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The Ten Commandments for a remote therapist

Practical information for therapists

Remote treatment (for example on Skype or Zoom) is already here and it is already a fact. And yet quite a few questions arise about the significance of this change in setting. It is no coincidence that dynamic therapists write about the subject and see it as an opportunity for dialogue about rules and breaking them. At a recent conference on the topic organized by the Psychological Federation, I tried to offer ten rules to a therapist considering entering the field. You can see the complete presentation here.

The reason why the Word of Ten Commandments crept into her here is no accident. We are dealing with the most sensitive and precious thing - the human psyche - hence clear reference to holy work.
To a great extent, many of us believe that interpersonal encounters are an important - perhaps central - factor in therapeutic work.

The possibility that treatment of the human psyche would be done through a computer seems truly blasphemous. Therefore, quite a bit of thought is invested in the possible way to conduct such treatment while adhering to the principles of psychotherapy.

One of the characteristics of the Ten Commandments is the existence of do's and don'ts. A well-known rabbi told me the following joke: When Moshe came down from the Moriah with the Tablets for the second time (after he first broke them in anger) he told his associates. I have good news: we managed to reduce the number of commandments to ten. The bad news is that "Don't Taste" remains on the list ....) Well as you will see, we have narrowed down the list, we have also made and do not, and we have touched quite a bit on the question of intimacy in treatment.

First Rule: Experiment!

About a year ago, for a seminar we did at the clinic, I submitted a questionnaire among therapists about their attitudes toward distance therapy. The questionnaire was transferred (how not ...) to the network and filled by about 40 therapists from different orientations.

It turns out that many therapists determine a position on remote treatment without knowing the issue. One notable finding was related to how remotely similar a treatment experience is to a close-up experience (hereafter treated in the same room). Apparently, those who did not experience such treatment thought it to be fundamentally different, on the other hand, as the therapist experienced the most Zoom treatments, the more remotely rated the treatment in the same room. Hence the first rule that proposes to experiment

You should start a Zoom conversation with friends and feel the different and similar.
In such an experience you will feel the "there is nothing" in such treatment. You will have the opportunity to pay attention to the talking heads experience ie the "absence of the body" in such a meeting (although as you will see below one of the rules will suggest a simple change that will change the feeling of a no-body meeting. Of the patient in a large and clear face on the screen It would be fair to say that today's technology face-to-face sitting allows you to better detect slight changes in the patient's emotions as revealed by facial expressions. It will also be an opportunity to experience the ease with which you can communicate with the remote person Thousands of miles away and the almost grandiose experience of overcoming the border.



On the other hand, you can also experience the frustration sometimes associated with technology limitations: call disconnection, poor resolution where you see the other image partially and most of all the delay that is sometimes characterized by slow Internet calls.



Rule two: Make every effort to start a face-to-face meeting

The basic rationale is simple: biologically we are made to know through physical encounter. And in our development we respond to smell, touch, movement and of course sound and sight
On the other hand, the human brain is so adaptive that it can learn to connect the experience in a face-to-face encounter to the remote encounter.

It seems to me that after a few sessions where we met the "patient's body" we could also experience his presence in remote care.

The first sessions allow us to learn each other better after this step can "complete the blanks" even when we are treating screen-to-screen.

Important key content in understanding the transfer will actually be through the comparison between the "same room" experience and the Zoom-based treatment.

The process of transition and the importance of comparison:
After a few face-to-face meetings, a Zoom meeting for trial. It is important to prepare the patient for possible difficulties.


It is important to talk to the patient about each of the formats
This is a wonderful opportunity to know the patient's needs. What matters to him is why he longs for what he avoids.


Rule Three - Try to create similar conditions for "meeting in the same room"


I believe that good treatment is based on two key characteristics: an interpersonal encounter that has listening, empathy and holding as well as useful research knowledge of effective techniques and interventions.


Quite a few studies have shown the efficacy of technology-based treatments. About 15 years ago, I was a consultant to a British company that developed psychologically assisted technologies. I believed that to bring back and resonate with the effects of the therapy session, they had to be preserved through applications that remind the patient of the topics we were working on in the session. And so I helped develop a software called Beating the Blues, a software that gave the patient some principles of cognitive behavioral therapy. The company management thought unlike me that this software can be used even without a handler.


I then got into a bitter argument with the company's management. I argued that it would not work. I boarded barricades and declared that there was no treatment without a human encounter. After seven studies performed in the UK and proved the effectiveness of the method. I had to "eat the hat," and admit that there are different ways leading to Rome. The way I understand the findings today about the efficacy of different technologies is by saying that "there is only one type of treatment" and that there are many ways to make a person change, and that one treatment is not necessarily expected to be the same.


In particular, in the case of Zoom-based therapy, it is very different.


Here I do suggest using the gold standard of treatment in the same room. My goal is to make remote treatment very similar to close-up care. I will also add that quite a few studies have shown that this is indeed the case, for example in meta-analysis (Backhouz et al., 2012) it was found that in 14 different studies, both patients and caregivers experienced the therapeutic alliance in remote therapy as strong, as compared to face-to-face treatment.
It was also found that patients' satisfaction with same-room and remote treatment was similar (King et al., 2009; Morgan et al., 2008)

The following set of rules is thus intended to further reinforce the importance of interpersonal encounters as read in good psychological therapy.


Rule Four: Seating Distance - Be Warned of the Common Mistake of On-Screen Sitting

Certainly part of the way we perceive others is through the body. Voice and appearance are an important but not unique component.
Most therapists who engage in remote therapy cling to the screen, thus losing the experience of meeting the body.
We suggest doing it differently - doing it in a manner similar to conventional treatment. The rule is simple. Instead of sitting on a chair close to the screen. Sit on your therapist's armchair about a foot or two away from the screen, similarly ask your patient to sit in a similar way on a comfortable armchair. This way, you will see the patient quite similar to the way you see him in the treatment room.

Rule Five: "Time for Intimacy"

We understand that a situation where we meet another person through a screen and sometimes his character appears at low resolution and his voice arrives late - such a situation may block the sense of closeness that develops in close attention.


The role of the therapist, therefore, is to be aware of this difficulty and to invite the patient into intimacy


The time for intimacy
I write this and some of the books in my bookcase begin to whip me: one book falls on me and highlights the importance of abstinence. A second article says passionately: intimacy cannot be artificially created. Either it is created or not.


Still, when I think about how I try to overcome the distance and perhaps the coldness of remote therapy - I sometimes find myself telling the patient "I want to see your eyes" or "Let's try to feel like we're together in one room." I undoubtedly get into an inviting (or tempting?) Position for intimacy.


My experience of the level of intimacy that can be reached in remote therapy does not fall short of the meeting in the same room. And sometimes even more: some patients report that the physical remoteness allows them to be more visible.

In continuation of this rule, I offer the following: Invite eye contact


In day-to-day life, we have a special ability to recognize when we look into our eyes. Such eye contact has important abilities in creating closeness and not surprisingly so people with a variety of psychological problems avoid eye contact.


In remote handling this is even more complex since the camera is located higher than the eye level of the interlocutors and so it often seems as if the patient is not looking straight. The solution we found is to sit farther away from the screen and then have more eye contact.


In the context of the invitation to intimacy, our very request for an eye meeting has a message of I don't give up on meeting our souls. Even if we do not meet physically.

Rule Six: Beware of fake intimacy

A recent article on (an excellent site edited by Victor Yalum) bears the provocative title "In bed with your therapist" in this article, two therapists describe their experience in remote therapy when the patient is in bed.

Many of the computer habits today are based on tablets or laptops and many people tend to do this on their knees and often in their bed. Some patients see it but it is natural to make the conversation while lying down or sitting on their bed.

I say immediately - I oppose it and ask them to always sit in the same room and as if possible on a comfortable armchair.

The Facebook world and fast-paced messages have created a culture of pseudo-intimacy and quite a bit of cybersex. It is precisely the remote encounter that has the disconnect from a possible contact is sometimes inviting to an inappropriate flirtation.

An example of a patient who chose to "take a book from the bookcase" as she approaches her chest where the camera is and asks if I enjoyed it.

Surprisingly (or not) a fair number of psychoanalysts have attempted to reconstruct the experience of lying on the analytical couch when they recommend that their patients lie down in their bed. These therapists even aim their camera so that the patient does not see them but the ceiling. Of course, I think this goes against the important rule of creating therapeutic intimacy.

Rule Six: Insust on a fixed room for treatment

So many settings we break in the remote treatment so that if we have the setting of the patient's room and the therapist's room - it will be a great blessing.

The patient room is important to be well closed, not only not in the middle of the living room, but also to make sure a good sound seal. And sometimes you might even want to ask the patient with a headset and a microphone to protect their privacy.

Still - we will benefit from entering the patient's home

As mentioned, the treatment is done in the patient's home is not trivial. It changes something very basic in the atmosphere of therapy.

But as mentioned, we will try to "earn something" from this disadvantage. We have a rare opportunity here to take a look at the patient's room or in less intrusive words - we have the opportunity to know what pictures he hangs in his room, how neat or messy the room is.

Rule 7: Dealing with glitches 

Malfunctions are an integral part of remote therapy.


Often the picture freezes, the voice goes awry or worse the call goes away.


A common experience is the delay - the patient hears what you said late and answers a previous question when you've already had the chance to ask a few more questions.


All of this creates frustration for both of you and it will be interesting to see how you process it.
The therapist would do well to use this opportunity to see the patient's ways of dealing with frustration.


A common occurrence in the event of a malfunction is the "guilty search experience": This is manifested when the Internet connection is disconnected and then searched for whether the problem is on the therapist's computer or Internet connection or patient's. At these moments, one can see mechanisms of guilt seeking in the face of another possible attitude of tolerance towards the difficulties.

The eighth rule: a few words about the payment

Many patients and therapists ask how the issue of payment is handled remotely. The answer is simple today and it is very easy to make online bank transfer. And also in "regular" treatments, patients pass on the payment to me in this way.

It is also very easy to open a paypal account to which the patient can transfer the money.

I am aware that the payment method is often of psychological significance. Recognizes the phenomenon of the patient "throwing the banknotes" on his chair when the session ends, as opposed to those who write the pouch and serve it at the beginning of the session. In the circles of friends who went to the care of a well-known psychoanalyst, the story revolves around the fact that she always asks for a cash payment in the statement that only in this way can the patient experience the simple connection between treatment and payment.

I'm also being asked about the costs of remote care. The reason for paying for remote care should be the same as paying for care in the same room. I find no reason for different rates in this case.



The Ninth Rule: The long distance meeting gives us the opportunity for close understanding

Many patients are debating early on whether remote sessions will be good for them.

If there is anything we have learned in psychotherapy, the following is the rule: Anywhere with deliberation or ambivalence call it awareness and conversation.

So when a patient shares his or her difficulty with lying on the couch as opposed to the experience of sitting face to face with the therapist - these are wonderful moments when treating him or her with the patient's emotional needs.

Here, too, we have the opportunity to learn what he lacks and what he produces in remote care. I recommend being sensitive to the patient's internal dialogue about remote therapy.

One example is related to a patient who divides his time between working in Israel and working in a foreign country. And so we meet from time to time in my clinic and sometimes meet via Zoom or Skype.

This form allows him to share with me how much he misses sitting in my room, with his particular mess, as well as his good feeling with the simple coffee I make for him.

And on the other hand, he knows how to talk about the benefits of remote therapy:
Some of the reasons are technical - no traffic jams, it's easy to find time for meetings, you can meet in a closed room at work.

A patient who is had been with me time mainly with Skype based sessions but who had started face-to-face meetings once said

"In the Skype sessions, I'm much more candid with you - I dare, and sometimes even feel closer"

Tenth rule: The remote encounter also invites a conversation about the patient's dialogue with technology and modern life.

The decision to meet via Zoom is not trivial. Neither for the patient nor for the therapist. This is a point where they are aware of what they are losing as well as why they are making a profit.

It is possible that what characterizes the present century is the moment when technology really changes our lives when we both enjoy it and feel how it has taken over our lives.

This is an opportunity for the patient to tell how much he is or is "addicted to technology".

And it also allows me to finish the article and admit that one of the reasons I entered this field a dozen years ago is the fact that I love technological innovations. And on the other hand, I live and breathe psychology and love psychotherapy.

So in conclusion, the psychotherapeutic encounter is sacred to me and should be treated with caution. However, I believe that flexibility is a key condition for treating and used in remote therapy is one of the examples of therapeutic flexibility. However, I would like to emphasize that, as far as possible, the traditional face-to-face meeting in the same room should be pursued.

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