Therapy Online: On Seeing and Being Seen

​My first therapy job in the UK began during Covid, when we were all seeing each other exclusively online. Being camera-shy all my life, I was secretly horrified to realise that my practice now involved speaking to people through a video camera--to be honest, I nearly chickened out right then. The idea of sitting in front of a camera, talking to someone else who's sitting in front of a camera--it seemed utterly bizarre. And on top of the weirdness of being so divided by geography and virtually brought together by technology--I wasn't at all certain that online therapy could work at all. I had deep misgivings, but needs must, and I decided to give it a go.
Nearly five years later, doing therapy online is second nature: 15-20 minutes before a session, I scan my notes and have a little think, move the laptop to the desk, cue up the email with the link in it, make sure the phone is on Do Not Disturb, adjust the webcam and light and login to the meeting. The client arrives; we fiddle around with our sound for a few seconds, and begin our conversation.
It does "work". It's not the same as being in the room together: I wouldn't say one way is better than the other in terms of connection, conversation or outcomes. The ways are different, certainly.
One thing I noticed is that, in the absence of seeing each other from top to toe, both the client and I pick up on facial and voice cues with more sensitivity: with practice, and knowing each other, micro-expressions can have the same impact as, say, throwing a cushion across the room. And it works both ways: I might say, "I notice you smile when you're telling me this difficult thing," and someone might say to me, "Your eyes just changed: I think I know what that means." We're not only noticing micro-expressions; they become part of the conversation, and deepen the ways that we know each other.
One of my first projects during Covid was to lead groups of students and their tutors from a local college: the counselling centre had contracted to provide online wellbeing sessions. Remember--I was still new to working online. I found in the groups that many students didn't turn on their cameras. Even worse, some of the tutors wouldn't turn theirs on, either! I found myself speaking into a black void, and if I was lucky, someone might respond to a question and let me know there was someone actually out there by a sigh or occasionally, a laugh.
My suspicion was that, as students (and tutors)  didn't have to prove they were paying attention, many put the laptop on, crawled back into bed and spent the hour scrolling on their phones. It felt awful to talk and not know if anyone was listening. People's names showed up in the sidebar when they logged in, so, in theory, at least. people were attending. And when I asked a question of a particular person, their voice would come out of my speaker with an answer. But not seeing anyone whilst knowing they could see me was disturbing to me--even distressing. It seemed unfair, rude even--and it made me cross.  And the sense of anger and injustice arising in me made me curious. Why did it bother me so much?
Therapists who study attachment have found that when an infant's mother doesn't respond to her child--looks at the baby with no particular expression and ignores the baby's invitations to engage--the baby first tries harder, then very soon becomes distressed and despairing. This all happens in about a minute--that's how finely tuned we are. We need to be seen by our mums, and we need to know we are seen. We need that feedback, or we quickly lose hope. 
The problem with a meeting that lets people attend without being on camera is that, although they can see other people, they can't be seen. For many people, that's the wish: to be able to see others and remain hidden. After all, if others see us, they will quite possibly judge us--and find us lacking. (I'll mention here that many times at the start of the session, the client and I are both not only adjusting the sound, but, suddenly aware of being seen, are fiddling with our hair.)
What we think we want is to see whilst staying safe from the eyes of others. Voyeurism--the word is usually pejorative, with all sorts of undertones of sex and control and power--but we can also see it as the wish to see without being exposed ourselves. To some extent, we all have that wish to remain safe, our flaws hidden. For some, it is as strong as the wish to belong: they try to be part of the group without risking actually being seen.
And it doesn't work. We become bored, lost, alienated.
It's not only about the unfairness of seeing others when they can't see you; what is crucial about belonging is that not only do we need to be seen; we need to feel that we are seen by others. Without knowing we are seen, without that feedback of another's eyes on us, we are like the baby whose mother doesn't smile back: we are lost and alone. But as adults, we may not know that on the top of our minds: the need we first experienced in infancy lies buried under layers of experiences and fears about what it is to be seen and possibly judged, and even about what we actually need versus what we think we want. 
In the middle of the night when she wakes up crying, a baby can be held, even in darkness when she cannot see her parent's face. She can smell the unique scent of the person who holds her. As adults meeting online, there are only two points of connection: video and audio. We can't even shake hands online: in the absence of touch, we are even more adrift. 
So, the reasons to be visually present when working online are several--. 
it's polite, yes. It's fair. It's reassuring to the people you're meeting with, as they know they are being seen by you--it nourishes the part that from birth needs the feedback of another's gaze. And by the same token, the thing you may think you don't want, that doesn't seem worth the risk of showing up--is actually the thing you need at a level so deep you may not even recognise it as a need. 
To belong, we all have to take risks: there's no free ride. The payoff is when you know someone is not watching you, but seeing you, and the ways that seeing leads to knowing. As infants we need to be acknowledged and brought closer, as adults we need to feel that someone else is interested in knowing us. Online, that takes the form of looking into another's face and knowing they're looking back. In therapy, research shows again and again that it's not the type of therapy you have that makes it work: it's the relationship between the therapist and client that makes the difference. Being known and accepted, and knowing and accepting in turn create powerful healing. Inside, we're all still the infant who needs to connect with someone who cares. To do that, we have to see them seeing us.
​It didn't take me long to draw a line with the online groups: you had to turn on your camera. In those early days of Covid, no one had really worked out the rules for living together online, but in the intervening years, I think we've all come to some understanding about how to work together online. We have our setup rituals, backup plans for when the internet lets us down and moments of unexpected delight--as when a random cat wanders across someone's keyboard. Sitting in a room or meeting online, we make the time and take the effort to know each other, to belong in that time to each other. Whether we're in the same place or not, the way we see and are seen by each other--that's what nourishes and sustains us: that's where the magic happens.