Therapy in seclusion

Some thoughts on the experience and practice of geographically ‘secluded’ therapy.

Research into online Cognitive Behavioural Therapy (CBT) – in terms of measured outcomes – suggests it can be at least as effective as face to face therapy (Lewis et al. 2018). But is that true for all kinds of psychotherapy? And in what ways is ‘virtual’ therapy different, especially for trauma survivors? During this period of physical isolation due to COVID, many of us have had to move therapy sessions online or via phones, as the only way to continue. Others will have to start online as the only available option.

What do we need to think about when we engage in therapy from separate physical spaces? How can we make it as good as it can be, as therapists and clients?

Having made the move from face to face therapy to ‘remote’ therapy back in the autumn of last year, because we are travelling overseas on our sailing yacht, I want to offer some reflections on how it is different and what helped the transition. There have been obstacles, which I acknowledge, but I generally focus on what has worked to overcome these.

I have also drawn on the wisdom of therapists and survivors I know who have experience to share. Big thanks to all those who contributed. All views are of course my own, and are based on my belief that the therapeutic relationship is one of compassion and trust. All relationships are based on connections, and that goes both ways. I believe it is important to connect with and care about my therapist, as well as for her to have care and compassion for me. That doesn’t mean that we have the same role – I am not there to meet her needs. But I can be considerate and kind in my dealings with her and take responsibility for my part in getting the best from our work together. This point of view will be obvious in some of the things I am suggesting.

Of course we are all unique so not everything here will be relevant or useful to you. Please feel free to take what you can, and to disagree (constructively) and add your own experience and wisdom in the comments, or privately through the contact page.

Some thoughts on what we call this expression of therapy. I have considered and rejected several terms:

Online – refers to one mode of communication; but of course we could use phone, text, email, videos, even letters…
Virtual – implies it isn’t real, which of course it is.
Remote, dislocated or detached– implies that we are also emotionally distant, which shouldn’t/needn’t be the case.
Distant – similar problems to ‘remote’, plus in the current situation you could live in the same street but still have to meet in different spaces.

I was drawn to ‘physically (or geographically) secluded’ because it recognises there is a degree of separation that we might need to work at overcoming; but there is no need to be emotionally or relationally separated just because we cannot meet in the same physical space. In the end I have chosen ‘Mobile Therapy’ because I like to emphasise the positive (not what is lacking) and as I see it, I am staying in my home base and the therapy is coming to me! (I would be glad for someone to come up with an even better term).

Helps and Hinderances
Recognise that connecting through different technologies will be triggering for some, enabling for others, unsafe or impossible for a few.

I know many survivors who struggle to get out of the house some days, or even at all, never mind through the door of a therapy room. A wider acceptance of therapy that comes to me, via different communication methods, and an increase in its availability, is therefore welcome and inclusive.

For others, the technology may be difficult or excluding – not everyone has the resources, signal or knowledge to use online technologies. For some of us, it can be positively triggering; for example, if you were filmed or photographed as part of your abuse. For those living in abusive, shared or crowded homes, finding privacy and a safe space may be impossible.

If therapy is a relationship, then the quality of that relationship is important, especially for trauma survivors. Trauma researchers such as Judith Herman and Bessel van de Kock have shown us that a positive relationship of trust and acceptance is not just an essential part of therapy, it is the foundation for all recovery. Trauma ruptures our attachment to care-givers, who abuse us when we expect love. Experiencing a relationship of trust and unconditional positive regard, where we can relearn safe attachment, is the first step towards healing those trauma wounds.

Creating relationship
How do we build such a relationship when we are physically apart? It is a challenge, as so much of our relationship with others is physical. We communicate emotions and thoughts, both verbally and through our body language, gestures, expressions, proximity. The subtle changes in the tone of our voice, the little sighs and mmhmms, the regulatory effect of our steady breathing. Leaning in to signal connection, leaning out to give space. For some therapists and clients, touch and somatic exploration are key.

Video links, (through applications such as Whatsapp, Skype, Zoom) can make this easier than just voice or text. But they still miss a lot of those subtle clues and the physical proximity and non-verbal connection that is usually such a key part of our relationships. So we need to be prepared to work harder to establish connection and trust at the start of a new therapy relationship. Some suggestions to think about:

– can you allow more time for the relationship to build? If you normally work to a fixed number of sessions, this may need to be extended.
– Talk about the challenges of this for each of you at the start, and come up with some solutions together. They will be different for everyone and need different solutions.
– As therapists, have conscious strategies to build relationships through different communication media. A tool such as the One Page Profile, used in social care and social pedagogy, might be adapted here. Both therapist and client share a one page profile about themselves to create connection at the start.
– As clients, we can think about what helps us to connect with our therapist. What is our virtual equivalent of a handshake and introduction? What do you feel comfortable sharing about yourself, to help the level of bonding you need? What would help you trust your therapist?

Developing relationship
In my case, the relationship was already established, although only for six weeks, so I didn’t trust her with everything yet! We have had to work out how to maintain and build our relationship differently, with the additional challenge that I am bobbing about in a yacht several thousand miles away, with unreliable mobile signal. Some things that help us:

– Acknowledging that it is difficult for both of us. Then when I feel frustrated or dejected because I can’t communicate how I wish, it becomes a shared problem that we tackle together, not something else that is wrong with me. We can even share a laugh about it, amidst the frustration.
– Visuals really aid me. We find video calls generally create better connection. When we can only manage voice calls, it really helps me that my therapist has her photo on her profile, so I can still see her smiling face. It helps to keep her real, and a sense of both of us being present in the session. For others, voice calls may be better. Take time to find what suits you.
– Find other ways to sustain connection. We have an agreed level of text and email interaction, that can compensate for the lack of physical presence. Therapists will need to think about how to charge for that.
– I did need a little practice to ensure inter-session interaction didn’t slip into sessions leaking over. After my emails got longer and longer and started to ‘let it all out’, we had to redraw the boundary that this is about connection, not doing therapy. My therapist was quite clear that she would always read my messages, but may not have time to send more than a smiley face, or a quick ‘I heard you – we’ll talk about it next session’ kind of reply. It works for us that I can send an occasional text saying ‘shit’ or ‘yay’ or ‘ouch’ and get an acknowledging, holding reply that helps me to remember that there is a real human being at the other end of the mobile signal, who still cares about me even when we can’t be in the same room.

So how can we be more present with each other, when we can’t be on the same physical space? How to practice safe holding, and co-regulation, and all the other usual tools of the therapy room? It is challenging, and different, but with a little creativity and flexibility, we found alternative ways.

– Practicalities are important. We both needed to think about where we would be when holding the session. How to preserve privacy and a safe space? That can be exceptionally challenging in a small living space such as a boat. I think it was a first for both of us when because of urgent repairs, the only private space I could use was the forward ‘heads’ (boat term for toilet)!
– Setting up the space helps. Therapists might want to think about the light, and having familiar, reassuring things in the background, nothing too intrusive, distracting or disturbing. I gather cushions, a cloth throw, my journal, teddy, a cup of tea, paper and crayons; and negotiate with my husband to have a space undisturbed for at least an hour (even if it is a clean toilet!)
– Talk about safety and privacy beforehand. Check any necessary boundaries around when and where to message, who calls who, what to do if someone interrupts the session, or is using a shared device. Some clients might need a prearranged code word or signal, for example in a domestic abuse situation, to indicate that the session has to end abruptly, or quickly talk about something that isn’t confidential.
– If you are using video, think about where to position the phone /screen so you can see and be seen, without having to hold a phone. Earphones and a microphone help sound quality and privacy.
– Share visuals in other ways. I sometimes draw something and send a photograph of it beforehand. Once I sewed an artefact that helped me to express and explore shame (the ‘cloak of shame’).
– Use other tools that can be started outside the session, for example the worksheets based on Polyvagal Theory, by Deb Dana.
– Create rituals, both shared and individual, to help prepare, start and end the sessions. I try to protect a quiet time before the session to think about what I want to bring; and afterwards to reflect and make notes or draw reflections from the session. This helps to replace the processing time I used to have on the journey to and from the therapy room. —- Our session normally starts with a check-in. Because I have ‘little parts’ who often speak during the session, we have arranged that my therapist will always remind me when we are nearing the end, in time for my adult self to take charge again. I usually text her soon after to say thanks, and maybe name something significant about today. This helps to replace the usual rituals of goodbyes, fetching a coat, walking to the door etc.
– Say what you would do if you were physically together ‘If I was there now I would offer you a hug’.
– Describe what you are feeling and doing ‘I am feeling really scared. I’ve scrunched up in the corner and am hiding behind my pillow.’ Therapists may need to ask more questions to elicit feelings and somatic reactions that you can’t see or sense.
– Use tone of voice and pace to calm and regulate, if you can’t use facial expression, body language and breathing. Often the way my therapist speaks had more impact than what she says (especially when my emotional state means I’m not listening properly!)
– When you are together, and whenever you think of each other between sessions, be conscious of holding each other in your hearts, as real people in relationship, not just disembodied voices or characters in a video.

There will be some losses from the lack of shared physical space, but are there any advantages that are unique to mobile therapy? I can suggest a few:

– It makes therapy more accessible to those who cannot easily travel or leave home, or live in remote areas far from therapy practices.
– Enables us to be more creative about other ways to connect and communicate.
The pauses and time delays of mobile phones over many miles have made us slow down and listen more.
– It has really helped my self-awareness, as I have practiced consciously describing what I know is significant, but my therapist can’t see or hear (‘I want to disappear.’)
– Sometimes I have felt less self-conscious about sharing, because we’re not in the same space. It is easier to hide afterwards, if I do feel awkward about what I have said!
– Even if the plan is to return to the therapy room at a later date, at least (and most importantly) the connection has been sustained. For me, physical presence and touch is important. I am still longing for a leaning in, a softening of the face, a hug when I am distressed. This mobile therapy has helped me to hold on to the hope that we will manage that, when it is possible again.
– Mobile therapy works too! It is different but -dare I say – equal? I have seen and physically felt less; but I have probably talked, and definitely written and drawn more. This works really well for me as writing is my favourite method of communicating and reflecting.

Wounded presence
My six months of ‘mobile therapy’ have sustained me through an extremely painful and challenging #metoo reporting procedure, and some deep trauma processing. It has been a lifeline, a space to process much, to hold me safely and to work on issue such as dissociation, attachment, trauma wounds, shame, emotional pain, self-hate and self-love, forgiveness, my trauma story, faith and spiritual issues. Pretty good for just an hour a week!

For me the main thing has been to remember that we are still the same people, whether we can occupy the same space or not. Our challenges with the transition, and supporting each other to adapt, have sustained that shared wounded presence that I believe is so key to trauma recovery. I am still all the parts I bring to therapy, whether she is in the room or in my earphones. She has shown me that same compassion and big heart, over the 6,000 miles that physically separate us. She has brought herself to meet me in my space, and that is all that matters.

Dana, D, The polyvagal theory in therapy: engaging the rhythm of regulation. London: Nortin & Co.
Herman, J. (1992). Trauma and recovery. New York: Basic Books
Lewis, C., Roberts, N.P., Bethell, A., Robertson, L. & Bisson, J.I. (2018). Internet‐based cognitive and behavioural therapies for post‐traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD011710. DOI: 10.1002/14651858.CD011710.pub2.
Van der Kolk, B. A., Pelkovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996). Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. American Journal of Psychiatry, 153, 83-93.