I offer psychotherapy and counselling consultations on Skype. Some of the people who see me regularly sometimes use Skype to ensure that, wherever they may be in the world, they can keep to regular appointments. Skype offers a greater depth of communication than the phone, because it is possible to convey a greater array of non-verbal cues (which for over 95% of all of our communications).
As per the words of some of my patients, “it works”. This means that they think and feel that they still receive what they need from a consultation that is conducted via this method of communication. However, is it possible, as a rule, to engage meaningfully with the process of psychotherapy on Skype (or even on the phone), whether the sessions are all or partly held via this medium?
Is therapy on Skype “real therapy”?
While developing this medium for my practice, I have carried out research into how it affects the therapist, the patient, and the therapeutic relationship. I wrote a short paper and gave a lecture on this topic at the Multilingual Psychotherapy Centre. You may read a short summary here.
I have noticed that, when using Skype, some of the traditional boundaries of psychotherapy are blurred. First, it is no longer just the patient visiting the therapist: the two parties physically see into each other’s spaces (rooms, offices) and are therefore invited into each other’s worlds. Second, both parties can see a “selfie” thumbnail superimposed upon the image of the other, like a moving stamp onto a moving postcard. And third, patient and therapist seem to become talking heads to each other, which begs the question of Skype being a watered-down version of its face-to-face counterpart.
These challenges are real, but my my experience of Skype is that it does not create new problems for therapy – it only highlights essential aspects of the human encounter, which become lines of inquiry in the therapy, and therefore means of helping the patient become conscious of themselves.
Indeed, therapists are always figuratively invited into the patient’s inner world – Skype makes it concrete. Similarly, we always see a reflection of ourselves in the other (this is supported by neurological research into the phenomenon of mirror neurons), and again, Skype makes it concrete. Finally, communicating via Skype helpfully brings into conscious focus the challenge that true relationship represents.
In short, I have found that, for all the challenges that it presents, Skype is a meaningful medium for psychotherapy, especially when it is combined with face-to-face sessions.
Integrative psychotherapy and coaching – how do the two mix?
As published in the Autumn edition of the Newsletter for the Association of Integrative Coach-Therapist Professionals (AICTP) Coaching interventions in psychotherapy: challenges to the transferential relationship
As I was looking for inspiration to write this short piece about how we can draw upon our coaching skills as psychotherapists, I noticed a thought-provoking comment on the AICTP discussion thread “How do you manage movement between disciplines when using an integrative coach-therapy approach?” A participant described how he had decided to challenge his client, who was “reluctant to make external decisions and changes” so that she would get out of the comfort zone of her inner exploration, and suggested moving from counselling to coaching.
It is quite a common assumption (which I have seen expressed even by the most senior practitioners of counselling and psychotherapy in London) that coaching is future-oriented and psychotherapy about the past, and that coaching is about the outer world, and psychotherapy about one’s inner world. If we choose to accept the assumptions as the truth, then it follows quite naturally that there is a line in psychotherapy that the therapist and his or her client need to cross together when the focus of the work shifts away from the inner life and the processing of unmet childhood needs, and towards achieving life goals within a partnership of equals. The participant’s comment on the AICTP thread describes a situation when it is the therapist who takes the initiative of introducing the coaching perspective in order to shift the focus of the work.
I have also frequently observed in my practice that it can be the client who requests that the therapist intervene as a coach. This can be the case when clients feel particularly stuck in their therapy, or are particularly anxious for their lives to change in a way that they can control. I noticed that people who suffer from addictions and who experience repeated relapses will from time to time ask for a directive, solution-focused approach.
What is then supposed to change when we make coaching interventions in psychotherapy or move the relationship on and away from therapy, towards coaching? If coaching is about the future-external and therapy the past-internal, are the corresponding ways of working respectively dictated by concrete goals, and by the inner process unfolding in the person? And if so, what is the effectiveness and appropriateness of doing so, and what are the pitfalls?
What are the appropriateness and possible pitfalls of switching between therapy and coaching?
One of my patients, a woman in her late thirties who has been in twice-weekly therapy with me for the past three years, has been constantly frustrated by her inability to build lasting relationships. She was also unsure whether she should seek a same-sex or heterosexual relationship, and her inability to decide has caused her great frustration. During the early stages of her therapy she was able to discover, accept and act on a sexual appetite, which she had perceived as non-existent since her early teens. As a result of this, she had several same-sex encounters, sometimes resulting into brief and casual sexual relationships. She also formed an ambivalent attachment to a man of her age, who already had children from a previous marriage.
But she continued to berate her inability to “get started in earnest” and remained deeply dissatisfied at the “sterile” nature of her encounters and longs for a steady partner, with whom he would be able to settle down and have a family.
A few months ago I took the initiative of introducing goal-oriented work in one of her sessions with me. Rather than reflecting back her helplessness, her frustration and her anxiety, I decided to help her articulate and clarify her hitherto vague thinking about what needed to be done concretely to start looking for suitable partners and making herself available to be found.
As I expected, the first part of the conversation resembled a game of “why-don’t-you-yes-but” game (Berne, 1971), but instead of reaching the conclusion of mutual defeat described by Berne (the therapist runs out of suggestions and the client demonstrates that there is nothing that she can do to change), she trailed off and eventually said to me: “it feels quite weird, you coaching me like this. I know why you’re doing it but I don’t think my problem is about that”. I ventured “it feels weird to be coached when you don’t actually know what you want”. She agreed completely with my statement. This allowed us to explore how ambivalent she was towards her sexuality, arriving at the conclusion that in her mind, having a sexually satisfying relationship and a relationship in which she could thrive and find meaning in seemed mutually exclusive.
This proved to be a watershed moment, as she fully realised that her ambivalent position towards creating relationships exactly mirrored her mother’s own ambivalence towards her family, manifested by a series of affairs that were never spoken of in the family. My client had known that this mirroring existed in the way she conducted herself in her life. But until it only ‘landed’ when it was made real and tangible as a manifestation in her therapy. She was able to relate emotionally and intellectually to an past-internal item on the basis of a failure to progress on a future-external one.
What is at the heart of Coaching?
My decision to change my stance and become more inquisitive, active and even risking suggestions by asking such questions as “…and have you thought of doing x?” momentarily changed the dynamic of the relationship. As I fostered her taking ownership of the problem, she became aware that her problem was not so much in her inability to take appropriate action, but to know for sure what it was that she needed to do in the first place.
In my view, the heart of coaching lies more in the process where two parties reach a clear contract about the boundaries, means, general purpose and outcomes of the coaching session, than in the set of actions that the coach agrees to hold the coachee accountable for. With the above example I hope to have shown that by making interventions that challenge the client by bringing up her outer world and goal-directed activity in a space that is in principle dedicated to the exploration of her inner world, we can draw from essential aspects of the contracting process in coaching in order to create awareness.
However, before seriously considering experimenting with a coaching intervention I had to identify and reflect on all the aspects on my own countertransference of helplessness and frustration, lest my intervention be an acting out.
This is what has I am in the process of exploring with another patient, a young man who has come to me because he currently lacks the vision and confidence to plan and execute a change of careers. He was referred to me by his GP, after suffering a series of panic attacks.
This young man is expressly asking me to coach him, but wants a coach who has the “sensitivity of a psychotherapist”. He explained in the initial consultation that his parents would react very strongly if they knew that he is seeing a therapist, and that they have very strong prejudices against psychotherapy. This is why he chose to speak to a coach. He told me that he knew that it was likely he needed to work on himself, but that his priority would be to create concrete actions. It seems that he is asking me to focus on concrete actions and remain “sensitive” to the way that he feels in himself. All the material that he brought to the session was linked to his family and his relationship with his partner.
At the end of the consultation I recommended that he consider psychotherapy above coaching, and bring to the therapeutic space any concrete problem that he wished to explore, and that he could set a short-term review deadline to make an informed decision about what he felt would suit him best. I told him that by agreeing to coach him I would enter into a contract that perpetuated his childhood experience, where his inner life would be in full view but not the focus of my attention. I also felt – but did not tell him – that he was setting up a transferential situation where I would get and experience close to his childhood’s, which was to feel a frustration at not being able to engage with him as he genuinely needed.
The healing process in therapy and coaching
With both clinical examples I hope to have shown that it is possible, to some effect, to change one’s stance towards a client to either help raise awareness. However, in my experience, this change of stance should be clearly “called” (by the client or the therapist) and it should function within, and not instead of, the transferential relationship. With this in mind, it would seem that the assumption that seemed to underpin the comment on the thread is incorrect because it posits that therapy and coaching work only in succession, not in unison.
The essentially ambivalent position of the therapist (as a separate person and a recipient of various projections and transferences) is, I feel, brought in sharper contrast when the therapist is also a coach. I would like to suggest that in person of the coach-therapist, the client is seeking the clear line that may exist between the past and the present, the outer and the inner. If we do not give due consideration to the transferential factors that arise out of this situation, we run the risk of facilitating an inner split when we act as if that line were really there. As integrative coach-therapists, we need to ensure that we facilitate integration in the person, not splitting. It is my view that the client always knows what is good for them, but that the vagueness of the cues they give us (their requests for different modes of intervention, and our countertransferential feelings) is commensurate to the vagueness of this self knowledge. It us up to us to tolerate this vagueness and help the client connect meaningfully with their own healing process.
This recent article by the Guardian, “Why do identical twins end up leading such different lives?” adds yet more weight to the argument that even though our genes may predispose us to certain traits, and therefore give us strengths and vulnerabilities, our epigenetic makeup, i.e., the pattern by which certain genes are expressed or not through of our interactions with the world, will make a huge contribution to the building of our personality.
Very often, psychotherapists in London and elsewhere will mention under the same breath that they help people with “anxiety and depression”, almost as if it were one and the same thing. This is probably because, according to the ONS, there are almost three times more people who suffer from both depression and anxiety that people who suffer from depression alone. Indeed, depression with anxiety is experienced by 9.2% of people in Britain, while depression without anxiety by 2.8%.
What is the relationship between anxiety and depression?
It is hard to say if unmanageable anxiety triggers depression, or if a state of depression generates anxiety. It depends highly on individual cases and even then It often feels like a circular situation and in my experience it is not helpful to try and find out what came first. The essential is to help the client address these feelings as a whole in their therapy, and to consider anxiety and depression as intricately linked as opposed to separate phenomena requiring different approaches.
An apparent paradox
It sometimes seems paradoxical that depression, whose symptoms are said to be mostly negative (i.e., describing the absence of something), can co-exist with anxiety, whose symptoms are mostly positive (i.e., describing the presence of something). For example, in depression, sufferers experience lowered mood, loss of motivation, loss of meaning and loss of concentration, while in anxiety it is the positive symptoms that seem to prevail, for example, increased heart rate, presence of recurrent unpleasant thoughts and restlessness.
How to approach individual treatment of mixed anxiety and depression
As an experienced counsellor having helped many people deal with issues of mixed anxiety and depression in London, I have noticed that people suffering from this problem fall in three very broad categories:
those who feel that they will benefit more from guidance and education, and expect from the therapist clear instructions and coping strategies,
those who prefer a non-directive approach and want to explore their experience in an open, unstructured manner,
and those who feel that it is most helpful for them to experience both in their therapy.
As an integrative psychotherapist, I believe that it is best to offer my clients what is going to be helpful to them and not just what a specific approach says I should do. This is why I mostly offer my clients a space to be with themselves and also a forum where they can clarify, understand and plan concrete life changes.