Online or in the room: what actually changes

The question almost always comes with an apology attached: I imagine in person is better, but I live far away. It is worth separating what really changes from what is merely feared.

What does not change

The length, the frequency, the way of working and the confidentiality. Nor does the thing people fear most, which is being able to say difficult things: there is a large literature on this and it does not show the difference people expect.

The three things that do change

• You only see half the body. In the room I notice hands, posture, the way someone settles before saying a particular sentence. On a screen that shrinks to a rectangle. It can be compensated for, but it is a real loss.
• The journey is missing. The walk home after a difficult session is not dead time: it is where things settle. Online you go from the session to the kitchen in three seconds, and it is worth carving out ten minutes before picking the day back up.
• I do not guarantee the space. In the consulting room the space is protected because I look after it. At home it is on you, and that is where video either works or does not.

The condition that matters

A room where you can shut the door, and reasonable confidence that nobody will come in for fifty minutes. This is not a practical detail: if you are afraid of being overheard you say different things, and at that point the gap between online and in person becomes enormous. If no such room exists at home, it is worth saying so and finding an alternative together — a parked car works better than it sounds.

When I do not suggest it

In situations where physical presence genuinely counts: significant clinical risk, an acute crisis under way, or when something emerges in the work for which the screen becomes a way of staying at a distance. In that case I say so, and we talk about it.