Between the Screens: Strategies to improve the efficacy of video conferencing by Claire Edmonds

Don’t get me wrong, I do not think the fear of the pandemic itself has improved depressive symptomatology nor reduced anxiety in my patients or in the general public for that matter. To the contrary, it clearly has exacerbated fears for a great many. What I mean to say here, briefly, is that in our professional duties we rarely have had the opportunity to enter a patient’s home. But the necessity of using video therapy during COVID-19 has allowed us this window, one that has a three-fold benefit. First, it reframes and normalizes our exploration of their inner world. Secondly, if I may generalize from my experience, it can provide the therapist with insights difficult to achieve in our more sterile office setting. Finally, it adds a comfort to the therapeutic alliance akin to a neighbour dropping in for a cup of coffee….but with a backpack full of knowledge as to how to help. Our invisible walls, during these moments, seem to vanish. Mary-Ann Saltstone has a Ph.D in Psychology. She is a Registered Psychotherapist in private practice in North Bay with her husband Rob, a psychologist. She spends her free time playing the piano, writing music for short films, walking northern trails, and playing with her three dogs, Scout, Baron and Sammy.

Between the Screens: Strategies to improve the efficacy of video conferencing.

by Claire Edmonds, Ph.D., RP

Recent studies support the use of videoconferencing as a modality to deliver a variety of psychoeducational services (Campo, Bluth, Santacroce SJ, et al., 2017; Richardson, Reid, & Dziurawiec, 2015, GonzálezOrtega, Ugarte, Ruiz de Azúa, et al., 2016; Rotondi, Anderson, Haas, et al., 2016). The global novel coronavirus pandemic has necessitated the sudden and unprecedented adoption of videoconferencing, replacing inperson meetings for everything from medical visits, classes for school-aged children, and psychotherapy. Therapists everywhere are experiencing a sharp learning curve adapting our psychotherapy practices to the videoconferencing environment.

I hope to summarize in this short paper some of the lessons I have learned along the way. Sharing strategies with one another, we all benefit as a profession. First, let’s take stock of some of the challenges we are encountering.

Challenges in individual treatment

As a psychotherapist I teach active listening skills to volunteers as well as professionals. I deeply appreciate the expertise that deep listening requires. When we listen we need to be sensitive to forms of expression such as timbre, tone, intonation, the rapidity of expression, breathing, gaps, pauses, and force. We are also aware of how the speaker presents to us, whether they are groomed, their posture and mannerisms, their general presentation and other impressions they give us. At the same time we are taking in a myriad of other non-verbal cues such as eye gaze, the tapping of a foot, or hand gestures. We are also highly attuned to the muscles of the face, particularly around the eyes and mouth that express subtle feelings like impatience, frustration, fear, anxiety, disgust, disdain and grief. Overall impressions emerge, including engagement, disinterest, and truthfulness. When there are more than two people in the conversation, the skilled listener is also gauging the interactions in the room, who is aligning with whom, who is a leader, who is a follower, who is an external processor (speaking before ideas are fully formed), who is an internal processor (more likely to express fully-formed ideas)), and who is influencing the group process, that is, setting the tone. Together these cues, many of which are picked up at an unconscious level, create a gestalt or complex picture of the whole situation.

What happens when the richness of all these interactions are channeled through videoconferencing? We lose a great amount of information, especially body language. It has been estimated that non-verbal cues comprise 80% of the information a skilled listener relies on(Young, 2009). In place of that wealth of information we are left with faces in little boxes, like the opening title to that 1960’s sitcom, The Brady Bunch. I have worked with psychoeducational groups as large as 30 people where the faces are about the size of postage stamps and cover two pages so that I have to scroll back and forth to view all the participants.

The image feeds we see are also subject to freezing and cutting out. Sometimes clients are frozen in a frame, looking very much like the face in the painting, The Scream, by Edvard Munch. A few seconds of interrupted video can feel like minutes, during which we are in the dark as to our client’s experience. When the feed reconnects we may be tempted to interpolate, that is assume what the client has said in the meantime, because asking them to repeat themselves can break the flow of their process. Our client too, may be embarrassed or uncomfortable to ask us to repeat ourselves after a break in the feed. Pauses in conversation can feel less spacious and more pressured. The client and therapist have to work not to interrupt one another. With some clients this comes more easily than with others.

As humans, we are uncomfortable with incongruence, meaning a discrepancy between various sensory inputs. Think about how difficult it is to watch a poorly dubbed film when the actors’ mouth movements and facial expressions are out of sync with the dubbed voices. We want to see, hear and perceive congruency in order to easily process incoming information.

Then of course there is the challenge of being conscious of a camera pointing at our faces, unrelentlessly highlighting every feature that we don’t like about ourselves. We may sometimes become so distracted by our own image that we forget that it is only when we look straight into the camera that the viewer feels that we are directly speaking to them. We must therefore manage our output, in terms of our own performance and self-presentation, not just the input from the participants.

Further, clients coping with post traumatic stress disorder (PTSD) experience depersonalization, dissociation, numbing and nightmares, disturbed sleep as well as flashbacks (Van der Kolk, 2014). In my own work, people coping with cancer often have symptoms of trauma to a varying degree. When clients with trauma feel triggered, they may respond by ‘zoning out’, or depersonalizing, in order to defend themselves from feelings of terror. In face-to-face sessions, therapists can be aware of when a client depersonalizes, or has a panic attack and we can gently help them return to the present and focus on the moment. On screen it can be difficult to discern if a participant has depersonalized and requires the support of the therapist to down regulate. 4 In group therapy, the facilitator is responsible for managing the overall process, identifying feelings that may be emerging in the group often unbeknownst to the participants, slowing down or speeding up the discussion and querying participants as to their understanding of the group’s proceedings and using multiple techniques and metaphors to explain concepts.

With online group meetings, however, this process is interrupted. Smooth interchanges between groups of people rely on a variety of cues, both physical and verbal, that create a rhythm to the discussion. This is harder to attain during videoconferences. Traffic control becomes the priority. Each participant needs to remain on mute except for the speaker, because the ambient sounds of their environment are distracting for the participants and can obscure what is being said. Thus, each person must unmute their microphone when they talk and then re-mute when they are finished. This process can be cumbersome even with experienced users. There can be awkward silences as the host tries to elicit comments. The natural flow of conversation is replaced by a stop-and-start effect with the unwieldy management of microphones, particularly when the technology is new to participants. All of this leaves facilitators juggling to best interpret what people are saying.

Notwithstanding these many challenges in the use of videoconferencing, my clients and group participants have given high ratings in their feedback. This is supported by the high attendance that we continue to see over 8- and 10-week programs. Clients who are in active medical treatment express appreciation for being able to attend online when they feel too unwell to come to the centre. On occasion they may not turn on their cameras so they are able to listen without worrying about how they look. Even when we experience technical difficulties the participants express their gratitude that we are trying to bring them support during these times of uncertainty due to COVID-19.

Certainly, as a facilitator, I prefer to work in-person; it is a far easier and smoother process, with the added dynamism of spontaneous group engagement. Yet, as nonprofit providers acclimatize to post COVID-19 fiscal constraints, they may be less inclined to have brick-and-mortar offices with all the expenses that they incur. Online programming may be able to reach many more participants on the fraction of the cost as in-person groups. Given these possibilities, it is up to us to adapt to this brave new world.

Here are some of the strategies I have found useful and can suggest to you when working online:

• Be mindful of developing an alliance with your client by replacing the in-person contact with purposeful and intentional connection through the video. Look straight into the camera when addressing a client so that it appears you are looking straight at them. Speak to them specifically by using their name, e.g., “Lesley, I’m so glad you can join us. I imagine that this might feel like a new experience to you. I am here to guide you and support you through today, please let me know if there is anything I can do to help you feel more comfortable.” Remind participants about confidentiality, that they need a quiet room that is private with a door so the comments and identities of other group members are kept private. Also, some online platforms use a waiting room feature in which you can identify the members you let in, and so no strangers are allowed into the group.

Headphones can be helpful to enhance your concentration as a facilitator, and may be more comfortable than earbuds.

Using breakout rooms where smaller groups meet on their own is useful for more intimate discussion. I prefer groups of three to four, and I ask one person per group to watch the time and ensure that everyone has an opportunity to share should they wish.

The message function can be helpful, but I find it difficult at times to manage the messages, the group, as well as the content, so I often ask people to raise their hands to speak rather than use the messages. Messages can also leave some participants out of the loop, especially if they cope with any visual impairment. On the other hand, younger adults and adolescents may be more comfortable with the message function, and that may encourage their participation. So, get to know your group.

Speak slowly and clearly, more slowly and clearly than usual.

Be aware of your facial expressions. I smile more and look clearly into the camera, then back to the faces on the screen. It is more effortful than in person, because our natural charm, that we communicate with body language, will be missing.

Zoom fatigue is real, be aware of your energy level as you work online. I do my large groups posttreatment young adult cancer survi25(6):1759-1768.

in the morning and leave my individual clients (online) for the afternoon, after I have had a chance to restore my energy.

Additional challenges and suggestions for providing online training

As a trainer for oncological psychosocial interventions with professionals and volunteers, I find that online training sessions require much more input from me as the leader. Some participants become passive when facing a screen, perhaps because of the privacy it affords or simply as a consequence of its similarity to entertainment viewing. I have taken a variety of different tactics to encourage participants to actively engage. The most effective strategy has been to use the breakout room option on Zoom, giving each small group several questions to tackle together and then to report back to the larger group. I have also alerted the group to our expectations that we “co-create” our sessions, and that everyone’s experience, questions and comments are helpful to our process. Should the group continue to be passive, I may then directly Pearson Education Inc., New Jersey.

challenge them to engage, call on people by name, use light humour (all I hear are crickets out there!), or allow for silence to encourage members to “pop up” with their comments.

In conclusion, there is a wealth of knowledge and expertise being developed by psychotherapists as we make the transition to online modalities. We need a forum to share our ideas and insights with each other, so none of us are Campo, RA, Bluth, K., Santacroce SJ, et al. (2017) A mindful self-compassion videoconference intervention for nationally recruited vors: feasibility, acceptability and psychosocial outcomes. Supportive Care in Cancer,

González-Ortega, I., Ugarte, A, Ruiz de Azúa, S., et al. (2016) Online psycho-education to the treatment of bipolar disorder: protocol of a randomized controlled trial. BMC Psychiatry 16:452.

Richardson, L, Reid, C.,& Dziurawiec, S. (2015). “Going the Extra Mile”: Satisfaction and Alliance Findings from an Evaluation of Videoconferencing Telepsychology in Rural Western Australia. Australian Psychologist, 50:252–258. Rotondi, A.J., Anderson, C.M., Haas, G.L., et al. (2016) Web-Based Psychoeducational Intervention for Persons With Schizophrenia and Their Supporters: One-Year Outcomes. BMC Psychiatry, 16:452.

Van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma, Penguin, UK. Young, M.E. (2009). Learning the Art of Helping (4th Ed) left to invent the wheel on our own.

About the Author

Claire Edmonds earned a Ph.D. specializing in psycho-oncology from York University. She worked for over 20 years at Princess Margaret Cancer Centre as a clinical researcher in the Healing Journey Program. As a Registered Psychotherapist, she now works at a variety of community cancer organizations, including Wellspring and the Canadian Cancer Society where develops programs and trains professionals. Claire has also coped with cancer herself, which has profoundly deepened her understanding of the cancer experience. She has a small private practice in Toronto, where she happily lives with her husband.