Seven Tips for Maintaining the Frame in Online Therapy

While we are in the midst of a pandemic, teleconferencing technology can be a source of both stability and insecurity in the therapeutic relationship; on the one hand, it confers the near-miraculous ability to remain connected at a safe distance, while on the other hand it upends the basic conditions under which therapy takes place, like simply being in the same room together.

When striving for continuity in the transition from in-person to online therapy, a possible pitfall is to conserve the verbal elements of therapy and ignore the rest. This is counterproductive since the nonverbal aspects of therapy have an arguably greater impact on patients, and without them words can be ineffectual. The set of nonverbal conditions that engender trust, confidence, and security in patients and allow the words of therapy to be effective is called the therapeutic frame. The following tips are meant to help maintain the therapeutic frame during this precarious time, specifically in the transition from the office to the screen.

1. Create some distance: One way to preserve a familiar and comfortable frame is to observe personal space online as one would in the office. It would feel awkward, intrusive, and exhausting to sit four feet away from a patient and stare directly into her face for an hour straight in the office, yet we do that regularly online. Perhaps we are compensating for feeling distant in other ways or perhaps we simply can’t see or hear very well. It’s ok to back up, and some technological modifications can help (see tip #3). The extra space might allow both parties to feel less self-conscious and more at ease, less focused on maintaining a perfect affect and more on the therapy.

2. Body language matters: Here’s another reason to back off the camera a bit: Expanding the field of vision to include not just facial expressions but also upper-body language (for example, hand gestures, posture, distance modulation) has been shown to increase empathy measures, according to David T. Nguyen and John Canny in the article “More Than Face-to-Face: Empathy Effects of Video Framing.” Experiment with this. Sit back, expand the visual frame, move, and gesture as you would in person—find what feels connective and go with it. In addition to camera distance, the angle matters too; if the lens is positioned at a height lower than your eyes it may appear to your patients that you are looking down on them. Stack some books under your monitor to avoid the impression of being overbearing or aloof.

3. Mind your tech: Some minor technological improvements might be required to see and hear clearly at a less awkward and more full-bodied distance from your camera. Headphones with a built-in microphone preserve volume and fidelity at any range. A high-definition camera and a large monitor enable clearer images especially from farther away. If you use a laptop, you may need to plug in a keyboard and mouse to operate it from a convenient distance. Poor internet connections are an immutable fact of life for many these days, but for others, paying a bit more per month can buy a much smoother experience.

4. Minimize gaze error: The somewhat disconcerting deviation from direct eye contact that occurs in all videoconferencing is called “gaze error,” and it results from the distance between the image of the person on your screen and the camera above it. Naturally, then, you can minimize gaze error by moving your patient’s image as close as possible to the top of your screen.

5. Keep it formal: Panning out from the technological, we consider the physical frame shift from the professional office to the home. The office setting conveys a therapeutic formality that can be lost online. An appropriate amount of formality can signal and maintain professional boundaries, which in turn establish a frame of stable and secure expectations and ultimately engender trust. Your patients (or you) might want to wear pajamas and stay in bed, but you would be within your professional mandate to demur. Dress up. Sit up. Mind the backdrop. Lock the kids out. Stick to the clock. Encourage your patients to do the same.

6. Adapt your authority: Another function of the professional setting is to clarify the leadership role; the office frame is your turf and your prerogative. Not so online. How does the dynamic shift when patients feel right at home? Perhaps they experience less paternalism and a more level playing field. Good. In contrast, they may feel less confidence in your authority, unsupported as you are by the professional edifice. The tip here is more diagnostic than curative; if you feel more challenged and exhausted in your sessions, consider whether a shifted authority dynamic is part of the altered therapeutic frame, and discern how much therapeutic authority would be beneficial to recover.

7. Own the frame: The many factors that influence the online therapeutic frame (for example, technological, social, regulatory) are in constant flux, especially in a time of crisis; some of these tips will likely be irrelevant in a few months and antiquated in a few years. To adapt, stay tuned to the collective wisdom, but also adopt your own frame-oriented approach to future circumstances. Clarify for yourself what elements seem foundational for therapy (for example, trust, confidence, security), discern what frame conditions engender them (for example, easy communication, formal cues, therapeutic authority), attend closely to the ways that the new online environment creates barriers to these conditions, devise ingenious ways to overcome them, and share your wisdom freely. ■