Online Therapy: An Unexpected Space of Freedom

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

Bare: Psychotherapy Stripped

Editor's Note: The following is an excerpt taken from Bare: Psychotherapy Stripped, by Jacqueline Simon Gunn, published by University Professors Press © 2014 and reprinted by permission of the publisher.

I think Dostoevsky was right, that every human being must have a point at which he stands against the culture, where he says, this is me and the damned world can go to hell.
—Rollo May

Please Don’t Let It Be Her

“Jacquie? Is that you?”

Oh no, please don’t let it be her. The voice came from behind me.

But of course it was, the slightly nasal, overly enunciated voice always unmistakable. My body tightened. Of all the people to run into — in Bloomingdale’s, no less — while looking the way I did: sweaty, smelly, and disheveled. Served me right for doing my training run, then squeezing in an errand before showering, while convincing myself I could manage to escape notice of someone I knew. The Big Apple may be big, but it is not that big.

“Jacquie? Jacquie.”

Her voice doesn’t sound close. Maybe if I move fast enough, I can get lost amongst the shoppers. But then I heard the distinct sound of hurried heels clacking on the tiled floor, and
before I could slip into the crowd, a hand touched my shoulder.

“Jacqueline!”

I bolstered my spirits, and turned to face the inevitable. Maybe it’s time I bring this relationship to a close.

Tess was my newest patient. I had just earned my psychologist’s license a few months prior to our first meeting, and subsequently accepted a full-time staff position at the Karen Horney Clinic. I had already been employed at the clinic for two and a half years, first as an intern and then as a post-doc fellow, so when they offered me the position — nearly nine years ago now — the decision to accept it wasn’t difficult. I could continue with my current patients while I received some additional supervision, all providing me with the ability to slowly transition into private practice.

A colleague who had been working with Tess for nearly two years referred her to me. Another client would pack my schedule, as I was carrying a nineteen-patient caseload at the time, so I initially felt hesitant to take on a new client. After extensive consideration, I agreed. “I wholeheartedly believed I was ready to push myself professionally.”

How could I have known what would happen or the effect she would have on me?

My colleague had to prematurely terminate her work with Tess because she and her husband were moving out of state. At my request, she gave me only a small amount of background information; I am not a fan of learning about a new patient second-hand. I have found it more beneficial to be exposed to patients’ narrative directly from them. The referring therapist did tell me that Tess was 61 years old, suffered from chronic depression, and having an inordinately hard time with the aging process.

She added, “You’ll be a good match.” When I wondered why, she responded, “Tess needs a tolerant, warm and empathetic therapist. I think you’ll work well together.”

I was not finding that to be the case.

Appearances

When Tess came in for our initial meeting, I immediately noticed her striking appearance. She was quite attractive, small framed and perfectly made up. What I found most significant was her choice of attire; dressed impeccably, she reminded me of someone clothed for a night at the theater. Though curious about the façade she put on display for the world, it was much too soon for such a personal inquiry, so I held my thoughts and associations in abeyance to be brought up later in therapy.

Within just the first moments of session, however, I managed to ostensibly muck things up. I called her Contessa. Tess does not like to be called Contessa, which I soon discovered. And her displeasure spoke to that fact through her terse reaction. “It’s Tess.”

Though my colleague had referred to her as Tess, I noted in her file that her given name was Contessa. Nicknames can be a highly personal experience, and I did not want to presume familiarity too soon. So I called her Contessa. But I knew better. I should have asked her outright what she preferred to be called. Just like a nickname can be personal, so too can a given name be a source of anxiety, as well as a seedbed of myriad emotional triggers.

“Tess, I’m sorry. I didn’t realize you dislike Contessa.”

“I hate Contessa. It’s a family name. And it reminds me of someone who’s ancient and stodgy.”

And just like that, with tightened lips appearing like she’d just sucked on a sour candy; she folded her arms in a resolute stand against distasteful nomenclature.

“Really? I think Contessa is a beautiful and rare name. It evokes such elegance.”

“Nonsense.” She dismissed my opinion with a wave of her hand and flutter of eyelashes. “Now, Tess. That’s fun and youthful. Tess is a model’s name.” Her eyes twinkled when she said that, encouraging me to make the leap, to associate her with models. And honestly, though I am normally savvy enough to avoid that slippery slope, she did carry herself like one. And that is exactly where my thoughts landed. I bet she could’ve been a model in her day. I wonder if she was.

As the session moved along, Tess began describing her long history of depressive episodes, her numerous hospitalizations, and her propensity to isolate from others. I had so many questions for Tess, but I wanted to allow her the liberty to express herself without interruption during this first session. Some clinicians prefer to perform an extensive intake evaluation during the first few sessions, in order to collect adequate background information. I find this sort of structured interview interferes with the patient’s process of describing personal information, so I allowed Tess to tell me her story while I listened attentively with compassion and empathy.

I learned in the first session that Tess lost both of her parents at a young age; she lost her mother first when Tess was 17, and then her father when she was 24. I felt a twinge of pain as she revealed this; it was only the first session and I already could feel the heaviness, the burden she was carrying, and I felt sad as I listened. She was also married for ten years, from 36 years old until 46 — when her husband, who was having an affair during the last year of their marriage, left her for another woman.

Now 15 years later, she still had not recovered from this. I began to notice through her narrative that she blamed herself for the numerous hardships she endured in her relationships — and this was only the beginning. “Throughout our treatment together, I would hear many heart-wrenching stories from her past”, as well as experience and bear witness to her suffering resulting from some serious and frightening occurrences that happened during our course of therapy.

As I listened, I also wondered about her feelings surrounding the termination with her previous therapist. I found it significant that she didn’t bring this up. In my experience, premature termination most often brings up mixed emotions for our patients: abandonment, anger, betrayal, loss. Why wasn’t Tess bringing this into the room? We were near the close of our session when I realized this — too late to bring it up now — so I made a mental note to inquire about this at our next session.

With only five minutes left, Tess began to inquire about me. How old was I? Was I married? (She did not see a ring and assumed that I was not.) Did I want children? When questions such as these come up at the end of a session, it is always difficult to negotiate how to respond.

Early in My Training

Early in my training, I almost never answered patients’ personal inquiries. I was trained from a classical psychoanalytic perspective. Residing under this particular model of psychotherapy, personal disclosures are looked down upon and are thought to have a negative impact on the evolving of transference — the response of the patient to the therapist, both conscious and unconscious. This level of neutrality never felt quite right to me; it truly felt inauthentic, but I was still in training and didn’t have the confidence yet to feel comfortable following my intuition. My own way of working, which at times involves personal disclosures, evolved slowly over the years.

Though it was not official at the time, I considered Tess my first private practice client, so I wanted to display a sense of confidence and maturity that I believed I should possess. It was more for me than anyone else, really. I had counseled countless patients prior to Tess, so I was confident about my abilities; however, since I was not yet seasoned, I floundered when she riddled me with personal questions. Tess challenged almost every aspect of the delicate balance that I eventually learned was a key factor in using self-disclosure as a therapeutic technique. In psychotherapy, as in life, experience is often the best teacher. Well, Tess, she was akin to a full-time professor.

I felt anxious; I did not know Tess well enough yet to have a real understanding of what these questions, and my choice of whether or not to respond, meant to her. I acknowledged her inquisitiveness and replied with what I hoped embodied an empathetic tone, “We can talk about these questions at our next session.” What an unoriginal answer. I quickly berated myself, but I really needed to understand her better before I could make a decision about how to handle these quite personal inquiries. By the time she left the session, I was exhausted. I also felt the urge to cry. I really needed to think about what was going on for me; these feelings obviously communicated something quite essential about our dyad.

I would find out soon enough.

A few nights later I had the most unnerving dream. I arrived at an important psychoanalytic conference, preparing to present on self-disclosure in the treatment setting. I walked in, my flowing mint-green dress billowing with each step. My most favorite frock. I felt confident. All eyes were on me. The dress had done its job.

And then my gaze swept across the room. The crowd milled about clad in black (mostly suits), their formal outfits a stark contrast to my lustrous gown! Sudden discomfort settled in. My skin burned from embarrassment.

I woke up drenched in sweat. Even in the dream, I remember thinking, “What a curious dream.” And despite its obvious disconnect from reality, I couldn’t shake the residual uneasy feeling. Quelling all the thoughts spinning around in my mind — I know this dream, there is something so familiar about it — I attempted to set aside my strong desire to self-analyze, and instead prepared to leave for my office with a lucid mind.

Flowing Mint Green Dress

While still trying to distract myself from ruminating about the meaning of my dream, I ruffled through my closet deciding what to wear. And there it hung: my flowing mint green dress. I shuffled past it, searching for the right outfit for Tess — For Tess? Why for Tess? — but my eyes repeatedly returned to the green dress. What an odd juxtaposition. I usually wear my most professional clothes when seeing a new patient (partly to set them at ease, partly to establish professional boundaries), yet here I stand, still trying to divert my attention away from the green dress that hung in my closet before me, hindering my ability to avoid the dream and to find some “appropriate” clothes to wear. My experience that morning, after only one meeting with Tess, already began to mirror the difficult relational dynamic that would infiltrate our journey together.

Tess came to our second session flawlessly dressed and made up. Again, images of my flowing mint-green dress distracted me. However, this time I associated thoughts of the dress to the feeling I had when observing Tess’s attire; she looked lovely, but over-dressed for a therapy session. This time I observed her posture and cadence as she walked in. It was incongruent with her impeccable makeup and high fashion. She walked with her head down and back slouched, a remarkable difference from her model-like stature of the previous session. I associated her demeanor with someone who was just beaten up.

She slumped into the chair.

“I’m boring, right? I have nothing in my life except my dog.” She frowned and averted her eyes.

“Boring?” On the contrary, you’re absolutely fascinating. “It actually seems that you have quite a bit to talk about. Where is this feeling coming from?” It was then that she began to tell me about what I eventually dubbed “Her Fall from Glory.”

Tess had been a well-recognized author and editor; she and her former husband actually met while she was working as an editor of a reputable magazine. She also published a book about her personal experience battling and overcoming breast cancer when she was 49 years old. Before her breast cancer, which eventually led to her losing her breast (she made sure to add that she had an implant), she had many friends, an exciting social life and a loving partner who stood by her through her year-and-a-half ordeal.

““I was beautiful, so beautiful; I had many men. Many.” Her pain permeated every word.” “Now men don’t even look at me when I walk down the street.” She sighed, heavy and long. “See? I have nothing.”

Now this is a telling statement!

“Nothing.” She repeated, overly enunciating it, drawing out, then punctuating, each syllable — each sound — with the kind of attention to detail one might find in a pillow embroidery.

My mind raced with all the different paths of inquiry she left open for me to explore, but the amount of information she generously offered so overwhelmed me that the session ended before I realized it, leaving me no opportunity to explore any of her story or encourage her to elaborate. I did want to give her something to leave with. This is vital to the therapeutic process — giving the patient a part of you by acknowledging what they have shared and offering some empathetic insight.

“You’re a fascinating woman, Tess, and I have so many questions for you.” I noticed her curious expression. “You’ve been through so many hardships.”

“Interesting? Really?” Her remark took a sad turn. “But I have nothing now, Jacqueline. You’re young. Don’t wind up like me.” Is that a little envy in her tone? Or was it hostility? And she just glossed over my comment about her hardships? She gathered her belongings, moving with slow sadness, and left looking even more broken-down than she did when she came in. Again, I felt like crying. And again, I forgot to ask about her experience terminating with the previous therapist.

Tess began therapy with me on a twice-weekly basis. I typically prefer to understand a patient’s internal dynamics and interpersonal style before increasing the frequency beyond once per week. What one might think would be helpful for a patient — added stability, consistency and containment — may be too much for them in the early stages of the treatment. But since Tess was seeing her previous therapist twice a week during their second year of treatment, we collaboratively decided to keep this therapeutic frame. As I thought about Tess after our second meeting, I sensed that twice-weekly sessions were ideal for her, but I did wonder if it might become a bit overwhelming for me.

The content of her narrative — losing her parents at a young age, cancer, divorce — as well as the feelings being evoked while sitting with her, already felt overpowering. “During the first month of treatment with Tess, she spoke endlessly about her “Fall from Glory.”” I sensed that she felt shame about where she was in her life now; in order to sit with me and expose her current situation; she desperately needed and wanted me to know who she was prior to her “fall.” I would later understand that this “fall” happened as a result of losing her breast, coupled with her almost complete emphasis on her outward appearance as defining her. For Tess, I came to understand relatively early in our treatment, outward appearance was all she believed she had to offer; it was who she was. This was at the core of all her issues and eventually established a quite frustrating dynamic between us.

Having conceptualized her dynamics early on, I decided that my therapeutic position should be to listen attentively to who she was prior to her breast cancer. I believed it would help her feel less shame when, in later sessions, I would be encouraging her to focus on where her life was in the present. Through this active listening, I gathered a lot of background information; although I did notice that when I tried to explore her early childhood experiences, particularly her relationships with her parents, Tess met me with harsh resistance. Okay, so I guess this is important. Though I made a mental note, I didn’t push her; this was obviously an area of great devastation for Tess. We would get to this material at some point, but definitely not yet. She had other, more pertinent, news to share with me.

“Everyone cheats.” This came out of her mouth with the nonchalance of someone placing a dinner order. She wasn’t making an observation solely about the men in her life because “everyone” included Tess. During her ten-year marriage, she confessed to multiple liaisons with other men. For some reason — likely having to do with my sense that she thrived on external validation of her desirability and worthiness from men — this information didn’t surprise me in the least; but it piqued my curiosity.

“Tell me more about this?” And she did. She went on to describe the many sexual partners she had through her twenties and thirties. In fact, all her friends had extra-marital affairs and, she reiterated, cheating was merely a part of marriage. I experienced a visceral reaction as she provided this information. How strange to hear those words come from this 61 year old woman sitting across from me.

“I pondered why I felt strange learning about Tess’s clandestine liaisons.” I don’t get it. I’ve heard countless stories like hers, especially from all those sex workers I’ve counseled who have repeatedly described having sex without any emotional connection. I guess this Tess, the Tess-Post-Fall-From-Glory, is not the same woman who enjoyed those extra-marital affairs. This Tess is depressed and broken. I found it difficult to imagine her with the sexual prowess she described, of being a woman who ostensibly detached emotion from many of her sexual experiences and enjoyed sex for the pure physical pleasure it offered. It was clear that she did; that is, before she came to see her body as deformed.

One of the men she had an affair with, Barry, was the man she eventually developed an ongoing and quite serious relationship with after her divorce. She described Barry as “the love of her life” and the man who stuck by her during her fight against her breast cancer. He eventually left her for another woman once her battle with cancer was over and she was healthy again. When Barry informed her a few months later that he was married to this other woman, Tess described feeling abandoned and devastated. This, too, added to her “Fall from Glory.” Tess was 51 when this relationship ended.

“I haven’t been with another man since.” Tess broke eye contact with me. She focused on the floor and kept her gaze there.

Interesting. Men make up such an integral part of her life. She thrives on their attention and affections. That’s a long time to keep yourself alone.