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From the Couch to the Screen — Online (Group) Therapy

Haim Weinberg, PhD, CGP, FAGPA Published in the Winter 2020 AGPA Group Circle

The future is already here. More group therapists are using a video conference application to facilitate online groups. It would not be surprising for clinicians to assume that moving from the office circle to the screen requires new knowledge and training, and changes the way we think about therapy, self, relationships, intimacy, and human connectedness. This article focuses on the main obstacles that exist when we work online with patients, especially in video communication and specifically with groups.

First, we must consider legal and ethical guidelines: 1. Do not practice across state borders; and, 2. Comply with HIPPA standards. The first requirement means that if you are licensed in California, you cannot have a group member from New York in your online therapy group (although lately, some states started flexing this rule). The second requirement excludes the popular application Skype since it is not HIPAA compliant and does not notify clinicians when breaches occur. In addition, cyberspace has loose boundaries, so we should take extra measures to protect confidentiality in online communication. We may also request members to review and sign a Group Contract that overviews the risks they may encounter when joining an on-line group.

Screen relations (Russell, 2015) reduce human connection from three to two dimensions. As therapeutic outcome depends mainly on the relationship between the client and the therapist, we should identify what is missing in that online relationship and find ways to overcome it.

While my main assertion is that online therapy is not the same as in-person therapy, this does not mean that we cannot help our clients online. We can reach good results in online therapy, and contemporary research is finding positive therapeutic outcomes of online treatment (Dunstan & Tooth, 2012). Most of this research measures the efficacy of on-line CBT group therapy modalities.

The question of whether it is the same therapy or a different one than in-person therapy is related to the dilemma of how much we want to force this similarity on the setting. Take, for example, the issue of the seating arrangement. Using video conferencing, we usually see only the upper half body of the participants, or sometimes just the face. If we want the situation to reflect the same “reality” we have in our offices, we should sit in a couch further from the computer so that the patient will see our full body. We can take it to a ridiculous extreme and require that when we use the psychoanalytic frame of reference online, the analysand should lie in their bed/couch in front of their computer.

So, what are the main obstacles that we should take into consideration and compensate for when we shift our practice to the screen? We can count four main difficulties: 1. losing control of the setting; 2. the disembodied environment; 3. the question of presence; and 4. ignoring the background.

 

Losing control of the setting

The setting is a crucial aspect in dynamic and process-oriented therapy, and many articles and books have been written about it. Usually, the therapist has control over the setting: s/he chooses the decoration in the office, arranges the chairs in a circle (in a group, ideally the same chairs), puts a tissue box in the middle of the circle, arranges for a calm music in the waiting room, etc. Foulkes (1964), used the term “dynamic administration,” meaning that facilitating the group always acquires a dynamic meaning (e.g., different comfortable chairs can be interpreted with hierarchical meaning). Taking care of the environment sends the message that we take care of the patients’ needs. It creates a holding environment. However, when we move to the screen, therapists cannot take care of the environment anymore, as we do not control the environments from which the patients, or group members, connect. We cannot even guarantee that anyone listens to the group conversation on the member’s end. How do we compensate for this shortcoming?

The easiest solution is to instruct the group member to prepare a holding environment for themselves. It can be addressed simply by adding some items to your standard group agreement. For example: “Please connect from a quiet room, with no interruptions, where your privacy is guaranteed.” If you meet with group members before the group in order to bond, screen, and prepare them for the group (a common practice), continue doing it online, and use this meeting to clarify their responsibility for a safe environment. One possible result of shifting the responsibility to the client might be that we encourage more adult coping skills and less regression. It can be an advantage or a disadvantage, depending on the point of view and the specific client.

 

The disembodied environment

The body-to-body interaction is important in any close relationship, including the therapeutic one. The Interpersonal Neuro-Biological approach (IPNB) claims that we regulate one another through our body interactions: The therapists’ warm gaze, their calming tone of voice, and many other aspects of their body, help the group members to feel held and to regulate their affect. Theoreticians who presented at AGPA Connect, such as Porges (2011), Siegel (1999), Schore (2003), Wallin (2007), Iacoboni (2008) and others, all emphasize the importance of the body in human relationship and therapy. They talk about right brain-to-right brain communication and the unconscious influence that our bodies have on one another. Affective, relational, and regulation change mechanisms are central to group psychotherapy. Much of this can be lost when we go online: We lose the eye-to-eye contact so we cannot shift our eyes from one group member to another to signal that we see them. We lose the smell, the pheromones that affect our feeling intimate and attached. How do we regulate the other (and how do group members regulate one another) online? This can even affect co-leaders; I once co-led with someone I knew well whose eyes usually told me when to become more cautious, a message I could not read online!

We should remember that one part of our body is seen more clearly online: the face. We can see and identify facial expressions much better online than in-person because we see people close-up. If we train ourselves to be sensitive to facial expressions, we can get more information about the group members through their faces than in our office. But, of course, this is not enough.

We also should remember that, contrary to the common belief, the body is not absent in online relations. We still sense and feel our body, and the group members still sense theirs. It’s the body-to-body communication that is missing. Ogden and Goldstein (2020), suggest to be more active online in asking the group members to report their body sensations and in requesting that they move in the room (distance themselves from the screen or get closer to it) according to the changing circumstances and needs. As they use the sensorimotor approach, which focuses on the body and sensations, they offer many creative ways to overcome the absence of body interaction in online therapy. As said, it requires more active participation and instructions given by the group therapist. In fact, when we lead an online group, we usually have to adopt a more active approach.

 

The question of presence

Presence has been described as one of the most therapeutic gifts a therapist can offer a client (Geller & Greenberg, 2002). Therapeutic presence is defined as bringing one’s whole self to the engagement with the client and being fully in the moment with and for the client, with little self-centered purpose or goal in mind (Craig, 1986). Therapists’ presence is understood as the ultimate state of moment-by-moment receptivity and deep relational contact. It involves a being with the client rather than a doing to the client. For many reasons, it is much more difficult to stay present online. There are too many distractions, and the screen barrier might decrease and dilute the presence of the therapist. However, just as some television presenters can pass the screen and transmit their presence through the ether, group therapists can learn to do so as well.

One way of increasing presence is to use yourself more. More self-disclosure is helpful in creating presence. The appropriate kind of self-disclosure and transparency is about the here-and-now, namely our feelings toward the group members and the group-as-a-whole. In addition, paying close attention to the facial expressions of group members can help us identify unexpressed frustration and dissatisfaction, especially about the group therapist’s interventions. Taking responsibilities for mistakes and for empathic failures is another way of increasing the presence of the group therapist.

 

Ignoring the background

It is surprising how we ignore events online that we would never ignore in our office. Imagine someone entering the room in which we lead our group. None of us would ignore such an intrusion. However, when someone has passed behind one of the group members when they sit in front of the computer, no one would comment on it, including the group therapist. It is as if these background details become transparent to us. Special attention and training are needed in order to not ignore these events.

 

Conclusion

Leading online groups requires specific training and supervision. Just as it is not enough to be a good individual therapist to become a group therapist, it is not enough to be a good group therapist to become an online one. At AGPA Connect 2020 to be held in New York City this March, I am going to chair a one-day course on online therapy, The Theory and Practice of Online Therapy: Group, Individual, Couple and Family where we will learn best practices with this approach. This course is based on Theory and Practice of Online Therapy (Weinberg and Rolnick, 2020), a book that I co-edited with my colleague Arnon Rolnick, PhD, who will join me in teaching this AGPA Connect course. You are all welcome to join.

 

References

Craig, P.E. (1986). Sanctuary and presence: An existential view of the therapist’s contribution. The Humanistic Psychologist, 14, 22–8.

Dunstan, D.A., & Tooth, S.M. (2012). Treatment via videoconferencing: A pilot study of delivery by clinical psychology trainees. The Australian Journal of Rural Health, 20, 88–94.

Foulkes, S.H. (1964). Therapeutic group analysis. London: George Allen and Unwin.

Geller, S.M., & Greenberg, L.S. (2012). Therapeutic presence: A mindful approach to effective therapy. APA publications.

Iacoboni, M. (2008). Mirroring People: The Science of Empathy and How We Connect with Others. New York: Picador.

Ogden, P. and Godstein, B. (2020). Sensorymotor Psychotherapy from a Distance. In H. Weinberg & A. Rolnick (eds.) Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Families, Groups, and Organizations. pp: 47-65. New York: Routledge.

Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W.W. Norton.

Russell, G.I. (2015). Screen relations: The limits of computer-mediated psychoanalysis and psychotherapy. London: Karnac Books.

Schore, A. N. (2003). Affect Dysregulation and Disorders of the Self, WW Norton & Company, New York

Siegel, D. (1999). The developing mind. New York, NY: Guilford Press.

Wallin, D.J. (2007) 'Attachment in Psychotherapy'. NY: The Guilford Press.

Weinberg, H. (2014). The paradox of internet groups: Alone in the presence of virtual others. London: Karnac Books.

Weinberg, H. & Rolnick A. (eds.) (2020) Theory and practice of online therapy: Internet-delivered interventions for individuals, families, groups, and organizations. New York: Routledge.

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