Susan Warren Warshow, LCSW, LMFT Founder, the DEFT Institute
This article first appeared in the Los Angeles Psychologist Magazine and is reprinted with permission.
author bio at end of article.
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Being a right-brained kind of person with no natural affinity with technology, I've often felt annihilatory rage toward my computer. If you'd told me I'd be presenting a telemedicine workshop, I would have said, "No way!" I empathize with the sense of shock for many of you when the pandemic abruptly thrust you into an online practice.
Hopefully, you’ll find encouragement knowing that I've somehow managed thousands of teletherapy sessions over the years. I began using Zoom to help clients who were ill, didn't have access to the therapy they wanted in their location or didn't have the time to sit on a freeway. My approach (DEFT) involves deep affective trauma reprocessing, shame sensitivity, and creating secure attachment across a wide range of psychopathology.
I'm writing this article for those of you who feel tired, intimidated, or dubious about seeing clients via technology. I'd also like to elaborate on a few of the principles that allow me to reach unconscious emotion, whether through a computer screen or in my office.
Much to my surprise, I've discovered that my clients tolerate unstable internet connections very well, even at highly emotional moments. When the audio/visual breaks up, I tend to feel more upset than my clients. Maybe their tolerance comes because we prepare for potential problems in advance. And maybe they're just sophisticated about what to expect. But I’ve never had a course of therapy terminated due to technology, despite occasional aggravating moments.
We conducted informal interviews at the DEFT Institute and asked several colleagues about their views on telemedicine before engaging in it. Many held strong negative opinions. I wonder if you agree with these representative responses:
Referencing polyvagal theory, one therapist said, "So much goes on at the visceral level that telehealth would not even touch.”
2. "The absence of a full view of the client's body and not being in the same room together inhibits attunement and is certainly less conducive to trauma reprocessing."
Regarding a lack of visceral connection in telehealth, I believe my recorded sessions contradict this idea. My clients become filled with grief, rage, and love just as they experience their feelings sitting in the room with me. My body easily fills with feelings as I immerse myself in their trauma experiences. Therapists will sometimes cry watching my recorded material, just as we can become highly emotional viewing a film. Many of us develop attachments to people we've only known through a screen. The human mind, heart, and spirit have an infinite capacity to connect, Just ask Helen Keller.
Massive amounts of research on telemedicine exist, which include studies on depression, PTSD, and chronic pain. Controlled studies included in a Systematic Review of studies on the use of videoconferencing (VCP) in 2019 reported no statistical differences between VCP patients and patients receiving the same intervention in person.
A University of Zurich study found that online therapy reduced depressive symptoms in 53% of patients compared to 50% of those receiving in-person therapy (Journal of Affective Disorders, 2013). A large scale four-year Johns Hopkins study of approximately 100,000 veterans found the number of days patients were hospitalized dropped by 25 percent if they chose online counseling (Psychiatric Services, April 2012)
How much non-verbal signaling can we perceive through a computer screen? From a paper written by Alan Abbass, MD, and Jasen Elliott, Ph.D.: "Ideally, it is best to have your client sit far enough back from the computer web camera so that you can see them from the waist up or at least the gestures of their arms and upper body. This arrangement allows you to detect changes in muscle tension (e.g., hand clenching, sighing respirations) and other markers of emotional activation. Similarly, it is best for you to back up enough so that the client can see your emotional responses, arm gestures, and other nonverbal responses."
Paul Eckman has written extensively on microexpressions transmitted through the face. My work strongly emphasizes shame sensitivity and seeks to overcome the sense of aloneness and isolation linked to feelings of unworthiness. As I consider all the ways the therapist can create a sense of safety, the feelings that come through the eyes may be the most important. Signaling occurs through facial expressions moving back and forth between us.
One woman expressed this beautifully:
"Your face comes to mind so often when I am in one of my moods where I'm unkind to myself, and a voice comes up that says, 'Be gentle with yourself.' I see your eyes, and I see the compassion that comes from them, and I 'remember' to be present and real in my gentleness, to stop the self- hatred and stop the sabotaging personality from making me miserable."
Unfortunately, problems with a device can make it difficult at times to make eye contact. I told myself that therapy would be impossible without eye contact, but when my client and I had the will to overcome obstacles, we could often find the capacity.
Key to deep affective processing in my work online or in the office is the alliance to uncover unexplored, shameful, or forbidden parts of the self. Creating such a partnership to take new relationship risks requires strong motivation borne of a visceral connection to one's therapeutic goals and the sense that the therapist will "stand by me" through the strongest winds of intense emotion. In collaboration with my client, I essentially chip away at the barriers to intimacy. As these barriers fall by the wayside, the true underlying feelings find a path to freedom.
This process involves raising the client's awareness of specific self-protective strategies and fears of closeness with a heightened sensitivity to shame. Another powerful catalytic component is something I've named the "therapeutic transfer of compassion for self." When such a transfer takes root, a mysterious and seemingly miraculous healing force that I refer to as “will” often emerges, allowing buried affect to bring forth revelations and new capacities for connection. I knew that a visceral attachment had formed through cyberspace when a highly resistant online client emailed me, “It is your caring that is the icing that makes the cake worth eating.”
My conclusion about online therapy is this: the quality of relationship and proximity of the heart transcends time and space.
Susan Warren Warshow, LCSW, LMFT, is the founder of the Dynamic Emotion Focused Therapy Institute (DEFT) and the author of A Therapist’s Handbook to Dissolve Shame and Defense: Master the Moment, soon to be released by Routledge. She is an international presenter, a Certified IEDTA Teacher/Supervisor, a faculty member of the ISTDP Institute, and has published several articles in professional journals. She treats individuals and couples, offers clinical supervision, online therapy, and coaching.