Several years ago I lived and worked in a highly stressful environment with no access to professional support, for over three years. This was one of the hardest experiences of my life, but it did enrich me in a number of ways. One of them was what I learned about remote delivery of professional support, both giving and receiving it. Since my predicament is actually quite common, I’d like to share some of what I learned.
Beautiful mountain kingdom
Imagine a beautiful mountain kingdom, whose lowest point is farther above sea level than that of any other country in the world. The air is clean, there are few cars, snowy peaks rise in the distance in winter months. And, a quarter of the people are HIV positive. Among women between 30 and 40, that rises to half. The nearest hospital equipped to deliver full services at high standards is almost 3 hours drive across the border.
With two toddlers I moved to Maseru in 2010, capitol of the tiny southern African country of Lesotho, following my husband who was working for an international organization. My husband first went for a year alone. In this time we found a great job there for me as well. We thought. It turned out very mixed, but that’s a story for another day.
Working as a therapist alone + no friends = recipe for burnout
For the first year I was blessed with the presence of another counselor also working in the project who became a dear friend and helped me cope with the confusion and distress of the project mismanagement we were experiencing. Then she left the country and for almost a year I had not even one good friend nearby.
I was working with clients victimized by complex trauma. The combination of an impossible administrative environment, a clientele whose emotional impact on me was heavy, and life in a still-new culture with virtually no personal support networks was predictable. Within a matter of months after my friend left I was experiencing classic symptoms of burnout.
Sometimes desperation leads to innovation
I had been doing therapy as a client for several years already when I first left my home in 2004. After the move, I tried to continue with my therapist by Skype and found it unsatisfactory.
But in 2010 I was living in a remote and under-resourced mountain kingdom. I needed professional support and guidance in working with hard cases of gender-based violence. Even more important, I needed someone other than my husband to talk with and help me reconnect to inner resources for coping with our isolated social environment. At that time, I was the only therapist in the country and access to a suitable professional required a 3 hour car trip across the border.
So I decided to try again with what I came to call “e-therapy”. It took more than a year to recover from the burnout, both physically and emotionally, but the support I got was so helpful it felt like it saved my life.
About the time I started regular e-therapy appointments, a new friend arrived, and life began to feel much better. I also expanded my practice, which helped me feel alive professionally and brought meaning to my life. E-therapy is not the way I would have chosen to do therapy, but this extended experience as a client taught me useful things about how to make it work.
The demands of being a therapist made me remember longingly the support I once took as a given at home: regular sessions that I got as a therapist to process challenging cases with a supervisory therapist. Encouraged by my experience with personal therapy on Skype, I now began to use e-therapy for supervisory sessions as well. In the end, I was getting personal therapy, clinical supervision and medical guidance – all electronically!
First try with expressive e-therapy
Necessity again drove me to e-therapy as further needs arose, this time as a therapist. Transition is a given for professionals working abroad and most of my clients were internationals. Some went home to countries where they had access to local professionals, but they wanted support during the transition. Others transferred to posts where there were no local resources for ongoing therapy. Eventually, I left myself, saying goodbye to several clients. E-therapy made it possible to continue support to clients in all the above categories as needed..
As readers of previous posts will know, I use an integrated approach in work with clients. A central pillar is the use of expressive therapy modalities, in particular, psychodrama. Most of my clients had been with me for at least six months prior to leaving, so they were familiar with the experiential tools.
In my first e-therapy sessions as therapist, I used notes from past face-to-face sessions with my client to remind her of psychodrama vignettes she had done in the therapy room with me. At some point this seemed to be insufficient. As I might have done in face-to-face therapy, I suggested we do role reversal and doubling. It worked! It felt surprisingly natural and soon we were back in a familiar flow, using the same therapeutic language we had used in the therapy room. Unexpectedly, expressive e-therapy worked just as well with other clients.
E-therapy in practice
For me, e-therapy does not equal face-to-face work in quality and impact. Nevertheless, people who want to do therapy in circumstances where face-to-face options do not exist can figure out ways to do so that are quite rewarding.
Since I work with clients living in areas with limited services, often they have no access to high speed internet. This means voice only sessions with no video. I try to align expectations with reality in advance. With new clients, I let the person know, by email or preliminary phone call, that what we will be able to do remotely is somewhat limited and will mostly focus on containment, self care and stress management. With clients with whom I’ve already worked face-to-face these constraints don’t apply. We continue where we left off.
The same principles that govern the client-therapist relationship in face-to-face settings apply in e-therapy. The therapist has a duty to consider - and probably to discuss with the client - how to protect anonymity and confidentiality. When the therapist is hired by an organization, this is particularly important and potentially complicated. Organizations rightly feel responsible to make good decisions regarding deployment of their staff and seek professional input from a therapist. This presents dilemmas for protection of confidentiality.
At a minimum, the client needs to know from the beginning, the extent and nature of reporting expected of the therapist to the organization. Organizations need to acknowledge the weaknesses and limitations of long distance therapy/consultation and understand it as a short-term solution, equivalent to R&R leave (eg: Rest & Recuperation 5-7 days rest and recuperation in a remote location).
In each session an e-therapist has to consider standard issues of containment and sustainability. How will the therapist structure the interaction in such a way that the client has space to express emotions, reflect on them and then regroup internally before the session ends and the client returns to gritty reality alone?
This raises of course questions about what type of therapy is useful. My preference is to focus attention of clients on recent experiences rather than past ones, and to help them explore resources, strategies to manage stress and development of a personal self care plan. This is closer to what some might call psychological first aid than to "traditional" therapy.
Usually I find that five or six sessions about one week apart are sufficient to help a client assess causes of stress, pinpoint personal strengths and vulnerabilities in responding to it, review resources for coping, and establish a program for self-care and stress management based on these. Here’s a short outline of a typical series of sessions.
E-support – Psychological First Aid
A large number of service providers in our world are exposed to trauma without proper support. This is true even in economically prosperous places, and far worse many other places. Unfortunately, global warming is likely to increase the problem as disasters increase.
There is little doubt in my mind that in the near future aid organizations will routinely include specialists in secondary trauma on teams working with trauma-afflicted populations, to support other caregivers to cope with the stress of interacting with large numbers of traumatized people. Until that day arrives, e-therapy and self-care consultation may offer a valuable tool for addressing this gap, especially if used in conjunction with R&R.
Do you have experience as a therapist or a client with e-therapy? Please share how you found the experience and your insights about how to make it work.
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