Aspects to consider for online therapy

According to data from the Online Psychology Barometer (Mundopsicologos.com, 2021), around 95.30% of psychology professionals offer online therapy. As in other professional fields, the pandemic had an accelerating effect on the remote therapy modality, considering that in 2017 only around 52% of therapists provided this type of digital service. In the field of health psychology, the adaptation of these professionals to the new reality has meant a cultural and operational change, and online therapy services have increased substantially and are now in great demand. 

What are the differences between face-to-face and remote therapy?

To answer this question, we should remember that, in remote therapy, the technology, the environment, and the factors associated with the client and the therapist's skills are different. Below we will review some aspects to be taken into account by psychology professionals in order to enhance their work in online therapy:

Technology

• It is sometimes taken for granted, but not all digital platforms are suitable for video calls and do not meet the requirements of encryption and privacy to carry out online therapy with guarantees. In the population, it has become widespread to "do a Skype" (commercial brand), but as a professional, you must ensure. 
• It seems obvious, but we must have computer equipment that supports video calls with quality. In addition, the internet connection and coverage must be strong so that no interruptions or loss of connection could harm the therapeutic alliance with the patient. Seeing one of the actors in therapy frozen or moving slowly on the screen generates discomfort, even anxiety and feelings of poor service, regardless of who has the connection problem.
• Do not experiment in the middle of a therapy session. Try out the video call platform beforehand and familiarise yourself with its options and possibilities (e.g. audio, backgrounds on the screen, sending files, watching videos, etc.). Everything takes learning. We are psychology professionals, but when we do online therapy, we must have a minimum of technological skills. Be comfortable and confident in using the various technological resources available to us. Take it slow and practice in advance. Each platform has its particular logic and functionalities.
• For greater privacy and intimacy, there are currently headphones on the market that isolate sounds very well and give you great comfort in online sessions.

Environment

• It is common sense, but choose an office or room where you will not be interrupted, especially if you do it from home. Take care of lighting aspects to provide a correct service. Pay attention to a background without distractors or an annoying spotlight. Lighter, softer colours may work better for moods than darker colours. Hearing outside sounds, closing doors, other people talking, footsteps, or heels can disturb privacy and trust with the patient. Equally, the person receiving therapy should be in a place with sufficient privacy and the security of not being interrupted or overheard.
• Choose an ergonomic chair in which your posture is natural and comfortable. Long hours of sitting in online sessions can lead to musculoskeletal problems and can be a risk for sick leave. Therefore, the chair's height in line with the computer screen is essential. Risk prevention guides explain the appropriate angles (usually at eye level) and how to position your hands, spine or legs to be as comfortable as possible.

Psychological skills

• Structure the session well to reassure the patient and avoid improvisations that, in the distance, can generate more confusion and affect the quality of the therapy.
• Remember that in video calls, on the one hand, contextual information is reduced and, on the other hand, non-verbal facial communication is concentrated and overloaded. Work well on feedback and ask the patient about their well-being and whether they understand your messages well. Make them feel heard and understood. Respect their pauses and remember that silences on camera are perceived differently and can generate more significant discomfort as they feel more observed than in a live office, where a simple glance can change.
• The therapeutic alliance must be excellent, and you must cultivate it from the first minute. Explain each step and make your patient feel accompanied throughout the therapeutic process. It would help if you worked to create an appropriate climate and rapport with your client/patient. 
• Be careful with psychological techniques. Not all techniques are valid in a literal way in face-to-face therapy, or, at least, they need to be adapted to the online modality. For example, if you expose the patient to an activity with a high emotional impact, think that you will not be close enough to contain and reassure them in case their emotions and memories overflow. 

Patient

• Exposure to a camera can consume more attentional resources as we feel observed and react more to demands than face-to-face therapy, so do not be too demanding and give breaks to reduce attention. Remember that a sense of humour can be an excellent ally in reducing tension.
• Respect their times, and each person has their rhythms. Play with silence as a therapeutic resource and use much active listening.
• Try activities outside the session to complement what you have been working on during therapy.
• Some studies speak of the phenomenon called "Zoom Fatigue" (Bailenson, 2021) due to video calls, for example, with the overload of non-verbal language or a complicated interface. Therefore, remember to dose your verbal and non-verbal messages because of the high demands on the patient in this therapy modality, as although you are face-to-face, you are not in the same space.
• Depending on their availability, you can occasionally arrange a face-to-face session to get to know each other, put a face to each other and improve your therapeutic alliance.

As therapists, are we prepared and trained to provide a professional and quality service?

Throughout the general training in the University Degree in Psychology, future therapists are provided theoretical competencies to develop and successfully deal with face-to-face therapy sessions. However, online therapy is not usually treated with the same interest. For example, trying to accompany a person online with a specific problem or psychological disorder sustained over time requires specific therapeutic skills. If this is not the case, the therapist-patient relationship suffers in one way or another.

Some of the basic requirements for working in online therapy would be:

• Be friendly. Show authenticity and genuine interest in our patients, together with a good dose of kindness. If you do not achieve this, your patient will likely perceive this, affecting the rapport or psychological attunement between the two of you and the therapy itself.
• Be competent. It is not easy to provide help to anyone with a mental health problem. To advance in the process, it is more than convenient to specialise (as it is very complicated to cover all age groups and disorders), master the most appropriate techniques for each intervention, continuous recycling and supervision, which is fundamental in the profession of the therapist. 
• Being reliable. Our patients give us their trust, and we can repay them with our professionalism. Being a therapist implies that a person we do not know will tell us about their circumstances, sometimes painful situations and will be vulnerable, so we must make them feel that they are safe, in the right place and with the right person. 
• Be flexible. Not all patients need the same approach and degree of directionality in session. With experience, you will become aware of the characteristics of the patient and what they need from you. For example, with a dependent person, you will have to encourage their autonomy, so they do not repeat the pattern of dependency with you. Depending on the socio-economic and cultural circumstances, we will adapt our speech and intervention according to the patient's needs. 
• Being a good listener: active listening. Encourage and favour the patient's verbal expression to create a climate of comfort so that they can express their concerns and, in addition, pay special attention to their non-verbal communication. Give appropriate responses so that the patient feels that he/she is listened to and understood, which is closely linked to emotional validation.
• Be empathetic. It seems to be a standard skill for a person who wants to work in psychological therapy, but it is not so. It must be worked on and mastered at a professional level. Making our patients feel understood, not judged and unconditionally accepted helps to create the ideal climate for successful therapy.
• Be a therapist with a sense of humour. Used at the right moment, it can help to reduce tension and create a climate of trust and intimacy with the patient that is very favourable and therapeutic. 

As a therapist, which type of therapy are you more comfortable with, face-to-face or online?

Online therapy is here to stay, either exclusively or complementing face-to-face therapy. Sooner or later, it seems natural that we will use this modality both because of social demand, whether forced or in a period of the pandemic, or because technological advances allow us to access a more significant number of patients at any time or place.

It is an excellent opportunity for the professional who performs psychological therapy. However, online therapy requires minimum competencies and therapeutic skills that every therapist must learn before getting in front of the screen.

With experience and intense recycling, we will be polishing these online therapeutic competencies to provide an increasingly higher-quality service. Our patients will appreciate and notice our professionalism in front of the screen.