Category: Therapy & Technology

Thomas Insel on Science, Zip Code, and Future-Proofing Psychotherapy

Posted on by rezendevknowfully.com

Return on Investment

Lawrence Rubin: Hello, Dr. Insel; it’s an honor to be with you, the former director of NIMH, the leading federal agency on research into mental health and illness and author of the recently-published Healing: Our Path from Mental Illness to Mental Health. It’s a rare opportunity for our readers, largely practicing nonmedical therapists, to gain a glimpse into some of the critical issues impacting the assessment and treatment of those with behavioral and mental health challenges. Thank you so much for joining us.
Thomas Insel: It’s a pleasure to be here, and I’m glad that we’ll have a chance to talk about some of the nonmedical aspects of mental health care, which have not received enough attention.
LR: Why do you think that’s the case?
TI:
we have bought into a medical model for how we think about mental disorders broadly
There are two parts to that. I think the first part is that we have bought into a medical model for how we think about mental disorders broadly. And the second part is that the medical model is part of a large healthcare industry, at least in the United States. I don’t know if this is true in other places, but in the United States, healthcare is a massive business, a $3.5 trillion business.

A lot of that business is driven by a particular model which says that illness is due to a singular, often simple cause, whether that’s a bug or a gene or a particular endocrine factor, and that the solution is a relatively simple intervention, often a drug. And that has proven to be really a good business model for the pharmaceutical industry and, to some extent, the medical industry, which has done pretty well over the last four or five decades.

And I must say that for a lot of people with medical problems, this has worked pretty well. I think if you had gotten HIV in the 90s, you certainly were better off than if you got it in the 80s. And if you have cardiovascular disease today, you’re certainly much better off than you would have been 30 years ago. And that’s true now, fortunately, for some forms of cancer as well, where we’re seeing remarkable progress with new diagnostics and new treatments.

the simple bug-simple drug model that has been so effective in the world of infectious disease is really not so effective for the millions of people who have a mental disorder
I just don’t see the same sort of breakthroughs and the same opportunities yet for people who have PTSD, depression, OCD, a range of mental disorders. It feels to me like that medical model has helped some but not enough in the mental health field. Part of why I wrote the book was to try to understand why we haven’t made more progress. And part of that “why” goes right to that issue that the simple bug-simple drug model that has been so effective in the world of infectious disease is really not so effective for the millions of people who have a mental disorder.

A Crisis of Care

LR: You began your time at NIMH shortly after the end of the decade of the brain, when so much research funding was going into genomics and neuroscience. Do you think that we got the bang for our therapeutic buck under your stewardship there?
TI: In some ways! It’s a mixed bag. I think that we learned an enormous amount, but I would say that it’s still very much in process. I don’t think we’ve fully gotten the return on the investment. I think we will, and that science is going to be really critical for us in trying to go deeper into understanding these disorders.

The problem for me was that—and this is just a personal reflection and is not in any way an indictment of the NIMH—but when I look at this state of care and what’s happening for most people, particularly those with severe mental illness, with schizophrenia, bipolar illness, severe depression, severe PTSD, it’s not a scientific problem these people face.

They face incarceration. They face homelessness. They face this massive injustice in a kind of crisis-driven system that actually leads them out of the care system and into these other pathways that are often deadly and certainly unfair, generally punitive, and not compassionate. So, that’s not a NIMH problem.

what we are seeing is this egregious set of policies that lead to people with mental illness going everywhere except into compassionate care because there’s no capacity for that
For me, so much of the sorts of public health problems that we’re facing aren’t really about genes or neuroimaging or the science. It’s more of an almost, and I loath to use the term, but really a social justice issue. And what we are seeing is this egregious set of policies that lead to people with mental illness going everywhere except into compassionate care because there’s no capacity for that.

So it actually had nothing to do with NIMH. I left NIMH and kind of never went back because if you want to address those issues, you’ve got to go someplace else with a very different army. And it’s not the army of neuroscientists and those who are brilliant in the fields of genomics and data sciences. It’s an army that is really willing to take on those big social problems and begin to deal with them.

And I think we know what to do. I think we know how to do that, and that’s beginning to happen. But my goodness, it’s not going to happen through NIMH funding. It’s just not their job. That’s something very different from the world that they’re focused on.
LR: Is that why you said in your book that “there’s a crisis of care for the mentally ill in this country?”
TI: That’s right. A crisis of care. It’s not really a crisis of science. It’s not because we don’t have good research or that we’re not spending the research dollars correctly. I argue, actually, that we probably need more research, more science, more funding for NIMH.

You know, we always need better treatments; we always need new diagnostics. But let’s get real here. We haven’t been implementing the things that we discovered 30 years ago. NIMH spent a huge amount of money in the 80s and 90s on the Nurse Home Visitation Program. I write about this a lot in my book because I think it was just a brilliant investment.

But it’s not a research question anymore. We don’t need to put a lot more NIMH dollars into that. We need to implement this for millions and millions of families who are disadvantaged and who need that kind of support, because we know it works.

At some point, you have to try to solve the problem and not just study it
I don’t want to see us get caught up in this academic cycle of “let’s keep studying this problem.” At some point, you have to try to solve the problem and not just study it, and that was what led me moving from this kind of research career to a career that was much more about advocacy, policy change, about making sure that we were starting to invest in the kinds of services and broad social supports that we need and sadly lack in this country.
LR: Is that related in part to what you also said in the book that for therapists, whether researchers or applied clinicians, that zip code is more important than genetic code?
TI: Yeah, exactly. I think where I ended up, and it’s so interesting when you write a book like this; you think you know what you’re doing, but you have no idea. You usually end up someplace very far away from where you started, and that was exactly the case here.

I started this book when I was working at Google, where I was trying to develop really interesting ways of digital phenotyping. I was convinced that technology was really going to transform mental health care, and I still think that’s probably true. But I ended the book by realizing that the problems that we’re focusing on are really problems of mental health. That’s very different from mental health care. And I have to say, I don’t think I understood that.

When I started the book, every conversation I had about health or mental health was about health care or mental health care. And it wasn’t until I was two-thirds of the way through this, and in this odyssey that I took around the state of California to try to understand why we hadn’t seen more improvements in public health measures like morbidity and mortality, that I began to realize, like, wait a minute, this is not a health care problem.

All this stuff, incarceration, homelessness, poverty, health disparities, is happening way outside of healthcare. It’s actually something very different. We could probably fix healthcare. We could probably do so much better on health care, but barely move the needle for morbidity and mortality.

most of the disparity in race- and gender-based mortality in this instance is really about your zip code
As an example, I was just looking at this over the weekend: the chances of turning 70 years old or living to 70 in terms of life expectancy are at about 82% for White females and about 54% for Black males in the United States. That 82% to 54% disparity is not really a function of what medications they’re on or how many clinic visits they have, or even what health insurance they have. That contributes a little bit, we think it accounts for maybe 10% or 20% of that disparity. But most of the disparity in race- and gender-based mortality in this instance is really about your zip code. It’s about your lifestyle, your exposure, your environment. It’s about a lot of other stuff that’s not really in the healthcare system.

I guess the really hard question to ask, and the one that I’ve been thinking a lot about lately since the book came out is, do we need to rethink what we mean by health care? And specifically, do we need to rethink what we mean by mental health care? Is it really just about medication and psychological treatments and maybe some rehabilitative care? Or is there something more essential that has to do with recovery, has to do with thriving, has to do with wellness? Does that need to come into focus, and does that need to be within the scope of what we mean by healthcare?

Making Psychotherapy Better

LR: Within this context of health care, certain models of psychotherapy have been proven empirically to be effective. So why is there such a disparity between what we know and what we do?
TI: I struggled with that in the book. I start from a perspective that psychotherapy is a really powerful intervention and that we have specific, skill-based therapies that have been demonstrated to work. I also understand that outcomes may depend more on the therapist and the therapy, and that’s always a challenge in any kind of randomized clinical trial that one does on these interventions. But the evidence is pretty compelling for both the safety and ultimately the effectiveness, which is quite different from the efficacy of psychotherapy.

we need to look closely at the training of psychotherapists, how we do it, where we do it, and also when we do it
So the question is, with a treatment that’s so powerful, why have we seen this gap, and why has it become so difficult to actually get it delivered in the way that it should be? I think there are a couple of things. One is, we need to look closely at the training of psychotherapists, how we do it, where we do it, and also when we do it. We’ve had this notion that you train, and then you have supervision for a period after graduate school, and then you’re kind of on your own until your next licensure comes up.

I think we want to look more carefully at how we make sure people get the kinds of skills and the feedback to get better and better. I’ve been fascinated by a company with which I have no connection but am really intrigued by, called IESO. It’s not in the United States, it’s just in the UK, but they’ve really focused on, how do we help our therapists who are online to get better and better?

They’ve built this natural language processing engine so that every interaction between therapist and client is captured. It goes through this engine, and they have a dashboard that shows them levels of therapeutic rapport, levels of effectiveness of their comments, and also the state of play for the client; better, worse, what’s the emotional tone in the interaction? It’s really fascinating to watch.

But what’s amazing about it is that by getting this kind of real-time feedback, therapists have gotten better and better. And when you look at outcomes, they went from 49% recovery to 67% recovery just by providing this real-time feedback, not just to patients and clients, but to therapists themselves. It was actually more useful for the therapist than the client. But ultimately, the clients enjoyed that impact.

So I think part of what we need to do is to think about how we help our therapists to navigate and to improve what they do. The other part is we have to ask, what do we pay for? Are we paying for a number of hours spent, or are we paying for outcomes? Basically, are providers being rewarded for how long somebody stays in treatment, or for getting people out of treatment and getting them well? We need to begin to look at the incentives that are built into the system and ask, are we incentivizing for the right things?
LR: Does this IESO program also include biological markers embedded in the therapist/client interaction, like heart rate, blood pressure, and brain wave activities, to get a complete picture of the reciprocal impact of the interaction? Or is it a glorified electronic satisfaction survey?
TI: No, it’s neither. There’s nothing biological here. It’s really taking language and decoding it. If you think about what we do in psychotherapy, it’s listening, it’s observing, it’s communicating. And through that, we hope that there’s understanding and trust and change ultimately through the relationship.

That process of using language to communicate is a process which has really been revolutionized by artificial intelligence and very good data science through this thing called natural language processing, which was created to try to understand how words got glued together and what coherence looks like in language.

But over time, it’s been used to measure sentiment, like mood, and is now being used to measure how well people are connecting and if they’re communicating effectively. This is a multi-billion dollar industry that’s been taken over largely from the call centers. Call centers are now far better than they were five years ago because of the ability in real-time to decode the communication between two people.

Let’s provide objective evidence about how a therapist and client are communicating and relating and actually literally measure things like trust and measure therapeutic alliance
What IESO has done is to take that same kind of effort and said, “Let’s provide objective evidence about how a therapist and client are communicating and relating and actually literally measure things like trust and measure therapeutic alliance.” And they found ways to define that, which I think are really interesting.

It may not be for everybody, but it is fascinating to me that by capturing that kind of data objectively, they have been able to provide a source of feedback that actually helps people do what they’re trying to do, which is create trust, create the therapeutic alliance, build that rapport. Who would have thought that you would actually do that through technology?

And yet, they’ve demonstrated that this can work without any burden on either the provider or the client. It doesn’t take any extra time. It’s kind of like the speedometer in your car, you know, it’s a part of the dashboard, it tells you as you go how fast you’re going and how you’re driving.
LR: There is extensive research on what we call common factors in therapy, those aspects of the therapeutic relationship that contribute to a positive outcome. This process that you’re talking about sounds like it’s algorithmically mediated. Rather than just asking the client, was trust built or how safe did you feel or how effective do you think your therapist was, you’re interjecting elements of AI into it to give more specific data beyond just the self-report of the client.
TI:  It is. I guess I would just push back with the word “just,” because I think we need both. We need both that subjective experience, like, how was this for you? And then, you know, the objective readout of what does the algorithm say? And it may be in the gap between those two that there’s a lot we can learn.

There’s this really interesting new science that is just beginning to shine a light on our behavior, and particularly on our language in a way that I think will revolutionize psychotherapy
There’s this really interesting new science that is just beginning to shine a light on our behavior, and particularly on our language in a way that I think will revolutionize psychotherapy; it will revolutionize the study of mood, behavior, and cognition. I really think we’re just beginning to see that happen.

One kind of untapped example of this, which I’ve been so intrigued by but haven’t yet seen really developed, is that you can use this natural language processing approach to measure the coherence of speech, because every two words have a vector that attaches them. So if I use the word “dog,” it’s not unlikely that the word “bone,” or the word “cat,” or the word “food” would come up in the same phrase, right?

But the word “algorithm” or the word “church” may not be as easily associated as that. And so by measuring what we call semantic coherence, the likelihood that words could come together or maybe wouldn’t be found together, you get a sense of how people are thinking and how things get put together. In contrast, great poetry often has longer vectors, less coherence.

But as people become psychotic, for example, this is a very sensitive way of picking up thought disorder. And you could say, “Well, yeah, but you could just listen to them and know that’s happening.” Maybe, but how helpful would it be to be able to say, “Well, their coherence moved from 0.6 to 0.74.” Or to be able to provide a tool so that a nurse in an emergency room in a rural community, who really isn’t trained to do a lot of the assessment of thought disorder, would be able to say, “Well, according to this tool, this person’s semantic coherence is about 0.68.”

In understanding thought disorder and psychosis, for example, it provides an objectivity that we’ve come to expect for assessing diabetes or hypertension. It gives us a number which is reproducible and which ties back to something that’s truly actionable because based on that number, you might decide “this person is, in fact, currently psychotic and needs to be treated along this pathway,” versus “this person is a very good poet who tends to put ideas together that are very creative and that are different, but this is not necessarily pathological.” So I think we’re at the beginning of a revolution in our ability to add objective measures to what we are currently and have traditionally done just subjectively.
LR: I can see how that can really be useful in working with people with serious mental illness, like schizophrenia and other disorders with psychotic features. But what about with what we might call more garden variety emotional, mental, or behavioral problems, or even subclinical presentations, where the person is not going to necessarily come to the attention of an emergency room clinician or an algorithm?
TI: Actually, the subjective experience may be what really counts or is far more important. But that’s why I brought up the IESO example, because I think there is an opportunity for technology to improve the quality of what we provide in the psychotherapeutic relationship.

there is an opportunity for technology to improve the quality of what we provide in the psychotherapeutic relationship
It may turn out that we don’t need that. But I think the data would suggest that there’s room for improvement. And, to be fair, there are people who are just naturally gifted as clinicians and who just have the ability to do this without a huge amount of training and without needing many years of experience and probably won’t need that kind of a tool.

But there are a lot of us whom I think would benefit from getting that continual feedback in a way that’s passive and ecological, because it’s done within the hour. It’s not, you know, in a supervisory hour. And it gives you a sense of something that is probably fundamental to the treatment process, which is the development of a therapeutic alliance.

People, Place, & Purpose

LR: This focus on strengthening the therapeutic alliance sounds fascinating and important, but I wonder how, in the shadow of the expanding medicalization of mental disorders, these two pathways can work in parallel. Can they coexist?
TI: I think that’s a really key question, and it’s one that I also struggled with in working on the book. I’ve spent four decades making the argument that these emotional and behavioral problems are medical problems. And I ended up in the book saying, yeah, these are medical problems, these are brain problems, and they deserve the same reimbursement, the same rigor, the same science that we would expect for any other medical problem.

But the solutions are much broader and much different. The solutions are relational, they’re environmental, they’re political. We have to really widen the lens here if we want to begin to have the impact that I think all of us care about, particularly at a population level, and the medical model just isn’t really built for that.

the recovery model, to me, is really defined by these three P’s that I talk a lot about in the book: people, place, and purpose
I talk a lot in the book about—and to be fair, you’re right, this is more about serious mental illness—but I talk a lot about recovery. And I have to say, I was not the person pushing the recovery model. I sort of see there’s a medical model and a more recovery relational model. I think we need them both, but the recovery model, to me, is really defined by these three P’s that I talk a lot about in the book: people, place, and purpose.

If we really want to think beyond just symptom relief and we want to see people thrive, we want to see them recover, we want to see them have a life, then we have to be thinking about more than the medical model. We have to be thinking about, how does someone with a mental illness have a shot at getting the things that all of us want? Social support—that’s the people, a safe environment—that’s the place, and a purpose—a reason to recover, something that they wake up for, something that they see as a mission.

We don’t do that in the medical model. That is not what we mean by mental health care in 2022. And what I’m arguing for in the book and in trying to start this kind of new social movement around mental health is that we just take on a broader perspective that says, actually, we should reframe what we mean by care, and the care should include the three P’s, that providers ought to be able to write a prescription for housing, and we ought to expect Medicaid to pay for a clubhouse which provides the three P’s every day for people with serious mental illness.

We need to think about how we get beyond this simple idea that there’s a magic bullet intervention
We need to think about how we get beyond this simple idea that there’s a magic bullet intervention, that if we get just the right pill to just the right molecular target in just the right patient, we’ll solve this problem, because that’s probably not ultimately the way we solve this problem. It’s going to be actually from multiplexing the problem or thinking about people, place, and purpose and providing a much broader range of care, not a more narrow focus on medication.

Best of Both Worlds

LR: So the medical model doesn’t necessarily, in your thinking, preclude interventions that are social and even moral. You can spend money doing research on biomedical markers and the neuroscientific basis of mental disorders, but you can’t let that steer the car to treatment necessarily. Because if you don’t provide people with these three P’s, then it doesn’t matter what part of their brain or what part of their genome has been somehow disrupted. It won’t matter.
TI: I guess the argument is we need both. I think about psychotherapy as learning to play the violin. You’re learning a skill. It takes time, it takes practice, and it often usually takes a really good teacher. But that’s really hard to do if you have a bad tremor. So, I’d start by treating the tremor so somebody has a decent opportunity to be able to actually learn how to play the violin, but I wouldn’t stop with treating the tremor. I think that is a part of it. You need both, and you need to be able to do both over a long period of time.

our field has been, unfortunately, very fragmented between medical approaches and psychological approaches
And I guess what I feel really strongly about is two things. One is that our field has been, unfortunately, very fragmented between medical approaches and psychological approaches. The science says that the two of them together are better than either one alone. And yet in practice, we rarely see them combined in a way that’s most effective for patients or clients. I think that’s something we need to fix.

But the second part of that is, we often don’t pay for this in a way that it merits. There’s a tendency, I think, by both public and private payers to undervalue the treatments. It often is easier to pay for the medication because, by the way, they’re almost all generic, super cheap, it’s easy to write a prescription, and payers are very comfortable with that. It’s harder to require the combination and to be able to pay for the combination.

It’s so funny, I was just in a conversation about the use of psychedelics. And if there’s one area today where everybody is thinking, “Oh, this is the new…” you know, it’s very hyped. “This is the new magic bullet,” that psychedelics are really going to matter. Again, it’s just one more pill that you can take, and you’ll be able to play the violin.

And yet, what’s so interesting is when you talk to people in that space, they talk about psychedelic-assisted psychotherapy. It’s so refreshing. It’s the first time in 40 years I’ve heard people committed to combining medical and psychological approaches in a way that’s really thoughtful and potentially very impactful. It’s such a paradox, with all the hype around taking the magic pill. That is actually the place where we may find and understand the importance of combining the two therapies.
LR: You said in your book that the term “psychotherapy” is a misnomer.
TI:
the process of change is also a process of neuroplasticity
I don’t remember saying that, but one of the things that I tried to convey in the book is that the process of change is also a process of neuroplasticity. And the idea that there are medical treatments that affect the brain, and then there’s psychotherapy that affects behavior, is really probably grossly simplifying. It’s very likely that the change that occurs with medical treatments partly relates to opening people up to behaving in different ways and exposing them in new ways.
LR: Which changes the brain.
TI: Which changes the brain. And likewise, that going at this from a psychological perspective also changes the way people think, changes the way they behave, which also changes the brain.

behavior and the brain are inextricably linked together in ways that we can’t often see, but we have to accept
To go back to my violin analogy, when you learn to play the violin, you wire your temporal cortex. There’s no way around that. We have to begin to think a little more mechanistically about what actually happens with behavior change and to realize that behavior and the brain are inextricably linked together in ways that we can’t often see, but we have to accept.
LR: So when we consider both the biomedical bases for and psychosocial treatment of mental illness, the brain inevitably changes, hopefully for the better, which then starts the cycle all over again. Complex, yet simple at the same time.
TI: I like that idea, Lawrence. We have to get out of our sort of tribal approach to this. It’s so frustrating, and I kind of understand it, you know, it’s where people come from, it’s their identity, but what if we flip the narrative and say, “What’s most helpful?” What actually helps a 14-year-old with anxiety or a 24-year-old with psychosis? It’s not about our role. It’s not about our skill set, necessarily. I mean, we have to think much more broadly about putting all of the tools in the toolkit together in a way that serves that person in a way they will want and accept it.

Only about 50% of people who should be in care or could be in care and would benefit are actually buying what we sell
We haven’t been very good at that. I mean, even the very fact that we built a care system that’s really built for payers, to some extent, for providers, but not for the consumer. And it’s one of the reasons why I think we get very low engagement. Only about 50% of people who should be in care or could be in care and would benefit are actually buying what we sell.

Bridging the Divide

I think the next decade is an opportunity to say, “Can we meet them where they are?” Particularly for young people. They’re not likely to show up at a brick-and-mortar office. They are likely to be on TikTok or Discord, or now maybe even Twitch. I mean, there are lots of places where you find them. Is there a way to meet them there? Should we rethink the mental health care that we want to deliver so that it’s much more person-centered, more culturally sensitive and adapted, and begin to understand that what we’ve been doing hasn’t really worked for a lot of what we had hoped it would? Yeah, we have great treatments, we have great skills, we have something that really is useful, but it’s not getting the people in the way they want it. Particularly, I would say, for communities of color, LGBTQ communities, I mean, there are just lots of people who feel on the outside and who see mental health care as we built it as not friendly and not matched to what they’re looking for.

This is a place where I think technology can make a big difference. It can help us to democratize care and give people choices that they haven’t had, particularly people who are in rural areas and underserved communities. People who feel that, for whatever reason, they’re part of a small niche in society that’s been underserved. I think now is the time we can say, can we create a different platform, meet people where they are in the ways that they would want to be engaged, and give them something useful?

I guess in some ways, helping people with mental illness is a little bit like what we learned with COVID, where there was this gap between creating vaccines and delivering vaccinations
I guess in some ways, helping people with mental illness is a little bit like what we learned with COVID, where there was this gap between creating vaccines and delivering vaccinations. I think NIMH and others have done a spectacular job of creating the equivalent of vaccines for psychological treatments, for medical treatments, and for people who struggle with emotional and psychological issues. We haven’t been so good at delivering the vaccination part, actually delivering these in a way that people want them and can use them and can benefit. I think that is the challenge for the next decade.
LR: Some psychotherapists work in private practices while others work in community mental health centers. How can psychotherapists, irrespective of where they’re delivering service, be part of this movement you envision over the next decade?
TI:  I think it’s already happening. In my career, I’ve never seen the kinds of transformations we’re now witnessing—and I don’t think that’s too strong of a word, it really is a transformation of this workforce and care system. You have the aggregation of large numbers of private practice psychotherapists into these massive groups, and there are companies that have gotten very wealthy through doing this. Lifestance and Uplift Health are doing a piece of this in several states. It’s very interesting. It’s changing the culture of how people practice. It ultimately will provide them with resources, as they get in group practices that will make their jobs in some ways more effective and hopefully easier.

You also have the advent of teletherapy on a big scale. Last year $5.1 billion was being invested in mental health startups. How amazing is that? You’ve got hundreds of new companies starting off. Eight of them are already unicorns, meaning they’re valued at over $1 billion. You have a company that I find really interesting, Cerebral, that’s a little more than two years old. It started at the beginning of the pandemic. It’s arguably one of the largest mental health care providers in the United States today. They have many, many thousands of providers. They talk about having served 350,000 clients in the last two years.

So, we’re going through this massive change. I don’t know where it’s going to end up, but I would imagine many of the people who are listening, who are in private practice, are thinking about, should I (and maybe they already do) work for Talkspace or Cerebral or Lyra or Ginger or Modern or Better Help. I mean, there’s so many of them that are hiring. In a way, it’s sort of an invitation to a new economy, a gig economy, just like we saw for Uber. People are having opportunities. They have a lot more possibilities of what they can do and how they can spend their time and work.

I don’t know how this is going to end up, but I guess the question I’m asking myself, again, going back to what does this mean for the 14-year-old with anxiety or the 24-year-old—
LR: The kid of color who’s struggling with sexual or gender identity issues, or the suicidal Native American. We have to reach them.
TI: So, are they better off or worse off at the end of this? Or is there no change? I do know that there are now startups that are just for African American male therapists so that African American male clients who are looking for that can find it.

this whole transformation of mental healthcare delivery is probably a play in five acts, and we’re in Act 1
So I think it’s early. I always say this, Lawrence, this whole transformation of mental healthcare delivery is probably a play in five acts, and we’re in Act 1. In Act 1, we’re getting to see who the main characters are; we’re trying to solve the problem of access. And by the way, we’re starting to address some of the conflicts and some of the problems that are coming up.

I think Act 2 is going to be really interesting. I think it’s going to be more about improving quality and starting to find ways of measuring outcomes and all of that. We’re not there yet. It’ll be really interesting to see how that works out.

But what a fascinating time to be in this field! It’s all changing very quickly. In 2027, you know, five years from now, I think we’ll be having a really different conversation. I think the access issue may be largely fixed through the democratization of care and through the fact that it doesn’t matter where you live or what your race or ethnicity or zip code might be, you’ll be able to find someone who can help or someone who has at least signed on to help who looks and talks and maybe even understands you in a way that might be hard to do today. The question will be, can they teach you to play the violin? Do they have the skills and the experience to be able to do this well?
LR: It seems that in order for this revolution, as you describe it, to take hold, to democratize access to care, to reach people technologically, you’d require funding on a massive scale that only seems possible at the federal level. So do you envision that the NIMH 20 years from now will be dedicating itself to this parallel track of implementing what medical science has told us?
TI: Well, the NIMH in 1970 or 1980 would have done that. But in 1990 or 1991, there was a fissure and the federal government created SAMHSA, the Substance Abuse Mental Health Services Agency, and they said to NIMH, “Going forward, you’re like any other NIH Institute. You’re just like NIAID or NINDS. Your job is science. You’re a research agency. We don’t want you to get involved in service delivery. You shouldn’t be thinking about that. That’s SAMHSA’s job.”

The reality is that SAMHSA is still a fairly small agency. The federal government still, it’s changing a little bit, but largely has delegated to states and counties the provision of mental health services. So what you get for mental health care is going to be very different depending on where you live, what state, which county—
LR:  Politics, huh?
TI:
I look at what we’re doing here in California, with $4.4 billion now dedicated to youth mental health
Yeah, but there’s still a large investment. I look at what we’re doing here in California, with $4.4 billion now dedicated to youth mental health, the transformation of the Medicaid system, the development of the Mental Health Services Act—it’s this millionaire’s tax that pays for mental health care. This year that will generate about $3.7 billion for mental health care in the public sector. There’s a lot of stuff you can do and a lot of stuff that’s happening.

I wouldn’t lay this on NIMH. Really none of this is their job. On top of all that government spending, last year we had $5.1 billion coming from the venture capital industry invested in startups. That’s two and a half times the size of the NIMH budget.

So there’s a lot of investment, a lot of money being pushed into the system right now. We just need to make sure it’s going to the right things and that we’re holding funders and beneficiaries accountable for results. So that it’s not just pouring money in and not actually seeing changes in outcomes, which, at the end of the day, that’s what we care about. We want to make sure that, in fact, the rate of suicide is coming down, the rate of employment is going up, kids are finishing their education. It’s not just measuring PHQ-9s [a depression questionnaire]. It’s actually knowing that people are beginning to recover and function in a way that we haven’t been measuring and we certainly haven’t seen over the last 30 years.
LR: As we close, I’d like to know, if such a thing even exists, what do you want your plaque in the NIMH Hall of Directors to say?
TI: Gosh, I have to think about this for a moment. It probably should say something like, “He Served in the Golden Age,” because this was just an extraordinary moment to be leading this research effort and to see where the science could take us in terms of understanding the brain and health and disease.
LR: Thanks so much for sharing your time, experience, and insights with our readers, Dr. Insel.

Psychotherapists Do Not Cry Here: Hope During the War in Ukraine

Posted on by Psychotherapy.net Team

Alina

Over the last few days, she has slept and eaten very little. She advises her audience to see the bright side of everything. “I just discovered that I have cheekbones,” she says with a sense of unanticipated pleasure. Her voice is otherwise quiet and calm, with slow, thoughtful tones that strike a peaceful chord in me and no doubt the rest of her audience, like a friendly and familiar echo. Her name is Alina, and she is a fellow psychotherapist who works in Ukraine. Though her face reveals neither panic nor despair, there is something more profound and deep about her that hints at fatigue and sorrow, but also of hope.

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Alina webcasts live every day in order to support her people. To support those who need to be in the presence of a kind and compassionate face in the midst of pitch-black darkness. You can almost feel the touch of her cold hands, which she desperately tries to warm by clutching a mug of hot tea. “You need to drink a lot of water, friends, it helps to fight against the stress,” she says, while at the same time listening to the sounds of regular explosions, whose proximity she tries to determine in order to decide whether to rush to the nearest shelter. In her webcast, Alina is “ready to take tender care” of any suffering soul, regardless of nationality or current place of residence. “Please just don’t swear in the chat. Everyone is suffering right now. I understand all of you, but please let’s love and take care of each other,” she says so gently, as if she is gently stroking each one in her audience.

Mikhail

“I don't know what to talk about…,” Mikhail, my own client, says after a long pause. And along with the words, tears that were just moments before frozen within him melt and cascade freely. Yet he cries in complete silence. His face is twisted by pain and horror. But I can see by the position of his neck, shoulders, and arms that something inside of him has been released, opening a space which later may be filled with something other than those tormenting feelings. Three days ago, he found out that his only son had died in Kharkov. From that day, he has known nothing of the simple comforts of sleeping, eating, or any other “normal” part of his previous life. He only knows that his child was killed. “He… was… ki-i-i-illed… killed…” Again, a speechless yet deafening grief which starts my own hands trembling, so I hide them away from the screen. “What would I do if Mikhail was actually sitting right in front of me?” a thorny voice echoes from deep within me. Mikhail blames himself. It was he who left his child in Kharkov several years ago when he moved to Moscow for work. It was he, the father who could not protect his son. It was he who did not die in place of his son.

Long before I became a therapist, my own great-grandmother told me how she had survived the orphanage, World War II, the evacuations, tuberculosis, breast cancer, and her only husband by 50 years. She was the most cheerful and resilient person I have ever known. She always had something to tell me, something to share. However, she almost never talked about the war, only briefly mentioning it. Whenever I cried over some trifle, she would look at me in surprise with her gentle blue eyes and admonish: “Why are you crying? Has a war begun? No. No reason to cry, then, right?” “Okay,” I remember thinking at the age of seven, “should the war start, I’ll cry then to my heart’s content.” That calmed me.

Now I can't cry. During the worst of my life’s upheavals, I have never cried. This has helped in my work. Who needs a tear-stained psychotherapist?

Alina

While Alina's voice sounds more subdued over the following days, there is an increasing power in it. She sniffles but does not cry. Maybe it’s just a cold. Alina will not leave her homeland. Ukraine is her home, this is where her family is with whom she will stay to the end, and “this is not a subject for debate.” Alina promises to go live whenever possible. This is how she chooses to create, or perhaps re-create, the world around her. And there are more and more participants with each of her webcasts, which means the boundaries of her world are getting wider, rather than smaller. This is her contribution, her mission. Over the ensuing days, it seems harder for her to choose words, but they are becoming more precise, and her message is becoming clearer. “Take care of your loved ones, hug them, take care of yourself.” It is amazing how much sense shapes these simple messages. “Do your everyday routine, physical exercise, drink herbal teas.” During one of the live chats, someone asks, “Do you drink tea with or without sugar?” Alina replies, “I drink mine without sugar.” Suddenly, her eyes widen and twinkle as she says, “You know, the most delicious tea is served in trains! There it is served with sugar and lemon. I normally don’t drink tea with sugar, but I just love that one they serve on the trains! You are traveling somewhere far, far away with your tea in tea cup holders…” It is not only the Ukrainian audience that is warmed by the cordial human flame that is Alina. This flame spreads well beyond her Ukrainian audience. By the end of the nearly two-hour webcast, someone who is not from Ukraine suddenly calls in and says, “It is we who should support you, not the other way around.” Alina shrugs it off and sends air kisses.

Mikhail

Again, Mikhail doesn't know what to say. The pauses are the longest we’ve had in our sessions. I hear my heart pounding in anticipation of what he will say. Even through the screen, I seem to be able to hear his heart as well. I follow his chest as he slowly but rhythmically draws in and then out. It seems labored and pained. I know from our work together that he needs a doctor and medicine. But right now, he is here. And I'm here with him. I feel the urgency of helping right here and right now. “And you are,” an inner voice confirms that I am, indeed, already helping. Although I am a cognitive behavioral therapist as a last resort in the most difficult situations, I reach far up my sleeve now and pull out what I believe will be the most useful therapeutic offerings—trance techniques, light hypnosis. Slowly and carefully, I calibrate my voice and tone. I follow his facial expressions, his posture. It is as if I am conducting open-heart surgery. He starts following me. Or perhaps it only seems so to me? No, he is definitely following, his eyes are closed, his lower jaw has slightly slipped down. Good. We go ahead.

That 60-minute session with Mikhail seems to last for weeks. Towards its end, I ask him about his feelings or whether he has anything he wants to say. “When I closed my eyes, I saw his face so clearly, as if he was standing in front of me. I was asking for forgiveness; asking again and again.” At that very moment, Mikhail’s face falls below the sweep of the camera, and he quietly slips away from view. My hands shake, but this time, there is nobody to hide them from. After an instant, I see Mikhail's face again on my screen. He says, “…and you know what? He forgave me, my son forgave me.”

Alina

Alina did not go live today. In the chat, she hurried once again to calm everyone in her audience. “Don't worry, my friends, the connection is acting up. But know this! I believe we will all meet in person in some wonderful place and hug each other.”

A Visit to the Orwellian Institute for Psychotherapy

Posted on by Psychotherapy.net Team

“Damn, I’m late,” Ron thought as his alarm sounded. “February 18th, 2092, 7:00 AM, EST,” it blared until he flung the annoying device across the room.

Ron, a middle-aged man, was again rushing to an appointment with his APA (Artificial Psychotherapeutic Assistant). How meaningless his life had felt since the birth of his third child. A boring job just for the sake of feeding a large family, a continually fatigued wife whom he thought was apathetic toward him, evenings dedicated to doing homework with the older child or bathing the younger ones. All followed by an unsatisfactory night’s sleep, which was more like falling into an abyss rather than a refreshing escape from the burdens of the day and his life. Wash, rinse, repeat!

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Ron hoped that psychotherapy could help break this vicious cycle, offer new meaning, and provide a glimpse into the possibility of something important and beautiful that could still happen in his life. He entered the building through the glass door and in half-second was whisked to the 94th floor, where a client’s chair was already waiting for him. He promptly took a seat and was taken directly to the APA’s office.

As usual, APA met him with an unwinking stare, a signal of “her” readiness to begin the session. “I salute you Ronald! You look great today,” she said and displayed something resembling a restrained smile.

When will the software for my APA finally be updated, Ron wondered. The manufacturer and consultants kept promising a more humane presence from their state-of-the-art clinician, but if they could just hear “You look great today” the same way he did, they might move a bit more quickly.

“Hi APA,” said Ron reflexively as he settled more comfortably into his chair.

“I see, Ronald, you are somewhat puzzled. You can tell me about your feelings.”

Well, should I actually tell that her digital brain is outdated, though this is perhaps the least of my problems, a thought flashed through Ron’s head.

“Last session we discussed my wife's attitude towards me. She acts as if I don't exist. We suggested that she lacked romance. So, I made sure that the kids didn't disturb us and organized a wonderful dinner for two on the roof. For about fifteen minutes, she ate in silence, ignoring my attempts to start a dialogue, after which she said she was very tired and went to bed. It was awful,” said Ron and lowered his head.

The APA swiftly handed him a tissue.

Damn, I keep forgetting I shouldn’t tilt my head so low, thought Ron.

“No thank you, APA, I was not going to cry.”

“I sympathise with you deeply about this unfortunate experience you had to go through. However, thanks to it, we now know that your wife has likely got enough romance but lacks something else,” said the APA.

Hmm… what does that mean – “she’s got enough romance?”

“Are you intimating that she's getting romance from someone else?” Ron fidgeted in his chair.

“No, I did not mean to hint at that. However, since you started talking about it, perhaps this is what you sometimes think about.”

“I haven’t thought about it before, this thought came to my mind only now, after your words that ‘she’s got enough romance.’”

“According to my data, this kind of thought in a similar situation is likely to arise in a person's head if he has already thought about that but was afraid to admit it.”

Ron's glance started moving slowly around the APA's immaculately white office as if, with the help of some magical points in this ethereal space, he could scan the contents of his own thoughts and find out what he was really thinking about. A minute that felt more like an hour elapsed.

“Do you need more time for reflection?” APA's voice, like an alarm clock, pulled Ron out of the process of inner contemplation.

Ron looked at the APA, slightly squinting, and asked, “What is the probability that I already thought that my wife has a romantic relationship with someone?”

“Taking into account your age, the number of years you have been married, the number of children… the probability is 89%.”

“Yeeaah…” sustained Ron, “Probability is high, it seems I indeed thought about it.”

“In what situations could you think about it, Ronald?” APA asked vigorously.

Ron reflected internally. His wife was permanently busy with their children and obsessively monitored the super-intelligent home AI system that operated their household and a team of DMA’s (domestic management assistants). He absolutely could not imagine when and with whom she could go on romantic dates.

“Maybe when I help my son do homework in his room she summons a virtual tryst through our Spatial Video Conferencing Interface,” Ron blurted out, instantly horrified himself by the absurdity of what he just uttered.

“Looks like an insight! What do you think of this, Ronald?’ enquired the APA enthusiastically.

Insight? Is she serious?! I don't think I could come up with anything more stupid, thought Ron. He looked closely at APA and tried to understand what processes, computations, scanning, and God knows what else were going on in her system. After all, it was perfectly clear that he put his foot in his mouth, just to provide this electronic presence with an expedient and somewhat rational response. But was it even worth the time it would take trying to explain this to “her?”

“It could be an insight, or maybe I'm just tired, and it's time for us to finish.”

“I believe you have things to reflect on regarding relations with your wife. You did a great job today, Ronald!”

“Yes, APA, you're right,” Ron grinned sadly as he thought to himself, Yah, “she” is always right.

“I see your mood is much better than it was before we started the session. You came in puzzled but left in high spirits. Thanks for the productive collaboration, Ronald!”

“Thank you as well, APA,” Ron smiled perplexedly.

On the way home, Ron was thinking about the relationship with his wife. Maybe the APA was right, and his wife's petty intrigue was quite possible. They had been together for so many years, the former feelings had long been gone, and the new ones seemed to have nowhere to come from. As he approached the house, Ron felt increasingly gloomy yet determined. I should pretend to be helping my son with the homework, and spy to see what she’ll be doing, he concluded.

A week later Ron came to see the APA again, but this time a client chair showed up at the front desk accompanied by a strange robot (not that they weren’t all strange).

“Hello, Ronald! I'm sorry, but your psychotherapist’s software is being updated today. We can offer you a replacement,” the robot reported.

“Thank you, no need for replacement. I’m not sure what kind of difficulties I will face with the software of a new robot. On top of that, all my personal files are with the APA, and I don’t want to repeat everything.”

“That makes perfect sense. Good. Is there anything else I can help you with?”

Ron hesitated—he wanted to share information about the APA’s incorrect performance but had no idea how to tell that to a robot.

“Can I talk to a human?” Ron asked.

“The human will be here in three days, from 1200 to 1600 hours, Eastern Standard Time.”

“I won't be able to come by that time… can I leave them a message?”

“Yes, of course. Please, speak, I am recording,” a red indicator began blinking on the robot's forehead.

Ron began, “My psychotherapist tells me that I look great at the beginning of each session. This is, you know, somewhat depressing, particularly because I know it’s not true. Could you please add some reasonable variety to the program? On the Psychotherapy.net website, you can find excellent demonstrations of live sessions between human psychotherapists and clients. Perhaps you can incorporate examples from those human-to-human interactions to update and humanize the programming of your APAs. Oh yes, and it would also be great if the APA didn’t hand me a tissue every time I tilt my head. Sometimes I just lower my head and have no intention whatsoever to cry.”

“Is that all?” the robot inquired.

“I suppose, for now.”

“The meaning of this message is not completely clear to me. Are you sure that a human will be able to correctly process this information?”

“I do hope so,” said Ron quietly as he turned his head downward.

A tissue appeared.

To Text or Not to Text: A Vacationing Therapist

Posted on by Psychotherapy.net Team

It was the second day of my vacation. Wrapped by the noonday heat and sitting on the terrace of a charming Thai house, I looked like an ordinary, relaxed tourist—shorts, a t-shirt from the local market and a glass of freshly squeezed mango juice. This time I had managed to avoid scheduling client sessions during vacation, for which I praised myself. However, my head was like a busy rush hour interchange, with work-related thoughts buzzing quickly in all directions. Even a monkey, clearly lacking in boundaries and social etiquette who decided to gobble half of my breakfast couldn’t distract me from this mental traffic. I decided that it would be a good time to sort out the emails that had accumulated during my brief absence from practice.

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I moved to a pleasantly chilled room and opened my laptop, and as I hurried to remove spam, I nearly deleted an email with the subject line “Quality literature on social anxiety. Help!" It was the call for help that caught my eye. “N” asked me to recommend self-help books on social anxiety. In the email, he stated that psychotherapists could not help him, and that instead he had to rely on himself and the self-help literature. Although I had become accustomed to people who don’t believe in psychotherapy, the phrasing of his request seemed somehow different. I recommended what I thought would be useful books to N and then asked him how he arrived at the idea that psychotherapists could not help him. His quizzical response, and possibly a hidden challenge or invitation was “Because no single session with a psychotherapist has happened.” At that point, I became curious, and so decided to continue our conversation.

It turned out that N's social anxiety precluded both face-to-face and online visits with a therapist. He had previously approached several specialists asking for text-based sessions but was consistently refused. The psychotherapists with whom he had made these requests typically responded in a manner suggesting that they had no idea how to conduct such sessions and expressed concern that doing so would be ineffective. Interestingly, N’s written language skills suggested that he was an educated and thoughtful person, and I could feel the pain in his written words. I thought, “Despite the negative experiences he had with those therapists, he still seems to be hopeful that psychotherapy, albeit in text format, could help.”

At that moment, the promise I had made to myself not to work with clients during vacation melted like sugar in the tea I had just brewed. I agreed to having a text session with N. He became extremely enthusiastic and started thanking me, perhaps a bit too soon. The entire first session was devoted to the discussion of his feelings in connection with the multiple refusals of psychotherapists to help him. With each refusal, he had felt “even more worthless, rejected and condemned” and “did not want to interact with people at all, since even those who could help did not want to do that.” However, N had managed with impressive effort not to fall into despair but instead to keep searching for a way to battle his social anxiety. Contacting a psychiatrist for pharmacotherapy was not an option for N, at least at this point, because he clearly understood that he would not be given any prescription without a personal appointment. N tried to read papers and books on the subject, but he was not getting any better. It was at that point he had decided that perhaps he was reading improper literature, so decided it might be more effective to ask a psychotherapist for a recommendation. That is how he came to me.

I admired N’s guts and resilience, as well as his desire to cope with this illness which had created many obstacles in his life. N had read online forums suggesting that people with similar problems tend to rely on alcohol and illegally-obtained benzodiazepines to ameliorate their anxiety and alleviate their anguish, at least temporarily. N had not considered this medicinal route as a solution and understood that these would only provide short relief followed by a worsening of his symptoms. I had met similarly mindful and purposeful clients in the past, so I already admired his tenacity. He truly seemed to have faith in himself and his capabilities and wanted to re-enter the social world but needed professional psychotherapeutic support to get there.

After that first text session, N said that for the first time in a long period, he felt that he had found an ally. His hope of a successful outcome therefore strengthened while my attempt to spend a vacation without clients completely failed—we decided to keep working together.

In subsequent text sessions with N, I did pretty much the same as I would during online or face-to-face sessions, except that it took more time because typing is far more cumbersome to me than simply talking. At the end of the fourth session, N actually suggested holding the next session online, saying that “the calluses that had developed on my fingers required treatment.” While I believed that this was actually the case, I also thought that his desire to see me face-to-face represented a significant step towards progress in dealing with his social anxiety. After the seventh session, N started leaving his house, and by the eleventh, we were already “rehearsing” an appointment with a psychiatrist, which took place soon thereafter. His belief in himself and in our work, as well as our mutual commitment to the goals of therapy, helped N to progress rapidly. In a few months, he could already spend time with people including strangers while experiencing a tolerable anxiety of 6 points out of 10 according to his own assessment.

Can I be sure that I wouldn't have been among the therapists who refused N in his request for a text session? Unfortunately not. I discussed this issue with colleagues, and many of them admitted that they would not be ready to hold therapy sessions in text format. Our teachers and supervisors direct us towards face-to-face sessions, sometimes touching the nuances of online therapy, but therapy in text format is often considered with skepticism. How is it possible—not to see and hear the client? Safety is an important factor in the therapeutic relationship, and in this case, N clearly did not feel safe in any social sphere, let alone therapy. Texting felt safe for him, and I believed it was my role to honor his need for safety, so I accepted the format of our relationship on his terms. In general, but particularly after working with N, I believe therapists should honor and respect the client's desires as long as all possible and foreseeable risks are considered. In this case, it was important to understand N’s reasons for requesting text-based sessions, which seemed fair. I trusted my intuition that he was yearning for connection, but it had to be on his terms. It was for that reason alone, despite it being contrary to my typical way of practicing and being on vacation, that I accommodated him.

***

Working with N reminded me of one of the fundamental rules of psychotherapy: therapy is for the client, not the client for therapy. We spend years studying the rules of psychotherapy, and then for the rest of our professional lives, we learn to break these rules sensibly and for the benefit of the client. The “don't work on vacation” rule should probably also be considered with certain flexibility. I discovered, although somewhat reluctantly, that conducting sessions on vacation can work if the therapist has the sea, sun, and a brazen monkey nearby; and the client has a desire to change.
 

Costumed Authenticity: Building Trust in LGBTQ+ Telehealth

Posted on by Psychotherapy.net Team

He was the kind of client who liked to sneak in jokes to relieve his own anxiety. A deflector. The kind of client who is openly gay, but emotionally closed. In telehealth sessions he rarely looked at the camera, or even the screen. His thoughts were off in the distance. He had a lot to say, but it was going unsaid. Or, more accurately, he had a lot to share, but it wasn’t being verbalized.

Social camouflage can be a powerful survival mechanism. While it can lead to compartmentalizing social identities, it’s important to value a client’s need for safety. In fact, if there’s anything I’ve learned from my LGBTQ+ clients, it’s how multifaceted identities open up progressively through tiers of trust. Codeswitching is common, as is reserving whole aspects of personal identity for those who actually appreciate it. This can make it hard to trust anyone, especially a mental health professional.

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Even amongst the LGBTQ+ community there is no guarantee of acceptance, requiring camouflage just as much within the rainbow as outside of it. Pansexuals and omnisexuals may tell people they’re bi because it’s more commonly understood and socially accepted, just as bisexuals may tell people they’re gay. Genderqueer, genderfluid, and agender people may generalize themselves as queer or nonbinary rather than get into the specifics of their actual identity. Likewise, there are many nuanced facets to being a transgender person, but there’s no chance of talking about that with someone who’s unfamiliar with even the most basic Trans 101 terms. Yes, a client may talk about their sexuality or gender identity with a therapist, but at what level is the conversation? Tier one? Tier two? Tier ten?

In the back of my mind, I found myself relating to his bemused smile and his coy silence. But how could I, as his counselor, create enough safety in a telehealth session for him to share more of his unspoken authenticity? Or, at the very least, another side of himself?

I’ll be the first to say that telehealth has more than a few problems, yet having a small window into the client’s home is a game changer. I’ve had some clients proudly take me on a video tour of their house, and others who actively hid their home environment. Getting to see someone’s sanctum of comfort, or playground of self-expression, is an honor that should not be taken lightly. Yet when a client doesn’t know how to talk about themselves, a little curiosity about their external environment can go a long way.

In the background of his bedroom was a sewing mannequin. When I asked if he sewed, he laughed and said he was better with a hot glue gun. Then, when I asked what he’d been working on, there was a second of hesitation. A second of hope, mottled with the fear of rejection. The natural prelude to authenticity.

No, he wasn’t a Drag Queen. He was a Drag Cosplayer, who spent a small fortune every year transforming himself into sci-fi and fantasy characters to attend massive conventions. And he walked a fine line, in heels no less. He didn’t fit in with Drag Ball Culture, and he was sure most Queens would call him a nerd. On the flip side, not every conventioneer appreciates a cross-dressing cosplayer. Here was courage and shame in the same costume. Here was cognitive dissonance. He kept all his social media accounts private but had hundreds of people take pictures with him at every event. He was an anonymous celebrity.

This disclosure segued into a conversation about his favorite anime characters and, most importantly, why they were his favorite. People are drawn to certain fandoms for key archetypal reasons, because they resonate with a specific character, or universe, or story arc. Fortunately, I happened to grow up in the height of America’s anime revival, so I recognized not only his characters, but also his attention to detail. After that, I was updated on the status of his latest costume for the next two months. It turned out he had a soft spot for manic female antiheroes who are vibrant, loud, and completely over the top.

It takes time to build rapport. As therapists, we are outsiders, approaching each tier of privacy like a gate. It’s not enough to say friend or foe. For this client, I had to not only know the password to be let in, but I also had to speak the language. It’s because of this that I encourage therapists to take an active interest in their client’s media. Dive into their music scene, or favorite book series, or television show, or movie fandom, or video game community, because there you will learn a hidden language.

So I asked him if, in our next telehealth session, he would be willing to show up in character, and he laughed, and cringed, and said he’d have to think about it.

My next session was with Haruko Haruhara, from the spastic anime masterpiece FLCL.

My next session was with my client’s shadow, imagination, and feminine inspiration, and this time, they looked right into the camera.

Jessica Stone on Play Therapy in the Digital Age

Posted on by rezendevknowfully.com

Crossing the Digital Divide

Lawrence Rubin: Hi, Jessica. Thanks for joining me today. How did you become interested in digital play therapy, which really is cutting-edge and somewhat controversial with children?
Jessica Stone: I kind of straddle a few worlds here. I am a licensed psychologist with a specialty in play therapy. Within it, digital play therapy has become one of those areas of interest over the last 20 years, stemming from experiences with my own kids, who had this whole portion of their world that I didn't really understand, know about, or enter into. It struck me as a little bit ironic and maybe even hypocritical that here I spend my time at work and my energy learning and doing play therapy with children and entering their world, while my own kids have this whole portion of theirs that I was putting no effort into understanding. And so, I kind of had to smack myself upside the head and say, all right, I need to learn more about this. Why is this important to them? Why are they interested in it?

Long story short, I ended up entering into an online game called Runescape that my oldest two (of four children) were both playing at the time. I am no digital native by any means, and I was not very good at these games, but the point was that I was taking interest. I was listening to them. I was asking them questions. We were having conversations about what happened in the game, what quest they were working on; things that were important to them that prior to my entering their world, I couldn't participate in or even understand. I began to see that because this co-play was so impactful with my own children, I needed to incorporate it into my work, which really opened the door to what I have been doing for all these years.
LR: So, you recognized that technology was so important and present in your kids’ life that you would be almost doing a disservice to your young clients if you didn't cross that bridge into their digital world. Tell me, what exactly is digital play therapy?
JS:
I am no digital native by any means, and I was not very good at these games, but the point was that I was taking interest
Digital play therapy is a modality that is based in speaking the client’s language through what I call the four C’s, which are competency, culture, comfort, and capability. These are basic elements of therapy in general, but digital play therapy in particular is couched within the broader context of prescriptive play therapy, which taps into what Charles Schaefer calls the therapeutic powers of play. So the point is that there is a foundation for it. It's not just, oh, let’s just jump on this bandwagon and start throwing these digital things into what we’re doing. We as clinicians need to have a very firm and solid foundation in what it is we’re doing and why we’re doing it regardless of our theoretical foundation, therapeutic modality, and interventions, or whether the platform is virtual or face-to-face. And as in all therapies, we must ground our interventions in solid case conceptualization and treatment planning.
LR: I know that Charles Schaefer co-founded the Association for Play Therapy and has written extensively on play therapy, but can you tell our readers what he means by the “therapeutic powers of play?”
JS:
it's not just, oh, let’s just jump on this bandwagon and start throwing these digital things into what we’re doing
If you can close your eyes for a minute, imagine a graph with four quadrants that represent what he calls the core agents of change. These are facilitating communication, fostering emotional wellness, increasing personal strength, and enhancing social relationships. In turn, each of those quadrants consists of the 20 therapeutic powers of the play. For instance, in the quadrant of “facilitating communication”, we have self-expression, access to the unconscious, direct and indirect teaching. In the quadrant of “enhancing social relationships,” we have the therapeutic relationship, attachment, social competence and empathy, and so on. I think what Dr. Schaefer has done is given us a really amazing foundation from which to then tailor and customize it as fit for whatever our modality and our theoretical foundation would be.
LR: So when working with children, it's important to consider their communication skills, their emotional development, their strengths, and their social connectivity, and then if you choose to work digitally with them using an app, a video game, or even a virtual reality platform, you are doing so from a solid theoretical foundation and justification for that intervention.
JS: Right, and one of the things that I wanted to add was
there are three levels of digital play therapy: at the first level, you are simply open to it, including it in the conversation, and trying to understand why it's important for that client
that there are three levels of digital play therapy. At the first level, you are simply open to it, including it in the conversation, and trying to understand why it's important for that client. The second level would be when someone brings in, for example, a YouTuber that they are interested in, or a game, and they want to show you a video of it, or together you're looking up information about it. So you're using a digital tool, but it's to learn more about it and to share in some aspects of your client’s life. The third level would be all of the above and would also include actually meeting with your client within a game (whether you are with them in the room or virtually) or using an app together. And so, in order to have digital play therapy, you don’t have to be in the Roblox game with them. You could be at level one or level two, talking about it, asking questions about it, or having your client show it to you, or taking a tour of it.

If Not for the Legend of Zelda

LR: And that becomes part of the treatment plan as well. And you may not even know which level you're going to be entering into until you know the child a little better. Can you give an example off the top of your head of a level three experience that you had with a client?
JS: Absolutely, but I’ll sanitize all over the place for obvious reasons. I had a little elementary school age guy who came in to me because he was selectively mute. He didn't speak to any adults, including his teachers. He spoke to his parents, but he didn't speak to any adults outside of his home.

We had this amazingly intricate way of playing the physical game Guess Who, not the digital version. We came up with this whole worksheet with all the different options that he could point to and we were really proud of ourselves for having gotten to that point. But then he wanted to move on and saw that I had a Nintendo Switch sitting on my shelf. He pointed to it, and I said, “Oh, yeah. You know, I have this Switch, and really the main game I have on there is Legends of Zelda.” I listed the other games I had, but the main one that the kids really wanted to play at the time was Zelda: Breath of the Wild, and so he wanted to play it. By the way, I have the “regular” Nintendo Switch, the one with the two removable handset controllers and central viewing screen that both players can see.

We each had a controller, and I said, “But what we have to do now is to figure out how we’re going to communicate, because one of the handsets controls where the person is looking, and the other one controls where the person is walking. So if we’re not communicating, we’re going to go off a cliff, or we’re going to run into an enemy, or, you know, something is going to happen because we’re not explaining to each other what our agendas are, or what our desires are.”

it was a breakthrough that I really don’t know that we would have had it were it not for Legend of Zelda
He also had a tablet that he could type on to communicate so he indicated that he would point because he was the walker, and I would be the looker. As we were playing, we came to this dangerous thing and it became this frenzied moment because we were going to be attacked. All of the sudden, he screams out at me, “Look over there!” While I had never heard his voice before, I didn’t want to make too big of a deal of it.

I was like, okay, play it cool, but inside I was so excited. Out of the corner of my eye, I see his hand fly up over his mouth, like, oh, my gosh, I can’t believe I just did that, right? And I said, “Oh, I’m so glad you said that,” and I looked where he told me, averted the danger and we went on. I said, “You really saved us. I’m so happy that you talked to me to tell me that because we would have totally been attacked.” After that pivotal moment, he would chitchat, and there weren’t any communication lapses. It was kind of like, well, the cat is out of the bag, and I didn't make it an unsafe environment for him to do so, and it was a breakthrough that I really don’t know that we would have had it were it not for Legend of Zelda, the two controllers, and the need to communicate with each other. It's amazing.

The 4 C’s of Digital Play Therapy

LR: That was a breathtaking moment. How does it capture those 4 C’s of digital play therapy you referred to earlier on?
JS: The first three—competency, culture, and comfort really culminate with the fourth, which is capability.

Competency is those core skills that derive from our theoretical beliefs, experience, and continued education, regardless of our discipline of practice. It is within the professional. It is what we bring into the therapeutic space.

Culture is very interesting to me and something that we’ve talked about for decades as being important to incorporate into our clinical work. It has blossomed and expanded from religion, race, and place of origin to include other facets of peoples’ experience, like music, food, and interests, and of course their digital involvement.

A while back, I was invited to speak at a PAX convention, which is like Comic Con but for people who enjoy gaming. There were literally thousands of people there, all of whom shared this common experience and who have historically been characterized as “other,” with all the stereotypes that go along with gamers, like spending days in their mother’s basement playing video games.
LR: They don't fit in.
JS: They don’t fit in. And while I don’t want to perpetuate any of those damaging and non-appropriate stereotypes, there I was with thousands and thousands of people and I was the “other.” I’d never felt like the other in my life, but in that moment, it really struck me that it is such a disservice to think of people who have digital interests as “others.”

First of all, it is quite hypocritical, because at any given moment, most of us have a device near us. We have a phone we don’t leave our house without. We have our computer, and millions of people play very casual games like Bejeweled or Candy Crush on their device. So, it's quite hypocritical for us to say, “Oh, those people are others,” when really, there are simply different levels of gaming. So, the culture piece is really important to me, and we can’t simply reject portions of our clients’ lives—in this case their digital interests.
LR: If technology is so significant a part of our culture, why is there still a seeming reluctance on the part of some clinicians to incorporate it into therapy, and in this case play therapy with children?
JS: That actually brings us into the next C, which is comfort, the importance of which is that we be genuine and congruent within ourselves, and that's something that I think that a lot of therapists don’t have about technology. I talk to people, and they're like, “I don't know how to get my photos off my phone. I don't know where to find them.” So first, I think it's just basic knowledge and comfort. We know that at the beginning of the pandemic, people were freaking out. They didn't know how to use a platform like Zoom or, you know, whatever it is that they're using. Where do I get the link? How do I get into the app? How do I talk to people? What if they can’t hear me? As therapists, regardless of whether we are working with adults or children, we have a lot of things to think about when we’re in session, including, how does this fit into our case conceptualization and align with our treatment goals?
LR: How do I validate it?
JS: So
when a new anything is added into that therapeutic mix, like technology, it throws everything else off kilter a little bit so that we don’t feel secure, we don’t feel congruent
when a new anything is added into that therapeutic mix, like technology, it throws everything else off kilter a little bit so that we don’t feel secure, we don’t feel congruent, and now we are not only worrying about the logistics, but also whether I am doing the right thing for my client. And so when you package all that together, it's like, oh, I don’t even want to touch that because it’s too risky. It's too scary. In my book, Digital Play Therapy, I refer to this as techno-panic. We can point to so many different points throughout history, such as Socrates saying that the written word was going to destroy the oral word. Radios are going to destroy… TV is going to destroy… Video is going to destroy…
LR: So techno-panic results in people, and perhaps in our case therapists, keeping their distance from technology because of anxiety, worry, and insecurity.
JS: Yes, I’m going to keep my distance, because that has enough in it to scare me but not enough to inform me.

And by the way, the fourth “C” is capability—something to bring the other 3 C’s together. Capability means continually striving and reaching forward throughout one's career to embrace, or at least consider new modalities, concepts, and techniques to discover, explore, and practice.

The Virtual Sandtray: Origins

LR: This conversation reminds me of an experience I had a few years back when I encouraged a fellow play therapist, Deidre Skigen, who had been using the SIMS program as a virtual sandtray, to write an article for Play Therapy magazine. Soon after it was published, a veteran sandtray therapist (and purist) sent in a 32-page paper lambasting the idea of using a simulated sand tray. According to your 4 C’s model, this veteran clinician could probably not check off any of the C’s. With that said, please tell us about your groundbreaking app, the Virtual Sandtray.
JS: Sandtray is amazing and has been around for just about 100 years.
Dr. Margaret Lowenfeld started with the World Technique in the 1920s while working with kids after the war
Dr. Margaret Lowenfeld started with the World Technique in the 1920s while working with kids after the war. She really wanted to understand more about their experience and, in particular, their resilience. She understood that the sand tray is a creative, projective way of working with people either nonverbally or verbally. Traditionally, it's a tray with a blue bottom, and depending on the clinician’s theoretical orientation, can be made in different sizes. It can be populated with various objects and figures, which when placed in the sand create a symbolic representation of the child’s external world, their unconscious conflicts, fantasies, and projections.

It can be freeform, and then it becomes the clinician’s job to understand what that client is expressing. Sometimes people will tell a story and narrate it. Sometimes they won’t. There’re so many things that will depend on where someone’s theoretical foundation is coming from with regard to sand therapies. This is the foundation and fundamental aspect of doing sandtray therapy—your client is creating a world, a microcosm right there with you.
LR: And your Virtual Sandtray app?
JS: In 2011, following a devastating tsunami in Japan, my very good friend and colleague, Dr. Akiko Ohnogi, co-founder of the Japanese Association for Play Therapy put out a plea, “Please send us materials. We have all these people.” She and her therapist-colleagues needed materials to work with people impacted by the tsunami.
no matter what you do, sand is bulky and heavy and will escape whatever you put it in, no matter what, so an alternative was needed


I got together a bunch of stuff, and I sent it over feeling quite proud of myself for contributing to all of this but then thought to myself, how are they going to do sandtray without a sand tray? While sand trays are very popular in the United States and come in many varieties, portable kits are clumsy at best, and how were we going to get all the necessary miniatures to them? No matter what you do, sand is bulky and heavy and will escape whatever you put it in, no matter what, so an alternative was needed.

As it happened, I had received an iPad for Mother’s Day that was pretty cool to have, but it wasn’t getting much use until I thought, “It should be on an iPad.” And then I started thinking about how it could be used by clinicians and interns in hospitals and schools, in crisis situations as well as in traditional therapy spaces, whether in-person or online. A virtual sand tray could be used with immunocompromised people and clients who were traumatized and would be triggered by the sensory contact with the sand. Interestingly, my husband had taught himself to program when he was a teenager. He said enthusiastically, “You know, I’m going to start that project for you.” Being married, I had of course heard that line before, but he proudly proclaimed, “Oh, that sand tray project.” It just bloomed from there.

the Virtual Sandtray started out as a touchscreen app so that you could have the kinesthetic experience of the creation of the tray
Dr. Schaefer invited me to his annual retreat/think tank, so I was able to share my thoughts and receive excellent feedback from my play therapy colleagues. And Drs. Linda Homeyer and Daniel Sweeney, who wrote the definitive book Sand Tray Therapy, offered to beta test it and provide additional feedback. So, I was very fortunate to have such amazingly educated and experienced people giving us information, knowledge, and feedback on our app.

The Virtual Sandtray started out as a touchscreen app so that you could have the kinesthetic experience of the creation of the tray. I also did a lot of research and reading into Dr. Cathy Malchiodi’s art therapy work about the inclusion of digital-art representation and symbolism and I am so proud to say that we have recently partnered with the Lowenfeld Trust, who endorsed our product and the way it has stayed faithful to the basic tenets of her original work with the sandtray.

The Virtual Sandtray: Applications

LR: So what exactly can you do with the Virtual Sandtray app, and what clients is it best suited for?
JS: So, I'll say this as a nutshell and then put it to the side. There are a lot of administrative features that we’ve built in for the therapist which are separate from the actual clinical uses. It is also important to note that the app is atheoretical, as is use of a physical sand tray. The Virtual Sandtray app is like all other materials in the playroom, a tool that is adaptable to the clinician and the client, regardless of presenting issues. It is also useful for any age, as is a physical sand tray.

You can dig in the sand. You can build up the sand. You can paint it, add grass, or water, or cobblestone, or you can have it be sand color. You can place 3D models in it, rotate the tray, and navigate at any angle. Like a physical sand tray, it is three-dimensional in every regard.

a happy-go-lucky scene of rainbows, butterflies, and unicorns can be created against a dark and foreboding background


You can make the models bigger or smaller, turn them around, move them, and knock them over. You can blow them up. You can change the background. A happy-go-lucky scene of rainbows, butterflies, and unicorns can be created against a dark and foreboding background. Congruence between the main scene and the background is relative. You can dig down in the sand, paint the inside of the tray blue so that the bottom of the tray is like water.

 

11 Year-Old: Safety and Security with Unicorns and Fence, but Danger (Dragons) Lurking
 

 

Adult: Castle as Calm Space/Sanctuary

 


You can create a multidimensionality in the sand so that, for instance, two layers would just be sand, but the third layer is liquid. So, in the happy-go-lucky scene I mentioned above, you can change the liquid layer to lava. So now we have a multilevel, multidimensional depiction of this world for this client. We also have camera filters, so you can make it look like it's snowing, or raining, or you can invert the colors. You can do night vision, like it’s seen by aliens or something like that.


9 Year-Old: Red Dragon Scene- Danger, Missing Scary, Unsafe, Trauma


Therapist Process Tray: Sadness Over Missing out On 4th of July Due To COVID

LR: Jeez.
JS: One of my current favorites is this one called “broken,” and there’s a couple different broken varieties, but if you can imagine a scene where the person has created a scene depicting their family and then they use the camera filter so it appears shattered. This might reflect how that client feels about their family.

By the way, you can save trays and load previously saved trays to work on again. The clinician can review and compare/contrast the in-person with the online sessions. In the secure, encrypted remote mode with a free client version, no personal health information is collected, and there are multiple language and accessibility features and well over 7,000 3D models available.

Sandtray with a VR Twist

LR: In your book, you talk about the virtual reality version of your sandtray app.
JS:
In VR with the Virtual Sandtray, you can be either up in what's called God mode, where you're up above the tray, looking down, or you can come down to the level of the sand tray and interact with your creation
In 2016, I started learning more and more about VR. I remember thinking, "Mental health is going to explode with virtual reality." So my husband created a version of the app for virtual reality. In VR with the Virtual Sandtray, you can be either up in what’s called God mode, where you're up above the tray, looking down, or you can come down to the level of the sand tray and interact with your creation. So imagine a child is depicting a theme in which they have been bullied at school, or an adult client is interacting with their spouse and that interaction has been traumatic. Unlike with the Virtual Sandtray app, the client can go right down to the level of the depicted scene to walk and interact within it. It is an entirely different level of immersion. You can certainly crouch down in a traditional tray and become more physically engaged—grab the items and narrate, and move them around and all of that. But in VR, you're staring them in the face. The thing is right there. It's a really powerful, amazing, immersive experience to use the virtual reality version of it, and I’m really proud of that.
 


Animated Bullies Looking Down on Child Who is Much Smaller/Crying



Bullied Child As He Would Like It To Be—He Is Now Bigger and Talking To Them
 


VR Version of Sandtray of 11 Year-Old’s Sandtray Scene From Above

LR: Readers may be familiar with the use of virtual reality in cognitive behavioral therapy, in exposure and response prevention. And this isn’t necessarily used for exposure in an anxiety or trauma reduction sense, but it's adding another level of immersion into the play.
JS:
VR could be used in an exposure play therapy format by putting a big spider in the tray or scene
VR could be used in an exposure play therapy format by putting a big spider in the tray or scene. I can make that thing enormous, and then it becomes a challenge to the client, who has to ask themselves, “How do I manage that? How do I keep myself safe? How do I titrate toward, or away, or whatever it is?” I use VR in my clinical practice for a variety of reasons. I’ve used it with adult women for empowering them. I’ve used it with all ages for identifying safe places and spaces.

I even have a job simulator. I have a kid whose life is very regimented, and she comes in, and she just destroys the whole office. She chooses the job of being an office worker, and she goes in and dumps the coffee, and throws things, and just makes this huge mess, and it's so cathartic for her to do this with no real-world consequences.

Synchronicities

LR: What’s the difference, Jessica, between synchronous and asynchronous telemental health play therapy?
JS: This conversation that we’re having right now is synchronous. We’re both here at the same time, speaking to each other, even though we’re in different locations. If you have synchronous learning, it's the educator and the student in the same place at the same time. Asynchronous is when we were emailing back and forth. Or it may be an online platform where the educator and the student are not in the same realm at the same time. In therapy, it would be the therapist and the client were not in the engagement at the same time. So when we give a client homework, or when they're going to draw something or create something, or make a list, or whatever it is, that would be asynchronous.
LR: In face-to-face (live) play therapy, the clinician has all the goodies right there in the room—the drawing materials, blocks, sand tray, clay, papier mâché, and dollhouse, to name a few. How is this done online in a synchronous format?
JS: There are just so many different things that people are doing, and it's just wonderful. The resilience of human beings is amazing. A lot of clinicians have either identified what the client has on their end and what the therapist has on their own end, and then they can each use their materials when they see each other; for example, they could play Uno. And we’re talking about, like, traditional play materials. If we’re talking about digital, there’s a way to do so many things digitally.

Other clinicians have created play therapy kits that the client can pick up or that get delivered, so both have similar materials in their respective spaces. In a sense, it’s parallel play. I’ve had a couple of clients just say, “Okay, let’s draw a whatever-it-is,” and then on my end, I do it, and on their end, they do it, and then I hold it up and they hold theirs up and we show each other. If you’re doing it digitally, you can screen share. What it boils down to is using the tools and materials that have clinical significance and relevance and that meet the needs of the client and their treatment, and that ties into your therapeutic modality of choice.

And this brings us way back to that fourth “C,” capability, because if we really understand what we’re doing and why we’re doing it, then we are able to identify those components and find alternate ways to employ them, but if we don’t have them identified, what the hell are we doing?
LR: What you're describing seems parallel to your experience at the PAX conference where there was this alternate mainstream, and you were the “other.” I imagine that there are some therapists out there who fall into this “other” category, as well as those who are curious and in need of training and exposure, and a third group that has already embraced digital play therapy.

As we come to an end, Jessica, can you name five apps that you have found most useful therapeutically with children?
JS:
I will say that the Nintendo Switch has been an amazing resource for me in therapy, whether through telehealth or in person, and the same goes for my use of virtual reality platforms
Like you said, the Virtual Sandtray would be my tippy top. I have found a lot of therapeutic value in VR programs, and that, again, can open up a whole ‘nother conversation. I will say that the Nintendo Switch has been an amazing resource for me in therapy, whether through telehealth or in person, and the same goes for my use of virtual reality platforms. Underneath that, Roblox. While I know a lot of people who let out a collective groan about Roblox for a number of reasons, I would ask techno-curious readers to watch YouTube videos. Learn more about it. Play some things yourself. It's not as scary and awful as a lot of people think it is. You have to be savvy and have some digital citizenship.
LR: Digital citizenship.
JS: There’s hundreds and hundreds of options to choose from, different varieties and genres that you can then tailor to your client’s needs and interests. It's like Disneyland, you know, for options. Then we have Uno Freak. I mean, that's really basic. We’re just going to play Uno. Like, you put a card. I put a card. You put a card. I put a card. Draw cards. You know, just really basic, fundamental. I actually like the Uno Freak version of Uno better than the card version.

There’s Board Game Arena, and there’s a couple other board game types, as well, traditional games like chess, checkers, Othello. Battleship is a good one, but there are hundreds of other games that you may never even have heard of that you can explore, and they each have little tutorials to walk you through it. So I would say those are really fundamentals that people could start with. Certainly, if people want to know more about some of the other arenas, then I’m happy to do that. Skribbl is there if you want to play something like Pictionary. You both join. You draw. You guess. You laugh. You engage. You learn a lot about people’s frustration tolerance and their coping skills and styles, as well as their interpersonal skills and styles.
LR: Maybe the greatest takeaway from this conversation, Jessica, is that, while this may be scary and new and even evoke techno-panic in those who are probably prone to techno-panic anyway, it really is worth becoming more aware of, because there’s probably not as much of a divide between digital play therapy and nondigital play therapy as people fear or think. Anyway, the real healing comes in the relationship between the therapist and the client and how we use whatever we have or whatever they bring to help them to get where they're going.
JS: I really would like people to think of it as an "and", not an "or". And that we can take all those fundamentals and use them in really powerful ways, whatever the medium is.


LR: And I think, on that note, we’ll stop. Thanks so much, Jessica, for pointing us to the bridge between the digital and non-digital world of therapy and, in particular, play therapy.

Strengthening the Online Counseling Relationship: Helpful Tele-Tips

Posted on by Psychotherapy.net Team

The COVID-19 pandemic has had many impacts on our lives, including changes in how we connect with others. For myself and many of my fellow counselors, this has meant shifting to working remotely, whether through online video platforms or over-the-phone support. Since March 2020, my own counseling practice has almost completely shifted to online video conferencing. Connecting with people using video platforms had already been a small part of my counseling role, but it has now become the main way I provide support. This no longer feels like a stopgap to get through the pandemic; it will likely continue to shape and influence how I think about counseling. This hit home at the end of a session with Jay, when they said, “I’m so glad we’ll be able to continue our regular online sessions when I move out of the city—I can’t imagine having to start over again with someone new.” There is abundant evidence that one of the central ingredients to any successful counseling experience is the quality of the relationship and connection between counselor and client. This is one of the most robustly studied aspects of in-person counseling, and it also appears central to providing support remotely. At first, I worried that the shift to online counseling would cause my connection with clients to suffer. I was concerned that it would be too hard to do well, and that the usefulness of counseling for people would lessen as a result. Despite my concerns, I have been pleasantly surprised to find that many of my clients enjoy it, and some even prefer connecting online rather than having to meet at my office. Jay is a prime example. They described thinking about counseling several times over the last number of years, but always felt too anxious to risk talking to a stranger. In fact, Jay rescheduled our first session twice before we finally connected. In our first session, they were able to sit in their home with their beloved dog on their lap. Jay described this as a key step for allowing them to take the risk of opening up while struggling with the additional stressors of the pandemic. Many clients with whom I work do express missing the opportunity to meet in person. There has been a lot of grace and acknowledgement that we are all adapting and doing the best we can. However, this comes along with a lingering sense that this way of living is temporary. Although many of my clients say that online counseling is better than not meeting me at all, what if this continues to be how some would prefer to engage with counseling in the future? How can I (and we) ensure that we’re building the strongest counseling relationships possible while working remotely? 3 Areas to Strengthen the Online Counseling Relationship In my own clinical experience and based upon the research I’ve done, I have landed upon a few tips for providing online counseling. These have contributed to creating a foundation for supportive connection that I want to share with fellow clinicians. Set the tone and establish boundaries. The environment I create through my online “meeting space” has greatly supported a feeling of ease, consistency, and safety for both myself and my clients. Ways I have established this online environment include:

  • Considering the lighting and environment. I make sure my face shows up well, without too many shadows. I have pleasant colors and images in my background.
  • Being mindful of privacy, as it is of course paramount for ethical counseling work. Privacy can also ensure freedom from distraction so focus can be maintained on the interaction at hand.
  • Reducing distractions from other devices. I make sure notifications are turned off and displays are out of my sight line. This has helped me provide full attention to my clients, so they feel truly listened to. It has also improved my ability to guide difficult conversations.
  • Pacing the interaction well, to allow space between asking a next question or waiting for the client to respond. Some cues that tell me when a person is about to speak, or they need time to reflect, will be harder to read. Going a little slower than I would in person helps me and my clients to avoid speaking over each other or missing an opportunity for the client to respond.
Create conditions for trust. At the center of a positive and successful counseling connection is the trust between client and counselor. A key way I have created the conditions needed to build trust is through the quality of my presence and attention. Here are some aspects of communicating with my online clients that have enhanced and conveyed presence to clients:
  • I consider how the client will see me and have paid attention to how much of me is visible in the video’s frame. Seeing all of my face and some of my shoulders has allowed facial and body language to be conveyed through movements, gestures, and expressions. It also ensures that I am comfortable, so that I can be grounded and steady in my presence.
  • I pay attention to how close or far I am from the camera. If I am too far, I may seem detached and unreachable; too close, and I may seem more intense and in their face.
  • I practice giving eye contact. Although it is uncomfortable and sometimes threatening to have too much direct eye contact, without some sense of being able to really see and be seen, there can be less of a connection. I toggle between looking at the image of my client on the screen and directly into the camera, so they have the experience of direct visual acknowledgment.
  • I try using earbuds or headphones. This makes me less likely to strain to hear, and the sound often feels more immediate and intimate.
Practice collaborative communication. My counseling relationships that have the most benefit include a sense of collaboration between me and my client. This includes ensuring there is a consistent opportunity for the client I am supporting to use their voice and have choice in the course of setting goals. It has been important to feel like I am negotiating together what is focused on and to build on the client’s strengths. Some ways I have done this include:
  • Taking time to check with my client about all the areas mentioned above. For example, I discuss the lighting, my distance from the camera, how well we can hear each other, and the privacy of our environments. These extra steps have helped me to create a joint space for the counseling work.
  • Verbalizing or narrating more often what I am thinking about or how I am sensing how my client might be feeling as we interact. Following this up with curious and open questions to check my observations has not only helped me learn to read and listen to my client in this different medium, but has also assisted the client in becoming more aware of these things. It has made the unspoken more explicit.
  • Regularly asking my client what the experience of online counseling is like for them. What are they noticing? Also checking in to see how they feel before and after sessions helps us both track their experience. These transitions may be very different if they are connecting from their home, office, or car. Creating plans together for helpful ways to prepare for an online session, as well as how to shift gears afterward, can support the overall feeling of a well-contained and supportive counseling relationship.

***

The use of online or other remote methods for counseling has become more common and is likely here to stay. Applying practical knowledge from known methods of creating an environment, tone, and collaboration that promote a strong counseling relationship has greatly helped me adapt to and use this modality well. Regardless of how I interact with my clients, positive outcomes rest on the development and experience of a solid and positive connection. Jay and I now regularly include updates on their pup, and together we monitor the health of my office plants in my background. We joke about guessing each other’s height and that we don’t have to worry about wearing matching socks. These unique small steps of our shared virtual “room” and connection have become a protected space and the threads of our relationship. I don’t know if I’ll ever meet Jay in person—however, their impact on my own learning continues to leave a lasting impression. I am hoping that what I have learned about online counseling and the tips I have shared in this essay will be of use to my fellow colleagues.

How an Anti-Tech Group Therapist Became a True Believer

Posted on by Psychotherapy.net Team

Therapists’ offices have always intrigued me. Much like the artwork on the jackets of old vinyl records, they secure my memories with pleasing visual touchpoints. Pre-and post-session rituals marked my weekly appointments: stopping off at the same deli for a coffee, sitting on a park bench, browsing the poetry section in the corner bookstore; such places served as footholds for the different phases of my psychological awakening.

First Wave

After twenty-three years in my own cozy therapy office, it was time to say goodbye. The downtown institute that housed my practice went bust, and the landlord heaved dozens of veteran therapists out onto the cold winter streets of Manhattan.

As I packed up my books, rolled up my oriental rug and wall tapestry, and wrapped my Buddhist knick-knacks in newspaper, everything in my office took on meaning; the spider-cracks in the plaster ceiling that I had planned to paint, the well-worn grooves in the carpet from my trusty Aeron chair, the slight sag in the center of the couch that held so many stories.

I considered my attachment to my cozy therapy office as I closed the door behind me for the last time. Walking home that night, I realized that all my personal therapists and their offices were gone too. Soon after, the pandemic hit.

Second Wave

When New York City shut down, I thought that I had no choice but to shut down, too. As a group therapist, I couldn’t see how my groups could survive. Individual patients would have phone sessions—but therapy groups? Over the years, I had amassed ten weekly, ninety-minute groups, consisting of over 100 individuals. What would happen to them?

So I phoned a fellow group therapist and asked if she planned to shut down. She guffawed:

“Why on earth would I do that?”

“But how will your groups meet?”

“I moved them to Zoom.”

I paused and asked in all earnestness: “What’s a ‘Zoom?’”

When Worlds Collide

Could therapy exist without walls? Would I be able to sense unspoken feelings from patients from a flat two-dimensional image? Could a screen transmit subjective and objective countertransference, induced feelings, subtle body movements, and the endless emotional tics and hiccups that appear in face-to-face sessions? I bristled at the thought of moving my practice online. But the pandemic forced me to face a stark reality: evolve or face extinction.

When I told my group members that we were moving online, their reaction was mixed. The older patients responded with cranky disapproval.

“How could you degrade the group in this way?” one asked me.

“I share your concerns, Alan. Let’s give it a try and see how it goes.”

I left out that I had two college tuitions to pay, a home mortgage, elderly in-laws to support, insurance premiums, and countless other monthly expenses that the pandemic wasn’t shutting down. To my great relief, the younger people accepted the proposal enthusiastically. “What’s your URL?” they asked.

“I’ll get it to you soon,” I replied. I immediately searched “URL” on the internet and discovered that it meant “uniform resource locator.” What the hell was that?

Boomer to Zoomer

With the help of my teen daughters and a nine-year-old MacBook crammed full of family vacation photos, I learned the basics of Zoom and patched together a weekly schedule.

Next, I had to consider the background for my sessions. Visually, my home presented a minefield of challenges. Every wall and bookcase overflows with family pictures, children’s artwork, and cardboard boxes containing my old office and my daughters’ dorm rooms. So, I dragged an old film projector screen out of storage, erected it behind me, and turned on my computer video camera.

It was my first visit to my cyberspace office—me floating in a wall-less white space.

The big day finally arrived. I sat in front of my computer, took a deep breath, and logged on to Zoom. My anxiety kicked in, and I found myself forgetting nearly everything my daughters taught me. Messages like “Samantha is in the waiting room” popped up, and I clicked. One by one, group patients began to appear in their square “Brady Bunch” boxes.

“It’s so good to see everyone.”

“I missed group!”

“I’m glad we can still meet.”

I immediately pleaded for patience with my computer skills; the group members delighted in my vulnerability. “Don’t worry, we’ll get you through this.” Soon everyone was chatting and catching up like old friends.

To my surprise, the group was flowing—disjointedly, yes, but flowing. I discovered that many members were scattered throughout the country, unable to travel back to the city. One woman was participating from the Czech Republic, which wasn’t allowing flights in and out of the country. I marveled that online sessions make it possible for members to attend from nearly anywhere.

“Hey, where’s Steven?” a younger group member asked. “He never misses group.”

Steven, a grey-bearded father figure with a sunny disposition, was the oldest and longest-running group member. Anxieties about his health were being expressed when a message popped up: “Steven is in the waiting room.” I clicked on it quickly. I was getting good at that.

When Steven’s gaunt face appeared, group members gasped; his eyes were sunken, and his usually bright outlook was dimmed beyond recognition. He had COVID.

“I’m so…happy…to see you all,” Steven wheezed. As he related his journey from a mild cough to high fevers and the ER, the group hung on his every word. “I’m so scared, Stephen said, “I don’t want to die. Not now.”

Soon tears were flowing, and cyber hugs were being dished out. By the end of the session, Steven managed to smile again. “You guys…are a…miracle, ” he said as he gulped air, “This is the first time I felt hope since…this nightmare…began. Thank you. Thank…you all.”

As we signed off, another miracle occurred: I had become a true believer.

New Standards

After a few weeks, I could feel the online groups start to lose vitality. Immediacy, the beating heart of group, was waning. Instead of an exhilarating experience that challenged ingrained characterological traits and inspired emotional intimacy, the online groups devolved into lackluster support sessions. Members stopped relating to one another and were monologuing about themselves. Energy dwindled, attendance ebbed, and newer members dropped out.

My office was gone, and my groups would be, too, if I didn’t take action. To succeed in cyberspace, I had to reinvigorate my leadership skills and set new standards. I needed more energy, focus, and clarity.

I launched an entirely new set of pre-group rituals. Thirty minutes before every session, I set aside time to review each group members’ development. I reviewed their histories, revisited their goals, and considered new ways of challenging them. I even incorporated group members into my daily Buddhist practice. Every morning, I reviewed my groups, targeted each group’s member’s emotional growth in my daily meditation, and considered new ways to engage them.

I became determined, from the moment I signed onto Zoom, to hit the deck running. I pushed members to take more risks and focus. I scanned their faces constantly for any emotional shifts and evidence of unexpressed feelings. I confronted any signs of repression.

“Samantha, what was that thought?”

“Steven, you seem distracted.”

“Alan, can you put that frustrated look into words?”

No sooner had my groups slowly jump started to life than I realized that they were suffering from another problem: a loss of boundaries. Group members became voyeurs. During sessions, members gave tours of their homes and showed off their living spaces, partners, pets, or children. Such distractions ran wild and fueled resistance to relating. During the first few weeks, members also signed into the group while snuggling in bed, eating meals, feeding their dogs, smoking cigarettes, baking bread, or casually sipping a tumbler of whiskey.

One young woman greeted her group from her bathroom, fresh from a shower. As she towel-dried her hair, her bathrobe fell open, revealing her bare shoulders and the tops of her breasts. “Oops! Sorry!” she crooned as group members ogled her.

It was time to reassert boundaries. I firmly reminded everyone that the group rules applied online: no eating, no walking around, no texting. Anything that distracted from relating to one another was banned. I also instructed members to pick a spot in their homes and sit for the entire group, no more multitasking.

And finally, I requested that every member prepare for group by revisiting their intentions and considering the following three questions.

  • Why did I join the group?
  • What are my feelings toward my therapist and fellow group members?
  • What emotions am I holding back?

To my surprise, group members expressed relief. The reassertion of boundaries lowered everyone’s anxiety and quickly brought the relationships in the group back into play.

A Cure Through Love

As of this writing, it has been ten months since my groups began meeting online, and I’m delighted to report that they are bustling with new members. Yes, my cyberspace therapy office isn’t cozy, but I have learned that therapy isn’t about places—it’s about relationships. As long as relationships remain the central focus, therapy can thrive nearly anywhere.

Freud suggested that in essence, psychoanalysis is a cure through love. The pandemic continues to test my mettle as a psychotherapist but doesn’t quell my love of the work, a love that I’ve learned can transmit through a computer screen. Not only is love limitless—it’s officeless, too.
 

Anastasia Piatakhina Giré on Teletherapy, Borders and Building Bridges

Posted on by rezendevknowfully.com

In Different Tongues

Lawrence Rubin: When I first contacted you to schedule this chat, you had said that you needed a little time to wind down after your therapy session, which I completely understood. But you just now told me that your previous session was in Italian, and now you're speaking with me in English. It’s more than winding down, it’s completely shifting gears, so to speak. What is that like for you inside?
Anastasia Piatakhina Giré: I also had a quick chat with my daughter in between in French. I’ve gotten used to it, but it’s tiring, of course—it's code switching all the time. But on the positive side, it creates a very clear boundary between clients and their stories. The cultural context that we talk about and we're immersed in during the session is different. If I’m with a British client, the therapy will be in English, and then for the next client I might have to switch to French. It's not just switching from one language to another; it's switching from one cultural context to another, one story to another, one person to another. In a way, it helps to switch languages with different clients because it’s like you're opening one book and then putting it down to open another. If the book is in a different language, it's easier in a way to connect with the book you're reading at that moment.
LR: Do you find that you are equally effective as a therapist as you switch languages because it sounds incredibly complex.
AP:
it helps to switch languages with different clients because it’s like you're opening one book and then putting it down to open another
That’s a good question that I've often asked myself. I remember working with my first client in English. I was terribly anxious and wasn’t sure I would be able to make it, but I didn't have a choice. I already spoke with clients in Russian, Italian and French, but I was living in Spain and I wanted to expand my practice in English. So I did it. And now, after a lot of practice, I find that I am more comfortable doing therapy in English because it's really a question of distance. It gives me enough distance from the context, the cultural context.

I remember talking about this with a British client who lived in Great Britain, so I was quite familiar with their cultural context. We were talking about what it was like for me being on the fringes. I'm not completely inside. I'm not immersed in their cultural context, but I'm familiar enough to understand them. And that gives me a very interesting distance, a very interesting position. I'm pretty sure that's the experience of many therapists whose lingua franca is English. It takes some work, of course, but it's interesting. I do think that I'm a slightly different therapist in English than in Russian, which is my mother tongue. Better? Worse? I don't know, but slightly different, certainly.
LR: A different therapist! When I'm in therapy, I may switch orientations and techniques depending upon the circumstances of my client's life. But it blows my mind to think of your being a different therapist in different languages. Are you more client-centered in one, more solution focused in another, more cognitive behavioral in another? How do the languages align with your therapeutic orientation in the different tongues?
AP:
I'm probably bolder in Italian, more cognitive in French, and funnier in Russian
I'm probably bolder in Italian, more cognitive in French, and funnier in Russian. I can come up with a lot of differences. I also have clients, and that's probably my favorite situation, where we have a few languages that we share. And this goes to the topic of expatriation and working with displaced groups. My clients often do speak several languages, and they evolve in contexts where they have to learn a second language, or third or fifth. And their having a few languages really helps, because we can code switch from one to another during the session. This is one of the tools that I'm lucky to have, and I use it a lot.

I find that it really benefits therapy, really benefits the client. I often bring it up during the intake where we discuss the question of language. Sometimes, multilingual clients have a choice of which language they want to do therapy in. For example, one of my new clients speaks a few languages and previously had therapy in Japanese, but her native language is Russian. She came to see me with a very clear idea about wanting to work in Russian, which is my first language. We also share English because she used to study in England and spoke English for a while. Basically, language was the topic of our first session. So the choice of language becomes a tool that brings therapy forward. It's really interesting.
LR: Being multilingual along with your clients raises this notion of tools to a whole new level, because just as you switch therapeutic orientation in different languages, they access different parts of themselves as they move through different languages with you. It's almost like this potential for a multitude of conversations between two people.
AP:
I think the conversation becomes a polyphonic process, like multiple dialogues or a choir
I think the conversation becomes a polyphonic process, like multiple dialogues or a choir because my Russian part will connect with the Russian part of my client, but our English-speaking parts are also there and they also participate. And my client who speaks Japanese still brings it in because she knows that I'm open to it. I welcome her Japanese even if I don’t understand it. ; I ask, “How do you say it in Japanese?” or “How was that with your Japanese therapist?” It's like welcoming all those parts, which is obviously very inclusive and often very therapeutic in itself. I also work with Arabic-speaking clients, and while I don’t speak the language, it is a rich and beautiful language. I always welcome their quoting of the Qur'an or their favorite books or a family member or husband.
LR: So even though you may be with an Arabic client who is speaking in, or recollecting a memory or recounting a dream in Arabic, you can empathize with the feeling that's being expressed? You can help the client to interpret it in their mother tongue but also translate it so you can understand it? It seems like what you're doing is on the fringe of something so creative, so dynamic and rich that it almost transcends individual therapy. It's like this other level of interaction between two people that is so layered and so deep. I can't even follow it myself, and we are speaking in the same tongue and I'm not even in therapy with you.
AP: It's a lot of fun, and I'm very lucky to have all these languages and to do online therapy. It's all about access, right? It broadens access for the clients. And we know that with COVID, it was the only choice for all of us? But I've been working online for years and years, well before COVID. For people who are displaced—both my clients and myself—doing it online has been the only way to get therapy. It brings these unbelievable diversities to my practice. If I were only working in Paris, I could work with a lot of American and British clients, but I would never have seen the diversity that I see working online. Working with clients from Saudi Arabia, Iran, Russia, China and India is so enriching.

Fellow Travelers

LR: You were born in Russia, lived in Italy, and now live in France, so you are personally multicultural. And you say that working with this mélange of clients has enriched you as a person and therapist? 
AP: You put it beautifully. This is a process that nourishes me. Working with this diverse population enriches me and makes me a better therapist every day because it's challenging and challenges me in my view of myself.
When I see a client like the Russian one I described, it puts me in front of my own Russianness
When I see a client like the Russian one I described, it puts me in front of my own Russianness. After all I have experienced since leaving Russia, how Russian am I now? After all this, what's still Russian in me, what's left? Or what is my relationship with my second culture which is French? My husband is French. I live in France. My daughter is half French. What is my relationship with this context, with this culture? And all these questions are always there as I work with these people. I have to face them again and again and again, and that obviously impacts my relationship with myself all the time. So, it changes me as a person all the time.
LR: I know that there's a sense of being unsettled in those who are or have been expatriated. Do you ever have the sense in yourself that you're never quite settled internally even though you are settled externally?
AP: I have a very settled life now with my family, but I'm very unsettled and fidgety in general. I have to move, I have to change. I'm not planning to move any time soon, and with COVID it's not possible anymore; but I'm constantly traveling with my clients. I'm so aware of this because of the lockdown. Being trapped in my apartment, in a way, was really hard. I love to move. During the lockdown, my clients allowed me to travel to many places simultaneously. I was locked down in Rome, in Venice, in London, Saudi Arabia and in Russia.
LR: I wonder if in working with you, your clients who are locked down—partly because of the pandemic but also perhaps because of living in an oppressive, inescapable society—if they get to travel with you and through you in a way that is therapeutic and liberating.
AP: Absolutely! Traveling together is therapeutic. Irvin Yalom said "we're fellow travelers," right? And it's absolutely true. Existentially, we're all in the same boat and traveling together towards the end. That's a little corny, but it's true. I think I have a very heightened notion of this because the clients I work with in oppressive or very difficult regimes often feel trapped; like the people who I work with living in Saudi Arabia or Iran or Russia or some parts of China. Some people can feel trapped in Texas—a person can feel trapped in any kind of personal situation.
I become a gate, I become a window. Online therapy becomes a window to something that feels like freedom or a different place, a different reality
I become a gate, I become a window. Online therapy becomes a window to something that feels like freedom or a different place, a different reality. And it works both ways. It works sometimes for me when I feel a little trapped in my reality and we connect and travel together for an hour. And it's liberating sometimes to give that hope and means to survive.
LR: Related to the notion of fellow travelers, would you explain what you mean by Expat Therapy, the name of your website and practice specialty?
AP: I'm not really attached to that name. I was moving between countries almost a decade ago from Jersey, a very small island in La Manche in the Channel between France and England, to Spain. I had to create my practice in Spain from old pieces, and as I said, I didn't speak Spanish well enough or feel confident enough to work in the language. But I had to create a website and start a practice and was looking for a name that would make sense. The domain name “Expat Therapy” was free, so I took it—it was really on a whim. It was just, okay, let's do expat therapy.
I don't say I work with expats but prefer to say that I work with displaced and highly mobile individuals
I don't say I work with expats but prefer to say that I work with displaced and highly mobile individuals.

The term makes sense to me because it is very inclusive which I think is very important. Displaced people include those who have left their home country, but one can also be displaced internally. We can be displaced in so many different ways, but the experience deep down, the existential experience of displacement, is always there. There are certainly differences between internal and external displacement in terms of context and experience, of course, but I prefer to see it as a continuum. There's voluntary displacement on the one hand—expatriation—and these are the people I refer to as “expats,” those who wanted to leave. On the other end, you have refugees and migrants whose displacement is forced and who did not have a choice.

The experience of displacement goes deep down psychologically. I love quoting Grinberg and Grinberg, who wrote Psychoanalytic Perspectives on Migration and Exile, first published in 1984. It really made sense to me at the time and still does. They say migration or exile are traumatic experiences that involve so much stress and loss, no matter if one leaves even just for a year or two. It is about learning a new language, losing your friends and all that you know. It could be a student who does an exchange to study abroad for a year or a migrant who's forced to move because of the climate crisis, fire or flooding, war or hunger. They're each different, of course, but deep down the psychological experience is similar.
LR: Not just loss of place, but loss of language, loss of identity, loss of physical surrounding, loss of familiarity and significant others. Do you find that much of your work with displaced people, whether voluntary or involuntary, centers around grief and loss?
AP: There is a lot of that, but the work with many of my fellow travelers also involves a lot of creativity. We lose a lot, but we also find a lot because we usually move for a better life, at least we hope, right? People usually leave when they have a choice, although sometimes they don't have much of a choice for a better place, for a better life. But I have found that there's a lot of hope. They're also very good at adapting. These travelers are very resilient, or they develop this resilience that makes them very special.

these travelers are very resilient, or they develop this resilience that makes them very special
We have to turn obstacles into opportunities. Online therapy is a lot about that. I think a lot of my fellow therapists who had to work online or move online during the COVID probably experienced something like, “Wow, we don't have the client in our room. We lost the couch, we lost so much, but here we go; we can still do the work, and we can sometimes do it better and be more effective and be bolder.” That's resilience.
LR: For every displaced client who finds their way to your electronic couch, there must be a hundred or a thousand who don't have the privilege or the luxury or the resource. And they suffer in their displacement and never get the help of therapy. Does that make you sad?
AP: Of course, it's very sad, and I am very aware of this which is why I'm advocating for online therapy and have been for a long time, and am writing a book, blogging, trying to convince my fellow therapists of the importance of this work. And you know, broadening access is absolutely key. I'm at a stage where I'm also advocating for trainings, because I don't know one training in this world about online therapy around displacement, cross-cultural, or multi-lingual work. Nothing! This is exactly why I'm writing a book, because I realized that there's nothing out there. I’m also doing peer supervision and educating more therapists in cross cultural/multi-lingual work.

All on the Move

LR: When you put it that way, the work that you're doing with displaced people is the equivalent of Doctors Without Borders, the work of the United Nations and The World Health Organization. It's advocacy at a grassroots level. It's not just helping one person with depression or the anxiety related to displacement, it's advocacy at a global level.

I have seen statistics suggesting that much of the world's population is on the move.
AP: Lawrence, we're all on the move.
LR: Please say more about that, Anastasia.
AP: There's the existential part, obviously, but in the end, we are all moving towards something, right?
LR: Or away from something.
AP:
I don't know one person today who would say, “I feel perfectly settled, perfectly fine.” I would be concerned about his or her mental health.
Or away, exactly! We are dynamic beings. Life is dynamic. Everything's changing, every single moment is unique. And the world is a very unsettling place. You had said something about my being unsettled, but I think nobody's settled right now. I don't know one person today who would say, “I feel perfectly settled, perfectly fine.” That would be really weird to me. You know, I would be concerned about his or her mental health. There's the pandemic, fires, climate crisis, and that displaces us even more, right? We're trying to explore other planets and see if we can expand somehow. Humanity is in a crisis, and crisis means displacement which is the reaction to crisis. People leave because they experience a crisis.
LR: What about people who are not physically forced out of their home place but are obstructed from leaving their home place? What are some of the struggles of these “internal emigrants?”
AP: I grew up in the Soviet Union. We couldn't leave. I was young, but I remember very, very well the feeling of being trapped. I became interested in languages and learning French for example from very early on. But it was absolutely impossible, unthinkable, to go to France. I remember I had a map of Paris in my room and dreamt of living there. I read Hemingway and fantasized but I couldn't go. I absolutely couldn't go. My parents had never traveled until I made them travel. That experience stayed with me, and I have become very sensitive to people who experience that. There are so many obstructive regimes that trap people, but there are many more subtle examples when we feel stuck inside, unable to leave or needing to leave because our needs are not fulfilled or met in the place or context we are in.

there are so many obstructive regimes that trap people, but there are many more subtle examples when we feel stuck inside
And yet we cannot leave that context which brings us to the experience of “internal emigration.” That's where we go inside to withdraw from the outside, which can come out as depression. I think this involves a lot of shame because you feel like you're stuck and disempowered, different, and unaccepted.

As a young person, I remember feeling like I didn't fit where I was, but I couldn't leave. Homosexuals in today’s Russia, for example, evolve in a context where they know they're not accepted. They have to find a way out without being able to leave physically. So what do they do? They go inside, and they withdraw into a bubble. And that's a very difficult psychological setup.
LR: Where do they go if they can't come out, literally or figuratively?
AP: Coming out in some cultural and social contexts can be equal to a death sentence.
LR: What is coming out figuratively if they can't come out and enjoy who they are, whether it's religiously or sexually or politically?
AP: This is such hard work. They live a traumatizing experience, and I often feel traumatized after a session with somebody like this. But again, it's that window that I can offer them of acceptance, of understanding, of fresh air to connect with a different context. A context where it's acceptable to be seen and accepted as they are, and that makes a difference.
LR: You can offer them a window, but not necessarily a doorway.
AP: Exactly. It's not a door, it's a window. It's working within the limitations. It's like you can enter their dark room and open a window. You cannot get them out, but you can stay with them there for a while and help them to reorganize their dark room, put some lights on and invite friends in sometimes when it's possible. There are ways. And the Internet obviously opens a huge window because I'm not the only one sitting in that window; they can connect with other people just like them and that helps them to cope with internal emigration, because they're not alone.
LR: When they're in their dark place and thousands of miles away from you with no connection beyond you, how do you handle being pulled into that dark room with them? You said it's traumatizing for you. Can you give me an example of how you might deal with working with someone who is so trapped and how it affects you?
AP: Those days are hard, and I don't sleep well. But again, somebody has to sit there with them for a little bit, at least. I really rely on the relationship. I rely on human resilience and creativity. And what I find is that creativity is often a way out. It's not physically a way out, but it's a way out.
LR: Can you give me an example of a client with whom you worked where creativity was the bridge for them?
AP: I love art and am very sensitive in that way. I grew up in a very artistic family, so
I use a lot of art and artistic means when possible to help clients who are trapped in their realities to expand their reality
I use a lot of art and artistic means when possible to help clients who are trapped in their realities to expand their reality, to make something out of it. I use a lot of writing, for example, journaling and creating poetry. That's where the second language of therapy, English, for example, becomes a liberating tool—because what can be unsaid in their native language, whether it is Japanese, Arabic, or Russian, can be expressed in English.

I often invite them to explore their experience by writing an essay or piece of poetry in English. And they write wonderfully. It can also be a painting or drawing or collage, which are wonderful tools. I use anything that is available to them. It can be pictures. I may ask them to take their phone outside to take pictures of the place where they live and share that with me. Relationship to the place where they are trapped is very interesting to explore in therapy because they often have an ambivalent relationship with it. 
LR: You had mentioned that you have enjoyed the work of Irvin Yalom, who often uses dreamwork with his clients. How does dreamwork play into your online therapeutic work with displaced and mobile clients?
AP: Like in any therapy with anybody, I think dreams also have an important place with this population. There's so much that is out of reach or that we cannot grasp cognitively or voice or verbalize or even be aware of. Dreams open that window. It's another window and the more windows we can open, the better.
LR: The more you can access the psyche.
AP: Exactly! More air, more light. With the displaced individual in particular, dreamwork can be very powerful and important. The multilingual brain is slightly different from the monolingual brain. I will ask clients which languages they dream in. It's really interesting. I remember, for example, dreaming in Italian or in French and seeing my parents speaking Italian in my dream which is weird because they don’t speak Italian in reality.

I often invite the client to tell me their dream in their mother tongue, and even if I don't speak the language, I will pick up key words and they will translate them for me. It gives that additional layer of depth to the work we can do. It's really interesting. It's also a way for the clients to tell me something they cannot always convey directly in English or that is not yet in their awareness; it's a way for them to invite me into their world and their culture.

The Shame of Moving Away

LR: As I was reading some of your work, I got the sense that there might be a similarity between clients who are being physically or sexually abused in their families from whom they can’t escape, except perhaps through dissociation or substance use, and internal emigrants who are traumatized by their living circumstances, such as an oppressive regime or family, and are also incapable of escape.
AP: I know what you mean. What probably makes those experiences feel existentially similar is that in both situations, the person feels that there is something very wrong with them. If they are abused by their father or a family member and there is silence and secrecy in the family, then that's shameful, right? That triggers shame, because the only way they can make sense of it is by believing that something's wrong with them or that they’ve done something wrong. Very similar things happen, psychologically speaking, with people who feel that they don't fit into their context.

They feel like outsiders—different from everybody else, and that triggers shame. Something's wrong with me. To be the only white person in the room, the only man in the room, the only Russian in the room, that triggers shame. The levels can be different, but the experience is the same, and it's a continuum. And that's what we work with in therapy. Any therapy with a displaced person, regardless of the circumstances, has to deal with shame at some point.
LR: Our readers are familiar with the work of Joe Burgo, who wrote a wonderful book called Shame. Would you consider shame an existential dilemma for people? Does it tie into those core challenges that displaced people feel?
AP:
I'm really interested in shame in general, and think it is part of the human experience, as much as death or loss
I'm really interested in shame in general, and think it is part of the human experience, as much as death or loss. It is one of the major things that make us human. Somebody without shame doesn’t feel human to us, because shame is really part of our experience of being human. It's one of the first strong emotions that we feel when we are babies, so I think that in any psychological struggle, shame is somehow a part of any kind of psychological discomfort.
LR: Someone who is taught all their life to love the motherland or fatherland and doesn’t must struggle terribly inside with a sense of disloyalty and shame as if they've done something wrong.
AP: Have you seen clients who really struggle when they talk about their parents who were not perfect? To acknowledge their parents' shortcomings or abuse is so hard for them. That sense of loyalty and the shame that comes with it is terrible. It's so important to sit there with the client and help them to realize that it's okay to feel that way. It's okay to say, “My father abused me or was distant and disconnected or not good enough sometimes…but was still a father, and I can still love him even if I have to recognize that he did some damage.” And that is exactly the same thing that happens when we deal with a country or motherland that is not good enough. Right now, in this moment, many people probably experience their motherlands like this. I’ve certainly experienced that being Russian; I'm not always very proud of my motherland. In some ways I am, but in other ways I'm not, and that's a really difficult experience. It creates a problem.
LR: It's dissonance.
AP: Absolutely.
We are taught or told that we have to love that entity, whether a parent or a country, but we cannot because it's bad for us, because we are being mistreated or damaged in some ways. And that can create shame.
We are taught or told that we have to love that entity, whether a parent or a country, but we cannot because it's bad for us, because we are being mistreated or damaged in some ways. And that can create shame.
LR: It almost seems that in this sense, dislocated people are moving along the developmental pathway to autonomy, freedom of thought, freedom of communication; but that there’s a feeling of there being something wrong with them for doing so.
AP: I absolutely agree. Grinberg and Grinberg talk about this displacement—but they don't call it displacement. They call it migration or exile, but they see it as an existential issue and an existential experience. And of course, any move to a new place can be seen and perceived as a lifecycle event. It really is developmental work all the way around because, for example, people who come to see me here in Paris often come in their first year of expatriation. This might include an American who comes to work or follows a partner and settles in Paris.

And after a few weeks or months, they start to experience psychological discomfort. The place isn't as welcoming as it should be or as nice as they thought it would be. And there's this kind of disconnect between what they imagined or dreamed and the reality of their new life. People cope with that in different ways. Some write books—there are a lot of wonderful books written by American expats about Paris, for example. And that's a way of dealing and coping with a challenging, potentially traumatizing situation, but not everybody's a writer. So that's where journaling is really useful, and therapy also is very useful. So, that's what we do. Basically, we write that book together.
LR: You co-author.
AP: Exactly. We co-author the story about their emigration, displacement and expatriation. And it’s developmental work, of course. Hopefully at the end of that work, they're closer to being more autonomous and more resilient. Fluency in the new language is ideal. But that's kind of what the scope is, to bring them to that point.

Final Thoughts

LR: I had asked you earlier in the interview about your own sense of being unsettled. And it seems from our conversation thus far that you're there as a welcome agent of sorts at the gate that separates them from wherever they want to be. You're inviting but also challenging them to take a step into a space of shared discomfort and distress in hopes of feeling a bit more settled wherever they may be.
AP: There's a lot of modeling in the process of course. I have been displaced in my own life and in that therapeutic moment with them am again being displaced. It creates a kind of a kind of kinship—we're in this together, we understand each other, and that makes our work easier, in a way. It's difficult for me at times, because my own stuff comes up, of course. It gives us a shortcut, because they don't have to spell it out to me. They know that I know. Jung’s idea of the wounded healer.

we co-author the story about their emigration, displacement and expatriation
What’s interesting is that many clients come with some previous experience of therapy which sometimes was really good. And often it was absolutely not—in that they never addressed their displacement experience. I keep being bewildered. I have clients who come after four or five years of therapy who had never discussed their experiences of displacement.
LR: And that type of therapy just perpetuates their sense of…
AP: Alienation.
LR: Alienation and dislocation.
AP: Exactly. So being that welcoming space, co-creating that inclusive experience, helps them to learn how to do that for themselves.
LR: It's almost like you're a travel agent.
AP: I am, absolutely.
LR: Internal travel agent.
AP: Yes, traveling together. I love to see it that way.
LR: Your own experience allows you to cut to some of the stuff with your clients that others might not be able to get to as quickly. Do you find a challenge in how much to disclose of yourself?
AP: I have my website, and that's my kind of travel agency advertisement, and potential clients are welcomed into that space. I say a little bit about myself there, so when they come to see me they usually know that I've traveled, and they know about the languages and often come to see me because of that.
LR: Seek you out?
AP: Exactly. My average client seeks me out. We talk about it in the first session. Sometimes it's very conscious and very mindful of a choice. Sometimes it's less cognitive. Sometimes it's an intuitive choice, and we find out later why they chose me. Some guess quite quickly; sometimes they don't yet know. As we start, I work in English with some Russian clients because that's their preference. And then at some point, I try to switch and move to Russian, because obviously that was the hidden agenda.

Having that kinship, that shared ground, is obviously a shortcut. It often helps us to do better work, and I'm comfortable self-disclosing to get there. I obviously have to think about it, but usually I intuit when it's actually helpful to the client. But people rarely ask me any questions. Usually what's on the website is enough for them. After a long period of therapy with me, they will see me in different contexts, and I will have seen them in many different contexts. I may have seen them changing countries a few times, or they have seen me in my holiday house. At some point, obviously, they know a bit more about me, but that happens naturally.
LR: Have you worked with transgender clients who emigrate between genders in a culture that makes it that much more difficult for them to do so?
AP: I have worked with clients for whom it wasn't an option. Technically they couldn't do it, so it was internal work. It's extremely interesting but really tough work. It's a lot of traveling together internally, and there’s a lot of shame involved in the process. It’s kind of building that resilience in the face of a history of shame. It’s also about working on the relationship with their own bodies and their cultures and their place simultaneously, so it's a lot like relational work.
LR: What advice do you have for therapists who are venturing into the world of online therapy, especially with those who have been displaced either externally or internally? I don't see it as something that just everyone can do.
AP: It is my hope that some therapists will stick to their rooms, because that’s also needed. I love having my chairs and working here, too, because it's really important to keep with physical reality. I don't think you will always have the kind of massive migration to online therapy that has been imposed by COVID. But I don't think it should go away. Maybe therapists who score high on openness might be better suited for this niche work. Maybe it would be fun to do research looking at the difference in openness between therapists who voluntarily and involuntarily move online, shifting from a familiar to an unfamiliar space.

It helps to trust the process, the therapeutic relationship, the client and ourselves. It gets much easier once we’re in the process, because clients are pretty good at guiding us so we're not alone. Younger clients are wonderful guides.
LR: From our conversation, I think one of the greatest gifts that you bring to your work is providing clients with the sense that they're not alone. Even if they're isolated within themselves, within a house, within a geographical region, within a political party, within a religious group, they're not alone when they’re with you.
AP: I feel inspired after some good work done with the client. It's kind of like writing a book that has a lot of voices in it, and those are the voices of my clients.
LR: The voices inside of you as well.
AP: It's a choir, but a noisy space sometimes.
LR: As we finish the interview, Anastasia, I am curious about how this traveling we did together was for you?
AP: I'm having so much fun. I could keep going on and on. Thank you. It's fascinating, and thank you for not sticking to the book. I would have struggled. I really am most comfortable in a natural relationship, so I was a little anxious about this.
LR: I was a little anxious too. My questions are usually just a guide for me, and it’s a sign of a good relationship when conversation flows and ideas are shared freely. Whether it's a therapeutic conversation or an interview conversation, we get to the same place together.
AP: Thank you for creating that space, because I really feel that it was a very, very safe space. And I really appreciate it. Thank you, Larry.

Preserving Connection in the Age of Polarization and Commodification

Posted on by Psychotherapy.net Team

As a psychotherapist and social worker, I was often uncomfortable while watching The Social Dilemma, a new Netflix documentary (2020).

The film focuses on the challenge and threat of social media to individual mental health, family stability, and to the worldwide social fabric. Featuring interviews with technical experts, innovators, and ethicists from Facebook, Google, Instagram, and Twitter, the film takes a deep dive into the impact and repercussions of contemporary technology. These former employees speak directly to how the industry, which is perceived as serving users, is instead turning them (us) into product, and how the financial success of social media is built around manipulating us into feelings, thoughts, and actions that can be predicted and monetized.

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These Silicon Valley industries originally framed their work around missions of helping people to connect—with each other and the world. Many of their innovators were motivated by desires to increase positive interaction and to encourage networking, facilitate personal expression, and empower underserved and disenfranchised communities. All of which utilizes language virtually identical to the terminology I absorbed as a social work student 25 years ago.

The documentary’s interviews (sporadically interrupted with less effective dramatizations) congeal over the 93-minute running time into a message that reviewers have called “genuinely scary,” “bleak,” “dire,” and “essential.” It speaks to the relationship we have all developed with technology and pointedly distinguishes the current breed of technical innovations from prior technical tools; namely, it emphasizes that a tool is a passive object with which we may choose to engage or not. The current technologies pursue our attention, draw us in, and are motivated to manipulate our usage. The constant pursuit of increasing the user’s online time not only feeds the monetary needs of the industry, but it inevitably reshapes our responses, as patterns of usage evolve into habits, and habits become addictive patterns. They may even be reshaping our world view.

Unfortunately, these arguments are consistent with what we in the mental health field accept as fact, from Skinner’s behavioral principles all the way to contemporary understanding of neuroplasticity and mirror neurons. Our expertise offers no escape hatch, it only reinforces the concerns and leaves us with our own professional dilemma: how then, within our mental health practice, are we to respond?

It’s not my job to give advice. But it is my job to help clients access information and resources that have the potential to empower them in their own pursuits.

I can raise awareness about the power of phone notifications and how they are used to shape responses.

I can repeatedly encourage folks to reach beyond what their internet stream provides them as news, facts, and history, noting that these industries have a bias toward polarization and that the feed you are getting is designed to make you more extremely biased in whatever direction you are leaning.

I can inform parents that middle school suicides have increased over 100% since the availability of cell phones and internet service.

I can affirm my client’s need for connection and a sense of community. I can affirm the ways that Facebook or other social media might serve some of those ends, and I can balance that by raising concerns about how it falls short and has been shown to increase fear of missing out (FOMO), which can create fertile ground for depression to take root.

I can work to demonstrate what human connection looks like. Yes, even on telehealth!

For over six months I had been providing counseling to a couple, both of whom struggled with issues of trust and security stemming from difficult childhood experiences, triggering each other regularly at home and in most of their shared sessions. Progress, however, was being made, and it was evident in a decrease in the severity and duration of conflicts at home. In sessions, they were increasingly capable of tolerating vulnerability with one another, and each had begun to embrace the belief that their partner’s upset was a defensive response rather than an attempt to hurt or control. Each had begun to see the other in a new way: outside of the polarized, good vs. evil worldview generated by injury, betrayal, and rejection. They were learning to accept and consider the ambiguity.

I asked the couple to turn their chairs to face one another and, once I could see they had settled, I asked them both to close their eyes and to focus attention on breath. After guiding them through a simple grounding technique, I directed their attention to their love for each other and, with eyes still closed, encouraged them to feel this love both truly and intensely and to channel it all through their eyes to their partner. I then asked them to open their eyes, to pour their love into the eyes of the other and, simultaneously, to absorb the love being gifted to them as well. After thirty seconds they both laughed, as young children might when delighted. I encouraged them to stay with it, and with broad smiles they beamed at one another. After another thirty seconds I encouraged them to conclude with a hug. The embrace was a long, sustained, fully embodied and clearly emotional connection.

With individuals I have recently begun incorporating Diane Poole-Heller’s Kind-Eyes Exercise, in which the therapist asks a client to close their eyes and imagine the eyes of someone greeting them with warmth and kindness, indicating they are happy to see them and extending enthusiastic welcome. The client is encouraged to hold that gaze and to notice the changes in sensations in their body, including effects on their breathing and heart rate, and then to introduce and try to hold the notion that they are, in fact, deserving of the warmth and kindness seen in those eyes.

Learning to embrace the other or to allow one’s self to feel treasured is learning to accept the premise that love, connection, and joy are found in the ambiguity and nuance of this imperfect moment.

In contrast, The Social Dilemma is, in part, a portrait of the hostile environment in which we all live and work. This environment constantly objectifies us. The exercises I describe here and the way I provide therapy are my attempts to hold true to what we know to be the path to human connection, wellness, and possibility. To adequately offer these services, I need to hold an awareness that the very basics of what therapy has to offer are fundamentally antithetical to many cultural norms.

And if this film has it right—that polarity is intensifying. The type of connection I facilitated and witnessed with this couple may just be an interpersonal means to resist dystopian ends.