My client doesn’t want to be on camera during telehealth

Therapy often happens on video, but what if the camera stays off? It’s not just a personal choice. Telehealth format can affect access, equity, and outcomes.

Understanding why some clients avoid video and how to provide quality care over the phone is essential for every mental health professional. This post explores the reasons behind audio-only sessions, their impact on therapy, and practical steps you can take to support your clients effectively and safely. We’ll look at why a phone call is still a vital tool and how to make the most of it.

Why do some clients choose phone over video?

Many people assume clients who opt out of video are simply being difficult. The reality is much more complex. People choose audio-only sessions for valid and varied reasons, which often fall into two main categories: practical barriers and personal concerns.

Practical and structural barriers

For many, using video isn’t a simple choice. It can be a significant hurdle that prevents them from getting care. Not everyone has reliable, high-speed internet or a modern device with a camera. In many rural and low-income areas, broadband is slow or unavailable. Some households share a single smartphone, making private, uninterrupted video calls nearly impossible.

Some people, especially older adults, may not be comfortable with video technology (ever FaceTime with your grandparent’s forehead in the corner?). Setting up apps, logging into portals, and troubleshooting connections can be stressful and overwhelming, creating a barrier to starting a session.

Personal and psychological concerns

Some clients turn off their cameras during video sessions so they can multi-task (for example, cooking, working, or handling chores) while talking to their therapist. While this flexibility can make it easier for clients to attend sessions, it may also reduce their focus and level of engagement. Multi-tasking can make it harder to connect emotionally and limits the therapist’s ability to read cues or address distractions as they happen, which could affect the depth and effectiveness of therapy.

Clients may worry about having you see their living situation, which could be a source of shame or discomfort. They might also fear that family members or roommates could overhear or see their session, stripping away the confidentiality that therapy requires.

For some, the perceived anonymity of a phone call makes it easier to open up. Research shows that people are often more willing to discuss sensitive topics when they don’t have to make eye contact or worry about their facial expressions. This is especially true for trauma survivors, who may find direct eye contact—even through a screen—to be threatening.

The clinical impact of audio-only sessions

When a client doesn’t use video, it changes the dynamic of therapy. The biggest challenge is the loss of nonverbal cues. You can’t see a client’s body language or facial expressions. This makes it harder to assess their mood, spot signs of agitation or intoxication, or notice environmental details that might be important for their safety. It can make sessions feel less nuanced, and less flexible since you can’t adjust based on subtle cues or reactions.

However, the evidence we have is encouraging. Studies on depression, anxiety, and PTSD show that therapy over the phone can be just as effective as video sessions in reducing symptoms. Furthermore, offering a phone option can significantly improve attendance.

The bottom line is that audio-only care is a vital lifeline. For many, the choice isn’t between phone and video; it’s between a phone session and no session at all. Abruptly removing this option risks cutting off care for the very people who may need it most, including older adults, individuals with low incomes, and people from marginalized communities.

4 steps for effective audio-only care

How can you balance a client’s comfort with your clinical responsibility? The key is to be intentional and structured in your approach. Here are four steps to guide your audio-only sessions.

Step 1: Prepare before the first call

Good preparation sets the stage for success. Before you even have your first session, take these initial steps.

During intake, ask clients about their access to a private space, a reliable device, and stable internet. This helps you understand their situation from the start. If they face technology hurdles, you can explore solutions, whether that’s finding a private third space with good internet, or helping them find resources to solve tech issues.

Your consent forms should cover both video and phone sessions. Be sure to explain the limitations of audio-only care, such as the difficulty in assessing nonverbal cues, so clients can make an informed choice.

Step 2: Evaluate risk levels

Assess the client’s risk level to determine if audio-only is appropriate.

For high-risk clients with active suicidal thoughts, psychosis, or severe substance use, strongly recommend in-person or video sessions whenever possible. If the phone is the only option, schedule a same-day safety follow-up and get contact information for a trusted friend or family member.

For most other clients, phone sessions can be a safe and effective option. You can use structured assessment tools like the PHQ-9 and Columbia-CSSRS orally to monitor their risk over time.

Step 3: Adapt your in-session technique

Without visual cues, you need to adapt how you communicate and gather information.

At the start of every call, verify the client’s identity and their exact physical address. Re-confirm their location if the call drops and you need to call back. This is critical for emergency situations.

You can gather information by asking direct questions. For example, instead of observing their energy level, you might say, “I notice your voice seems a bit slower today. Can you tell me more about how you’re feeling?” Ask about background noises or any distractions.

Your empathy needs to be verbalized. Since a client can’t see you nod in understanding, you have to say you understand to check in and create connection.

Rehearse the client’s safety plan regularly. Document emergency contacts, steps for limiting access to lethal methods for suicide (called  means restriction), and even a “code word” the client can use if their privacy is suddenly compromised during a call.

Step 4: Plan a path toward video (if appropriate)

While respecting a client’s choice, you can also gently encourage them to try video when they feel ready.

Suggest trying a session with the camera covered. This allows them to get used to the video platform without the pressure of being seen. You can also offer to help them with privacy settings or help them find a loaner device through community assistance.

Periodically check in on their preference regarding video. Every few months, you can ask if they’d be open to trying a video session. For clients with moderate or high risk of harming themselves or others who rely solely on the phone, suggest occasional in-person visits to get a more complete clinical picture.

The future of telehealth is flexible

Audio-only telehealth is not a lesser form of care; it’s an essential and effective tool for reaching people who face significant barriers to treatment. By understanding why clients choose the phone, adapting your clinical skills, and implementing clear protocols, you can provide safe and effective therapy. Meeting clients where they are, whether on screen or on the phone, is fundamental to building trust and fostering healing. 

If you’re looking for more tips to run a telehealth-focused practice, we have seven you can read here.