Trauma and Teletherapy
Discerning Our Clients’ Needs
Over the phone lines, I could hear Maria’s voice trembling in protest. “I can’t believe you’re doing this!” she cried. It was mid-March, and I’d just told my client that we wouldn’t be able to continue meeting in person for an unknown period of time.
I tried to reassure her. “It’s not safe for us to meet in person, but I have a lot of experience doing therapy with clients online,” I said. “We can definitely continue our work together. It may seem strange at first, but you’ll get used to seeing me on the screen.” I made my voice as soothing as possible. “Hopefully, this pandemic will be under control soon. Then we’ll meet again in person.”
Maria was inconsolable. “It’s already bad enough that you’ve been away on vacation,” she wailed. “Now you’re dropping this bomb on me and expect me to be okay with it?” Her tone stiffened in anger. “Well, I’m not okay! I feel abandoned and alone! I’ve always had it in the back of my mind that you’d abandon me, just like everyone else in my life. And my worst nightmare is coming true.”
As I listened to the anguish in Maria’s voice, a painful awareness of my own arose: maybe there was some truth in her accusations. Was I inadvertently stepping into a reenactment of her childhood by suddenly changing course without warning or preparation? Was I actually the one abandoning her now, even though I was trying to protect both of us in the midst of an emergency health crisis?
Maria had grown up in a violent, alcoholic family. The only thing she’d been able to count on was unpredictability. The younger of two children, she’d watched and heard her parents fight bitterly, until they’d separated when Maria was six. Her alcoholic father took the kids. From that point on, she and her brother were limited to several visits a year with her mother, who was clearly happier to see her children leave than stay. Meanwhile, her father’s daily drinking worsened, and his eruptions of rage became more frequent, often continuing through the night. There was no sense of safety, no source of comfort. She remembers calling her mother on the phone regularly, begging her to let her and her brother live with her. The answer was always no. During one of these pleading calls, her mother crisply suggested, “Curl up in a blanket.”
And now, here I was, Maria’s therapist, on the other end of the phone as she pleaded with me to see her in person—in the same way she must have pleaded with her mother. “I don’t understand why you won’t see me!” she cried.
“It’s not that I don’t want to,” I said. “It’s because it’s not safe, and I’m doing what I believe is best for you, especially since I could already be exposed to the virus from my recent travels.”
Maria was unmoved by my logic. “I’m willing to take the risk,” she said. “I have to see you one more time in person. If I don’t, it feels like I’ll never see you again. I’m scared I’ll lose it.”
Reluctantly, I agreed. Observing strict social-distancing guidelines, we sat in my office and talked more about what was triggering her and the best way to continue working together, going forward. While Maria understood that her overwhelming sense of fear and abandonment was about her childhood, she said, “I can’t help but react that way.” As a trauma therapist, I understood her reaction. For someone who’d been abandoned as a child, this was more than a health crisis. My decision to go virtual was intended to be life-preserving, but for Maria, it felt life-threatening.
Our in-person session eased the transition to a virtual format, but only a bit. Maria had lost her husband two years before, and now, living alone amid a pandemic with no end in sight, she felt her sense of loneliness and disconnection deepening. After just a few online sessions, she reported feeling increasingly cut off from me, and from herself. “I’m alone,” she said. “I’m not making that up in my head. It’s real.”
When Teletherapy Is a Trigger
When I converted to online therapy last spring, it seemed the only obvious solution for the health of everyone concerned. And for some clients, it’s worked perfectly well—or well enough, anyway. But in my experience, teletherapy can have unintended negative consequences. As a trauma specialist for 30 years, I practice and teach eye movement desensitization and reprocessing (EMDR) therapy, emphasizing the centrality of the therapeutic alliance as the container that makes it possible for clients to approach their trauma. As I began seeing clients online, it quickly became evident that for some of my more severely traumatized clients, especially those who have attachment trauma and dissociative disorders, moving to “screen therapy” posed some real hazards. Not only could it create barriers to treatment, but in some cases, it could actually worsen symptoms. I’d seen it with Maria and with others: teletherapy can be a trigger itself.
Many of my clients have tried hard to adapt. Janine, who also has complex trauma and attachment difficulties, was initially open to online therapy. Even though she lived alone and struggled with depression, she had underlying health conditions and didn’t want to risk exposing herself to the virus. She grew up in a large family and is now unable to see any of her extended family or friends, except online.
As a teenager, Janine had been sent away to boarding school, where she’d been sexually abused by a teacher. We were in the throes of processing these memories with EMDR when the pandemic hit, and she readily agreed to switch to a virtual format. She’d already experienced her symptoms abating and felt optimistic about making continued progress.
But after several online sessions, Janine reported that she’d begun to feel distant from me. “Everything feels flat, kind of one-dimensional,” she said. For the next several weeks, we worked with this painful experience of separateness, and I hoped that, in time, teletherapy would feel more comfortable to her.
To try to maintain connection, I asked her about her experience more often throughout the session. I moved my body toward and away from the camera to try to offset her experience of one dimensionality. I dug into my toolbox and brought out every technique I knew to try to reestablish authentic, alive contact with Janine. Nothing helped.
Finally, we surrendered and tried the phone. Almost immediately, Janine felt reconnected to me. We discovered that her having a visual of me without a tactile connection had triggered the experience of being alone in the company of others. “We all kind of did our own thing,” she said of her family of origin. “I never felt like anyone was looking out for me.” The phone allowed her to use my voice to feel into our connection and more readily access her memories, despite the absence of visual cues.
We continued with the trauma processing by phone, relying on our voices to stay in good contact, and I adjusted the tone and pacing of my words to help her regulate her intense emotional experience. Both of us felt that our phone contact was working well; in fact, after one processing session, Janine exclaimed, “This was some of the best work we’ve ever done!” The same thought had also occurred to me. We continued working hard to develop the keenness of our listening, much the same way a blind person develops greater auditory acuity. Quite literally, we were tuning into each other.
The Disappearing Therapist
David, a man in his 60s, is currently seeing me to work with self-esteem and self-regulation issues. His mother suffered postpartum depression after he was born, and he experiences himself as “not enough” in his relationships with others, which he attributes to his mother’s neglect. Although he knows intellectually that her depression had nothing to do with him, he continues to feel that he could’ve done more to engage her into taking better care of him.
In our first video session, David perceived me as being more detached than when we’d meet in person. We agreed that his experience was likely a response to transitioning to an online format, with the loss of the physical connection he relies on to feel more present with me. But I also wondered if he was right—maybe I was more detached. I decided to make more of a proactive effort to be present with him, and to demonstrate that. I made my gestures bigger; I worked with my voice intonation; I moved in and out of the screen. As a therapist himself, David expressed his appreciation for my strenuous efforts. But, he admitted, “They’re really not helping.”
Finally, I asked, “David, what do you think is making you feel so disconnected from me?”
He shook his head. “I don’t really know. It’s just me. I just need too much!”
I responded, “No, David. This isn’t about you, even though this is your go-to response. There’s something we’re missing here.” Desperate to help my client, I went for broke and stood up from my chair, and then backed up a bit from my computer screen so he could see me from head to toe. “What’s your experience now?”
There was a pause. Then he said, “Oh! There you are! I can see you—and I can feel you, too!”
As we began to talk about this experience, it emerged that David relied particularly heavily on reading people’s body language as a means of tracking their response to him. From earliest childhood, he’d learned to depend on these signals to read his depressed mother’s feelings and try to elicit a warmer response from her. His inability to see my whole body limited his access to the subtleties of our nonverbal communication.
“I guess I interpreted the absence of that information as your absence,” he said. Not only was I disembodied to him, but our physical selves weren’t exchanging information as they typically did. The powerful language of the body that allows people to be in communion had just up and vanished.
For clients like David, who have complex trauma and early experiences of pervasive neglect, the absence of a physical source of connection can be devastating. He was triggered into a profound sense of aloneness—that of a young child whose mother is barely responding to him. But once he could name that trigger, and make that past–present connection explicit, he was able to reflect on his experience, rather than be fully absorbed by it.
He and I reconnected around our shared, present-moment reality, which allowed him to restore the sensory-based connection between us that was already familiar to him. “Okay with you if I jump around a little more?” I asked. When he nodded, grinning, I upped my nonverbal game, moving up and down from my chair more frequently, shifting in and out of camera range more dramatically, and further exaggerating my nonverbal gestures so he could better track my presence.
Our video sessions are working pretty well now, but only because we’ve directly addressed and altered the way we connect online. Nevertheless, at times, David will look up at the ceiling or gaze out his window, and sigh loudly. “This just isn’t the same,” he says. “It’s different. I don’t see how we can replicate what happens in your office on Zoom.” No, we can’t. But what we can do is stay aware and adaptable and give it our all.
Doubt and Opportunity
Let’s face it: it’s not just our clients who are having mixed reactions to virtual therapy. We are, too. My community of EMDR therapists has been divided on the issue of offering trauma processing online. Some believe that teletherapy is an obstacle to effective treatment, citing concerns about the dangers of trauma processing without the physical presence of the therapist to ensure the client’s emotional safety. Some trainers have issued blanket statements that EMDR memory processing online is contraindicated, and that therapists should limit their on-screen interventions to techniques designed only to increase stability and provide resources. While I understand these concerns, I also believe it’s dangerous to apply a one-size-fits-all approach to teletherapy. When deciding what kind of approach will work best, we need to look carefully at who our client is, as well as who we are, as therapists and human beings.
In a recent group supervision meeting, a student of mine shared a story of trying to do EMDR with an adolescent client who was meeting with her virtually from her bedroom. Over the course of the hour, every member of Lindsey’s large family found a way to interrupt the session, some of them knocking first, but others just barging into her room unannounced with a question or demand that couldn’t wait. The therapist reported being furious that she wasn’t in control of the client’s situation, so she could ensure a positive therapy experience. I validated my student’s frustration, and then I asked, “By the way, what were you working on with Lindsey? What are your goals for treatment?”
The young therapist ticked off a few goals, the last of which was “establishing good boundaries.” A lightbulb flashed. She realized that she’d missed a powerful, in vivo opportunity to help the teenager assert her boundaries more effectively, rather than getting embroiled in her own inability to control the therapeutic environment in her usual manner. She readily appreciated that her reaction was more about her need to be in control—both professionally and personally, it turned out—than about the situation itself. Moral of the story? Notice and harness opportunities as they naturally present themselves. Trying to exert control over a therapy situation that feels alien is a totally understandable reaction, but rarely a helpful one.
At our next supervision meeting, we asked the young therapist to update us on her work with Lindsey. “I was ready for it this time!” she said. “Right at the start, we made a plan for the next time she got interrupted.” Indeed, later in that session, Lindsey’s older sister burst into the room, clamoring to borrow a skirt. This time, the therapist found herself curious rather than angry. She watched the client turn to her sister. “Please don’t come into my room while I’m in my therapy session,” Lindsey said, her voice shaking just a bit. “If my door is closed, it needs to stay closed. We’ll deal with the skirt when I’m done.” The sister clucked her tongue and flounced out of the room, slamming the door after her. And the clinician and client shared a smile.
This was a triumph for the therapist as well as Lindsey. Working with our clients from home offers a unique opportunity to understand and sometimes experience firsthand the everyday challenges our clients contend with. With Lindsey and many others, the struggles around online therapy center more around their physical environment than their capacity to respond to teletherapy itself. The more the clinician can become aware of this larger environment and use it productively, the more effective virtual therapy can be.
I’ve experienced this in my own practice. With Maria, who’d vehemently protested the transition to online sessions, I’ve come to enjoy sharing her relationship with her two cats as part of our therapy hour. While I initially saw them as furry intruders, now I can see how they soothe Maria when she becomes upset and help her return to the present when she begins to feel disconnected. Who’d have thought that Pete and Repeat would become significant participants in therapy as Maria and I navigate our new, virtual space together?
Stressed to the Max
While some clients need to set better limits with others in the space they share, others don’t have the space to begin with. Over the summer, when the pandemic was pushing the healthcare system to its limits, I began working with Debra, an emergency room doctor. Because she had no privacy at home, she asked if we could do teletherapy in her car. This was a new one for me, but I thought, Why not? There was a second challenge: unlike with many of my clients, Debra and I had never met in person before, so there was no preexisting trust and connection between us. We’d have to establish that from moment to moment.
Debra’s presenting problems were urgent. People in her hospital were dying from COVID-19 every day. She was overwhelmed, sleep deprived, and struggling to concentrate at work. Given her long shifts at the hospital, sometimes days would go by before she saw her family. Moreover, her wife struggled with alcoholism. Debra described acute symptoms of PTSD.
Quickly, I had to size up my new client’s capacity to tolerate the processing demands of EMDR memory work, as well as whether I could track her moment-to-moment experience remotely, without ever having met her in person. When I asked her how she felt about proceeding with trauma processing, she replied, “Sure, as long as we don’t open up Pandora’s box of childhood memories. I just need to be able to concentrate so I can do my work.” I expressed concern about her sense of safety and privacy while sitting in her car in the heat of summer. She replied, “This is as good as it gets for me. Let’s just do it.”
Debra had purchased the equipment that made it easy for her to self-administer the EMDR technique of bilateral stimulation while having visual access to me via her phone screen. The memory we targeted was a recent experience with a patient who’d become furious with her about the ineffectiveness of a treatment she’d administered. Debra immediately plunged into a familiar negative belief—I’m not enough—accompanied by corresponding surges of shame and anxiety. When I asked her to rate her distress level on a scale from 0 to 10, she didn’t hesitate. “Ten,” she said. Her face was tight and pale.
After several sets of bilateral stimulation, Debra linked the recent distressing situation to two residency experiences in which both patients had died from their conditions. My throat tightened a bit. Here I was in my home office, while Debra was in her car somewhere, potentially tumbling down memory lane into a rabbit hole. “Debra, I know you didn’t want to go into childhood stuff,” I said, “but your brain wants to go to medical school times. Is that okay with you?”
“Yes,” she replied. “I can handle this. In fact, it makes sense that my brain is connecting these experiences. It feels just the same to me. No wonder!” I affirmed her observation, and we were both relieved. We didn’t have to plunge all the way down the rabbit hole; we could feel our way down, step by step. Whew!
After two more sessions of EMDR processing, Debra had significantly improved. She was sleeping well again and could concentrate on work, and her PTSD symptoms had largely disappeared. In our last session, she remarked, “I had another patient get really mad at me this past week—and it didn’t bother me. In fact, I could really understand her frustration and fear.” Onscreen, I watched Debra square her shoulders. “You know what? I feel like I can be her doctor and do the best I can with what we have to offer. As doctors, we’re trained to save people, and right now, we don’t know how. These are hard, hard times for everybody.”
Debra hasn’t come back for therapy, but I think of her often, wondering how she’s doing as a frontline healthcare provider who’s treating patients amid a pandemic, putting herself and her family at risk every day. I was so glad to be able to help her, and grateful that she was able to tolerate teletherapy. In a car, no less. Under great duress. Over and over, my clients’ grit astonishes and humbles me.
Timing is Everything
But just because we can make virtual therapy work doesn’t mean we always should. Gerry was referred to me just as the pandemic was reaching its peak on the East Coast. He made clear that he was comfortable meeting online, as he’d been working in a virtual environment for years. He was seeking EMDR therapy for a panic attack he’d suffered while on a meditation retreat. “It scared me so much I’ve stopped meditating altogether,” he said.
In our first session, Gerry was upfront about his struggle to access his emotions and attune to the emotional states of others. I proposed that we meet online for two or three sessions before deciding how to proceed. I was quietly concerned that it might be difficult to get him to access his emotions and tolerate them without the safety and comfort of an in-person session, where I could help him ease into his experience in small increments.
Gerry was remarkably clear about why he was seeking therapy. “My friend who was also at the meditation retreat thought my panic attack was a result of repressed trauma, and that I needed EMDR,” he said. “So here I am.”
“Hmm,” I said. “What are your thoughts about why you had a panic attack? Have you ever had one before?”
“Nope,” Gerry replied.
“As far as you know, has anyone in your family had panic attacks?” I asked.
“Nope,” he replied again.
“Hmm,” I said again. “Can you think of anything that happened in your life just before you went on the retreat, or even while you were at the retreat, that upset you in some way or was out of the ordinary?”
“Nope,” he replied.
After asking Gerry a few more questions about his current life situation, his relationships, and family history, I asked, “Have you had any anxiety or panic since the meditation retreat?”
He pursed his lips, thinking, and then shook his head. “No, I actually haven’t,” he said. “And it’s been a few weeks.” I ended our first session by asking him to think about whether he’d be willing to do some exploratory work to better understand the root causes of his panic attack, and, if so, to consider whether this was the right time to open that door.
When Gerry and I next met, he told me that he’d thought about my question. “I’m not sure we need to go on with this,” he said. “Since I haven’t had another panic attack, it seems to me that the problem might be solved! What do you think?”
“I think that timing is everything,” I said. “It might be a good idea to go forward, but maybe now isn’t the right time. If you have another panic attack or any other symptoms that concern you, you can always get back in touch. Maybe by then, we can meet in person, which might be a better situation for you and me to take a closer look.”
Since the issue wasn’t time sensitive, we agreed to touch base in a few months if he was interested. For me, Gerry was a tough customer under the best of circumstances. He’d learned to be a spectator of life, rather than a participant, which was challenging for me as a therapist, living as I do in the world of relationships with self and others. More importantly, for someone like Gerry to approach his inner life and feel into his experience for the first time, I strongly believed he’d need the physicality of an in-the-flesh, mutually shared space. Why make the process even harder for him than it already was—and perhaps even hazardous?
The Big Outdoors
Maria, who’s continued to meet with me online, alternates between periods of feeling connected and phases when she “just can’t hold on to it.” Recently, we were talking about the unknown duration of the pandemic and how hard that is for her, because it reminds her so much of her experience growing up. “The only thing I knew for sure was that I never knew what was coming next,” she said. “This feels like the same thing. It’s to the point where I hardly remember what it was like to be in your company, face to face! Isn’t there some way we can meet again in person? Please?”
On the one hand, it felt like déjà vu, listening once again to Maria’s pleading, insistent entreaties; on the other hand, her request seemed legitimate. Part of our work in therapy has been about helping her learn to ask for what she needs, as an adult, in a way that makes it likelier to get a favorable response. So here was another window of opportunity for me to respond to the real-world demands of living amid a pandemic while keeping safe and maintaining appropriate therapeutic boundaries. “Okay, so let’s talk about this,” I said, hedging for time as I reviewed possible options. “How would it be for you to meet me in my backyard, in person, sitting at least six feet away without any physical contact?” I asked. “No hugs, no elbows even.”
There was a brief silence. Then: “I can’t believe you’re even willing to consider this,” she said, a grateful grin spreading across her face. “This is great! Of course, I completely understand and promise to not push for more.”
And so, three weeks later, Maria and I had our first in-person session since March. It had been five months. Because she’d arrived a few minutes early, I escorted her through the backyard gate and took her on a tour of my perennial garden. Then we sat in the chairs I’d arranged earlier, which faced each other beneath the shade of a large Japanese maple. The water pitcher and box of tissues sat on a table nearby. “I’m happy to see you, Maria. I really am,” I said.
“Me too,” she replied, her face shining. “I feel like I’m filling up my gas tank!”
I was glad that Maria could ask for what she needed and that we could figure out a way to make it work without undue complexities. Five weeks later, we had one more backyard session, focusing on how she was going to reach out to her friends and neighbors for more outdoor, in-person visits that allowed her to feel more connected. “This pandemic has forced me to figure out what I need to be okay, and then to figure out how to make that happen,” she said.
“I couldn’t agree more,” I said, and we shared a long, warm smile.
Remote, but Not
Figuring it out. That’s our task, really—to puzzle out how we can best help our clients while keeping everybody safe in a radically changed world. This requires a flexible, inventive spirit on everyone’s part. You may find yourself meeting online with a client who’s sitting in her attic with her laptop, next to a stack of boxes and some insulated pipes. If you meet virtually with a teen in her bedroom, you may end up teaching her how to set boundaries with intrusive family members. Maybe teletherapy turns out to be too frightening for a client and you switch to the phone, or to an outdoor locale. If you use EMDR therapy, you may work with clients who use their cellphone to see your face while moving their eyes back and forth between two smiley faces pasted on their computer screen. They may be crying their eyes out while you’re quietly freaking out, hoping this is all going to turn out okay.
It’s material for a New Yorker cartoon. But it’s also very serious business. In this brave new world of online therapy, we need to recognize that each client has a unique history and set of needs that may or may not be a match for teletherapy. Particularly for traumatized clients, many of whom have attachment disorders, the move to virtual work can trigger experiences of abandonment and panic.
Let me be clear: I’m not making an argument for not using online therapy. Right now, it’s pretty much what’s available, and most of us will be using it for some time. But in my experience, it’s crucial to assess all clients for their capacity to tolerate, and even thrive under, virtual conditions. If they can, that’s great, and certainly convenient. But if they can’t, or can’t fully, we need to stay flexible and creative, looking for opportunities for both therapist and client to grow and learn. We need to figure out how to work remotely without being remote. It’s tricky. It’s an art form. Gradually, and with tons of practice, I believe we can master it.
ILLUSTRATION © ILLUSTRATION SOURCE / LARRY MOORE
CategoriesClinical Practice & Guidance In the Therapy Room Issues & Developments Anxiety & Depression Clinical Skills & Experience Mind, Body, Brain Trauma
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