It was the second day of my vacation. Wrapped by the noonday heat and sitting on the terrace of a charming Thai house, I looked like an ordinary, relaxed tourist—shorts, a t-shirt from the local market and a glass of freshly squeezed mango juice. This time I had managed to avoid scheduling client sessions during vacation, for which I praised myself. However, my head was like a busy rush hour interchange, with work-related thoughts buzzing quickly in all directions. Even a monkey, clearly lacking in boundaries and social etiquette who decided to gobble half of my breakfast couldn’t distract me from this mental traffic. I decided that it would be a good time to sort out the emails that had accumulated during my brief absence from practice.
I moved to a pleasantly chilled room and opened my laptop, and as I hurried to remove spam, I nearly deleted an email with the subject line “Quality literature on social anxiety. Help!" It was the call for help that caught my eye. “N” asked me to recommend self-help books on social anxiety. In the email, he stated that psychotherapists could not help him, and that instead he had to rely on himself and the self-help literature. Although I had become accustomed to people who don’t believe in psychotherapy, the phrasing of his request seemed somehow different. I recommended what I thought would be useful books to N and then asked him how he arrived at the idea that psychotherapists could not help him. His quizzical response, and possibly a hidden challenge or invitation was “Because no single session with a psychotherapist has happened.” At that point, I became curious, and so decided to continue our conversation.
It turned out that N's social anxiety precluded both face-to-face and online visits with a therapist. He had previously approached several specialists asking for text-based sessions but was consistently refused. The psychotherapists with whom he had made these requests typically responded in a manner suggesting that they had no idea how to conduct such sessions and expressed concern that doing so would be ineffective. Interestingly, N’s written language skills suggested that he was an educated and thoughtful person, and I could feel the pain in his written words. I thought, “Despite the negative experiences he had with those therapists, he still seems to be hopeful that psychotherapy, albeit in text format, could help.”
At that moment, the promise I had made to myself not to work with clients during vacation melted like sugar in the tea I had just brewed. I agreed to having a text session with N. He became extremely enthusiastic and started thanking me, perhaps a bit too soon. The entire first session was devoted to the discussion of his feelings in connection with the multiple refusals of psychotherapists to help him. With each refusal, he had felt “even more worthless, rejected and condemned” and “did not want to interact with people at all, since even those who could help did not want to do that.” However, N had managed with impressive effort not to fall into despair but instead to keep searching for a way to battle his social anxiety. Contacting a psychiatrist for pharmacotherapy was not an option for N, at least at this point, because he clearly understood that he would not be given any prescription without a personal appointment. N tried to read papers and books on the subject, but he was not getting any better. It was at that point he had decided that perhaps he was reading improper literature, so decided it might be more effective to ask a psychotherapist for a recommendation. That is how he came to me.
I admired N’s guts and resilience, as well as his desire to cope with this illness which had created many obstacles in his life. N had read online forums suggesting that people with similar problems tend to rely on alcohol and illegally-obtained benzodiazepines to ameliorate their anxiety and alleviate their anguish, at least temporarily. N had not considered this medicinal route as a solution and understood that these would only provide short relief followed by a worsening of his symptoms. I had met similarly mindful and purposeful clients in the past, so I already admired his tenacity. He truly seemed to have faith in himself and his capabilities and wanted to re-enter the social world but needed professional psychotherapeutic support to get there.
After that first text session, N said that for the first time in a long period, he felt that he had found an ally. His hope of a successful outcome therefore strengthened while my attempt to spend a vacation without clients completely failed—we decided to keep working together.
In subsequent text sessions with N, I did pretty much the same as I would during online or face-to-face sessions, except that it took more time because typing is far more cumbersome to me than simply talking. At the end of the fourth session, N actually suggested holding the next session online, saying that “the calluses that had developed on my fingers required treatment.” While I believed that this was actually the case, I also thought that his desire to see me face-to-face represented a significant step towards progress in dealing with his social anxiety. After the seventh session, N started leaving his house, and by the eleventh, we were already “rehearsing” an appointment with a psychiatrist, which took place soon thereafter. His belief in himself and in our work, as well as our mutual commitment to the goals of therapy, helped N to progress rapidly. In a few months, he could already spend time with people including strangers while experiencing a tolerable anxiety of 6 points out of 10 according to his own assessment.
Can I be sure that I wouldn't have been among the therapists who refused N in his request for a text session? Unfortunately not. I discussed this issue with colleagues, and many of them admitted that they would not be ready to hold therapy sessions in text format. Our teachers and supervisors direct us towards face-to-face sessions, sometimes touching the nuances of online therapy, but therapy in text format is often considered with skepticism. How is it possible—not to see and hear the client? Safety is an important factor in the therapeutic relationship, and in this case, N clearly did not feel safe in any social sphere, let alone therapy. Texting felt safe for him, and I believed it was my role to honor his need for safety, so I accepted the format of our relationship on his terms. In general, but particularly after working with N, I believe therapists should honor and respect the client's desires as long as all possible and foreseeable risks are considered. In this case, it was important to understand N’s reasons for requesting text-based sessions, which seemed fair. I trusted my intuition that he was yearning for connection, but it had to be on his terms. It was for that reason alone, despite it being contrary to my typical way of practicing and being on vacation, that I accommodated him.
***
Working with N reminded me of one of the fundamental rules of psychotherapy: therapy is for the client, not the client for therapy. We spend years studying the rules of psychotherapy, and then for the rest of our professional lives, we learn to break these rules sensibly and for the benefit of the client. The “don't work on vacation” rule should probably also be considered with certain flexibility. I discovered, although somewhat reluctantly, that conducting sessions on vacation can work if the therapist has the sea, sun, and a brazen monkey nearby; and the client has a desire to change.
File under: The Art of Psychotherapy, Musings and Reflections, Online Therapy, COVID-19 Blogs
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I moved to a pleasantly chilled room and opened my laptop, and as I hurried to remove spam, I nearly deleted an email with the subject line “Quality literature on social anxiety. Help!" It was the call for help that caught my eye. “N” asked me to recommend self-help books on social anxiety. In the email, he stated that psychotherapists could not help him, and that instead he had to rely on himself and the self-help literature. Although I had become accustomed to people who don’t believe in psychotherapy, the phrasing of his request seemed somehow different. I recommended what I thought would be useful books to N and then asked him how he arrived at the idea that psychotherapists could not help him. His quizzical response, and possibly a hidden challenge or invitation was “Because no single session with a psychotherapist has happened.” At that point, I became curious, and so decided to continue our conversation.
It turned out that N's social anxiety precluded both face-to-face and online visits with a therapist. He had previously approached several specialists asking for text-based sessions but was consistently refused. The psychotherapists with whom he had made these requests typically responded in a manner suggesting that they had no idea how to conduct such sessions and expressed concern that doing so would be ineffective. Interestingly, N’s written language skills suggested that he was an educated and thoughtful person, and I could feel the pain in his written words. I thought, “Despite the negative experiences he had with those therapists, he still seems to be hopeful that psychotherapy, albeit in text format, could help.”
At that moment, the promise I had made to myself not to work with clients during vacation melted like sugar in the tea I had just brewed. I agreed to having a text session with N. He became extremely enthusiastic and started thanking me, perhaps a bit too soon. The entire first session was devoted to the discussion of his feelings in connection with the multiple refusals of psychotherapists to help him. With each refusal, he had felt “even more worthless, rejected and condemned” and “did not want to interact with people at all, since even those who could help did not want to do that.” However, N had managed with impressive effort not to fall into despair but instead to keep searching for a way to battle his social anxiety. Contacting a psychiatrist for pharmacotherapy was not an option for N, at least at this point, because he clearly understood that he would not be given any prescription without a personal appointment. N tried to read papers and books on the subject, but he was not getting any better. It was at that point he had decided that perhaps he was reading improper literature, so decided it might be more effective to ask a psychotherapist for a recommendation. That is how he came to me.
I admired N’s guts and resilience, as well as his desire to cope with this illness which had created many obstacles in his life. N had read online forums suggesting that people with similar problems tend to rely on alcohol and illegally-obtained benzodiazepines to ameliorate their anxiety and alleviate their anguish, at least temporarily. N had not considered this medicinal route as a solution and understood that these would only provide short relief followed by a worsening of his symptoms. I had met similarly mindful and purposeful clients in the past, so I already admired his tenacity. He truly seemed to have faith in himself and his capabilities and wanted to re-enter the social world but needed professional psychotherapeutic support to get there.
After that first text session, N said that for the first time in a long period, he felt that he had found an ally. His hope of a successful outcome therefore strengthened while my attempt to spend a vacation without clients completely failed—we decided to keep working together.
In subsequent text sessions with N, I did pretty much the same as I would during online or face-to-face sessions, except that it took more time because typing is far more cumbersome to me than simply talking. At the end of the fourth session, N actually suggested holding the next session online, saying that “the calluses that had developed on my fingers required treatment.” While I believed that this was actually the case, I also thought that his desire to see me face-to-face represented a significant step towards progress in dealing with his social anxiety. After the seventh session, N started leaving his house, and by the eleventh, we were already “rehearsing” an appointment with a psychiatrist, which took place soon thereafter. His belief in himself and in our work, as well as our mutual commitment to the goals of therapy, helped N to progress rapidly. In a few months, he could already spend time with people including strangers while experiencing a tolerable anxiety of 6 points out of 10 according to his own assessment.
Can I be sure that I wouldn't have been among the therapists who refused N in his request for a text session? Unfortunately not. I discussed this issue with colleagues, and many of them admitted that they would not be ready to hold therapy sessions in text format. Our teachers and supervisors direct us towards face-to-face sessions, sometimes touching the nuances of online therapy, but therapy in text format is often considered with skepticism. How is it possible—not to see and hear the client? Safety is an important factor in the therapeutic relationship, and in this case, N clearly did not feel safe in any social sphere, let alone therapy. Texting felt safe for him, and I believed it was my role to honor his need for safety, so I accepted the format of our relationship on his terms. In general, but particularly after working with N, I believe therapists should honor and respect the client's desires as long as all possible and foreseeable risks are considered. In this case, it was important to understand N’s reasons for requesting text-based sessions, which seemed fair. I trusted my intuition that he was yearning for connection, but it had to be on his terms. It was for that reason alone, despite it being contrary to my typical way of practicing and being on vacation, that I accommodated him.
***
Working with N reminded me of one of the fundamental rules of psychotherapy: therapy is for the client, not the client for therapy. We spend years studying the rules of psychotherapy, and then for the rest of our professional lives, we learn to break these rules sensibly and for the benefit of the client. The “don't work on vacation” rule should probably also be considered with certain flexibility. I discovered, although somewhat reluctantly, that conducting sessions on vacation can work if the therapist has the sea, sun, and a brazen monkey nearby; and the client has a desire to change.
File under: The Art of Psychotherapy, Musings and Reflections, Online Therapy, COVID-19 Blogs