Creating a virtual therapy office

Many therapists have at least dipped their toe into doing online sessions with clients nowadays. I have always embraced it wholeheartedly: I am an alpha geek who was an early adopter for webcasting, long before my own therapy days. Online counseling is often ideal for clients who travel, leave the area, need urgent sessions outside of office hours, or are housebound. At any given time, two or three of my 15 or so weekly sessions are virtual ones.

Online sessions are generally easy to do with a laptop with a webcam and a headset, but my project this Thanksgiving holiday was to take this a big step further: to have a real virtual “office” for online psychotherapy. A space that is warm, inviting, and feels more like a live session than a web chat. And I was fortunate to have the perfect setting: my home’s glass-enclosed living room overlooking the hills outside of Ithaca, NY, with great views and lots of natural light.

My view of the office

The client's view of the office

The results far exceeded my expectations: after investing less than $200 in equipment (in addition to my existing wide-screen HDTV and laptop computer), I now have a real therapy office where my client is visible at close to actual size on the television monitor, we hear each other at a normal voice volume, and I am sitting across from him or her in a comfortable chair taking notes. It now feels a lot like a real therapy session, for everything except the parting handshake. Here is a summary of what I did, as a recipe for creating your own virtual therapy space.

1. Interfacing your computer and TV

It helps a great deal here to have a recent-model laptop computer with an HDMI interface. Most modern wide-screen televisions have HDMI interfaces, which normally give you the highest quality picture. Equally important, HDMI cables carry both video and sound, eliminating the need for a separate audio interface.

I had HDMI at both ends, so all I needed to do was hook up a standard HDMI cable between my laptop and the HDMI 2 input on my 42-inch HDTV. Now, switching between TV and therapy is as simple as toggling between HDMI 1 and HDMI 2 on my television’s remote. If you don’t have HDMI on your computer, you may need to purchase an interface box and cables to convert from your computer’s VGA video and analog audio to HDMI, or to composite video plus audio input. Unfortunately, given the cost (often $150-200), it may make more sense to simply invest $350 or more in a basic HDMI laptop.

2. Webcam

Instead of using my laptop’s low-res webcam, whose narrow viewing angle requires sitting in front of the laptop itself, I installed a Logitech HD webcam - their top-of-the-line Pro Webcam C920 model, costing roughly $75 - that mounts on top of my HDTV and connects to my computer via a USB interface. Its wide-angle view allows me to sit anywhere in my “office,” just like a regular therapy session, and gives the client a great view of the hills outside.

3. Audio

Audio will be your biggest challenge in setting up a virtual therapy office. Why? Because of "lag." When a client speaks, there is a lag time before their voice is audible over your speakers, which can cause an echo when they hear their own voice later. The same is true with your voice if the client is using speakers.

When you both use headsets, this solves the problem by definition, because neither of you can hear the other person's audio output - however, this means that you are "tethered" to your equipment. I have found that using a combination of a high-quality microphone and low speaker volume often prevents the need for a headset.

Currently I use the integrated dual microphones included with the Logitech C920 webcam, together with the laptop speaker located off to the left of my HDTV - not the HDTV's speakers themselves. This also has the advantage of combining the webcam and microphones on the same USB port. Previously I had tried a USB-powered Samson Go Mic (a very good condenser mike), however this only worked if the mic was right next to me with a low speaker volume.

Most of the time this setup works well, and I can speak comfortably and naturally with the client while sitting in my chair. In some cases, however - for example, when the client is traveling to a faraway location and lag is an issue - I use an inexpensive Plantronics Audio 326 headset with a long extension cord to prevent lag from being a problem.

4. Cordless mouse and keyboard

Using a quality cordless keyboard and mouse – in my case, a Logitech K360 keyboard and a Logitech M525 mouse – gives me the range to sit across the room from the TV and computer and still control the therapy session from my chair. These both share the same USB controller, only requiring me to take up one additional USB port for both.

This also has the added bonus of allowing me take notes electronically during the session, with the caveat that you must use an encrypted, password protected drive or disk partition for compliance with HIPAA privacy regulations.

5. Software

Therapists often talk about having “Skype sessions,” however in reality Skype is technically no longer legal for therapy use under current HIPAA privacy regulations. (Skype has in fact always discouraged its use for therapy: its video conversations go through their servers, and they understandably don’t want the hassle of meeting HIPAA requirements.) I use a HIPAA-compliant peer-to-peer solution called VSEE that is both high-quality and free. One note: I had to go through VSEE’s settings and change the default sound output, microphone and webcam to use the HDMI channel and USB devices I added – and then it worked great!

Online therapy: the practicalities
Any drawbacks to online therapy? Just two in my case. One, online sessions are generally not reimbursable by insurance, so it is largely for clients who are self-pay or willing to pay for extra sessions out of pocket. Second, online practice is generally only legal (and covered by liability insurance) when you are licensed in your client’s home state, so my practice is currently limited to New York residents. Eventually I plan to obtain reciprocal licensure in at least a couple more places, starting with my family’s home state of Arizona.

There is a third and more subtle drawback as well: online therapy isn't for everyone. *I* think it's great, of course. But many clients have a hard time wrapping their heads around the idea of having a therapist pop up virtually on their computer or smartphone. Some prefer the richness of a real, live human interaction with another person, where you can see subtle cues of facial expression and body language. Others have legitimate privacy concerns at their end, because of the presence of partners, roommates or family members. And for some forms of therapy, such as EMDR or trauma therapy, eye contact is very important.

For my particular brand of therapy (cognitive-behavioral therapy and relationship counseling), which is very practical and skills-based, the online modality seems to work very well. And as a rule, I find younger clients who are already savvy with computers and social media are much more comfortable interacting online. So I expect the use of this approach to continue growing over time.

I strongly feel that online therapy is the wave of the future, as well as a tool to reach people who ordinarily might not obtain counseling. And with the right technology, it is starting to increasingly resemble traditional live psychotherapy. I hope to expand my own online practice in the future, and would encourage more therapists – and clients – to give it a try!

The do-it-yourself family therapy kit

I sometimes joke that when I am not busy defusing angry people on stage as a public speaker, I put myself in the middle of other people's family conflicts. But seriously, I really do enjoy being a marriage and family therapist. It is gratifying work where couples and families often move from a place of anger and pain to re-discovering one another again, with a little guidance.

At the same time, I have to be honest with you: what I do is really pretty simple. There is more science behind it than you might think. And you can do it yourself in your own relationship. Looking back on a couple thousand therapy sessions or so, I could boil many of them down into five simple rules:

1. No criticism. Ever. Really. Before my first session with a family is over, I tell them my mantra: you can never successfully criticize anyone for anything, ever. There are few less successful undertakings than trying to convince someone else they are wrong.

We all have a hard-wired survival instinct to push back against criticism – listen carefully – no matter how right it is. Get this and everything starts changing.

2. Ask for what you want. So now what happens with all those grievances you have with your loved ones: the crumbs in bed, the bad attitude, the affair two years ago? Here's what you do: ask them for something specific and actionable. And remember, NO criticism.

I can read your mind right now. You are saying, "Look, I've asked my partner over and over and over to stop doing X, and she keeps doing it anyway." No you haven't. You've been complaining to her in a tone of voice that would curdle milk, and she's responded with human nature. So try it again: "Agnes, honey, I see why you do X. It makes perfect sense to me. From my end, I would love to figure out another way that would make us both happy - I might suggest Y. Where could we go with this?"

Maybe the other person will say yes. Maybe they will say no. Maybe the problem is unsolvable, like when she wants children and he doesn't. Either way, you'll be talking productively, instead of watching the other person respond passively or aggressively to your gripes. So ask them to go mountain climbing, see a movie with you every week, or kiss you passionately. Then watch what happens.

3. Ask what they want. What makes your kid happy? What is your partner most worried about? How do they feel about the X that you are asking for? Knowledge is power, and most of us spend too much time wondering what to say to someone and not enough time wondering what to ask.

4. Cheer the other person on. Do you have a rotten kid, or a complaining spouse? Pop quiz – how often do you compliment them, or say things that accept them for who they are, or comfort their mistakes? There is a stronger correlation between these things than you might think. People are capable of amazing transformations when they feel loved and supported.

5. Create your own great life. In grad school, they teach us a spectrum. At one end people are "enmeshed" – highly reactive and dependent on others for their emotional well-being. At the other end they are "differentiated" – loving and secure, but not needy. We want you to be more differentiated and less enmeshed. So start being a great partner or family member by making yourself happy.

Is that all there is to it? Well, not always. But as long as you both care, and aren't beating each other with sticks or recovering from trauma, this is actually a pretty good summary of where a family therapist might lead you. Try it for yourself, and watch some amazing things start to happen with the people you love.