Category: Blog

Nothing To Say

Posted on by Psychotherapy.net Team

Clair* walks into my office this morning as she does every week. She sits downs and looks up. “I’ve got nothing to say today,” she tells me. Sometimes, I say nothing. I just sit and wait. Something will come. The unconscious mind can often be counted on to send something forward into the silence. But sometimes I feel the need to help things along. “Well,” I say, “What’s most on your mind?”

Clair has been with me for a little over a year. We’ve sorted through some muck together. I’m not her first therapist. There’s been a lot for her to talk about over the years. With me, it was mostly empty nest syndrome, peeling back yet again the layers of her abusive childhood and her loving, but sexually dormant marriage. We’ve been over the sadness, the joy, the poignancy. We have been talking about making her sex life better. She is interested in this, only mildly. Seems like in these more senior years they are both okay with a collectively lower libido and comfortable companionship.

So today there is nothing pressing. We make small talk. The weather. The upcoming holidays. Less small: the anniversary of her mother’s death. A little more silence. We have an easy connection. Just sitting together is healing in its own way.

So we sit in quiet comfort for a minute or two.

“Did I ever tell you about the time I was gang raped?” She says.

I shake my head.

“I was sixteen. You know in the projects there was a lot of that.”

I nod.

“Funny. I remember it like it was yesterday. Don’t think I’ve ever talked about it to anyone before.”

“Hmm.” (me)

“There were six of them. All colors. Was like the United Nations. I was walking home from school, under an underpass. You could pretty much not be seen in there. Up closer to the bridge. It was a big underpass. One held me down. One was a look out. They took turns. ”

Silence.

“I wonder if that has anything to do with the nightmares I always have. You know, that one where I feel something holding me down. The one where I think someone’s hand is on my throat. I’ve have that one so many times. I guess I never put it together.”

Silence.

“Nah. Never mind. I don’t think that’s it. I think it’s something else.”

Nod.

Silence.

“Well. That was a long time ago. Funny. Hey, do you know that George (husband) wants to take everyone on a Disney Cruise for Christmas this year? I think the grandkids will love it. But I don’t know. The last one we went on was so crowded. The food was good. You ever been on a Disney Cruise?”

Shake.

Silence.

“I told my mother. She didn’t believe me. Told me to stop being so selfish, always trying to get attention. Well, she was drunk anyway. Time up?”

Shake. Gently.

“They had good Karaoke on the last cruise. George loves it. Of course he put on ten pounds.”

Nod.

“I should never have walked home that way. My eye was black for two weeks. I don’t even remember that part happening. Just my mother yelling at me for getting into trouble. I told her, ‘Ma, I was not fighting. I told you. I got jumped. They raped me.’ But she didn’t want to hear it.”

Nod. Slight. Gentle.

Say something Melissa. I am telling myself. Say something. Go ahead. There is so much to say. There is everything to say. There is this: Oh My God! All these years! And how did you manage? And how did you cope? And how alone you must have felt! And all those feelings! And by yourself! And your mother! And why now? And can you say more? And. And. And Oh my God. And Oh. Oh. Oh. Oh baby.

I know. I don’t think that it would have quite come out that way. If I spoke. If the words would come. But I don’t have the words. I have the feelings. I have the thoughts. I have the quiet safety of my office.

I am just here. Just with her in the story. I am back in 1966 under an overpass in the projects watching a sixteen year old girl get gang raped. And for now, just for now, I have nothing to say.

*Names and dates have been changed.

The Secret to Getting More Therapy Referrals from Smartphone Users

Posted on by Psychotherapy.net Team

The shift from desktop/laptop computers to mobile devices—especially smartphones—has progressed faster than anyone predicted. In most parts of the United States, it is now typical for over 50% of searches for therapists to happen on iPhones or Android phones. Google itself admitted in May 2015 that there are now more searches on mobile than desktop/laptop computers. And while Google commands only about 67% of desktop/laptop searches, they control over 80% of searches on smartphones.

On the surface this would seem like a bad thing for private practitioners: a smaller screen that can only show a tiny part of your website; more distractions through nearby apps; and even shorter attention spans than on computers (around 8 seconds according to a recent Microsoft study). Does this make internet marketing, already a very competitive endeavor, even more difficult to succeed in?

Not necessarily. The fact that people are searching on a phone that knows its location, and can communicate easily with the outside world is an enormous opportunity to generate even more referrals to your practice. To take maximal advantage of this opportunity, you will need to do five things:

1) Take Google’s Mobile Friendly Test—Google will severely penalize websites that are not deemed “mobile friendly” by their free test.

Google wants to see a “responsive design” that automatically reformats based on the size of the screen. They also want to see buttons that are large enough for human fingers to touch and spaced far enough apart to not be confusing to the user.

2) Be Sure you Have a Verified Google Profile—go to www.google.com/business and be sure your business has been verified and is active in the Google system, and that your address and phone number are correct.

3) Add TEXTING as an Option to Contact You for Initial Inquiries—to take advantage of the fact that texting has become the preferred mode of communication for many people of all ages, be sure you offer this option for people looking for a therapist. If you don’t want to use a real cell phone number, simply get a free number in your area code to use exclusively for texting at Google Voice and configure the settings so you get an email every time someone texts you. And if they text you, call them back, do NOT text them back.

4) Be sure options for phone, texting and email are shown at the TOP of every mobile page. People do not scroll down mobile pages very far.

5) KEY ITEM: Make sure that ONE TOUCH is all it takes to initiate a phone call, text or email to you. No one will copy and type in your numbers or email address.

TWO BONUS ITEMS:

6) If you use Google AdWords, be sure you are using Call Extensions to enable people to call you directly from an ad.

7) Get rid of those cute Social Media icon links on your mobile pages. The last thing you want to do is invite someone to socialize when they finally get to your page. The chances of someone contacting you after going to the multiple distractions of Facebook is essentially zero.

Using exactly these items, I have been generating over 60 calls and 20 texts a month to my psychotherapy practice. We all would rather get phone calls to our office than visits to our website, and this is the exact formula to make that happen. And the trend toward mobile is only going to accelerate in the coming years. Take advantage of this opportunity now!

Hide-and-Seek in Online Therapy

Posted on by Psychotherapy.net Team

I thought we had our session today…

My client Jane was right, I had just missed the therapy session we had booked. It had not happened to me before, and I felt guilty.

Online therapists know how the virtual and body-less nature of the encounter makes it easier to fail each other, be it for the client, or for the therapist. The precious relational tissue seems even more fragile. I always attend to mending these ruptures as well as I can, but with Jane I had struggled. She had that particular quality which made her slip away from me as soon as our sessions were over.

Winnicott often came to my mind when I thought about Jane: “It is a joy to be hidden but disaster not to be found.” We all play hide-and-seek with others, and the therapeutic relationship we develop with our clients is no exception. A therapy room easily turns into a perfect place for hiding, with its couch, so inviting to hole up behind.

Jane was skilled in hiding.

The day we connected for our first session, her camera was off. All I could see was her profile picture, with her face concealed behind a pair of fancy sunglasses. It took me some time to convince her that seeing each other was essential for her therapy.

She finally switched on her webcam. She actually looked younger than her picture, her body language transmitting bubbles of anxiety.

Further on, Jane would typically connect from a poorly lit room, with a window behind her, darkening her traits against the light.

Or she would choose a place with a poor Internet connection to call me, her face blurred into a pixelated image.

Reflecting with Jane on her choice of having a therapy online, we ended-up realizing how much this was an integral part of her unconscious hiding strategy: the distance between us preventing me from getting too close, close enough to eventually find her.

She had come to see me about her binge eating and compulsive dating, but her main complain was about the shallowness of her relationships, her inability to get truly engaged with others.

When she finally trusted me enough to share her early history, I could discern its emptiness, a lack of emotional closeness with her depressed mother and alcoholic father. She never expressed anger or resentment towards her parents. She seemed indifferent, empty herself.

She was unconsciously inducing me to forget her, but what she craved for was to make an impact on me, to be remembered, and cared about. Emotionally, she was that child kept hidden behind a couch. Torn between the desire of closeness and the fear to be discovered, she felt consecutively manic or depressed.

Did she really want me to find her? Or was she comfortable and feeling safe in her dark hiding place? She would steadily turn up for our weekly sessions, and that made me hope.

Eeny, meeny, miny, moe… was I counting, every week, looking for her on my screen.

The more she pushed me away, the more I made it clear that she would always find me there for her, counting, seeking her out.

You are really stubborn. She once said, and I thought she would send me away with a simple mouse-click. But she did not, and we kept playing the old game.

My stubbornness responded to her need for consistency.

Eventually, Jane became convinced that I would not abandon the game. She had learnt to count on me. She did not completely give up her ‘behind-the-couch’ corner, but she allowed me in sometimes. Then we would sit there together, in the darkness and dust. Sharing that space with her, I often felt suffocating and anxious to get out, but at the same time terrified to be left there forever. Those moments were the hardest in the sessions with her, but they also helped me to understand how it really felt to be forgotten.

Jane’s therapy is finished for the time being. She went out of my screen, with her usual grin, and I wonder: was I able to make up for those who had abandoned her, hidden and forgotten?

I can only hope that our virtual hide-and-seek practice will have helped Jane to be finally found for real, by somebody in flesh and blood.

Statistics Don’t Lie…Except When They Do

Posted on by Psychotherapy.net Team

As I was working on my doctorate I became interested in home stereo amplifiers. Armed with a fellow doctorate student who possessed infinite knowledge in this area I began the search for the perfect amplifier.

My interest rapidly escalated into what could arguably have been diagnosed as a full-blown obsession. I visited stereo stores near and far. I read an endless stream of articles in the stereo magazines. I spoke with salesmen, saleswomen, and manufacturer's representatives. I attended stereo conventions. But most of all, I kept my eyes on the specifications of the various units. Ah yes, the statistics. Show me the evidence! My fellow grad student warned me not to put very much stock in specifications claiming that good numbers don't always translate to superb sound, but I knew better.

Statistics told the whole story. Finally, after nearly three years of nonstop research and spending at least as much time picking out a stereo amplifier as I did on my studies (okay, maybe a hairline more), I purchased a unit with "seriously good specs." A unit with triple digit distortion of .005—so low your dog couldn't hear it.

I hooked the unit up and to my chagrin, it sounded tinny! Convinced it was my speakers, I replaced them. It still sounded thin. (Stereo talk for tinny.) I bought speaker wire that cost more than my wardrobe and cables with a thickness rivaling my wrist measurement. No improvement was noted.

On a whim I purchased a used bargain basement priced amplifier for less than a twenty dollar bill at a pawn shop. To me it sounded much better than my expensive model. I could blame it on my hearing at the time except that everybody who auditioned the two amplifiers like the old cheapie with the "crummy specs" better.

While struggling with my stereo amplifier addiction I was able to secure my doctorate and a few years later I landed a job as a program coordinator at a major metropolitan suicide prevention center.

Because suicide was the one of the top three killers of teens (it still is) and one of the top ten causes of death for all age brackets (here again, it still is) I gave lots and lots of suicide prevention speeches. I often responded to crisis situations at schools, churches, and even major corporations, and helped run a suicide survivor's group for those who lost a friend or loved one. This continued even after I left the center. I stopped counting when I had lectured to approximately 100,000 people on this life and death topic including quite a few seasoned psychotherapists.

My point is merely that my lectures and professional activities allowed me to meet literally thousands of people who in some way, shape, or form, had been touched by the act of suicide or a suicide attempt.
Now one of the key points in my lectures was to tout the benefits of a suicide prevention contract or what experts and ethical bodies would later dub a "no suicide contract."

But, enter statistics or evidence-based practice (EBP) also known as evidence-based treatment (EBT). According to the purveyors of these numerical meta-analyses, suicide prevention contracts don't work. Even some major suicide prevention organizations and top experts in the world have adopted this stance.
What? Really? You're kidding, right? Tell that to the over-the-road truck driver who approached me after a public speech to share that he was only alive today because his eighth grade shop teacher made him sign a suicide prevention contract. Tell that to the woman in one of my college classes who volunteered that she would not be in my class if it had not been for a caring high school guidance counselor who insisted she sign a no-suicide contract in her sophomore year. "I'm a woman of my word," she told me. And what about the woman in group therapy with me who pulled a no-suicide contract out of her purse to show me. The white paper was yellow inasmuch as the document was now over 25 years old. "This saved my life," she said with tears in her eyes.

These are just three of the many cases I heard over the years. I could go on, but I think the point is obvious. Even if you can show me 100 more cases, or even 1000 where contracts didn't work, I will show you the ones where these simple contracts clearly did. Science is often what works and if a contract saves a single life then it was worth it.

Now in defense of the EBT crowd who renounces these contracts, many experts do recommend a beefed up version of the document called a safety plan. Others in this camp prefer a commitment-to-treatment document. Yes, safety plans and their second cousins, commitment-to-treatment plans, are possibly superior. But in the real world there are often times when a clinician does not have the luxury of drafting a long, drawn out, document.

In such instances, a therapist or hotline worker should do his or her best to get a short verbal, or better still written, no-suicide contract. I personally think it is downright unethical not to use the old tried and true contract. And my fear is that if we teach upcoming professionals this information they may well do nothing if they don't have the time or information to draft a full-fledged safety plan when a life is on the line.
If the average shoe size is statistically an 8M and you wear a 6W would you buy the 8M? Well, would you?

Statistics don't lie . . . well, except when they do. And a life, unlike a shoe size or a brand of stereo amplifier, is too valuable to base on a few research studies that could easily be refuted in the coming years.

The British Prime Minister, Benjamin Disraeli once quipped, "There are three kinds of lies: lies, damn lies, and statistics."

I think the Prime Minister might have been on to something.

Our Psychological Crisis: Making Sense of the American Psychological Associations Collusion with Torture

Posted on by Psychotherapy.net Team

The recently released Hoffman Report, the independent investigation conducted by former Inspector General of Chicago David Hoffman into the American Psychological Association's (APA) collusion in the torture of prisoners at Guantanamo and other CIA "black sites," has sent shock waves through the psychology profession, whose members are not at all happy to be the public face of torture in America. Listservs around the country are erupting with consternation and outrage, with demands for accountability and justice and reform and cries of betrayal. Our profession is in a full-blown crisis and psychologists around the country are confused, embarrassed, unsure of how to respond in a meaningful way.

What shocks me is how shocked my professional community suddenly seems to be, since much of the information in the Hoffman report has been available to the public for many years, thanks to the ceaseless work of activist psychologists like Steven Reisner, Stephen Soldz, and Jean Maria Arrigo, who first blew the whistle on the APA's cover up back in 2006. Arrigo had participated in APA's bogus Presidential Task Force on Psychological Ethics and National Security, known as the PENS Task Force, which sought to investigate the ethics of "enhanced interrogation" (torture) by appointing a panel made up almost entirely of military personnel who had direct experience with torture at one or more of the various CIA black sites. They, and a small handful of other psychologists out on the frontlines of this battle have been intimidated, publicly maligned, and marginalized by the APA in their attempt to discredit their critics and deflect attention from their dirty secrets.

I was a doctoral student in clinical psychology when news first broke about psychologists' involvement in torture. I had entered my studies with such optimism and hope about my career, feeling that I had finally found my home in the world–a vocation, not just a job–where I might make good use of my deep love and empathy for people and my desire to do some good in the world. It was shocking, then, to hear in my second year of training that people in my new profession were torturing people. I couldn't fathom how those people could be psychologists. Weren't we healers? Weren't we Carl Rogers and Virginia Satir and Freud and Carol Gilligan and…torturers? I couldn't wrap my head around it at all, so I decided to write my dissertation about it in order to get to the bottom of this incongruous debacle.

As I began to research the events around the torture of prisoners at CIA black sites, I discovered that financial embeddedness and collusion between the APA, the CIA and the Department of Defense spanned half of the last century, beginning with mind-control research at the start of the Cold War, then onto the torture of Vietnamese prisoners of war, CIA-backed training of torturers throughout Central and South America (at venues like the School of the Americas), and in a natural progression to the war on terror. The degree of entanglement between the military and the psychology profession, it turned out, was so longstanding, broad and deep that it would have been shocking had psychologists not been enlisted to prop up our latest war. (For more information on this sordid history, read Alfred McCoy's A Question of Torture: CIA Interrogation from The Cold War to the War on Terror.)

Though people are utterly enraged at the actions of the American Psychological Association, let's remember the context in which these unscrupulous actions unfolded. Our President—no our entire government save one dissenter, Congressman Barbara Lee—decided that bombing, kidnapping, torturing and killing the civilian population of Afghanistan was an appropriate response to a terrorist attack on American soil. But much worse, our government decided that a "shock and awe" mass-murder approach to deposing Saddam Hussein, who had no connection to 9/11, was an appropriate sequel. Bush's legal counsel at the Department of Justice rewrote American law to circumvent constitutional and international law regarding treatment of prisoners of war. In short, this was a time of collective national insanity—not a diagnosis covered by insurance, mind you—and the APA was, for the first time, at the seat of absolute power.

Let's also remember that one of President Obama's first acts in office, besides not closing Guantanamo as he had promised, was to summarily reject the notion of investigating, much less prosecuting, the Bush Administration's crimes during the war on terror. This was a powerful signal to those at the APA that they could simply "look forward, not back," without fear of punishment. If our former President, and all of the president's men (and Condoleeza), could get away with lies, deception, torture and the murdering of civilians, why would these psychologists, this professional organization, bother to reckon with itself and its past?

What I struggle with today, as the "shocking" revelations finally seem to have penetrated the psychology profession and the public at large in a way they simply haven't over the last decade, is how to reckon with the intensity of our denial–as a nation, as a profession, as a collection of individuals struggling to make our way in the world. Even my socially progressive little graduate school in Berkeley, CA, received my research with indifference, with one administrator dismissing it as "totally insignificant," the concern of a couple of "ultra-lefties" with no relevance to our profession. This is Berkeley. We're supposed to be cultural revolutionaries in this town, and yet even here, the fact that the association that accredits and determines the curriculum for our training institutions was providing professional and legal cover for an illegal and deeply immoral torture program was deemed irrelevant. If that doesn't suggest a need for a radical overhaul of this profession, then this is not a profession I want to be a part of.

But I'm not turning in my shingle. What I know from this work is that crises of this nature open up the possibility of radical transformation. We psychologists–most of us at least–are loving people with big hearts and empathic natures and a desire to be instruments of healing and change. We are imaginative and inquisitive and have the capacity to hold many (sometimes too many) truths at once. But as we sort through the crisis in our midst, we must break free from thinking we are either confined or defined by this terribly dysfunctional professional organization. A change in leadership, changes to the ethics code, prosecution for those involved in illegalities, democratic checks and balances–these are essential acts of reparation. But to truly find our moral grounding again, nay to find our passion again, we must turn our sights beyond the APA and remember what it means to be healers, not just of individuals, but of society and the planet. If we put love of humanity at the center of our agenda, and reorganize our leadership, our ethics codes, our research and our training institutions around social, economic and ecological justice, putting aside once and for all the advancement of profession over people, we are sure to find our way.

Birthplace

Posted on by Psychotherapy.net Team

There are places I’ll remember all my life.

—I was born in a small Russian town, a very cold and dirty place.

This was one of the first things Anna shared about herself in a long introductory email reaching out to me for online psychotherapy.

In this description of her native town, I could sense her sad childhood: a lack of emotional warmth and possibly some neglect.

The way people describe their early surroundings usually tells something significant about their life story.

We developed early bonds with our caretakers, but also with a place. We end up internalizing the qualities of the landscape or family house where we grew up.

Can we ever detach ourselves from our original place? Does it not persist inside us, long after the physical building has been knocked down?

Anna had left her native town early, to study and work in Moscow, and then she had moved abroad. Her departure had been more of an escape: eager to leave, she had barely said her goodbyes. Since then she had changed countries several times, and finally landed in London. But the original “coldness” and “dirtiness” had followed her, as a malevolent shadow from her past.

It was only our second session, and I was experiencing Anna as frozen and difficult to reach out to. She complained that no town ever felt good enough to her: “too cold” or “too dirty.” Through the videoconferencing, I could have a glimpse of her current London interior, which looked unsurprisingly impersonal and rather messy.

Anna’s restlessness was partly due to her conscious desire to find a more nourishing environment, but this was conflicting with a deeper sense of hopelessness and despair: she believed that such a place did not exist for her.

Even in a warmer and more welcoming country, she would always feel alienated by a feeling of guilt—as if betraying her birthplace, her motherland. That felt deeply wrong.

But at the same time, she could not feel belonging to this new and “better” place, she felt painfully “different.”

Deep inside she kept being “a girl from a dirty and cold place,” her life stained by it forever.

As often happens with expatriates, something shifted when Anna went back home for a holiday. We had an online session whilst she was there. As her face appeared on my screen, I was struck by how different she now looked: instead of her usual impeccable jacket, she was wearing a loose t-shirt; her hair was messy; and without make-up she looked younger.

This was a unique opportunity to accelerate the process.

She was staying at her parents’ flat—the very one where she had grown up, and was certainly getting in touch with some early emotional experiences of her childhood.

Internet connection is always bad here, so maybe we will need to switch-off the video at some point. She warned me, preparing a retreat in case the session triggered too much shame. She was also reminding me how “imperfect” her childhood place was.

Shame was indeed around for the whole hour, but Anna was brave enough to stay with it, and we managed to navigate through this experience together.

Using her laptop’s webcam, Anna finally showed me around. This was a real risk-taking, and I could appreciate how exposed and vulnerable she felt. The place was indeed muddled, and was a testimony of an un-nourishing childhood environment.

Anna’s mother, born just after the war, had been stockpiling all sorts of things, an aversion to discarding possessions which qualified her as a “hoarder.” Understanding her mother’s struggle helped Anna make sense of the level of messiness she grew up with, and the shame she was feeling about it.

That “back home” session actually was a turning point in my work with Anna.

She realized how much she was actually attached to her birthplace, with a painful loyalty that did not let her leave it completely behind.

Making a better sense of her mother’s mental condition, Anna was now able to re-evaluate her own relationship with her family home and her native town. This place was not her. It did not define her; it was rather a sum of her experiences, which had started in that town, but did not have to end there. And the latter was her choice—such an empowering realization.

Maybe a warmer place existed somewhere for her after all…?

Je Taime…Me Neither

Posted on by Psychotherapy.net Team

This couple therapy session was the last chance before Anna and Guy’s upcoming wedding in Paris. They had reached out to me for a premarital counselling session via Skype, knowing that I was working with mixed couples.

Their situation, as Anna exposed it to me in her short email, needed to be addressed with some urgency: they were due to get married in the town hall of Guy’s native Paris within two weeks, and Anna still had serious doubts about her final “yes.”

Their two faces appeared on my screen, one next to each other, cramped into the frame of the Skype window. From the start, I mentioned one of our challenges: neither of us was using our native language here. Anna is Polish, Guy is French, and I am Russian. From my experience, this multilingual field would be played out at some point during this session, but how?

Their respective English was fluent, even though Guy had a strong French accent, which made him sound like an odd TV-series character. In the first minutes, I learnt that they had started dating online, and now Anna had finally moved in with Guy in Paris. Since then, their respective lifestyles had been drastically altered: Anna had an 8-years old daughter from her first marriage, and Guy had an autistic sister who lived in the same building. Those two were constantly challenging their shared existence. They were their respective “burdens,” as Guy shared.

When he pronounced this word, Anna’s face hardened with pain. She was clearly hurt by the reference to her daughter as a “burden,” and was getting defensive. Their typical argument then started to unfold. These fights happened on a daily basis, leading inevitably to door- slamming and painful silences.

Now their faces were flushing with all kinds of emotions.

“You are so slow and uninterested!” she stated, bitterly.

“You always sound so aggressive and impatient!” he responded, defensively.

I could clearly see what both of them meant. Anna did sound irritated; her aggressive facade seemed to hide a deep insecurity. Guy did come out as a bit slow and detached. He was carefully looking for his words, avoiding eye contact, and every time, before speaking, he would make a pause, recollecting and revaluating his thoughts. This habit of his could be easily taken for a lack of interest or passion. In Anna’s view he simply did not feel enough love for her, or enough acceptance for her daughter, to become a good husband and father.

And yet, they were really willing to look at their relationship, ready to fight for its survival, avoid its ending. I was starting to wonder how I could be of any use, when I heard the sound of a distant doorbell. They both jumped on their chairs. Anna smiled badly; Guy shivered and disappeared from my sight.

“See?! This is what happens. She comes in and out when she wants, uninvited.”

I understood that Anna was talking about Guy’s sister, and I invited her to pause and wait for Guy’s return.

Such interruptions of the sessions are frequent in my online practice. They are somehow an unexpected gift of this particular setting. I always endeavour to make the most of them. In this virtual space, silences are tougher to tolerate, even for the psychotherapist.

Anna and I were staring at each other, hearing their voices at a distance, and I could sense her disappointment and growing anger. She looked lonely and lost, with the other half of my screen left empty by Guy’s absence.

When he finally came back, she had that look of resignation. They are not going to make it, I thought.

Guy, clearly shaken by this sudden illustration of “his side of the problem,” muttered some excuses in French (he knew I understand it well). In his native language, he sounded surprisingly fast and emotional.

We had only half an hour left in the session, and a few days until the big day, so I decided to risk something, and suggested an experiment: would Guy be willing to repeat what he had said earlier about their “respective burdens” in French? I knew Anna could understand most of it.

“Je t’aime…”—this is how Guy started his difficult speech. He talked about sharing their respective pains and responsibilities: his sister but also her daughter. He talked passionately. His body animated (at least the upper part which I could see). He seemed to almost forget about me.

Anna was listening, and this time she did not seem impatient.

That was the midpoint of the session, and such a precious opening! I felt blessed.

We then explored how using his native French had changed their common experience. Guy was finding it difficult to understand all the details when Anna spoke English quickly (which she did naturally). So his mind wandered, he looked uninterested. It reminded Anna of her first husband, who was distant and absorbed by his own activities.

As for Guy, he would see his role as a protector of his autistic sister. In his speech in French he said something valuable, which became an anchor for the rest of our session:

"Elles vont être maintenant notre fille et notre sœur."

I made sure Anna understood this: “they will now be our daughter and our sister.”

That felt manageable for both, and Guy was here to protect them all. It switched the whole perspective.

I cannot know for sure whether Anna and Guy will stay together, but I know that they did try hard to understand each other better…

Losing the Couch: Finding the “Sacred Place” in Online Therapy

Posted on by Psychotherapy.net Team

I clearly remember my very first visit to my British psychotherapist. She used to receive her patients in her conservatory. Her dogs sometimes got impatient and produced considerable clatter, which I could clearly hear from inside the house. The front door would be unlocked. Clients just had to push the gate to get through an unkempt garden into the peculiar therapy room. She would be already comfortably sitting there in the same old chair, and a flowery cup of tea would be ready; weak for her, and strong for me. When I was late, my tea was cold. Maybe it was her subtle way of punishing me…

I actually loved this place. Years later I can still recall its particular smell of wet dogs and a damp garden. That therapy room had become an anchor for me, which safely attached me to the Island that was then my temporary home; I was in the midst of yet another international move.

Now that I use the online setting for my psychotherapy practice, I sometimes wonder what my clients will remember of our encounters. No particular smell of madeleines will ever be attached to a virtual space.

Any therapist, myself included, hopes that his therapy room can become some sort of “sacred place” to his clients, a place for individual growth. We all work towards this goal, creating small rituals and paying careful attention to the boundaries of the therapeutic relationship.

With the current expansion of online counseling, therapists and their clients are seeing this sacred element of therapy being taken away. Our cherished therapy rooms are disappearing, replaced by a simple desk and a computer.

I have kept a traditional face-to-face practice in Madrid, on top of my online work, so when I connect with a client on Skype, he can always spot behind me the background of a traditional therapy room decorum: two large armchairs, a box of Kleenex, a smiling Buddha statue… a pale reminder of the physical space where our encounter would have had to take place just a few years ago.

A couch, a bookshelf, and a coffee table… we have been familiar with these traditional attributes of a therapy room for ages. Anybody coming to a therapist for the first time knew what to expect, and rarely got surprised. In a space, tightly bound by walls, boundaries tended to be clear: the therapist had his own chair, the client might have a choice between two chairs and a couch. In this place both the therapist and the client felt safe. This space seemed eternal… until the online option emerged, bringing confusion.

Now online therapy is practiced within a no-place space. The couch is gone. And each of us therapists responds to this loss in different ways, which vary as in any grief—from denial and anger to acceptance.

During an online session, two people stare at their respective computer screens, without sharing a common place. This becomes an opportunity to build their own space together. It is very much like coming to a new empty area, and building from a green field a house here or there, then eventually a village.

In my experience, this lack of a physical place actually fosters creativity.

Many people I meet in my practice live very mobile lives, geographically unsettled; so the perceived neutrality of the no-place becomes a real asset in addressing the displacement-related issues.

Amélie’s story is one such case. She was back to Paris after 10 years in Korea for her husband’s career. There, Amélie had felt isolated and disoriented in her vast house, while her husband was travelling extensively. She had had to leave behind her music teacher job, and after several years of this expatriate life, she was feeling lost. Now back to her native Paris, she was feeling depressed. Her first panic attack happened in a shopping mall. She did not know where she was and was not able to get out of this unfamiliar place crowded with strangers. She was struck by an acute sense of derealisation. She reached out to me, in addition to her local psychiatrist.

“How is it for you to tell me your story here, online?” I asked.

Actually, Amélie felt safe, her anxiety was stepping back. She was relieved, as she could meet with me from the only place that still felt familiar—her parents’ Parisian flat. Driving to a therapist’s office would have been too much for her at that point. The online space we shared became in this case a way of dealing with her confusion without re-introduction of another different place.

Every time I connect with a client, especially for the first time, I am ready to get surprised. Those who seek therapy online generally use and abuse the flexibility allowed by the technology, so I “meet” them (virtually) in their holiday house, hotel room, office, kitchen, or lounge.

Without moving from my desk, I am then able to spot small samples of their physical realm. I always feel touched by the trust involved in this “letting me in.”

The whole situation has now been reversed: it is not the therapist who lets his client in, but the client who is choosing which of his sceneries to share with his therapist.
These “unexpected gifts” somehow make up for the lost couch.

In any successful therapy there is a time when the client ends up internalising the reparative relationship with his therapist, creating the “safe place” within, that anchoring gift I received from my first therapist. When this happens, the concrete place does not matter as much as the “virtual” place discovered. And the person is able to go anywhere, feeling safe enough to further explore the world.

As in the case of Amélie, the placeless reality of the online setting accelerates this natural shift from place towards relationship.

I enjoy both my online and my face-to-face practices. When connecting with a client, I always attempt to recreate the ever-important “sacred place” of a therapy room, together with my client, in this ethereal space offered to us by technology.

Psychotherapy in the Year 2045

Posted on by Psychotherapy.net Team

According to Ray Kurzweil, futurist extraordinaire, the singularity is approaching at the speed of Jimmy John's delivery. The technological notion of the singularity asserts that computers, robots, and related super-intelligent machines will reach a stage when they match and then exceed the capabilities of human beings.

When will the singularity occur? Ray has his calendar marked for 2045, so I should have the majority of my credit card bills polished off by then. Now, of course, we could dismiss Kurzweil's predictions as ludicrous, except for the fact that he possess 20 honorary doctorate degrees, has received honors from three U.S. presidents, and enough inventions to make Benjamin Franklin green with envy.

Make no mistake about it: If the singularity casts its shadow it will be a major game-changer for the field of psychotherapy, and I am not the only pundit sounding the alarm. University of Missouri at St. Louis graduate professor and book author R. Rocco Cottone recently penned an article in the 2015 April issue of Counseling Today titled, "The End of Counseling as we Know it."

So let's get a tad self-centered here and see where we as helpers fit into this movement.

At first the future looks bright, as therapists will be needed to program these electronic psychotherapists. Those therapists who obtain double degrees such as psychology or counseling and computer science, or perhaps social work and computer programming, will likely have their pick of jobs. (By the way, that wouldn't be yours truly. I'm still struggling to learn the features on my semi-prehistoric flip phone and I am dreading the day—which will surely arrive prior to the singularity—when I can no longer secure a battery for this dinosaur.)

The next phase. Well, that's where the proverbial bottom drops out. First these techno-wonders will surely be able to surpass our human scores on exams like the EPPP, the NCE, or the CPCE. "And the job goes to the bright silver nanobot in the corner with the terrahertz processor." Of course that will end therapists' interview anxiety when it comes to those "tell me about your weaknesses" questions.

For those who are skeptical, please recall that on February 10, 1996, an IBM supercomputer dubbed Deep Blue beat Garry Kasparov, the world chess champion, in a match.

On the positive side, Kurzweil makes it clear that we will indeed have the technology to load all the world's information to our brains. Hence, I would imagine that after that any red-blooded therapist could ace their licensing or certification exam with a perfect score. But what's a therapist to do if insurance refuses to pay for the procedure? Good question, isn't it?

The final phase will take place when every cell phone, flat screen television, tablet, Google Glasses, and only God knows what, will sport an app with an Albert Ellis clone right down to the New York vocal inflections. And if you don't like Ellis, no problem. Just tell the app you would like a humanist, and a virtual Carl Rogers appears. But is that what we really want for our clients? Wouldn't it be better to learn to have a relationship with another human being rather than a computer program with artificial intelligence (AI), governed by Moore's Law, that has passed the Turing test? Just asking. I don't know about you, but a computerized Rogers doesn't sound very humanistic to me.

And say the client develops a positive transference toward a virtual Freud. Do we applaud that sort of behavior or shall we advocate for a new DSM category?

It is only fair to mention that not everybody is buying the Kurzweil version of the future. Dr. John Grohol of the PsychCentral website is adamant that since we actually don't know how the human brain functions, it is futile to worry about us creating artificial intelligence systems which will occupy our seats in the therapy room.

As for me. I just want some assurance that the techno-human counseling my client isn't hacked or isn't a hacker. But then again, I would imagine that would be a user support issue.

Creative Writing as Psychotherapy

Posted on by Psychotherapy.net Team

“An interesting fusion.” That’s what my project Wild Words was once called by a fellow psychotherapist, and yes, he was looking down his nose at me. But I’ve discovered a huge demand for the fusion of body-based, nature-based, and narrative therapy, via which I help people to find creative flow in their lives. Here’s one recent example.

A stooped 17 year-old man came to me. He had a mop of black hair and smelled of spirits. There were tensions in the family, and his father thought “that some poetry tuition might help relax him.” As I’ve seen many times, my authority as a university creative writing tutor allowed the family to ask for help, without having to admit to themselves or others that what they were really seeking was psychotherapeutic support.

Jed told me that all he wanted to do was to be a poet, but “nothing comes out right.” He didn’t care about my qualifications, but he liked the concept of writing “Wild Words.” He said it would be nice to feel like a wild animal when he wrote, but instead, he usually felt more like his little brother’s hamster, going round and round on its wheel.

As we talked, he asked me crossly why I hadn’t yet asked to see his writing, and motioned to the groaning backpack sitting at his feet. But I didn’t need to look at his writing to understand what was going on, I only had to look at his body. His skin was sickly white. His hands were blue with cold, even though the room was warm. Sometimes, when he told me about the subject of his poetry, color rose in his cheeks, but it was quickly followed by a deflation of his body, and a draining of color. And then, of course, there was the smell of alcohol.

He asked me, even more angrily, why I hadn’t asked him for the reasons for his “writer’s block,” the reason he couldn’t write well. I said that I was sure he already knew the reason, and that he’d probably already thought through it a thousand times to no avail. I was going to try a different approach. He looked skeptical. He told me the reason anyway. Apparently, his father was a well-known poet. “I’m scared that I will never write like my father,” he said. “And it’s ceasing me up.”

I asked him then to remember a time when he did write well, when the words flowed. He told me about a writing competition he had won when he was twelve. I invited him to close his eyes, to remember that experience, and to see how it felt in his body. He told me he felt a warmth, a relaxation spreading from his chest out through his limbs.

Next, I asked him to think about a time when he sat down to write but felt blocked. Where in his body was that physical sense of block? He told me it was in his stomach. At this point he started telling me again about his fears of not matching up to his father’s success. I told him not to think, but to just stay with his bodily experience. If he scanned his body, despite the feeling of block in his chest, was there a place where he still felt the warmth or movement from the writing competition experience? He said yes, there was. It was in his hand. I then got him to move his attention back and forth between his stomach and his hand, touching into the block, and then back again to a place of relaxation.

Through doing this in the session, and by practicing it at home, he gradually found that he could pick away at the edges of the feeling of block his stomach, and integrate it with the feeling of flow in his hand. Eventually that enabled him to find flow in the whole of his body. This process led spontaneously to writing ideas flowing from his body on to the paper. He was an unblocked writer.

The day this happened, he called me immediately. He was excited and laughing, but also confused. He told me, “I’m writing, the words won’t stop coming, but now I have another problem, I’m writing a comedy screenplay, not poetry. That’s not what I want to write. I’ve always wanted to be a poet’.

The psychotherapist Peter Levine has a saying: ‘The body knows.”

This is what I told him. Your body knows what it needs to say. From then, my work with Jed, which lasted six sessions, became about helping him to find his own voice rather than meeting his father’s expectations or trying to follow in his footsteps. He found a creative flow in his life, as well as in his words, and the tensions within the family lessened considerably.