“‘Curiouser and curiouser!’ cried Alice (she was so much surprised, that for the moment she quite forgot how to speak good English); ‘now I’m opening out like the largest telescope that ever was!’”
—Lewis Carroll, 1865

One day in therapy, I started crying as I recounted the time I danced in the parking lot of my mother’s long-term care facility. I had been trying to make my mother smile while she spoke to me on the phone and watched from the window above, but she waved longingly for me to come up. Her memory was deteriorating rapidly, and she didn’t understand that the precautions imposed by the pandemic would prevent me from being in her presence for months.

I was not crying copiously, but enough to reach for a tissue. Oh. I halted, hand hovering in midair as the realization caught up with me. My therapist didn’t have his tissues. Or, at least, I couldn’t access them where he was, somewhere across the city in an unfamiliar home office. For the first time in years of psychoanalysis, we were connecting by video conferencing.

I spied an almost spent roll of toilet paper near me, a few sheets stuck to the glue of the cardboard. I peeled them off, dabbing at the moisture in my eyes before it ran over. By the time this pandemic is over, I said, my mother may no longer remember me at all. So many newly distorted connections. In that moment, as I spoke with my therapist, I was a patient learning what it means to share your thoughts and feelings through a webcam.

The experience came through the looking glass with me as I faced Margo (not her real name), my next patient, later that day. I peered into her living room, which she shares with her cat. You see, I am also a psychiatrist, and I help lead the virtual mental health program at the Centre for Addiction and Mental Health, in Toronto.

This was Margo’s first virtual appointment with me; before COVID-19, our sessions were always done in person. Her microphone was not working. At first bemused, she became unsettled and then frustrated as she tried to communicate in exaggerated gestures. She could hear me. I urged her to restart her computer, but a panicked look crossed her face. (She later said she was worried about losing time during the appointment.) “Don’t worry,” I reassured her, only half joking, “I’ll still be here.”

As I waited in the intervening chasm, I wondered, What does being here really mean? I knew from previous experiences with Margo that even this brief missed connection, the fading of my face from the screen, had the potential to awaken long-buried feelings of abandonment. Even as we connected across the digital divide, I could still feel for her, her discomfort, her uncertainty.

For eight years, I have led the development of virtual care as a means to create access for patients in underserved communities, mostly in rural and remote areas in northern Ontario and Nunavut. With my colleagues Gillian Strudwick and David Wiljer, I have been studying the ways that compassion in health care is translated into virtual care. The first two papers we co-authored on the topic were published just before the pandemic. We never expected that our work would be put to the test as quickly, and at such a massive scale, as it has been over the past few months.

Since the start of the pandemic, we’ve expanded from 350 virtual visits per month to almost 6,000 per month. At the same time, I, too, began experiencing virtual care as a patient. Everything I thought I knew about virtual health has been upended as I’ve navigated relationships on both sides of the screen—as a health care provider, as a patient, and with myself. As much as I thought I’d be prepared for such a moment, I’m discovering how much there is still to know about how we display, read, mirror, and respond to emotion across digital media. What’s surprised me most over the past few months has been experiencing for myself what our research had already shown: that, even at a distance, emotional connectedness and compassionate action are still very possible. Virtual therapy at this unprecedented scale seems to be working—for now.

Therapy requires ongoing observation not just of what a patient is saying but of their body positioning, facial expression, and tone of voice, among other things. Technology can distort and interrupt nonverbal communication, making it harder for us clinicians to read our patients—and for our patients to read us. Therapists haven’t yet found a way to talk about the effect of technical glitches, either in research or with their patients. I have encountered these disruptions on both sides of the screen—faces freezing in distorted emotional expressions, hearing my voice echo oddly on the other end of a bad line, the havoc of talking over each other that a slight delay can unleash, appointments interrupted in both banal and poignant moments. I’ve become aware, as I’ve tried to coach Margo and other patients through technical difficulties, that the digital format requires me to assume a new role—as a more directive and informative guide but also as a source of potential frustration when I cannot resolve the problem. This failure could have real impact, such as less time to meet or an inability to connect at all, whether technically or emotionally. This added pressure may be one of the factors in the strain that some are calling “Zoom fatigue.”

A more systemic failure to connect happens for some patients who, because of poverty or other structural inequities, lack not just the technology or internet connection but also the privacy to access virtual care. Patients who live in shared spaces worry about being overheard; some prefer to call in from their cars for that reason. For those who have experienced cyberbullying or exploitation online, feeling vulnerable in a virtual space can be painful or traumatic. And many patients have privacy concerns about sharing personal information online.

Compounding these technical challenges is the question of what happens, in virtual sessions, to the experience of shared emotion between therapist and patient. How important is the therapist’s physical presence in helping patients learn to manage intense or overwhelming emotion? I know that, because Margo and I have developed a strong sense of our relationship in person, for example, I am able to push a little during our virtual session as she recounts an episode with her sister. I tease her in a familiar way to have her contemplate her sister’s perspective alongside her own. Even over the computer, I can sense her bristle, see her roll her eyes at me and then grin as she ruefully acknowledges another perspective. But would I have read her response, her emotion, correctly if I hadn’t already spent so much time in her physical presence? Could she, similarly, have found reassurance in my gentle teasing?

I’ve asked myself the same questions in my own therapy. I had initially dreaded connecting virtually. I found the close-up, face-to-face frame of the video intrusive. There were changes to our expected space and routines: I had grown used to the flow of moving from my therapist’s waiting room to his office to his anteroom; used to the positioning of and distance between the furniture in his office; used to the quiet and privacy; and used to the ritual moments of greeting and goodbye that began and ended each session. Instead of the room we have met in for years, I now look at what I imagine must be his home. There is a closed door in the distance, and I am acutely aware of a life beyond it. I can see the clock on my computer screen when typically only he would see the time. Instead of getting lost in the reflective space of each session, I find myself monitoring how much time we have left.

I cannot read the same cues that were familiar in our in-person sessions. My therapist has this habit, for example, of pushing his feet into the floor. I am usually aware of this and read it as a sign of impatience or frustration, one that I usually take to mean I am stuck or preoccupied rather than moving forward. It is a useful sign, one that I can receive as part of his overall compassionate stance toward me. It is genuine. Meeting virtually, I can see only his shoulders and head. I stare at him straight on. I am aware that the “gaze” I read is an illusion. We are both looking into a camera, which if angled just right gives the impression of eye contact. Yet I experience unanticipated compassion and connection. In the moment when I am tearful about my mother, for example, I see him lean in. He exhales a small empathic sigh, and I feel the care, acceptance, and connection that’s become familiar to me over the years.

There is some research exploring the quality of the virtual relationship, and it generally shows that patients rate their online relationships with health providers as highly as they do their in-person relationships, although health providers do not. It is not known whether this is because health providers like the experience of virtual sessions less than patients or because they know more about what factors are important for establishing a trusting and beneficial alliance in therapy.

There are many theories to account for how change occurs in psychotherapy. A relational perspective, which understands change and growth in the patient as occurring within the relationship with the therapist, highlights what psychotherapy researcher Daniel Stern calls “moments of meeting.” In these moments within therapy, the therapist and patient connect in an authentic way in the present moment. According to Stern, this sharing results in a new state of mind and being for the patient and can also affect the therapist. I have been surprised that these moments have continued with my therapist despite our transition to online care. In these moments of meeting, the reality of our separate locations disappears.

But my therapist’s ability to respond empathically to my tears, his generosity of understanding, our shared laughter over some new strangeness or absurdity, all of it builds on what I know from having been in the same room with him over years. How will this relatedness—the compassion, the moments of meeting—flourish in space that is increasingly virtual, where patient and provider never meet in person? I find this difficult to answer.

Some clinicians say we should pay attention only to the reduction of the symptoms that people come into therapy with, in which case most evidence, such as through clinical questionnaires that assess symptoms, shows that video-based therapy is not inferior to in-person therapy. To me, that view of success is partial because the therapeutic process itself can add meaning to many patients’ lives and is something that they can hopefully continue to draw from long after the therapy is over. The legacy of this recent massive shift into virtual realms, and the impact on the therapeutic relationship, will likely become clear only from a vantage of several years.

Several months into my virtual psychoanalysis, a dream I’d had finally made sense to me. The dream had occurred within a few weeks of our new online appointments. I’d told my therapist that I had a dream about an “unknown man.” This man seemed like a person I had an intimate relationship with, yet I didn’t recognize him. In the dream, I approached him with blue surgical gloves on. I felt a sense of unease and also of uncomfortable intimacy. He was lying on a couch and had sores on his body that I was supposed to examine, but I cringed both at the thought of this intimacy and at the thought of hurting him.

Perhaps unsurprisingly, I now understand that I was dreaming about our uprooted therapy. In the days before the dream, I had offered my therapist unsolicited advice about getting set up for virtual therapy. In my “expertise,” I had unsettled my usual way of relating to him, more doctor than patient. As much as I was uneasy about meeting virtually, I also imagined that this new setup was uncomfortable for him. In order to ensure better privacy, I had set up a desk in a nook in my bedroom, and although my bed was not visible on camera, I was all too aware of new frontiers of intimacy as I intruded into his home and he into mine.

The other day, I found myself picking up my phone spontaneously during an appointment with him to read a poem that had moved me. This impulse belied my earlier self-consciousness. I found myself caught up in a moment, feeling the deep, embodied resonance of the poem shared while also suddenly laughing with him at the absurdity of holding up my phone for the two of us, on our separate computer screens, to gather around. My “new normal” in virtual health care still feels entirely strange and disorienting, but although it is “curiouser and curiouser,” as Alice remarks in Alice’s Adventures in Wonderland, “it’s no use going back to yesterday, because I was a different person then.” I am one of many therapists wondering how this new way of meeting contributes to their own identity and satisfaction as a therapist as well as how they can sustain their own wellness through virtual practice.

At the end of a long day, the numb feeling of being Zoomed out sets in. Despite all of my scheduled encounters, traversing great geographic distances across multiple contexts, I have remained largely unmoving, in a chair, my body receding. Out of a desire to be there, over the past few months of the pandemic, I have been virtually available to patients and colleagues all the time. I hear other colleagues talking about how exhausted they are providing virtual care. As research and our own experiences have taught us, becoming exhausted and burning out can wear away our compassion for others, leading to so-called compassion fatigue.

As part of a strategy to sustain myself, I have adopted a practice of bringing mindful and compassionate awareness to myself before I enter a virtual space. I take a few meditative moments to notice my body, to feel my chair and the floor, to focus on my breathing. I take off my shoes so that I can enter softly and with an open heart. My patients can’t see my bare feet.

Allison Crawford
Allison Crawford is a clinician scientist at CAMH and the founding director of HeART Lab (healthequityart.com), at the interface of technology, health, and the arts.

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