Back to remote therapy sessions
Dr. Arnon Rolnick & Adam Leighton. Inspired by a book we are editing with Dr. Haim Weinberg.
This post was written with the experts' warnings in the background of the increasing rate of infection and in light of the recommendations to reduce the face-to-face meetings as much as possible. Some of us will probably go back to work remotely again.
We will try to give here some recommendations, and point out some of the benefits of working remotely and offer an observant look at the process that psychotherapy is going through under the influence of the state of emergency created by the corona.
Indeed many of us became acquainted with remote therapy during the period of stress and confusion that characterized the early days of the COVID pandemic. In our previous waves and rounds with the zoom we were quite busy with the question "whether and how it can be done as a regular treatment". In this post we will offer a different stance. A viewpoint that not only “mourns” the lack of physical encounter but also points to the possibilities that remote therapy brings.
In light of the next wave that seems to be approaching - let's ‘prepare ourselves for coming winter'.
We will begin, with a few 'psycho-technological' points, technical aspects that greatly influence the therapeutic setting. The psychoanalytic tradition, on which many of us grew up, made a separation between the inner world and the outer world. We tend to think that our job is to engage only in the inner world. It was Paul Wachtel in his book Relational Theory and the Practice of Psychotherapy, who protested this separation and argued that it was our job to engage with the outside world as well as the internal. Indeed, once we move to remote therapy, we need to engage with the outside world as well: we need to be experts in technology, internet speeds, sending links, hot-spots and more.
To quote the empathy expert Lou Agusta: Once we deal remotely we are also a "technical help desk". Or perhaps a more relational formulation: to discuss with a patient how the modern world requires us to constantly deal with technological innovations - let's talk together about how each of us deals with the difficulty and ways of coping.
As we invest time and effort into creating a suitable setting in our clinic, we consider the location and distance between the armchairs in the clinic, the tissue box and the relative quiet in the room, so we need to invest in the virtual setting:
Invest in an external microphone (it doesn’t need to be expensive)! The use of an external microphone allows us to move away from the screen, to sit at a reasonable distance where we can also show body language beyond our face. We can even move away, get up, turn around - slightly detach the umbilical cord that the screen / microphone / camera may tie us down with.
Let's not settle with talking heads' - it is certainly possible to allow 'present bodies'.
In order to continue the disconnection from the virtual umbilical cord, it is worth investing in an external camera instead of the basic camera that the computer came with (especially laptops). A function that exists today in many cameras is the ability to zoom in and out of our image and thus also create a sense of dynamic involvement.
When working with couples, it is highly recommended that the couple have a camera with a wide lens (about 90 degrees).
One of the difficulties in working remotely is the experience of disconnection, each in his own room and more precisely in his own square. In Zoom and Microsoft Teams software - there is a possibility for all participants to share a common background without noticeable boundaries. Give it a try!
Dealing with technical difficulties: It is always a good idea to have a way to communicate with the patient if the zoom session fails. It is worthwhile to create an alternative of using mobile internet to back up a situation of home internet downturn. Also get to know and talk about the possibilities for another video call (whatsapp video, google meet, etc.)
Internet Speed: If you have decided to work remotely please make sure you have fast internet and if possible your computer is connected to the network wired (and not wirelessly)
The active therapist - 'striving for contact'
We strive to add depth to the experience of the remote encounter, to move from a two-dimensional experience to a multi-dimensional experience. The treatment should be "alive and present" and we will try to give an experiential dimension. It's not enough "to talk about it" we should "experience it". It is possible that in the not-too-distant future, the virtual and augmented reality capabilities currently being developed will enable the 'leap forward' in the remote therapy experience, meanwhile we need to examine what we can add depth to our remote sessions.
While many of the therapeutic approaches emphasize a therapeutic position that involves a lot of listening (even if active), it tends to be passive. In online therapy there is a danger that such a position will reduce the therapeutic presence of both the therapist and the patient. Remote therapy calls for a therapist who is willing to introduce the patient to inner experiences that are not always comfortable for him. This approach of striving for contact with the patient's defenses or avoidance methods is accepted today both in the dynamic modalities (see Experiential Psychodynamic Psychotherapy) and in CBT approaches (see for example the Unified Protocol and ACT) - but remote work further emphasizes the need to create presence by an active therapeutic approach.
Presence of the body
The presence and ameliorated experientiality can also be achieved by increased use of the body. It is possible to combine full-body activation (including legs!), for example activities that include movement, standing or walking. Combining different senses during the remote encounter can give the therapist and patient an experience of physical presence. You can share a sip of a cup of coffee together, listen to a song together, watch the view from the window of the patient's room together and more and more.
Shared experiences can enrich the process, you can even return to childlike places and experience different games together during the meeting. We have practised in sessions singing together, walking barefoot at the same time, and many therapists even attended and watched teenagers play computer games as part of the session. Using the digital whiteboard opens up many game options such as Winnicott's Squiggle.
Deepening the meeting using online tools
Since we are in front of a computer when meeting online, there is access to a variety of different tools that can contribute to the meeting:
Use of music and videos: Shared viewing of photos or videos of the patient. Pictures from childhood, of the children, of the safe place for him/her. Videos can be a significant tool in exposure sessions during remote therapy.
Knowledge transfer: YouTube offers an endless selection of videos that can suit almost any therapeutic discipline. It's worthwhile to prepare in advance in your bookmarks videos that you may want to use. Other examples include the use of useful information sheets, skills practice sites - in fact from here you can also continue part of the therapy, outside the session - and more on that later.
Shared experience: Listening together to music, videos or pictures that the patient presents (significant people in his life, safe place, meaningful experiences). Sometimes it is possible to ask the patient to prepare the photos / videos for the meeting, in order to reduce the time involved in 'logistics' during the meeting.
Filling out forms: You can of course share documents / forms that you have on your computer. An additional level of collaboration can be achieved by letting the patient write a form on your computer. As part of 'Preparing Your Car for Winter' approach, maybe a quick refresher in sharing a screen and providing remote control to the patient in the online session could be useful?
Specific tools: Close your eyes for a moment. Try to remember the different facilities you have in the clinic. A box of tissues? A cup for water? Metaphoric cards? Maybe a ballt? Games? Maybe you sometimes take advantage of the view seen through the window in your clinic? Now ask yourself how you can use different websites to provide similar experiences. Here are some examples of sites that can be used during a session:
Digital therapy cards: metaphoric cards and specific cards for a variety of different uses (such as sorting values, identifying emotions, situations, identifying thought patterns and more). Examples: Digi Card Therapy, Values Exercise | Think2Perform
Tools for Dealing with Thoughts: Example - Pixel Thoughts
Here too, we suggest preparing in advance sites that may be relevant to you and adding them to your browser's favorites list.
Get out of the closet
The remote encounter does not have to be limited to my square frame on the screen, let's get out of the zoom closet together! You (and your patient) can get up from your chair, move around. Ask the patient to take off their shoes, walk around together and feel their feet. We can ask a child to run around the room a bit. Send him/her to bring their favorite game.
For those of us who like chair work, there is no reason not to practice chair work online! Ask the patient to bring another chair - and go ahead! Maybe you don’t use this method presently, could the (increased) return to online therapy be an opportunity to experiment with this technique?
The more we integrate the space and the full body of the patient and ourselves, the more we can deepen the online therapeutic experience.
Work between sessions
The understanding that one treatment per week has limited power to change ingrained patterns of behavior and emotion is common to most therapeutic approaches. The psychoanalytic approach tried to solve the problem by creating a setting of between 4 and 5 sessions per week. CBT tends to solve the problem by giving homework.
The use of a computer and recordings as done in Zoom work allows for activation and reverberation of content that has come up in the treatment. And in the opposite direction, using zoom style applications, it is possible to perform homework by recording an activity and sending it to the therapist.
In couple therapy it is possible to record the interaction of the couple during the meeting and allow the couple to observe the exercises they did in the clinic even on days when there is no treatment. Conversely patients can be offered to record crisis situations and allow the therapist to watch them.
Here, too, since we are in front of the computer anyway, using digital tools may be more natural. There are various sites that allow you to send content that has been defined by the therapist and the patient as instant reminders, thus continuing to 'resonate' the encounter and increase the assimilation and change of behavior patterns.
Seeing ourselves and facial expression
One of the characteristics of remote therapy, which almost got there by chance, is the fact that in the zoom and similar software both the therapist and the patient see themselves. As we have described in the past, this opens up important possibilities for talking to the patient about what we convey to each other through facial expression. Some studies suggest that people are not aware of what their facial expressions convey. An important possibility opens up here: after all, we therapists are usually in a position to interpret the patient himself by listening to his voice, tears, etc.… But sometimes the patient is not conscious of the expression on his face , his feelings, and what feelings he communicates to others through the expression of his face.
There are many patients who for various reasons are challenged in their ability to identify and / or express emotions nonverbally. In the RO DBT approach, it is customary to attribute 'social-signaling deficits' to a population that they call over-control (Over Control or OC).
The self-image and the ability to focus on facial features in remote work, open up an opportunity for us to practice expressing and recognizing emotions using facial features.
This state of self-image allows us to discuss with the patient various aspects of his self-perception. One can develop his dialogue with his face or certain parts of his face (how he relates to his eyes, the structure of his mouth, the length of his nose, etc.). This dialogue may often lead to deeper areas of self-criticism. For example: "I do not like my look that indicates my longing for a relationship" or "I do not like my attached eyebrows that remind me how critical and angry I am." In a sense, working with the zoom creates an element of exposure: exposure to self-criticism - a topic that underlies many psychopathologies. Perhaps the self-image can offer another window to reveal the patient's (and the therapist's) basic beliefs about himself.
Zoom allows working with two therapists
Many of us today understand the need to find an integrative therapeutic model, the veterans among us who have already undergone dynamic / psychoanalytic treatment themselves are also familiar with the magic of it as well as its limited ability to bring about change in a short time. On the other hand, many of us who have been looking for more practical solutions within the CBT approach, understand today that part of the process of change actually takes place in front of an attentive therapist who is not necessarily attached to a particular protocol. However many therapists find it difficult to incorporate multiple therapeutic approaches.
One of the solutions we use in my clinic is a combination of two therapists during treatment. The easy but complex solution is that each therapist sees the patient individually. The more successful solution is to work in co-therapy where the two therapists are present at the same time during the session.
Before the days of remote work, this required considerable coordination work: coordination of the times during which the two therapists can come to the clinic and, of course, coordinating this with the patient. When it comes to zoom therapy it's much simpler.
Remote therapy makes it possible to restore the systemic therapy approach.
The systemic approach suggests not only focusing on the "Identified Patient" but also on significant figures in his life. But it is easier to work with one patient than with the system around him. It is easier to work with a couple than with the extended family or the family of origin. Once the possibility of connecting remotely has become accessible, different people can be invited to the therapy session and not just the patient himself. You can see the child in his family setting, you can invite the parents who may be at that moment elsewhere. You can invite the teacher to the meeting. Any of the persons who effect our patient can easily join the session.
The emergence of a new Tradition?
This title, which describes "the birth of a new tradition," has a question mark attached to it. The question mark appears first out of humility. After all, the name “The Emergence of a Tradition” is also the name of a book from the Relational Psychoanalysis series edited by Stephen A. Mitchell Lewis Aron. In the opening of this book they say something like this: Traditions cannot be established or created consciously; they can be discovered only in retrospect, in self-reflection. Something works well or was exciting, or felt good, and you want to do it again. People become aware that they have done certain things the same way, planned activities, used concepts, over and over again. After a while, a sense of tradition for events or approaches accumulates.
Is it possible that remote work can fall into this definition? Has a tradition been created here?
Over time, rituals, some positive and others less, join the tradition. We must allow them and at the same time examine them critically. It is the diversity of experiences that enables 'natural selection' and continued growth.
We like the title “The emergence of a new Tradition” because the word emergence contains both the root ‘emerge’, which means to form and also the association to emergency and indeed for most of us remote therapy is born out of a state of emergency. But as we showed in this post, it also has its benefits.