What’s the Deal with Online Therapy?

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Marlene M. Maheu, a therapist, uses video conferencing to communicate remotely with patients. She has served on task forces to address issues of online therapy. Credit Sandy Huffaker for The New York Times

Online counseling or “web therapy” is an emerging practice in the world of social services.  Although online counseling is not a substitute for traditional psychotherapy, it has many benefits, including flexibility, anonymity, comfort, and convenience.  Perhaps you are nervous about going to therapy—with online counseling you can test it out for as little or as long as you’d like in many different modalities.

Many services are offering “Skype” or video counseling using secure software, or voice phone calls directly with a therapist, or even text message/email therapy that is not offered in “real time”—giving you and the therapist both a chance to respond when most convenient for you.  Whichever modality you choose, the world of online counseling can introduce you to therapy in a non-invasive, comfortable manner at your own pace.

However, online counseling is not appropriate for everyone.  Online counseling likely does not include prescribing medications, which can be essential to the recovery of severe mental illnesses.  It is also not appropriate for anyone who is currently suicidal or homicidal, or anyone who is currently experiencing psychotic symptoms. If this is the case, you should immediately call 911 or your local emergency authority.

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? Read More

Most importantly, anyone who needs intensive support or hospitalization is not a good fit for online counseling. Online counseling should be used as additional support and not a replacement for those needing intensive treatment.  Another limitation of online counseling is the difficulty in interpreting voice tone, body language, and other forms of non-verbal communication in traditional therapy methods.

Although online counseling is not appropriate for everyone and some professionals are still skeptical about it, there are studies showing online counseling can be just as effective as face-to-face in person therapy with a better attendance rate.

The Journal of Affective Disorders reported a University of Zurich study divided a group of 62 patients in half and found that depression was eased in 53 percent of those given online therapy, compared to 50 percent who had in-person counseling. Three months after completing the study, 57 percent of online patients showed no signs of depression compared to 42 percent with conventional therapy.

In an April 2012 edition of Psychiatric Services, it was reported that in a four-year Johns Hopkins study that included close to 100,000 veterans, the number of days that patients were hospitalized dropped by 25 percent if they chose online counseling. This is slightly higher than the number of hospital visits experienced by patients who used face-to-face counseling.

Lastly, according to the American Psychiatric Association in 2007, patients in Ontario, Canada were assigned to face-to-face or live video counseling and experienced statistically the same clinical outcome and level of patient satisfaction. The only difference was that the cost of providing the online service was 10% less per patient.

Overall, online counseling permits the client to access therapy when it’s convenient for them and without having to leave the comfort of their home.  It could be a type of counseling that can reach more people in need which is necessary and important.  What do you think?

Self Doubt in Your Clinical Practice Skills

Self Awareness is critical to the therapeutic process. By being aware of your self-doubt, you are already heading into the right direction. In graduate school, we talked about  the importance  of “use of self” and “self disclosure”.  It is certainly important to talk about how your words and actions will have an impact on the service user, but it’s also important to evaluate how the service user’s responses will affect you.

candoThis is certainly not a new concept in which Freud coined as counter-transference. Not only will the client have feelings towards their therapist, but the therapist will feel both their strengths and inadequacies through the client. A new practitioner starting out in her practice was feeling overwhelm with self-doubt, and she asked the following question:

Hi, I was wondering if you could make a post for me to help my practice? I’m wanting advice on how to portray as a confident practitioner when you may have self doubts, but letting these doubts show may result in the service user ‘walking all over you’. I’m not sure how to word it!

On the surface level, the easy answer would be as Socrates said “I am the wisest man alive, for I know one thing, and that is that I know nothing”. Simply stating, “I am not sure about that, but I might no someone who is” certainly is better than making something up on the fly which will most likely come back to haunt you.  As we peel the layers of the onion, what this interaction really reveals is more about your desire to have the answer.

You are probably responding to the fact that you are their therapist and you are supposed to have “the answer”. We have to remind ourselves and the client that social workers are human beings too. We don’t always have the answer. In our clinical work we make mistakes, we feel things, and don’t know everything. This is why supervision and having a good team behind you is vital, and it is imperative for you check with the team, check with your supervisor, or do more research to expand your knowledge.

Thinking back to working on a psychiatric inpatient unit for adults, I really struggled with the complete lack of insight that comes with psychosis and delusions. I remember meeting with a client who was begging for a discharge due to having an active delusion, and  it was the first time I felt terrible, powerless and even guilty. At the same time, I remembered thinking, you really have no idea why we are keeping you here, and also I remember the feeling of the client was “walking all over me”.

It froze me like a deer in headlights because I had no answer. Then, the client stormed out the room. What I learned to say is that I can’t make these decisions on my own, it is a team decision.  I also discussed my feelings about psychosis and delusions with my supervisor, and I actually utilized a couple of supervision sessions to wrap my head around it.

However, in private practice situation where you are “on your own’, you may need to develop a different strategy. First, I would recommend finding some sort of supervision whether it be with paid professional or a peer.  There is no real computer that you can enter a scenario like this and get a neat answer. The therapeutic process is about assisting people who are in pain or distress in order to help them improve their outcomes. The level of pain and distress can vary greatly and so can your response.

Tackling self-doubt and self-awareness should be an ongoing process for any practitioner. My take home message is that it is normal to feel self-doubt in your practice just as it is to feel confident about a practice method you have may have perfected. Continue to self-reflect and be self-aware of your strengthens and weakness in order to develop a plan to address them. Most importantly, you owe it to yourself to develop and maintain a professional support system that will help you build and grow your practice. I hope this helps, and please feel free to comment below.

Ending the Therapeutic Relationship: Creative Termination Activities

Amy Bucciarelli, MS ATR-BC, LMHC, Board Certified Art Therapist, helped Frank “Dylan” Dinkins make a painting for his parents. Bucciarelli works with pediatrics patients at UF Health Shands Children’s Hospital.

Termination is a highly important part of every therapeutic relationship that should be addressed throughout each stage of the process. While many adult clients have the ability to easily think back to their experience in therapy, for youth this is often more difficult.  Because of this I like to provide clients with some sort of physical representation of their time in therapy that will help them reflect on their experiences, highlight their strengths, remind them of what they learned and provide them with tools they can use to help prevent regression, and even continue their progress on their own.

These activities let you both reflect on their time in therapy and transition out of services in an engaging way. I’ve also found that using metaphors often helps young clients to better understand termination and makes after-care instructions more salient.  Below are some ideas for creative termination activities that are easily adaptable to fit your clients’ needs. I am not sure of the origins of all of them, so please let me know if there is someone that I should be citing.

Session Trackers

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I recently spoke to an intern who was confused when a number of her clients seemed surprised when it came time to terminate, despite her verbal reminders.  It is sometimes helpful for young children to be able to have a visual representation of how many sessions are left, and it can help them better prepare for termination.  One way to do this is to create a session-tracking chart.  In the examples above clients color in one image, or choose a sticker, at the end of each session.  The activity is quick and also provides a good opportunity for therapists to check-in with clients and help process any feelings surrounding termination that come up throughout the process.

Ready to Set Sail: Termination Activity

By Jodi Smith, LCSW, RPT-S at “Play is Powerful”

Supplies: Toy boat, paper boat, paper mache boat, box with a boat drawn on it, etc.

Directions:

  • I’ve found that the use of metaphors increases the amount of information that clients retain and internalize so I use them frequently in termination.  Start by explaining to the client that because of the progress they have made they are ready to sail off on their own.
  • Reflect on what that feels like and process any anxiety, and transition into talking about all the things they will “take” with them to help with their journey.
  • Have the client answer each question and write their response on the back of the cards.  The boat will contain cards related to tools they will take with them (supports, coping skills, etc.), things that may get in their way and strengths (as identified by the client and therapist).  Along with my pre-made cards, I also give them blank ones.

Treasure Chest Termination Activity

Supplies: Treasure box (Michaels Crafts has wooden “treasure” boxes that are cheap and easy to decorate.  A link to directions on how to make a paper one can be found here; Stick-on plastic jewels (found at crafts stores, oriental trading co., etc.); Small note cards (cut to fit the box); Pen.

Directions: First, have your client decorate a treasure chest.  Then stick a jewel to each card as your client writes down the “task” that is assigned to that specific color (see below).  On the back of the card, they include a specific example of how what they identified has helped them in the past and/or how it will help them in the future.  Below are examples of possible color codes, but you should change them to meet your client’s specific age and needs.  In the end, the chest will be full with a stack of jeweled cards.

  • Blue: Strengths (Identified by both the client and therapist)
  • Red: Coping skills
  • Green: Supportive people in their life
  • Orange: Resources from therapist (ex. hotline numbers, therapist referrals or directions for reenrolling in services.)
  • Purple: Self-care activities
  • Pink: Inspiration (future goals, motivational quotes, etc.)
  • Yellow: Things they have learned in therapy

 Suitcase Termination Activity

At termination, your client is finally ready to continue their journey on their own.  Even though they will be leaving you behind, they can pack up everything that they have learned during their time with you to take with them.  This metaphor is easy for most people to identify with and it is a fun activity.

Supplies: Plastic or cardboard suitcase; Blank sticker labels; Paper luggage tag; String; Cards; Travel stickers.

Goals: Process termination; Provide transitional object; Help prevent regression; Identify accomplishments, goals, coping tools, etc.

Directions:

  • Have your client make and/or decorate their suitcase.
  • Then they write something they will “take with them” from their time in therapy on each card provided (I print cards with travel clip-art on the back).  These can be things they have learned, coping skills, supports, resources etc.
  • You can also integrate this with the after-care kit I posted.
  • On the labels, they write or draw goals they have accomplished.  (Like the old suitcases in movies that are covered with stickers of past travels).  I also provide additional travel stickers.
  • On the luggage tag, they write where they are going next.  This could be a new life stage (ex. my 8th graders usually write “high school”) or a goal they would like to accomplish that the contents of the box will help them achieve on their own.
  • Process feelings about termination throughout the activity.

Therapeutic Goodbye Cards

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This is such a simple, yet powerful termination activity.  I got this idea from a client who gave me a very touching thank you note during our last session.  It is something I have kept and reflect back on, and I realized that it could potentially play a similar role for a client.

  • The focus of the content is on the journey through therapy and what has been accomplished.  I highlight strengths, review coping tools and lessons learned, and express my thoughts about termination. In the end, I usually include instructions of what to do if they decide to enter therapy again.  You could also have the client write a letter to their future self that they can read when they are struggling.

Summer Bucket List

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I put a therapeutic twist on this summer craft.  Most school therapists are unable to see clients throughout the summer but may pick up treatment again during the following school year, which is not ideal.  This activity can help encourage adherence to after-care recommendations.

Directions: Have your client design a bucket that will help them to continue your work together on their own and prevent regression.  On the back of the paper bucket, they can write goals for the summer, self-care activities, etc.  For the 3D buckets, these can go on cards placed inside the bucket.  On the shovel, they write down “tools” that will help them to accomplish their goals (social supports, coping skills, resources, etc.)

You’ve Got Mail: Group Termination Activity

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Directions: First, have your clients create their own paper mailbox.  Then, each person, including the therapist, writes a short note to every other member of the group.  You can instruct them to write something that they have gained by knowing that person, a strength they can identify in that person, a motivating message, etc.  The notes are then placed in the mailboxes for the group members to take home.

Graduation 

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Certificates are very simple to create in programs like Word, Pages, etc., and are a good wrap-up for clients who have worked hard to meet their therapeutic goals.  In my example, I left space to write specifics about progress, accomplishments, reflection, etc.  One the last group session we have a “graduation party” where we have fun, reflect on our time together/progress made, and process termination.  They are then presented with their certificate.

10 Ways Therapists Go Wrong

It’s not uncommon for a client to enter my office with previous experiences in therapy elsewhere. When meeting a new client, I always make sure that I ask: “Tell me what you liked or did not like about therapy before. What worked? What didn’t work?”

I don’t want to offend a client in the same way another therapist may have and I really don’t want to waste time trying interventions that just don’t fit.

Here are some of the ways therapists have gone wrong, according to clients I have asked:

1. “They made me talk about _____ when I really needed to work on ______. ” 

Missing the mark.  Sometimes it is hard to not push our own agenda as therapists, especially when our knowledge and experience is telling us what clients really need to work on. Having buy-in from the client is crucial.  I think we explain why it may be important to discuss a certain topic, then clients are more receptive. Another common complaint here is digging up the past when unnecessary.

2. “They were late all the time.”

I have trouble understanding this one. Barring crisis situations, therapists need to respect and model time boundaries. I think 15 minutes is reasonable, but I’ve heard stories of clients consistently waiting over an hour. Frequent cancellations are another common complaint.

3. “I left their office feeling worse than when I came in.”

I think this could relate to unnecessarily digging up the past, but it also has to do with hope.  Of course there will be sessions where problems aren’t solved in 50 minutes, but homework and talking about future improvement is important. Effective therapy can bring up uncomfortable feelings, but hopefully with informed consent and some discussion, clients can learn to accept temporary discomfort as part of getting better.

4. “They wanted to pray during sessions.”

I hear pretty frequently about situations where the therapist tries to bring religion into therapy unsuccessfully. Many clients find religious practices to be a helpful adjunct to their treatment. However, we need to take care to be culturally competent and respectful of others’ religious beliefs. Remember that freedom of religion also means freedom to have no religion for many people.

5. “They relapsed.” or “They invited me to use with them”.

Self-care is so important for therapists, especially when they are in recovery from substance abuse or mental illness themselves. It can be really damaging to a client’s confidence that they will get better if even their expert therapist has failed. It is okay for therapists to have problems, but we are also responsible for demonstrating how to cope with these issues.  If you are having an acute substance abuse or mental health problem you need to get help, even if that means leaving your job until you are well enough to return.

6. “They fell asleep”

This one is hard for me to believe, but I’ve heard it several times. We all have clients who are depressed, flat, monotone or dull, but there is no excuse for falling asleep during a session. If you are so exhausted that you risk falling asleep during a session, then you need to get a strong coffee or cancel appointments for the day and rest up!

7. “It was too expensive.”

This is one that most therapists can’t avoid.  Truth is that overall, therapy is a luxury for most people. Offering sliding scale or case management to get appropriate healthcare resources can help.

8. “They didn’t seem accepting of _____.”

Just fill in the blank with anything remotely controversial. I’ve heard of clients who felt their therapist didn’t respect their sexual orientation, mixed race relationships, spiritual beliefs, culture, politics, you name it.  I think most therapists view themselves as being open minded, but everyone has their own bias and it can really show to sensitive clients. Refer to another provider if you need to.

9. “It seemed like they wanted to talk about their own problems.”

Sounds like a pretty classic self-care issue. It can be really helpful to disclose to clients your own experience, but this needs to be done very carefully and ideally after consult with a supervisor or colleague. If a client gets the feeling that you need them to listen to your problems, they probably will end up feeling like you can’t handle their issues. Not to mention feeling neglected themselves.

10.” They abandoned me.”

This is a by-product of our mental health system that has left too many therapists with the experience of showing up to work only to find a note on a locked door saying the company has closed. It is unfortunate that this happens because it can be so damaging for clients.  My first two jobs as a therapist ended abruptly and despite my attempts, I was forced to say goodbye to my clients with very short or no notice. I felt so guilty and awful that I wasn’t able to even make referrals for some clients to get set up with a different therapist elsewhere.

Ideally terminating the therapeutic relationship should involve wrapping up unresolved therapy issues, transferring to a new therapist, referral for community resources and a session to reflect back on the experience and say goodbye.  It is so rare in life that we get appropriate goodbyes in our relationships, so what a great experience to have if you can provide it.

I think what is most important is that we ask clients about their experiences and approach therapy as a collaborative process.  Checking in with clients periodically throughout treatment provides an opportunity for feedback.  If we are unaware of where we are going wrong, we can’t fix it.  What have your experiences been with helping clients who have dealt with some of these wrongdoings?

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