Background

As a result of the worldwide state of emergency during the COVID-19 pandemic that started in 2020, there has been a massive shift towards the use of online communication for purposes of work and social contact. Face-to-face, on-site therapeutic processes have been moved to online platforms causing changes in patterns of practitioner–client interaction. Online psychotherapy has rapidly spread in recent years due to, among other things, its accessibility and convenience in reaching a wider population. Several comparative studies give support to this new modality assessing its validity, efficiency, and effects on the therapeutic alliance and treatment (Backhaus et al., 2012; Cataldo, Chang, Mendoza, & Buchanan, 2021; Hilty, Luo, Morache, Marcelo, & Nesbitt, 2002; Norwood, Moghaddam, Malins, & Sabin-Farrell, 2018; Simpson, 2009; Simpson & Reid, 2014). Studies also scrutinize the advantages and disadvantages of online therapy (Kocsis & Yellowlees, 2018; Schuster, Topooco, Keller, Radvogin, & Laireiter, 2020; Stoll, Müller, & Trachsel, 2020; Wegge, 2006). However, unlike therapeutic processes carried out mostly in the online modality, the current situation has compelled a shift to online platforms and many therapists and patients have had to adapt to a modality they were not used to. This situation allows us to explore the contrast between the modalities by examining first-hand experiences, particularly the role of nonverbal communication, embodiment, and intercorporeality before and after the switch.

There is widespread agreement that embodied aspects of intersubjectivity play a substantial role in the psychotherapeutic process (Hauke, 2016; Shaw, 2004; Siegel, 2019; Tschacher & Pfammatter, 2016). Intersubjectivity here refers to the co-creation of meaning between two or more people as well as their lived experience of mutual presence and recognition (Gallagher & Zahavi, 2012). The enactive approach, as a branch of embodied cognitive science (Newen, Bruin, & Gallagher, 2018), highlights the constitutive role that sensorimotor engagements with the environment play in mental life (Di Paolo, Buhrmann, & Barandiaran, 2017; Thompson, 2007; Varela, Thompson, & Rosch, 1991). In social situations, interpersonal engagement relies on all kinds of aspects of interaction, not only gestures, expressions, and utterances, but also factors such as bodily posture, interpersonal distance and rhythms, and micro-movements. The concept of intercorporeality refers to how social interactions or the presence of other persons shape pre-reflective bodily behaviors and gestures (Merleau-Ponty, 2012). Such pre-reflective elements allow individuals to attune to each other in bodily and affective resonance and set the basis for participatory sense-making processes by which they mutually influence each other’s cognitive and affective activities (De Jaegher & Di Paolo, 2007). Participatory sense-making is defined as the ways people make sense together, of each other, the world, and themselves, in moving together. For this, they rely on both pre-reflective and reflective coordination processes at many levels, from regulation of interpersonal distance and mutual orientation to joint activiities and conversations. These coordination patterns have long been studied (Abney, Paxton, Dale, & Kello, 2014; Dale, Fusaroli, Duran, & Richardson, 2013), and we find, for instance, physiological correlates in autonomous responses such as heart rate variability, skin conductance, and inter-brain synchrony (Kleinbub, 2017). Participants also coordinate movements and utterances (Fuchs & Jirsa, 2008; Kendon, 1990). These multiple kinds of bodily resonance and other forms of intercorporeality (Fuchs & De Jaegher, 2009) serve as the primary way by which participants perceive each other and together generate meanings in the interaction, with reflective, dialogic, and other gestural engagements relying on this basic pre-reflective substrate. The idea of participatory sense-making suggests that not only the presence but also the particular time-course of such intercorporeal synergies contributes to building the therapeutic alliance and processes of change (García & Di Paolo, 2018; Koole & Tschacher, 2016).

The effectiveness of online therapy, in which intercorporeal cues are altered (in general diminished) by the video-call setting, might be construed as a counterexample to the enactive perspective. If online sessions can be effective (Lingely-Pottie & McGrath, 2006), then perhaps intercorporeality is not as important as enactivists suggest. On this issue, the literature on online therapy shows two apparently opposing views. On the one hand, efficiency studies report that there is no statistical difference between online and face-to-face interventions (Norwood et al., 2018) and the quality of therapeutic alliance seems also to be equivalent in both modalities (Cataldo et al., 2021; Simpson & Reid, 2014). On the other hand, there are compelling questions about whether online therapy can support the implicit nonverbal and embodied aspects of the therapeutic relationship. Russell (2018) examines the limitations of online therapy, without discarding its advantages. These limitations concern the role of embodied co-present interactions in building trust (see also Rocco, 1998) and the absence of implicit bodily cues that help patients and therapists regulate meaning and memory together. The case is, as we explain next, that there is not so much an absence as a transformation of intercorporeal patterns in online interactions and the question remains whether these changes have an effect on the quality of participatory sense-making.

Participatory sense-making in online social interactions

There is a tendency to consider digital online communication as a sort of disembodied virtual reality. However, all interactions with technology are embodied in the sense that they take place in the context of everyday sensorimotor engagements with the world (Price, Roussos, Falcão, & Sheridan, 2009; Smart, 2014). The online/offline contrast cannot be mapped onto a disembodied/embodied distinction. The idea that cognition is embodied and technologically extended encourages us to see our interaction with communication devices as constitutive of cognition in general (Clark & Chalmers, 1998; Wheeler, 2019). Work on cognitive anthropology and material culture (Hutchins, 1995; Malafouris, 2013) demonstrates how technologically mediated interpersonal encounters modulate, enhance, and constrain lived experience. Digital technology is rather a mediator, that is, more than just conveying a message, and it transforms, translates, distorts, modifies, and even scaffolds meaning (Håland & Melby, 2015; Latour, 2005).

Indeed, from an enactive approach, there is no un-mediated perception since perception is always constrained and constituted by sensorimotor contingencies enacted by an agent (Di Paolo et al., 2017; Noë, 2004). Any environment offers certain potentials for action both physically and socially (Suthers, 2006). As an illustration, we may consider the measurement of Social Presence, which is often used to rate different technologies in terms of sociability and the moment-by-moment awareness of the co-presence and engagement with the other (IJsselsteijn, 2003). Although mediated communication can result in detriment of emotional and other forms of crucial information, it can also support new ways of communicating and interacting (Furukawa & Driessnack, 2013; Newman, Szkodny, Llera, & Przeworski, 2011; Price et al., 2009). Thus, we should move away from the ‘just transmitter’ or ‘just impoverished’ approaches to technology-mediated interactions in order to recognize new forms of embodied interactions that technology affords.

Social cognition, in a enactive sense, is a participatory sense-making process, that is, the ‘coordination of intentional activity in interaction, whereby individual sense-making processes are affected and new domains of social sense-making can be generated that were not available to each individual on her own’ (De Jaegher & Di Paolo, 2007, p. 497). In social encounters, there is a co-regulation of the coupling between individuals that generates interactive dynamics, that is, a relational domain that acquires a certain autonomy from individual acts and intentions (see Figure 1). This interactive autonomy is evidenced in cases where interaction continues even when participants are trying to stop it, for example, the narrow corridor ‘sideways dance’ when people walking in opposite directions cannot get past each other, phone conversations that reignite after having said goodbye, or the tendency of therapists and patients to synchronize their movements in the conversation (Koole & Tschacher, 2016). These interactive processes are manifested intercorporeally as shared rhythms, synchrony, spatial configurations, and bodily/affective resonance between participants. Fuchs and De Jaegher (2009) describe such intercorporeality as the basis for intersubjectivity and social cognition. Unsurprisingly, these processes of embodied intersubjectivity play a fundamental role in building the therapeutic alliance (Bizzari, 2020; Tschacher & Pfammatter, 2016).

Depiction of the co-regulation of the coupling between two self-constituting agents (full circles) in interaction with each other and with the environment (vertical waves sideways). The arrows on the circles illustrate the self-constitution of the agent and curved arrows represent the co-regulation of the coupling. (Reproduced with permission from Di Paolo et al., 2018.)

A core element of participatory sense-making is the dialectical articulation between two forms of autonomy and normativities, the individual and the interactional (Di Paolo, Cuffari, & De Jaegher, 2018). Individual autonomy arises from the sustained integration of organic and sensorimotor agencies in each participant. Interactive autonomy is the result of self-organized and self-sustained relational patterns that emerge in social interaction. These two autonomies can give rise to different normativities and constitute the primordial tension between the individual and relational intentionalities, a tension that is ongoingly transformed and regulated, but never entirely absent. This double normativity is clearly shown in cases where the interactive autonomy generates sustained relational patterns regardless of the individual intentions. For instance, systemic phenomena such as the aggressor–victim–rescuer dramatic triangle (Karpman, 1968) manifest the autonomy of relational patterns. It is important to notice that the primordial tension does not always imply a discord between individual participants, but rather, it manifests the sensitivity of individual sense-making processes to being affected by relational patterns. This explains how therapeutic relationships have potential for transformation and healing. Moreover, the constitutive processes of the autonomous agent are precarious in the sense that these processes would dissipate in the absence of enabling conditions of the whole network that makes up the agent (Di Paolo & Thompson, 2014). In social cognition, then, the relational domain is also precarious. That is to say, the relational autonomy must be sustained by the activity of individuals even if it cannot entirely be under their control (De Jaegher, Peräkylä, & Stevanovic, 2016). As a consequence, there is a mutual regulation, as well as a tension, between the relational and the individual domains.

The concept of participatory sense-making has been used in a wide range of interactive situations, for example, psychiatry (de Haan, 2020), autism (De Jaegher, 2013), narrative and story-telling (Popova, 2019), joint music and dance experiences (Hermans, 2019; Ravn, 2016; Schiavio & De Jaegher, 2017), and sport psychology (Araújo & Davids, 2016). It helps explain, in these varied contexts, how meaning is co-constructed and continuously negotiated in interaction. This pervasive phenomenon occurs in every social situation and is particularly salient in therapeutic encounters (García, 2021), where the course of the relational dynamics (in the sense of alliance building, ruptures, enactments, and change moments; Boston Change Process Study Group, 2013) marks significant events in the therapeutic process.

In asynchronous social interactions, such as e-mail communication or discussion threads on social media, the general attenuation of immediate shared rhythms and other intercorporeal processes can impair the co-creation of autonomous relational patterns, as Maiese (2013) suggests, for instance, in assessing transformative learning in online education, or in health technological services (Håland & Melby, 2015). However, these intercorporeal processes are very much present in synchronous interactions such as video calls and phone conversations used in psychotherapy online encounters. As we have said, we must move away from the idea that technology simply impoverishes habitual forms of interaction towards the idea that each technology affords specific modulations and interactive regulations (Arminen, Licoppe, & Spagnolli, 2016).

Methodology

Motivated by the question of whether online therapy fits within the enactive perspective on intercorporeality, we study how intercorporeal patterns change in the switch to the online modality. For doing so, we adopt a phenomenological stance (Galbusera & Fellin, 2014) to assess the experience of participants at the pre-reflective and implicit level. We use interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009), a qualitative method that combines phenomenology and hermeneutics fostering a dialogue between participants’ first person experience and enactive theory (Larkin, Eatough, & Osborn, 2011; Stilwell & Harman, 2021).

Design

The lived experiences gleaned from the interviews are used as triggers for theoretical reflection. It is clear that these experiences are sometimes incommensurable, so we make no claim about their generality. We do, however, attempt to extricate in some detail the possible underlying factors that affect these experiences and provide interpretations from the perspective of embodied and situated intersubjectivity. Since the study focuses on relational, intersubjective phenomena, we applied a multiple perspective design (Larkin, Shaw, & Flowers, 2019) by combining both therapists and patients’ perspectives. This two-role focus is combined with a multiplicity of therapeutic schools in order to have a multiperspectival view on the phenomena.

Recruitment and participants

Between 15 March and 1 June 2020, we have interviewed 4 practitioners and 3 patients (one was excluded due to technical problems during the interview) [see Table 1]. It is worth mentioning that patients are underrepresented in our data. Two pairs participate in the same therapist–patient relation (Manuel/Martin and Julio/Javier; all names are fictitious), but we do not analyse the particularities of their relationship. The therapists are all experienced and belong to different schools. There was no specific filtering by diagnosis or population. All participants started their therapeutic process in the face-to-face modality and continued their sessions via video call. Participants were recruited via email with the collaboration of the Federation of Spanish Psychotherapy Associations (FEAP). The interviewees have all given their consent to participate, and the study was carried out under the approval of the ethics committee of the University of the Basque Country (M10_2018_184).

Table 1. Table of participants Therapist Gender/age Type of therapy Modalities Prior experience with online therapy Julio Male/middle-age Relational Psychoanalyst (RT)

Video call

Telephone

No Martin Male/middle-age Relational Psychoanalyst (RT) Video call No Clara Female/middle-age Gestalt Therapist (GT) Video call Yes, she has had new online patients Monica Female/middle-age Cognitive–Behavioral Therapist (CBT) Video call Yes, she uses online supervision Patient Gender/age Type of therapy received Modalities Prior experience with online therapy Manuel Male/middle-age Relational psychoanalysis (P) Video call No Javier Male/middle-age Relational psychoanalysis (P) Video call No Data collection

Interviews were semi-structured with the aim of identifying therapeutically relevant changes undergone due to the switch to the online modality. Unlike usual IPA interviews, due to the pandemic restrictions, we had to conduct the interviews over the telephone. A recorded research diary was kept to reflect on personal feelings in each interview. No specific impediments to the communication of personal experiences were noted due to the use of telephone communication. The interviews contained 22 questions gathered into 4 topics: spatiality, temporality, embodiment, and relationship (duration approximately 1 hr). A list of questions can be found in Appendix S1. Quoted passages have been translated by the authors (two of them native Spanish speakers) with discussion of nuances in meaning and sensitive expressions. Transcriptions of the interviews (in the original Spanish) are available by request.

Data analysis

The analysis was performed using the interpretative phenomenological approach (Smith et al., 2009). We followed a three-step multiple perspective design (Larkin et al., 2019). In the phenomenological step, data are analysed idiographically by codifying and commenting each interview separately. We analysed individual perspectives and identified each person’s main thematic categories. We used a computer-assisted qualitative data analysis software (Atlas.ti) for codification and categorization. In the second comparative step, we identified the synthesis, integration, and/or resonance between themes keeping a two-related-role (therapist-patient) distinction. Some of the themes extracted (those related with the COVID-19 effect on therapy and personal circumstances) were not included in the analysis. In the third hermeneutic step, we interpreted the themes attending to the concepts of intercorporeality and the primordial tension of participatory sense-making, advancing possible enactive explanations of the lived experience of participants. The analysis, thus, is not assumed to be theory-free, but it shows our reflexive engagement in the co-construction of meaning.

Reflexivity

The first author performed the thematic analysis, and the second author revised it and translated the quotes in a separate phase. As reliability control and check of the analytic process, we use an ‘inter-rater reliability’ (Brocki & Wearden, 2006) procedure where authors EG and EDP agreed on the interpretation of the data and on the resulting thematic categories. There was also a final reading of the data to ponder the level of interpretation and distance from interviewed experience. Descriptive data about the respondents are included, and the enactive perspective of the researcher is acknowledged and highlighted.

Results

This section presents the four superordinate themes and the sub-themes that emerged from the analysis: Communication (Interferences, Management of Silences), Embodied Interaction (Corporeality, Visual Contact, Self-image, Distance), Space/Time (Transparency, Separation, Transition), and Relationship (Structure, Styles). A full table of results with selected quotes can be found in Appendix S2.

The general impression about the switch to online therapy was quite positive for both therapists and patients. Participants stress the importance of having conducted previous sessions in a face-to-face setting in order to establish a strong therapeutic alliance. ‘The therapeutic alliance can withstand this [switch] and more’ (Julio, RT). Having started treatment face-to-face, the therapeutic dyad needed to adapt to a new form of interaction. Due to such adaptations, online sessions are sometimes regarded as a ‘bracket’, as transitory states, or as ‘a little break’ (Martin, RT). However, some participants report that after an adaptation period, they managed to overcome initial concerns and prejudices, carrying the therapeutic process forward. Thus, the results presented here correspond to this adaptive process and cannot be generalized to long-standing processes or to therapeutic processes that started in an online setting.

Communication Both patients and therapists reported a loss of interactive flow and spontaneity in their interactions.

The fluency [in interaction] might be slower. (Javier, P)

[The interaction] is getting a bit solidified. (Martin, RT)

However, some therapists show an increase in their verbal and non-verbal activity in order to compensate for such loss of the interactive flow.

I have found myself being a bit more controlling, telling them [the patients] “this and that”. Like giving more direction in case there was a loss of attention in them or a bit more apathy due to the lack of physical presence. (Monica, CBT)

Some participants report communicative interferences produced by the signal latency of the video call as an important factor for the loss of the interactive flow.

That small delay that we, you and I, are having, these microseconds. Who’s going to say something? And then you interrupt yourself, “no, you go first”. All this breaks the spontaneity that is, yeah … basic, necessary, indispensable for a therapy to carry on. (Martin, RT)

According to some interviewees, changes in the management of silences are more salient in video call sessions than in telephone sessions. The reason is that the intrinsic latency that can sometimes take place in video calls can make ‘you interpret as silence something that isn’t silence’ (Julio, RT).

Therapists, in particular, highlight the technical role played by silences in the therapeutic process. Silences are more difficult to sustain and work through in the online modality.

Physical space facilitates and normalizes silences that can be more reflective silences, more resisting, disquieting, or more felt. In the videoconference, having the therapist’s gaze or the patient’s gaze fixed, practically locked on you, those silences are more difficult. (Julio, RT)

Embodied interaction All participants agree that the image on the screen focuses exclusively on the face, setting aside other parts of the body. This results in a loss of awareness of the whole body, posture, and potential misperceptions of hand gestures and other movements.

It’s true that without a spatial reference, movements on the screen sometimes seem more pronounced than they really are. (Javier, P)

In online therapy I only see them from shoulders up. (Monica, CBT)

The screen does not modify only the perception of the other, but also their own posture and movements in front of the screen, and the embodied interaction between them.

The camera demands stillness. (Julio, RT)

I myself am sitting down here on the chair in a way I’ve never sat during therapy. (Martin, RT)

I think that the synchrony between patient and therapist, in a bodily sense, can happen more physically in face-to-face presence. (Monica, CBT)

‘You cross your legs, you lean backwards and you can see the other person moving. Normally it is more like a dance. Here, I think it doesn’t happen, because you lose the lower body.’ ‘You are more rigid during the session.’ (Martin, RT)

The relative distance between therapists and patients in the online setting is felt as closer than in a face-to-face interaction.

I see them closer, visually, the plane of the face is closer than if I was sitting in front of them. (Javier, P)

One of the main differences in the online setting is the lack of mutual visual contact. For most participants, direct visual contact is not possible:

Each one is looking at the screen, not at the camera. And if we looked at the camera we wouldn’t make visual contact either. It is really impossible. (Manuel, P)

I think that if we had a very direct gaze across the screen—imagine it was the same as a face-to-face gaze—I think it would be very intimidating. (Clara, GT)

For Clara (GT) and Monica (CBT), however, even if there is no direct eye contact, they still perceive the interaction of the eye movements in online settings and use different clues to adapt.

Yes, I think so, there is such contact, more or less the same… that visual coming and going, stop looking, and reconnect back; I think it is there. (Monica, CBT)

I realize that [eye contact] is replaced by another type of gaze. (Clara, GT)

Regarding gaze behavior, Julio (RT) highlights the change in introspective and emotionally intense moments:

[In face-to-face sessions,] I don’t remain looking at the person. I lower my gaze or look elsewhere. Not so much disconnecting myself, but allowing them to be as they are for the time they need, as if removing myself from the scene somewhat. (Julio, RT)

He continues:

When I’m here [in the video call], I don’t do this. I don’t do it because I get the impression that the patient will think I’m disengaging. If I stop looking at the camera, then I stop looking at them. (Julio, RT)

In this vein, he reports:

they [the patients] feel more under observation than accompanied (Julio, RT)

Another important aspect of the online setting is the possibility of seeing the self-image on the screen. In general, this is seen by both patients and therapists as potentially disrupting their attention from the therapeutic interaction, and changing the awareness of their own embodiment.

Yes, it’s the strangest sensation, because you stop sensing yourself to look at yourself. (Martin, RT)

If it is there [the self-image], I sometimes look at it and I move my attention away from the relation with the patient. (Clara, GT)

However, we find differences in how both patients and therapists use the self-image on the screen. Self-observation tendencies of the patient can also contribute to the interactive dynamics by providing relevant information to the therapist. The relationship of the patient with their own image and their self-observation patterns are a manifestation of self-regulation. This information is perceived by the therapist either reflective or pre-reflectively and they can respond accordingly:

It gives you clues about the degree of emotional inhibition or how patients regulate their narcissism at that moment … or their experience of embarrassment. (Julio, RT)

In this regard, a patient reports how seeing his self-image on the screen elicits a process of self-reflection and self-esteem:

[It helps me] tolerate my own image and my own presence in different situations. (Manuel, P)

On the therapist’s side, self-observation is more related with the aim of guiding the interaction by providing adequate conditions for communication (lighting, noise, focus, etc.) and by controlling one’s own facial and bodily expressions.

Especially if the emotions are uncomfortable, serious, or profound, I’ve found myself looking at my image to see if I was wearing the right expression, one that’s fitting or congruent with the emotional charge being communicated. (Julio, RT)

I remove it [the self-image] or leave it on depending on the attention level I want to have. It is also a way of establishing distance, or not. (Clara, GT)

Space/Time Interviewees remark on the changes in the space where patients and therapists are located. All therapists agree that the information provided by the space surrounding the patients affects their interventions in the online modality.

It gives you direct data about the person, about the place they inhabit. (Julio, RT)

It’s like when a patient speaks about aspects of themselves, even though you’re perceiving other aspects they don’t talk about. (Clara, GT)

Yet they feel that this [the consultation room] is a place where they can be safe. And they feel safe because, among other things, this place is not “my place” but the therapist’s place. In the therapist’s room, the therapist directs, the therapist receives me, the therapist listens to me, questions me, confronts me, reaffirms me, the therapist supports me. It is the therapist’s space. In such a place I feel safely welcome. This is a basic experience. This is lost in online sessions because the patient is in their place and you in yours, the consultation room. It is a physical difference, you know? And this makes patients not feel at ease in the same way. (Julio, RT)

Both patients and therapists comment on the relevance of having a transition process from everyday life settings to therapy sessions and back in order to prepare internally for the session and to assimilate the experience.

[In the therapy room you] leave all the shit there and come back feeling renewed. But this more physical process, you don’t have it so much when you are at home. (Javier, P)

The immediacy of the online format does not allow for such extended transitions between settings. In compensation, both therapists and patients report having adopted rituals for keeping both spaces separated.

I wear different hats in the same room depending on the situation [metaphorically]. (Manuel, P)

As a therapist, I also have my rituals for getting ready, moving there, taking my time […] I get ready to be a therapist. (Clara, GT)

Relationship Participants report that the therapeutic relationship does not change significantly as a result of the switch to the online format insofar as the therapeutic alliance had already been built face-to-face. However, Martin (RT) reports an interesting change at the level of the structure of the relationship.

A more pronounced horizontality [in the relation], because horizontality is enforced [...] I think that new fields for horizontality are opened, because it makes us, therapists, more open. (Martin, RT)

This horizontality (i.e., a more symmetrical interaction where the separation between roles becomes less sharp) is a result of being in similar situations, both with similar devices and each in their own place. Indeed, not having the possibility of modifying the physical arrangements of spaces and intimacy represents a relevant change in the usual relational asymmetry between therapists and patients.

All of these changes also affect the intervention style of therapists, for example, a confrontational intervention that may challenge a patient's attitudes.

Perhaps in the face-to-face format if there’s a confrontation that, say, puts the continuation of the therapy in doubt, I can take that risk more easily. Here [in the online format] I’m not sure how to take that risk. (Clara, GT)

Discussion

From an enactive perspective, we define social interactions as encounters between participants where their individual autonomies are not curtailed by the encounter and, in addition, the relational interactive patterns acquire a dynamic autonomy of their own (De Jaegher, Di Paolo, & Gallagher, 2010). In this way, the primordial tension between relational and individual autonomies has its manifestation in the modulation of interactive patterns that are sustained through reflective, pre-reflective, and even non-intentional embodied processes (Di Paolo et al., 2018). In this regard, participants report how a switch from a habitual face-to-face modality of encounter to a different, online one systematically changes aspects of intercorporeality, potentially displacing non-intentional and pre-reflective patterns onto a more reflective register.

Communication

As therapists report in the interviews, moments of silence can be clinically meaningful in psychotherapy sessions. Silence may indicate introspection, emotional connection, restructuring of behavioral patterns, beliefs and attitudes, etc. (Lane, Koetting, & Bishop, 2002; Weisman, 1955). They are particularly relevant to understanding therapeutic micro-changes. In online sessions, some participants refer to the difficulty of sustaining moments of silence. Since the intercorporeal possibilities are reduced, participants tend to compensate by increasing verbal and nonverbal behaviors.

The difficulty of sustaining silences by therapists and patients can indicate two things. At the individual level, the lack of silences could indicate some emotional inhibition in the patients. At the interactive level, the overuse of linguistic inputs can function as a compensatory mechanism for the diminished intercorporeal cues that help sustain the interaction. Bodily resources such as orientation, joint attention, posture, gaze, and even subtler aspects such as breathing patterns work as intercorporeal processes that contribute to keep the interaction going. When the spectrum of these resources is reduced, there is an attempt to sustain the interaction by increasing speech, permanent attention, fixed gaze, and postural rigidity, as ways of reaffirming one’s presence and attention to the other.

These compensations can be seen as manifestation of the primordial tension between the individual and the interactive autonomies of participatory sense-making. They are felt as demands on the participants’ resources and strains on the lived experience of interacting. The management of silences modulates both the individual and the relational regulatory loops, reflecting and modulating the intertwinement between individual and interactive processes.

Embodied interaction

The uncertainty about what a silence might mean hinders the enactment of introspective silences. The difference between video call and telephone sessions in this regard reveals an apparent paradox. One might expect intercorporeal processes to be easier in video calls than on the telephone due to the addition of the visual channel (Ball, McLaren, Summerfield, Lipsedge, & Watson, 1995). However, in video calls, we find a saturated visual channel, that is, a visual channel that has fewer degrees of freedom for interactive regulation. Thus, it is common to find a therapist with static attention, the gaze fixed on the screen, and visual interferences such as hands moving in and out of the screen without a clearly perceptible trajectory.

The example of Julio (RT) modifying his gaze behavior to regulate emotionally intense moments illustrates how intercorporeal processes, in this case gaze direction, must become more regimented in order to sustain the online interaction, and lose the flexibility needed to succeed in their regulatory function, supporting the saturation of the visual channel. Indeed, in face-to-face interactions the shared space allows for joint attention to a third object, a behavior that coordinates and regulates the intentionalities of the interactors and contributes to alliance building (Roth, 2014). This possibility is hindered (practically removed) in online settings. A similar rigidity can be found in facial expressions and bodily posture too.

Participants highlight the difficulty in achieving mutual eye contact as another process that contributes to the saturation of the visual channel. In Western culture, eye contact in face-to-face encounters activates physiological autonomic responses and generates a synergy between participants (Senju & Johnson, 2009). In dyadic conversations, eye contact increases presence in communication and sense of reality (Storbacka, 2020) and it favors the phenomenological experience of togetherness and mutual recognition (Koudenburg, Postmes, & Gordijn, 2013). Coordinated gaze behavior and visual contact serve to negotiate the intersubjective space.

Laboratory studies show that physiological responses such as autonomic arousal and facial movements are statistically equivalent in face-to-face and video-call conditions (Gehrer, Duchowski, Jusyte, & Schönenberg, 2020; Hietanen, Peltola, & Hietanen, 2020; Prinsen & Alaerts, 2019). However, it is questionable whether these results are directly applicable to naturalistic/ecological contexts, where the variability of devices and parameters are manifold. Although parameters such as the distance from the camera, the visual angle or the placement of the camera can be fine-tuned to obtain a semi-realistic condition (Huggins, 2016), these parameters are in general highly variable in typical devices (smartphones, notebooks, etc.). In most cases, there is no possibility of strict eye contact; instead, there is a situation of oblique gazes. It is unclear whether this oblique gazing can generate the same synergies as proper visual contact. Indeed, even if something like normal eye contact were possible, since the relative apparent distance between faces on the screen tends to appear shorter than in face-to-face interactions, it can still be felt sometimes as an uncanny situation.

Social cognition is qualitatively different when interacting with someone from when just observing them (Froese & Gallagher, 2012; Hari, Henriksson, Malinen, & Parkkonen, 2015; Schilbach, 2016; Schilbach et al., 2013). As Martin (RT) reports, patients feel more under observation than accompanied. Patterns of observation and interaction can change in online settings, favoring more reflective and observational forms of social cognition. Indeed, one of the main interfering factors mentioned by interviewees is the possibility