This coronavirus pandemic has presented considerable challenges for those professionals who have no experience with telephonic or video therapy. But it has also forced all mental health professionals to overcome discomforts with unusual new norms, and to embrace new ways of conducting therapy that challenge our cherished beliefs of what is the essence of good therapy.
I am sharing best practices for providing safe therapy techniques with my students and therapists all over the world, who are learning to do supervision and therapy on Zoom, including Somatic Experiencing®, a research-based body/mind centered healing therapy created by Dr. Peter Levine and supported by Dr. Stephen Porges’ polyvagal theory.
Taking time to practice and learn the benefits and drawbacks of online therapy is essential. Learning the basics, like making sure your computer system can support the program, checking the platform you are using for number of participants and duration of time available to prevent frustration and confusion are important; also arriving early to the session, setting guidelines for confidentiality and content, making sure people know how to mute, using a headset so others cannot overhear the conversations and addressing the HIPAA compliant issues are crucial.
Of course, our presence and energy in the room are powerful adjuncts to whatever methods and theories we use. Therapists tell me that with Zoom or Skype, it is not the same thing for them and their clients, and it will never be. Yet, I have found that with Zoom or Skype therapy formats, our presence and energy can still be felt very strongly, and that there are added advantages.
We must develop our hearing and vision as if we were blind and deaf.
Our energy and presence can be transmitted through the close ups of both therapists and clients. Personally, a video therapy format makes me aware of so many very subtle expressions, which I find add to my understanding of my clients; and I observe that my clients are tracking very closely my every expression, which reminds me the more authentic and caring I am, and the more successful my therapy work is.
When clients pause for a longer time on the phone, for example, our more acute hearing can pick up the held or deeper breath, or the silent tears. We can pay attention to every little pause since such hesitations might relate, beyond shortness of breath, to constriction, constraint, embarrassment or shame. We can then take more time and soften our voice even more to inquire about what’s going on.
While I am always sensitive to changes in people’s voices, in video therapy and even more so in audio therapy, I try to pick up the smallest variation and nuance in the clients’ voice and sounds they can make and track their voice modulation.
Video therapy allows me also to engage clients in a new way. From my screen, while I can still track breath movements, I am less able to track movement in their legs or hands, or any other motion that may be outside the screen. I ask my clients to track their bodies and inform me about their bodies’ motions outside of the frame of the computer screen. This participation helps them develop more observing awareness of their body movements and bring their neocortex online. If I am doing more body-oriented therapy, I ask them to position themselves so I can see most of their body.
This crisis gives us the opportunity to adjust the normal (and generally desirable) constraints around therapy work. How flexible must we be? Should we still give sessions for our clients who cannot afford to pay us right now? Do we make ourselves available for urgent calls? How do we take care of them while taking care of ourselves, and how do we set the right boundaries?
Of course, the response will depend on the circumstances of every therapist, his/her availability, economic situation, and so forth… But we can be firm about setting our boundaries, no matter how much we give of our time for free or for pay.
I want to improve to the best of my capacity the safety measures regarding run-wild activation while on online therapy. I try to establish safety rules with my clients to work with me under an online “contract,” that if they are upset, they don’t leave abruptly an online or audio session without our discussing and agreeing that it is the right place to stop, and what the follow up would be. By creating these parameters, I can assure more compliance that the client will grant me access to help them when they become too activated and I have less access to them.
For those who are uncomfortable with online therapy, they can find solace in focusing on the fact that seeing them online is much more helpful for their clients than having no therapy.
Clients also may find it difficult to adapt or feel awkward about online therapy. They may miss the whole ritual of coming to the therapy session, the coffee they stop to buy on their way to our office, the familiarity of our room, and the reassuring objects in it. Because of this, I make a point of showing them my online surroundings, where I am sitting, what I have around me, and ask them to show me theirs to help alleviate their reluctance in doing work online.
Concerns for clients and therapists, alike
Some of my clients are upset about having no choice but to isolate. They feel coerced or imprisoned. Often times, they just need a simple reframe that this is being asked from them in order to protect them and their loved ones, that the possibility of leaving their home is still there, (albeit a bit confined) and they should take advantage of it. We must all remember that it is just a temporary situation. I was pleasantly surprised how well they responded to this simple reframe.
For some people, attachment issues can come up full force. They can feel frozen and stuck when they are immobilized, like their life just stopped. They need help to explore and discover the richness of their confined space, including, for example, taking stock of what there is in their home, maybe looking at their space through the lenses of a camera.
If we are entering a piece of deep trauma, I ask them to bring their resources around them, prepared ahead of time, or to have people they can go to for support at that moment.
Some people are dealing with loss and grief, and this is handled as usual, making room for the healthy grief, and discharging and reframing the toxic grief.
And of course, most people are also dealing with some of these additional topics, including coping with stress and managing anxiety and fear. “I’ve lost my job how do I cope?” “How can I help my children, or homeschool them?” “How to maintain healthy relationships with partners when we are home all day, Or manage work and employees remotely?” How do I stop my brain from catastrophizing, instead of taking it one day at a time?”
And for too many there are the effects of self-quarantine, the anguish and despair of social distancing and social isolation, and what to do to feel less lonely; the confusion and guilt about bringing the virus on by their own neglect: washing the hands is easier than remembering to not be OCD and touch our face.
Breaking through our inhibitions, our hesitation in doing things in an irregular way, while emotionally and possibly even ethically challenging, allows to become more flexible, and to adjust and modify our habits and help make everyone feel supported and safe.
Maybe the most challenging aspect to this new way of support is that therapists can be going through the same situation and feelings as their clients – terror, uncertainty, confusion and anger. Personally, it was important for me to hold the belief for myself, that while the circumstances are beyond my control, where I directed my mind, was, is and remains under my control. I am convinced that guiding my brain and activities towards the positive, towards what was working, towards the silver linings I could uncover, is what helps me keep my nervous system centered, and boosts my immune system, the two most precious things that I need during this crisis.
I am committed to supporting our health care community and the medical community during this time of crisis. I am working with our professionals not only to deal with their clients but their own struggles in this time of uncertainty. I am reminding them that relying on their resources and using the tools we have to balance our nervous system will help everyone. We are all warriors in the fight against this virus. One of the most important things we can do is to build resilience in ourselves as first responders.
Ultimately, holding the field for all my students, clients and family cannot be accomplished without holding the field for myself. My task at this moment is to regulate my nervous system and boost my immune system, by focusing on what is positive and integrating with gratitude all the creative ways that people show how much they care and want to help.