Jul 20, 201612 min read

Psychotherapy Online: The Not So Final Analysis

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, carried out by The Zurich Lab and Stillpoint Spaces International, relied on video conferencing software in order to connect our focus group of counsellors and therapists (referred to as participant therapists) working online. This post is the sixth and final report of our findings. If you’d like to start from the beginning, please click on the appropriate link:

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.

The Research Participants Learned by Participating in the Research

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:

“One concrete, and fairly concrete insight that I remember having in an early session [of this research] discussing the excitement around the medium and the excitement provoked by the nature of this medium was this feeling of realisation of performance anxiety. And I do believe in my work with clients online now that I had become a little bit more aware of that, that there’s something for me in this medium that sort of pushes me a little bit to say a little bit more, to be a bit more active at times, and to not sort of sit with the silences in the same way. So that’s something that I think I became more aware of in this research.”

Others disagreed and felt that the medium took away the possibility for a strong empathic connection:

“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.”

Further Research:

Our small research project is just beginning to lift the veil on the understanding of psychotherapy when it is conducted online. Just like live psychotherapy, the subject is an unwieldy one, and we are unlikely to come to many concrete findings that fit for everyone. However, we do come to understand the process better, and to respect the process as one that is different from offline work. At the same time, many participants felt that online/offline itself was a false binary:

“So I think this online and offline, there’s something in that sort of dividing, I think it’s necessary to do it at this stage to look at the online work, but I think in a way if I would have had further research, it would really be about talking about, it’s about doing the work. It’s about doing the work today for me, it’s not about working online and offline specifically. Yes, it’s important to understand the nature of this medium, but it’s also very important to understand that this medium, this online thing,”

He continues:

“I don’t want to come off as overly positive about the online because I do feel the necessity to keep both. I feel like there’s a complimentary aspect of the online and the offline work, it’s what creates the potential container today. And that’s really what I’m interested in explaining … Is this the frame that we . . . should hold to or not? … So that’s a complete sort of dispersal of the frame. No frame. It’s not what I’m speaking of. I mean that is already happening. The frame is completely blown up. That’s already happening. What we’re doing might already be dinosaur sort of work. It might already be that the new type of therapy’s some sort of different ways, and we’ll offer therapy in complete different, you know, formats and markets or whatever.”

We can’t get away from a sort of post-modern feeling here. Our frames of reference are changing. And the question arises, “how are psychotherapists supposed to meet this challenge?” We can accept the terrain, we can challenge it, in any case, we have to make choices.

Historically, classical psychoanalysts would accept payment after each session, because the transfer of money is so psychologically important. The way in which a patient paid was so important for analysis. Even today many traditional analysts refuse to take anything other than cash or a cheque, feeling that a bank transfer, behind the scenes, forbids the analysis of the exchange.

But who writes cheques today?

In a sense, this is an analysis of money transfers that harks back to the 20th century. What is the use of analysing an exchange that hardly ever occurs anymore? Wouldn’t it be better to see what comes up, if anything, in the nature of the bank transfer? The will to analyse and understand the exchange remains important, but the means by which we exchange money has completely changed.

The same is true for the way we communicate. The nature of our communication infrastructure is changing fast. As psychotherapists we must accept this, but that doesn’t mean that we have to take our work online any more than a traditiaonl analyst has to take a bank transfer. However it is incumbent upon us to understand the medium of exchange between individuals today, and bring our psychotherapeutic knowledge to bear on that process.

We have taken advantage of the ease that technology gives us to publish to you our findings as we go along via these posts. However, the engagement required of a long read (an even longer read than this) requires a different medium. So at some point in the future, we hope to make this research available in a more traditional format.

With great respect, we thank our participant therapists for giving their time and thought to this process and sharing their experiences publicly, and we hope that you learn from it too.