Author: Psychotherapy.net Team

Online Therapy

When engaging in psychotherapy by Skype or other video conferencing system, clients will often keep their appointment even when they feel too sick or fragile to attend school or go to work. They reach out to their online therapist from the comfort of home, sometimes wrapped in blankets in a cozy chair, sometimes lying on a couch.

And sometimes, they will have their session from bed, cradling their on-screen therapist in their lap. As an occasional change of locale, it makes sense and is far better than missing the session.

Other clients actually prefer to hold their appointments in bed on a regular basis. Both authors have held continuing weekly sessions with men and women who connected with us from their bedrooms, usually clothed and lying on top of the bedspread, often leaning back against the headboard with pillows. The session venue a client chooses often makes a subtle statement, but our clients who take us to bed instantly get our attention.

Therapists in bed with their clients. It raises so many uncomfortable but fascinating issues. Does it mean we, as therapists, are failing to preserve good boundaries? Are we allowing our professional role to be trivialized? Is the erotic transference (or even more troubling, the erotic counter-transference) at work?

We believe that occasional sessions from bed can be useful, maintaining contact that might otherwise be interrupted by illness or some other factor. We have found that the choice of ongoing sessions from the bedroom provides important information, to be understood and made use of in therapy. Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of this unusual choice—to take your therapist to bed.

Kyle and Lisa are two clients whose stories show how bed sessions can be both constructive and revealing.

Kyle and the Shame Spiral (Joseph Burgo)

Early in our work together, Kyle used to suffer from what we referred to as the "downward shame spiral." Fearing that he might humiliate himself at some upcoming event such as a job interview, Kyle would postpone that appointment at the last moment; but doing so only filled him with shame and made him dread the rescheduled interview even more, which he would subsequently reschedule once again with another feeble excuse, and so on, until the employer lost interest.

Eventually he would become so overcome with shame about his behavior, feeling himself to be a “total loser,” that he would retreat from the world and retire to his bed, often for days on end. Sometimes he would cancel one of our twice-weekly sessions at the last moment; on other days, he slept right through the hour and emailed me much later. Missing the appointments intensified his sense of shame and failure, which made it even more difficult for him to break out of the downward spiral. Overcome with shame, he couldn’t reach out to me for help.

I came to recognize when Kyle was on the verge of one of these retreats by reading his facial expression … or rather, his complete lack of expression when he appeared on screen. Kyle’s usual manner was quite lively and engaging; he had a good sense of humor and a compelling smile. In the grip of a downward shame spiral, however, his face looked deadened, as if it were numb. While he and I normally had a warm and friendly relationship, at these moments, he gave me an impression of complete indifference, as if he felt nothing about me. He seemed encapsulated and cut off from me. I could usually predict that he would miss the next two or three sessions.

Eventually, Kyle would emerge from his shame retreat, re-engaging with me and the world at large, though we never understood exactly why and how he recovered. It felt almost biological, as if he had to pass through a physiological cycle over which he had no control.

This state of affairs went on for six or seven months, with downward shame spirals kicking in every few weeks or so. As many times as I encouraged him to reach out to me, as warmly as I expressed my concern, nothing seemed to help him withstand the call of bed. I felt frustrated by the many missed appointments and wondered if I was really helping him. During one of our sessions at the end of this period, he came in with the “dead face,” as we referred to it, and I didn’t expect to see him for our second session later that week.

I nonetheless logged onto Skype at the appointed time to wait for him. A few minutes into the session, I received an email from Kyle. Running behind. With you in a few. I sat at my computer and waited. About five minutes later, Skype showed Kyle “online” and he soon initiated the call. My screen came to life. “Usually, Kyle would speak to me while seated at a table in his apartment, or sometimes in a small conference room at his workplace. Today, he was in bed, lying down so that his unshaven face appeared sideways in the screen.” His hair was rumpled. He still wore the dead face expression but at least he had shown up.

“Is this okay?” he asked. “I wasn’t sure if you’d mind my Skypeing you from bed but I couldn’t make myself get up.”

“You’re here,” I assured him. “That’s what matters.”

Kyle filled me in on the last couple of days. He had indeed fallen into a downward shame spiral after our last session and retreated to his bedroom. He’d cancelled some appointments and dropped the ball on some important commitments, but he didn’t want to remain in seclusion any longer. I could feel him searching my face for disapproval or judgment; I told him that I was very glad he had managed to keep our appointment.

Over the course of the session, Kyle shifted to a sitting position, his back against the headboard, with his computer positioned in his lap. Though not exactly lively, his expression no longer seemed completely immobile. By the end of the session, he had resolved to get out of bed after we signed off, and so he did. When he appeared on screen for his next session, he was fully clothed and in work mode.

The in-bed session was a transitional space for Kyle: allowing me into his place of seclusion helped him to bridge the gap and reconnect to his world. I considered it a sign of progress that he had reached out to me and indeed, over the next half-year, the downward shame spirals lessened in both frequency and duration. We conducted one or two more sessions from his bedroom, but eventually, the strength of our emotional connection allowed Kyle to keep his appointments no matter how badly he felt.

Eventually, the downward shame spiral became a thing of the past.

Lisa's Artist's Block (Anastasia Piatakhina Giré)

Lisa was an attractive woman in her late fifties whose marriage to a successful businessman allowed her to pursue her passion for art. The first time we met, Lisa was lying in bed, weak from a recent flu. A bright floral canvas appeared on the wall behind her. She told me she was a painter and proudly announced that she had her own “atelier” in her home. The painting on the wall was one of her own.

I enjoyed meeting with Lisa, even if the décor—the flowery bed linen and a bedside table with a pot of face cream on it—made me feel rather uncomfortable and aware of boundaries being crossed. “Lisa apologized for “receiving me in bed,” but didn’t look uneasy about it.”

At first glance, Lisa seemed to have everything a woman of her age could wish for: two grown children, a supportive husband, and a very exciting hobby. But she acknowledged a feeling of profound sadness and almost physical emptiness, which she could not explain or share with anyone else. In fact, for the past few months she had been unable able to paint and was actively avoiding her studio. Describing her artist’s block, unusual for her, made Lisa blush with shame.

As the weeks went by, she continued connecting for sessions from her bed. She looked perfectly healthy, with no signs of depression or any other debilitating condition. Unable to escape from that bedroom, my uneasiness kept growing and I gradually began to feel trapped.

What was Lisa trying to convey by “keeping me in her bed”?

When I finally shared with her my curiosity about her choice of place for our sessions, she at first seemed surprised. She had always thought that online therapy “was this thing you could do from anywhere.” Then we began to explore what “bed” represented to her. I asked whether it was a space she usually shared with her husband, Charles.

No, they had being living in separate rooms for the last decade as Charles’ sleeping problems kept him awake for most of the night. In the beginning, he used to make frequent visits to her bedroom; they would often stay in bed together, chatting and sometimes making love. Over time, his visits became increasingly rare; now, he would pass by her room with just a quick “hello,” moving on to his own bedroom. Sharing this for the first time, Lisa looked profoundly sad, her usual cheerfulness replaced by tears.

I understood that her bed had become a lonely place where she felt trapped, unwanted, and too old for sex. To express these feelings verbally, either to her husband or to me, her therapist, was far too difficult because she felt so ashamed of this “pathetic and needy” part of herself. Though Lisa couldn’t express her desire for sexual contact with her husband, was she unconsciously making me his replacement by taking me into bed?

I encouraged Lisa to take the risk and tell Charles how she felt. The confession took him by surprise: he had no idea that his wife still desired him and had assumed that she preferred him to keep his distance. Charles soon came back to visiting her bedroom regularly. Now that she had replaced me with a more appropriate “bed” companion, Lisa began connecting for sessions from her atelier, a far more suitable location for therapy.

For our last session, Lisa was dressed in her working outfit—clearly Charles’ old shirt, oversized for her. She was bubbling with a new energy, and announced to me that her artist’s block seemed dissolved, “gone by magic.” She was able to paint again.

Up Close and Personal

These two vignettes illustrate how online psychotherapy can facilitate progress and provide information that in-person sessions cannot, at least not as quickly. No doubt Kyle would eventually have made his way back to the consulting room after a shame attack, but the middle-ground of therapy-in-bed provided a helpful bridge. In all likelihood, Lisa would eventually have communicated her isolation and longing for intimacy to an in-person therapist, but without the visual setting that prompted her online therapist to probe deeper, it likely would have taken much longer.

In discussions of online psychotherapy, professionals and laypeople usually see it as second best to in-person therapy. After practicing in the online setting as well as in person for several years now, the authors have come to believe that it is neither better nor worse, but truly different. Experiences like being “taken to bed” by our online clients often provide a kind of insight that would never be available to a therapist seeing all of his clients in a physical therapy office.

We’ve also discovered a special intimacy that is idiosyncratic to online therapy. Even if both were sitting up, the in-person therapist would never see a client such as Kyle so intensely “up close and personal.” During an online session, the computer image often seems analogous to a movie screen filled up by an actor’s face, conveying high intensity anger or fear or shame to the audience. While in certain respects online sessions are less immediate than in-person psychotherapy, we have found them to be even more intimate, more emotionally evocative in this particular way.

Online sessions also allow a client like Lisa to show rather than to tell, and as any fiction writer will tell you, a vivid and visual scene more effectively engages the reader than straight narrative. Clients who connect from bed often show us something deeply personal and painful that would be much harder to narrate later during an in-person session. Consciously or not, they invite us to witness their personal world first-hand, to enter their story lines, so to speak, rather than hearing about them after the fact. This conveys to the online “here-and-now” a very distinct, moving quality.

Such moments of real intimacy and shared vulnerability are precious, helping us to forge a strong therapeutic relationship with our clients, even ones who may be thousands of miles away on another continent and who we may never actually meet in person.

This essay is condensed and adapted from the authors’ forthcoming book In Bed With Our Clients (and Other Adventures in Online Psychotherapy).