The Surprising Intimacy of Therapy Phone Sessions - Daniela Gitlin 30 Jun 2020

I’ve been working remotely since the middle of March. While most of us seem to be using video chat programs such as Zoom, Facetime, or doxy.me, I find video so inferior to phone contact, I’m not using it at all in my practice. Surprisingly, all my clients have refused the video option too. Why?

Obvious reasons include not having access to the internet (common in our rural community); not owning a computer, tablet or smart phone (also common); not having the skills (the elderly, the tech challenged), or simply being too ill to manage being online.

A less obvious reason, but possibly more compelling, could be this. Clients make themselves vulnerable enough when they shower and dress to come in to see me in the neutral space of my office.

Video chat takes away that safe neutrality by visually letting me into their homes, which violates their privacy and arouses a variety of trust-undermining feelings, such as of shame, anxiety, and humiliation.

“It’s a mess! I don’t want you to see it,” one client admitted. Meanwhile, I’m able to work from my office (I’m the only one there), which means my personal privacy is protected while theirs isn’t. Seeing me in my personal space wouldn’t level the emotional playing field, though. It would only be another distraction, yet another challenge to keeping the focus of treatment on them.

Many of my clients don’t have access to a delegated private space in their homes. “I can’t even hide out in the bathroom, we only have the one, and someone will need it once I’m in there,” another said. Clients can’t do their work in session unless they’re assured it’s confidential, without risk of interruption, eavesdroppers, or intruders. I believe the camera asks too much of clients.

From my side, video-chat technology destroys the intimacy required to do our sensitive work. The position of the computer, tablet, or phone camera rarely allows for reliable eye contact, which makes us both feel unsettled and uneasy. The image of myself in the upper corner is distracting: every movement draws my eyes and attention away from the client. The same has to be true for them.

The countless distortions that are a function of the way video images are digitally encoded, decoded, and adjusted cause the image to freeze, blur, and drop, and worst of all, to be out of synch with the audio. These glitches and delays scramble subtle social cues and interfere with perceptual processing. We unceasingly, out of consciousness, strain to fill in the gaps. A full workday of that leaves me exhausted, anxious, and dissatisfied. Rather than feeling connected, I often feel the opposite: isolated and disconnected.

If we must have technology in session with us, the phone approximates live contact better. The rate of speech transmission is closer to live conversation and the fidelity of sound far higher, especially from a landline, which is what I use when calling clients. Because I’m deprived of visual cues, my hearing sharpens and my sensitivity increases to subtle nuances of speech rate, rhythm and tone; pauses; and—this is really helpful—the client’s breathing. There are many more moments during the session where all my available senses are fully engaged, and it’s the same for the client.

It’s true my mind wanders more but I use the usual self-management techniques to rein it back. That said, here’s a silver lining to phone work. Thinking requires looking in. In a live session, when a client is speaking and looking at me, I maintain eye contact unless they break it. If they do, that releases me to gaze inside to think. But I still have to keep my eyes on them so as not to miss their return. Phone work frees my eyes to do what they want (they tend to wander vaguely around the room), which lets me think while continuing to actively listen and engage with the client.

Here’s an example. Betsy, 65, works as the head of social work at a local nursing home. She’s been in treatment with me for over 25 years, initially to recover from her abusive marriage. As the years passed and layers peeled away, it became clear that the source of all her symptoms and interpersonal problems was childhood trauma. Four years ago, she had a disastrous affair with a man from work.

Breaking from him took two years and the struggle ripped away her usual defenses, allowing for new insights. Enter the pandemic and remote phone work.

It took a few sessions for the two of us to establish a working rhythm. In a way, it was like being with a new client. Much more frequently than I would in an in-person session, I mirrored, reviewed, and asked for confirmation that I understood what she was telling me. Then we had a real-time a-ha moment.

“So, wait,” I said into the phone, pausing to think as I glanced around the room without seeing it, “are you saying….” I leaned forward in my chair, my attention closely tuned to her breathing,“… that this boyfriend, and the one before, and your ex-husband, are all the same kind of man?”

“Yes!” she said. A long silence ensued. I waited, listening intently to her deep, regular, slow breaths. Then, a little huff, a pause, and— “Oh my god.” Her silence was so active, it was like hearing her think. “Could it be…?” she whispered.

“…they’re all variations of your father?” I said, feeling the risk run through my body even as I let the words go.

It’s not like we hadn’t discussed this insight before. We had, many times. But there was something going on here that was new, and it was important to not miss the opportunity. How would she react? I couldn’t see her. I couldn’t scan her face or her body language. All I had was the surf-like regularity of her breath in my ear. Then, a creak, and a rustling of cloth against cloth. She started chuckling, at first low and soft at the back of her throat, then building to a full out laugh. I sagged back in my chair with a combination of relief, amazement, and fatigue.

So you see, despite the limitations, it’s possible to do transformative work by phone. I don’t find that to be true for video. Still, it goes without saying (I’ll say it anyway) contact in any form is better than none. No matter how you “see” your clients these days, do it. They need us more than ever.

Daniela Gitlin, MD, is a psychiatrist in private practice for more than 25 years in rural upstate New York. Practice, Practice, Practice: This Psychiatrist’s Life is her first book. Contact: danielagitlin.com.

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