Therapy in a Digital Age
Given all that we’re experiencing with COVID-19, we want to learn more about how therapy is changing from the perspectives of people working in the field of mental health.
For this session, we sat down (remotely) with Raj Joshi, a Licensed Marriage and Family Therapist (LMFT) in Southern California. We talked with Raj about what new challenges he’s seeing and then asked him to share some solutions he’s tried.
Raj Joshi is a Licensed Marriage and Family Therapist (LMFT). A graduate of the Masters in Marriage and Family Therapy Program at Alliant University, Raj practices through the lens of Cognitive Behavioral Therapy (CBT). He is affiliated with Uram Family Therapy, where he sees adolescents and adults with Attention Deficit Hyperactivity Disorder (ADHD), Autism, anxiety, and depression. Raj also works in a Full Service Partnership (FSP or Wraparound) in community-based mental health, where his team provides behavioral health services that address systemic challenges to mental health for children and their families.
Figuring out technology
Raj notes that simply setting clients up with remote communication tools has been a big challenge. “In an FSP…we have a lot of clients that may not have access to WebEx, may not have access to Zoom, or to any of these means, and are slowly working towards them. And we have clients who may not have access to the internet. They’re having to do all their sessions via phone. When you lose that face-to-face contact, you lose a piece of connectivity to that person.”
- What’s worked for Raj: Spend some time collaborating on some new ground rules and expectations in the virtual environment. Doing so can help clients access the services they need. Meet clients where they’re at; understand what their needs are and address the basic ones first. If a client doesn’t have the internet, don’t push them to use a service like Zoom. When the client does have access to a service or technology, use the tools yourself and then spend some time to walk them through it. And if a client doesn’t trust technology, collaborate together and find a solution that works for both of you. But most importantly, be sure to work together with the client when creating these expectations!
- For more information: Dr. Kate Morrison and ABCT and Dr. Kate Morrison provide some tips for Getting Started with Telemental Health. The American Psychological Association provides a comparison of the latest Telehealth solutions.
“If a client is disengaged in your session, they can just hang up the phone.”
By creating a safe space where the client can feel comfortable sharing, the therapist and client can work towards creating a therapeutic relationship – one of the most important pieces of the therapeutic process. “I’ve had clients who say that- ‘when I come into the therapy setting, it almost allows me to feel like I’m ready for this process.’”
Not having the ability to physically meet in a consistent safe space creates barriers to building rapport and creating a therapeutic bond. “Clients tend to become less engaged in our session…so you can have a client that is on their phone talking to you but texting at the same time, or doing a Houseparty at the same time.”
- What’s worked for Raj: To help both of you stay engaged, come to an agreement that you’ll both avoid multitasking while in session. Try asking about what the client is doing when they seem distracted. Talk about what they’re currently going through, even if it doesn’t fit the treatment plan 100%. Talk about little things like what’s in their room. Get creative and find games to play with them digitally. Be sure to create a schedule together using a calendar and encourage routines. Be comfortable about any pauses or silence in the digital space.
- For more information: Consider this list of how to build rapport with youth via telehealth. This comes from the American Psychiatric Association: Telepsychiatry Toolkit.
In the current reality, therapists can often find themselves losing boundaries between work and home life, leaving them to stew in whatever they encountered vicariously through their clients. “One of the biggest challenges or changes is being able to learn how to turn it off and separate from work. Because now my office is 10 or 15 steps from my living room. My office and my bedroom are one and the same. You tend to work more and I noticed that I’m having a difficult time turning it off.”
- What’s worked for Raj: Take care of yourself first, in order to help others effectively. If possible, create a separate space for therapy or work (even if it’s just a specific part of your room that you work from). Take a physical break after work — go for a walk after each session to put yourself in a new headspace. “Pull out those old dusty instruments- YouTube how to play it. YouTube how to cook. YouTube how to sing. It’s such a great time to take that time for yourself.”
- For more information: The American Psychological Association has some additional tips about “Self-care advice for health-care providers during COVID-19”.
When providing remote therapy, there are added limits to the confidentiality of sessions; the therapist can’t fully guarantee that the client is in a physically and digitally safe space where no one can hear them. For example, family members might be walking around in the same room- not necessarily by choice, but because that’s the only space that they have. “[The client’s] point of conflict could even be at home.”
- What’s worked for Raj: Teach the client about the importance of private space and how to find it. Be honest and upfront about limits to confidentiality in this unique time; build this into your confidentiality agreement and go through this with each client. Be aware of your state and licensing board guidance about what rules might be shifting for now. When sending invites for Zoom or other video conferencing, be discreet; try using a subject line that is anonymous like, “Zoom Session”. Avoid sending the “one-click” links that don’t require passwords, and instead, send the link and password separately.
- For more information: The American Psychological Association has created a Telepsychology Best Practice 101 Series.
This is a new reality that we are experiencing for the first time. Through the range of experiences we are all navigating, there is a chance for us to learn from our shared experiences and better equip ourselves to support the mental health of others.
What are some other challenges you’ve found, and what are some solutions you’ve learned?
Here are some additional resources we’ve found for you to help manage through these times:
- Here are some great digital resources to use during COVID
- How do you become a tech savvy therapist? Here are two great articles by Sean Erreger and Dr. Ellen Belluomini
- From PositivePsychology.com: 16 Telemental Health Resources for Practitioners and Patients
- From ADAA: Keep Calm and Carry On: Clinical Practice During the COVID-19 Pandemic
- Continuing Education Opportunity: Foundations in Digital Therapy
Our thanks to Raj for taking the time to sit down and chat with us!