Category: Therapy & Technology

In Bed With Your Therapist: The Paradoxical Intimacy of Online Psychotherapy

Posted on by Psychotherapy.net Team

Online Therapy

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

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

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

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

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

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

Kyle and the Shame Spiral (Joseph Burgo)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Up Close and Personal

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

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

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

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

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

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

Birthplace

Posted on by Psychotherapy.net Team

There are places I’ll remember all my life.

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

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

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

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

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

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

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

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

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

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

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

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

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

This was a unique opportunity to accelerate the process.

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

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

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

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

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

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

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

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

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

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

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Psychotherapy in the Year 2045

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

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

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

Leave Your Degree at the Door, Dude

Posted on by Psychotherapy.net Team

The late 1960s and 1970s were exciting times for the fields of psychology and psychotherapy. Much of the enthusiasm was spawned by a body of landmark research. At the time experts postulated that humans had two distinct nervous systems: the voluntary and the involuntary. The voluntary nervous system allows you to brew your morning cup of Joe or take out the trash before you leave for work. The involuntary or autonomic nervous system controls your heart rate, blood pressure and the temperature of your baby toe. According to the existing theory, a human being could not control his or her involuntary or so-called autonomic processes. But all that was about to change.

Enter Neal E. Miller, a prominent psychologist and a past President of the American Psychological Association. By paralyzing animals, and hence knocking out voluntary responses, with curare (often dubbed South American dart poison) Miller demonstrated that involuntary or autonomic/automatic responses could indeed be controlled. And although later research would sometimes fail to replicate Dr. Miller's results, the implications for the human potential movement were staggering. If indeed Miller was correct, humans could do things to control their behavior that were heretofore considered impossible!

During this same era, the Menninger Foundation, a longstanding psychoanalytic foothold, located in Topeka, Kansas was doing some experiments that seemed to back up Miller's assertions. Subjects were asked to hold glass mercury thermometers and told to raise their hand temperatures. Not only did many subjects accomplish this, but as an added benefit, these same individuals often experienced relief from migraine headaches. When Miller was informed of this fact, folklore has it that he smiled and merely quipped: "I believe that in this respect men are as smart as rats."

Slowly but surely, thermometers and the like were replaced with sensitive electronic devices called biofeedback meters that gave subjects and clients the superior feedback necessary to make bodily changes at will.
With Menninger at least partially leading the charge, biofeedback seemed to be the coming thing in our field and I wanted to be on the cutting edge of the breakthrough. Luckily Menninger was offering brief biofeedback training sessions and as a graduate student I immediately applied.

I mean how fun would that be? I would get in my favorite car of all time and drive from St. Louis to Topeka—310 miles—to receive the best training of my life. The make and model of my favorite auto of all time are irrelevant to this discussion . . . okay, okay you twisted my arm . . . it was a 1965 Oldsmobile 442 and yes it was fast enough to get even the most conservative driver in a heap of trouble.
But as John Lennon once quipped, life is what happens when you are making other plans. Certainly, it proved true in my situation. I blew the clutch out on my 442 dream machine and thus an intercity bus transported me to the Mecca of biofeedback training.

The training was blow-away awesome and reached a zenith when at the end of the day's workshop we were given the exact temperature feedback monitor units Menninger was using to train clients to take home and experiment with. These biofeedback devices were manufactured in Lawrence, Kansas. Yes indeed, these gems were made in America and resembled a lunch box Larry Mondelo might have been toting in a classic Leave it to Beaver episode. In reality, the unit was a ultra sophisticated thermometer with 3 3/4 inch meter on the front. It would take a baseline, track the client's progress (or lack of it), and even had onboard calibration capabilities. We had the option of purchasing the units if we liked them and I did just that.

As for me, you won't find mine for sale on Ebay. After my brief training at Menninger I used this little gem to help hundreds and hundreds of clients with anxiety, habit control issues, and migraine headaches. It also came in handy for performing hypnosis and systematic desensitization; but that's a tale for another blog.

But here's where the story gets very interesting. On the night I took my unit home I had fairly good success raising the temperature of my hand. This practice was theoretically helpful in combating anxiety and once again helping those with migraine headaches.

As I was walking from my hotel to Menninger the next morning I spied a psychiatrist who was in my training class.

"Hey how's it going?" I asked.

"Not well. This biofeedback stuff is junk," he told me.

"What do you mean?"

"Well," the psychiatrist asked," were you able to make the temperature on your meter go up."

"I was," I proudly announced, "but I take it you could not."

"Right. My meter did nothing," lamented the psychiatrist.

"Look," I said trying to be nice. "It could be the biofeedback meter they gave you is defective."

"Ha. I don't think so," he responded. "I let my five year old son play with it and he was pegging the meter on super hot so easily I had to reset it several times for a higher temperature."

"Okay," I calmly responded. "I think I have an answer for you. You know too much. I mean look. Your five year old doesn't know squat about the nervous system. You tell your five year old that his hand is getting hot or to imagine that he is outside on a warm sunny day and presto . . . his hand temperature genuinely goes up. You, on the other hand are a medical doctor. Therefore, you know all these facts about the central nervous system versus the autonomic nervous system. You know the traditional theory forward and backward. You can tell me with great detail why a person should not be capable of raising his or her hand temperature. Too much traditional knowledge can be a dangerous thing."

"Al-right Rosenthal, maybe, just maybe, you are correct. So what in the heck should I do about it?"
"That's easy," I replied, "Just leave your degree at the door dude!"

"Hmm. Well what about you Rosenthal. Are you going to leave your degree at the door?"

"Not me." I said. My degrees are nonmedical and not focused on physiology. I might just know less about the nervous system than your five-year-old son. So, to put it bluntly, I'm good to go."

Dial-Up Connection

Posted on by Psychotherapy.net Team

Thirty-five years ago I got my first paid therapist job as a second-string telephone counselor for an enlightened radio station in Sydney, Australia. The radio station ran a daily one-hour program called “Kid’s Careline,” and my boss was the first string counselor who fielded on air calls from the radio audience. She was so brilliant at it that she kept three of us second stringers busy 9 to 5 fielding the calls that did not make it onto the air.

It was in this job that I began to learn about the unique power of telephone counseling. Stints of supervising and fielding crisis phone calls at Suicide Prevention and Parental Stress Services in Oakland enriched my learning. These experiences eventually culminated with me adding telephone counseling to my private practice, which I have done for the last 20 years.

I have an Intersubjective/Relational approach and specialize in working with individuals whose traumatic childhoods have burdened them with Complex PTSD. I am excited by my accumulating anecdotal evidence that significant attachment repair work can be done over the telephone. I have especially noticed this with clients whose trauma is so extensive that they are incapable of handling the anxiety of face-to-face work. Some of my clients have lived reclusive lives but sought me out because my website articles explain how their childhood traumas created their attachment disorders.

Complex PTSD survivors typically operate from a deep belief that “people are dangerous,” and feel less endangered on the phone because they know that they can escape in a second if necessary. Moreover, the phone seems to offer them enough protection, that they are able to drop into authentic and vulnerable relating quite quickly with me—often more quickly than new clients in face-to-face sessions. Once again, I believe this is because phone work offers them a greater sense of safety.

Telephone therapy can foster a uniquely rapid building of trust. In best case scenarios, as with in-person work, this eventually encourages some clients to look elsewhere for similarly trustworthy relationships. More than a few of my telephone clients have experienced enough relational repair within two years of weekly sessions to venture out successfully into the world of real live relating. Often this starts with participating in online support groups, and then expands into joining in-person groups.

I believe that part of the healing dynamic in phone work is that voice contact can be as soothing and brain-changing as the eye contact that seems so fundamental to forming attachments. I wonder, in fact, if voice contact is even more fundamental than eye contact, as the soothing sound of a mother’s voice may be laying down the framework for bonding long before the baby is born. Moreover, as most seasoned therapists know, voice tone, timbre and pitch carry a great deal of emotional communication. The client’s voice can tell us a great deal about her unexpressed distress. And our voice can carry our good will, compassion and, dare I say it, love to the client.

As I write this I flash back guiltily to my adolescence and my dog, Ginger. I once unconsciously experimented with teasing her with the tone of my voice. I soothingly and sweetly told her “You are a very, very bad dog Ginger!” and her dog smile lit up her face as her wagging tale oscillated furiously. Then I switched to an angry tone: “Good dog, Ginger, Good dog!” As I vituperated she fawned nervously and her tail disappeared between her legs. Now I flash on my mother lambasting me throughout my childhood: “Of course I love you!” and 60 years later, I feel my whole body contract and imagine my ears lowering like Ginger’s.

And now let me free associate further. I think of three different friends whose parents read to them as kids, and who still love to be read to. My parents, on the other hand, frequently spoke in tones of anger and disgust, and despite a great deal of attachment recovery, I still find little pleasure in being read to. My nine-year-old son, however, drinks it up like soda. When I come home and sit on the couch he often leans into me and croons: “Read to me, Daddy!,” and lucky man that I am, I still get to read to him for hours every week. We’re on our ninth Gordon Korman book this year. (Gordon Korman is a brilliant children’s author whose books are wise, funny and replete with emotional and relational intelligence.)

Coming back to the issue of therapy, I feel I now understand why traditional psychoanalysis works so well for some clients, despite the analyst sitting out of view behind the couch, and despite the criticism some attachment therapists express about it lacking the intimacy of eye contact.

Technology and Psychotherapy

Posted on by Psychotherapy.net Team

A recent article on a study from the University of Zurich offered the headline, "Psychotherapy Via Internet as Good as If Not Better Than Face-To-Face Consultations." It does not surprise me when I think about many of my clients’ everyday lives in the Bay Area: technology tends to be seen for the most part as a fun, useful and normal part of life. It also makes sense when I think about the ways that technology, if wielded strategically, can sometimes make things simpler and more immediate. Grandkids and grandparents all over the world would agree (thanks Skype!), as would families with service members deployed in far-off countries.

Here's a quote from the article in Science Daily about the online psychotherapy study, "In the case of online therapy, the patients tended to use the therapy contacts and subsequent homework very intensively to progress personally. For instance, they indicated that they had re-read the correspondence with their therapist from time to time. ‘In the medium term, online psychotherapy even yields better results. Our study is evidence that psychotherapeutic services on the internet are an effective supplement to therapeutic care,’ concludes Maercker [one of the study’s authors].”

Skype therapy could improve outcomes while it lowered the barrier to accessing therapy. In one way of thinking about it, what was once a trip across town and a 2-hour commitment is now 50 minutes at one’s desk.

But I notice a conservatism and even a bit of prejudice against technology use among therapists: Skype, texting, online scheduling, and other things can be treated as if they are volatile substances when in fact they are more and more a part of everyday life, used by lots of people to great effect. Therapists can benefit from remembering the wisdom that often what seems unstable and jarring to an older generation is soon enough just “the telephone”—utterly banal and safe.

A few years ago a former Supervisor warned me against texting with clients about appointments and scheduling shifts. When I questioned him further, however, he admitted that email was ok for this, and that he emailed with clients about appointment times, though not clinical material. Most therapists under forty who I ask about texting with clients say it is the same thing—just a quicker form of email. I have even heard a client assert, “It’s rude to call someone on the phone now. You interrupt their day and make them say ‘how are you?’ Texting is more polite, faster, and doesn’t require needless formalities.”

I think that the obvious insight here, that technology changes and what seems outlandish today will soon be normal, can go one step further. What if therapists could harness the excitement and convenience of technology to improve our usefulness to clients and to improve our ability to help clients change their lives?

I've been thinking a lot about therapists and technology lately, as I have been part of a group testing out a new mood-tracking app called Senti. With Senti, users answer a few relevant questions about mood and emotion throughout the day and Senti keeps track of how they seem to be doing. The questions both track useful information (“Thursday tend to be a rough day for me”) and also function as a mini-intervention, just as if someone had texted you to say, "hey, put your feet on the floor, take a deep breath, and tell me how you're really feeling right now."

But when I described the app to another therapist she was skeptical. "It sounds great," she said, “but therapists are late adopters. You'll never get them to use it with clients." Similarly, The New York Times recently ran an article by therapist Lori Gottlieb with the headline, "What Brand is Your Therapist?" In it, she ponders whether therapy as we know it is a think of the past. "I hate to think that therapy is an outdated idea, too slow and too private to satisfy a population that has come to expect immediate responses and constant gratification."

I see people each day needing help coping with divorce, eating disorders, anxiety, depression, and other problems that cannot be repressed and forgotten and that need attention. There is a great need for inner work and for the relief of human suffering. Rather than thinking technology is a barrier to connection, we can ask what Darren Kuropatwa asks in his presentations about technology and learning: “What can I do now that I could not do before?”

What if instead of a necessary evil, technology could facilitate a different kind of depth—the depth of a therapy that can be held by a client in their hand; where self-support, self-inquiry, and a therapist at the other end of the wi-fi connection make transformative work more possible? After all, there is nothing about Skype or about an email exchange that is inherently glib or false. What matters is the content and the material and the depth to which the client can face themselves, with the powerful support of another person trained to be of use. Whether the therapist is on Facetime or tweeting reminders to followers to pause and breathe when angry feelings erupt, what matters is that people get better and the world gets better. And for that project we need every tool we can get.

Psychoanalysis is Alive and Well

Posted on by Psychotherapy.net Team

Although we have evolved many schools since Freud articulated psychoanalytic theory at the turn of the 20th century, in almost all of them conspicuous analytic features remain. These are so familiar that for the most part they exercise their dominance without our being aware of them or their origins. We may think psychoanalysis has been discredited and that almost no one practices it any longer, but there are ways psychoanalytic theory is present in our listening and thinking because of the vocabulary we employ and have come to take for granted.

An example, from an older use of language. Freud’s German word for cathexis (a word that goes in and out of fashion) is besetzen, which literally means the occupation of an area by a military force. The metaphoric atmosphere is of course lost in our translation, but not perhaps in our understanding of the supposedly aggressive way we take hold of an object and occupy it with our attachment. Even when we use a different vocabulary, when we say someone is “over-attached” to something, or “fixated” on it, we import the negative psychoanalytic attitude. Of course, a cathexis might also be viewed as a passionate interest in something; then we would not have to burden it with a military metaphor.

Or the word resistance: A number of implications reside in this word, most often hidden. Clients use the word, therapists who have never been trained analytically also use it and succumb to its seductions. It is tempting to believe that we, the therapist, know the right thing for the client to be talking about, and if she isn’t talking about it, she’s resisting it; that is, she is avoiding a thought or feeling we think she ought to be discussing. Our meeting together has been turned into a battle: between the client and the content supposedly being resisted. I try not to use the word, although my clients do. I tend, instead, to talk about self-protection. If someone seems to be venturing forth, then cutting herself off, then taking off on an apparent tangent, she might say: “I just can’t figure out what I’m trying to say. Am I resisting it?” I assure her that the timing of this discussion is entirely up to her. The choice is hers, to go forward now or to save it for another time. People tend to take this permission much to heart. I have noticed how often they touch back on a subject they didn’t feel ready to discuss, perhaps to mark it, to hold it as potential, to keep track of it. Eventually, when they feel safe enough the self-protection no longer seems necessary and the content emerges. Best of all, the timing of this important moment has been left to them. I see no reason to call this process of hesitation and caution, of delay and postponement, a resistance.

And then there’s the concept of repression, another word that has entered our common language. A wary, watchful, guarded, unexpressive, anxious and withdrawn person is said, even by people who do not know the technical meaning of the word, to be repressed. But known or not, the word carries implications. It is also used in our political discourse, where it evokes the circumstance in which a group of more powerful people is repressing another. We know this circumstance; it costs lives, evokes rebellion, is most often an affair drenched in blood. Our clients also have these associations to the word. Is it useful to bring this imagery into our understanding of an individual who has come to talk with us?

People coming into therapy for the first time seem to know the rules, the lingo, the appropriate behavior and much of this is, I think, a carry-over from psychoanalysis. They often expect a fifty-minute hour, as if this length for a therapeutic session had been written as law. I’ve had people say to me “Are you sure you’re doing this right?” because I invite them to go on past what they assume is the set time. “I know I’m not supposed to ask you questions,” is another popular assumption. “Or well, I guess I can ask but I know you’re not supposed to tell me the answer.” Who says? It is important for my clients to know the worldview I hold because, obviously, it is going to influence the type of listening I do. Having left psychoanalysis behind we are no longer constrained to be detached listeners. But do we sufficiently tell our clients who we are in our listening? I mean, really take pains to inform them? To explain the school we adhere to? And what its assumptions are? And if not, is that not still the shadow of psychoanalysis falling upon our work?

Why Its Time to Take Mobile Seriously

Posted on by Psychotherapy.net Team

I was looking over my Google Analytics stats last month, and was shocked to see that 19% of my clicks in Google AdWords for psychotherapy searches were done on smartphones. People of all ages are now looking for a therapist on their phones, with almost all of the searches being done on iPhone and Android devices. And while Google owns about 2/3 of the search results on desktops and laptops, they command an astonishing 97% of all searches on mobile devices.

What's driving this trend, and what does it mean for marketing your psychotherapy practice?

Three things are driving the trend toward increased searching on smartphones:

1) Larger Screens—the recently-released iPhone 5 stretched to 4.87 inches high, while the most recent Android phones (especially those from Samsung, such as the Galaxy S3 and Note) are well over 5 inches high and almost half an inch wider than the latest iPhone. Larger screens mean more information can be displayed, so the phone becomes a viable alternative to the laptop or desktop computer.

2) Faster Input Options—with faster processors and better software, both Apple and Google have made significant gains in the speed and accuracy of inputting text into the search box. Both offer very accurate voice input, and in Google's latest operating system, Jelly Bean, they offer a rapid "swiping" option that allows users to keep their fingers on the screen while rapidly moving around the virtual keyboard. The virtual keyboard is less of a limitation than ever before in using your smartphone for search.

3) Faster, More Accurate Search Results—Apple offers Siri, who despite her limitations, can respond to many natural language inquiries with accurate search results. Google’s search software is even better, offering remarkably fast and accurate information in response to voice or keyboard input.

There are six important implications of these trends for marketing your practice online:

1. You now need to make sure your website displays properly on a wide range of devices, from smartphones to 7-inch tablets to full-size 10 inch tablets. The good news is that almost all websites look fine on full-size tablets, and most look okay on the 7-inch tablets. But most of the action is in smartphones, and that's where your website might not display properly. 

There are several ways to address this issue. The best way is to hire a programmer who will program your site to dynamically reconfigure based on the size of the screen. This way you don’t have to have two separate sites that need to be optimized for search.

Another option is to use a service such as dudamobile, which will walk you through a step-by-step process to create a mobile version of your existing site. They have a free version, but to get unlimited pages and your own URL, you need to pay $9/month. Google offers a free mobile site creator (with an awful user interface), but it does not integrate with your main website; for details click here.

2. When you send out email responses to potential client inquiries, you need to be sensitive to how they will format on a smartphone screen, since over half of all emails are now first read on a smartphone. It’s a good idea to have a short subject line. The last words of a long subject line may not be visible in the mobile phone's display. Also, consider sending plain text emails instead of HTML. The line width in text is almost always adapted to the display width.

3. Search Engine Optimization (SEO) is different for mobile searching. According to Google, a typical mobile search is only 15 characters long. Google will compensate for this short entry to using “predictive search”—when you type in only 1 or 2 characters, Google will offer suggestions based on the most frequent searches which start with those characters.

For example, someone may search for "individual counseling in San Francisco" on their desktop or laptop, but on their smartphone it might be "counseling SF." What are the most common “predictive search phrases” that are related to your practice and location? Test this out by searching for your practice on a smartphone, and see which predictive phrases Google offers as suggestions, since these are the ones people are likely to click on first. Be sure those phrases are on your site and in your meta tags.

One huge bonus to Mobile SEO on smartphones is that your phone number can be clicked on, which places a direct call to your office. This is a tremendous advantage over someone visiting your website, since on average it will usually take over sixty visits to your site to trigger one phone call.

4. Google Places Profiles—be sure you have a free Google Places profile, because they often show up near the top of a mobile search results page. You can create or edit a profile at www.google.com/placesforbusiness

5. Yelp Profile—as part of Apple's competition with Google, the Siri program will initially search for services on Yelp, not Google. Many iPhone users choose Siri over Google search. To take advantage of this, get a free Yelp business profile at biz.yelp.com

6. Consider a Mobile-only Google AdWords Pay Per Click Campaign—this may be the highest return on investment of any advertising available to private practitioners today, because of the high number of direct calls to your office it will generate for very little cost. If you do this, make the “Call” button very large and prominent on the first page of your mobile Landing Page, to be seen without scrolling.

The move to mobile is accelerating every month, so the practitioner who takes advantage of these trends will have a great advantage over those who wait. The time to act is now.

The Truth About Facebook and Your Practice

Posted on by Psychotherapy.net Team

Many marketing professionals point to the 900 million worldwide users on Facebook and say you must have a strong presence there to have a successful practice. They discuss the myriad ways you can use Facebook: your profile; a business page; advertising and frequent posts. They tell you how to get more “Likes” and “Fans” and the referrals will come. As a psychologist who has experimented with everything Facebook has to offer a private practitioner, I totally disagree with this common advice. You can waste a great deal of time and money on Facebook and have very little to show for it if you go into it naively. In this post I’ll discuss why this is so, and review one area I have found that does work well to generate referrals from Facebook.

Yes, Facebook has millions of users, and it also has the longest time per visit of any website (about 20 minutes). But monetizing those eyeballs is not easy, since few people go on Facebook with a primary purpose of seeking information. People go to search engines to find information, and go to Facebook to socialize, play games, look at pictures and videos their friends have posted, and comment on those posts. This means the only way you can successfully promote your practice on Facebook is to return to the 20th century model of “interruption Marketing,” where you do what the major TV networks, newspapers and magazines of that era did: you interrupt people's attention from what they are focusing on to check out your product or service. But we're in the 21st century, where the prevailing advertising model is “permission marketing” (see Seth Godin's brilliant 1999 book by the same name). As consumers we now get to choose what we want to see and hear. We give people, businesses and networks permission to tell us about their wares—and get annoyed or angry when this permission is violated. And on a rapidly-updating newsfeed such as Facebook, a post about your practice will usually elicit far less interest and attention than the photos from a friend’s vacation or the video of a sibling’s new puppy.

While every practitioner should have a free business page on Facebook (see https://www.facebook.com/pages/create.php), gathering “fans” for your page or getting people to “like” your posts is almost always a complete waste of time. Becoming a “fan” of a psychotherapist page or liking one of their posts is a quick, superficial action that implies a very low level of engagement with your work (aside: what does imply more engagement is when someone gives you their email address; building an email list is a very wise practice-building activity).

The one unique advantage that Facebook has over the search engines involves pay-per-click advertising. Unlike Google, who is forced by their business model to let everyone play the search game, Facebook has an exact way to segment who sees your ads. Thanks to the remarkable amount of personal data Facebook users put on their profiles, Facebook can offer the most highly targeted advertising in the history of business. Pick your target market very precisely—by age, gender, education level, city of residence, marital status, age of children or personal interests—and Facebook has a way for you to get your message out only to that specific niche of people. Specialize in working with children between the ages of 12-15? Want more referrals from women between the ages of 35-55 with a college degree who live only in two very affluent zip codes? Have a new workshop for Baby Boomer retirees? No problem; no one else but those people will ever see your ad. Combine that with an emotionally engaging photo and a problem-oriented headline (i.e. "Panic Attacks?" or "Still Arguing?" or "Defiant Teenager?") and you have a great chance of interrupting focus from the social activities to your service.

One important note: when people click on your ad, Facebook gives you the option of having the person visit your Facebook business page or leave Facebook and go to a specific page on your website. Get them off of Facebook to your website! There are far too many distractions on Facebook that greatly reduce the chances of someone focusing on your services for more than a few moments.

In summary, approach Facebook with caution and experiment with pay-per-click ads—but only if you have a very specific, targeted niche. For all others, create a business page, update it when necessary, and enjoy the social aspects of Facebook. Just don’t expect it to fill up your practice.