update the software you are using and, if necessary, try a different web browser, to see if the connection is more reliable. Do this in advance of the session and remember to troubleshoot so you optimize the signal from your end first.
Online therapy has opened up opportunities for many therapists and clients in caring, parental roles, or with disabilities and health conditions, to deliver and receive therapy from the comfort of their homes. It’s important to problem-solve difficulties with your internet connection as a team with your client. Come up with a plan in advance so you know what your go-to solutions will be in the moment, according to an assessment of the spaces, fluctuations in connectivity in your home, software use, and environmental factors. Message your plan for resolving the issues with your client in a chat or text message as you are about to action it, so your clients know what action you are taking from your troubleshoot, and where, for example, to find your new video link.
Ultimately, it’s easier for a client to disengage online. As a gesture of goodwill, you might consider offering a discounted or free session in the future, to support your therapeutic alliance, and improve your re-booking rates.
References
Andrews G, Basu A, Cuijpers P, et al (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. J Anxiety Disord. 55 :70-78.
Wagner B, Horn AB & Maercker A. (2014). Internet-based versus face-to-face cognitive-behavioral intervention for depression: a randomized controlled non-inferiority trial. J Affect Disord. 152-154: 113-21.