Telepsychiatry appointments (eg, video conferencing) initially replaced face-to-face outpatient encounters during the first phase of the COVID-19 pandemic. However, as offices reopened for in-person appointments, many patients still prefer “virtual” appointments. Telepsychiatry allows for easier delivery of mental health services, including psychotherapy, and may become the new normal.
Although therapy conducted via video conferencing allows you to connect with patients at a safe distance, it alters the basic conditions under which therapy occurs, such as being in the same room.1 While focusing on preserving the verbal elements of communication, you might inadvertently forget the nonverbal elements, which at times might render your words ineffective.1 The main elements of nonverbal communication are facial expression, gaze, posture, gesture, and proxemics (ie, how much space you take up, and your distance from others).2 The following tips can help you preserve the nonverbal elements of communication when conducting telepsychiatry sessions.
Reduce gaze error. Gaze error is the deviation from direct eye contact that occurs during video conferencing. It results from the distance between the image of the person on your screen and the camera above it.1 Gaze error can muddy intended cues and communicate unintended cues.2 Examples of gaze errors include downcast eyes (the most common gaze error), sideways gaze, or gazing over the person’s head.2 These errors can communicate social deference, evasion, insincerity, or even boredom.2 To lessen gaze error, move the patient’s image as close as possible to your camera.1 In addition, avoid looking at yourself on the screen; some video conferencing platforms allow users to hide their self-view.
Create distance and incorporate upper body language. In the office, sitting very close to your patient and staring directly at their face for an hour would be awkward and intrusive.1 Doing so online is no different. While you may be tempted to move close to the screen to compensate for feeling distant or having difficulty hearing or seeing your patient, you should back away from the camera. Doing so will help both parties feel less self-conscious, more at ease, and more focused on the session.1 Backing up from the camera will allow patients to see your upper body language (eg, hand gestures, posture) as well as your facial expressions.1 Empathy improves when patients can see your upper-body cues.2 Keep in mind that the angle of your camera is just as important as the distance. For example, if your camera is positioned so that it is looking up toward your eyes, patients may perceive that you are looking down at them.1 This problem can be remedied by stacking books under the monitor to raise the camera.
Be aware of your facial expressions, posture, gestures, and proxemics. Ensure that your face does not go slack when you are listening to patients talk.3 Just as you would do in person, a slight head tilt and occasional head nod lets patients know that you are engaged and actively listening.3 Maintain an open body posture by keeping your feet firmly on the ground and putting your hands on the table in front of you.3 Lean in when patients share intimate information, just as you would in person. Avoid hunching over the laptop/keyboard because this could make you seem tired or tense.3 Pay attention to your arm and hand movements so that you do not exaggerate them.
Maintain office professionalism. The office setting conveys a therapeutic formality that can get lost online.1 As tempting as it may be to conduct online sessions in pajamas or sweatpants, continue to dress as if you were in the office. Be mindful of your backdrop, set all cell phones to silent, turn off your email alerts, and lock the room.1,3 Stick to the clock as you would in the office, and encourage patients to do the same.
Minor technological improvements—such as headphones with a built-in microphone, a high-definition camera, a larger monitor, or a faster internet connection—might be needed to improve your nonverbal communication during telepsychiatry sessions.1 Although this is not an exhaustive list, these tips can serve as a starting point to ensure effective communication while you are physically distanced from your patients.