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Taking therapy online: research into therapeutic practice in the digital age

Stillpoint Spaces launched its online counselling platform to support its international community to carry out psychotherapy in our globalised world. However, as a community of practitioners we are committed to high quality practice and do not see the provision of online therapy as the functional equivalent as working face to face. Because of this, we committed ourselves to learning more so we could offer a critical approach to online working. In 2013/4 Aaron Balick facilitated a year-long qualitative research project with Stillpoint Spaces counsellors working across our MyStillpoint platform to get a deeper understanding of what happens during online psychotherapy from the therapist’s perspective. He originally released these reports (one written by Stillpoint Spaces founding partner Evangelos Tsempelis) as a series of blogs after each focus group. We have now brought our findings together here for anyone who wishes to learn from it. This was originally published in 2014.

Index
Introduction

In the face of so many technological developments in recent years the practice of psychotherapy can seem strangely anachronistic and traditional; for the most part it is still two people talking to each other in a room. As I discuss in greater detail in this article for Contemporary Psychotherapy, the practice of therapy today has to respond to its environment, but it has to do so in a thoughtful, responsible, and ethical way.

 

We feel that we are in a position to investigate the provision of online depth psychotherapy – a practice that is widely administered today, but as of yet, under-researched. We will be illuminating this quickly growing area using a qualitative psychoanalytic approach to the material. In essence, this means looking at the process of what is going on without getting lost in the content alone.

 

Stillpoint Spaces is an international community for the psychologically curious – our main aim is to encourage the exploration of psychology in depth, both inside and outside of the consulting room. To support practitioners in their online work, we created MyStillpoint in 2013. MyStillpoint is a secure online platform through which counsellors and coaches from across the globe see clients via video-conferencing, manage billing and invoices, schedule sessions and find new clients.

A Psychotherapy for Today

We recognise that the delivery of online counselling and psychotherapy has grown astronomically in the past decade. We are also aware that most practitioners who are working in this way are doing it in a casual, ad hoc manner. While there is some training available for counsellors who wish to work online, and several books to help them (see Psychotherapy 2.0 for example), there is little work out there that seriously investigates the dynamic processes that may be occurring by way of such interactions. Our consortium, with a particular interest in dynamic process and modern culture, is perfectly set to deliver this kind of cutting edge research.

The Research

Our pilot project involves a series of focus groups with counsellors and psychotherapists already working online. In keeping with the general theme of “a psychotherapy for today” all of our research will also be “for today” and will be carried out over the medium of video conferencing – just like the therapy delivery we are researching. We have selected a grouping of international psychotherapists of differing orientations who have varying degrees of experience working online. This will constitute research into the “delivery side” of online counselling. “Client-side” research is currently under development.

Using a Grounded Theory approach we will be running a series of virtual focus groups that will enable us to get a sense of the dynamics, challenges, and opportunities that online counsellors are currently facing. Themes that emerge will be coded, categorised and worked through amongst our enthusiastic team of participant researchers. At the end of the research we will write up what we have learned so we can enable further research and development in this exciting and growing field.

Literally, we know the answer to the question of where our online world exists: within the cloud. While this cloud is itself distributed over a myriad of data centres across the globe, its activities generally operate so seamlessly that we feel it is happening right in front of us on our desktop computers or tablets, or in the palms of our hands without smart phones (we certainly notice when it’s not working so seamlessly). With the social web available at our beck and call, the gap between ourselves and others collapses to such a degree that it’s as if they reside in our pockets: buzzing, pinging, and ringing their way into our consciousness night and day.

 

While the population at large will be using technology to communicate and connect as a matter of course, psychotherapists and counsellors working online have to think it through very deeply to make online relationships psychologically as useful and ethical as possible. While our research at Stillpoint Spaces aims to find out how therapy online can be better delivered, a happy byproduct of this research is insight into the psychological nature of online spaces in general. One of the consequences of our research will be enabling other aspects of online social media to be better equipped to deal with complex human psychology and emotion.

Important differences and similarities between online and offline spaces

Our research is already beginning to show that there are important differences and similarities between therapeutic work online and in person. While this may seem obvious, the ways in which these similarities operate can be surprising. For example, long before video conferencing, psychoanalysts were very clear that much of what makes up the relationship between patient and therapist is not just the “real relationship” between them, but also the relationship in the mind. We call this the “transferential relationship” – that part of the relationship that isn’t just “in the room” between two people, but also that piece that exists in the mind.


We tend to fill gaps in our understanding of other people’s minds with the experiences that we’ve gained from previous relationships. So, for example, when you are trying to understand what your boss is thinking (and she’s not giving much away) you may expect her to respond to you like your mother or father did. The same thing happens in therapy. In short, the entire relationship was never all in the room, even when therapist and patient were working in the room together: there was always the shadow of previous relationships.

When moving this relationship online, it really throws this “fill in the blank” transferential relationship into relief. It isn’t lost on either patient or therapist how limited the literal frame of a computer screen is, which in turn limits what we can see and experience with each other, which can increase fantasy and projection. Our research subjects (who are all “participant therapists” who work online) expressed concerns about not being able to see enough body language, or noticing how one might gesture with their hands when speaking. The nature of technology too, enables distractions that would not normally be tolerated in a consultation room – such as emails or alerts that might be contaminating either the therapist’s or the patient’s computer screen.

I think people are very conscious of just how selective this frame is, and in this kind of artificiality that we never quite know, just how artificial is this box?

– Research Participant-Therapist

I noticed that by working online, technology sort of surrounds the session. And the session stands completely on this kind of technology . . . I identified that my fantasy of what psychotherapy is, or what a psychotherapist is supposed to be, it’s usually sort of very fleshy and incarnated and related; and this sort of setup, sort of, turns me off-balance, and I have to find balance again.

– Research Participant-Therapist


Psychotherapy online isn’t just a matter of translating live practice to online practice, but requires careful thinking about the meaning of working through technology:

Meaning is crucial in depth work, and the fact that working over tech has meaning of its own is evidenced in one therapist reporting the dreams of his patient that included the technological mediation between patient and therapist. Other meanings, particularly in relation to the sometimes unreliability of the technology, can provoke feelings of abandonment in the patient – something our therapist research subjects were painfully aware of, with one therapist-participant noting that it’s as if they have to “own the experience of disruption” – but also related this to the disruptions (like traffic noise or building work outside a consulting room) that often interrupts therapy in the real world.

Many of our research participant-therapists note how they experience anxiety about how well the technology will work and may compensate for this by being extra attentive. One participant-therapist sees the same patient live and online depending on whether or not they are in town, and report an important difference. This therapist noted the effort this patient made to “look good” during live sessions by way of carefully applied makeup and wearing designer clothing. During online sessions, however, the look was much more casual and the therapist reported that there was a “marked difference” and “I felt a lot closer to her in the online space.” Other therapists also note that patients seem less inhibited online.

“When you sit and work with someone in another country it really frees, it really puts the finger on what a psychic thing realty is . . . I was very surprised by how deep and how far you can go almost accelerating that in your connection, actually, because it breaks down that physical space.”

-Research Participant-Therapist

Many of our research subjects reported that there was indeed a sense that working online was more casual, and that they met patients in a variety of settings that the therapists had little control over. Therapists themselves reported feeling different if they were working from their normal consulting room, or in a different place, such as their home or a hotel room. In an article in Forbes psychoanalyst Todd Essig expressed concern about this potential casualness in online work, describing one case in which a patient took his therapy while driving via hands-free telephony. Therapists working ethically online would share Essig’s concern and would set appropriate boundaries. The nature of this very research is to identify the potential “slippages” in working over technology, so they can be dealt with thoughtfully and respectfully.

Most of our participant-therapists agreed that there was a difference in working online and offline, and we are getting towards qualifying exactly what those differences are. In some ways, as discussed above, online work can feel less inhibited and because of that more relationally “real,” while in other ways, there is no escaping that there’s an artificiality to it. There is simply no one way of looking at it.

What is becoming clear is that the online space is indeed a kind of real space, a limited space, and a psychological space between two people. One participant-therapist asked simply “What is the space where we meet?” and went on to draw his mind’s picture of that space:

The room of the person speaking was something like the continuation of my space, of my room. So the middle of the space is . . . my room [and the other wall behind the patient] is actually the wall of the person in front of me which is thousands of kilometers away from me . . . and I know it’s not easy to explain or understand it, and even I don’t really understand it” it’s like being in an imaginative space.

– Research Participant-Therapist

In this quote, we can again see the imaginal nature of this online “in between” space, and think about useful ways of understanding that in order to achieve what we so value in the depth psychotherapies – meaning making.

By creating an opportunity for therapists who are working online to discuss freely what it is like, and what emerges for them, Stillpoint has created a resource for each other to make meaning of the work that we are doing. By continuing the grounded theory approach to this space, we are also collecting themes that will enable us to create more thoughtful, contained and psychologically effective online spaces for therapists and patients alike. Our stated goal of creating a body of research from which we can further extrapolate to other online spaces is well underway – and very much a work in progress.

Online Therapy, Where Hugs Are Not Possible

This section was written by Stillpoint Spaces’ founding partner Evangelos Tsempelis

It is part of the mandate of Stillpoint Spaces to bring psychoanalysis to unlikely contexts. Driven by that passion, we have been engaging over the past couple of years in a series of experiments in Berlin, Zurich, Barcelona and New York City under the banner of Psychoanalysis-on-the-Streets. These engagements, which continue to take place in diverse settings – galleries, cafes, and in Stillpoint Spaces Berlin – have been impactful experiences to all of those who have been involved.

By exposing psychoanalytic ideas to the public in new ways (outside of the usual framework of the lecture room, the counselling office or the training institute) we enable psychoanalysis to have a new and exciting impact in the community. This act of exposure has come with the requirement of shedding entrenched professional attitudes in order to re-experience psychoanalysis in a new way that is often incomplete; within a language that is under construction as we try to relate and engage meaningfully with what is constellated in the moment often beyond our comfort zone.

At Stillpoint Spaces Zurich, we began to wake up to the growing realization that the Internet is in some way the quintessential “street” of our globalizing culture.

It was in this context that we decided to create, with Prairie Care (a US based provider of psychiatric care), a safe online platform where practitioners could engage in delivering psychological services to clients around the globe.

Engaging in Responsible Research with a community of Research/Practitioners

It soon became evident that this work of reflection would have to be systematized and undertaken with rigorous intent if we wanted to research the deep dynamics at play when we work online. We undertook to carry forward this research initiative with UK based relational psychotherapist and pioneer researcher on the cross-section of psychotherapy and the digital age, Aaron Balick. Together with a remarkable group of psychologists, therapists and analysts working online over Stillpoint Spaces we embarked on a deep exploration of the dynamics, experiences, fantasies and fears encountered as the frontier of therapeutic work is pushed forward into the virtual space. These ongoing exchanges, comprising the prima materia of a developing research project, are already becoming profoundly meaningful experiences for all of us who are engaged with it.

It’s a process of discovery – of technology, and ourselves

We are discovering how impactful in our online work it already is to have created a space where we can actually share and admit our fears and concerns with like-minded colleagues.

Many of us have discovered that working online brings with it a subtle, often not immediately conscious, sense of guilt.

That guilt is often driven by the awareness that the online environment is a grey zone where the conventions and norms that regulate psychotherapy become dubious or unclear.

As we bring our practice online we each have to ask ourselves both how we define our work and how do we engage with clients in a new unfamiliar framework. Psychotherapists are trained to be cautious and to put their clients’ wellbeing at the highest priority. The safety of the client is directly linked to the idea of creating a safe holding environment, a container as we often say in our lingo. In a time of growing news about cyber fraud, crime and surveillance, that container can seem to be compromised from the get-go. So entering the online space may come with anxiety-laden fantasies of committing a crime or of breaking a sacred oath.

Working Therapeutically Online and Off

This is why, as we are discovering, being part of a community of online practitioners and working through a platform, developed specifically with online counselling in mind, are important steps in the direction of sealing the container and assuaging apprehensions about the safety of our clients and the sacredness of our work. Still, even after such negative guilt-ridden fantasies have been addressed and rendered fully conscious, there is sometimes a concern that somehow the online work is not on-par with our work in the “real” physical world.

When we work online we are stripped of our sensory field. We are engaging in a technologically-mediated exchange. We can only see and be seen from neck up. The artificiality of a video image seems to hit against deep sensibilities regarding the therapeutic importance of restoring dignity to an often objectified human existence. Video image is immediately associated with artifice, with manipulation and control all of which go directly against the very notions of authenticity, care, and meaningful contingency as cornerstones of therapeutic work. As one colleague poignantly said, when we were exploring the psychological significance of a moment of return/arrival of a client back to the consulting room following a prolonged period of working online with his therapist,

There are no literal hugs in online therapy

Yet, the more we allowed ourselves to speak openly of our biases against online therapy something also begun to shift. A memorable moment, perhaps a shifting moment was when we all paused to acknowledge a sound which had impinged on the virtual cloud of our online group meeting. Here we were a group of ten or so counsellors from different cities in Europe and the U.S. suddenly listening to the cathedral bells tolling in Strasbourg, France (home to one of the colleagues in our meeting).

When you begin to really ask the right questions, one finds that the answers that emerge are much larger than the simple differences between “offline” and “online” work.

When you begin to really ask the right questions, one finds that the answers that emerge are much larger than the simple differences between “offline” and “online” work. We began to ask if the fact that we were deprived of our full sensory experiences in the online environment in fact rendered us more acutely aware of other aspects of our reality which often would remain imperceptible or subliminal. What did it mean to hear these bells? What fantasies did this otherwise familiar sound unleash in this particular digital context in which we stood? Along the same line of thinking, what other fantasies or anxieties, otherwise unconscious in our every day natural attitudes, did our awkward occupancy of the online cloud invite for thematization?

We soon begun to realise that our physical practices too are mediated by technology and infrastructure of which we are often forgetful. The particular lighting, the artwork on the walls, the chairs, the carpets that we use to decorate our practices are all potentially rife with implications and suggestions (socio-economic class, taste, professional status to just name a few) which they too, as powerful triggers of fantasy, are capable of impinging the sealed analytical/therapeutic container. Seen from that point of view:

“We are always in the world” as phenomenologists say. Critical theorist and member of the Frankfurt School, Theodor Adorno once said that the hidden desire of every writer is that someday he or she will be read and understood exactly as one intended (…). The fantasy of a direct encounter of unmediated meaning is one to be taken seriously in its analytical implications. Asking what it means to work online, may become an invitation to also ask what aspects of our world or the world of our client have we chosen, unconsciously, to disregard by complicity to our privilege or comfortable natural attitude.

Equally, insightful have been our observations regarding the anxieties of technological failures. Once so often, the video supported image will freeze, an Internet connection will fall and counsellor and client will be confronted with what in Lacanian language can be referred to as an eruption of the real. Namely, the discovery that the symbolic world of our language, which sustains our meaningful engagement with the world in fact contains gaps, lacks and voids which allow something horrific, a symptom, to announce its presence in an unexpected traumatic interruption.

Making the transition from thinking of the failure of the technology in objective terms to interpreting it psychologically may be a remarkable shift in attitude on the part of the online practitioner. Seen from the former point of view, the technological failure is an embarrassing moment to master and cover up, an impingement in the therapeutic work. Seen from the latter vantage point, the failure of technology is potentially a moment of rapture to cohabit and survive with one’s client: a moment where the unconscious anxieties about death can potentially surface and be addressed. It is a moment where authenticity and integrity, in the face of what always lies beyond our control, can be re-negotiated and re-stored. As it is, just as “hugs are not possible online”, there is similarly no “end session button” in real life: whether online or offline…

The following sections were written by Aaron Balick.

The psychotherapy consultation room is seen as a sacred space. Just look at Freud’s. Those who have been seduced by psychoanalysis over the years come to it with a sense of reverence – like going to a secular mass. Consultation rooms haven’t changed since Freud’s time (except, perhaps, the replacement of the couch by a chair); in fact, the therapist’s consultation room is probably one of the most tech-free spaces you’ll find these days. That is, however, outside the thousands of therapists who have taken their practices online.

Our research project has now completed its sixth focus group session with therapists working online. The feedback has been positive. Not only are we producing dozens of themes and experiences from which we can get a better understanding of the challenges of online work, but research participants are finding that the project itself is actually improving the way they are doing their own online work.

Working online is not a simple translation of face-to-face work to doing the same thing on Skype

While the work continues to be therapeutic, the mode of delivery has changed, and this is something that therapists need to be mindful about when working online. One of the big themes that arise in relation to this difference is the notion of containment and holding: online, containment can seem more porous.

One research participant-therapist noted that the online container is more easily breached because the therapist, though in control of his or her own space, is not longer in control of the client’s. In such a case, the client may not be working in a secure space and thus the container might be breached:

[for example] the client is at work, co-worker suddenly pops in, opens the door and interrupts . . . there seems to be much less security, stability, materiality. It seems like maybe we’re more willing to tolerate that as well, because this sort of thing would never happen with that in-person meeting.                        
– Research Participant-Therapist

 

The lack of “corporeality” or real-life interaction can be frustrating for both therapist and client:

That container has changed when my client has moved away . . . [the therapeutic relationship] is in me, it’s an accelerated frustration that I sense . . . in not having what we used to have, in not having that container that was there, and . . . I sort of need . . . for the client to be back in the room to be able to meet on that level.                                                                                               –   Research Participant-Therapist

The Porous Container of Unreliable Technology

Through the research we have come to understand that the container that we seek to achieve in face-to-face meetings (which is also vulnerable to porousness sometimes) is particularly vulnerable to disruption and distraction. Therapists, who have usually spent more time doing face-to-face work than online work will be hyper-vigilant to such disruptions and they often feel quite anxious about them. Because of this anxiety, they will often compensate to “make up” for it.

Simply by working online can feel like a taboo to many psychotherapists:

 It feels sometimes as if I was breaking some fundamental aspect of psychotherapy . . . I start with guilt, like sort of feeling like a crook, right, like a criminal. And just by being super nice and super empathetic . . . so I can sort of forget myself towards the end of the session.                                                                  
– Research Participant-Therapist

 
In contrast to this, therapists who have been working across the platform longer have noticed the anxiety change into a kind of excitement:

Much of what was being identified as a source of anxiety [in the research group] has been a major source of anxiety for me earlier . . . where I did feel like a crook, uncertain at points in time, where I did feel like I was breaking a taboo, where I did suffer the consequences of . . . all kinds of criticism. That … helped me realise that the difference was mostly a difference of time and place rather than an actual psychological difference in terms of how I perceive online … I would say that I have come to realise the importance of the framework that everybody has been underlining and how important it is to be extra careful in the online environment . . .

And you know this is where, my anxiety, my fear, my guilt turns into excitement and to a genuine sense of appreciation for the opportunity to be doing this [research]”                                                                                        
– Research Participant-Therapist

 

When the tech goes wrong, and the picture freezes, or the sound goes wonky, therapists usually feel responsible for it:

 I can very much relate to the guilt … owning the responsibility [of the] disruption.


Despite these interruptions:

 What the online environment offers for me is the sort of freeing the psyche from certain information materialisation… when you sit and work with someone in another country it really frees, it really puts the finger on what a psychic thing reality is. And that’s what I sense very much, and some of the profoundest meetings I had is . . . I was very surprised by how deep and how far you can go almost accelerating that in your connection, actually, because it breaks down that physical space.”  
– Research Participant-Therapist

The research group was pretty much unanimous that working online and face-to-face is very different indeed. But as discussed in our post about space, there is something universal and intangible about the space between two individuals engaged in psychotherapy that seems to transcend the apparatus over which it is deployed.

Sacred, Profane, and Even Worse, Banal

Many of our participants recalled their own face-to-face therapy and the feelings they experienced when they would arrive for it. A number of visceral and tangible images came to mind:

§  The nature of the journey to and from the therapist’s office.

§  Crossing of “the threshold” into therapeutic space.

§  Seeing their therapist, maybe shaking their hand, making eye contact.

§  The smell of the room, its decoration, its feel.

§  The sense of sitting in the chair or lying on the couch.

§  The sound of the therapist’s voice, the non-verbal sense of connection.

All of these elements, and more, gave clients (all of our therapists have also been clients) a sense of something sacred. When moving to online work, there was a sense amongst our participants of breaking a taboo, of taking this sacred space and making it profane. This sentiment was referred to in some of the quotes above in reference to the breaking of the frame, making the therapy vulnerable. However, on further discussion, we discovered that it was the banal, not the profane that was the true worry:

Perhaps the danger, the ultimate threat is not profanity, but banalisation. Yeah, that the banality of the medium is probably the gravest danger”  – Research Participant-Therapist

Our computers are where we do our most banal stuff: our emails, our Facebook, our taxes and our shopping. When going to the physical location of our therapist’s consulting room, we purposefully move out of that banal space, into what one might call the sacred – and there, we may talk about the profane (to be fair, we also talk about the banal). But what happens to us when the sacred work that is to be done by therapy is done over an essentially banal platform?

What happens when we move from answering an email straight into a therapy session, or straight from our therapy session into our online grocery shopping for the week? It has the capacity to banalise the work.

Taking a more reflexive and active approach to the work online

If this is the case, then therapists working online need to manage, in some way, the encroachment of banality. But how? First, by taking responsibility for what is happening at the therapist’s end of the line.

§  Are all disrupting windows shut down?

§  Are we sure the session won’t be interrupted by notifications of emails, text messages, etc.

§  Have we got a backup plan if the technology fails?

§  Have we taken as much care in the preparation of our space as we would in our face to face consultation room.

§  Have we addressed the medium of communication with our clients and discussed what this might mean, what the limitations are, etc.

§  Have we enquired deeply enough into the choice we’ve made to work online (in general, and with particular clients).

§  Have we carried out any kind of assessment as to whether or not is is appropriate to work online with this particular individual?

On a deeper level, should we be encouraging our clients to take space, maybe ten minutes, before and after a session to create a virtual “threshold”? While this makes some sense, it also implies that we are trying to translate our offline consultations into online ones. We have found that we need a new way to approach online work, as it is not a matter of a simple translation from one deployment of psychotherapy to another medium. Having agreed to this, we need to deploy our therapy thinking skills to adapting to this particular medium.

What is clear is this. For those of us working online (at least in this research group) there is a real will to create a particular kind of psychological space, that may be described as being sacred on a medium that is clearly banal. In a sense, a consultation room is also banal. It’s a room with two chairs in it – but the intention of that space makes it special.

Online space is different, but it is equally amenable to intention. With the right intention we can get closer to offering something that transcends the medium itself. This is a matter of will and thought from the therapists working online, and the way in which they develop online containment. However, we are also discovering that this project involves an active engagement with the technology itself to enable the possibilities within the medium to be creative, therapeutic, and ultimately, transcendent of banality.

The AT&T jingle, “Reach out and touch someone” – a jingle that encouraged us all to pick up our phones and call someone that we loved. It’s a clever jingle because, clearly, you can’t reach out and touch someone physically from the other end of a telephone. The idea of that ad was that you could reach out and touch someone’s heart, you could touch them emotionally even if you could not feel the warmth of their skin.

This typical ad from 1987 demonstrates this by showing us how a mother’s intuition overcomes the obstacles of a disembodied voice. Like the seasoned psychoanalyst, she sees through the words and gets right to the meaning of it, right to what’s going on. Technology and dismissive words aren’t going to put this mom off the trail.

But this is, of course, an advertisement – its aim is to “get you” emotionally in order to sell you a product – to convince you that it’s worthwhile to reach out and touch someone over the phone, because it works. It may not be as good as a hug, but it’s pretty close. Can we say the same about psychotherapy by Skype* – not as good as a hug, but pretty close?

Gillian Isaacs Russell covers this question in her important new book Screen Relations: the limits of computer-mediated psychoanalysis and psychotherapy. In it she notes that psychotherapy that occurs only on Skype lacks an important potential for real life physicality. As one of her subjects stated:

Skype actually obscures the therapist’s potential for professional fallibility, while it may heighten the potential for his fantasy unchecked by reality. You might think, ah, well, that’s a good thing surely. But not so fast. The good therapist chooses to be professional in drawing physical boundaries. But Skype forces the therapist to draw physical boundaries. Therefore, the patient can never observe the therapist’s choice to create a safe environment and not to act on impulse (38-39).

During Skype based therapy, there is no potential of being kissed or kicked

Clearly, it would be an ethical violation for a therapist to kiss or kick their patient. However, as Russell points out, the potential for a boundary to be broken in this way creates a space in the live encounter that doesn’t exist over Skype (though there are myriad ways in which boundaries can still be broken). For therapies that involve a profound re-working of fixed attachment strategies, being in this zone of potential threat with a trusted therapist who chooses not to break such boundaries can be a profoundly healing experience – particularly for individuals whose boundaries have been broken before. By missing this zone of possibility by doing an entire psychotherapy over Skype, are we missing something? If you’d like to hear more from this perspective, please check out this freely available webinar that Dr. Russell did with Stillpoint Spaces’ online community.

Research Continues

Stillpoint Spaces research continues to interrogate this point of difference between co-present and online work. Our aim is not to show that therapy by video conferencing is “just as good” as co-present work. We simply recognise that more and more people are engaged in such work as a matter of necessity or convenience. Recognising this we acknowledge that we to think critically about it so we can better understand it, and make improvements where necessary.

Since we run our own online counselling platform we feel it is our responsibility to also understand as best we can the psychodynamics of relating over it for the purposes of psychotherapy. As a platform developed by therapists for therapists, we aim to be responsive to research in the field while using our own local resources to research our own work.

- Psychotherapy online is reaching out and touching people – yet we want more

Every single one of our research subjects (who are psychotherapists delivering depth psychotherapy by way of video conferencing) has said hands-down that they have had profound relational moments online. Yet, for so many of us, this still doesn’t feel like enough. One of our research participant therapists strongly stated:

I have come to the conclusion recently though some experiences with my patients where the relationship has felt very much real. This is a creative relationship never met in the offline space, and it’s felt attached, it’s felt therapeutic, and it’s felt very real.

While many others in the focus group identified with this experience, many express a sense of still wanting more. Another research participant therapist stated:

I find myself wanting to [physically] reach out…not that I would touch a client in my practice… but then [I] compensate.. you know leaning into [the computer screen] just leaning in.” This therapist went on to say “several clients have articulated, ‘maybe someday we can meet…for real’. While there is a sense of loss that comes with this knowledge that the client may never meet their therapist in the flesh, there is also a sense of safety, she continues, “the knowledge that I [client] will never meet you [therapist] walking in to the grocery store provides me with a sense of safety”. In reference to Russell’s perspectives above, we have to ask whether or not this sense of safety is one that enables therapy to progress, or if it gets in the way by destroying some sort of active potential.

“Click, click, click, and you’re gone.”

The use of a technical platform in which one remains very much in control of the relationship is another contributor to a different kind of power dynamic that doesn’t exist in co-present work. One of our subjects was concerned that this enables greater objectification of the other**:

The other becomes an abstraction. He or she becomes an image, it can be managed, it can be turned off, turned on, saved, it can do all things to our image and to the images of the other in a screen like that…

In co-present psychotherapy there is no way to have such omniscient control over the other. In a previous post we encountered the problem of the platform, the home computer, being a technology of banality. This theme was followed up by a participant who remarked about:

the banality of being able to click, click, click, enter, exit.” She goes on to say how much more is involved in coming and going to an actual therapy session in a real place in the world, “there is so much that a client coming offline has to do, that effort that is required to come into the office, all those things as being preparatory to enter . . . what they do as they exit and go back into the other world, those kind of thresholds maybe are collapsed when you just click …


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You can’t just move offline therapy online and say, “it’s the same!”

While our research grouping continues to acknowledge that profound work can happen via video conferencing, we also unanimously agree that such work is not a simple translation of offline to online. A lot more thinking has to go into what happens when the thresholds that one would normally expect from a depth psychotherapy experience (preparing for a session, travelling to the therapist’s consultation room, arriving with all the sensory experiences that come with, the ending of the session and the leaving) are collapsed into click, click, exit. While some members of the group suggested creating, digitally, some kind of threshold, others argued that we should simply try and understand the collapsed thresholds better. In any case, such thresholds are collapsing all over the place, not just in therapy sessions:

Maybe the work is not so much to lower the thresholds but to unpack…many of the thresholds that have been collapsed by virtue of framing this work online…one would really have to incorporate the very architecture of these spaces, the very essence of what does it mean to actually be involved in the rite of travelling to get to an alternative space as we do in the physical world where and when we meet with the therapist.

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Therapy by technology isn’t just a matter of when it goes wrong, it’s also about when it goes right

While our earlier focus groups were very much concerned with dealing with technological failure (when the wifi goes down, when images get pixilated or there’s a great deal of interference) we seem to have progressed to thinking through the problematics of when it goes right too. The tech difficulties we encountered in our group (which was on online focus group with small windows in which most of us could see each others’ faces) were often very disturbing. One participant had to leave and come back, having missed an important part of the discussion:

I felt a bit disconnected…not from the group, but lagging behind a little, So I might have formulated an idea and thin I missed the next but….there’s been a kind of catch-up moment for me every now and then, which happens in sessions too.

 

Another participant, who was unable to join us by video link, but listened in and shared by voice only:

I do feel a certain sense of fragmentation, and I think it has mostly to do with the technology that I don’t see you, you don’t see me. I can relate but I felt that the conversation was really moving and I sort of did relate to most of the topics, but I also felt a bit scattered, a bit sort of difficult to ground myself.

 
As co-researchers we recognise that the events occurring in an online focus group are not the same thing as conducting a one-to-one therapy session online. However, the experiences we share do resonate and d, importantly indicate that the register in which we are working, when working online, is profoundly different from co-present therapy.

- The findings we are coming across here have broad application way beyond the consultation room.

In my own work, The Psychodynamics of Social NetworkingI apply what I discovered first-hand in the consulting room to what I believe to be occurring in today’s culture, between people, everywhere. I explore the psychological effects of our continued emotional investment in social media by taking the dynamics that I learned in the consulting room and applying them to the external world. This current research can do the same.

We are all subjected to collapsing thresholds. We are all, most of the time, reaching out to touch people that we cannot touch – and then we may both miss their touch while also feeling relieved that we don’t have to negotiate it.

What are the consequences of this kind digital relating? We are not going to find the answers through quantitative studies. We need to find the answers by making more in depth enquiries into people’s experiences. People’s selves are extended into the digital sphere like never before. Psychotherapy research has a privileged vantage point from which to observe and better understand this phenomenon. The results of such research will extend well beyond the consultation room, as we better understand the consequences of the “click, click, click, exit” nature in which we relate to others across contemporary technologies.

Technology enables us to communicate with each other; it underlies this very blog allowing me to share with you the conclusions of our year-long research into online psychotherapy by video conferencing. You’ll get the general idea I’m trying to convey from these posts, but they won’t be quite as good as seeing me deliver the same information in real life (IRL) – nor will it enable us to get to the bottom of the complexities and/or disagreements through direct dialogue. While it’s a good start, it’s still best if we can do both.

Technologically assisted communication is never the “functional equivalent” (Russell 2015) of real-time, face-to-face dialogue. It’s not necessarily better or worse either, but we should be making clear choices about why and how we are using it, and for what purposes. When it comes to conducting research or therapy, there are certain qualitative conditions that need to be considered. It turns out this is the case in research too. Our pilot study relied on video conferencing software in order to connect our focus group of counsellors and therapists (referred to as participant therapists) working online.

Our research took place over the period of about a year. Volunteer therapists were asked to log onto software that enabled about a dozen of us to be online at once, in a grid of videoed faces (think a grown up version of The Brady Bunch), speaking about their online work (via a Skype-like platform provided by Stillpoint). Using a broadly “grounded theory” approach, themes that emerged from therapist experiences were collected and analysed – then written up after in a series of blog posts. This is the final post. A more comprehensive analysis will follow in the future.

What participants learnt

The participants, who were all counsellors or psychotherapists working at least partly online, found their participation in the research very helpful to their own practice. Primarily, this was due to being able to share experiences in a safe environment, speaking to others who “spoke the same language” and share the complexities and challenges of working on an online platform. It also enabled participants to think about the process psychologically, even when it didn’t go well:

“I found it difficult to stay in tune with the group and with the research when there was a big lapse of time in between … So, in a way it seems that the space between our sessions felt enormous. And coming back to this has been a challenge to me. So what I’m saying is in a way an experience, but also a kind of assessment of the methodology that we used.”

 

We will be taking this learning, reflected by others too, into future research where we hope to contain the process more effectively through regular and more frequent session. Despite these challenges, however, the research did indeed enable our participant therapists to feel supported:

“… another effect of this research is that I feel less alone. I know that I’m really not alone in that, struggling with the same questions and same issues. And if I had to pass on something to a therapist who would like to explore the online work, it would be really I would invite him to reach out to the community of other practitioners who are doing it online too and exploring this tool. Because it’s really helpful”

In many ways the research itself highlighted what can go right or wrong in online psychotherapy. While we tried to keep our sessions regular, organising a dozen counsellors in as many time zones can be difficult. Furthermore, sometimes the technology let us down centrally, or individuals dialling in may have found themselves struggling to connect from their end. These are the very same potentialities that dog those conducting psychotherapy via video-conferencing, and so enabled the participants to grasp the situation better.

Silence, which operates quite differently in a consultation room than it does online was also an issue in the research:

“I was just noticing that I couldn’t tolerate the silence . . . so I had to say something . . . [what I’ve learned most from this research is to] remain conscious of the process that you’re in online, and be aware of it, and use it and comment on it, observationally and interpretively like you would anything else. Don’t forget that the frame is, the frame itself is here, the data, and influencing the data. Like anything else in the frame be aware of it and use it.”

Another participant therapist remarked that due to participating in the research:

“I’m more mindful, I’m reflecting more, even more than before. I bring it up with the client more. The limitation of the tool, and I ask almost at every session questioning about how the client feels about being in this setting, seeing me on the screen.”

Silence, we learned earlier, is more difficult to manage online than in a traditional consultation room. Therapists feel that they have to compensate for it, to talk more. But we found that by reflecting on the medium itself as part of the psychological relationship can enable a more honest interpersonal relating rather than a pretence that it’s the same kind of relating, but just online.

For example, as our previous research highlighted there is no “threshold” in the online world, so comings and goings can be quite abrupt – as abrupt as clicking a virtual button. This is very different from the journey one makes to and away from a therapist’s real-world office. We discussed whether there should be a virtual threshold to prepare the client and therapist for the start of their session to “prepare the client that they are going into a new space” said one participant, “to keep the frame clear in the online setting” said another.

However, another participant experienced such a virtual threshold in which the patient waits for their session in a virtual waiting room:

“I had a kind of a strong reaction to a couple of these virtual waiting rooms that I saw … And that was wait a minute, this is actually not the therapist’s waiting room. This is probably a picture of a waiting room that nobody sits in and waits in, and you know what, I don’t like the decor. I’m not sure I like it. So again, back to this, even around the question of the threshold, trying to pretend to have it something that it isn’t. This kind of sleight of hand, you know, around the intimacy. So yeah I think there has to be some threshold, but maybe better just a symbol or a sign … please not the cheesy fake waiting room.”
 

Another participant therapist notes:

“So I feel like that whole ritual around what I so much feel is lost with online at times are the ritual before and after, what happens before the therapy, how do I get to the therapy, what happens after the therapy. So this is something else I think partly based on this research that I discuss more with the client, sort of how do we subject in each session, I mean with each client, how can we create the ritual around the work, or a symbol as, maybe a symbol is… yeah, I think it speak more toward a ritual you know, so that we know, so that the person is not moving to the next window, or to the next continued computer work, but that it actually needs to answer the medium”

This is a concern that Gillian Russell (2015) also meets in her book Screen Relations importantly noting that this orientation is not only important as a means of threshold, but also that the navigation centres of the brain that gets you to your therapy session are important for your learning and remembering that session. There is some evidence to show that the lack of this literal orientation may make online therapy sessions less memorable.

So we come back to functional equivalence – while a waiting room might make a lot of sense in co-present psychotherapy, a “virtual waiting room” it may feel like a total sham. So what to do? For some, replication of some sort of threshold seems necessary, while for others, the job is to expect the medium, and make sure that acknowledgement of that medium is included in the therapeutic work.

Other participants spoke about their own emotional responses to technical problems within the online research environment – problems that provoked anger and frustration:


“I became very aware of the fact, you know, it’s just easier to chop off or cancel a session because it’s just online”

 
This is very similar Russell’s (2015) findings – that online sessions are more easily missed, forgotten, and cancelled on both sides, client and therapist.

- Anxiety Provoking or Energising? Real or Virtual? Thinking Type or Feeling Type?

Our participants varied widely in the way they felt about their online work, and many had varied thoughts within their own practices – sometimes feeling confident in online work, and sometimes not. Often this depended on the personalities of themselves and their clients.

As one participant noted in relation to typology, “I think the more one is inclined to be a thinking type, the less one will be disoriented by this frame. The more one is inclined to be a feeling type, like X and I, the more disoriented one will be by this frame”.

This idea of the approach to online work being highly influenced by typology may become central to future research – both in assessing the productive use of online work for both therapist and client. Below, one can really see the difference in how various research participants found the work online gratifying or not:

“For my part I don’t have the same body sensations … online and offline. I can feel more, I mean, there is something in the space, there is an energy if you can call it an energy … And also this provokes more anxiety, because we have, for example with [a client who] was very angry at me… I knew she was angry at me but I can’t feel her, I mean, I can’t feel her. And it was very difficult for me to approach that feeling, because actually I didn’t feel it. I was so dis-attached, so far away from this. It’s a way that you need to rationalise a little bit more.”

 

Another participant therapist reflected that he felt that the frame causes a “fragmentation” of what feels real or genuine and feels that it’s very important not to “pretend that it’s something that it isn’t … So real things happen, but in a disoriented frame that’s in part because it’s a disembodied experience of the real. And our usual experience of the real is extremely embodied. But I think this frame allows us to have a different sense of the real, but is not, at least not embodied in the same way. And I think in an important sense disembodied.”

On the theme of disembodiment, yet another participant therapist noted, “There is also as a subset perhaps to embodiment, nevertheless a separate category, I think there is a certain degree of immediacy that is not … readily available online”

This instability or fragmentation doesn’t necessarily militate against closeness:

“Sometimes the connection seems so fragile and almost non-existent, or like just very, very fragile. And in the same session with the same client you can experience something extremely powerful and real, and it’s so easy to go from one to another one. Somehow really unstable. And that reflects in a way the tool, I think, which is unstable. And like the connection, physical connection can just break down at some point and the image of the client gets frozen and we need to start all over again. It’s very fragile.”

Another paradoxically notes, “I also want to just to say something on fragmentation, because paradoxically enough yes it does evoke fragmentation, the medium, but most of all it does the opposite.”

- So Much of “Real Life” has Moved Online Anyway

Philosophically, participants were mixed around the idea of resisting the ubiquity of technology, or accepting it, though accepting it thoughtfully and critically. There was a sense of wanting to maintain the sanctity of the therapeutic encounter while at the same time acknowledging how most of us live today and providing a realistic therapy in the face of that:

“the medium is a reflection of the lifestyle, how we live today. So that is paradoxically what I find very, very interesting and on the positive side of things, that it actually brings a containment to the process.”

 

There is also the notion of space, the virtual one, and the real one that is transmitted via the technology. One therapist, reflecting on his experience as a client notes that nature of the different potential spaces, not being limited to being in one consultation room, offers new opportunities:

“I … feel in general a greater sense of intimacy … For example I was doing an online session [with my analyst], and I was, you know I was surprised to hear her light up a cigarette to go with her cup of coffee. And you know that just to me; that showed sort of a degree of comfort on [her] part. And on another occasion I showed up [for a live session and my analyst] had been expecting an online session. So [she] met me at the door, and she, I saw, you know, the different preparation that went into in person versus online. She looked really embarrassed, she was quickly trying to brush her hair and you know, so suggested to me that she, you know, for the online sessions she’s more relaxed let’s her hair down so to speak.”  – a participant therapist reflecting on their own therapy that was both online and offline.
 

In short, the opportunity that is offered when we, by way of a virtual technology, end up in the client’s space:

“When we go online, the client isn’t coming to our space, our office, they’re able to be in their own, their own, you know, home or wherever they are. And that can bring a greater degree of comfort for them, and also lets us into their space a little bit more as well.”

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