Delivering Directives Effectively in Telehealth Sessions

We occupy a smaller space on a screen than we do in an office, yet our influence must remain the same size. We recognize that the digital environment provides a unique opportunity for the client to feel they can escape the gravity of our presence. In a physical office, you control the doorway, the chairs, and the clock. In a telehealth session, the client controls their own immediate surroundings, which can undermine the hierarchical structure necessary for a directive to take effect. You must reclaim this authority by controlling the only thing available to you: the digital interface itself. You do this by establishing rigid rules for the session before the clinical work begins. You require the client to be in a private room, seated in a chair that does not rock or swivel, with their camera at eye level. If a client attempts to conduct a session from a car or a public space, you do not proceed. You inform them that the session will begin only when they have secured a fixed, private environment. This is not a matter of convenience: it is the first directive.

I once worked with a corporate executive who attempted to hold our sessions while he walked through a park. He claimed the movement helped him think. I observed that the movement allowed him to avoid the discomfort of focusing on the failure of his marriage. I instructed him to return home, sit at his desk, and place his hands flat on the surface for the duration of our next meeting. When he resisted, I told him that every step he took during our call was a step away from a resolution. By the next session, he was seated and still. We use this control over the physical posture of the client to reestablish the hierarchy that the technology threatens to dissolve. When the client is still, the words you speak have more impact.

We must also manage the visual frame to maintain authority. You should ensure your own background is neutral and that your lighting does not obscure your eyes. If the client cannot see your eyes, they cannot feel the weight of your observation. I once worked with a man who would look at his own image on the screen rather than at me. This allowed him to maintain a self-conscious performance. I instructed him to place a physical piece of paper over the part of his screen that showed his own face. I waited until I saw him reach out and tape the paper to his monitor. Only then did I deliver the instructions for his weekly task. You use the camera as a tool of precision, not just a medium of communication.

The screen share function is a primary tool for task planning. We do not simply tell the client what to do: we use the shared visual field to make the directive a tangible reality. When you want a client to perform a specific task, you open a blank document and you share your screen. You type the directive in large, clear letters while the client watches. This makes the instruction an objective fact in their environment. It prevents the client from later claiming they misunderstood or forgot the details.

I worked with a woman who struggled with procrastination regarding her tax returns. I opened a screen share and pulled up a blank calendar. I instructed her to name the exact two hours on Saturday when she would sit at her kitchen table. As she spoke, I typed the time into the calendar. I then asked her to name the specific penalty she would pay if she did not complete the task. She decided she would go without internet access for the entirety of Sunday. I typed that into the shared view. We do not leave these details to memory. We use the visual field to lock the client into the ordeal. You watch the client’s reaction as the words appear on the screen. The movement of the cursor and the appearance of the text create a sense of inevitability.

We use written follow-ups to extend our authority beyond the hour of the session. In strategic therapy, the directive is the most important part of the intervention. If the client leaves the session and immediately forgets the directive, the intervention fails. You send a brief, formal email immediately following the session. This email contains nothing but the directive itself. You do not include pleasantries, summaries of the conversation, or reflections on the client’s feelings. You provide a numbered list of the actions the client must take.

I once worked with a mother and daughter who were locked in a cycle of constant shouting. I gave them a directive to only speak to each other in whispers for the next six days. If either one raised her voice, she had to immediately leave the room and scrub the kitchen floor for twenty minutes. I sent this in an email three minutes after our call ended. The subject line was simply: Instructions for the Week. This email serves as a physical contract. It stays in their inbox as a reminder that the practitioner is still observing them. We use the permanence of the written word to anchor the change.

Resistance in a digital space often manifests as technical difficulty. A client may claim their microphone is broken or their connection is lagging when the conversation turns toward a difficult directive. You must treat these technical issues as clinical data. I worked with a husband and wife who were experts at interrupting each other. When I tried to intervene, the husband would suddenly experience a connection drop. I changed my strategy. I told them that because their internet was unreliable, they would have to communicate through the chat box for the next fifteen minutes. I muted both of them. They had to type their responses to my questions. This forced them to slow down their communication and prevented the husband from using technical failure as a shield. We use the limitations of the medium to create new rules for interaction.

You must also consider the timing of your directives in a telehealth context. Because there is a slight lag in most video calls, you cannot rely on the same micro-timing you use in person. You must allow for a longer pause after you speak. We use this pause to let the directive settle. If you speak too quickly after giving an instruction, you dilute its power. You should deliver the directive, then sit perfectly still and look directly into the camera lens. Do not look at the client’s face on the screen: look at the lens. To the client, this appears as if you are looking directly into their eyes. You maintain this gaze until the client acknowledges the task. This use of the camera creates a sense of intense focus that can be even more powerful than in-person eye contact.

I once worked with a young man who could not complete his university assignments. I directed him to open his screen share. I told him to pull up his bank account statement. I instructed him to choose a charity he despised. He chose a political organization he found repulsive. I then dictated a letter. If I do not send the first paragraph of my essay to you by Tuesday at five o’clock, I will authorize a payment of fifty dollars to this organization. You watch the client type these words. You see his hands move on the keyboard. This is how we use the medium to enforce the ordeal. The screen is no longer a barrier: it is the place where the work happens.

We emphasize that the digital directive must be more specific than an in-person one. You must define the time, the place, and the exact physical movements required. If you tell a client to practice being more assertive, they will do nothing. If you tell a client to stand up and speak to their boss via a video call while wearing their most formal suit, even if the boss cannot see their trousers, you are giving a strategic directive. I worked with a man who felt intimidated by his manager during online meetings. I instructed him to place a small, ridiculous object, a plastic dinosaur, just off-camera on his desk. Every time he felt intimidated, he was to look at the dinosaur and remind himself that he was the one with the secret. This physical anchor in his digital space changed his hierarchy of power. We find that these small, physical interventions are essential when the primary interaction is virtual.

You must remain the director of the digital space. If the client tries to change the subject, you use the mute function if necessary, or you simply repeat the directive until it is heard. We do not negotiate the terms of the task. We present the task as the only solution to the problem the client brought to us. If the client refuses the task, you do not argue. You simply state that the work cannot continue until the task is completed. You then end the session. This maintains the hierarchy of the practitioner as the one who provides the plan for change. The authority you project through the screen is determined by your willingness to hold the client accountable to the directives you issue. Change occurs when the client follows an instruction that disrupts their usual patterns of behavior. We observe that a well-delivered directive in a digital session is as effective as any given in a mahogany-rowed office.

We categorize directives into two primary types when working through a screen: those that require direct cooperation and those that rely on resistance to achieve a result. You choose the straightforward directive when the client’s motivation is high and the power struggle is low. For example, I once worked with a corporate executive who complained of chronic procrastination. I directed him to turn his laptop camera toward the clock on his wall and spend exactly fourteen minutes every morning at eight o’clock writing down every task he intended to avoid that day. He had to show me the list through the screen at the start of our next session. Because he respected the hierarchy of the digital space we had established, he followed the instruction precisely. The list became a physical anchor for his commitment to the change we were engineering.

Paradoxical directives require a different level of technical theater. You use these when the client is locked in a symmetrical struggle with you or with their own symptoms. In a digital environment, the paradox often involves prescribing the very technical or environmental failures the client fears. I treated a woman who suffered from social anxiety that manifested as a fear of looking foolish on video calls. We spent three sessions where I directed her to intentionally freeze her face for ten seconds at a time while speaking to me. She had to maintain a ridiculous expression while I sat in the stillness. By prescribing the freeze, we removed the spontaneous fear of it. She discovered that she could control the awkwardness of the medium.

We use the client’s physical proximity to their own life as a leverage point that was previously unavailable in the clinic. In the office, a client tells you about their messy kitchen or their difficult spouse. In a telehealth session, the kitchen is thirty feet away and the spouse is in the next room. You must use this proximity to increase the force of an ordeal. I instructed a mother who was constantly fighting with her teenage son to keep her laptop in the kitchen during our session. When she began to complain about his lack of hygiene, I told her to get up, take the laptop into his bedroom, and describe the mess to me while standing in the middle of it. This forced her to confront the reality of her environment while I maintained the observer role.

The traditional fifty minute hour is a relic of the office that we should often abandon in the digital space. We find that twenty minute sessions spaced three days apart can create a more persistent sense of clinical influence than one long session. You use the frequent, short contact to reinforce directives before the client has time to lapse into old habits. I used this strategy with a young man struggling with an internet gaming habit. We met for fifteen minutes every Monday, Wednesday, and Friday morning. My only task was to check his progress on a directive to unplug his router and give the power cord to his neighbor every night at ten o’clock. The frequency of the check in made the directive impossible to ignore.

Stillness functions differently in a video call. In a room, the absence of speech is shared. In a digital session, the quiet creates a pressure that forces the client to look directly into the camera. You use this pressure to wait for the client to accept a difficult directive. We do not fill the gap when a client hesitates. I once sat without speaking for nearly four minutes after giving a directive to a husband to apologize to his wife without using the word but. The digital lag and the lack of physical movement made the tension palpable. He eventually looked at the camera, nodded, and agreed. Had I spoken or adjusted my chair, I would have released the pressure.

Directives in the strategic tradition must often be physical to be effective. You should never assume that because the session is digital, the task must be digital. I worked with a man who had a habit of interrupting his partner during their joint sessions. I directed him to find a heavy book in his home and hold it above his head every time he felt the urge to speak while she was talking. He had to remain on camera with the book visible to me. The physical strain of the book served as a reminder of his impulsive behavior. We observe that clients are more likely to remember a directive involving their own space.

You can turn any household object into a tool through the power of the directive. We call this anchoring the task in the client’s geography. I told a woman who was mourning a relationship to take a single shoe belonging to her former partner and place it on her dining table. She was directed to speak to the shoe for five minutes every evening at sunset, telling it exactly why she was better off alone. She had to describe the shoe to me during our next session, including the wear on the sole and the color of the laces. By making the shoe a central point of her daily routine, we moved her grief to a manageable task.

You must treat every technical interruption as an opportunity for a directive. If a client’s connection drops, we do not simply wait for them to return. We send a message through the chat or an email immediately with a specific task to perform before they reconnect. For example, if the video fails, I might tell a client to take three minutes to write down the one thing they are most afraid of saying to me before they try to log back in. This ensures that the clinical authority remains intact even when the technology fails. It prevents the client from using technical issues as a way to escape the tension of the session. The technology becomes a partner in the ordeal rather than an obstacle to it.

The presence of others in the home is not a hurdle but a resource. We often direct clients to involve family members who are not officially part of the session. I once worked with an agoraphobic woman who lived with her sister. I directed the sister, who was in the other room, to come into the frame for two minutes at the end of the session. I gave the sister the directive to lock the front door from the outside and take the key for one hour every Tuesday morning. The client had to watch her sister do this on camera. This moved the therapy from a private conversation into a family ordeal where the hierarchy was clearly defined.

The final moments of a telehealth call are the most dangerous for the loss of authority. We avoid the casual wave or polite lingering. You must give the directive and then terminate the call yourself, immediately. This leaves him alone. Authority remains.

You assess the success of a directive during the first ten seconds of the follow-up session. We do not ask the client how they felt about the task or if they found it helpful. These questions invite a subjective narrative that allows the client to reclaim the power of the expert observer. Instead, you look for physical and environmental evidence that the instruction was followed. If you directed a woman to rearrange her home office to establish a clear hierarchy over her intrusive stepson, you look at the background of the video call. You check the position of her desk and the visibility of the door. If the desk remains in the same position, the directive was ignored. We treat this ignore as a clinical datum rather than a personal slight. You immediately assign a more difficult ordeal to address the new resistance.

We recognize that a client who fails to follow a straightforward directive is providing information about the rigidity of their family system. If you told a father to take his son to a park for exactly forty-five minutes without speaking and he reports that they ended up talking about school, the father has maintained a secret alliance with the boy against your authority. You do not scold him. You do not explain why the silence was necessary. You respond by prescribing a more demanding task that is harder to subvert. You might instruct the father to wake up at four in the morning to write a ten-page letter to the son about the importance of silence, which he must then burn without showing anyone. This ordeal makes the act of talking during their next outing seem like a minor rebellion compared to the loss of sleep.

I once worked with a young man who suffered from debilitating social anxiety that prevented him from attending his university lectures. He spent his days in a dark bedroom with the curtains drawn. During our third telehealth session, I noticed he was still sitting in that same dark room. I instructed him to purchase a standing lamp with a very bright bulb. I told him he must place this lamp directly behind his computer screen so that it shone into his eyes during our sessions. I also directed him to keep his curtains open during the daylight hours for one week. If he closed the curtains for even one minute, he had to donate fifty dollars to a political party he despised. In the next session, I saw the light from the window reflecting off his glasses. He complained about the glare and the heat from the lamp. I did not offer sympathy. I observed that he was now visible to the world and to me. This physical change in his environment forced a change in his internal state. He could no longer hide in the shadows while claiming to seek help.

We use the follow-up session to solidify the new hierarchy. If the client has completed the directive, you offer a brief, clinical acknowledgment and move immediately to the next task. You must avoid the trap of praising the client like a child. Praise can be patronizing and invites the client to perform for your approval rather than for their own change. You simply state that the task was completed and observe the result. If a husband successfully spent three nights a week sleeping in the guest room as you directed to disrupt a cycle of late-night arguing, you ask how his sleep quality has changed. You do not ask if he and his wife are getting along better. You focus on the mechanical result of the intervention. This focus keeps the responsibility for the relationship on the couple while you remain the director of the action.

You can use the digital frame to deliver metaphors that the client hears but does not consciously analyze. In the Ericksonian tradition, we know that a story told to a person who is looking at a screen can be more effective than one told in person because the screen focuses the attention while the person remains in their own familiar environment. You might tell a story about a gardener who had to prune a rose bush so severely that it looked like it would die, yet the next season it produced the largest blooms in the garden. You tell this story while looking slightly away from the camera, as if you are remembering it rather than telling it to the client. This posture allows the client to overhear the message rather than receive it as a direct instruction. The message bypasses their resistance to being changed.

I worked with a woman who was obsessed with her health and constantly monitored her heart rate. She would hold her wrist during our sessions. I told her a story about a man I once knew who was fascinated by the ticking of a grandfather clock in his hallway. He became so focused on the rhythm that he could no longer hear the birds outside or the sound of his own children playing. One day, the clock stopped. For an hour, he was terrified by the silence. Then he realized he could finally hear everything else. As I told this story, I watched the woman’s hand slowly drop from her wrist to her lap. I did not mention her hand. I did not mention her heart rate. I simply finished the story and transitioned to a directive about her grocery shopping list.

We must prepare for the moment when the client attempts to return to their old patterns. This is often called a relapse, but we view it as a systemic test of the new structure. If the client reports that the symptom has returned, you do not express disappointment. You treat the return of the symptom as a reason to increase the intensity of the directives. You might suggest that the client was not quite ready to be over the problem and that they should practice the symptom even more vigorously. If a woman who was overcoming a cleaning compulsion reports that she spent five hours scrubbing her kitchen floor again, you direct her to scrub it for eight hours the next day, starting at midnight. This move puts you back in charge of the symptom. When she eventually stops, she is following your lead by stopping, or she is rebelling against your lead by stopping. Either way, the compulsion is no longer under the control of the old pattern.

Termination of the clinical relationship in strategic therapy is not a long, emotional process. It is a functional exit. We terminate when the client has achieved the goals they set at the beginning and the hierarchy in their life is restored. In a telehealth environment, this termination can be very clean. You do not need to have a final session where you review everything that has happened. That often leads to a sentimentalizing of the problem. Instead, you decrease the frequency of the sessions until the client realizes they are managing their life without your input. You might move from weekly sessions to one session every three weeks, and then one every six weeks.

You give the final directive during the last scheduled session. This directive is usually a small, ongoing task that the client must perform to keep the problem from returning. For example, you might tell a man who had trouble with anger that he must continue to spend ten minutes every Tuesday morning thinking of every person who has ever annoyed him. By making the thinking a scheduled task, you keep the emotion contained within a specific time and place. When he stops doing the task because it is boring, he has successfully moved beyond the need for the anger and the need for the therapy.

I once closed a case with a family where the parents were constantly undermined by their teenage daughter. By the end of our time, the parents were making firm decisions and the daughter was attending school regularly. In our final video call, I directed the parents to have a private dinner once a month where they were forbidden to speak about their daughter. If her name came up, they had to pay her five dollars. This directive ensured that the parental unit remained a separate, higher entity in the family hierarchy. I did not wish them a long life or tell them how much I enjoyed working with them. I told them that I expected the monthly dinners to continue for at least one year. Then I ended the call.

We know that the final impression the client has of the practitioner should be one of quiet, steady authority. They should not feel that they have lost a friend, but that they have graduated from a school of hard practicalities. You want the client to walk away with the sense that they did the work, even though you were the one who drew the plans. This is why you must remain the director until the very last second of the connection. As practitioners in the strategic tradition, we understand that change is not a matter of insight but of action. You have provided the client with the opportunities to act differently, and they have taken them. Your role is to disappear so that their new life can begin without the shadow of a clinical observer. The success of a digital intervention is measured by the silence that follows the final click of the mouse. The absence of the symptom in the client’s actual living room is the only evidence of a job well done.