Online or Distance Therapy Archives - Page 3 of 5

Joseph Burgo on Shame, Narcissism and the Art of Empathy

Posted on March 29, 2019February 11, 2026 by rezendevknowfully.com

A Personal Journey

Lawrence Rubin: You’ve been a practicing psychotherapist for over 30 years and have authored several best-selling clinical books. You seem fascinated by the clinical concept of shame. What’s its appeal to you personally and professionally?

Joseph Burgo: I guess it begins personally because for the last 15 years I’ve been coming to terms with my own shame, learning to recognize the role it has played in my life that I didn’t quite understand even at the end of my analysis. During that time I’ve been applying my new understanding to my clients in my clinical practice, and writing a book about it that would be helpful to people who aren’t necessarily in therapy. So, I suppose it’s the case that when you’ve been researching, and writing and thinking about something for a while, it takes a central role in your life.

Right now, it seems to me like shame explains almost everything

Right now, it seems to me like shame explains almost everything.

LR: It seems to be a really elastic concept that can be applied to all forms of pathology and client presentation. What kind of therapist do you think you were before you worked through your own shame issues?

JB: I was a blank-screen, classical sort of psychoanalyst trained in the object-relations school—Melanie Klein, Donald Winnicott, those people. I focused on issues of need and dependency because, from the object relations framework, everything is viewed in the context of maternal-infant relationships—what it’s like for a baby to depend upon her mother and the emotional impact when dependency doesn’t go very well. This is when the infant must protect itself from unbearable feelings of pain and disappointment.

That was the old paradigm. I wouldn’t say that I don’t think that way anymore, but I focus more now on shame and self-esteem. I don’t like the word self-esteem but it’s the word we’re stuck with. I focus more on shame and defenses against shame, the way we protect ourselves against feelings of defect and unworthiness, rather than defending against feelings of neediness and helplessness.

LR: If your personal work on shame has allowed you to be freer of its pull, would you say that, irrespective of the type of therapy you practice, you’ve become a better or different therapist as a result of your own resolved shame issues?

JB: I like to think so. I’ve become a more empathic therapist for sure. I’ve always been empathic and had the ability to empathize with what my clients were going through, but for too many years I regarded that as information I needed to use in order to formulate interpretations. I still do that, but often now it means that I need to say something a little more personal or more directly empathic like speaking to the agony of their shame and letting them know that I have felt that way too. I understand what they’re going through in a way that isn’t distant, isn’t intellectual, but is immediate and authentic.

I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience

I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience. It isn’t enough just to make interpretations.

LR: That’s interesting because somewhere in my readings about or by you, you said that clients must wait for their therapists to grow enough to be able to help them. Is that what we’re talking about here?

JB: It is, and when I wrote that I was thinking in particular about two of my very long-term clients who went through a fallow period in their therapy until I addressed my own shame, and then understood shame better and could help them address theirs. That took a while. And it’s interesting that one of them will sometimes refer back to that period when I hadn’t quite figured it out as a fallow period, when we were kind of spinning our wheels.

LR: That fallow portion of the therapy was in part influenced by the growth that you had not yet made!

JB: I think eventually I was able to communicate that to them. However, in the beginning of that fallow period, I defended myself. I had been giving the correct interpretations, but they weren’t making use of them. I didn’t say that, but I think that was my attitude, and it was a somewhat blaming attitude.

LR: It must have been very empowering for you and those particular clients to reach out of that fallowness and find your ways to growth.

JB: It was. It was very productive. It was very moving and relieving that we found a way through that impasse.

LR: You also mentioned that you’ve been most successful in helping those clients whom you have found endearing. Has your own growth around shame allowed you to find clients more endearing and maybe, by association, have you felt more endearing?

JB: I don’t think so. I think this has been a feature of my work from the very beginning. The longest-term client I’ve dealt with, who I’ve mentioned in some of my writing, is very difficult, very volatile, probably in the realm of borderline personality disorder. And yet, endearing to me from day one for some reason. I don't know why, and that was many, many years ago.

LR: Do you find that you’ve become more endearing as a person and a therapist as a result of the work you’ve done on your own shame?

JB: It’s something I hadn’t thought about before. I know I’ve become warmer, more accessible, less intimidating for sure. I don't know if I’ve become more endearing. I think to my closest friends, yeah, probably. They will remark on how I’ve changed.

LR: What are some of the signs that a therapist is being overly influenced by their own shame to the point that it’s adversely affecting their work?

JB: I would say that one of the most common ways is for the therapist to hide behind their professional role and to allow clients to view them in an idealized light–as if they’ve got it all together. This sustains a therapist’s own defenses against their shame. I think this is common, and you hear about therapists who are amazing to their clients, adored by them, and their personal life is a disaster.

The Value of Shame

LR: What do therapists need to understand about working with clients whose pathology is shame-based? Clients don’t come in wearing t-shirts saying, “I’m shame-based.”

JB: I think there are several things. First, I think we need to expand our idea of what shame is.

We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing

We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing, and it usually has to do with some intolerant social perspective, some way that people are influenced by perfectionism and intolerance in the broader culture, and the work of John Bradshaw and toxic shaming. That’s the way we view it. That’s one of the things I try to challenge in my new book, to help people, both clients and therapists, look at shame as something else. The other thing I’m trying to do in that book is to look at the ways that everybody defends against shame. There are a consistent set of defenses that people use when shame is unbearable in their lives. I talk about as avoiding shame, which is in the realm of social anxiety; denying shame, which focuses on narcissistic issues; and controlling shame, which is more in the realm of masochism and self-deprecation.

I think you have to learn to recognize a defense against shame, understand what it is, and then help the person to gradually, over time, defend less against it, understand what it is that they’re running from and learn from it. Sometimes, when we’re behaving in ways that we don’t respect, we have a lesson to learn about our behavior, and shame is a message to us that we need to take a look at ourselves. Sometimes shame is telling us we need to try harder and that we’re not holding ourselves accountable. Sometimes shame is telling us that we have some room to grow. That’s a way I really try to reframe shame as an opportunity for growth rather than this uniformly bad thing.

LR: If we look at shame as part of being a human, we can then consider whether it is serving us and how we can develop a new relationship with it so that there’s more room for growth.

JB: I think so. I think that’s a good description.

LR: You wrote about a client named Caleb, the one we highlighted in the excerpt on this site in a chapter called “Superiority and Contempt.” Upon reading, I didn’t like him and know that you struggled to feel connected with and empathetic toward him. What impact did he and clients like him have on you?

JB: It’s a challenge working with a client like that because your own feelings of worth are impacted. Intentionally and inevitably, when a client like Caleb is in flight from their own shame and defending against it, they will often project it onto other people and then hold them in contempt as inferior and defective. Even though I’ve evolved a lot, I still see the transference and the working relationship between therapist and client as a microcosm of the client’s issues, and often the best way to address them.

Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful

Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful. If you’re not aware it’s very easy to become defensive and to make the sort of interpretation that might be shaming to the client, or to sort of shore yourself up, and end up in a tit-for-tat relationship. It’s a conversation that’s being had beneath the conversation in therapy.

LR: Exactly. This very morning, I had to decide to delete a contact from my phone contact list, a guy that I’ve known for 50 years. We are in a constant tit-for-tat, but it seemed that at the core was his need to shame me. He finally stopped communicating with me, and then I texted him on his birthday and got no response. I texted him again yesterday with no response, and this morning I was thinking, and this was my own shame talking, “What can I say that will shame him the most deeply?” And I came up with a perfectly crafted text that would have probably put him through the roof, but instead I decided that that’s sort of a poison you take waiting for someone else to die, so I just said “the heck with it,” and deleted his contact.

JB: The difficult thing about that experience is when someone doesn’t communicate with you and ignores your texts, what they’re saying to you is that you are unworthy of their attention, which is shaming. It’s painful when you express interest in somebody else and they don’t return it. That’s a kind of shame, and it’s natural for people to want to retaliate in kind and to say, “No, you’re the one who ought to feel ashamed.” But you did really do the right thing, which was to recognize that you wanted to shame him, and then decide not to do it.

The Flip Side

LR: We seem to be in a golden age of narcissism. A few years ago, you wrote, The Narcissist You Know. Why are we all so fascinated by narcissism?

JB: Well, I will start off by saying that nobody wanted a book on shame. I originally tried to sell a book on shame about 10 years ago. It was called Learning from Shame: The Less Traveled Road to Self-Esteem, and nobody wanted it. I was told by agents and editors that the book was a downer and that nobody wanted to read about shame. So, I said, well okay, I will then write a book about narcissism, which I see as the flip side of shame, because everybody’s interested in narcissism right now.

I think that

as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it

as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it. We’re not repelled enough by it. We’re fascinated by it because we really enjoy these images of people–particularly celebrities–who seem to have it all, who are beautiful, rich and successful, and we like to believe that somebody actually does get to have that ideal life. Then we spend our time on Facebook, Instagram, and Twitter convincing everybody else that we’re leading this incredible life, that we have these amazing vacations, and we go to these fantastic parties, and here’s this amazing meal I’m having at this incredible restaurant. It all feels really unhealthy to me.

LR: So, narcissism is a destination for people in hopes that once they are on display and revered, they will be able to escape shame? So, as you say, narcissism the flip side of shame?

JB: Yes it is. It’s the primary defense against shame, to disprove to everybody else and yourself that you’re damaged in any way.

LR: What’s interesting to me is that both are equally illusory and not tangible, though both can have tangible impacts on the body and mind. They seem so illusory but so powerful in their ability to just take over a person and deprive them of a true sense of self.

JB: Well, I agree. I think the problem is that for the narcissist, shame feels like an actual condition, an actual state of being in which they’re damaged, defective, ugly. It’s felt on an almost physical level to be a real sort of damage, a deformity, and that’s unbearable. So, they try to create this opposite steady state, this idealized self, that’s perfect and complete, which completely denies the existence of that other steady state: shame and the sense of being damaged.

That’s the problem I see.

The quandary for the narcissist is that either you’re perfect and you’ve got it all together—you’re fabulous; or you’re so damaged and defective that you’re beyond hope and there’s nothing to be done

LR: And it makes sense that the dichotomy of shame and narcissism are part of borderline functioning, this either-or, black or white, idealized or brutalized images of others.

JB: Absolutely.

LR: Is that why in your writing and thinking you’re drawn to borderline pathology–because it is the epitome of this dual narcissism-shame quandary?

JB: I also see the same issue in bipolar disorder. You see people vacillating between thinking that everything about themselves is so damaged, so screwed up that it’s hopeless, and then going on a manic flight into some magical state in which none of that’s true; they’re super powerful, super capable, they can do anything. I see the polarity not only in borderline symptoms but also in bipolar symptoms.

LR: We seem to be so caught up in seeing bipolar disorder as a so-called emotional disorder of dysregulation, so we medicate people for it. But the medication is not going to modify the core dynamic that drives the bipolar behavior, which is the vacillation between shame and narcissism.

JB: Exactly.

The Challenge of Treatment

LR: What are the clinical challenges of working with narcissistic clients, especially those whose narcissism is considered toxic? It must be very trying and demanding for a therapist.

JB: Well, yes. But the truth is that the people who have extreme narcissistic symptomatology usually don’t come for therapy. They think they’re fine or they’ve got some other mechanism for dealing with it that doesn’t involve acknowledging their own difficulties and asking for help. But when they do come, it is a challenge, whether or not you’re dealing with someone like Caleb, the therapist client we were talking about who projected shame into me, or some of the clients who struggle with borderline symptom.s People who have struggled with borderline symptoms are challenging because they go back and forth between idealizing you and hating your guts. As the transference gets underway, it’s a very volatile and emotionally immediate relationship in which what’s going on between you and how you’re viewed is at the core of the work. It’s very painful to have clients say, “Fuck you. I hate your guts. You’re a leech feeding off my neediness,” and on and on and on. I’ve had clients say the most vicious things to me over my career, and the hard part is that the clients I’m describing often are very insightful in certain ways, like they’re able to identify something true about you but use it against you in a really hurtful way. So, your own issues get stirred up. Are you going to defend against that because it’s so painful? Or are you going to hear it and maybe learn something from it yourself? I don't know. I would say

I’ve grown the most with my clients who were the most difficult

I’ve grown the most with my clients who were the most difficult.

LR: I can imagine that a therapist who’s not done their personal work around shame and whose self-esteem vacillates would have the most difficulty and be caught up in the most damaging counter-transference relationships with clients like this.

JB: I think so, and I think those clients probably don’t stay very long with that type of therapist.

LR: I briefly had a client who I really messed up with because he was like Caleb, but younger and much more energetic, and I constantly found myself trying to prove myself. And there are some clients I’ve had that I wish I could call now and say, “I’ve grown. Can you come back and give me another try. I think I could help.”

JB: Oh, do I know that feeling. And the shame of failure. I feel that.

LR: Some people reify therapists, perhaps out of their own shame and inadequacy. We are the mental health celebrities, the equivalent of the celebrity athletes who they idolize. Then when we fail in their eyes we also fail in our own.

JB: Yes, absolutely. It’s kind of nice to be idealized in the beginning. It can easily feel great that somebody thinks you’re a really together person, and you’re full of insight and empathy, and they look up to you and want your attention. That’s flattering, right?

LR: Until it’s not.

JB: Until it’s not. Until they flip to the other side.

LR: You got that little thing there, doctor, in your teeth and now I’m going to just tear you to shreds.

JB: Exactly.

LR: It seems that working with these complex, characterologically involved clients is not about going to an evidence-based manual and pulling out a couple of techniques drawn from a meta-analysis. It’s not that kind of approach. Can you say a few words about the orientation, beyond technique, that’s necessary to work with narcissistically damaged or shame-influenced clients?

JB: It’s a very personal experience for the therapist because inevitably you’re going to be triggered and your own narcissistic issues are going to be stirred up. So, working with that kind of client means that you have to be paying a lot of attention to yourself. You have to be learning and growing from your shame experiences and acknowledging when you’re off base, when you make a mistake, when your interpretations aren’t helpful, and modeling a kind of ability to tolerate shame experiences and to learn from them for your client. So, it’s really personal, I think.

LR: I’m just sort of wandering back to this morning and how I spent 15 minutes crafting the most toxic, shaming message I could to someone who seemed hell-bent on diminishing me over the years, five decades, and how liberating it was, although painful, to delete his contact. Not that I couldn’t find him if I needed to, but the symbolic gesture of saying to myself, “I won’t allow myself to be shamed in this way anymore because I don’t need to pursue shame.” It came with the package.

JB: But they key element there, I think, is that you said it was painful.

Too often I think we want to take flight into some sort of superior position where we don’t feel any pain

Too often I think we want to take flight into some sort of superior position where we don’t feel any pain. We want to think “In fact, they weren’t worth wanting anyway. They were a terrible friend and I don’t really care about them.” That’s an understandable position to take. I always think that allegory of the fox and the grapes explains so many things. That’s one position we can take but what you said is, “Look, this isn’t good for me because this hurts me.”

LR: The allegory of the fox and the grapes?

JB: It’s the “sour grapes” story. There are some grapes hanging over the wall and the fox keeps jumping up to try and get them because they look so yummy. And then when he can’t he finally decides, well, they were probably sour anyway, I didn’t want them.

Rebuilding Esteem

LR: You have been interviewed by countless folks like me. You’ve offered your words in a public venue. You’ve written, so your words are out there. Does this feed your narcissism in a good way or bad way?

JB: I’d say both. In my new book I talk about how the real antidote to deep feelings of shame is to behave in ways and achieve things that build self-respect and pride to sort of off-set this sense of defect and damage. That has been absolutely true for me. I was at a low point in my life following the economic downturn in 2008 and 2009, following the end of my first marriage. I was just feeling bad about myself. The temptation was to sort of give up and to sink into despair. But I worked hard instead to build my website, rebuild my practice, write my first, second and third books, and to become an authority in some sense on a number of subjects that matter to me. I would call that healthy narcissism, building pride and self-respect, and I feel so much better about myself now than I did 10 years ago.

At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk?

At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk? And why aren’t I a public authority who’s making lots and lots of money off very similar ideas? So, I think there’s an unhealthy sort of narcissism that wants me to be bigger and better than I am.

LR: I understand in ways that sort of transcend this interview. My work with Psychotherapy.net came at a really good time for me. I was a low point professionally, just tired and drained. Teaching but not giving, more withholding than anything else, and wondering how much I really knew and protecting what little was left of my energy and empathy. I feel good about what I do know and what I’ve learned. I feel better about myself, so I think there are those of us who, like you said, embrace opportunities to escape shame and others see shame as sort of a deceptive friend that we can’t quite let go.

JB: That illustrates exactly what I’m trying to say in the book. There was a choice point in your life. You could have continued in that kind of ungiving way. You could have abandoned your profession and looked for something else, or you could find this opportunity that allowed you to apply everything you knew in this new framework where you felt good about yourself. You built self-esteem by doing something you feel good about.

Exploring Defenses

LR: We’ve been talking about shame and narcissism, your training, and your own professional evolution. It seems that at the core of your understanding and your work is the notion of defense mechanisms. You wrote a book called, “Why Do I Do That?: Psychological Defense Mechanisms and the Hidden Way They Shape Our Lives.” Is it always necessary to attend to a client’s defense mechanisms? And if we don’t, is the therapy doomed to a lesser level of effectiveness?

JB: No, I don’t think so. We all have defenses. We couldn’t get through life without our defenses, and some defenses are healthy and helpful. I don’t think those need to be pointed out or challenged. But, when defense mechanisms are deeply entrenched and pervasive, they get in the way of everything. And that’s why we have to draw our clients’ attention to them and help them understand what they’re defending against, so that they can deal with the pain in a more constructive way. For example, narcissism is a defense against shame, and we need to help our clients see how their defenses—their narcissistic behaviors that are meant to defend against shame—are causing all sorts of trouble in their lives, and that the solution is worse than the problem.

LR: So, if a therapist is not psychodynamically trained, and does not understand how to work with defenses and is themselves shame-based or defended against shame through narcissism, is the therapy doomed to a lesser level of positive outcome if for whatever reason defenses don’t get acknowledged or worked through? Is it just going to be patchwork?

JB: I think that a lot of growth and development can occur even if somebody doesn’t think the way I do. Even if they don’t view people in terms of their defensive structures or they don’t see shame in narcissism the way I do, lots of growth can occur. There are a lot of great cognitive behavioral therapists who are helping people, but certain issues aren’t going to get addressed, that’s all. I think that the deeper, more profound issues aren’t going to be addressed. That doesn’t mean it’s not helpful.

LR: The book itself is a self-help manual. I agree, as you said, that a lot of good work has been done by CBT therapists. There are apps for CBT. There are self-help manuals for CBT. Is a self-help manual for dealing with defense mechanisms really going to be helpful without the supplemental work with a real live therapist?

JB: I have clients who have asked me the same question and challenged me on having written self-help books. I don’t know. I do know that I hear from people all the time who have read my book saying how helpful it was to them and how it opened their eyes to themselves and they saw things they hadn’t seen before. You know, I just feel that most people can’t afford therapy. That’s the bottom line. Are we just supposed to say, “Well, you can’t afford therapy, so you’re doomed?” Or do we try to find some way to bring these ideas that inform our practices into a book that people can read, and offer them exercises that they can work on? I feel kind of obligation to do that.

Digital Empathy

LR: As we wind down, I want to draw attention to your involvement with distance therapy for these last five years. What are some of the advantages and disadvantages that you see in this delivery method?

JB: Mostly I see advantages because it gives people the opportunity to have contact with a professional when there isn’t anybody they can see face-to-face. I’ve worked with ex-pats in other countries where there isn’t anybody available. I’m thinking of a client I work with who is married to a Japanese woman and lived and taught in Japan. He couldn’t find anybody there that really would be able to understand him and his culture. So, there’s that great advantage, or there are places where there just isn’t anybody.

It’s usually very convenient for everybody involved, but sometimes there are obstacles. The client might live with somebody else so privacy can be a challenge. When I was in analysis it was really time consuming because I had to leave enough time for traveling and parking. When you do it digitally, you can log on and have your session and then you’re done with it.

Other therapists are often very skeptical about the fact that you’re not in the same room and feel that that might mean there’s a lack of immediacy and lack of a real personal empathic connection. I understand that, and I understand that’s got to be true to some extent but, especially after researching how empathy works in my last book, it’s not magic, and it doesn’t necessarily have to do with physical proximity. When we empathize with other people, we are reading their emotional experience on their faces, and we are unconsciously bringing our own facial expressions into alignment with theirs, which stimulates an echo of their experience inside of us. You can do that on a video screen, and I do.

I do feel a deep empathic connection with my clients when we’re face-to-face over a computer

I do feel a deep empathic connection with my clients when we’re face-to-face over a computer. I have worked by telephone. I won’t do it anymore because it’s so inferior if you can’t see somebody’s face.

The other thing is there’s often an extra bit of information that comes with seeing a client in her own milieu that you don’t get when they come to your office. That’s your terrain, right? I wrote an article for The New York Times about some of my clients who have pets and who connect from their homes, and how I get to watch them interact with their animals and I learn things about them that way. You learn things about people by what they choose to include in the video frame for their sessions. You sometimes have intrusions from people who forget that your client is in session then and they’ll come into the room or there’ll be sound from another room in the home. There’s all these extra bits of information that make it a very rich experience.

I do understand the reluctance of some therapists to work this way, and the sort of mystical view of empathy as this kind of ESP that happens when people are physically in the same space, but my experience tells me otherwise.

One of the personal bonuses of working in distance therapy is just this exposure to all these people I never would have had the chance to meet and work with on the west side of Los Angeles. It affords me the freedom to transcend the only thing I have never liked about my job, which is that I’m stuck in one place. I spent two months in Europe this summer and I worked the whole time. It’s always been my dream to not be a tourist but to just go somewhere and have my daily life there. I would do what I would normally do but at the end of the day rather than being home in Los Angeles or Palm Springs, I’d be in London or Paris, which is what I did, and it was fabulous.

LR: So, doing distance therapy can be liberating in that you’re in many places by virtue of the clients with whom you’re working, but you can also be in many places and sort of get filled up in that way.

JB: That’s a good way of putting it.

Distance therapy feeds me, and it makes me a happier therapist to be able to do that

Distance therapy feeds me, and it makes me a happier therapist to be able to do that.

LR: A happier therapist is a better therapist.

JB: Yes.

LR: Has it expanded your world view as a therapist in addition to making you a happier therapist?

JB: I like to think so. It’s kind of a humbling experience. I remember I was working with a man who came from a wealthy family in India. He had grown up in India, then been educated at boarding school in England, and was presently working in a family business in Dubai. There were so many aspects of his experience that I had to keep reminding myself that my set of cultural assumptions really weren’t going to hold true for this guy. I just had to listen and learn a lot about his experience and not try and impose my own fully Westernized values on him. It was challenging.

LR: I would imagine that the ability to rise to that challenge is based on one’s humility, but as you said, it is about empathy–the willingness to open yourself to others no matter who they are, where they are, and how they struggle.

JB: People might have different sets of cultural values and assumptions but their faces all express emotion in the same way. That’s biological.

LR: I guess that is as good a place to stop as any. Thanks so much for your time today and the wonderful conversation.

JB: I really enjoyed this interview, it was different from many that I’ve had before. Thank you for reading my books and for giving me the opportunity just to go on at length about subjects that mean a lot to me. This was very enjoyable.

Changing Places

Posted on March 26, 2019February 11, 2026 by Psychotherapy.net Team

The Nesting Instinct

Thirty years is a long time. When I started my psychotherapy practice as a newly-minted licensed psychologist in 1986, I didn’t expect to spend my entire career in one office. But the brownstone building and the location were great, and the space felt comfortable. The office was part of a suite with five offices, a shared waiting room and a bathroom. It was a large room with windows overlooking a tree-lined street. I never felt the desire to relocate my practice. Recently, however, the noise from new tenants in the apartment above my office became intolerable. The landlord was unwilling to intervene and clients were starting to look up at the ceiling due to the sound of a toddler jumping out of bed overhead. Additionally, the condition of the waiting room and bathroom had deteriorated. My frustration finally compelled me to start looking for new office space.

Although psychotherapy is about helping people realize change in their lives, personally I am often resistant to change. I love to travel and explore new things, but ever since my parents’ divorce when I was a young child, I developed a strong nesting instinct. Creating familiar and warm surroundings is core to my well-being. I will venture out into the unknown, but I like my surroundings to stay the same. “Moving is not something I do lightly”. During those same 30 years, I had moved homes twice, each time to accommodate a growing family. I was always grateful that my office stayed the same. It was the constant in my life, a proverbial “room of my own.”

There had been days when the comfort of my office extended to me as much as it did to my clients. Each time I was pregnant, I would nap on the couch whenever I had a free hour. The office was never cluttered with the accouterments of young children or the inevitable accumulation of “stuff.” Every night as I closed the door behind me, I knew I would find the office in the same condition the next day. The familiarity of the space was reassuring to me.

Time for Change

Therapists often admonish clients against “a geographical cure,” but sometimes relocation is the right decision. As I began looking for a new office, I knew I wanted to stay in the same neighborhood. Keeping my phone number and location was important to the stability of my practice. I was fortunate to find, just three city blocks away, an office with large windows and my own waiting room. The ceilings were higher and the building was non-residential. I signed a five-year lease, guaranteeing myself some permanence. I reassured myself that there were important lessons for me, as well as my clients, in this decision.

In the weeks leading up to the move, I was aware of feeling uncharacteristically unsure of myself. Finding a new parking space was challenging and I regularly forgot the code for the bathroom in the building as I checked the progress of the renovations in the new office. When I had the opportunity to meet the psychologist who was leaving the office, he reassured me that “The office has good karma.” He was retiring after 30 years and welcomed the opportunity to bequeath this important space in his life to another psychologist. He shared helpful insights about how the building worked and volunteered to introduce me to fellow therapists on the floor. His clear desire for me to be happy in the office eased some of my doubt about having made the right decision. The fact that he had had a successful practice in that space for thirty years seemed like a good omen.

It was critical for me to manage my own anxiety about unforeseen consequences of moving so that it would not be detrimental to my clients. Like all therapists, over the years I had weathered personal difficulties while continuing to work. During those times, I relied on a few trusted colleagues to support me. This time, through word of mouth, I sought out other therapists who had moved offices to learn from their experiences. It was enlightening to learn just how complicated most therapists find this decision. We all agreed that our attachment to our office was a by-product of our work. Opinions varied about how far in advance to tell clients about the move and whether or not it was important to bring anything from the old office to the new one. One colleague who had moved due to a fire in her old building, rather than by choice, spoke about how this trauma had been more than some of her clients could bear and consequently they did not follow her to her new office. Another colleague shared that after his move a few of his clients told him how uncomfortable they had found the previous office, something he had not been attuned to. In retrospect, he realized that his own comfort in the space had kept him from recognizing how dilapidated the surrounding neighborhood had become. These conversations, along with my own self-reflection, led me to wonder what was in store for me as I made my own move.

My Clients React

A therapist’s office reveals the personality of the therapist in subtle ways. Although family photos or other highly personal artifacts are typically absent, the color of the walls, the seating, and the artwork are chosen with care to convey safety and comfort. Indirectly, these choices do reveal something of our personalities to our clients. I had redecorated my old office a number of times over the years. Now, as I looked at the new space I was about to occupy, I wondered what to bring with me and what to replace. A complete makeover felt too unsettling. In the end, I decided I would paint the walls the same green I have loved for the past eight years and keep most of my furniture. I added an oak, two-drawer, lateral file cabinet and changed the artwork from Gauguin to Sargent. Having my own waiting room for the first time, I thought about how I wanted to present myself to potential new clients as well as my current caseload. It was exciting to have more control over my space. I doubt I would have felt comfortable in a professional office building at the start of my career, but now I was ready to leave the homey brownstone I was used to.

A month before my moving date, I informed my clients of the coming change. Relieved to learn I was not retiring, they had varied responses to the news of the relocation of my office. It was revealing to learn how deeply some of them were connected to the physical space, while for others the transition seemed seamless. One client enthusiastically said, “Where are we going?” Some were thrilled the new office would be closer to public transportation. Others talked about how much they loved the tree outside my window, and a few worried whether the new space would feel as comfortable as the one they knew. A couple of clients asked me directly what had led to my making this decision and when I shared my reasons about the noise from above and the general deterioration of the common space each one commented on how my decision to act made them feel cared for.

One long-time client, a woman who had a history of sexual abuse as a child, was very attached to my physical space. She revealed that, during many painful and uncomfortable hours of therapy, she had memorized the order of the books in my bookcase and counted the seashells on my windowsill when eye contact was too penetrating for her to bear. She took time to say goodbye to the office and to reflect on the hard work she had done over the years to voice her deepest fears. Her one request was that I put the books back on the bookshelf in exactly the same order.

One of the hardest truths for therapists is that we rarely get to hear the end of the story. On moving day I found myself overcome with an array of emotions, as I sat on the floor of my old office boxing up my files. Like long-forgotten photo albums dusted off only during a move, each file brought back the connection I had made with the person whose name it bore. There were some people I had seen for a single visit, but whose stories I had never forgotten. I’d known others for over twenty years. I grieved again the loss of someone’s son and the tragedy of a terminal illness. I calculated the current age of past clients and let myself wonder about them. Had he found love? Did she have children? There were clients for whom I was not a good match, a few who had left in anger. Reflecting on the depth of connections with clients past and present reminded me anew of why I love being a therapist.

Looking Back, Moving On

As I walked from my old office to the new one with boxes of files in my arms, I was aware that these were possessions too precious to leave to the movers. Of course, it is my duty to protect the privacy of my clients, but physically moving these files, my life’s work, over three trips, on my own, to their new home gave me confidence that this was a positive change. In a very real sense I was moving alone, but all the people I had known over the years were coming with me. I was no longer a brand-new therapist, but a seasoned professional eager to continue my work. Suddenly, the journey from my old office to my new one felt less like starting over and more like an affirmation that I was on the right path.

All of my clients chose to follow me which was a relief. I knew the move presented an opportunity for each of them to reflect on their commitment to therapy, and to me, at this point in time. For those where the connection between us felt more tentative, I was not sure if the disruption of the move would tip them toward terminating therapy. Other clients touched me by their vocal appreciation for my presence in their lives. A few even brought me “office warming” gifts and I was reminded that my ability to receive as well as give in my role as a therapist is helpful. I can model change, not just prescribe it. In fact, since the move, two of my clients who were unhappy with their living situations have made moves of their own. Perhaps this is mere coincidence, but I suspect not.

Change isn’t always for the better, but when it is, it is a great reminder that holding on for too long can be detrimental to growth. Initially, when faced with the need to move, I saw only the potential for loss. In fact, the opposite occurred. I am no longer distracted by unwelcome noise and the new space is beautiful. By listening to my feelings, but still taking action, I enhanced my own capacity to change. Undertaking this move at this stage of my career has reawakened in me the joy I felt starting my own psychotherapy practice so many years ago. The relocation of my office has affirmed for me the value of taking care of oneself. Unconsciously, I was overly attached to my old office and I failed to recognize that change could actually help me thrive. The insights I have gained from this experience will undoubtedly help me both professionally and personally.

Everyone loves the new office, particularly me. But the most important lesson I learned from changing places was summarized best by one my clients, “The office doesn’t make the therapist—the therapist makes the office.” After thirty years of practice, I have more confidence in what I offer my clients and I am looking forward to a vibrant next chapter in my career.

Language as Boundary

Posted on February 12, 2019February 11, 2026 by Psychotherapy.net Team

A Child of Tongues

In the post-Soviet world, boundaries were scarce. Growing up in the Russia of the 1990s, I had a heightened awareness of crumbling walls. Though that time felt mainly liberating, it was also scary; many of us felt unsafe in this new suddenly-turned-turbulent, wall-less world.

Unsurprisingly, in the same 1990s, learning foreign languages became the most obvious and appealing choice for many Russian youngsters, myself included. It was our way of pushing the barriers. “When I proudly announced to my father that I would pursue studying linguistics, he bursted out in anger” saying that languages were futile and would not give me any tangible skills. Growing up in the Soviet Union, my father had never had an opportunity to master a foreign language. This skill was not on the state’s agenda for its citizens, probably another means of keeping the iron curtain in place. In the most classical Ivan Turgenev way, what was the most liberating and empowering choice for me reminded my father of his own inability to speak any tongue other than his own, naturally triggering a feeling of shame.

Jhumpa Lahiri, an American writer of Bengali origin, reflects on her relationship with Italian, a language that she learned later in life and adopted for her writing. Her love affair with Italian resonates with my own feelings about speaking other languages and abounds in separations—shut doors, locked gates, permeable skin: “A new language, Italian, covers me like a kind of bark. I remain inside: renewed, trapped, relieved, uncomfortable.” This sensitivity to separateness is familiar to many of my multilingual clients who evolve on cultural boundaries and countries’ frontiers.

Language as Boundary

I have ended up practicing psychotherapy in three languages that were not originally mine; and through dialogues with my displaced clients, I have realized that learning a foreign tongue not only opens new doors but, in some cases, also becomes a way of installing a boundary where there was none.

In environments where we must put up with an intrusive parent who does not respect our boundaries, or with a totalitarian state that scrambles our personal space, we survive in different ways. Some make inner safe spaces of creativity, like my artist father; others actively rebel and flee to a different land, like many of my emigrant clients and myself. When leaving is the only way to develop better boundaries with the original context and with others, mastering a new language becomes a crucial step towards this goal.

“Much of my therapy work with displaced individuals happens through video conferencing”, thus we keep our regular sessions even when they return to visit their parents for holidays. As they connect “from home,” they sometimes choose to use their second language (when we share one), in order to protect their privacy from their family members. These sessions open a window to their original context—a concrete opportunity for me to get a sense of the place which they come from.

This way, I get to enter vibrant Indian houses filled with the whir of fans; small Russian kitchens where I can nearly smell the sour cabbage soup of my childhood; Victorian manors straight out of British novels; and other colorful contexts in which my clients were brought up. In such situations, the language that they have acquired later in life acts as a shield protecting them from the intrusiveness of their home; something that was not possible for them during their childhood.

The Case of Andrey

In the case of Andrey, the first and only session we had in English offered a fascinating opportunity to reflect on his past. Andrey was a Russian violin player who had made a life in the United States. He came to therapy because of his feelings of shame about his failure to find stable orchestra work and about his deteriorating marriage.

We started off rather smoothly, as Andrey was able to identify the main reason for his struggles—his incapacity to be emotionally present with others. He was fearing intimacy and had found refuge in music, which now seemed to isolate him from his wife and friends. He would easily blame himself for his shortcomings, never questioning the adequacy or fairness of others, nor the environment itself. Was he unable to secure a stable orchestra appointment because of a lack of talent, or was it due to the competitiveness of the field and bad luck? Despite his multiple prizes and other achievements, it felt clear to Andrey that he was just not good enough.

This tendency to take the blame too quickly and entirely made it difficult to access his real feelings. This was another boundary—a cover up—a way of hiding from the more complex reality in which others failed to meet his needs. I was feeling frustrated with having to constantly point out this unbalance when Andrey decided to go back home for Christmas.

His parents were living in a small town in the very North of Russia. Snow covered much of the industrial squalor for six months in a row, offering an immaculate landscape to those who would dare to go outside; many preferred to contemplate this view from behind a frosted window. Andrey had often felt guilty about not being back home more often, but the trip was complicated and costly.

Just after Christmas, he connected from his parents’ flat, the very one where he had grown up. In the background, I could spot the familiar, trapped-in-the-past decorum of a Russian kitchen. To my surprise, even before I could greet him, Andrey kicked off in English. “My parents are just behind the wall,” he said in a whisper; “so for them, you are an American colleague, and we are talking about a forthcoming concert.” It felt odd to be suddenly transformed into an American musician.

The stigma associated with mental health issues and therapy was still omnipresent in this remote corner of Russia. In order to be able to talk openly, Andrey had to use our shared second language. His English was fluent, but during the first minutes, I had to make an effort to switch off an uncanny voice in my head that offered synchronous translation of his words back to Russian, our usual therapy language.

In Search of Sanctuary

During the session, Andrey recognized that having privacy had always been a struggle when he was a child: his mother always insisted that the doors of their small flat should stay wide open. “Why are you closing the door?” her high-pitched voice would resonate in the small flat every time Andrey would try to isolate himself in his small bedroom.

Maybe she wanted to make sure that her teenage son practiced his violin, or she was just too scared to be alone in front of her own inner realities. Back then, unable to find any space unpolluted by his mother’s intrusive presence, Andrey found refuge in music. She was not a musician, and through interpreting the most rebellious and passionate Romantic pieces, he was able to express his anger, his pain, and his isolation.

With time, this protective boundary turned into a fortified wall, efficiently separating him from others. His wife was bitterly complaining about the lack of intimacy that was haunting their marriage. He found it increasingly strenuous to get out of this space, or to let her in. Their marriage was on the brink of failure.

As Andrey was talking in English from his parents’ kitchen, we managed to recognize his feeling of shame, nurtured by the pressure to succeed that he had always felt. In his native town, the only hope for a brighter future was to work hard and be chosen for the Moscow Conservatorium. His father was a violin teacher in the local music school for children. He was drinking most of the evenings, as a way of escaping his own disappointments. Andrey had always known that he had to become a solo player to realize the dream his parents had instilled in him. But bursting out to the bigger classical music world had come with a price—the competition was such that Andrey had quickly realized that the soloist career was not for him.

During that ‘kitchen session’, Andrey told me how, the day before, he had picked up his grandfather’s old violin inherited by his father. He had not played the family instrument in years. Its sound, smell, and smooth touch brought up so many memories—the first time his father had let him play that violin was after he had successfully passed his music school exam, opening the direct path to Moscow…and freedom. What a pride he felt back then, what a commitment to music! All this had faded away, he had now lost these higher aspirations, after years of teaching American kids in a foreign language that he would never master as he mastered playing violin.

His parents had grown older but had not changed. His father was drinking less, as his health had deteriorated. But he had kept following his son’s artistic career with anguish. His mother was suspicious of his “frivolous” wife (she was French and a dancer). She was also pressuring him about having a grandchild. Andrey strongly suspected that she was eavesdropping from the corridor every time he was speaking to his local friends over the phone.

Andrey was not able to open up to either of them, out of fear of being judged or causing distress. His mother had a habit of crying, slamming doors (only to insist that they remain open later), and threatening him with heart failure. They were totally unaware of his anguish about his unemployment and his collapsing marriage.

“Ironically, Andrey had never been able to share all this in Russian”. The perceived neutrality of the English language may have provided the necessary distance for him to get in touch with the feelings he had previously been avoiding as unacceptable or threatening. What had allowed this shift to happen? Was it the juxtaposition of his original environment (filled with familiar significant objects like the old violin) with the neutrality of his second language that had built a bridge between his younger and adult selves?

In retrospect, Andrey recognized that being able to connect with me from his parents’ place had allowed his adult part (usually pertaining to his “life abroad”) to penetrate his original home. He felt supported and valued by me, as he had never been able to feel at home with his parents.

Maybe the fact that I could understand both facets of his life helped this integration—I was familiar with the peculiar culture of the intimate Russian kitchen conversations. I was also familiar with the intricate dynamics of the broader professional music world. Making links and recognizing echoes between these two realities that constituted his fragmented world, helped Andrey sort through his struggle. After all, he did not really have to endure the continuous pressure of his professional world. This was no promise of a sustainable subsistence. Once he recognized the shortcomings of his original environment, Andrey was finally able to think more creatively about his career and find other less mainstream ways of developing his potential.

Soon after that session, Andrey returned to the United States, and we have never spoken again in English. At the opposite side of the border, our native Russian is a perfect shield to protect our therapy space when his French wife is around. The session in English has remained our shared anchor, a time when we both started to see and understand him better.

Hotel Room Therapy

Posted on February 6, 2019February 11, 2026 by Psychotherapy.net Team

As I offer therapy online, many highly mobile and displaced individuals naturally drift into my practice. “We meet in a couchless space unattached to any physical location”, or rather suspended in between the two places—my office perched below the Parisian rooftops and the often-fluid, ever-changing locations of my fidgety clients.

Sometimes they connect for our sessions from a hotel room. I always pay attention to my client’s surrounding—and when an unfamiliar background sparks my curiosity, I naturally inquire into this new place, and we spend some time locating ourselves. The client might tell me about the country or town they are currently in, about this particular hotel or the area.

These “hotel sessions” tend to bring up “a sense of discomfort that resembles lostness—a feeling of displacement, of not-quite-being there,” in the striking words of a wandering writer Anna Badkhen. As a displaced person myself (I grew up in Russia but now live in France), I can easily relate to this feeling, and every time I notice an anonymous hotel room behind my client’s back, my heart sinks in recognition.

Lorraine

One day I stumbled on an essay by Suzanne Joinson dedicated to “hotel melancholia”, and the author’s experience reminded me of so many of my mobile and displaced clients; especially, Lorraine.

“Lorraine’s consultancy work made her travel constantly”. She would usually spend a four-month period in a country, only to then move to the next assignment, always located in a different country, often on a different continent. I cannot remember ever seeing her connecting from any other place than a hotel—she was my quintessential ‘hotel room client.’

Lorraine was in her mid-30s, bright, successful, and extremely lonely. After a few sessions, I finally asked about whether she had a “base.” Lorraine marked a short silence—her beautiful pale face rarely showed any emotion: she did not. Her very few belongings were stored at her parents’ basement in Canada. She had given up on having a home years ago. She travelled light; just a big suitcase and a laptop.

Lorraine lived in hotels, usually big chains—comfortable, impersonal and exactly as Suzanne Joinson describes “it was fun, for a few years, until suddenly it wasn’t.” I came into the picture when the fun had gone. However, Lorraine never complained—it was “not too bad”, and, after all, every couple of months she would be allowed a break to spend a few days elsewhere. These short trips would be just enough to keep her sanity.

In our co-created placeless bubble, we communicated in English—a second language for both of us. We also had French in common, but Lorraine had unequivocally chosen English from our very first email exchange. She confided that she felt more comfortable in this language that she acquired as a teenager when her family relocated to Canada.

“Lorraine was a Third Culture Kid”—brought up by a biracial family in a country that was neither of her parents’ original home. She was half-Korean, half-French.

Why was she in therapy? Sometimes I wondered, as she seemed rather content with her transient life. Talking with her often created a strange cognitive dissonance—I sensed her distinct unhappiness, but she would never verbalize it, never express any deep dissatisfaction or nostalgia for a home or a relationship.

She had friends of course—mostly dispersed all around the globe. She would visit them during her breaks, sometimes for an adventurous holiday, sometimes in their homes in case they were freshly settled and building a family. Strangely, after these trips Lorraine would not express any more desire to settle or to attach than usual. “It was nice,” she would comment.

Lorraine seemed attached to her itinerant lifestyle more than to anybody or anything else. She did not seem to miss her parents. Their presence in her adult life seemed to create more hassle than anything, as they got used to asking her for help in doing their paperwork, relying on their daughter’s indisputable competence. In her constant relocating from one place to another, being able to deal with paperwork efficiently was a question of survival. Efficiency was something Lorraine valued highly. I learned that in her vocabulary “being inefficient,” meant many other things too; like being overwhelmed, exhausted, or emotional.

When she was a child, her family moved a few times for her father’s professional assignments. I never really got a sense of how it was to grow up in her family. She was an incredibly docile child and later a very capable adolescent, never creating problems for her parents. She simply did what she was supposed to do and did it well. She worked hard at school, gained a commendable degree and went on to take a lucrative job. It seems that in her family everything was about efficiency. Her Korean mother was a perfectionist and would get very upset if something was not done exactly how it should be, whilst her French father was hard on people who did not live up to his expectations.

Emotions had little or no place in this family. For somebody as well educated as Lorraine, she had little awareness of her emotions and struggled to name her feelings, usually using the words “bored” or “frustrated” to cover up other emotional experiences.

In therapy, she was hard work for me.

Holidays and Homes

Of course, occasionally she would travel back to Canada to spend Christmas or Easter with her parents. Every time I offered to maintain our session during those holidays, she would decline—too busy with playing catch-ups with family and friends. So, I never had an opportunity to have a glimpse of her childhood home, and my attempts to suggest that such session ‘from home’ would be interesting, never produced results. This house in Canada that she never really described felt ghostly to me, and I wondered if she had the same feelings about it.

Interestingly enough, when her parents retired and decided to sell their family house, Lorraine seemed indifferent. They bought an apartment in the South of France, in the village they used to visit during their European holidays. Wasn’t she sad about her childhood home which contained her memories, her things in the basement, disappearing forever? No, she was not. After all, she always knew her family would never settle there forever. Almost all of her friends from that place had already left and had either settled elsewhere or were travelling around the globe.

Would I feel the same numbness if I was to lose connection with my original town? This thought only fills me with sadness. Even after living all my adult life abroad, I still feel attached to my native Saint Petersburg, where all my childhood memories reside. Lorraine’s displacement was of a different nature; she grew up out of place, with no deep roots in any of the cultures she was surrounded by. The Korean world was only barely familiar to her; she identified herself as French, but even that belonging had some clear limits.

This state of things was going on for quite a while. Lorraine moved from one country to another a few times, and I grew more and more frustrated with the lack of depth that our work was presenting.

Occasionally, I would be travelling too, and also connect for our sessions from a hotel room. The first time this happened, Lorraine looked strangely annoyed. She was even less talkative than usual, and I could sense that something was going on, but as usual she resisted my questions.

“Would your bad mood be linked to my being elsewhere than in my office?” I asked.

She paused, seemingly perplexed. “Maybe.” She was used to seeing on her screen my now familiar background, filled with bookshelves and artwork. The consistency of place that our sessions offered her was actually something that meant a lot to her. That ‘double hotel session’ was not a breakthrough in any spectacular way, but something had shifted, allowing more awareness into her displaced condition.

Several weeks after that session, Lorraine passed through Paris, and we were finally able to meet in person. I always feel a mixture of excitement and apprehension when an online client of mine visits my city, and we plan for an in-person session. Not having a screen between us breaks the settled frame; with some clients it feels like a welcomed change, with others less so. In Lorraine’s case, I was hoping that the encounter could bring some interesting grist to the mill.

Facetime

She sat in front of me; composed, pale as usual and much smaller than I had ever realized—a not unusual surprise of screen relationships. All the semblance of closeness we were able to build online seemed to dissipate. Lorraine was back to her shell.

She was between two assignments, but not for long, and seemed ready, almost eager, to move into the new hotel located somewhere in the Southeastern Asia that was soon to become her “home” for the next four months. She had already checked its situation—it was one of her favorite chains and was equipped with a decent size gym and a swimming pool. She seemed a bit lost, homeless for real, without the hotel room that usually would contain, at least temporarily, her belongings and her life. She made no comments about the area of my office, or about the room that she had seen only on her screen before.

“How do you feel about us being in the same room?”

“Not much, maybe a little uncomfortable.”

She was not used to sharing her room with anybody; she actually never had. Her childhood family home was big enough for everybody to have their own bedroom. They rarely spent time together downstairs, as both parents had their own office space. When she would come home from school, she would usually grab something from the fridge and retreat upstairs, directly to her bedroom.

This was actually the first time Lorraine was sharing some tangible details about her childhood. As she spoke, I could finally picture this big, perfectly organized house surrounded by snow. Her mother loved white lacquered furniture and was always preoccupied about keeping everything in perfect order and maintaining all the surfaces spotless. This was probably the reason why Lorraine was never allowed to invite friends to her house; and none of her birthday parties took place at her home. Her home had always felt like a hotel to her—it was comfortable, clean and temporary. Since a very young age, Lorraine knew that she would leave and go elsewhere. Her childhood was about waiting for this to happen, and now that it had finally happened she did not really know how to live any differently.

Now, as an adult, she had to learn how to develop an attachment, to a place, to a person. Our shared online space was a tentative model; a little relational bubble in which this process hopefully could begin. At this point Lorraine was not ready to fully grasp that the life she had built was as dysfunctional as her childhood. The defensive walls that she had built in the past were still in place, protecting her from the terror of her attachment-less reality.

I chose not to accompany her there, not yet.

Supply and Demand Psychotherapy

Posted on October 2, 2018February 11, 2026 by Psychotherapy.net Team

I am a believer in psychotherapy. For close to three decades I had the privilege of working with clients as they transformed their lives in amazing ways. Nothing is more satisfying in life than hearing from a former client years later and learning about the wonderful ways their lives unfolded after our therapy was completed. As a psychotherapist, my entire focus was on the person sitting in the chair across from me. I rarely thought about the people who didn’t make it into my office. I didn’t focus on the waiting list or the people who were referred out. I was content and satisfied in providing effective therapy and a great therapeutic relationship to my clients.

When I became an administrator, whose primary clinical responsibilities were to oversee all of service delivery, my awareness of those who don’t make it into a therapist’s office was heightened. I worked in college and university mental health clinics, and the consequences for students who were made to wait were dire. If a student waited four weeks to get treatment for their depression, they were likely to lose their entire semester. If they failed classes in a particular semester, the entire trajectory of their lives could be altered. Their graduation prospects were in jeopardy, graduate and professional school could be out of reach, and job recruiters might very well may pass on them.

As an administrator, I found myself in the intolerable position of determining who would flourish and who would flounder based entirely on the date on which that student sought services. If a student arrived in late August, we rolled out the smorgasbord; group therapy, individual therapy, biofeedback, psychiatric consultation. Whatever they wanted we could provide. In contrast, if a student arrived in early October, they would get a quick triage and then be placed on a waitlist, sometimes for a month to 6 weeks.

Compounding the problem were the obvious differences between the people who came in August and those who waited a few weeks. Students who sought services in August were more likely to have been in therapy before. They were also more likely to come from higher socioeconomic groups-they were more often white. On the other hand, students who waited tended to be from lower SES families, first generation college students and “of color.” We were operating a system that provided advantages to the already privileged, and disadvantages to the already oppressed.

I could not continue to have our agency work this way. I had to find new ways to provide effective help to these young people on their way to adulthood. We needed to increase our capacity without sacrificing effectiveness, knowing we would never be able to hire our way out of our supply and demand problem. Our efforts to solve this problem lead to the creation of my company, Therapy Assistance Online (TAO). Problems of supply and demand are not unique to college counseling centers. Over 106 million people in the US live in federally designated underserved areas for mental health. About 56% of US counties have no licensed psychologists or licensed clinical social workers. We are unlikely to ever meet the mental health needs of the population through face-to-face individual psychotherapy. In digital and online tools and services we have the best hope for putting a dent in the problem.

Our software (TAO Connect, Inc.) is used in 120 college and university counseling centers and we’ve expanded into community mental health centers, employee assistance programs in the US and Australia, a Canadian Province, and two large provider groups. I am very proud to know that our software is helpful to ten times more people than I was able to treat with individual therapy. Recently, one of our university clinicians told me the story of a student whose anxiety disorder was so overwhelming that she had to leave school. She did not have insurance to cover any private therapist, so she worked with TAO’s online CBT for anxiety course. She was able to recover fully and returned to school, and had a great semester. She credited the TAO course with teaching mindfulness skills and learning to challenge her unhelpful thoughts.

As a field we need to explore, develop, research, and test digital and online tools, especially to populations at great risk. Too often mental health apps are developed by software engineers with little or no input from mental health practitioners. Our input is vital if effective tools are going to be developed consistent with what we know works. Practitioners in mental health need to be at the forefront of addressing these dire supply and demand problems and we need to lead in the development of effective tools. We can’t afford to concede our field to software engineers.

Why Therapists Choose Online Therapy for Themselves

Posted on May 29, 2018February 11, 2026 by Psychotherapy.net Team

More and more fellow therapists contact me to seek online therapy (through video-conferencing) for themselves. They come from various places – rural areas or large cities, and from different continents.

What are the reasons explaining this choice?

In a survey that I ran this year with online therapy users about their rationale for choosing this setting, several practitioners happened to be among the responders. One of the reasons they named was that they already knew socially all the good local therapists. This is particularly true for smaller towns and rural areas, but it also often becomes the case after a few years of practice in larger cities.

Another reason is the broadened choice of practitioners. Therapists make sophisticated clients: they usually know what they are looking for, and want a particular approach that may not be available locally. With online therapy, the options are almost endless.

For trainees, having access to a long list of online therapists makes things more affordable, especially for those training in places like New York, California, or London, where the rates of therapists are higher.

Additionally, more and more therapists move frequently to another state, city, or even country. Mobility naturally brings people to online therapy, because when they move they don’t necessarily want to discontinue treatment and start over with a new therapist

My own experience actually combined both – mobility and training needs. When I reached out to an online therapist I was in training, with personal therapy hours to accumulate for my professional accreditation. Simultaneously, I was facing an international move, and it was causing me a great deal of emotional turmoil. It was not my first expatriation, but this time it was hitting me hard – I was feeling uprooted against my will, immensely angry at the circumstances and literally sick with anxiety. I was relocating to a country where I did not speak the language well enough to reach out to a local therapist. A therapist online, with face-to-face sessions via videoconferencing, seemed like a reasonably good option. It turned out to be a bold choice that worked for me.

Beyond these practicalities there is a subtler psychological reason: the feeling of shame.

Marie Adams discusses therapists’ mental health in The Myth Of The Untroubled Therapist: there is a tacit expectation for us, as therapists, to be “all sorted.” But ironically enough, we are not immune to the shame associated with mental health struggles.

Reaching out to a therapist who comes from a different cultural background and lives thousands of miles away can help us overcome the “shame barrier.” Many of my clients acknowledge that online therapy allowed them to jump into it, overcoming the very natural feeling of shame associated with the exposure that any therapy requires.

Among my online clients, therapists make a very inspiring bunch. Negotiating this particular type of peer therapeutic relationship presents its own fascinating challenges. The enhanced face-to-face experience offered by the screen enables intimacy for therapists who often find it uncomfortable to be in the client’s chair or, in this case, on the other side of the screen.

The online option may also foster cross-cultural exchanges beyond borders: there is no better way of satisfying our curiosity about how colleagues work in a different culture. I remember my own excitement as I first reached out to a therapist across the Atlantic.

As with everything new, the very idea of a therapy that is not in one single room but rather through video-conferencing can be associated with some risk-taking. I hear cautious or even suspicious remarks, mainly from therapists who have not yet tried this new way of making therapy happen. This being said, are we not expecting our clients to take risks daily, venturing into new territories? Therapy, by its very nature, is about risk taking, and as our world changes we have to adapt, and possibly take on the role of explorers ourselves.

PhDs in Therapy

Posted on December 5, 2017February 11, 2026 by Psychotherapy.net Team

Academics and Mental Health

My online psychotherapy practice attracts PhD candidates from around the world. Young academics are passionate people—articulate, often self-aware, intelligent, and eager to learn. But one would not guess how much this population suffers from poor mental health, how exposed and fragile they can actually be.

Research on occupational stress amongst academics indicates that it is widespread, with younger academics experiencing more mental health issues than their older counterparts. A recent Belgian study suggests that PhD students are 2.4 times more likely to develop a psychiatric disorder than the highly educated general population.

Other studies show that as much as 50 percent of doctoral students leave graduate school without finishing; it is reasonable to imagine that mental health issues play a major role in such an attrition rate.

“Young academics are often reluctant to disclose mental health problems to their universities out of fear of stigmatization and punishment in the highly competitive academic world.” PhD candidates who do their fieldwork abroad are particularly vulnerable. Not only do they feel a high pressure to achieve their fieldwork, but they also lose their social support system and have to adapt to a different culture.

Opening Doors with Online Therapy

Online therapy can be a unique opportunity for postgraduates to get support and resolve some developmental issues.

This vignette illustrates such a case.

When Jane engaged in online therapy with me, she was in the third year of her PhD program from a top American University. She was studying literary theory, and her fieldwork had just brought her to St. Petersburg, on the trail of the Russian thinker Michail Bakhtin and his main object of fascination—Dostoevsky. This city, affectionately called “Piter” by the locals, happens to be the one where I grew up before leaving Russia in my late teens. A bit of nostalgia was triggered inside me.

Jane had arrived in St. Petersburg in November. It had greeted her with gale-force winds and freezing weather, even worse than what she had imagined after reading the novels of Pushkin, Gogol, and Dostoevsky. At first she had been excited to discover its canals and lightless courtyards (kolodzi or “well-yards” in Russian) hidden in the middle of buildings, but after the first months, her fascination with the place was replaced by a lingering anxiety that she was not yet able to understand.

For our first session, Jane connected from the room that she was subletting in a big kommunalka, or shared apartment. The room was dark except for a surprisingly green wall gleaming behind her back, where she sat barely illuminated by the Russian winter’s scant natural light. Jane was slowly plunging into depression, which was draining all joy out of her research and her life. The faculty members she had met at the local university had first seemed friendly enough, but now she was avoiding any contact with anybody who could ask her questions about her research progress or about anything else for that matter.

The only window in her room was facing the plain yellowish wall of another building. If at first this grim view on the bare well-yard had reminded her of Dostoyevsky, it now felt like a metaphor for her current life prospects—long, dark Russian winter, loneliness in this foreign place, and a very uncertain outlook for a career in academia.

The day before she reached out for therapy, Jane had found herself sitting on the windowsill, looking down upon the dirty snow, and imagining her body lying in the middle of the well-yard, covered with her quickly freezing blood.

Now we were starting our first session, and she greeted me in Russian:

“Zdravstvuite.”

After a few minutes, I could sense that she was struggling, looking for words to describe the way she felt. As is often the case with bilingual individuals, we spent some time in this first session exploring Jane’s relationship with her two languages. Her Russian had developed through academic work, becoming her language of organized thought; when she wanted to describe her feelings, we had to switch to English. This going back and forth between the two languages allowed us to make better sense of her experience.

Soon we settled into our linguistic routine, using either language according to the subject. As with many emigrants, this arrangement suited us both, letting our multiple selves into the encounter.

Jane spoke Russian the way linguists often do—with unnatural care and respect for its intricate grammar. Strictly speaking, Russian was her mother tongue, but her mother had always been emotionally disconnected from her, and preferred to speak to her daughter in a limited English, without nuances but enough to give orders or rebukes. In high school, Jane then learned proper Russian, a language that she had until then perceived as unsophisticated.

Her father was a Texan estate developer. He had met his wife during one of his visits to Kazakhstan, where he had high-risk-high-reward investments. Jane’s mother was at that time young and beautiful; her secretary job was just a step towards her glorious future, where she knew she would have a shiny red car and a penthouse with views on skyscrapers gleaming in the night.

When Jane was born, her mother had already experienced deep disillusionment with life in general and her husband in particular. Texas was nothing like she had imagined, except for the consolation of owning her shiny red car; she used to drive on the endless dusty roads with fury.

As Jane grew up, she only added to her mother’s disappointments: she was neither beautiful nor particularly gifted for any girlish activities. Her academic achievements did little to change her mother’s opinion that she had been thwarted by fate in her motherly aspirations.

By the time Jane turned twelve, her father had lost most of his estate investments. She could remember him drinking whisky and grumbling about taxes and politics, only to rouse when his wife would come back home and scold him, provoking a fight. They both seemed to enjoy fighting, often loudly and in front of their daughter or other unwilling witnesses.

When Jane was accepted into a top university, her parents seemed relieved at the idea that she would finally be “out of the way.”

The First Session

In our first session Jane seemed withdrawn and extremely vulnerable. I wondered whether it was best for her to meet a therapist online. It probably was not, but she felt unable to get out of her flat and make it through the snow to the practice of one of the few English-speaking therapists available locally.

Looking through the dark window in front of her, Jane told me that she felt lonely and homesick. The homesickness felt even worse because she did not have a proper home back in the States any more. “This feeling of homesickness paradoxically associated with the experience of homelessness resonated with me.”

Her college friends were spread all around the country, busy with their own research or jobs. During her first months in Russia, she had managed to maintain the illusion of contact with some of them through Skype or WhatsApp, but now the calls were becoming rare. Maybe they had lost interest in her; maybe they never had any genuine interest at all. She had started doubting everybody and everything. Her parents had not paid her a visit.

And for several months, her academic advisor had not even been responding to her emails. Jane felt hurt and humiliated by this lack of interest from someone who had initially seemed so supportive and enthusiastic about her research. Her advisor was a middle-aged woman known for her feminist views and a difficult character.

Jane complained that her advisor’s silent ghost seemed settled at the end of her desk, at the other end of the room. Jane had been unable to sit there for days, and preferred to connect for our sessions from her sofa bed, crumbling under books and printed papers that she was unable to read or remove, even though sleeping in the middle of this improvised library—“the den,” as she called it—was becoming tricky.

As Jane was lying low in her den, the ghost was comfortably occupying her desk—an ever disapproving and punitive presence. Each time she tried to formulate a thought and write it down, she could sense, almost physically, the imaginary advisor winking in distaste at her poor efforts; simply knowing that the results would never be good enough. This room that Jane seemed to share with her imaginary advisor was suffocating, but the anxiety she felt at the thought of getting out was even worse.

As Jane described her advisor’s malefic ghost, I asked how its presence made her feel.

Alienated, confused… little.

As we explored these feelings, Jane’s usually calm face changed. She looked like a young and very upset child.

Have you ever felt like this before?

She had; it was a strangely familiar feeling when she curled up in her den, sucking her thumb at times she confessed. This is how she used to sooth herself, alone in her childhood room, when her mother was annoyed with her for some reason, or busy exercising.

As a child Jane often secretly thought that she had been born to these particular parents by mistake: she had little or no affinity with either of them. Roald Dahl’s character Matilda resonated deeply with her.

Jane had had as little choice when an academic advisor had been allocated to her, as she had had in choosing her own mother. She actually resented both of them. “The awareness of her dependence on her advisor was producing a deep anxiety—the same she used to feel when she was dependent on her mother.” This time the advisor seemed to be failing her in the same way her mother had done before, and this resonance made Jane’s anger even more overwhelming.

I knew first hand how the supervisory relationship, not unlike the therapeutic one, has the potential to repeat earlier traumatic experiences.

Shame in Academia

This incident opened a door into what would become the most important part of Jane’s therapy: working with and through her shame, towards a better sense of self and higher self-esteem.

During her first steps in academia, Jane had quickly learnt that she had to justify her every word or thought. Entry into the academic environment can trigger a feeling of shame in newcomers. It is easy to feel small and under-developed when entering a community of seasoned academics that you look up to: a dwarf in the presence of giants.

Jane would spend hours imagining how her advisor and other committee members would “laugh in her face” as she presented before them. At night, she would stay awake picturing the most humiliating scenes of her academic fall made public.

As Jane was describing how little, insignificant and defective she often felt, despite her obvious academic success, it became clear that this was a familiar emotional experience for her. She had felt this way many times before. As a little girl, she idealized her mother—a beautiful, tall, elegant, and snobbish woman. She remembered how proud she had felt of her mother as her primary school mates were admiring her beauty and expensive clothes. But as she grew up, her mother lost interest in her; Jane’s awe was replaced by disappointment. Why didn’t her adored mom like her? Did it mean that something was wrong with her? A feeling of not being good enough, not likable, had put roots in her very nature. This shame was later exacerbated by the tough rules of the academic world.

A few months into our work, Jane’s mother announced that she would be visiting her in Russia. Jane felt disorientated and anxious. She thought that her mother must have been bored with her Texan life. But I could also sense how the little girl in her craved her mom’s attention; Jane was still hoping that her mother might end up appreciating her.

She went to pick her up at the airport. The first comment her mother made brought back the past: the airport hall looked provincial and rather under-equipped for a city praised by all touristic guides for its “emperor glory.” When they reached the luxurious hotel her mother had booked and sat together in the bar, facing the straight line of the Nevsky Prospect, Jane was already dreading the days to come. Looking at the middle-aged heavily made up woman, Jane realized that, however familiar she appeared, she did not really know her. In her bright yellow jacket, her mother looked strangely foreign. When Jane tentatively switched to Russian, she did not seem to notice, and carried on talking in her consistently poor English: Jane’s hope for acknowledgement of her efforts and progress in her mother’s tongue were vanishing. A young waiter came to take their order and smiled at Jane; she could not avoid noticing how her mother’s face froze.

When Jane finally heard her mother talking in Russian to people in shops and restaurants, she was shocked by the poverty of her vocabulary and the unpleasant notes of a foreign accent—maybe consciously produced by her Americanized mother.

Later on, reflecting on our use of Russian in therapy, Jane acknowledged that communicating in her mother tongue within a warm and genuine relationship was a meaningful experience to her. For a long time she had been reading about literary characters’ feelings in Russian; to speak about her own feelings in Russian to somebody genuinely interested was new to her. “Putting her childhood experiences of loneliness and hurt into words in Russian moved something deeper inside her: she was now able to express anger towards her academic supervisor, but also acknowledge the anger she felt towards her mother.”

The Work Continues

We eventually survived the winter together. As the days got longer and the first rays of a shy April sun illuminated Jane’s room, her shame seemed to lift. She washed her sole window for the first time since she had moved in, and realized that she did not feel any desire to fall. The snow underneath was starting to melt, and she noticed a neighbor looking at her from a window on the opposite side of the yard. She had never noticed any signs of life in that window before. As their eyes briefly met, she felt strangely alive.

Spring brought its own anxieties. Jane’s academic clock was ticking, and she had only a few months left to complete her fieldwork. Even if she now saw her adviser in a much less grim light, the support she was getting from her was scarce and inconsistent. The White Nights kicked in, and Jane lost sleep again over her work. Researching contemporary Bakhtinian thought, she was trying to contact the academics who saw themselves as his followers. The risk she was taking in reaching out to this closed circle triggered familiar shame: Jane was convinced that these seasoned academics would never take her seriously, and her Russian was certainly not good enough.

We had a session just before she was due to present her research project to this group, hoping to convince them to participate. Jane kept picturing how they would look bored or even leave the room before she could finish. She was particularly intimidated by one of them. This older professor looked like Bakhtin himself—the same high forehead and the white beard. Jane was not sure whether this resemblance was a cultivated forgery or unconscious mimicry. When they first met, he had spoken so quickly and pretentiously that he made little sense to her.

Her mother’s constant absence, combined with the little interest she had shown in her daughter, had never allowed Jane to confront her.

It took us a while to reach a point where Jane felt ready to have a direct and honest conversation with her advisor. She learned that she had been grieving her husband’s recent death and was being treated for depression. After this conversation, her advisor’s ghost dwindled and eventually left her desk, making space for her own thoughts. Her research journal came back to life and Jane’s eyes sparkled again when she spoke about her work.

One day Jane did not switch her camera on as we began our session. She wanted audio-only. When I asked her why, she said she did not feel well enough to shower or brush her hair. Or in essence, she felt too ugly and too unfit to be looked at. As she shared this with me, she cried. What Jane was painfully experiencing at that moment was a deep sense of inadequacy resulting in feelings of shame. To let me witness her shame felt unbearable to her; she was terrified to recognize in my eyes the same disgust that she used to see in her mother’s gaze.

Eventually we agreed that she had to take this risk to dispel her shame. After a few minutes, she was able to switch the camera on: her face looked puffy from crying and very young.

My natural response was to give Jane a hug, but the limitations of the online therapy added to the natural ethical concerns around touching a client. This time I was painfully aware about the physical distance between us.

Jane was close to cancelling but she did not.

The meetings of their little group were informal and usually held in the apartment of one member or another. She was kindly asked to bring a cake to go along with the tea. As she rang the doorbell, she was close to fainting. Once inside, she was greeted by a giant St. Bernard dog, which managed to lick her on the nose. The laughter reaching her from the sitting room and the familiar smell of the books lining the walls of the corridor reassured her. Bakhtin’s twin brother’s wife—a tiny woman with sparkly blue eyes (also a former ballerina as she would learn later)—accepted the expensive cake with an evident pleasure and led her into the sitting room. The place was warm and the academics looked like old friends enjoying a tea together.

After an hour, she felt an almost painful sense of belonging; for the first time she was part of a welcoming family. They listened to her presentation with genuine interest, asked questions, and ended up having a heated and mostly inspiring argument in which Jane was able to take part. She forgot about the imperfections of her Russian and was able to enjoy this simple warm connection with her senior colleagues.

The inclusion and warmth Jane experienced at that meeting gave her a new boost. On her way home, Jane bumped into the blond neighbour. He was walking his scruffy dog beneath her windows. She spontaneously invited him in for tea. In bewilderment, she found out that he was a PhD candidate too, but in physics. It was a long night; his dog turned out to be a real cuddler and accepted her as a new friend.

I continued meeting with Jane for another year or so. She moved back to the US and started writing up her dissertation. Bakhtin’s twin brother died suddenly a few months after their encounter, and she returned to St. Petersburg to attend his funeral. His ballerina widow gave Jane some of her late husband’s books, insisting that such had been his wish. Jane cried and felt like an orphan. Grieving for the friend and mentor she had found in this old Russian philosopher made her question her relationship with her father.

In the meantime, his drinking had got worse. Jane went to visit. She needed only one dinner in his company to realize that he did not seem able to listen to anything she attempted to say and was clearly craving another drink. Once she returned from this disappointing trip back home, we had to mourn her hope of having at least one “good enough” parent.

In the process she finished her thesis and started teaching. This activity brought back the familiar feelings of shame, but her genuine interest in her students and her revived passion for Russian literature helped Jane to eventually enjoy her work.

The therapeutic relationship we developed helped Jane survive the definitive separation from her parents; their absence in her life was not plunging her in despair any more. She has finally been able to thrive in other close relationships—with her friends, colleagues and, finally, with her first supervisees. In our ending session she talked a lot about how much our relationship meant to her, but also about her desire to be there for her students. This filled me with warmth and gratitude—towards her, but also towards my own supervisors who were genuinely and consistently there for me. Their presence has been a real game changer for my own academic journey.

The path towards a PhD is never easy. It takes a lot of work but also a lot of daring. As any transitional stage of life, it abounds with demons that we must tame.

Jane is actually a fictional character inspired from many stories of PhD candidates whom I work with in my online psychotherapy practice, or during the course of my own PhD. I admire their courage, hard work, and passion for knowledge. These qualities are a great asset in therapy, which is a natural and inspiring companion for such a journey.

Reaching out for therapy online can help young academics to get the much-needed support, even when they are far away from home.

References

Bozeman, B. and Gaughan, M. (2011) "Job Satisfaction among University Faculty: Individual, Work, and Institutional Determinants," The Journal of Higher Education, 82(2), pp. 154-186.

Kinman, G. (2001) "Pressure Points: A review of research on stressors and strains in UK academics," Educational Psychology, 21(4), pp. 473-492.

Kinman, G. and Jones, F. (2003) ''Running Up the Down Escalator: Stressors and strains in UK academics," Quality in Higher Education, 9(1), pp. 21-38.

Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J. and Gisle, L. (2017) 'Work organization and mental health problems in PhD students," Research Policy, 46(4), pp. 868.

Lovitts, B.E. (2001) Leaving the Ivory Tower. The causes and Consequences of Departure From Doctoral Study. Rowman & Littlefield.

Shaw, C. (2015) http: //www.th eguardian.com/education /2015/ feb/13/un iversitystaff-scared- to-disclose-mental-health-problems (Accessed on 23/9/2017).

Walsh, J.P. and Lee, Y. (2015) "The bureaucratization of science," Research Policy, 44(8), pp. 1584-1600.

Are High-Risk Clients Suitable for Online Psychotherapy?

Posted on June 22, 2017February 11, 2026 by Psychotherapy.net Team

Into the Virtual Unknown

When we first began practicing online via the Skype interface, each of us felt a similar trepidation. Four or five years ago when we started, online psychotherapy was in its infancy and there were no supervisors or established authorities to guide us, so there was an understandable fear of the unknown.

We also worried about mastering the technology, as neither of us is particularly skilled in computer matters more complicated than word processing and email composition. Should we use built-in or external cameras? Should we use headsets with boom microphones? How fast of an Internet connection did we and our clients need? And perhaps unnoticed at the time but inspiring a subtle anxiety: “Would we be less skillful as therapists, less confident in our abilities, when we no longer met with a client within the authoritative confines of our own offices?”

Another source of anxiety was deciding which clients to accept for online treatment. Uncertain of our ability to work in this new format, we originally believed that we ought to confine our online practice to high-functioning clients—people who’d be able to sustain the supposedly less intimate form of contact and, with only a screen image for bonding, wouldn’t feel detached or abandoned. High-risk clients such as those who self-injured or posed a risk of suicide were definitely off limits. Today, when we discuss the subject of online therapy with some of our colleagues, we encounter similar questioning, and sometimes profound skepticism.

Over the ensuing years, we’ve both become entirely comfortable with the technical interface offered by Skype and confident in our abilities to provide quality online psychotherapy. With experience, we’ve also come to feel that the population of clients who might benefit is much larger than we first believed. There are still limits, of course, especially when there is a serious risk to life or when a client is psychotic; but based on the past five years, we’ve found that nearly all prospective clients can benefit from online psychotherapy.

Joseph first began to envision a larger scope to his potential online practice during his early work with a client who had concealed the extent of her involvement with self-injury at the beginning of treatment.

Anastasia pushed the scope of her work when an ongoing client she had started treating face-to-face in Spain for acute panic attacks had to return to Russia: Transitioning to online therapy was the only way to continue working with her.

Danielle and Olga are two clients who didn’t at first appear to be good candidates for online psychotherapy as they both displayed ongoing instability in moods and behaviors.

Danielle (Joseph’s client)

Danielle had followed my blog for a couple of years before she contacted me for treatment, not long after I began working by Skype. On her client questionnaire, she disclosed a history of self-injury but described it as minor, under control, and not life threatening. She insisted that she wasn’t suicidal. In our email exchanges prior to scheduling a first session, I told her that I couldn’t see her less than twice a week; otherwise, I didn’t feel we’d have the conditions to manage her issues. If I’d been seeing her in person, I would have required the same twice-weekly sessions.

During our first exploratory session, before we committed to working together, I made sure that she had an adequate local support system in case of emergency. Danielle assured me that, if she did at some point feel suicidal or if self-injury became a much larger issue, she had resources to contact: her pastor as well as a local therapy practice to which her prior therapist had belonged before he moved to another city. Danielle was familiar with emergency medical services and knew whom to call. Although I felt a little apprehensive about her history of self-injury, I felt that we’d established the conditions necessary to begin treatment.

From the beginning, Danielle and I developed a strong working relationship. Because she’d read every one of my blog posts, many of which are quite revealing, it didn’t feel to her as if I were a complete stranger. I found her endearing, engaging, and a pleasure to work with. In her line of work, Danielle managed a team remotely and held daily meetings by Skype, so she was even more comfortable with the medium than I was. We met twice a week on Tuesdays and Fridays. It soon began to feel to me no different from meeting a client in person, as difficult as that is for professionals who haven’t worked by Skype to understand.

Although she didn’t disclose the full details of her past until much later, Danielle let me know early on that she’d been sexually molested by more than one of her stepfathers beginning when she was 7 years old. She also told me that her mother had looked the other way when a family friend began abusing Danielle later on; the mother needed the man’s help and essentially gave away her daughter in exchange for it. This arrangement went on for several years.

A month or so into treatment, it became clear that Danielle’s involvement with self-injury was far from “minor”; she admitted that she’d misrepresented how serious it was out of fear that I wouldn’t accept her as a client if she’d told the truth. In fact, “I probably would not have taken her into my practice had I known.” Relatively inexperienced in working by Skype at that point, I would have assumed that a client who self-injures needed the more immediate contact afforded by in-person therapy.

Minor hair pulling, pinching, and scratching helped Danielle to manage her emotions most of the time—she’d explained this to me at the very beginning. But as I later learned, when conflict arose with her ex-husband or work became especially difficult, she’d cut herself with razor blades to find release from emotions that threatened to overwhelm her. During that stressful period, a month or so into therapy, cutting had become a daily practice.

By that point, I’d already developed a strong connection with Danielle and didn’t feel I could simply stop working with her, although I did feel more anxious about her welfare. At the same time, I wasn’t frightened and didn’t make Danielle sign a contract binding her not to cut as a condition of treatment. I’ve worked with other women who self-injure and understand the dynamics of emotional self-regulation involved in cutting. I felt that together, given our strong working bond, we could help her find healthier ways to self-soothe.

A complicated transference relationship soon developed. While on one level, Danielle idealized me and developed some sexual fantasies about the two of us together, on an unconscious level, she also struggled with a great deal of rage toward me, displaced from all those “fathers” who should have looked after her but instead exploited her as a sexual object. The cutting also had more than one meaning. It provided emotional relief, as I’d seen with other clients, but it also gave Danielle an outlet for the rage she felt. As I put it to her during our sessions, she couldn’t hurt me directly but she could get to me by hurting my client.

To confront these emotional dynamics, along with one’s own anxieties about clients who self-injure, often makes professionals unwilling to take such people into their practice. It can be quite scary, especially when these clients often want to scare you. Sometimes it’s because they want you to come to their rescue; sometimes they want to “prove” they can be more powerfully destructive than you are creative; sometimes they need to express the rage they feel for having been helpless and exploited. Bearing with these emotions without becoming terrified or enraged yourself is a major challenge for the therapist. Most professionals understandably worry about a malpractice suit if a client actually were to kill herself. Nobody wants the guilt and regret for having “failed” a client who committed suicide.

But in my experience, the emotional dynamics and therapeutic methods for understanding and coping with those who self-injure are the same with both in-person and Skype clients. I made the same sort of interventions with Danielle as I’ve done with clients I’ve met in my consulting room. By remaining calm and engaged with her, and not retreating in fear or anxiety, I helped her over several years to find better ways to cope with her emotions.

“We survived a period of intense cutting, when severe blood loss brought on heart palpitations, and she began reaching out to me by email between sessions.” Although I don’t normally encourage email contact, I welcomed Danielle’s communications, just as I would have welcomed emails from a self-injuring client I was meeting with in person. Sometimes that extra contact during breaks is needed to support clients in their struggles to take better care of themselves. By the end of our treatment, self-injury truly had become a minor issue.

Early on in my practice by Skype, this experience with Danielle taught me that distance therapy is suitable for many more potential clients than I would have imagined. If she hadn’t concealed the extent of her self-injury at the beginning, I might never have learned this valuable lesson.

Olga (Anastasia’s Client)

When Olga reached out by email, I’d already had experience working online with complex cases. Olga had fled the war in her country and now lived in Prague as a refugee. Her existence was precarious in every possible way; she did not speak Czech and, feeling isolated, was barely able to navigate her new environment. She complained about panic attacks, depression and an “acute desire to die.” For several days previous to her “cry for help” (these were the exact words she chose for the “subject” of her first email), Olga was unable to leave her room and the only “food” she was able to consume was coffee and cigarettes.

I agreed to meet for an introductory session to see whether I would be able to help her. “While I felt an obvious sense of urgency and a natural desire to rescue her, I also secretly planned that after this first conversation, I would refer her to a local English-speaking therapist.” I usually try to avoid any rigid diagnosis, but I suspected that Olga might be labeled as “borderline” and could probably benefit from medication.

Only later, several sessions into our work, did I realize the full extent of Olga’s issues: She experienced social phobia and agoraphobia, was mildly self-harming, and felt suicidal most of the time. The level of isolation and despair she was experiencing at that point made it impossible for her to get out of her room, to struggle with an unfamiliar language or navigate foreign streets, and to engage with a local in-person therapist in her wobbly English.

There were several occasions in the early stages when I questioned my decision to welcome Olga as an online client. We were in the middle of our third session when she suddenly announced: “I need a break, just for a minute,” and she abruptly disconnected. “I sat there, in front of my painfully empty screen and thought to myself that I had lost her.” The intensity of the emotional response that she had read on my face must have made her panic. To see her own unexpressed pain reflected on somebody else’s face was too much for her.

In the chat box, I let her know that I would prefer to remain online whenever she felt overwhelmed by emotions. I was able to keep calm and stay connected without the sort of unpredictable outburst she would typically have received from her mother. Was it ok if I called back? A few minutes later, when we resumed our conversation, she was ready to reflect on what had happened.

The idiosyncrasies of an online setting allowed Olga to regulate her own risk-taking behavior and vulnerability. Temporarily logging off when she felt overwhelmed and then reconnecting once she had recovered was an empowering experience for someone who had been feeling hopeless and depressed for a long time. Such experiences, if used mindfully in the session, often provide great grist for the psychotherapy mill.

At first when we were connecting, Olga would be sitting on the floor: She felt too weak and too ashamed to hold herself upright. In a more traditional setting, the client is forced to adapt to the therapist’s environment. With clients who carry some deep psychological wounds, this can be simply impossible at the beginning of treatment. “The fact that we meet the client in his or her own environment opens a window into the client’s experience: Seeing Olga curled up on the floor of her untidy room, I could sense her shame and fragility.”

Later in treatment, on the day I saw her sitting upright in a chair, with her laptop on the desk in front of her, I knew we’d made some serious progress.

Several months later, when she had more fully recovered and was resolving her current life situation, I asked Olga to share her experience of working with a therapist online. I also informed her that I would use her account in an article. This invitation offered a therapeutic boost to her broken self-esteem: It let her know that not only was her opinion valuable for me, but it could also be of use to others who might also feel isolated and in desperate need. This is what she wrote:

“I remember that day when in the half fog, in the total despair, I plucked up the courage to write you an e-mail. After several attempts to commit suicide, after repeated uncontrollable impulses to harm myself, after feeling myself to be absolutely unfit to live, after realizing I not only can't carry on living like this but don't want to, and it would be better to die right now, what could I do? I could write an email. I didn't have anyone, anything, I wasn't even myself—that in short is how you could have described my condition. My Internet had been paid for. I talked a lot during our first conversation; you gave me this opportunity. I talked and you listened to me until I could get my breath back. I sat on the floor, leaning my back against the wall. Via Skype I could see on my familiar iPad, the calm, compassionate expression of an unknown face on the screen. I knew that at any moment I could press the button and ‘hide.’”

Olga took a huge risk, reaching out when her trust in herself and the world was broken. Now it was my turn to take the risk and be there for her, even if my support would be limited to the screen during our twice-weekly sessions.

Such limitations may at first seem like an obstacle to working with more challenging cases, but they often end up playing an important role in containing people who feel torn and fragmented: They allow these clients to regulate the intensity of the contact, and empower them to make choices about the physical conditions of the session. In the case of Olga, the choice about where and how to sit, and how long to stay connected, helped her to become more aware of the process and of her connection to me. This awareness gave us both insight into our quickly evolving relationship.

Working online with clients who are deeply distressed makes therapists keenly aware of the absence of touch. We cannot shake our client’s hand when we greet them at the door, we cannot offer the same warm gesture at the end of each session. Any online therapist is familiar with this frustration. But with Olga, this physical distance helped her to trust me enough so that she could engage in the process. Olga’s mother had touched her daughter in many abusive ways, asking to join her in bed and to give her endless back rubs. At the initial stage of our work, Olga knew she was safe and out of reach.

Like many online therapists, I often work with clients who are experiencing some form of displacement. Olga’s case may seem extreme, but what she was experiencing in an acute form (due to her precarious refugee status, her traumatic history, and a very particular sensitivity) is familiar to many emigrants as an unavoidable part of their lives. The benefits of online therapy for such individuals cannot be over-estimated. In the case of Olga, before we could get anywhere close to her borderline mother and the abuse she had experienced throughout childhood, we had to deal with the harsh realities of her current living situation: her fear of going out to buy groceries, her inability to engage with others, her disrupted sleep patterns and her struggle to feed herself. At this initial stage, the fact that she was able to connect with me from her own room—the only “safe space” she knew—became crucial. This is Olga’s account:

“… [A]t the very beginning, I deliberately focused my attention on ‘my familiar iPad.’ It has a small screen. For the first few sessions I didn't expand the window to full screen, after several sessions, I tried it for the first time, then forced myself and then I wanted to… Skype therapy was the only therapy possible… I am located within my ‘familiar space.’ I look at your face on the ‘familiar screen.’ I can sit there in whatever clothes suit me and with my hair unbrushed, with my legs pulled up under me, and thus I learn what I am and I don't have to pretend. I am not ‘attacked’ by the details of your room, my consciousness ‘does not float away,’ it doesn't get distracted… and when we finish the session, this screen, this room remains with me. Several sessions ago I was unbearably frightened after each session—do you remember the cries for help in my messages: ‘How can I live each minute?’ Then it became a little bit easier to finish a session and leave myself at least a small drop of the sense that I exist, when we aren't talking any more, I am in a familiar place, as before everything threatened me including myself and I was ‘on the lookout,’ but I can stay at home and immediately crawl under my blanket or continue to sit in the same place, giving myself time to get up and go and do something, however small.”

It took us a few sessions before she was able to follow my advice and reach out to a psychiatrist I had located for her in Prague. She agreed to take medication, which quickly improved her sleep and her concentration. The risk she took in leaving her room and meeting the psychiatrist was our first victory, a testament to our growing therapeutic alliance.

As is often the case with deeply troubled clients, Olga’s childhood had been catastrophic: She grew up in a dark, cold and neglectful environment. Her mother was unpredictable, volatile, and emotionally and physically abusive. She had never been diagnosed, or sought treatment, but her behavior indicated some severe personality disorder (probably BPD). Olga’s father was drunk every evening, and later in life discussed his suicidal urges with no regard to his children’s feelings. Her parents divorced when she was seven, and after that, her eight-year-old brother was supposed to take care of her. Both children cooked, earned money as they could, cleaned the apartment and protected their mother from distress. They knew far too well how violent and terrifying she could become when upset.

Throughout her life, Olga had felt completely responsible for her mother. She continued sending her money (often the only money she had) and supported her mother’s myth about her sacrificial parenting. This came at a high cost; her dysfunctional mother had taken up residence deep within her own bowels. Olga’s behavior toward herself and in her relationships with others mirrored her mother’s shaming, persecutory, and abusive manner.

In the course of our work together, Olga began to experience some intense kidney pain and vomiting, which did not seem to have any purely physiological reasons. On a psychological level, it marked the beginning of a separation and liberation process and an important stage in the therapy. As Olga struggled to separate from her mother, I stayed as “close” to her as I could. We met twice a week, sometimes more, when she was feeling particularly fragile. Through my screen, I bore witness as she relived many painful moments from her childhood; as a new narrative of her life emerged, she began to feel more alive.

As is often the case with online therapy, boundaries were easily challenged. Olga would reach out frequently, sending me distressed messages via the Skype chat box. Initially I felt stressed by these intrusions, but once I addressed the issue openly with her, we agreed on some simple rules: I wouldn’t always respond straight away, or would sometimes just confirm that I was there and thinking about her. This reassured her as to healthy nature of our relationship, strikingly different from what she had experienced with her mother who had constantly pushed, violated, and dismantled boundaries with her violent emotional storms.

The fact that I was located at a safe distance, in a different country, permitted her to experience separateness and create a safe space around her. Soon, she was able to fill it with her own thoughts and desires. Our relationship was by definition at a physical distance, so different from what she had experienced with her mother: They had lived together in the same small apartment for more than twenty years. At crucial moments, this distance and our limited physical access to one another kept us both safe.

Olga went on to experience powerful emotions of hatred and anger, which she could never have expressed to her mother. As for me, the “safe distance” offered by the online setting helped me to be “there for her” at those difficult moments without letting these emotions sweep me (and our relationship) away.

Towards the end of our work Olga regained the ability to deal with her every-day reality. She slowly resumed her daily activities and began engaging with others in healthier ways. For the first time, her life felt like it was actually her life, separate and apart from her mother.

Taking the Risk

In the process of dealing with such difficult cases, we’ve developed some useful strategies. At the outset, we always discuss the limitations of online therapy with new clients, stressing the fact that it doesn’t allow us to be physically present when we might like to be. Addressing this reality openly allows us to model ways of dealing with the frustrations and the limitations of a distance relationship. This modeling is extremely beneficial, particularly for those clients who have little healthy experience with appropriate emotional bonds or are confused about their own personal boundaries.

While we typically meet with our online clients weekly, we tend to offer a more intense rhythm in more challenging cases. In the two cases described above, we met with our clients twice a week, and sometimes more frequently when major shifts or breakthroughs were occurring.

We also found that online clients reached out to us between sessions more often than usual, and responding to their emails turned out to be a very important part of the therapeutic process. While we usually expect in-person clients to cope with the inevitable lack of contact between the sessions, this is sometimes too much to ask of online clients, giving the physical distance. Responding, briefly but mindfully to their emails, helps these individuals to maintain the sometimes-fragile connection. While this places an additional demand upon the therapist’s time, it can be crucial at some stages of the client’s recovery. Once the client starts to feel stronger, the email flow usually diminishes naturally.

In cases involving some serious disturbance, we can also insist that the client meet a psychiatrist in person. We typically raise this subject several sessions into therapy, once a good therapeutic alliance has been established. Even with the most resistant clients, this strategy eventually works out well once they’ve developed enough ego strength and trust in our support to take this challenging step of consulting with a psychiatrist and eventually taking a prescribed medication.

“Expanding one’s practice to the online realm can feel risky, and to accept clients with major disturbances can feel even riskier.” As with any venture into the unknown, however, the effort may widen our perspective: What we had felt to be out of reach suddenly becomes possible, at least with some of the people who approach us for treatment.

And in taking such a risk, are we not modeling something important for our clients?

Why Clients Choose Online Therapy

Posted on February 9, 2017February 11, 2026 by Psychotherapy.net Team

When I think about why clients choose online therapy, the first intuitive answer that comes to mind is about convenience: the comfort of being in your own office or home, no travel necessary, the time saved, and the possibility to have sessions during a work trip or a holiday.

For many of my clients online therapy was the only practical option. For example, I have worked with refugees or expats unable to find a therapist speaking their language within reachable distance. I have other clients who are constantly on the move, and don’t stay in one place long enough to engage in a stable therapeutic relationship (their peripatetic existence may indeed be a topic to explore in the therapy). I also work with women from some very conservative parts of the Middle East, for whom a therapist outside their country is the only way they are willing to open up and explore their religious beliefs, or their experience of oppression, without the risk of being judged or possibly persecuted.

In other, less dramatic cases, online therapy becomes the best choice for certain deeper psychological reasons. One such underlying reason is shame.

A feeling of extreme shame, of not being enough, freezes us, and makes reaching out for therapy nearly impossible. When the potential support is just one click away, and there is no physical exposure involved, we can take that step more easily. There is always the option to keep the camera off, which already reveals a lot to the online therapist.

Tim, a policeman from Ireland, had always suffered from shyness. He had grown up in a narcissistic family, which had left him with a deep sense of not being good enough. His father openly referred to him as a “failure” and the “biggest disappointment of his life.” He had sought traditional face-to-face therapy before, whilst struggling with drinking and depression, but hadn’t trusted the therapist enough to open up and expose himself to his potential judgment. He felt that his parents never really saw him, and any close emotional or physical contact seemed unbearable for him. Bound by shame, he had retreated into loneliness, which was his only safe space.

In the early sessions he would talk “at” me, and seek little input. His camera would easily get wobbly, focusing on a far corner of the room, avoiding his face: it seemed to enact his hidden desire to flee.

Later on, we explored the deeper reasons for his choice of online therapy with a foreign therapist. Tim reckoned that he felt safer this way: the distance between us and the differences in our cultural backgrounds made him feel more relaxed, allowing him to grade his exposure.

Another case, which comes up often with expats, is their tendency to develop extreme self-reliance.

As for Lucy, a Canadian aid worker based in Rwanda, she felt disillusioned by traditional face-to-face therapy. She had never been able to trust any of her therapists. All her previous attempts to get some support had only confirmed her belief that she could only “make it on her own.” This time, in the middle of an extremely unsafe environment, rigged with the weight of huge responsibilities, added to loneliness, she decided to give it another try and reach out to an online therapist.

At times, Lucy’s extreme self-reliance and difficulty in trusting others made our work challenging for both of us. But she gave it a chance. Letting a face on her screen slowly become a person, she allowed our therapeutic relationship to develop. She eventually learned how to trust again and receive external support. Paradoxically, a virtual online therapist facilitates the development of trust, especially when it seems nearly impossible. Turning potential obstacles into advantages is one of the creative challenges of online therapy.

In the same way as our clients do, therapists may display the avoidant attachment style and be uncomfortable with too much intimacy. Carl Rogers admitted that the intimacy he was able to develop with his clients in the therapy room "without risking too much of his person" compensated for his inability to take such risks in his personal life. I guess he would have become a keen online therapist…

The requirement for therapists to have an experience of personal therapy is an important one. I argue that any therapist offering his services online should go for an online therapy himself, experiencing the process “from the other side of the screen.”

My own personal therapy online helped me enormously to offer a better service to my online clients. The sensitivity and generosity of my “virtual” therapist also has continuously guided my work.

My choice for online therapy must have been influenced by my own displacement, and I often recognize in my clients who have left their country of origin, a familiar self-reliance.

Therapy is also about letting somebody else give you a hand.

Giving people who experience shame or extreme self-reliance the option of a seemingly easier way into therapy is not a trick; it is a gift to those who may otherwise never take the hand that is there to help them work on improving their lives.

House Call Revival

Posted on February 4, 2016February 11, 2026 by Psychotherapy.net Team

Welcome to my house.

We had been meeting for a month already, but this was the first time Nick connected from his flat for our weekly online psychotherapy session.

Because of our time difference—I am based in Europe, and Nick lives in the US, we were usually connecting during his early morning hours. I was by now fairly familiar with his work surroundings: a small office cubicle, neon lights, grey doors shut tight.

This time everything was different, and Nick looked younger and more relaxed. He was sitting on his tattered couch, and I could spot on the wall behind him a superb black-and-white photo of a beautiful model. It was certainly one of his own works—Nick was a successful fashion photographer.

Suddenly he volunteered to show me around, surprisingly eager to invite me in. And I quickly discovered, why. A wobbly image appeared on my screen: a tiny flat, barely lighted from a single window, some dirty dishes in the kitchenette, and a messy pile of clothes on a chair.

Up until this moment, I had seen Nick as anybody else “out there”—an extremely successful, nice-looking and polished man with a promising future in the glamour industry.

But now, he trusted me enough to show the other, well hidden, side of his identity—the one of an immigrant from a poor background, fighting for survival in a foreign capital.

Now I had an opportunity to appreciate first-hand the contrast between the two facets of Nick’s inner reality. As I discovered during our session, his “glamorous” dates had usually disappeared from his life after seeing this “other,” shadowy side of him. After a glittery night in a fashionable club and a drink at his place, they would dissipate in the morning light. They would never return his calls afterwards. Sharing this, a deep feeling of shame emerged in Nick.

As I expected, after this “house call” Nick cancelled the following session, and during several weeks tried hard to make me feel useless. But our therapeutic relationship survived, and once the shame finally stepped back, we could resume our work together.

Our further work naturally evolved from exploration of this internal split. Nick was now ready to get in touch with his more genuine desires and motivations.

“Do home visits,” Irvin Yalom advises in The Gift of Therapy.

And this is exactly what I am doing in my online practice. Or, at least, this is the way I like to see it.

“Home visits are significant events, and I do not intend to convey that the beginning therapists undertake such a step lightly. Boundaries first need to be established and respected, but when the situation requires it, we must be willing to be flexible, be creative, and individualized in therapy we offer.” Yalom wrote these lines at a time when online counselling had not really developed yet.

Decline and Revival of the House Call

From the earliest days of professional medicine to fairly recently, it was common for doctors to make house calls. Usually it was a general practitioner, a family physician armed with his Gladstone bag, coming to the patient’s bed. And if somebody were suffering from a mental problem, he would be seen by a priest, rabbi or any relevant spiritual authority, or left alone, living within the society as the village foul.

With the general specialization of medicine and its technological development, mental health practitioners have ended up locked in their therapy rooms, well protected from the unexpected. In America, house calls have fallen steadily down the list of medical priorities since the end of World War II. And the same trend has affected all Europe.

But recently there have been signs of a revival of the house call; for example this story published in the New York Times about a physician's assistant making house calls in New York. This initiative is isolated though.

Oliver Sacks had also visited one of his patients in her home to explore her way of dealing with a rare neurological condition: “I could get no idea of how she accomplished this from seeing her dismal performance in the artificial, impoverished atmosphere of a neurology clinic. I had to see her in her own familiar surroundings.” But these reassuring visits from an audacious doctor are rather an exception, mainly reserved for the rich and mighty. Most of the American and European population makes do with the “impoverished atmosphere” of a medical practice.

Why, apart from the time and money aspects, do home visits seems so bold and risky.

This warning from Counseling Today, a publication of the American Counseling Association, seems to answer this question: “A private, sterile and quiet setting for counseling may be difficult to realize in the home. Expect the unexpected. Other family members, pets and visitors may not respect or be aware of the boundary issues inherent in a counseling relationship.”

This “expect the unexpected” sounds familiar to any therapist who practices online through videoconferencing. Sometimes our webcams let us see our client’s children and pets, as explored by Joseph Burgo in the New York Times. As result, managing the boundaries easily turns into a tricky task.

When we enter the physical realm of our client, we instantly meet with the full complexity of his current existence, and not only its inner components. There is so much more to deal with than in our own “private, sterile and quiet” therapy room.

From the professional anecdotes shared by my colleagues, as well as in my own experience, the online setting brings up anxiety and suspicion amongst some of our peers working in a more traditional setting.

In other words it also feels bold and risky, exactly as the practice of the home visits does.

Lightly or not, any therapist starting to offer his services online undertakes such a “risky and bold” step automatically. The problem may lie within this “automatic” component: connecting with the client through a videoconferencing system, we are almost instantly propelled into his physical realm. The client’s interior opens up for us with just one easy click. In the past, to make a home call, the therapist had to drive or to walk; some conscious physical effort had to be made before he would stand on his client’s threshold ringing the doorbell.

When we meet with our client in his own home, we gain an instant and direct access to some of the things clients usually “tell us about.” These unexpected intrusions and visual clues enrich the peculiar “here-and-now” of every session, with, as counterparty, a loss of control over the environment.

Something similar happens whilst working online: anybody can enter the room from which the client connects, and thus interrupt the session. Distance makes any direct impact on the client’s space impossible. The therapist does not have any control over it; he can only witness what is happening “on the other side of the screen.” This situation naturally triggers therapist’s anxiety.

Boundaries, previously so neatly limited by the walls of our therapy rooms, get more easily blurred in the online work. Clients tend to feel less committed to this “virtual” relationship, and they do not grow attached to a specific physical place. In the peculiar online reality, we are introduced into our client’s homes before properly attending to the boundaries.

To deal with this situation on a daily basis mindfully demands flexibility and creativity. Friends and colleagues often ask me which way of conducting therapy I find easier, in person or online. I generally find that the online work is more demanding for the therapist, often draining. There is more to deal with, in particular all the unexpected intrusions and the wealth of material spontaneously emerging from the visual clues received from my client’s environment.

In the example of Nick’s session, the effect of his dirty laundry and unwashed plates was added to the normal unconscious processes happening between the two of us. As doctors who have been practicing home visits for years, an online therapist develops with time a particular mind-set, a lynx eye for the visual clues and a new, very particular pair of “rabbit ears,” adapted to this specific “here-and-now.”

A few years back, I saw a client in the hotel room where he was staying, grounded by panic attacks partly triggered by the coldness of that very room. André had reached out to me as I was at the time practicing locally in Spain but in his native French as well. He was in Spain on a 4-week business trip, but could not get out of his room on the third day, out into this foreign city that he perceived as dangerous and unfriendly.

I drove to his hotel daily for two weeks, usually in the evening. On that dark road in the middle of some unfamiliar outskirts of Madrid I felt anxious and unsettled by this potentially unsafe situation. I made sure my supervisor was aware of this happening and a friend had the hotel’s name and was waiting for my call at the end of every session hour. At the end in that hotel room there were two people scared to death, and I was the one attending to all this fear.

Now, a few years later, I would have simply connected with André through a videoconferencing system. I would certainly have felt safer, separated by the physical distance from this stranger in pain, but would I have been able to respond as effectively to his panic attacks?

Let’s explore what would eventually have had been different.

The fact that I was willing to make such a considerable effort as to drive to his hotel located far away from the city center facilitated the development of our therapeutic alliance. André got strong and tangible proof of his own importance to me. As result, he could trust me quickly, and a very particular kind of kinship (we were both strangers in this city) developed between us.

This alliance would have been much more difficult to build in an online setting, and very probably André would have not been able to engage with me in the same intense way.

Being physically let into this anonymous hotel room helped me to relate more authentically to André’s current experience. The anxiety I was experiencing was partly my own feeling in response to the unsettling conditions of our sessions, partly his mirrored terror. That hotel room was an unfamiliar, foreign space for Andrew as well as for me. I could easily relate to his experience of being lost, trapped and terrified.

When he was lying on the top of his bed, battling with overwhelming symptoms of an acute panic attack, I was able to hold his hand. At moments he was convinced he would die in this foreign city, and as he shared with me later, reflecting on these first days of our work together, this simple physical contact was what allowed him to believe in transience of this terrifying experience. He suddenly was not alone in that dark and deadly place.

This simple physical touch would have not been possible in the online setting. I would eventually have managed to compensate with some verbal stroking, but that would take much more time to sink in. And, maybe André would not have believed my willingness to be there for him after all.

I am also aware of the fact that maybe at the time when André reached out to me, his level of anxiety was such that he would not be able to tolerate the frustration and separation anxiety, that are intrinsic to the distant nature of online therapy.

When André’s panic attacks stepped back enough in order to enable him to fly back home, we eventually reassumed our work online. Through the webcam’s eye I could now discover some of his original surroundings: his bedroom, his office…

That was a very different experience altogether. I was not physically there, and some of the information was out of my reach (the smells from the kitchen where his wife was cooking dinner, or the view from the unique window of his room). But I was still able to grasp some precious components of his existence: the picture of his wife and kids on his office desk, or his surprisingly assertive and slightly aggressive voice that he used when a younger colleague would suddenly introduced himself into his office.

Working with this particular, moveable (as he kept connecting from different spaces at different times) “here-and-now” I could gain some further understanding of his life in that particular place—a small French city that I would almost certainly never visit.

Soon after returning home, André decided to stop therapy… abruptly and too soon, as I thought at the time. But he felt that his partner, who was now aware of his mental health problems, was now able to give him the necessary support.

Transitioning from one type of space to another—from that concrete hotel room to the virtual space of the online—was certainly far too premature for our new born therapeutic relationship. But somehow the authenticity and the immediacy of the experience we both had in the two weeks of my “home visits” gave him enough relational nurturing in order to strengthen his relationships at home.

“…We must be willing to be flexible, be creative, and individualized in therapy we offer.”
Both online work and home visits naturally induce therapist to a greater flexibility and creativity. Every client’s physical realm is unique, shaped by the realities of the place itself and the people who inhabit it. When the therapist is immersed, physically or virtually, into this realm he can only feed the work on it, adapting the therapy he offers.

Putting the online work into this perspective, allows every session to develop into a particularly significant event—a second best for a home visit.

Maybe the house call is finally back, but in a new form. Technology has developed, allowing therapists to penetrate into their patients’ homes without moving from their own practices or apartments. This change can become an opportunity to revive the old home-visit tradition—the most relational and supportive approach to healing. And this now can be achieved with a reduced cost and an extremely inclusive reach, not limited by the geographical location of the therapist or the client.

New Here?

What We Offer

Courses

Memberships

Contact Sales

Who We Serve

Group Practices

Universities

Using A Holistic Approach to Therapy with Clients Experiencing Chronic Illness, Disability, and Mental Health Challenges

Explore

Perspectives

About

Explore

Meet the Experts

CE Requirements

A Personal Journey

The Value of Shame

The Flip Side

The Challenge of Treatment

Rebuilding Esteem

Exploring Defenses

Digital Empathy

The Nesting Instinct

Time for Change

My Clients React

Looking Back, Moving On

A Child of Tongues

Language as Boundary

The Case of Andrey

In Search of Sanctuary

Lorraine

Holidays and Homes

Facetime

Academics and Mental Health

Opening Doors with Online Therapy

The First Session

Shame in Academia

The Work Continues

Into the Virtual Unknown

Danielle (Joseph’s client)

Olga (Anastasia’s Client)

Taking the Risk