Online Therapy in the COVID-19 Era

The outbreak of COVID-19 has thrown the world into disarray. With many countries going into lockdown, most therapists have been forced to undertake online therapy for some, or all of their clients. For many of us this has been a shock and we have had to re-think how we do therapy. There have been some struggles and some surprisingly positive stories. Most of us agree we have got to know our clients (and sometimes their pets!) on a whole new level. In this compilation of stories we hear four very different, but encouraging stories about working online.

Our Skinless knowing – an online session with a sick client
By Orit Badouk Epstein

Lockdown – first week.

Today, for the first time, I saw an infected and sick client for therapy. At first I said No! Stay in bed, please. But she pleaded saying that the isolation was worse than the disease, and so it didn’t take long before I agreed.

Seated close by, our heads almost touching the screen, I felt protected by the generosity of Skype, but I won’t lie, my mirror neurons fired; I flinched at every sneeze. My body shuddered each time she coughed. Nevertheless, like when Clarence Starling first visited Hannibal Lecter in prison, I too, felt somewhat invincible, facing this unpredictable and raging virus.

She felt poorly, her usual youthful look was pale. The heat on her body was invisible, yet noticeable. Her chest felt tight, and occasionally she would run out of breath, and so for a while we sat in silence, not doing very much else.

Whatever definition we hold for our modalities of therapy, this union was the most unconventional I’ve had by far. I felt like a therapist, a priest, a friend, and a mother who couldn’t hold her sick child.

We then decided that half an hour was enough. I told her that she can fight it, that she is a true hero and how proud I was of her. She said that she felt held, our closeness widened. She was grateful, and so was I.

I wished her better. I wish you all better.

Some surprising benefits of lockdown
By Pam Stavropoulos

Telehealth seems not only to work for some clients, but to assist self-states which have not presented in session previously. These comments (reproduced with permission), come from a client with whom I have had weekly sessions for several years, who scarcely spoke for the first couple, and who has multiple disassociated self-states.

She emailed a dream description which I found extraordinary; she spoke of feeling `exhilarated’ (not a word I have ever heard her use, or a state I had any sense she had experienced) during a train trip in the mountains which afforded a panoramic view, `pristine heavenly views’, and (this bit did not surprise me) `no humans in sight’.

She also followed with this reflection on her experience of social isolation and lockdown. She is a professional person, who is highly competent in her work, but as the above description suggests, finds interaction with others challenging to the point of being excruciating:

`The pandemic (lockdown) has been such a good time that “losing it” (lockdown) is really sad. It is not the same as just taking some leave and being alone. It was special because everyone else was also in the same boat and everyone was isolating. That’s it! If I am isolating by myself when others are having fun and going out with friends, then I am the one that is different. But now everyone is the same as me, and do you have any idea how good that feels? How ‘normal’ it feels? I know some people who also really “enjoy” the stand down and lockdown, but I’m not sure if it is for the same reason. It is not simply about having time alone. It is that EVERYONE is locked down. It feels really good to be part of what everyone is ‘going through’. It sounds really selfish… but yeah… I don’t mean that I want anyone else to suffer… I hope you know what I mean…’

`I also had another thought the other day. That somehow even the ones suffering now are relatively lucky because a lot of people are in the same boat and the world, no matter who it is, seems to understand this. Even governments are worried about people’s mental health. And on top of that the cause of the trauma is a virus. How can you blame a virus? … We can blame world leaders for not being transparent or serious about the pandemic. We can blame them for their inactions. But all that is an injustice towards a large group of people and everyone understands and sympathises. And at the end the virus is what does the killing and suffering. It is not a person hurting another person. If anyone was to say they are depressed because of the pandemic they don’t need to explain anything’.

Currently she is musing on the possibility that `returning to the world’ after the shared experience of lockdown may make it easier for her to communicate her preference not to be as sociable as she consistently felt pressure to perform before.

Have been working with a complex PTSD patient for several years now emphasizing self -regulation skills that has relied heavily on incorporating clinical hypnosis. One skill has been the daily use of self-hypnosis.

Meeting Pets in Therapy
By Jeff Schumacher

I have been working with a complex PTSD patient for several years now emphasizing self -regulation skills that has relied heavily on incorporating clinical hypnosis. One skill has been the daily use of self-hypnosis.

Over time, when hypnosis was used in person, Ms. T would rely more and more on placing herself into trance, and less and less on me providing an induction. However when online counselling started there was a bit of a need for me to provide the induction, which at first I balked at, then negotiated for my doing so on a temporary basis until Ms. T felt more confident once again doing so.

Did I mention that Ms.T has four chihuahuas? So not only was I feeling apprehensive about working online hypnotically, there was the distraction of the dogs to utilize in some way. The first few efforts were not ideal, one visit I watched her dog licking the phone while I was talking, another time there was one dog’s reaction to a neighbor’s lawnmower to deal with. Interestingly though, Ms. T reported that the dogs were gradually settling more and more over time. So we persisted, and now Ms. T tells her pets “it’s time for therapy” and they all jump on the sofa, settle in, and as they listen to my voice they gradually mellow out and go to sleep!

Helping child parts understand and orientate to telehealth
By Kate McMaugh

Just as Australia was starting to prepare for lockdown, an agency I work for made a decision to cease face to face sessions and move to online counselling. This was discussed with therapists at a fairly late evening meeting, and we were allowed one face-to-face session to prepare our clients to move to telehealth.

Unfortunately for me, I was working at the agency the very next day. I felt thrown by the suddenness of this change, by the chaos and confusion of the time, and the uncertainty we all faced. Working with DID in a sparsely populated nation has meant that I have been often approached to offer online therapy to people with DID who live in regional or remote locations. I have declined, concerned about client safety and also feeling it would restrict me to just ‘talking therapy’. Now, however, I was faced with having to do just that, with four of my seven clients the next day having DID.

I quickly faced a challenge I had never really thought of before: how to help dissociated child parts, often lost back in time, to understand the concept of telehealth? With my first DID client of the day, I spent most of the session talking this through and explaining how to use my telehealth platform. The client had never used any online meeting platform before. When I eventually felt confident she understood the platform and the process, I then asked if we could check inside how her child parts were feeling about the change. She listened for a moment in silence then said:

‘They’re really confused. They want to know if you’re going to be on TV.’

That threw me a bit. ‘No, I’m not on the TV. I’ll be on your computer.’

‘Like youtube?’

That was also a bit unexpected. ‘No, not like youtube.’

‘Will the ‘puter’ talk to me?

‘No. I’ll be talking to you. You’ll hear me. It’s like talking on the telephone, except you can see me as well.’

(Giggles) ‘That can’t happen. You can’t see on the phone!’

An exasperated adult part came back to the front. ‘For God’s sake, Kate. She thinks it’s still 1979! Try explaining teleconferencing to someone from 1979.’

The enormity of that sat with me for a minute. (I had a sudden vision of those old phones with the round dial and curly cords). ‘Okay, let’s use this as a chance to help them orientate to the present. How about next session we ask them to peek out through your eyes while you show them your computer? They can see me on screen then.’

They did come to therapy that first online session and spent quite a few minutes pulling faces at the camera and giggling with delight as they watched their own picture. The adult selves were somewhat embarrassed by this, but I have to admit I enjoyed spending some time with aspects of herself who were curious and playful. Mostly in therapy we are dealing with aspects of self who are distressed and traumatised.

This client, and I, have adapted well to online therapy and I think we work just as intensely and meaningfully online as we do face to face. In fact, I have been surprised by what has been possible with my DID clients. Yes, some techniques such as EMDR, sensorimotor work, and art therapy require some creativity to adapt, but there are other bonuses. Child parts have shown me items from their self-soothing kits and their sleep kits which are too big to bring to therapy (e.g. extra-large soft toys!). I have met beloved pets for the first time. Sometimes family or carers have been introduced to me. I have also still been able to do internal meetings, talk through to parts and help with the creation of safe places in their inscape. Even EMDR with tapping has been possible. Working online has become the new normal. It is only when I stop to think how much has changed, so quickly, that I feel a bit disconcerted. Only a few months ago, none of this was even imagined.