How did the therapeutic process and the intimacy between patient and psychologist change during the pandemic?
During the pandemic, therapists moved all office sessions online, on Skype or WhatsApp Video. So patients either continued with online sessions or dropped out. We asked psychologists how privacy in the therapeutic process is being changed by moving sessions online and whether the relationship between patient and specialist is suffering.
Online therapy sessions are an integrated part of all the resources that a therapist can routinely offer in therapy. There were patients who even before the pandemic preferred to hold sessions in this way (those who had gone abroad and found it easier to open up to a Romanian therapist or patients who could not come to the office).
An online session is conducted via Skype or WhatsApp Video. Just as in the office, the therapist becomes responsible for creating the right emotional space for each individual patient and making them feel comfortable. As sessions now take place on these online platforms, therapists say patients are more reluctant to continue or start therapy.
Difficulties are that in some cases patients feel uncomfortable talking in front of a screen or therapists find it difficult to maintain the atmosphere of the session or to achieve a certain intimacy (especially if there are difficulties with internet connection). “Perhaps the therapeutic relationship develops a little more slowly online than in the office,” says Ana Maria Dobre, psychologist and counselor. “You have to think a bit beforehand, get comfortable with the situation. When you go to the office, you see the office, you see the place where the person is practicing and maybe it gives you a feeling of professionalism, of security. But if you’re online, all you see is a blank wall.”
What’s also missing online is physical proximity. Therapists say it’s more difficult to analyze body language that can help them better understand how sensitive the patient is about a particular topic. Ana-Maria Ionita, a psychologist specializing in experiential therapy (based on living emotion and experience “here and now” and which allows the person to become aware of their own thinking through role-playing, metaphors, stories and various forms of art), does not believe that intimacy is at the same level as in office sessions and says that ideally, there should already be a therapeutic relationship between the psychologist and the client for online sessions to work. “It seems to me that in this online version you can’t do psychotherapy. Maybe counseling on a very specific problem or with some clients with whom you’ve been working for a long time and a relationship is already formed. I don’t think you can work deeply on certain traumas.”
However, online therapy can be an alternative at this time to continue the therapeutic process in which patients have invested energy, time and financial resources. Online therapy works differently for each individual patient and can work depending on how flexible both the therapist and the patient are (if the patient is engaged in the sessions, vulnerable, trusts their therapist and is willing to work with themselves, then the results will continue to show).
As the patient’s space is emotionally safe for them (their room, a place in their home where they feel comfortable), the sessions are intimate: “From what I have experienced these past weeks, [pacienții] they have been able to bring to the forefront the difficulties they had before. This situation has not hindered them from sharing what they are dealing with, beyond the Coronavirus pandemic, so I don’t feel that privacy has been altered”, says Andrada Cosma.
The online environment also offers other tools that psychologists can use: articles, studies or online quizzes or explanatory videos or techniques that can work in the same way as in the office. “As long as you’re a flexible therapist, you can reach people in other ways. I, for example, sometimes tell them that we can keep in touch through messages or voice messages. Sometimes they write, I respond vocally – because there’s more information I can pass on like this,” adds Andrada Cosma.
As for different exercises or techniques they used to work on in the office, psychologists say these can be adjusted and brought online. An example would be cognitive schema-centered therapy, which has an exercise called chairwork, a kind of chair exercise, where the person goes into different defense modes, and when they change modes, they have to get up from the chair and move to another place. “You can come up with solutions like – moving from the place on the couch where he sits at home to another place or just swapping, not necessarily moving. Solutions can be found. I also show videos online, all kinds of exercises, we discuss articles. I use this part and I find it works very well”, adds Ana Maria Dobre.
Oana Ungureanu started online therapy three weeks ago. Every Tuesday, she takes her laptop in her arms, sits on her bed and starts her Skype therapy session. As she lives at home and has a room upstairs, she asked her parents and sister not to go upstairs at all during the session to enjoy privacy. When she was asked by her therapist if she wanted to move the sessions online, she thought it would be a safe option for her, so as not to stop the therapeutic process, especially since the trip to therapy involved the bus and subway. Therapy was as natural a part of her routine as going to college or eating.
The first session was intimidating. She thought it was a new platform and it felt different to interact online or over the phone, compared to in-office meetings. “In the end, I adapted pretty quickly. This online context helps me because I think I can distance myself at any time if something doesn’t feel right or if I’m triggered by a certain state. I just close my laptop and walk away.”
She talks about the things they were talking about before: thoughts that she’s jotted down in her diary up to the time of the session that she’d like to share, how she’s feeling that day, or things that make her uncomfortable. During this time they also talked about how her life has changed during the pandemic: what it’s like to be stuck at home with her family, how to stay motivated and how to better manage her moods.
“I find it more intimate because it’s in my personal space, it’s in my room, the cat is there. Maybe it’s not the same degree of intimacy as physical closeness, but on the other hand, the fact that I’m in my own space, that my things are showing up, it helps me a lot. “
At the same time, she feels there are several distractions: sometimes her cat, her family, the neighborhood dogs, that she feels are disturbing her session.
Oana tells everything she feels during the sessions, she doesn’t feel reluctant to talk to the therapist, especially since she trusts her and they have been in a therapeutic relationship for two years. During this period, Oana is working a lot on introspection. She thinks about the things that make her happy and how she can better adapt and cope with the pandemic. She tries to focus on things that have finality, to let herself feel the uncertainty and analyze it, to see what makes her uncomfortable.
Also during this period she focuses on guided mindfulness exercises. “I listen to the therapist’s voice guiding me. Sometimes [exerciții] it makes me focus on surrounding noises, others on surfaces and my body. And the idea of these exercises, in whatever form, is to keep me mindful, to remain aware of what I’m doing, to try not to think about other things”, says Oana. “I think sometimes I find it easier to concentrate at home, it’s my space and I feel more relaxed. And my body feels safer.”
Online therapy can work at this ime if the therapists and patients involved in the process are flexible and replace some traditional techniques with new ones: ‘I think if you’re in a moment of distress, a lot of rules we have in our mind about how it should be fall away,’ adds Andrada Cosma. “It’s all about having someone you feel emotionally safe with.”
Thus, according to professionals, online therapy can be an alternative to continue the therapeutic process during the pandemic because the patient does not interrupt the therapeutic progress so far and continues their healing (in which they invested time and energy before the pandemic) and can hold the sessions in a familiar space (his room or a place comfortable for them). It also preserves anonymity (for some people for whom it was uncomfortable to come to the practice and stay in the waiting room where they met other patients) and the intimacy from the office (if the patient has a dedicated room for the sessions, where they are alone).
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For more details of practices in Romania offering free or discounted services online: https://mentalhealthforromania.org/serviciu/harta-specialistilor/.
