Are High-Risk Clients Suitable for Online Psychotherapy?

• Into the Virtual Unknown
• Danielle (Joseph’s client)
• Olga (Anastasia’s Client)
• Taking the Risk

We also worried about mastering the technology, as neither of us is particularly skilled in computer matters more complicated than word processing and email composition. Should we use built-in or external cameras? Should we use headsets with boom microphones? How fast of an Internet connection did we and our clients need? And perhaps unnoticed at the time but inspiring a subtle anxiety:

Would we be less skillful as therapists, less confident in our abilities, when we no longer met with a client within the authoritative confines of our own offices?

Another source of anxiety was deciding which clients to accept for online treatment. Uncertain of our ability to work in this new format, we originally believed that we ought to confine our online practice to high-functioning clients—people who’d be able to sustain the supposedly less intimate form of contact and, with only a screen image for bonding, wouldn’t feel detached or abandoned. High-risk clients such as those who self-injured or posed a risk of suicide were definitely off limits. Today, when we discuss the subject of online therapy with some of our colleagues, we encounter similar questioning, and sometimes profound skepticism.

Over the ensuing years, we’ve both become entirely comfortable with the technical interface offered by Skype and confident in our abilities to provide quality online psychotherapy. With experience, we’ve also come to feel that the population of clients who might benefit is much larger than we first believed. There are still limits, of course, especially when there is a serious risk to life or when a client is psychotic; but based on the past five years, we’ve found that nearly all prospective clients can benefit from online psychotherapy.

Joseph first began to envision a larger scope to his potential online practice during his early work with a client who had concealed the extent of her involvement with self-injury at the beginning of treatment.

Anastasia pushed the scope of her work when an ongoing client she had started treating face-to-face in Spain for acute panic attacks had to return to Russia: Transitioning to online therapy was the only way to continue working with her.

Danielle and Olga are two clients who didn’t at first appear to be good candidates for online psychotherapy as they both displayed ongoing instability in moods and behaviors.

Danielle (Joseph’s client)

Danielle had followed my blog for a couple of years before she contacted me for treatment, not long after I began working by Skype. On her client questionnaire, she disclosed a history of self-injury but described it as minor, under control, and not life threatening. She insisted that she wasn’t suicidal. In our email exchanges prior to scheduling a first session, I told her that I couldn’t see her less than twice a week; otherwise, I didn’t feel we’d have the conditions to manage her issues. If I’d been seeing her in person, I would have required the same twice-weekly sessions.

During our first exploratory session, before we committed to working together, I made sure that she had an adequate local support system in case of emergency. Danielle assured me that, if she did at some point feel suicidal or if self-injury became a much larger issue, she had resources to contact: her pastor as well as a local therapy practice to which her prior therapist had belonged before he moved to another city. Danielle was familiar with emergency medical services and knew whom to call. Although I felt a little apprehensive about her history of self-injury, I felt that we’d established the conditions necessary to begin treatment.

From the beginning, Danielle and I developed a strong working relationship. Because she’d read every one of my blog posts, many of which are quite revealing, it didn’t feel to her as if I were a complete stranger. I found her endearing, engaging, and a pleasure to work with. In her line of work, Danielle managed a team remotely and held daily meetings by Skype, so she was even more comfortable with the medium than I was. We met twice a week on Tuesdays and Fridays. It soon began to feel to me no different from meeting a client in person, as difficult as that is for professionals who haven’t worked by Skype to understand.

Although she didn’t disclose the full details of her past until much later, Danielle let me know early on that she’d been sexually molested by more than one of her stepfathers beginning when she was 7 years old. She also told me that her mother had looked the other way when a family friend began abusing Danielle later on; the mother needed the man’s help and essentially gave away her daughter in exchange for it. This arrangement went on for several years.

A month or so into treatment, it became clear that Danielle’s involvement with self-injury was far from “minor”; she admitted that she’d misrepresented how serious it was out of fear that I wouldn’t accept her as a client if she’d told the truth. In fact, I probably would not have taken her into my practice had I known. Relatively inexperienced in working by Skype at that point, I would have assumed that a client who self-injures needed the more immediate contact afforded by in-person therapy.

Minor hair pulling, pinching, and scratching helped Danielle to manage her emotions most of the time—she’d explained this to me at the very beginning. But as I later learned, when conflict arose with her ex-husband or work became especially difficult, she’d cut herself with razor blades to find release from emotions that threatened to overwhelm her. During that stressful period, a month or so into therapy, cutting had become a daily practice.

By that point, I’d already developed a strong connection with Danielle and didn’t feel I could simply stop working with her, although I did feel more anxious about her welfare. At the same time, I wasn’t frightened and didn’t make Danielle sign a contract binding her not to cut as a condition of treatment. I’ve worked with other women who self-injure and understand the dynamics of emotional self-regulation involved in cutting. I felt that together, given our strong working bond, we could help her find healthier ways to self-soothe.

A complicated transference relationship soon developed. While on one level, Danielle idealized me and developed some sexual fantasies about the two of us together, on an unconscious level, she also struggled with a great deal of rage toward me, displaced from all those “fathers” who should have looked after her but instead exploited her as a sexual object. The cutting also had more than one meaning. It provided emotional relief, as I’d seen with other clients, but it also gave Danielle an outlet for the rage she felt. As I put it to her during our sessions, she couldn’t hurt me directly but she could get to me by hurting my client.

To confront these emotional dynamics, along with one’s own anxieties about clients who self-injure, often makes professionals unwilling to take such people into their practice. It can be quite scary, especially when these clients often want to scare you. Sometimes it’s because they want you to come to their rescue; sometimes they want to “prove” they can be more powerfully destructive than you are creative; sometimes they need to express the rage they feel for having been helpless and exploited. Bearing with these emotions without becoming terrified or enraged yourself is a major challenge for the therapist. Most professionals understandably worry about a malpractice suit if a client actually were to kill herself. Nobody wants the guilt and regret for having “failed” a client who committed suicide.

But in my experience, the emotional dynamics and therapeutic methods for understanding and coping with those who self-injure are the same with both in-person and Skype clients. I made the same sort of interventions with Danielle as I’ve done with clients I’ve met in my consulting room. By remaining calm and engaged with her, and not retreating in fear or anxiety, I helped her over several years to find better ways to cope with her emotions.

We survived a period of intense cutting, when severe blood loss brought on heart palpitations, and she began reaching out to me by email between sessions. Although I don’t normally encourage email contact, I welcomed Danielle’s communications, just as I would have welcomed emails from a self-injuring client I was meeting with in person. Sometimes that extra contact during breaks is needed to support clients in their struggles to take better care of themselves. By the end of our treatment, self-injury truly had become a minor issue.

Early on in my practice by Skype, this experience with Danielle taught me that distance therapy is suitable for many more potential clients than I would have imagined. If she hadn’t concealed the extent of her self-injury at the beginning, I might never have learned this valuable lesson.

Olga (Anastasia’s Client)

When Olga reached out by email, I’d already had experience working online with complex cases. Olga had fled the war in her country and now lived in Prague as a refugee. Her existence was precarious in every possible way; she did not speak Czech and, feeling isolated, was barely able to navigate her new environment. She complained about panic attacks, depression and an “acute desire to die.” For several days previous to her “cry for help” (these were the exact words she chose for the “subject” of her first email), Olga was unable to leave her room and the only “food” she was able to consume was coffee and cigarettes.

I agreed to meet for an introductory session to see whether I would be able to help her. While I felt an obvious sense of urgency and a natural desire to rescue her, I also secretly planned that after this first conversation, I would refer her to a local English-speaking therapist. I usually try to avoid any rigid diagnosis, but I suspected that Olga might be labeled as “borderline” and could probably benefit from medication.

Only later, several sessions into our work, did I realize the full extent of Olga’s issues: She experienced social phobia and agoraphobia, was mildly self-harming, and felt suicidal most of the time. The level of isolation and despair she was experiencing at that point made it impossible for her to get out of her room, to struggle with an unfamiliar language or navigate foreign streets, and to engage with a local in-person therapist in her wobbly English.

There were several occasions in the early stages when I questioned my decision to welcome Olga as an online client. We were in the middle of our third session when she suddenly announced: “I need a break, just for a minute,” and she abruptly disconnected. I sat there, in front of my painfully empty screen and thought to myself that I had lost her. The intensity of the emotional response that she had read on my face must have made her panic. To see her own unexpressed pain reflected on somebody else’s face was too much for her.

In the chat box, I let her know that I would prefer to remain online whenever she felt overwhelmed by emotions. I was able to keep calm and stay connected without the sort of unpredictable outburst she would typically have received from her mother. Was it ok if I called back? A few minutes later, when we resumed our conversation, she was ready to reflect on what had happened.

The idiosyncrasies of an online setting allowed Olga to regulate her own risk-taking behavior and vulnerability. Temporarily logging off when she felt overwhelmed and then reconnecting once she had recovered was an empowering experience for someone who had been feeling hopeless and depressed for a long time. Such experiences, if used mindfully in the session, often provide great grist for the psychotherapy mill.

At first when we were connecting, Olga would be sitting on the floor: She felt too weak and too ashamed to hold herself upright. In a more traditional setting, the client is forced to adapt to the therapist’s environment. With clients who carry some deep psychological wounds, this can be simply impossible at the beginning of treatment. The fact that we meet the client in his or her own environment opens a window into the client’s experience: Seeing Olga curled up on the floor of her untidy room, I could sense her shame and fragility.

Later in treatment, on the day I saw her sitting upright in a chair, with her laptop on the desk in front of her, I knew we’d made some serious progress.

Several months later, when she had more fully recovered and was resolving her current life situation, I asked Olga to share her experience of working with a therapist online. I also informed her that I would use her account in an article. This invitation offered a therapeutic boost to her broken self-esteem: It let her know that not only was her opinion valuable for me, but it could also be of use to others who might also feel isolated and in desperate need. This is what she wrote:

“I remember that day when in the half fog, in the total despair, I plucked up the courage to write you an e-mail. After several attempts to commit suicide, after repeated uncontrollable impulses to harm myself, after feeling myself to be absolutely unfit to live, after realizing I not only can't carry on living like this but don't want to, and it would be better to die right now, what could I do? I could write an email. I didn't have anyone, anything, I wasn't even myself—that in short is how you could have described my condition. My Internet had been paid for. I talked a lot during our first conversation; you gave me this opportunity. I talked and you listened to me until I could get my breath back. I sat on the floor, leaning my back against the wall. Via Skype I could see on my familiar iPad, the calm, compassionate expression of an unknown face on the screen. I knew that at any moment I could press the button and ‘hide.’”

Olga took a huge risk, reaching out when her trust in herself and the world was broken. Now it was my turn to take the risk and be there for her, even if my support would be limited to the screen during our twice-weekly sessions.

Such limitations may at first seem like an obstacle to working with more challenging cases, but they often end up playing an important role in containing people who feel torn and fragmented: They allow these clients to regulate the intensity of the contact, and empower them to make choices about the physical conditions of the session. In the case of Olga, the choice about where and how to sit, and how long to stay connected, helped her to become more aware of the process and of her connection to me. This awareness gave us both insight into our quickly evolving relationship.

Working online with clients who are deeply distressed makes therapists keenly aware of the absence of touch. We cannot shake our client’s hand when we greet them at the door, we cannot offer the same warm gesture at the end of each session. Any online therapist is familiar with this frustration. But with Olga, this physical distance helped her to trust me enough so that she could engage in the process. Olga’s mother had touched her daughter in many abusive ways, asking to join her in bed and to give her endless back rubs. At the initial stage of our work, Olga knew she was safe and out of reach.

Like many online therapists, I often work with clients who are experiencing some form of displacement. Olga’s case may seem extreme, but what she was experiencing in an acute form (due to her precarious refugee status, her traumatic history, and a very particular sensitivity) is familiar to many emigrants as an unavoidable part of their lives. The benefits of online therapy for such individuals cannot be over-estimated. In the case of Olga, before we could get anywhere close to her borderline mother and the abuse she had experienced throughout childhood, we had to deal with the harsh realities of her current living situation: her fear of going out to buy groceries, her inability to engage with others, her disrupted sleep patterns and her struggle to feed herself. At this initial stage, the fact that she was able to connect with me from her own room—the only “safe space” she knew—became crucial. This is Olga’s account:

“… [A]t the very beginning, I deliberately focused my attention on ‘my familiar iPad.’ It has a small screen. For the first few sessions I didn't expand the window to full screen, after several sessions, I tried it for the first time, then forced myself and then I wanted to… Skype therapy was the only therapy possible… I am located within my ‘familiar space.’ I look at your face on the ‘familiar screen.’ I can sit there in whatever clothes suit me and with my hair unbrushed, with my legs pulled up under me, and thus I learn what I am and I don't have to pretend. I am not ‘attacked’ by the details of your room, my consciousness ‘does not float away,’ it doesn't get distracted... and when we finish the session, this screen, this room remains with me. Several sessions ago I was unbearably frightened after each session—do you remember the cries for help in my messages: ‘How can I live each minute?’ Then it became a little bit easier to finish a session and leave myself at least a small drop of the sense that I exist, when we aren't talking any more, I am in a familiar place, as before everything threatened me including myself and I was ‘on the lookout,’ but I can stay at home and immediately crawl under my blanket or continue to sit in the same place, giving myself time to get up and go and do something, however small.”

It took us a few sessions before she was able to follow my advice and reach out to a psychiatrist I had located for her in Prague. She agreed to take medication, which quickly improved her sleep and her concentration. The risk she took in leaving her room and meeting the psychiatrist was our first victory, a testament to our growing therapeutic alliance.

As is often the case with deeply troubled clients, Olga’s childhood had been catastrophic: She grew up in a dark, cold and neglectful environment. Her mother was unpredictable, volatile, and emotionally and physically abusive. She had never been diagnosed, or sought treatment, but her behavior indicated some severe personality disorder (probably BPD). Olga’s father was drunk every evening, and later in life discussed his suicidal urges with no regard to his children’s feelings. Her parents divorced when she was seven, and after that, her eight-year-old brother was supposed to take care of her. Both children cooked, earned money as they could, cleaned the apartment and protected their mother from distress. They knew far too well how violent and terrifying she could become when upset.

Throughout her life, Olga had felt completely responsible for her mother. She continued sending her money (often the only money she had) and supported her mother’s myth about her sacrificial parenting. This came at a high cost; her dysfunctional mother had taken up residence deep within her own bowels. Olga’s behavior toward herself and in her relationships with others mirrored her mother’s shaming, persecutory, and abusive manner.

In the course of our work together, Olga began to experience some intense kidney pain and vomiting, which did not seem to have any purely physiological reasons. On a psychological level, it marked the beginning of a separation and liberation process and an important stage in the therapy. As Olga struggled to separate from her mother, I stayed as “close” to her as I could. We met twice a week, sometimes more, when she was feeling particularly fragile. Through my screen, I bore witness as she relived many painful moments from her childhood; as a new narrative of her life emerged, she began to feel more alive.

As is often the case with online therapy, boundaries were easily challenged. Olga would reach out frequently, sending me distressed messages via the Skype chat box. Initially I felt stressed by these intrusions, but once I addressed the issue openly with her, we agreed on some simple rules: I wouldn’t always respond straight away, or would sometimes just confirm that I was there and thinking about her. This reassured her as to healthy nature of our relationship, strikingly different from what she had experienced with her mother who had constantly pushed, violated, and dismantled boundaries with her violent emotional storms.

The fact that I was located at a safe distance, in a different country, permitted her to experience separateness and create a safe space around her. Soon, she was able to fill it with her own thoughts and desires. Our relationship was by definition at a physical distance, so different from what she had experienced with her mother: They had lived together in the same small apartment for more than twenty years. At crucial moments, this distance and our limited physical access to one another kept us both safe.

Olga went on to experience powerful emotions of hatred and anger, which she could never have expressed to her mother. As for me, the “safe distance” offered by the online setting helped me to be “there for her” at those difficult moments without letting these emotions sweep me (and our relationship) away.

Towards the end of our work Olga regained the ability to deal with her every-day reality. She slowly resumed her daily activities and began engaging with others in healthier ways. For the first time, her life felt like it was actually her life, separate and apart from her mother.

Taking the Risk

In the process of dealing with such difficult cases, we’ve developed some useful strategies. At the outset, we always discuss the limitations of online therapy with new clients, stressing the fact that it doesn’t allow us to be physically present when we might like to be. Addressing this reality openly allows us to model ways of dealing with the frustrations and the limitations of a distance relationship. This modeling is extremely beneficial, particularly for those clients who have little healthy experience with appropriate emotional bonds or are confused about their own personal boundaries.

While we typically meet with our online clients weekly, we tend to offer a more intense rhythm in more challenging cases. In the two cases described above, we met with our clients twice a week, and sometimes more frequently when major shifts or breakthroughs were occurring.

We also found that online clients reached out to us between sessions more often than usual, and responding to their emails turned out to be a very important part of the therapeutic process. While we usually expect in-person clients to cope with the inevitable lack of contact between the sessions, this is sometimes too much to ask of online clients, giving the physical distance. Responding, briefly but mindfully to their emails, helps these individuals to maintain the sometimes-fragile connection. While this places an additional demand upon the therapist’s time, it can be crucial at some stages of the client’s recovery. Once the client starts to feel stronger, the email flow usually diminishes naturally.

In cases involving some serious disturbance, we can also insist that the client meet a psychiatrist in person. We typically raise this subject several sessions into therapy, once a good therapeutic alliance has been established. Even with the most resistant clients, this strategy eventually works out well once they’ve developed enough ego strength and trust in our support to take this challenging step of consulting with a psychiatrist and eventually taking a prescribed medication.

Expanding one’s practice to the online realm can feel risky, and to accept clients with major disturbances can feel even riskier. As with any venture into the unknown, however, the effort may widen our perspective: What we had felt to be out of reach suddenly becomes possible, at least with some of the people who approach us for treatment.

And in taking such a risk, are we not modeling something important for our clients?

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