From the Neck Up

“Hi. I’m Laurie. It is so nice to ‘meet’ (fingers doing air-quotes) you.” I seem to have said this to a new face on my computer screen umpteen times since March when I began conducting virtual-only psychotherapy due to Covid-19. This electronic introduction is always a little odd for me; I can’t imagine how nerve-racking it must be for a new client, especially a child or teen, who is already very nervous about the whole therapy process.

As is my usual, I am my silly self at first to help the person on my screen feel more at ease. I assure them that this is also a little strange for me to meet someone on screen, so if they are feeling weird or nervous it is completely normal and expected. I do my best to create a comfortable environment, as a first-time therapy appointment even in a warm, cozy office can often be intimidating and overwhelming. Sometimes I wonder if there is a little relief in talking to me from the comfort of their home. Teenagers especially who are cocooned in their rooms may relish the privacy and familiarity of their bed, desk, or beanbag which can settle the nerves a bit.

Whenever I meet with anyone under eighteen I need to have a parent present for part of the first session to review procedures and confidentiality. In these cases when the screen goes live, I am met with both the client and the parent. There is always the finagling of the screen to make sure everyone is in view as well as volume checks and adjustments before we settle in to become acquainted. The first several minutes are a crucial part of the first session, but now even more so as I want to assure and help them to become as comfortable as possible.

The good news is that despite these hurdles, virtual therapy has been working very well. I am amazed at how connected my new clients seem to be feeling even though we have never met in person. I have noticed that each subsequent session the client leans in more to the process. A normal practice of my therapy is to check in with a client during the second session. I ask how they felt after their first session, what if any, thoughts or feelings about therapy came to mind throughout the week and how they were feeling about meeting again? I find that this gives me insight into their initial feelings about the therapy. Do I need to move slower? Adjust my tone? Build more rapport before delving into the heavy topics? There can be subtle clues as we review their first session. On-screen it can be a bit trickier; eye contact can be fuzzy if the camera isn’t clear and there are often poor connections that interrupt what someone may be saying. So, although I continue this check-in routine, I am more tentative than had we been having an in-person session.

There have been sessions where I do miss pieces of the puzzle due to the fact that we are online. One mom was describing her pre-adolescent daughter’s school experience. She was talking about the daughter’s peer relationships and some of her struggles both during Covid and pre-pandemic. Out of the blue, the mom said to me “My daughter is 5’7”. I am 5’10” and her dad is over six feet.” I am positive I went wide-eyed with my jaw dropping as the mom went on to say that this is something I certainly wouldn’t know by meeting on screen. We both had a good laugh about the peculiarity of this mode of therapy and mom went on to say that being so tall in elementary school is a unique challenge for her daughter.

Another young teen with body image issues was sharing her struggles with both restricted eating and her desire to be “skinny”. As is always the case with this population I emphasize inner beauty over outer features and strive to re-focus the attention on personal strengths aside from how one looks (and as is usually the case with these young girls, they roll their eyes at me and return to how many calories they consumed that day). I digress, this is not an expose’ on the merits and challenges of eating disorder treatment, but rather to say I honestly had no idea what this young woman’s body looked like. And, not that it would make much of a difference in the treatment, but needless to say, it is informative to know whether a client with disordered eating tendencies is under, over or average weight.

Recently I met with a teen who is confused about gender identity. She is exploring these complicated feelings and bravely shared her thought process. She mentioned that “certain pants are more masculine, like the ones I am wearing right now.” Uhm, hello…I am seeing you from the neck up, thinks the ever chatty voice inside my head. Although there were many jokes early in the pandemic about people wearing shorts and suit coats on Zoom meetings, it would have been telling had I been privy to more than just what the screen allows.

I have thought a lot about these moments and wonder how many other therapy misses are occurring due to the limited visibility of virtual therapy. I wonder about all of the medical telehealth visits and how the physician can accurately assess the patient without taking a pulse or feeling for whatever it is that they are feeling for when they poke and prod away at my less than firm abdomen. I feel fortunate that psychotherapy is relatively successful via the screen, especially when I think of my masseuse friends and other personal care businesses like nail parlors and beauty salons who were unable to work early on when many businesses were shut down.

From the neck up is working. It is not perfect and many internet interruptions are necessitating a reboot or change of viewing platform mid-session, but overall, I am confident that the services that I am providing are, indeed, helpful. Many a time the smile that I see on my computer or the heartfelt thank you before we sign off reminds me that my clients will feel a little bit better once the screen goes dark.