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What happens to therapeutic relationships when I practice online?

This week marks an important anniversary - it's been 2 years since I became a cybertherapist. I remember how a diary-full of cancelled clients and school closures had left me out on a limb. I paced around at home, unable to enjoy the warm sunshine that beckoned me to go outside and enjoy the best of the British Springtime. Glorious weather could not mask the rapidly growing sense of pre-pandemic panic and a widespread fear of the unknown, and being outside in nature felt strangely unsafe. It's hardly surprising that turned on my laptop and searched for the first available online therapy training I could find. I set myself a goal to complete endless modules and online lectures, partly as a distraction from the new, COVID-shaped world, maybe because I felt that working online was an inevitable fate for all of us, and I may as well be armed and ready for when it happened. As a woman in my early 50's I felt a nagging combination of dread and frustration. Psychotherapy is my 2nd career that was carefully chosen as an escape from technology and automation. My age and life experience would be valued and not a hinderance. This was not how I imagined things would turn out.


The decision to take my entire private practice online seemed a fitting attempt to make my 'graduation' as a cybertherapist into something that mattered to everyone other than myself. I remember feeling like it was now or never. Part of me was excited to remove the word 'psycho' from my title, but I could barely say the word 'cybertherapist' without feeling slightly uncomfortable. This was going to be tricky!



At fist, I did my best to hold together a 'mash-up' of apps, innovation and my traditional modality - it was a make-shift marriage of technology, creative arts and psychoanalysis. My practice already embraced the concepts of immersion and distancing, and the impact on emotional arousal, all of which are vital components to the therapeutic process (Barbosa et al., 2017) Now I had the task to learn about immersive technology-based experiences; what it's like to see myself through a different lens, from different perspectives, and find simple ways for my clients to do the same online, in creative, meaningful ways. I gave myself an extended educational journey to experience different modes of technology with various objectives to shut out the world through the field of view, sound, vision and engage with a representational experience. (Bailey, 2017)


I now feel it's time to develop my experiences into a framework that's credible and robust - something that encompasses my practical questions about transference issues, boundaries, containment and my beliefs about the impact of working online on therapeutic relationships. It’s great being creative and curious, but I don’t expect anyone to pay me to make things up as I go along or worse still, to not practice what I preach. Reflective practice has taught me that there's nothing new under the sun, so I'm always on the lookout for others who have mastered the skills to deliver, in the areas where I lack experience. Since reading about relational approaches to outdoor therapy, (Jordan, 2015) I've become a firm believer that there’s plenty I can learn from eco-therapists, especially the ones who are willing to explore the impact that various levels of exposure to the outdoor space can bring to the therapeutic relationship (Harris, 2015). I reckoned his research would be a good place to start my metaphorical 'ramble', in search of clarity about the lessons I've learned from being in the online environment.


The therapeutic 3rd party


My existing framework is still influenced by Winnicott's views about the role of a 'facilitating environment' in the development of infants. Opinions are divided regarding the long term impact of the internet on our every-day lives (Carr, 2020) and for some, it's questionable whether it should feature at all in psychotherapy with children. Even though I don't believe it should ever take the place of human relationships, I feel in online therapy, that the relationship our clients have with technology and the internet should be considered as important as their relationship with me. This is comparable to Harris's view that clients' relationship with nature is as important as their relationship with the eco-therapist. (Harris, 2015). In reality, it's taken me a while to consider the online environment as a vital 3rd party to the therapy, and of equal importance. I've worked hard to give it acceptance, respect and sufficient boundaries; I acknowledge that just like nature, there's no hope of controlling it in the way that I could control an enclosed space.


To make space for my new therapeutic partner, I've needed to actively dismantle some of the boundaries that I have carried with me based on inequalities, hierarchies, and defences that protect a well-respected way of working in therapy based on object relations. I've probably found it easier than many to embrace this new union; After graduating as a psychotherapist, I was ready to create an authentic profile for myself. My 5-year learning journey to achieve an MA had involved many deeply painful experiences; a neurotypical, Eurocentric focus to the training meant disconnecting myself from significant parts of my identity in order to make the grade. In hindsight, although I was ready to dissolve my relationship with such a painful process, I was naive about the vast possibilities and new perspectives that cyberspace would bring to my identity and my practice. Personally and professionally, there have been far more gains than losses and I feel more freedom and support to be myself than ever before.


The gateway to a liminal space


My relationship with MyCybertherapySpace VR® my virtual therapy room, is an effort to hold onto the parts of my training which I still firmly believe in, and to bridge the gap between immersive tech and what is left of my original frameworks. It’s my inner longing to preserve the formality of setting up my therapy space in a certain manner and a way for my clients to cross into a threshold, which takes them away from their usual online social situations (Harris, 2015). My virtual therapy room represents an online liminal space which belongs to neither them nor me. Maybe having a ritual for that process is far more important for me than for my clients and many of my peers, but it also helps me to communicate with the stakeholders who commission my therapy service. For some, it represents something reassuringly familiar about therapy, holding their feelings of uncertainties, and allowing them to think more positively about the option of using technology in the therapy space.


I also draw from Winnicott’s frameworks for the parts of my therapeutic practice where I use images and objects to help clients to cross in and out of transitional spaces (Winnicott, 1971:2) and Jung's approach to explore the symbolic value of the various objects and characters (Jung, Jung and Franz, 1968) I’m really excited by the potential to use Augmented Reality to enable us to visualise our inner realities and our outer lives in these spaces and the challenges of integrating this into the therapy space I provide.

 

I'm a particular type of NPC, one which can learn and be changed and challenged in equal measure to the impact I have on my clients.

 


The human presence in the therapy


It's been interesting to observe my process as I project my own inner landscape onto the online world. Over the last 2 years I've experienced highs and lows as I have reluctantly relinquished control, trusting the creative process and re-discovering how to become a competent, child-centred supporter in the online therapy. In therapy sessions using video games, I'm comfortable describing myself as a therapeutic Non-Player Character (NPC), a character who is not controlled by a player. I don't see myself as being unable to think for myself, and controlled by a form of Artificial Intelligence (Cambridge University Press, 2022). When clients are fully immersed in a video game where I cannot keep pace, it's hard to not feel dismissed, and as redundant as a driver in a driverless car, yet I can also see myself as the source of much-needed tacit knowledge (Carr, 2020). I'm curious about how much tacit knowledge will always be needed in therapeutic relationships but for now, I consider myself to be a unique combination of human-NPC, one which can learn and be changed and challenged just as much as I impact my clients. For the first time, I feel this comes from a place of confident empowerment, and not from inner-anxiety.


I'm getting better at handling objections when I'm asked to explain my therapeutic framework, especially when others use dismissive language to express how clients 'prefer' a face-to-face therapist, or further still, that online therapy is 'not appropriate' for a particular client. For me, it's like defending someone's preference for a manual vehicle over an automatic one. I fully understand how passionate we can be for our own preferences and personally, I argue just as strongly for the right to keep my manual car. I only intend to part with it when I'm forced to by legislation!


The consumer becomes a creator


It's been many years since I had heard or used the term, 'skin in the game', but it resonated with me when a colleague recently described their personal investment in a venture they are involved in. I feel that having 'skin' in the online games and interventions I use has changed my outlook and attitude from a consumer to being a creator, giving back as much as I take from the online community. It drives my passion and my expectation that when I put the effort into learning and developing my tech skills, I will reap the rewards. Most recently I've revived my latent interest in simple coding, (who knew my humble CSE Computer Studies would pay dividends now?) which means that I have made more investment in the games and interventions that I use with my clients. I'll never be a programmer, but I do have more freedom and competence to support clients to take the direction of their choice, to be impacted by the landscapes they encounter online and express the symbolism that connects them to their inner landscapes. And other times, I simply allow ‘online nature’ to take its course.


This feels like a good place to be, given my initial concern that my lack of online experience, compared to some of my clients, brings inequality and additional transference issues into the therapy space. I can dispense with the challenge to become a 'gamer' in order prove that I was 'good enough' to use video games in therapy. It was not long ago since I relied on shelves and boxes filled with puppets and therapy toys. I have now made space in my mind and my practice for clients to create meaningful images, objects and experiences of their own, and to project onto the online environment what they would possibly have projected onto me.

 

I support clients to create meaningful images, objects and experiences of their own, and to project onto the environment what they would possibly have projected onto me.

 


Crossing Boundaries


Nowadays, I find it more and more difficult to explain to my tech-savvy clients why I don't allow us to play together in spaces where they might encounter others. Whilst I fully endorse the need for a ‘psychic boundary’ (Harris, 2015), for privacy and confidentiality, there is also a need to consider unexpected encounters. These are similar to the animals and other humans that clients might encounter when working outdoors. I'm often left wondering whether there is meaning and importance to everything and everyone who we might encounter in online spaces, similar to the animal and human-like characters you come across while exploring in Minecraft. By expanding the range of video games I now play in online therapy, there is now more space for interactive monsters, monstrous feelings, natural aggression and all of the elements of natural, developmental play. (McCarthy, 2007). I’ve seen first hand how important it is to allow my clients to witness how I deal with the unpredictable, frustrating nature of online forces beyond my control. Harris compares uncontrollable forces of nature in outdoor therapy with all the things most of us have faced with our parents (Harris, 2015). I wonder whether tech issues could also be compared to a symbolic/transferential mother?


Harris concludes that there is no clear answer to knowing the impact, if any, of the outdoor space on the therapeutic relationship; I believe the same is currently true for the online and virtual environments. My cyber-therapeutic framework is clearer than it was, but still work in progress (as it should be). I’m relieved that there are other modalities of therapy where practitioners are embracing positive therapeutic outcomes yet maintain the curiosity to challenge and explore. We're not the first profession to face a future where we are ill-prepared for change involving technology and automation. It's encouraging to see the flurry of recent conferences, papers and coalitions where well-respected mental health practitioners are seeking ways to make VR, XR and the Metaverse into safer immersive spaces, making it easier for therapists like me to use them as our 'partners' for mental health support. If virtual worlds and online spaces will be with us for the foreseeable future, it makes sense to learn how to embrace a connection to something larger than the conventional self (Harris, 2015) and support our clients to gain the most from online relationships whether in or outside of the therapy space.

 

References:


Barbosa, E., Amendoeira, M., Ferreira, T., Teixeira, A., Pinto-Gouveia, J. and Salgado, J., 2017. Immersion and distancing across the therapeutic process: relationship to symptoms and emotional arousal. Research in Psychotherapy: Psychopathology, Process and Outcome, 20(2).


Carr, N., 2020. The Shallows. [S.I.]: W. W. Norton & Company.


Dictionary.cambridge.org. 2022. NPC. [online] Available at: <https://dictionary.cambridge.org/dictionary/english/npc> [Accessed 21 April 2022].


Harris, A., 2015. What impact does working outdoors have on the therapeutic relationship? An interview with ecotherapist David Key. Self &amp; Society, 43(2), pp.120-127.


Jung, C., Jung, C. and Franz, M., 1968. Man and his symbols. New York: Dell.

Jordan, M., 2015. Nature and therapy. 1st ed. New York: Routledge.


McCarthy, D., 2007. "If you turned into a monster". London: Jessica Kingsley.


Winnicott, D., 1971. Playing and Reality.


Winnicott, D., 1990. The maturational process and the facilitating environment. 1st ed. Routledge: International Universities Press.


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Lesley Simpson-Gray