Category: Therapy & Technology

The I-Thou Relationship in the Age of Telehealth

Posted on by Psychotherapy.net Team

Clinicians have long understood the therapeutic relationship to be the most powerful meta-intervention supporting client change and transformation. As Carl Rogers observed, the prerequisite for therapeutic change is that the client and therapist be in psychological contact. But when a computer mediates between counselor and client, how much does that impair this contact and obstruct the potential for therapeutic movement? In a world increasingly reliant upon telehealth services, we are challenged to preserve the authenticity of meeting if we hope to effectively combat the challenges to real connection inherent in technology-mediated relationships. Luckily for us, philosopher Martin Buber dedicated his entire life to uncovering the invisible potential embedded in relationships, and much of what he discovered can help us to remedy some of these relational complications in the age of telehealth.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Martin Buber believed that we have the capacity to relate to each other in two distinct ways. When we actively and authentically engage each other in the here and now, Buber believed that we open up to ourselves and orient towards another as a “Thou,” which he characterized by mutuality, directness, presentness, intensity, and ineffability. He saw the I-Thou relationship as a bold leap into the experience of the other, while simultaneously being transparent, present and accessible to one’s own experience. I-Thou encounters in therapy occur when we are able to truly “show up” for our clients, which then affords them the possibility of embodying themselves. Martin Buber designated this meeting between I and Thou as the most important aspect of human experience. He viewed our capacity to confirm and be confirmed in our uniqueness by others as the source of growth and transformation that structures the foundation of our shared humanity.

However, to confirm another as a Thou is no simple task. We must be willing to embody the fullness of our own experience and release ourselves to the ambiguity of the moment if we are to open up the space for an I-Thou relationship. Instead, we tend to slip into seeing the person as an “It.” When we do this, the other person is experienced as an object to be influenced or used, or a means to an end. The world of I-It can be coherent and ordered, even efficient, but inevitably lacks the essential elements of human connection and wholeness that characterize the I-Thou encounter. When an extreme I-It attitude becomes embedded in cultural patterns and human interactions, the result is greater objectification of others, exploitation of persons and resources, and forms of prejudice that obscure the common humanity that unites us.

Buber emphasized the importance of holding a balance between these two necessary poles of existence. However, in the current age of telehealth, the computer itself fundamentally alters the medium through which an I-Thou meeting can emerge and tips the scale towards an I-It interaction. As technology pulls interactions toward I-It orientations, we increase the risk that our clients will miss the authentic growth and transformation that blossoms out of a real meeting between client and therapist. The process of trusting another person with one’s vulnerabilities and sharing a lived-in experience held and expressed through one’s body is much more dimensional than two talking heads communicating through a screen with words and ideas only. We must resist the danger inherent in telehealth, so the therapeutic encounter does not become abstracted, experience-distant, and limited to language spoken from the neck up.

I feel the gravitational pull towards I-It orientations when I find myself leaning into the comfort of familiar habits while facing a client on my computer screen. The presence of the technology tends to pull me into thinking about all the relevant interventions I could implement with my client in order to help them remove their suffering. This orientation is useful at times; however, it also encourages a lack of presence in the teletherapy session that bends attention away from the invisible elements of therapy that foster human connection and growth. Instead, therapy becomes centered on the visible elements of practicality that can distract client and therapist from the deeper therapeutic aim. However, I’ve noticed that I can counter this natural bending of attention by remaining centered in my body and trusting my intuition to guide me. Technology inherently obstructs the therapeutic relationship, but it does not destroy its potential. There still exists an invisible bond that can survive the medium of pixels, a power that can be actualized if we can trust our intuition to guide us towards opening up spaces for its potency. To do this, our presence must remain oriented towards the possibility of an I-Thou encounter.

However, I find that this new technology-centered therapeutic process can be much more draining than in-person therapy because of the extra effort needed to attend to elements that would otherwise be naturally apparent and expressed. The lack of ease in reciprocity in engagement is also dually draining for the therapist, as the usual “beats” of body-to-body communication are absent. I must remember to replenish myself with moments of deep connection and meaningful engagement outside of the therapy room if I am to sustain spaces for I-Thou encounters during the age of telehealth. Though the demand for therapists to pull clients into real participation requires us to hold an age-old responsibility in a new and complicated way, the taking up of that responsibility has the power to foster a type of healing that extends far beyond the therapy room. As Martin Buber once said, “In spite of all similarities, every living situation has, like a newborn child, a new face that has never been before and will never come again. It demands of you a reaction that cannot be prepared beforehand. It demands nothing of what is past. It demands presence, responsibility; it demands you.”

***
 

Part 2 will continue the conversation on how Martin Buber’s philosophy can help to remedy some of the relational complications in the age of telehealth, while expanding his concepts to include challenges from a client’s perspective, personal examples of my struggle to remain faithful to the I-Thou relationship, and the broader sociocultural implications of technology-mediated relationships.

Family Therapy in the Age of Zoom: What a Long Strange Trip It Has Been

Posted on by Psychotherapy.net Team

If there is no plan, nothing can go wrong
Kim Ki -Taek — Parasite

It’s not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.
Charles Darwin

It’s recycling day, can’t we just put the kids outside on the curb?
Parent — Pandemic, week five

Dude!…You’re Glitching!
Fourteen year old girl on Zoom session

Long Strange Trip

The pandemic has changed the larger world forever and will forever change the world of therapy. Our therapeutic ecology — how we practice our craft, where and with whom — will never be the same. It’s as if we’ve clicked into a science fiction show and can’t change the channel because we’re in it — clients and therapists have become talking heads, connecting as best we can and collectively feeling the fatigue attrition that accompanies the absence of being in person. The Grateful Dead were right: it’s been a long strange trip, especially for the empaths.

Michael is a single man in his thirties. He’s suffered a lifetime of painful shyness and being overweight. His job requires computer skills, so he spends most of his time in his cubicle, with little socialization on the phone or with co-workers. He’s described breaks and lunch as “torture.” Prior to lunch, he would get revved up with good intentions and then, he said, “I’m like Wile E. Coyote chasing the Roadrunner — I hit the wall.” One time, he got the gumption to attend a meet-up group for shy people, and no one showed. Yet, despite these challenges, he’s determined to be more social. Then, something happened. At our last Zoom therapy meeting, he was more confident and relaxed, like he’d just put on old slippers — smiling and even cracking jokes. For me, it was a kind of optimistic disorientation. At first, I thought that it was the combination of medication, his Wile E. Coyote resolve and hopefully some of the therapy that, like the British Baking Show, had produced a slice of Magic Pie. It wasn’t — it was the pandemic.

Because of “social distancing,” Michael paradoxically experienced being together with people while he was apart. Everyone now shared his life — now he could enter conversations with the knowledge that others also shared the taut, jangled wiring of his interior. It was as if he became an Italian apartment-dweller sheltering in place with his neighbors and singing together with them off their shared community of balconies, everyone listening with hearts joined in the absence of judgement and the voices of hope. Better still, because of the imposed distancing, Michael could now be safely social.

The Zoom Era

And what about therapists — what is this doing to us? Many are working from home. Those of us with children, pets or partners and who don’t have a home office have to find a “quiet space.” Ha! Good luck with that basement, people! Or, if we’re lucky and the landlord isn’t banning entry, we can go into our off-site office space — but that, too, has its own set of Zoomy consequences, not the least of which is “Zoom Fatigue.” By day’s end, sessions can feel like you’re in the front row at a lecture on sofa cushions where the speaker can see you. Just as you start to blissfully nod off, your head suddenly jerks back, and you snort loudly and say something weakly therapeutic like, “really..?” and then wipe the drool onto your sleeve — très embarrassing.

Zooming our client’s home space is not without merit. Back in the day when I was a probation officer in Cabin Creek, West Virginia, and then a social worker doing school evals, and then a research therapist on a project with heroin addicts and their families, I was blessed with being both witness and participant in the amazing diversity of the human condition. You learned to go with the flow and, you swam in the deep end of the family pool — dogs, cats, kids, babies, ferrets, frogs, multiple TV’s, radios blaring, grandparents, people who just showed up whom you didn’t know, dinner on the stove, or a silence that also spoke to you — all this before the age of the Internet. It was so powerful that when I first started my private practice, I would ask families to invite me to dinner and a family session at their home. “Now, we have Zoom — welcome to the shallow end. But we can all still learn to swim.”

You can observe a lot by watching.
Yogi Berra
Peter Lopez, a family therapist on the board of The Minuchin Center for the Family, is a home-based family therapist. On one of his Zoom visits, he wanted to speak to both parents and have an enactment with them that would increase the parent’s executive capacity and demonstrate to themselves and their kids that Mom and Dad were on the same page. In a moment of inspiration spurred by there not being enough headphones for everyone, he asked the parents to “move closer together so you can share…”

Another family therapist, a young woman who works with a diverse population of low-income families and mandated, substance-abusing high-risk teenagers, finds that being “in & not in” someone’s house can diminish her connection and, in some cases, embolden teens to challenge her — like the fifteen year old teenager who greeted her on FaceTime lying in his bed with his shirt off. “Would you do that in my office?!,” she asked, incredulous. “Uh, no, but I’m not in your office….” “Well, when we meet on Facetime, you are in my office!” And then, softer — “So when you put your shirt on we can start, and you can tell me how you’re doing.”

She still delineates the boundaries — for the kids she sees, her office is their safe space. To compensate for the in-person absence, she’s upped the amount of between-session “homework” that she and her clients then share at the next session. Trauma and disconnect are prevalent. A young girl being raised by her grandmother whose mother is absent provided a path in between sessions. Together they came up with an assignment to come to sessions with a weekly playlist of songs that emotionally spoke to the client. The girl picked “How Could You Leave Us?” by NF, which should come with a warning label and tissues — it’s remarkable.
We have to be inter-connected with everyone and everything.
Thich Nhat Hanh

You cannot solve a problem from the same level of consciousness that created it.
Albert Einstein

An informal survey asking therapists to describe their experience of practicing Zoom therapy in the pandemic seems to break into two distinct groups: one, maintaining a kind of Buddhist perspective of acceptance –— that life is suffering and impermanence in which every day is an opportunity to practice mindfully — to another, a bit less accepting — “I fucking hate it!”

A Third Way?

Which begs the question — is there a third way? The short answer is “Yes.” And it’s not without precedent. Einstein’s quote is like learning a brilliant escape trick from a gifted magician. The magic is not what is seen or said but in what he doesn’t say. What he omits is the specificity of consciousness — it does not have to be higher or lower, just different. And we therapists are all about being different. To be effective, we access different aspects of ourselves that then activate different and more adaptive aspects of our clients. It’s what Minuchin described as the “differential use of self.” If we want others to be different, then we have to be different. For systems thinking and for family therapy, in particular, those differences in thinking were already in the works well before the pandemic.

Lynn Hoffman pointed out in Foundations of Family Therapy (1981) that “the advent of the one-way screen, which clinicians and researchers have used since the 1950s to observe live family interviews, was analogous to the discovery of the telescope. Seeing differently made it possible to think differently.” And by circular extension, thinking differently also comes from acting differently.

Up until now, we’ve relied on our in-session felt experience, one-way mirrors and videotaping to guide ourselves as instruments of change. One recursive emotional and visual distinction between the now and the then of the one-way mirror’s transformative introduction, is that families could not see the people behind the glass, nor could the people behind the glass see themselves being seen. Videotaping sessions, however, offered a “third” answer, giving therapists the capacity of “seeing” themselves and the family’s patterns in context. It shined a light on how to experiment with adapting interventions systemically and collaboratively. While inventing Structural Family Therapy, for example, Minuchin, Jay Haley and Braulio Montalvo invited family members behind the mirror. They recognized cultural and class differences between themselves and the “natural healers” from the minority community that they were training to be therapists. Minuchin realized that “in order to join, we needed to change.”

“With Zoom however, there is a binding irony that holds therapists and clients in its’ grasp. It is as if we share front row seats watching a mystery play”. The opening scene’s roiling dense fog and dim lights mask the fullness of detail, so we squint, holding our breath hoping to see what’s really there. We’re doing our parasympathetic best to figure out the plot. It’s the work of it that fatigues us and leaves us wondering if this is as good as it gets.

Therapy is therapy as therapy does, but how we use ourselves in this new environment re-boots an age-old clinical question; what exactly is both necessary and sufficient to produce change? Montalvo called the position from which we work “The possibilistic premise.” Meaning that regardless of the location of the family’s pain, we are still faced with respectfully challenging the system’s homeostatic “stuckness.” We know that we can effect those changes in person. When Zooming, however, it can sometimes feel as if we’re “Major Tom,” floating in space, attempting to weld the hull as we circle the earth.

So, as Bowlby, Susan Johnson, the Gottmans and our own families have shown us, the quality and kind of our earthly and relational attachments are important. While we may feel even more like Russian Dolls, breathlessly stacked within each other’s context and the context of the world writ large, it’s not a question of “if” we adapt and attach in different ways, it’s more a matter of “How?” Perhaps as Theodore Reik suggested, we should listen with greater clarity, not just with a “Third Ear,” but now with ear buds. We are finding ways to compensate for what’s lost with diminished sight and the absence of physical presence. Our adaptive make-up is yielding results. However because we are inherently empaths, we feel the absence of presence. But we shouldn’t feel bad entirely. Rumi’s poem, “Love Dogs,” reminds that “the howling necessity” implores us to “cry out in your weakness,” such that “the grief you cry out from, draws you toward union.”
It’s the end of the world as we know it, and I feel fine.
R.E.M.

Postscript from the Bunker

After not seeing our granddaughters at our house for eleven weeks, my wife and I share a grandparental Folie à Deux — an ache like an old injury that we’d come to accept, now reawakened with every primitively crayoned coloring book that hung on our walls like an in-home Children’s Louvre. As grandparents of a certain age, now when my wife and I see all their stuffed animals in a pile, we silently share the Buddhist themes of impermanence and suffering. It feels like a Christmas Story staging of Toy Story — our precious time together is ghosted in front of us as a reminder to our mortal selves that “this is it.” This perfect time of their lives, full of wonder and imagination, is just another pandemic curtain closing on the “Duck Duck Goose” show. Now our own mortality is awaiting, as quiet mourners do when “joining” family and friends on a Zoom funeral.
Alone together.
Dave Mason

Then there’s this — amidst all the noise, people find themselves and others. I see a recovering alcoholic/substance abuser in his thirties. He’s been in recovery for seven years. He has a great sponsor and a solid home group. As the pandemic continued, he began to miss the in-person connection with his group and his sponsor. So last week, with the intent of doing “Step work,” he and his sponsor sat safely apart on his sponsor’s back porch. As night began to fall, he said that without any cues, they both simultaneously became silent and quietly surveyed the backyard as darkness fell. He said it was one of the best conversations that he’d ever had.

Like the scene from Little Miss Sunshine, when on their way to the “Little Miss Sunshine” contest, Dwayne flips out after finding out that his color blindness has just destroyed his dream of joining the Air Force, getting away from the “fucking losers” that constitute his family and having a life of his own. He’s profanely inconsolable. His mother says, “I don’t know what to do!” Then his stepfather says to Olive, “Olive, do you want to try talking to him?” Without a word or hesitation, Olive gingerly makes her way down the embankment, ignoring the dust scuffing up her red cowboy boots, and squats down next to her big brother. She puts her arm around Dwayne, leaning her head onto his shoulder. She doesn’t say a word. They both sit together as one in the silence. Quietly, as if whispering a confession, Dwayne says, “O.K., I’ll go.” He then helps Olive up the hill and says to his family, “I apologize for the things that I said, I didn’t mean them.” They load in the van and continue on.

“Off in the distance is a billboard, the message faded but visible, “United We Stand.” We can hope”.

Bret Moore on Military Psychology and Getting the Mission Done*

Posted on by rezendevknowfully.com

Challenges During the Pandemic

Lawrence Rubin: Good afternoon, Dr. Moore, and thank you for sharing your time with us today. Much has obviously changed in the world since the time we scheduled this interview. My understanding of the role of the military psychologist is that they serve the mental health needs of veterans and active personnel. What clinical challenges have you noticed in light of the COVID crisis?
Bret Moore: We often think about service members deploying and helping overseas, fighting wars and those kinds of things. But they actually have quite a strong mission stateside as well. So, in episodes like the COVID-19 pandemic, many military members are tasked to help support local response efforts in states like New York and California that have been been hit the hardest. You have probably seen the news where certain units have been activated to support those efforts — whether it be quarantine or getting supplies to individuals that are sometimes done by National Guard service members or active duty service members.

In the case of the COVID-19 crisis, one of the challenges to military clinicians is having to shift our practice to telehealth
In the case of the COVID-19 crisis, one of the challenges to military clinicians is having to shift our practice to telehealth, just like civilian practitioners are having to do. Obviously you have to be concerned about privacy and not violating HIPAA, and other related issues like what if the video's not working. Can you do the session over the phone, and how much good can you do without seeing each other and having that visual interaction, those visual cues? So, again, not so much unique to military psychologists, but it's something that we're struggling with. You did mention at the beginning that military psychologists provide mental health care to military members. But that is really only one small part.

We also provide consultation to commanders about morale and unit cohesion. In a way we also function as consultants and industrial organizational psychologists. We not only focus on individual wellness; we focus on unit wellness. We focus on organizational functioning. That's what I really like about military psychology. It is a very diverse field, and it is very difficult to get bored being a military psychologist. 
LR: Telehealth is a transition that military and non-military clinicians are making right now, feverishly trying to catch up, get up to speed, so to speak. Do you think that providing telehealth to military personnel, either active or veterans, is a different challenge at this point to military clinicians than it might be to non-military clinicians?
BM: I think the transition to telehealth may be a little bit easier from the standpoint that the VA has been doing telehealth for over a decade. All branches of the military — but primarily the army seems to have had the most sophisticated behavioral telehealth infrastructure for at least a decade, so we are somewhat used to it. Even clinicians within the VA and military systems who don't provide telehealth on an ongoing basis are certainly familiar with certain aspects of telehealth. So, providing telehealth during this crisis is not a shock. It's not a huge amount of adjustment for clinicians within those systems as it is to some of my friends and colleagues who were practicing outside of the federal military system and who are asking questions like, “What system do I use?” “Is it secure?” “How do I get paid?” “How do I bill insurance companies?” The nice thing about the VA and the DOD is that they are really somewhat of a socialized healthcare system. We're not billing insurance companies per se, so clinicians aren't really having to struggle as much with answering those kinds of questions that our civilian counterparts are.
LR: Is telehealth something that a military clinician might use for someone who is deployed, if that clinician is not deployed with them?
BM:
Telehealth has been provided in places like Afghanistan and Iraq, and we have telehealth services that are being provided currently to Germany. Wherever there's a connection
Telehealth has been provided in places like Afghanistan and Iraq, and we have telehealth services that are being provided currently to Germany. Wherever there's a connection, theoretically you could provide services. I think the VA has done very nicely, and I do believe that the Department of Defense is going to be coming online with providing care from federal hospitals, VA clinics, or Department of Defense clinics to patient's homes. Now the VA has been doing that for quite some time and I think we are going to be moving toward in the future. It's important for the VA mostly because so many veterans live in remote areas. When I worked in North Dakota for two years and when I needed to go see and check in, have a physical with my doc at the VA, I literally had to drive four or five hours. So, it is important to be able to provide these services in the home, and hopefully the Department of Defense will come online with that at some point.
LR: What advice might you offer civilian clinicians in our audience about what may be gained after this pandemic passes as opposed to what will be lost?
BM: Well, that's a tough question. It is an excellent question, but it is a tough one because that is something I have been thinking about over the past several weeks. What I hope to see is a deepening of relationships, maybe — certainly within the immediate family. We're spending all this time together and you see memes and jokes like, “We're going to end up killing each other because we're spending all this time together.” I think the opposite is probably more likely, in that people are starting to reconnect and rekindle some of the things that brought them together in the first place. And dads are learning more about their daughters, and mothers are learning more about their sons.

Hopefully, we are developing deeper bonds. But what I really hope is that we develop some compassion and connection with people we have never even met, with larger society in general. We watch the news and we see everything that's going on and it's hard not to feel some kind of connection to the people who are suffering the most right now. So, I am hoping we gain a sense of greater compassion. And I just really wish that we would stop fighting each other. And I wish our politicians would set a good example by showing how we can all play together nicely and respect each other and get along with each other.
But I do hope that we see a deeper connection between individuals once this is all over
But I do hope that we see a deeper connection between individuals once this is all over. 

Trained to Solve Problems

LR: If we want to call the battle against the pandemic a war, would you say that from the standpoint of a military psychologist, service men and women are uniquely prepared to address some of the mental health challenges that crises such as this one create? 
BM: Oftentimes I am asked if there is a certain type of person who joins the military. And the short answer is no. I mean there are a lot of shared characteristics, but there is a lot of individual variability. There is a strong sense of public service and patriotism that you see obviously within the military population. And those individuals who join tend to have people within their immediate family that have served in the military. So, there is a sense of something that is passed down from generation to generation. I will also say, to generalize, I think individuals who join the military already tend to be fairly resilient individuals. And I think that the hard work and training they do in boot camp strengthens their resilience, whether or not they are eventually deployed.

You're probably aware of some of the research that Martin Seligman has done with comprehensive soldier fitness, and how the military has made a strong effort to strengthen the cognitive reserve, cognitive strength and emotional, psychological, physical and spiritual strength of service members. I am not going to speak for that particular program, but I think in general,
our men and women in uniform are some of the toughest individuals you'll ever find. and probably are more equipped to deal with the anxiety and stress that comes with something like the pandemic we are dealing with now
our men and women in uniform are some of the toughest individuals you'll ever find. and probably are more equipped to deal with the anxiety and stress that comes with something like the pandemic we are dealing with now.
LR: Would you anticipate that the levels of anxiety, depression and fear that have been reported in the civilian population might be lower in the military because of their preparation, resilience and the skills that they bring to service?
BM: I would think so. Even though we're not in necessarily active conflict right now, many service members have done deployments, and in some cases, multiple deployments in some of the most stressful environments that you can imagine, where every day is filled with new anxieties and new tensions and new fears. So, yes, just based on that, I think from a larger standpoint or from a broader standpoint, these individuals would be better equipped to deal with the anxiety and tensions that we see today. Absolutely.
LR: Do you think that this preparation and hardened resilience might make it difficult for some military personnel to address the potential lethality of the pandemic? Might they downplay it or minimize the risk because they are accustomed to being ready and prepared for war and death?
BM: No, I don't think so. I think it is more of understanding what the challenges are, because military members and veterans are trained to be problem solvers. You identify the problem and you come up with several solutions. You pick the best solutions, implement them, and then if that doesn't work, you implement something else. So, it is really a calculated approach to things. But no, I don't think that they would under-appreciate the significance and the risks that are associated with something like this. If anything else, I think they may appreciate it more.
LR: So, although not prepared to handle pandemics per se, you're saying that military members, by virtue of their training, by virtue of the resilience and problem solving skills are uniquely prepared to help each other and civilians to address the challenges of the virus.
BM: Yes, absolutely.

The Caretaker’s Perspective

LR: During this crisis, what concerns do you have for the mental health of military clinicians?
BM: There's been a few studies out there looking at provider burnout, compassion fatigue, vicarious trauma.
In general, the stress for clinicians comes with managing their large caseloads, which are made up of trauma
In general, the stress for clinicians comes with managing their large caseloads, which are made up of trauma. A third or a half of their cases are post-traumatic stress. I think it's not so much which area you practice in. I think it's the kind of disorders and presentations that you see, just like a social worker who treats child sexual abuse cases nonstop. If you have clinicians that are constantly treating post-traumatic stress disorder, combat-related trauma, military sexual trauma, whatever the case may be, I think that's going to take a toll more so than someone who's treating adjustment disorders, or even depression or panic disorder. So, I don't think it is any different, but I think it is something that is shared across the profession. So, you know, working with trauma survivors can be very challenging, and I think we probably have a similar rate of burnout and compassion fatigue that you would see across the system.
LR: You had mentioned earlier that by virtue of their training and resilience, service men and women are perhaps better suited than the average person for dealing with crises like this one. Do military clinicians bring a unique blend of characteristics into their role during times like these?
BM: You have military psychologists who, like me, were in active duty for five years. I did two and a half years in Iraq providing services to service members. And then I transitioned back to the civilian world as a civilian psychologist for the Department of the Army. So, my experience is going to be a little bit different than someone that comes out of internship from a university and has never worked with this population, and steps into an internship working with combat veterans. You know, I think over time there is a strength that these clinicians build if they stay within the system long enough.

I do think that those who choose to enter the VA to work as psychologists or the Department of Defense oftentimes have a strong sense of public service and a strong sense of patriotism. One of the webinars I provide is on military mental health and how to treat PTSD and related conditions. I get a lot of clinicians saying that they like working with veterans because “my dad was a veteran.” “My uncle was a veteran.” “I used to sit on my grandfather's lap, and he would tell me stories about what it was like serving in World War II.” So they come with their own experiences, even though they may not be direct experiences. 
LR: When you made that transition from a combat to non-combat military psychologist, did you notice any changes in the way you practiced, or what you brought from the combat sphere into the non-combat sphere?
BM:
I trained as an Adlerian, which involves insight-oriented work and a focus on the past; but I had to shift. You do not get to spend six months doing in-depth insight-oriented work with veterans.
I trained as an Adlerian, which involves insight-oriented work and a focus on the past; but I had to shift. You do not get to spend six months doing in-depth insight-oriented work with veterans. A lot of times, at least with active duty military personnel, you may get four to six sessions. So, I had to shift my approach and, when needed, to be solution-focused. I had to work collaboratively with the service member and identify what it is that we needed to correct, to “fix,” so that they could continue to do their job.

My job as an active duty army psychologist was to care for the wellbeing and emotional health of the personnel, but it was also to make sure they could continue in the fight. You know, a soldier's job is to fight, to win wars. So, if they are not psychologically and emotionally healthy, they cannot do their job. So, not only do I have to take care of them emotionally and psychologically and help them, but also, I have to get them to return to the mission so they can finish what they started. And sometimes people who don't understand the military all that well have a deep conflict with that because they ask, “How can I as a psychologist try to patch people back up just to send them back out to fight?” Well, what is the alternative? Just send them back out to fight and not patch them up? They're soldiers. They're going to have to go to war. So, I need to be able to do whatever I can to make sure they can do their job to the best of their ability. 
LR: If you thought a particular combatant was not fit to continue, did you have the flexibility to send them back stateside, or was there a mandate to patch him up, get them back? In other words, was the threshold lowered because the mission was the mission, and your role was to get him back into the battle?
BM: No, I didn't experience the pressure at any point in my active duty days. The psychologist, the mental health professional in general, has a lot of power, a lot of control and influence over what happens with service members who may be struggling and are not mission-ready. Ultimately, it is usually the commander's call to decide whether to send a soldier away from the fight, maybe back to the States so they can recover. But in general, a commander,
a good commander will listen to his docs and say, “okay, if my doc is telling me that sergeant so-and-so is not fit, I am not going to put him back out there
a good commander will listen to his docs and say, “okay, if my doc is telling me that sergeant so-and-so is not fit, I am not going to put him back out there. Because not only does that put him at risk, it is going to put the rest of my unit at risk.” So, yeah.
LR: Did you ever feel caught between that conflicting obligation toward the military to continue the mission versus the person who might not be ready to get back in the fight?
BM: Near daily. Over two and a half years of being deployed, probably most every day I wrestled with that to varying degrees. Brad Johnson and Jeff Barnett have written a lot of great stuff about that. There is always that push and pull, and you have to find a balance, and you can't be overly rigid. This is not a black and white game. You have to think in various shades of gray and you also don't want to work in a vacuum. So, that's why if, when I was an active duty army psychologist, I got on my high horse and said, “all right, I'm just sending this person home, this person home, and that person home, I don't care what you think,” I wouldn't have lasted very long. There had to be some trust that developed through consultation and education, which oftentimes was an important part of my job, was to educate commanders about the impact of mental illness and mental health conditions on functioning. With that proper education, I was able to resolve most all conflicts in a rapidly short period of time.
LR: So, that moral conflict servicemen and women experience can also be experienced by the military clinician who struggles with the morality of where to send them in or send them back.
BM: Absolutely. I trained as a psychologist. I wanted to help people. If it would have been up to me, we would not have been there in the first place. But it was not up to me, and if it were up to me, I would send everybody home. But I knew I couldn't do that. That is not my job, not my responsibility. So, yeah, it was a challenge.

Military Clinical Competencies

LR: I would like to drop back to some of the core questions I had initially prepared because many of our readers will not have experienced military psychology. I recently did an interview about multicultural competence, and since the military is its own culture, I'm wondering if there might be core clinical competencies that a military clinician must have or develop in the course of their training and service?
BM: The core clinical competencies include being a generalist. The military and the VA definitely have specialists, including neuropsychologists, aviation psychologists, as well as behavioral medicine specialists. But to be a military psychologist, you have to be a generalist because, for example, you may find yourself deployed or in a remote location where you may be the only person available. So, you do not have the luxury to knock on the door of the specialist down the hallway.

There are some good articles and chapters out there about this notion of the distinctiveness of the military culture. In 2008, Greg Reger and colleagues wrote an article in The Military Psychologist in which they talked about the ethical challenges that military psychologists face that are not fully understood by the average clinician. The military has a unique language and a certain class caste system, a socio-economic status of sorts within the military that distinguishes the officers from the lower enlisted.

The lower enlisted have different responsibilities from the senior enlisted versus the officers. So, there is a hierarchy that must be understood.
Sometimes things in the military are not about fairness and it is not about the individual, it is about collectivism and working as a team
Sometimes things in the military are not about fairness and it is not about the individual, it is about collectivism and working as a team. You know, if you think about our current society, we put a lot of emphasis on individual rights and what is best for us. You know, what is best for me. If I take care of myself, I can take care of other people. You hear us say that as clinicians quite often. But in reality, that is not necessarily the mentality within the military. You take care of your group and then as you take care of the group, you are also taking care of yourself. 
LR: So, a commitment to a more generalized approach to intervention and an appreciation for the collectivism that is part of the military. Are there any other core competencies that you can think of that distinguish military clinical competence from non-military clinical competence?
BM: I think comfort with and being well trained in the treatment of trauma-related conditions. Combat trauma is a lot different from civilian trauma, meaning motor vehicle accidents or natural disasters and sexual assault. Combat trauma is more along the lines of complex trauma and multiple traumas. There is generally not one specific incident that leads to post-traumatic stress. For a combat veteran, it could be a year or years-long worth of traumatic events. So, it is about having a comfort to work with very trying and difficult cases, presentations and diagnoses, and being versed in evidence-based treatments. You know, the VA and the DOD are very focused on providing manualized evidence-based therapies for PTSD, like prolonged exposure and cognitive processing therapy. You also must be comfortable with a solution-focused, problem-oriented approach to care. Again, a psychodynamic psychotherapist is going to struggle a bit more than someone who is more of a behavioralist or cognitive behavioral clinician.
LR: Might a non-military clinician working with military personnel be more susceptible to compassion fatigue or vicarious trauma more so than a military psychologist who has worked side by side with these military personnel?
BM: I think that is a reasonable assumption to make. I'm not aware of any data to support that, but
plenty of friends and colleagues who have never served in the military or have never even worked within the military system, but who are private practitioners who take veteran patients, tell me, “Oh my goodness, how do you deal with this on a day-to-day basis?”
plenty of friends and colleagues who have never served in the military or have never even worked within the military system, but who are private practitioners who take veteran patients, tell me, “Oh my goodness, how do you deal with this on a day-to-day basis?” Some of the cases are very overwhelming, as they must listen to the horrific traumas that some of our men and women experience. And the military can be a difficult environment to work in. You know, there is no eight-hour shift for the most part. You work until the job is done. The mission comes first, whether it’s to complete training or to win a war. And that means everything else must come second, third, fourth and fifth, including family, friends, socialization and even self-care.

Non-military clinicians may say that these types of conditions and stresses are an unfair position to put clinicians in. How do you expect them to be happy when they are living in such a stressful environment? And so, I think compassion fatigue and an increased level of frustration are certainly going to impact the non-military clinician. And I think that is normal and to be expected that you are going to find yourself frustrated not only working with this population but with the system that you have really never been a part of. They may be hearing second hand the difficulties of working within that system, but not necessarily the benefits of working in the military. 
LR: It almost sounds like the clinician, whether military or non-, who is working with military personnel has to readjust their relationship with Maslow’s hierarchy of needs because in active military combat, there's not a hell of a lot of time for self-actualization.
BM: No, that is way down on the list.

The Privilege of Prescribing

LR: You are in a unique position because you are a prescriber, one of an elite group, so to speak, in a nation where very few states provide prescription privileges to psychologists. How has this added privilege been a benefit in working with the folks you have had to serve?
BM: It has reduced the number of referrals I have had to make. I will tell you that. I do a lot of medication management as well as administration. About half of my time is research and administration and half of my time is clinical work. I am not a huge proponent of medication and believe in using it sparingly, smartly and only in cases where psychosocial interventions have not worked. But as a clinician who trained initially as a psychotherapist, I know that sometimes psychosocial interventions don't work, or they don't work well enough, and then medications are warranted. I might at times have to refer to somebody else and lose that patient because they resist psychosocial intervention, but also resist having to start over and believe that they have to tell their stories over and over again, especially trauma victims.

So, I might lose patients once I attempt to refer, or if I could obtain a referral while convincing them to stay in treatment, it could be three months before there's an appointment. But, as a prescribing psychologist, I get to do both my therapy and medication management. I have the ability to provide a level of continuity of care that you don't get, I think, in any other mental health profession — even psychiatrists. You know, psychiatrists obviously can do medication management, but very few choose to or can do psychotherapy. So,
I really think prescribing psychologists are in a good position to show that continuity of care is important, that collaborative care is important, because we do best as professionals when we collaborate
I really think prescribing psychologists are in a good position to show that continuity of care is important, that collaborative care is important, because we do best as professionals when we collaborate. I collaborate with primary care physicians and other healthcare professionals. I do not operate in a vacuum. But I have become more effective, I think, as a clinician, and I have grown to truly appreciate the complexities of human nature and psychological presentations and have come to appreciate how powerful psychotherapeutic interventions can be as well. 
LR: Have you found any particular challenges prescribing to service men who are either predisposed to substance abuse or who have histories of substance abuse? Or who are actively using substances while serving?
BM: Not so much substances. My guess is that the rate of true substance use disorders in the military is probably equal or a bit lower than you would see in the general population. The challenge you tend to find as a prescriber within the military system is that there are medications that are not conducive to serving in a harsh environment. So, medications that require careful monitoring and updated laboratory values might not be the most appropriate during times of active combat. Medications like benzodiazepines — Valium and Xanax — can reduce a person's focus and concentration and can lead to drowsiness, so you don’t want someone who is rappelling off a tower on high doses of one of these types of drugs. But there are mechanisms in place if you put someone on one of these medications. Commanders are alerted that hey, these are some limitations that you need to follow while this or that soldier is on this or that medication. That is the biggest challenge.
LR: Are there difficulties certain service men or women have who are prescribed during active combat, and then return home or are transferred into a non-combat area?
BM: I kind of see it as the opposite. The need for meds is limited in a combat environment except for sleep meds. Sleep meds are very, very useful for service members who are working very long shifts in a very noisy environment where it is very difficult to sleep even when allowed to. So, what I find stateside is there's more time to ask the existential questions, even though you would think you would be asking these questions on deployment. But it's so busy and the operational tempo is so fast that you don't really get a chance to sit back and do a lot of introspection about the meaning of life, and why am I not happy, and what's this anxiety that I'm dealing with? When deployed soldiers return home to relative comfort and regular days, we start to see more anxiety and maybe more dissatisfaction with life.

I think transitioning medication from non-deployment to deployment is the bigger challenge — getting them off the medication so that they can be aware, alert and not have any cognitive deficits related to medication so they can really focus on the task at hand
I think transitioning medication from non-deployment to deployment is the bigger challenge — getting them off the medication so that they can be aware, alert and not have any cognitive deficits related to medication so they can really focus on the task at hand. I'll give you a concrete example with nightmares. There is a medication called Prazosin that’s used for nightmares. It's been shown to be really effective. And if you're taking that stateside, that's fine. But when you deploy and take it, one of the side effects is that if you get up too fast, you can faint and hurt yourself. So, yeah, if you are sleeping and a rocket comes in, you hop up out of bed too fast, you could fall and hurt yourself. There are just some medications that aren't conducive to a combat environment. 
LR: It sounds like in your training for prescription privileges, there were specific components of that training that addressed the issues of transitioning from deployment to non-, from non- to deployment, and to the use of medications in combat. Is it that specific during your prescription training?
BM: Not during the formal educational/clinical training. On the job training, yes. One of the nice things about the military is they tell you what they want you to do. There is no shortage of regulations and memos and guidelines to follow. So, there's definitely guidelines for which medications are a go versus no-go, and for what to do if a person is on a medication and they're getting ready to deploy or transition from one base to another base. So, there's definitely plenty of guidelines out there to help clinicians make those decisions.

Myths and Misconceptions

LR: Are any popular misconceptions about the military persona, the military psyche? 
BM: There are some popular misconceptions out there, likely based partly on some truth. Back in the day, the only people that went into the army were the people who went before the judge who said, “Hey, you either go to the army or you go to jail.” But it's not like that anymore. Actually, there are more people joining the military right now who are from the middle class. People tend to think that they’re from lower SES groups. So, it is more of the middle class, middle America that really serves. And the military can be a springboard for very successful careers, not only in the military, but after service ends. You can serve 20 years and get out at the age of 38 with a full retirement and then have another career set aside for you. I guess my point is the idea that people join the military because they don't have any other options is no longer accurate. It's just not true.
LR: Choice versus default. And it is the default conception that leads people to think that military personnel are unstable or simply do not have anywhere else to go.
BM: Sure, there is going to be a segment of military people that join because they do not have any other options. They may come from a small town where either they work at the sawmill or they go into the military. College isn't always an option. And the great thing about the military is it has a very robust college opportunity where if you serve, you basically can go to college for free. And there are some people within inner cities that say, “You know, I've got to get out of this. This is an opportunity for me to make a life of my own.” I don't want this to sound wrong, but it's not the bottom of the barrel of our country that joins the military by any stretch. It is people who come from hardworking families and the middle class, from across the country. And again, many who have a strong patriotism, a love of the country and want to serve others.
LR: You'll probably find the most misconceptions coming from those who are most removed from the military.
BM: Absolutely. Another misperception or conception that I think that some people have post- 911 or post-Iraq and Afghanistan, is that our soldiers are broken, busted, unhinged, crazy. It really, really troubles me. I know they've made great stories for media, but anytime a veteran does something that's not good, you know, a shooting or a high profile crime, they always lead with “combat veteran does this” in the heading — they don't lead when a non-veteran that does something bad, they don't lead with “non-combat veteran does this.” I think it's done to create some of the sensationalism. But I think it feeds into that wrong narrative that our service members are busted and broken, and they are really not. If you look at the vast majority of service members, they don't return home with post-traumatic stress disorder.

And if they do, they go on to lead very healthy and successful lives with symptoms of PTSD. We look at our World War II veterans, you know, the level of post-traumatic stress that these men and women dealt with — primarily men — they helped build this country into what it is today. And they didn't get a lot of treatment. They didn't get a lot of services, but they still found a way to live with those experiences. And that has led me to another area that I am really interested in, which is post-traumatic growth. Working with Rich Tedeschi and Lawrence Calhoun, we have found that
not only do returning soldiers experience symptoms following trauma, they experience growth
not only do returning soldiers experience symptoms following trauma, they experience growth. You can actually become a stronger, better, person following trauma and lead a more rewarding and fulfilling life because of what happened to you. 

Challenges to Military Families

LR: What are some of the challenges that military clinicians typically confront when working with the children and partners or spouses of deployed personnel when they come home, when wheels go down, as you say in one of your books?
BM: When the spouse stays home, it’s typically the female partner. The military member maybe took care of everything when they were home. But again, each household differs. What I found is that the stay-at-home partner or the partner that didn't deploy, the non-military partner, has to take on the responsibilities previously handled by the military member of the family, which creates a significant level of stress, feelings of being overwhelmed — “I'm doing this by myself. I'm having to raise the kids, but now I also have to take care of everything else that you were taking care of.” So, there can be a bit of anger, frustration and animosity toward the service member who is deployed, and when they return home.

But, I have also seen the transition from that frustration and animosity to a new sense of independence. After a year of paying the bills, after a year of making sure the home was being maintained and the cars were maintained, the partner who remains home might feel something like, “I'd like to keep doing this” or “I want to keep doing this.” So, now when the service member comes home and believes that they are going to take over their former responsibilities, there can be a bit of a conflict, as the stay-at-home partner feels, “I don't want to give this back up. I am more capable than I originally thought. I can actually handle a lot.” It's hard to turn that back over. I think non-military clinicians who want to work with couples, especially couples that had at least one party deployed, should understand that this kind of military-related conflict may be a common occurrence. 
LR: What are some of the issues that you've noticed in the parent-child relationship between the deployed and now-returned veteran and the child(ren)?
BM:
One of the complaints I hear from the returning service member is feeling disconnected from their family, especially if they were away for a long time
One of the complaints I hear from the returning service member is feeling disconnected from their family, especially if they were away for a long time, and the only previous contact was through Skype or phone calls. There is a sense of disconnection, and sometimes it is connected to post-traumatic stress, while other times it is outside of the realm of post-traumatic stress. I am not really clear on where that disconnection comes from. It probably has something to do with being separate for so long. And sometimes the children mature and develop in their own ways. So, that tends to be a struggle.

This is certainly true from an adolescent standpoint, particularly if the service member was a strong disciplinarian before deployment, and returns to an older and more independent child who feels something like, “They come back and tell me now what to do,” or “I've been taking care of mom or the sister or brother for the last year while you were off at war, so don't come home and start bossing me around.” The same thing may occur for the spouse, who feels, “Don't come home and start bossing me around. I'm the one that's been taking care of the household for this long.” But again, the nice thing is that with good counseling, marriage counseling, couples counseling, family counseling, this can be corrected. That is because a lot of times it's just a matter of understanding how expectations have changed and understanding how people are feeling, and helping these individuals discuss what they're feeling and what they would like to see happen going forward.
LR: So, is being a well-trained family or couples therapists enough to work with families of returning veterans, or is there additional training they should have in order to work with military families that are reunited after deployment?
BM: I think being a grounded and solid couple or family therapist is important, but also having some additional training. It doesn't have to be formalized training. It could be a CE activity or even reading a couple of books on military culture. Family therapy is family therapy is family therapy.
If the clinician can pair their skills as a couples therapist or family therapist with their newfound awareness of cultural, military cultural aspects, then I think they will be just fine
If the clinician can pair their skills as a couples therapist or family therapist with their newfound awareness of cultural, military cultural aspects, then I think they will be just fine.
LR: If, as we close, you could send a message to those military psychologists, military clinicians working in the combat theater or at home, what would you say to them?
BM: Well, first of all, thanks for doing such an incredible job over the years, and that's directed toward those that have been doing this for a while, because I think we have had a challenge providing for the many needs that our families and our service members have experienced over the past decade and a half. And for those that are new to this field and are just starting to work with veterans and military members, don't give up. You are going to feel frustrated. At times you are going to question, “Why in the world am I doing this? Why would I work with families or individuals that I really don't have a strong connection to?” Because as a civilian provider, you can oftentimes feel like an outsider if you don't have military experience.

Military experience and military service is valued by service members and military families, but it is not a requirement for helping them. But in honesty, in all honesty, it is valued. But for the non-military clinician or clinician who has no experience in the military, ask when you don't know something — don't try to fake it. If you don't understand what the terminology means, let the service member teach you. Let the family teach you. Develop a collaborative relationship, and don't give up. Just work through the frustration, because we have plenty of veterans and families that need the help of good clinicians. 
LR: Stay in the fight.
BM: Stay in the fight. Get the mission done.



* The views expressed herein are those of the interviewee and do not reflect the official
policy or position of U.S. Army Regional Health Command-Central, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense or the U.S. Government.

Integrating Technology into Mental Healthcare: Theory and Practice

Posted on by Psychotherapy.net Team

Recent Trends

A recent review by the American Psychiatric Association (APA) found that there are currently over 10,000 mental health apps on the market¹.

At first glance, that number is astounding. However, “technology in mental health is not necessarily a new concept”. The 1966 advent of the Rogerian artificial intelligence therapist named Eliza marked the first formal introduction of technology’s application to mental health in general, and to the process of therapy in particular. Although the limited technology that built Eliza was far from a meaningful contribution to the course of mental healthcare in America, it nonetheless represented an important milestone that has since snowballed into our current ecosystem of mental health applications used by billions of people worldwide.

While there are all kinds of mental health-related applications that service a wide range of functions, most of which are of the “self-serve” type, what has drawn my attention most are those that are used to supplement or enhance my own work as a therapist. Truth be told, my skepticism around the prevalent use of self-serve apps — particularly those with largely unfounded clinical outcome claims about producing a quick fix for [insert any diagnosis here] — has limited my interest in recommending these apps as an alternative to face-to-face therapy. However, technological innovation in the context of supporting, rather than replacing, the work that we do in therapy has piqued my interest for quite some time.

In this context, I have found that technology used to enhance the therapeutic process can be clustered into three overarching domains, which are detailed in brief below.

1. Technology for improving access to care.

It’s no surprise that the largest impact that technology has had on the mental health and wellbeing of individuals across our world is the advent of online telehealth platforms. Individuals who previously were denied care due to a lack of access to qualified health professionals (e.g., those in rural areas, with disabilities, or with limited resources for transportation) can now access quality care in a matter of minutes. Telehealth companies such as Regroup and Ginger are changing the way in which we understand the therapeutic relationship, and the process of therapy more generally, through the addition of a computer screen separating therapist and client. Although there are certainly several noteworthy factors that warrant consideration regarding providing telehealth services (client safety, confidentiality and boundaries come to mind), “even the technology-wary therapist has a hard time arguing against the profound benefits that come from increasing access to care for those who need it”.

2. Technology for screening, assessment, and risk management

Leaders in our field have advocated for measurement-based care for decades, and countless research studies have confirmed that integrating routine screening and outcome monitoring into your practice in one way or another significantly improves your ability to detect client deterioration, make appropriate referrals and make better treatment decisions throughout the course of therapy, among other benefits. However, the implementation of measurement into practice has traditionally been halted by the cumbersome process of collecting relevant information and, quite frankly, the annoyances that inevitably arise when administering and making sense of paper-pencil assessments during your sessions. As a result, less than 20% of clinicians currently practice measurement-based care². Luckily, technological advances are solving these issues by making it easier than ever to routinely screen and assess client symptoms and progress in therapy. For example, companies such as Blueprint allow therapists to assign rating scales and screeners for clients to complete on their own time while at home. These platforms can alert you when a client’s data shows a spike in severity and can even link the client to local crisis resources for just-in-time interventions. Although seemingly simple, these advances can make a world of difference when trying to integrate measurement and screening into your otherwise busy clinical practice.

3. Technology as an adjunct intervention

The research around combining app-based interventions with face-to-face therapy tells a similar story to what is commonly found in outcome studies for psychotropic medication and therapy: they work alone but are better together. Many mental health apps are specifically designed to serve as a supplement to individual therapy by focusing on aspects of care that you want your clients to be doing anyway, such as learning new skills and practicing techniques outside of the therapy office. In fact, simply monitoring thoughts and emotions daily, which represents a fundamental component of cognitive behavior therapy (CBT), has been identified as a leading predictor of early positive change in CBT for depression and anxiety. “It’s no surprise that self-monitoring apps are also among the most downloaded mental health related apps on the market today”. As therapists, we should be encouraging our clients to partake in this type of behavior as a means of engaging more fully in the process of therapy and generalizing skills outside the therapy office.

A Lesson Learned

For some of you, the addition of the three domains of technology into your practice mentioned above comes naturally. For others, myself included, it does not. In fact, throughout my early years of clinical training I was vehemently opposed to introducing technology and apps into my clinical work. The foundation of my focus was (and still is) all about cultivating the therapeutic relationship; between this and my burgeoning passion for helping clients build a contemplative/meditative practice into their daily lives, I just couldn’t fathom why I would ever want to pull up a computer screen or bring out my cell phone during a session.

It wasn’t until my clinical training with Hasbro Children’s Hospital & Alpert Medical School at Brown University that the integration of technology into quality mental healthcare was de-mystified. The psychologists I worked under had a wonderful approach to implementing the three domains of technology mentioned above in a non-invasive and rapport-strengthening manner, and in a way that enhanced the therapeutic work that was being done. I’ll share one small excerpt from this experience in the form of a case study to illustrate how technology can be integrated into your clinical practice to support your work and improve your clients’ mental health and wellbeing. Please note that all identifiable information and certain aspects of the case report have been modified for privacy purposes.

Case Study — Katie

Katie was a 16-year-old female who was referred to me due to PTSD symptoms following a traumatic experience with a family member. She initially presented as cautious, with flat affect, and with little ability for back-and-forth conversation. Given her presenting symptoms and overall demeanor, I used a trauma-focused cognitive-behavioral therapy (TF-CBT) approach to help her overcome distressing internal experiences that were holding her back from engaging fully in her academic, home and social life.

Following a few weeks of psychoeducation and building rapport, we started working on relaxation and grounding skills to help her reduce the panic and hyperarousal that she would experience in the face of trauma-related triggers at school and with friends. Although she would engage in exercises during our sessions, she had difficulty maintaining this practice outside the office. After reviewing several relaxation apps, we collaboratively identified the app “Stop, Breathe & Think” to support her independent practice of these skills. Katie found this app extremely helpful, particularly its feature to support paced breathing, as well as its daily journal function, where she could express her thoughts and feelings in the moment. Moreover, she enjoyed bringing up the journal entries during our sessions as a means of communicating significant events that occurred over the week with more detail than if she relied on recall.

Over the course of six months, Katie became increasingly able to manage her symptoms of PTSD and felt as though she was finally beginning to take back control of her life. However, an upcoming out-of-state move with her parents required that we make a decision regarding the remainder of her care. I felt as though she still required the support and assistance of a therapist, yet had progressed sufficiently to warrant holding off on transferring to a new therapist for continued care. As such, we decided on using a telehealth platform to continue having sessions virtually on a bi-weekly basis with the goal of ending services within the year.

Given that I would no longer be meeting with Katie face to face, I decided to implement a remote assessment and screening platform as an additional precaution for keeping an eye on Katie’s health and wellness as she adjusted to the move. Katie was assigned the Patient Health Questionnaire Adolescent (PHQ-A) and the Trauma Symptom Checklist Short Form (TSCC-SF) to complete through the mobile app on her phone on a bi-weekly basis. I would review the results with Katie during our sessions and bring up any noteworthy changes to her functioning for further discussion.

“Six weeks into her move, I met with Katie through the telehealth platform as usual and things seemed to be going just fine”. She was keeping up with her journal entries in the Stop, Breathe & Think app, which we would use as an additional source of communication. However, when reviewing her most recent assessment, I noticed that Katie reported “sometimes” to the suicide-related question on the PHQ-9. When asked about this response, Katie reported that she had been feeling “a little off lately” and that she had been experiencing suicidal thoughts that were like her experiences early on in our time together. Upon further inquiry and discussion, Katie and I jointly decided to make a referral to a trauma specialty clinic in the area that could better assess safety and set her up for a longer course of care with a local therapist. Katie and I had one final session before her transition to the new therapist, and at that time she was feeling hopeful and optimistic for positive change. Although Katie’s case doesn’t have a resolution for our story today, I hope that it is a helpful example of the ways in which technology can be integrated into clinical practice to support the process of therapy across the care continuum.

Looking Back, Looking Forward

 While the list of mental health apps entering the market is growing each day, the practice of psychotherapy is, and always will be, founded upon the uniquely human relationship that occurs between a therapist and a client – something that technology in and of itself cannot reproduce. As a result, it is our responsibility as therapists to adjust to this new culture and learn how to integrate these tools into our practice, while also being mindful of the limitations that technology may have in supporting our work.

For example, a primary area of interest in contemporary mental health app development is the ability to detect psychological disorders or pathological behaviors using complex data analytic techniques such as machine learning and artificial intelligence. Doing so would, in theory, enable better prevention through linking individuals to healthcare services earlier in the disorder progression, and would help therapists identify clients at risk for relapse before they exhibit observable symptoms or behaviors. However, despite this type of technology’s current availability the market, such innovation is far from obtaining widespread research support and validation. As a result, clients may be vulnerable to the effects of misinformation (e.g., being wrongly identified with a particular mental health disorder), and clinicians need to increasingly trust their clinical judgement amongst potentially opposing information from unvalidated sources.

In summary, technology can and should have a place in the therapy office. In particular, therapists should take notice of technology that increases client access to care, assists in screening and routine assessment, or can be used as an adjunctive intervention to support face-to-face therapy sessions. My own experience has taught me that cultivating a sense of curiosity and willingness for change, together with a healthy sense of skepticism, is the best approach to jump-starting a technology-friendly practice. I’m hopeful that with regard to integrating technology into your mental healthcare services, you all can get out of your comfort zone and do the same.

References:

(1) Torous, J., Luo, J., & Chan, S. R. (2018). Mental health apps: What to tell patients. Current Psychiatry, 17, 21-24.

(2) Lewis, C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglass, S., Simon, G., & Kroenke, K. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324-335. 

Who’s Listening? Smartphones and Psychotherapy

Posted on by Psychotherapy.net Team

We both hear the buzz. I watch as he reaches over to the table to pick up one of his phones to see who the message is from. First, he checks his work phone, then his personal phone. I observe the tension in his face and try to hold on to the moment we just lost. It is 7:15 in the morning. He tries not to work during our sessions, but the financial overseas markets are already open, and his work expects him to be available. He does not mean to be disrespectful. I get more of his undivided attention than anyone else, but still I feel frustrated at being put on hold.

No-Smartphone Zone

The therapy hour is the patient’s and it is sacrosanct. In addition to the therapist’s training and expertise, what the patient is buying is fifty minutes of her undivided attention. In the not-so-distant past, the therapist used to receive her patient’s undivided attention as well. But no more. Smartphones have transformed the therapy hour, at least in my practice.

Therapy sessions are a laboratory for understanding human relationships. In addition to the patients’ individual needs, larger cultural trends are exposed in a therapist’s office. Personal devices have simultaneously enhanced and impaired human relationships. Helping our patients (as well as ourselves) adapt to the ever-changing world of technology is essential to functioning in our society. Examining patients’ relationships to their personal devices within therapy sessions sheds light on various ways technology is changing private and public lives.

Being unavailable for as little as an hour without fear of repercussion is no longer possible for many people. In the workplace, schools and within families, we are always expected to be available. Even patients with a standing weekly appointment, who are accustomed to the routine and sanctity of the therapy session, are often interrupted during a session with a non-emergency request. For a few people the consequence of being unreachable is truly unacceptable, but for most, having their smartphone on is merely a habit.

So why not simply have a policy that bans smartphones during therapy, as some of my colleagues do? I forbid anyone to smoke or use drugs during their sessions and I am comfortable enforcing those rules, so why don’t I enforce a rule about cellphone use? I imagine that some of my patients would balk at a prohibition on smartphones in my office. I also don’t want to spend the beginning of each session negotiating whether the potential need to be interrupted rises to the level of granting an override to my ban. But, perhaps more importantly, “I learn things about my patients as I witness their relationship with their phones”. At this point I have no official policy, but rather have incorporated my observations of how my patients use their smartphones into my general understanding of how they function in the larger world. Understanding how people relate to technology reveals important aspects of their values and personalities.

The smartphones—and yes, some people bring more than one—may be out in full view, or they may be stuffed into pockets, handbags or briefcases. On occasion, if they have been inadvertently left in the car, patients excuse themselves to retrieve the phone, “just in case.” It’s not just the phone ringing, but the ping of incoming texts, voicemails and emails that punctuates the session. Increasingly, people wear smartwatches that light up with each incoming text or email notification, adding to the distraction. People claim that they need to have their phones on in case of an emergency, but rarely does the interruption meet that bar. In fact, in over thirty years of practice, I have only twice had situations where a patient had an actual emergency which necessitated leaving the session early. This underscores that “technology has changed the social norms for what constitutes an emergency”. Prior to cell phones, people came to the therapy hour with less worry and distraction about being reachable. There was an implicit understanding that for fifty minutes the world could take care of itself without dire consequences.

GoPhone or StayPhone

Our relationship to our devices is embedded far deeper in our psyche than most of us would care to admit. Thinking of our phone as merely an appendage, like the car keys, denies its emotional connection. This is part of why people feel so unsettled if they can’t find their phone or if the phone is off. It is as though they’ve lost a part of themselves. A recent study in the Journal of Social and Clinical Psychology discussed how limiting social media access could decrease anxiety and depression. It is both the content of what we are seeing as well as the need to be incessantly looking that is impacting our mental health. The understanding that constant connectivity is hurting us is gaining traction, but that does not mean people can easily go cold turkey for an hour a week. Counterintuitively, by allowing smartphones to be out and visible during therapy sessions, some of my patients are calmer and more focused than they would be if left to wonder who might be trying to reach them for that hour.

During my work hours, both my landline and my own smartphone are silenced. Before cell phones existed, patients would occasionally ask me to turn on the ringer to my landline, so a babysitter or physician could reach them if needed. But at that time, the norm was that there was no need for interruption during the session and our time together was the central focus. The patient-therapist relationship was built on the communication that occurred between us in the office.

A colleague reports, “For those who peek at their phones throughout sessions, it feels like a compulsion—they can’t not look.” Some people glance at their devices during sessions to read incoming texts and missed calls throughout the session—as a form of multi-tasking—seemingly unaware of how such behavior disrupts the flow of conversation or limits the emotional depth of our connection. Patients have always had ways of side-tracking themselves during sessions, such as changing the topic, glancing out the window or playing with a tissue box, but the smartphone provides a far more powerful distraction. “Its addictive properties and prevailing social norms that permit having it on at all times contribute to using our smartphones as a psychological shield”.

He takes notes on his phone after their fights because he wants to make sure I hear “both sides.” He is a chemical engineer by training and committed to getting the facts right. He “walks on eggshells in their marriage,” scarred by her words and blind to his own rage. He reads his notes to me during each session, a practice he finds reassuring, confident that he has gotten the wording just right.

Sometimes patients use their phones in therapy to bolster their position on an issue. They want me to agree with their outrage over someone’s insensitive comments or their disgust with inappropriate pictures shared on dating apps. I wonder if people have ever thought about the possibility these photos could be shown to a therapist before posting them. Just as people no longer rely on their memory for phone numbers or directions, whole conversations are readily available to be shared. The story doesn’t unfold. Rather, the evidence is presented like a legal argument. Many of my colleagues have acknowledged the beneficial aspect of this—it allows for a truer glimpse into the patient’s behavior in the outside world. But it can also easily thrust the therapist into the role of judge, rather than allowing for a more nuanced dialogue. For example, at the end of reading a text exchange aloud, the patient may look up from the screen with a fervent expectation that I will be nodding in agreement. This feels entirely different from a story being told in the patient’s own words while maintaining eye contact with me. In an effort to highlight the patient’s reaction, rather than offering my response right away, I typically ask the patient to reflect on what he just read.

Occasionally, patients are genuinely confused about how to interpret a message. They search on the phone for a text or email and read it to me. “What did she mean by this text? Is she trying to break up with me?” “How could he think that was funny? He claims it was a joke.” “How long should I wait before texting back? I don’t want to appear too eager.” Integrating this ever-changing technology into our relationships requires that all of us write the instruction manual in real time. I am not the Ms. Manners of smartphone etiquette, but I think people are turning to their therapists for help in this regard because we are experts in relationships. On a recent episode of the podcast The Cut, “Bad Sex, Good Sex: Fiction That Makes Sense of How We Bone” (2019), one of the panelists reported that she brings her phone into her therapy sessions because she was explicitly looking for help from her therapist with how to interpret the text message exchanges on her dating app. No longer was she relying on her own experience, but rather she read the text exchange aloud looking for help with interpretation. She said, “All therapists need to get hip to this because it’s not just crazy assumptions anymore.” The fact that it is now “he said, she said” in black and white rather than one person’s recollection can add powerful information to the session. The panel went on to discuss how important it is for therapists to be knowledgeable about the varied ways emojis are used.

Therapists have a deeper understanding of our clients’ issues than an advice columnist. For example, someone who is conflict-avoidant would much rather send a text than make a phone call when there is tension in a relationship. As professionals, “being fluent in how smartphones and other forms of technology are used to foster social connections is critical to offering relevant assistance to our patients”.

By making us more reachable, smartphones have increased not only our ways of communicating (a simple “I’m sorry” text on the way to work can ease an early morning fight), but also the expectation that a recipient should respond ASAP. It can be excruciating to wait for a response and people often have a strong reaction to a real or perceived delay in response. Family members, friends and bosses text or email rather than waiting for an opportunity for face-to-face conversation. Sometimes, phones are used in this way to control the communication, pounding out a monologue and hitting send rather than welcoming a dialogue. Patients can use their smartphones as a verbal weapon when they impulsively bombard someone with a rant. Alternatively, being “ghosted” can erode one’s self-esteem. Learning how to interpret both the content and the timing of someone’s texting behavior is on par with learning a new dialect. All these new ways of communicating are significantly altering how relationships are formed and nurtured.

Commenting on the absence of my smartphone during our sessions, one of my college-age patients recently told me, “You’re the only person I talk to who actually looks at me the whole time.” This statement opened a discussion between us about her relationship to her own phone. As Cal Newport wrote in The New York Times (2019, January 25) earlier this year:

Under what I call the ‘constant companion mode,’ we now see our smartphones as always-on portals to information. Instead of improving activities that we found important before this technology existed, this model changes what we pay attention to in the first place—often in ways designed to benefit the stock price of attention-economy conglomerates, not our satisfaction and well-being.

Many of my patients have expressed a desire to spend less time on their phones but feel uncertain about what the consequences for their social life might be. As more people experiment with “Dry January,” could we imagine a social movement toward “Smartphone-free September” where we return to using our Smartphone only as a phone?

Early in my training as a psychologist, a supervisor taught me that he waited 24 hours before returning a phone call from a prospective new patient. He explained that he wanted to “set the stage with realistic expectations about his availability.” I have continued that practice, but recently I have begun to wonder if the wait for a call back feels different to potential patients in this day and age. Do they just “swipe left” and move on to the next therapist’s profile? It is also interesting to see how long a week between sessions feels to different patients. The timing of sessions is always part of the treatment protocol, but in a landscape that is more 24/7 than ever and with so much instant connectivity, waiting a week to continue a conversation is no longer representative of how most relationships function. Increasingly, and counterintuitively, because we will sometimes communicate between sessions, I find I have to remind patients about what happened in past sessions to keep the thread of our in-session work alive. This is a change from earlier in my practice when our time together week to week was more demarcated. Now people are “in touch” with such frequency that it can be harder to hold onto what was said in the session as opposed to all the noise in between. To combat this, I encourage patients to organize their day in such a way that they have time after each session to quietly contemplate our work rather than squeezing it in between all the other parts of their lives. Sometimes “I explicitly encourage someone to not reflexively check their phone the moment the session ends, but rather give themselves time for reflection”. By delaying the inevitable distraction created by reentry into their busy lives, patients can make much better use of their therapy sessions. Ironically, this suggestion is undermined by using the smartphone as a calendar. As soon as patients turn on their phone to make an appointment, they are greeted with all the missed communications of the last hour. Consequently, the session ends abruptly even before the person has left my office.

Worth a Thousand Words

Her son is worried that he is getting fat. She is worried that her own body image issues are scarring her child. She reaches for her phone and offers to show me photos of her family. Her eyes reveal the fear she feels anticipating I will judge her as a bad parent.

With the introduction of photos on phones, I feel that I’ve graduated from radio to television in my sessions. Patients may hand me their phone to look at photos during a session. At times this can involve an awkward dance as we negotiate how to be physically next to each other. Do I get up from my chair or do they come over from the couch to me as I am introduced to the family? Because I usually hear the details of someone’s personality long before I see a photo of them, I often draw my own picture of the person’s appearance, sometimes finding out how wrong I was when I see their image. For example, a tyrannical father may have been only a few inches taller than my patient, but his forceful behavior had me visualizing him as much larger.

There have been occasions when I’ve asked to see an image of someone, such as after the death of a parent, as a way of feeling closer to my patient. Patients sometimes solicit my reaction to the photos they share, but in my role as therapist I always try to reflect to the patient that their opinion is the one that matters. It can be illuminating, though, to see the discrepancy between someone’s self-report and an actual image.

Sharing photos from major life events of my patients can also foster joyous connections with them. In many instances the result of our work was critical to the realization of a wedding day, a baby or a graduation. Prior to smartphones, patients might have brought photos with them to a session in a planned way to share these significant events, but now there can be the spontaneous sharing of a child’s first steps or the photo of a new home.

The availability of photos and videos on phones has also increased how much of my patients’ lives I can share virtually. I have heard musical performances, comedy routines and graduation speeches. I now have greater access to the full scope of my patients’ lives as they send me updates through texts or emails. In addition, the exchange of podcasts and articles to supplement the therapy hour can be beneficial, just as book recommendations have been. But this necessitates that I manage patients’ expectations about my availability between sessions. Sometimes people want me to read or listen to information as a way of getting to know them, rather than relying on the work we do together during the therapy hour. Potentially this can speed up the connection we have together, but there are other times when it feels like resistance to actual therapy.

Incidental Eavesdropping

In an effort to contain how my patients reach me between sessions, I am judicious about sharing my email address or cell phone number. Historically, all these ways of interacting would be considered “grist for the mill” in a therapy relationship. To an extent they still are, but I think it is important to monitor how effective the access to technology is for improving or hurting therapy relationships. An article in Forbes.com, “Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future” by Essig, Turkle, and Isaacs Russell (2018, June 7), articulates the slippery slope therapists are on when their behavior contributes to the notion that human interaction can be replaced by technology. From scheduling appointments to responding to patients’ requests with our own text messages, we are succumbing to the ease of using technology and missing the fuller exchange possible in a phone call or face-to-face meeting. When therapists’ behavior reflects social norms regarding technology rather than challenge it, the authors conclude, they are failing their patients.

She reads the text thread on her daughter’s account from her own phone as she tells me about how worried she is that her daughter will be expelled from boarding school.

Recently, one of my patients was complaining that her daughter, who is enrolled at an expensive private high school, was on her device during class time. The mother, my patient, is able to track her daughter’s use of her phone clandestinely. She saw that her daughter did not use her phone during lunch or free periods, when presumably she was having face-to-face contact with friends. When my patient questioned the school about their policy for the use of personal devices, they stated that they choose not to police students’ phones but rather to teach students how to police themselves. Ironically, the mother and I had this conversation while her own phone was lighting up with text messages to her from her daughter and she was paying me for my time. When I pointed out the contradiction between her unhappiness that her daughter was not paying attention in class and her own choice to be on her phone during our sessions, she grew quiet. She was so concerned about being available to her daughter at all times, she had failed to see how she was modeling exactly the behavior she does not respect.

I listen as he talks to his wife. I am a silent observer to one side of the conversation. I can see his facial expression and body language. I hear the frustration in his voice despite the polite language he uses. I wonder if she realizes how close he is to leaving her.

Once, a patient who was going through a nasty divorce continued his phone call with his wife for the first five minutes of our session. He was on his phone as he entered my office and, without acknowledging my presence, continued the conversation. I had heard him describe his frustration and hurt, but to actually hear the anger in his voice and see the veins in his neck throbbing as he shouted at her brought his pain vividly into the session. We are all privy to overhearing phone conversations with little regard for privacy as we go about our day, but hearing snippets of conversations can reveal aspects of patients’ personalities that otherwise might have stayed hidden far longer.

The Newest Addiction

Increasingly, the very topic of addiction to smartphones is the presenting problem in therapy. Patients are looking for help to manage their addiction to the use of the device and/or the content on the device. Hours are spent on pornography, dating apps and/or social media. People spend time chasing down news stories, only to find themselves more depressed than ever. In these cases, a discussion about the presence of personal devices during the therapy hour is essential. Some of my colleagues have a basket in their office with the expectation that patients turn off their phones and drop them in the basket. One colleague, who works primarily with adolescents, told me, “This (dropping phones in baskets) is so routine for them—at school, friends’ parties—they never question this expectation. My adult patients are much more likely to balk at the request with protests of needing to be available “in case of an emergency.”

Patients complain of partners who take their phone to bed and are text messaging with someone else or looking at the Facebook posts of friends as they lie there feeling ignored. Or they engage in parallel play, side by side, watching their own TV show or film. Single patients will talk about the hours they lose to being on their smartphones. It is easier to play another game of Candy Crush than meet a stranger for a date. “Feeling connected to the world virtually makes staying home feel less isolating, but it rarely touches their deep loneliness”.

Even though she knows “it’s crazy” she reflexively checks to make sure her phone is off before talking about her mother. She is terrified that her mother might hear what she is saying.

There are those patients who religiously turn off their phones and direct their full attention to our work from the beginning of each session. I have yet to find a way to predict this behavior by age, gender, profession or presenting problem. I’ve talked to other therapists and they say the same thing. Some patients eventually adopt this stance on their own. As the work gets deeper and our relationship closer, they invest more thoughtfully in our time together by turning off their phones, whereas in the beginning of treatment they may not have been as ready to do that. Some express relief to be away from their devices for an hour and to focus on themselves. Sometimes, when I observe a patient nervously looking at her phone, I may ask her if that is really how she wants to spend our time together. Turning off the phone can be an assertive act and contribute to enhanced self-esteem. It may also generalize outside the therapy office, giving people permission to ask others to turn off their phones for the purpose of decreasing interruptions or staying focused in a face-to-face conversation. Much like the transition from allowing people to smoke everywhere to limiting smoking to designated spaces, I find people are starting to long for a social change where they feel more empowered to ask people to turn off their phones. The quality of the conversation we have during therapy can become a benchmark for the kind of conversation people want to have with other people in their lives. Just as I encourage patients to meet someone for a first date at a coffee shop rather than a place where alcohol is served, discussing how to limit smartphone use before engaging in a difficult conversation seems critical to increasing the likelihood for a successful interaction.

She asks me to slow down as she types my words into her phone. She tells me that she reads them between sessions to remind herself that she has a right to exist.

A Place on the Couch

Smartphones are not the enemy of psychotherapy. In fact, therapy can illuminate how technology is changing the social fabric of society, especially relationships. Psychopharmacology was once seen as a threat to “talk therapy,” but it is now clear that they complement each other. Technology expands the possibility for people to receive treatment in remote areas where there may not be many providers. Through the introduction of Skype, FaceTime and other applications which allow for both visual and verbal communication, patients can have sessions during extended periods of being away. Recently, insurance companies have started to reimburse for teletherapy, thus making it easier for potential patients to find a provider. Although I still prefer to meet with people in person, there have been instances when, because of technology, I was able to continue working with someone, such as when a patient studied abroad for a semester, despite a geographic separation.

Linda Rodriguez McRobbie of the Boston Globe (2019, January 31), reported on a relatively new development- apps that deliver therapy without a therapist; the therapist in your pocket. People use their smartphones to establish meditation practices, exercise routines and various other self-help functions. Cognitive-behavior therapy principles are available to download as an alternative to actually engaging in therapy. Our reliance on our smartphones to fulfill our needs, even going so far as replacing human interactions, is troubling. Perhaps the best example of how seductive a relationship to a smartphone can become is revealed in the 2013 Spike Jonze movie, Her, (where the main character falls in love with his phone and takes it on dates).

Adapting to change is a hallmark of therapy. Therapists are in a unique position to experience as well as reflect on how human connections are floundering or flourishing by the presence of technology in our lives. “When technology enhances our connections, relationships blossom, but when technology becomes an overwhelming focus of our lives, relationships suffer”. The therapy hour can serve as a reprieve from being available, a training ground for practicing a phone-free hour. Ironically, I, of course, have my smartphone silenced and out of sight throughout every session. The person in front of me deserves my full attention and my behavior models that it is still possible to be unavailable to the larger world for an hour.

As I struggle with the reality that technology is omnipresent and ever-changing, I also continue to believe in the power of human connection. One of the benefits of a psychotherapy relationship is its consistency. Every week I show up at the same time ready to listen to the deepest thoughts and feelings my patients choose to share. Together, through our connection, I explore the needs and desires expressed by them to support their change and growth. This is my life’s work and it is enormously gratifying. I have adapted to changes in the field of psychology over the years, yet the heart of my work has remained my ability to establish a positive relationship with each patient.

Recently, a former long-term patient celebrated a milestone birthday. She called my office phone, the landline I have had for over 30 years, grateful to know I was still there. She wanted me to know that despite all odds—she was a newly sober alcoholic at the age of 35 when we first met—she had made it to the age of 70. When I returned her call to offer her my congratulations, she updated me about where she was living and her family members. Then she wistfully asked if I have FaceTime, so we could talk one more time, “in person.”

References

(2019, January 22). Bad Sex, Good Sex, Fiction That Makes Sense of How We Bone. The Cut Podcast. Podcast retrieved from
https://gimletmedia.com/shows/the-cut-on-tuesdays.

Essig, T., Turkle, S., Russell, G.I.. (2018, June 7). Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future. Forbes. Article retrieved from http://forbes.com.

McRobbie, L.R.. (2019, January 31). Apps can Put Therapy in the Palm of Your Hand. But What Happens When They Go Haywire?. The Boston Globe. Article retrieved from http://bostonglobe.com.

Newport, C. (2019, January 25). Steve Jobs Never Wanted Us to Use Our iPhones Like This. The New York Times. Article retrieved from http://nytimes.com.
 

Internal Emigration & Online Therapy

Posted on by Psychotherapy.net Team

“I was born in the wrong place,” one of my online clients told me. She is someone with fidgety feet and a knotty relationship with her homeland. Growing up she had felt out of place in her native town, tucked in the middle of Pennsylvania. I keep hearing different versions of this harsh statement, from clients from various cultures and social backgrounds.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

The feeling of not fitting in, not belonging to their original environment, is shared by many emigrant writers. Edward Said’s account of this experience is probably the most quintessential: “There was always something wrong with how I was invented and meant to fit in with the world of my parents and four sisters. Whether this was because I constantly misread my part or because of some deep flaw in my being I could not tell for most of my early life. Sometimes I was intransigent and proud of it. At other times I seemed to myself to be neatly devoid of any character at all, timid, uncertain, without will. Yet the overriding sensation I had was of always being out of place¹.

Said’s experience of being deeply flawed, his constant uncertainty and confusion about his own worth, are all indicators of various degrees of feeling shame related at least in part to his sense of not fitting in.

Joe Burgo, a psychotherapist and the author of a recent book Shame, insists that: “Unreciprocated affection or interest will always stir emotions from the shame family. As part of our genetic inheritance, we want to connect with a loved one who will love us in return; when our longing is disappointed, when we fail to connect, we inevitably experience shame, however we name the feeling². The motherland, which does not love us back, is similar to a parent that fails to meet our expectations of love. Both unfortunate situations naturally result in feeling that something is deeply wrong with us.

One of the ways we can cope with such circumstances is by leaving our original place altogether. For some, the decision to emigrate, often a difficult one, is unconsciously driven by the need to avoid shame provoked by the discordance between who we are and who we are expected to be in order to fit in. In many cases, the choice to leave home is the best survival strategy. The most obvious examples are queer individuals from countries that pathologize and punish homosexuality: they flee their homes in order to be able to freely live their lives in the way that feels right to them.

But such physical escape is not always possible. Individuals who grow up feeling that they do not fit in countries that they cannot leave for various reasons (e.g., an iron curtain of any kind, family situation, physical handicap, economic dependence) feel trapped and disempowered in the face of such an unresolvable conflict. Not being able to escape the place that is rejecting them only reinforces the feeling of shame triggered by a constant experience being different and not fitting in, and of being excluded.

When emigrating outwards is impossible, the only way of fleeing such reality is inwards. My own Russian culture offers abundant examples of such a psychological strategy for subsisting in an unfriendly reality. Soviet history gave us not only the concept of internal immigration, as mentioned by Angus Roxburgh in a recent Guardian article on life in the 70’s, but also a rich cultural heritage, which thrived “underground” despite the intermittently tyrannical regime. Many artists—Shostakovich being probably the most striking example—lived a paradoxical experience of inner freedom in the middle of an oppressive outer reality.

Russian emigrant writers give us a powerful lesson of resilience in dealing with hostile but inescapable realities. Through their art, they created inner bubbles of freedom, and often had to evolve in parallel realities like Joseph Brodsky who, decades before emigrating, introduced the notion of an “indifferent homeland” in his early work inspired by the quintessential poet in exile, Ovid.

Emigrant writers such as Brodsky or Nabokov’s use of a foreign language for writing is emblematic and has deeper meaning: they claim a new freedom from constraints imposed by their culture. Committing to a chosen second language, despite the difficulties and losses that this choice implies, is a powerful affirmation of individual freedom. This second language, according to Kellman, becomes the tongue of the parallel inner world and a language of freedom.

The same is true for some of my clients living in the state of internal exile. They often reach out to a therapist who speaks English even though it is not their mother tongue. This choice certainly complicates their therapeutic journey, but also allows it some unexpected depth and richness.

When I meet with clients who evolved under an authoritarian regime (e.g., Saudi Arabia, Putin’s Russia, China), I recognize the strength of this coping strategy. Our sessions happen online through videoconferencing systems, as the clients are often unable to find a suitable support in their home countries. The regimes they live under have no love lost for therapy, which aims at empowering the individual; they usually opt for a kind of punitive psychiatry, which was so well developed in the Soviet Russia. Its aim was, in Brodsky’s words, “to slow you down, to stop you, so that you can do absolutely nothing…”

Evolving in self-created bubbles of parallel realities drives us even further away from those who share this harsh external reality with us. This further isolation can only deepen the shame that we already feel about being deeply flawed and not fitting-in. Those who are restricted to these self-created inner worlds often display some recurrent symptoms: depression, anxiety, low self-esteem, and constant self-doubt.

Online therapy can offer these inward emigrants a third space, located outside of their unfriendly environment, on the outskirts of their inner reality. In these two conflicting worlds, they are alone, but in the virtual space of therapy, they find a friendly person in front of them, open and curious to learn about their worlds. The online reality shared with their therapist eventually becomes a safe space to reflect on the painful discordance of their inner and outer worlds.

Communication media that online therapy actively uses for its own scope often play an important role in dealing with life in unfriendly inescapable surroundings. Many of my clients living in the state of internal emigration turn to social media on the internet to find like-minded peers and feel less alienated and less ashamed.

There is an intriguing parallel between the voices of the free radio that had offered an opening towards the other side of the curtain during the Soviet times, and the social media of today. The latter is more interactive by nature. During the Soviet times, one was only able to listen and feel connected by a stranger’s voice talking in one’s own language from the other side of the divisive wall, whilst modern technologies offer the possibility for a dialogue, often in English used as the lingua franca.

I have witnessed many situations in which such an outlet kept individuals sane: Saudi women who connect with each other in the ethereal space of freedom; a gay man from Siberia finding connection with those like him and acquiring some form of validation of his own experience; a queer young woman in Putin’s Russia working for a liberal news online platform and through her work connecting with those whose thinking she can share.

Online therapy with a transcultural therapist, who evolved on the other side of the wall, in a different and often freer reality, becomes an ultimate opening for individuals who experience their external realities as oppressive. In some lucky cases it can shake up the juxtaposition of the two incompatible realities the individual is locked in and offer something else—a less lonely space in which they can experiment with fitting in, belonging and imagining other, less lonely and shame-filled, and freer possibilities.

References

(1) Said, E.W. (1999). Out of place: A memoir. New York: Knopf.

(2) Burgo, J. (2018). Shame: Free Yourself, Find Joy, and Build True Self-Esteem New York: St Martins Pres. 

Talkspace: The New Therapy Room

Posted on by Psychotherapy.net Team

I am always on the lookout for new opportunities and exciting options through which to share my mission of promoting positive mental health. I have been a psychotherapist for over 31 years. Working with adolescents has taught me many things, foremost among which is to expect the unexpected and be open to whatever is happening in the digital world. And it’s not like I’m a dinosaur who’s ignored trends in the digital world, but when did texting become the new form of talking, and can it possibly be an effective form of communication? For therapists?

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Along came Talkspace (TS), a highly sophisticated digital therapy platform which provides for communication with clients through audio and/or video messaging and live video sessions. I thought it was an opportunity, but even more so, a resource, I could not ignore. The “on-boarding” process, as it is called, required a significant commitment including providing my professional credentials, proof of liability insurance and completion of their comprehensive Talkspace University+ training, so that I could understand and effectively use their digital platform. Yes, it is HIPAA compliant.

Clients provide informed consent along with emergency contact information. One hopes to never have to use the emergency contacts, yet it is reassuring to have them readily available, if needed. Talkspace handles all financial transactions, including insurance, private pay and EAP (employee assistance program) fees. Clients are paired with therapists or can choose their own clinician. They complete a general application outlining their presenting problem(s) which triggers an assessment designed to establish a baseline of the frequency and or intensity of the presenting problem(s). Once client and therapist are paired, the therapeutic relationship begins. Rapport building beings and expectations related to frequency and mode of communication are agreed upon. For me, it involves five twice-daily visits to my “room” each week. The client has 24/7 access to their “client room” which is where we maintain contact. The relationship can form surprisingly quickly compared to some of the typical live sessions I have had in my on-ground or in-school clinical work.

Has it been significantly different for me from the traditional face-to-face therapy that I have practiced for so long? Yes and no! The convenience for myself and my clients is incredible. If you have an iPhone or iPad with a wireless connection, you can provide psychotherapy through the Talkspace platform. Italy, here I come! Yes, that does make it sound easy, however just as I have in my on-ground office, it has been important to trust in and use the experience I have accumulated to read through the message in the messages. Do I miss the nonverbal cues? Well, yes! This introduces the challenge of asking additional questions that I might not otherwise ask in my face-to-face work. For example, “What are your feelings about this? How are you processing all of this?” Yes, you ask these questions in face-to-face therapy, however it is typically more in the flow while you are reading the client’s nonverbal cues that insight into their feelings is acquired.

Most of us do not audiotape/review our sessions, we use notes and memory, right? Think about what YOU use to recollect your session. The nature of this digital therapeutic communication is very similar to in-person communication, but the entire exchange is right there on the screen. Client and therapist can read re-read the entire communication. This has allowed me to use the CBT model with greater impact. I encourage my TS clients to reread and review some of our previous messages to reinforce interventions, sometimes cutting and pasting in order to highlight and reinforce a concept. Here is an example of part of an interchange I had with a client:

Client: “I value my friends a lot and I genuinely do whatever I can to make them feel as good as I can get them to be.”

Me: “I am wondering if you can apply that thought/ideal to yourself. I value me a lot and genuinely do whatever I can to make me feel as good as I can for myself. How would that statement/thought feel? Try it on.”

Of course, I asked my client permission to use this. Within my message to ask permission, I once again copied and pasted the previous message for the client—an effective way of reinforcing and restructuring some of the negative thinking that occurs for her. One of the advantages of this platform is the ability to go back with accuracy to reinforce while highlighting the possibility of change. Additionally, I like the use of visuals in therapy such as the CBT triangle (thought, behavior, emotion), but as yet, it has been a challenge to bring these into the Talkspace room. I’ll get there.

The one constant in life, and no less in my evolving professional role, is change. Talkspace has challenged my preconceived ideas about digital therapy and enabled me to bring my clinical skills into the digital sphere. I welcome the research and data to support this work. I recently asked one of my digital international clients to articulate their experience with me on Talkspace. She said, “I don’t know if this could be of any use, but face-to-face therapy here in Saudi Arabia is really limited…I was faced with ignorance and people didn’t know how to handle me.” She continued, “With Talkspace, I truly felt heard and comforted in ways I couldn’t in face-to-face therapy. I’m sure professionals here are extremely good at what they do, but I was blessed to have you as my therapist and like I’m taking a huge step into bettering myself.”

Face-to-face and digital therapy both include rapport building, the establishment of baseline through careful assessment, the development of treatment goals, the creation and implementation of interventions and assessment of treatment outcome. Talkspace has brought me and my therapy room to clients who I, more than likely, would never have had the opportunity to work with. The clinical effectiveness, affordability and accessibility of Talkspace have worked for both me and my clients, allowing me to continue my mission to promote positive mental health. Therapy is not about a room, it is about creating a space for connection and healing. Welcome to the new therapy room. 

Train Professionals, Not Just Therapists

Posted on by Psychotherapy.net Team

Becoming Professional

After hundreds of class hours learning systemic therapeutic modalities and hundreds more working directly with clients in multiple clinical settings, I graduated from my master’s program in marriage and family therapy a competent clinician. I treat couples, families and individuals on issues ranging from depression to trauma to affairs. But graduating clinicians is not enough—graduate programs have a responsibility not only to train clinicians but to help them become professional therapists. And that task is far more complex.

A professional therapist entering the workforce must learn to navigate the employment landscape, land a first job, determine long and short-term professional goals, understand the financial and professional implications of each of those steps, and build the tools to curate a digital presence that supports professional growth. A professional therapist must learn how to conceptualize the digital boundaries between therapist and client in an ever-transparent world and integrate HIPAA compliant technology. The professional therapist must understand the ins and outs of the insurance industry, at least enough to intelligently interact with it. These are the elements of the professional. And currently, most new therapists are running blind.

I consider myself fortunate. By the time I entered graduate school to become a marriage and family therapist, I had worked in corporate marketing, built a resume consulting business, traveled the world, and gotten married. In my second year of graduate school, I published a book that became an Amazon bestseller. I had also been fired from a good paying job and struggled through six months of unemployment and under-employment. When I started graduate school, I did so with eyes wide open. I researched the elements of building a career as a therapist, not just as a clinician. I read books about entrepreneurship. I began writing and trying to build an online presence. But even I, far better equipped than the average student, had so much to learn about building a professional future. Particularly for those students that transition from undergraduate to graduate school, the intricacies and big picture conceptualization of one’s career can feel overwhelming and most feel ill-equipped.

Jumping into a career as a therapist comes with an incredible level of uncertainty. A student leaving a master’s level program must decide whether to pursue a doctoral degree. Upon hearing other students speak about their intention to pursue a doctoral study, I asked them about that decision and what they envisioned for themselves. Many said they did not know, it was just “what was next.” The trajectory outside of academia remains unclear, and involves understanding how to work in a hospital setting, community mental health or private practice, and decide whether to pursue an inpatient or outpatient role.

Job hunting. Entrepreneurship. Business ownership. Accounting. Marketing. Digital boundaries. Online therapy. Working in hospital settings. Whose job is it to teach budding professionals to navigate this landscape with finesse, confidence, and an understanding of what’s required to succeed? I believe that graduate schools need to play a much larger role in not only training competent clinicians but also in preparing professional therapists to enter their careers. If a degree is marketed as a professional degree, then a student has a right to learn how to become a professional. Why don’t graduate schools teach students about more aspects of professional life? I suspect the answer is multi-faceted.

Not My Job

Some argue that professional training related to the non-clinical aspects of a therapist’s career falls outside of graduate schools’ purview. In other words, not my job. We figured it out and you will too. This line of argument, akin to a verbal shrug of the shoulders, a relinquishment of responsibility, fails to compel me. That programs have yet to step up does not mean they should not. I am a student of systems, and to create change that reverberates down the course of a therapist’s career, the initial steps must include the tools necessary to succeed in the world. We can do better.

Some argue that, well, they had to figure it out, and you will too. Sure, I suppose that argument rings true. “Every professional confronts a steep learning curve when they transition from school into the workplace”. But let us not fall into an all or nothing thinking trap here. Teaching new therapists how to plan out their career progression, how to understand insurance systems, how to manage student loans, and how to approach the task of entrepreneurship for many who want to build practices, will not eliminate the steep learning curve. I argue not that the student should be coddled, but rather, that they should be equipped.

Many therapists struggle to connect their work with money. Training as a clinician aligns with the selfless task of helping others, while money, marketing and business models feel like its necessary seedy underbelly. At the agency where I work, a sign on one clinician’s door reads, “I do it for the outcomes, not the income.” While the sentiment is a lovely one, it only reinforces the minimization and vilification of financial success, and unnecessarily puts success and therapeutic work at odds with one another. This thinking also exposes a misunderstanding of the professional therapist. The professional therapist does not sell to sell, they sell to serve. The therapist who can build a successful enterprise, who can reach their target clients effectively (be they kindergarteners struggling with grief or couples on the verge of divorce), who can walk confidently into an interview to work at a hospital or community mental health setting, is a therapist that can effectively help more people. What would our sector look like if new therapists were armed with an arsenal of tools, ideas and resources to help them spread their message more effectively and reach the clients who need them. This model of service reframes the issue as one of great responsibility, deeply in line with the therapist’s work. This is the framework needed when thinking about the business of therapy.

Harsh Realities

Perhaps another obstacle in the way of open communication around therapist career building is the stark economic realities it would force professional graduate programs to face. One imagines the discomfort it would cause to have professors, teaching in programs charging ten to sixty thousand dollars per year, openly discuss the financial reality of most early career therapists. Students who find full-time positions with benefits (scarce in the mental health arena), often struggle under the sheer weight of student loans.

Community mental health positions often come with a rude awakening of fee for service work, extremely low pay, high no-show rates, high incidences of client trauma, and overworked supervisors incapable of meeting the needs of their outpatient therapists. Launching and maintaining a private practice involves daunting start-up costs along with the often bewildering and complex tasks that accompany the effective marketing of the practice, renting or finding a space, learning about billing, purchasing malpractice insurance, ensuring HIPAA protected note storage, and accounting.

Indeed, many programs discourage students from jumping straight into private practice, believing in the growth potential and importance of working in community spaces. Perhaps the prospect of asking students buried under tens or hundreds of thousands of dollars in student debt to take a low paying job for the experience would be a tough sell, or at the very least, an awkward one. I wonder how it would go over for students to learn that professors in their fields either still have student debt or benefited from high-earning spouses who enabled them to work despite the early career steps. These conversations force still more difficult conversations about the access to education and the capital needed to get going.

Alas, the professors and teachers best equipped to imbue their students with clinical skills may feel or be the least equipped to prepare students to operate in the digital landscape. Clinicians with more than 20 years of clinical practice have at most a bare-bones website. Their digital footprint may be limited to Psychology Today. They may not be adept at utilizing modern marketing tools, lead generators, and using SEO technology to bring in more referrals through google and other search engines. They may not know how to manage mainstream social media and address the realities of increased online transparency that translates into the therapy room. Many did not come of age professionally in the digital area, navigating the public and private boundaries that are a constant challenge for new clinicians. New therapists require mentorship from clinicians who have been in the field from five to ten years to learn the trade in its most recent form.

At present, “there is little pressure for graduate programs to reconceptualize their role and implement sweeping changes”. Without pressure, schools are unlikely to change. Without a roadmap, schools would need to dedicate themselves wholeheartedly to the task and not only implement new measures, but also create them.

During my final year of graduate school, I and many of my classmates struggled not only under the weight of coursework, but the questions about what would happen after we graduated. Some of us wondered how to translate our clinical experience into a resume that would attract employers. Others wondered whether to prioritize the stability of a full-time job with benefits or the position that enabled us to work with our target population in a position without benefits. A panel discussion of past graduates inevitably led to sheepish questions by students wondering if graduates would be willing to get specific about just how much they earned and how secure they felt. Now as a recent graduate, settled into a semblance of routine, current students approach me with the same panoply of questions. Year to year, the emotions underlying these questions remain: fear, confusion, frustration, excitement, and bewilderment. Guide us, we beg over and over. Please.

What Now?

Therapeutic training programs are hardly alone in their failure to prepare professionals. Law schools notoriously work their students to the bone learning legal intricacies while failing to touch upon the actual experience of working as a lawyer. When my husband Brian compared his experience of medical school with my late grandfather’s almost sixty years ago, he received more practical training related to charting and taking patient histories. He even had a class called “doctoring.” But medical students, who navigate a siloed version of the economy through their extended training, often complete their residencies with no training in financial management (despite averaging almost two hundred thousand dollars in debt), no training in private practice building or planning, and little understanding of the way that the changing healthcare landscape will impact their careers. Programs training other service oriented professionals, accountants, contractors, architects, artists, and hair stylists must provide their students with at least a starter kit of tools to help them navigate the realities of their craft.

The culture of training mental health practitioners needs a comprehensive overhaul to integrate professional training into the process of becoming a clinician. Some programs attempt to address student needs by bringing in the student career center to offer little more than talking points on general resume tips. These fixes fail to address the larger structural deficiencies and fall short of the students’ needs. Professionalism, entrepreneurship, finances and the like should be woven into the content so that one’s professional identity is forming alongside one’s clinical identity. For this to take place, academia needs to make room for the reality of the marketplace, something it historically struggles to embrace.

In the meantime, the private sector has filled the void left by educational institutions. Blogs, social media groups and businesses tout services aimed at helping clinicians build practices, market themselves, curate their social media presence, and guide new graduates through the job hunt and licensure process. There is absolutely a role for this market and the solutions created are often comprehensive and built by professionals who have been through it already. As most things in therapy, the answer likely is not one or the other. We need both.
 

Online Therapy: An Unexpected Space of Freedom

Posted on by Psychotherapy.net Team

Taking Risks

The dramatic story of the Saudi teenager Rahaf al-Qunun¹, who fled her family and country in order to request asylum elsewhere, resonated with many people in different ways. The oppressive background in which women like her evolve is generally far from our eyes, but I have, through my online therapy work, experienced several very touching stories from women in the Middle East.

Engaging in therapy is something that even Westerners do not enter into lightly. It requires taking a risk in opening themselves to a stranger to exercise the power of vulnerability. For women from countries such as Saudi Arabia, this entails a completely different level of personal risk and exposure. The fear of being misunderstood, judged, medicated, or reported to their family and consequently punished harshly, makes it nearly impossible for them to reach out for face-to-face psychotherapy.

As I grew up in Soviet and then post-Soviet Russia, I have firsthand experience of feeling trapped in a place where state-imposed values and rules did not align with my own. The exercise of one’s intellectual freedom turns into a road to salvation when other freedoms are unattainable.

For women in hardline Middle-Eastern countries, online therapy offers a safe space in which to exercise intellectual and spiritual freedom—they can explore their religious doubts, talk openly about their sexuality, voice their frustrations and anger, and eventually find meaning in their experience.

In an interview in The Guardian, Rahaf al-Qunun points out that in her country, no matter their age and life experience, women are treated like children. In a society governed and controlled by men, they are stripped of all power and infantilized.

These women continually strike me with their courage and resilience. One such brave woman was Laila (an amalgam of Middle Eastern women with whom I have worked in online therapy).

Laila’s Story

Laila was 36 and unmarried. She had a stable and reasonably well-paying job at a bank. When she received a promotion, she was allowed to move out of the family home to a nearby town in order to take the position. She was allowed to do this because her youngest brother lived in the same town and worked at the same bank. He was also unmarried and they lived in the same block of flats. He drove her to work every morning, as she was not allowed to drive herself.

Her brother was much younger but had more rights. Laila “needed” him for assistance with the most routine tasks—for example driving her to work or for travelling out of the country for a professional conference. This is how things work: women are made to need men.

Laila was different. At a deeper level, she did not believe or feel that she needed men. She did enjoy the company of some of her male colleagues and rare friends, but she did not desire them. Leila realized this about herself as a teenager, when back at school she felt compelled to kiss the beautiful face of her female best friend.

One of the duties Laila was not able to escape was mandatory attendance at family gatherings. She would sit there, her face uncovered, surrounded by women talking about their children and their little sons running around—already enjoying their privileged status in front of their sisters—and painfully feeling how little she belonged there.

All this fuss around men felt ludicrous to her. It was an ironic situation after all—she had to uncover her face with women to whom she felt attracted and was expected to be separated from men who represented no risk to her emotional balance.

Laila knew that she would never be able to live the life that she dreamt of. She loved her brothers, despite often feeling angry with them. She also loved her father, even if he would not listen to her or take her achievements seriously. She knew that, for her family, she was “damaged goods” and she would remain so, as she would never marry and give them children.

Laila eagerly waited to get old enough to stop receiving proposals from men that she did not know, who, as she grew older, wanted her as a second or third wife. In the meantime, she had occasional moments of joy with her few female friends and secretly experienced excitement and lightness in the body-less company of her virtual friends from the online community of women just like her.

Autocratic states use mental health stigma to control their citizens.Laila was very scared of being accused of being mentally ill. This is exactly what happened to Rahaf al-Qunun who, in the statement released by her family after her escape, was labelled “mentally unstable.”

An Online Refuge

As a therapist who works online with clients, my personal background helps me to understand and relate to what these women experience. Mental illness was stigmatized in the USSR, easily exploited by the authorities to punish and isolate any individual not complying with the strict rules of collective functioning. Therapy was almost nonexistent and was considered a medical treatment for alienated sick people. Online therapy was not an option as it is now, offering an opportunity to reach out to someone from a different culture, which can be useful when someone is trapped in an unfriendly world.

The effects of living in an autocratic country on individuals’ mental health are many. My female clients from hard-line Middle Eastern countries suffer from depression, anxiety, insomnia, dissociation, and difficulty trusting others.

Their individual boundaries are constantly transgressed and violated. The psychological effects of being raised in such an environment are like those experienced by a child growing up in a narcissistic family: the needs of the parents’ system (the society) take precedence over the needs of the child (the individual).

The only way to avoid being mistreated by a narcissist is to limit their power over you or to stay as far away as possible. Oppressed women like Rahaf al-Qunun have every right to rebel and protest as do children of narcissistic parents—they entirely depend on their caretakers and cannot freely leave their country or their family.

Individuals raised in cultures where they must abide by a very strict set of rules that do not take into account their needs, learn how to hide, to keep secrets, to lie. This is a natural way of adjusting to a system that does not accept parts of you; it becomes a question of survival. Such secrecy leads to an impression of living a double life. The cost of such fragmentation is often a lack of intimacy with parents and disconnection from those who are not aware of the “other” life that quietly happens inside or in the online space.

In a way, as their therapist, I must play a part in this secret parallel world, as my clients also hide from their families the fact that they are in treatment. Therapy, especially with a Western therapist, is seen as a transgression. My clients must come up with a plausible pretext for isolating themselves with their computer in a private room within the family home without being disturbed. I am often presented as a colleague, or an online English teacher. Here, the fact that their older family members do not speak fluent English comes in handy. The second language creates the much-needed safe and private space, in which they finally can explore their inner worlds, and the conflicts with the outer world in which they live.

Behind the Veil

I do not share a mother tongue with many of my clients so we must speak in English. Such use of the third, neutral language plays an important role in how the therapy evolves. It facilitates sharing thoughts and dreams that are defined as unacceptable in the clients’ original culture. Speaking English also provides us with an opportunity to play on even ground—as fluent as we are in our second tongue, we are still both foreigners, negotiating our accents, sometimes looking together for the right word. This experiment in equality has an additional reparative value, as being fully recognized as equal is not an easily obtained right in these women’s world.

As a Western woman with a limited knowledge and experience of Middle Eastern cultures, I let my clients guide me through their personal stories shaped by the culture, family, and place into which they were born. With them, I become an avid learner as we move towards a shared goal—a better understanding of who they are and who they want to be within the limits of their world. As we advance, pushing these limits becomes an existential necessity. For any transcultural therapist, this is a rather familiar role, but online therapy expands this in an extraordinary manner.

I have also had the opportunity to work with some Saudi women living outside of their country in Europe or elsewhere. Those with liberal, well-to-do and open-minded parents can study abroad. The sudden freedom comes with another set of psychological challenges—these young women must adapt to the transition and find a place in this new world, negotiating an acceptable balance between their original cultural values and the norms and expectations of the new place and culture.

During this stressful time, therapy offers them a space for dealing with conflicts and dilemmas that arise along the way—to wear or not to wear a headscarf; how to explain to their foreign peers the values and rules they choose to abide by; how to deal with anxious parents’ visits and a stressful life in an unfamiliar environment. Interestingly, they still retreat back to the familiar online space—which feels safer—to find friends or develop romantic relationships.

“Why does it matter that we, freer men and veil-less women, understand the struggle of women in these regions of the world” where many types of freedom are restricted? Will our understanding of their condition and our empathy change anything for them? My intuitive answer is ‘yes’; otherwise I could not do my work as a therapist. But how so?

Humans are social creatures, and the way we are looked at by others very often matters. We all have secret stories about how bad or how exposed we felt when people around us looked at us, judging our looks, words, or differences. In these circumstances, we feel shame. People with a handicap, sexuality difference or cultural/ethnic difference, all those who differ in some ways from the majority know far too well the emotional toll of such unwanted exposure.

How can a woman wearing the full veil feel when walking in the street in a tourist area of a big Western city? She is entirely covered in a black veil, her face hidden. On both sides of the veil we feel uncomfortable. The veil is a barrier, and, when we do not see the face behind it, we struggle to empathize with the individual. Behind the veil, there is sometimes deep discomfort and a feeling of shame. They may feel trapped, and our misunderstanding of their condition and our judging them for choices they do not have, may add to their suffering.

To connect with others and to be understood, without their body being seen, can be a challenge for these women. It is another reason why the online communities of Saudi women are thriving. Probably this is also what makes online therapy a hopeful space in which they can develop a connection with a Western therapist who represents this “other.”

As with any therapist, I am here for those who have psychological difficulties and struggle with some form of conflict. Surely, many women living in the strict Middle Eastern countries are happy enough with their circumstances, and not all of them would relate to my clients’ stories. But even if women I meet in my practice are a minority, it is important for them to be seen and acknowledged in their struggle, and to be offered a safe space like online therapy in which they can feel recognized and strive toward a better life.

Resources
1 Rahaf al-Qunun: “I hope My Story Encourages Other Women to be Brave and Free”

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

As a trauma therapist I am always interested in learning about my clients’ childhood attachment patterns. Growing up with parents who were either emotionally unavailable, inconsistently responsive, frightened by or frightening to their child has a profoundly negative impact on social, behavioral, emotional, and neurological development. “Trauma-informed care” includes assessing for adverse childhood experiences and reframing clients’ subsequent “symptoms” and struggles as the inevitable by-products and coping strategies of attachment trauma. However, I am concerned that a newer version of attachment trauma has invaded even the most “loving” families. Our reliance on, and, in some cases addiction to, digital gadgets and technology has hijacked the face-to-face parent-child interactions that are necessary for consistent, sustained and secure attachment.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Is this scenario familiar? After standing in line at the post office for fifteen minutes—a somewhat inherently traumatic experience in and of itself—I witnessed a two-year-old having a complete meltdown. Her mother’s immediate response was to hand her an iPad. In her wisdom, the child initially rejected it. In a soothing yet frustrated tone, the mother said “Use your iPad! Do you want to look at pictures? Play a game?” The child was not appeased and continued to wail. As the woman bent towards the stroller, I felt a sense of relief, assuming she was about to pick up her dysregulated child. Instead, she turned on the tablet and said with greater agitation, “look at the pictures on your screen!” After several more minutes of crying, the child realized that what she wanted and needed—to be comforted by her mother, not an inanimate object—was not going to happen. I watched as she went into collapse, emotionally shutting down and compliantly staring at the screen.

Believing her baby was now soothed allowed the embarrassed mother to comfort herself with a cellphone, tapping and swiping until it was her turn to buy stamps. In essence, they were two strangers in line together. I have seen similar scenarios countless times: in airports, malls, restaurants, and my waiting room. Preoccupied parents entranced as they stare at their iPhone, seemingly oblivious to their child’s needs. They are content to use digital gadgets as pacifiers and babysitters. They are not only modeling the excessive use of cellphones, tablets, video games, and laptops, they are actually encouraging their children to be just as hypnotized, and potentially, addicted.

At the risk of sounding old fashioned and judgmental, I believe this phenomenon is worrisome. Eye gaze, appropriate loving touch, and soothing words are the hallmark features of secure attachment. In families where there is abuse or neglect, these experiences get weaponized. Eye contact becomes a vehicle for threat or intimidation, or the neglecting parent avoids eye gaze, leaving the child feeling demeaned or invisible. Touch is either physically abusive, sexually inappropriate, or unavailable to the child. Words are bullying, shaming, hypercritical or lacking in love or support. This is why caretaker perpetration is such a betrayal and profound breach of trust.

But those three critical resources for attunement are also lost when a child is offered a screen rather than the loving and grounding experience of an available parent, which makes them feel safe, calm and connected to others. It may seem unfair to associate abuse or neglect with the disconnect that happens when a child is comforted, distracted, or cajoled by a digital appliance. But what is the long-term toll it takes on healthy attachment, affect regulation, and socialization skills? Mental health researchers and therapists alike need to assess for and explore that impact, as digital technology is not going away. Questions to consider:

  • Are kids with excessive exposure to digital gadgets less comfortable with face to face interactions and more likely to struggle socially?
  • Is it harder for them to read and accurately interpret nuanced facial expressions and body language?
  • Do these kids have a healthy ability to regulate their fluctuating or overwhelming emotional states?
  • Are these kids less likely to use relationships for soothing and comfort, and more likely to numb with endeavors that are hypnotic or dissociative?
  • Despite growing up in families that are well-meaning and financially secure, are these kids actually experiencing avoidant or insecure attachment?
  • And if they are, will they struggle with the same emotional fall-out and symptomatology as abused or neglected kids?

Since technology has made our lives much easier and resources more accessible, stakeholders may be reticent about tackling this issue head-on. I believe it is our ethical responsibility to address these dynamics with the families we treat. We must empower parents to set much stricter limits on screen time and to reconnect with the relational, face-to-face-benefits of parent-child time and family time. Many kids and teenagers need to be weaned from their overuse of digital gadgets—a kind of digital detoxification—so that they can reconnect with peers and re-access their own imaginations.

For traumatized clients, the reparative experience of secure attachment often happens within the therapeutic relationship. Therapists may need to be more mindful of addressing this issue with kids who have been overexposed to digital gadgets as a resource for comfort and soothing. They should keep technology out of the therapy room and model attunement, eye gaze and appropriate words and touch so that kids and parents alike can rediscover the power of relationship. Otherwise, the next generation risks losing the ability and the desire to be fully present with others and fully engaged in the world.