Camilo Henríquez
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February 17, 2022
If you ever wonder how is it to take online psychotherapy, this post could help you to get an idea. I will use a real case to demonstrate how it goes (the client authorized the sharing of her story).
The journey starts by contacting me through my website, FB, Instagram, or my number. Afterwards, clients receive two online forms that help me have a brief idea of their expectations, the problem, and the main clinical symptoms. Now, we are ready to book the first session.
The first session
Objective:
- Establish norms, expectations, and the setting of the therapeutic context (symbolic contract).
- Explore the problem.
- Explore general background (family, social life, symptoms).
- Give brief feedback to the client regarding the first encounter.
A short case story:
A client in her early 20 asks for a session, explaining that she prefers to work through Zoom.
The questionnaires previously taken indicate that she is experiencing strong anxiety, self-aggression, and interpersonal conflicts.
When we start the session, I usually explain the rules and how online psychotherapy works, trying to break the ice and make it easier for her.
I could perceive through the camera that she was nervous and didn't know how to start telling the problem, so I just asked general questions like: what does she like to do; favorite pets; and random topics to find something in common.
In this case, I found out that we both like music and play guitar. This was the first bridge.
From here, she tells me the problem the best way she can, which in short could be defined as an anxiety disorder with panic attacks. She claims to feel insecure when she leaves her house and enters spaces with too many people, reaching desperation at some point, increasing heartbeat, aggression, and feeling like she is losing her mind. As consequence, she doesn't go outside anymore, quit her job, and has been living with her mother for the last months.
Frequently, the problem evolves session by session, so I avoid to "label" it with a clinical diagnosis, but I do practically define the problem as simply as I can. In this case: she is afraid of being among people.
I also define her expectations: she wants to be among people and leave her house without experiencing panic attacks. Often, I reflect on my own experience working with similar problems and share this information with the client.
For example: "This seems to be an anxiety disorder, which usually takes a few months to overcome completely. Interventions based on mindfulness and exposure use to work very well".
Commonly, I start digging into the family history and other vulnerability factors like mental health problems on the parents; addiction in the family; domestic violence; abandonment; history of other health problems; and social relationships like friends, romantic partners, and work/study environment.
I like it in this way because frequently, during the second session, they come with more memories and awareness of their past.
I close the session by thanking her for her trust in me. Sometimes, I share talk videos about mindfulness.
Second and Third Sessions (maybe more)
Objective:
- Define the problem, triggers, context in detail.
- Build a thematic analysis of the problem
- Introduce Mindfulness tools
The skill of being "aware" of what I'm thinking is usually known as metacognition: think about what I'm thinking. It helps to identify our perception of the world from a less personal point of view; without identifying yourself with your thoughts.
To move from thinking: "I'm a horrible person!" to "I'm thinking that I'm a terrible person, but that doesn't mean that I am".
A similar process occurs with emotions and body sensations. Clients increase their emotional intelligence by naming and describing what they are feeling. The method facilitates a deeper understanding of their emotional experience.
An example is to move from: "I feel so bad and I don't know why!" to "I'm feeling angry: my breathing is agitated, my mind is aggressive, my jaw is tense... I feel upset because my expectations were not satisfied. Now, if I'm not careful, I may start a fight with people that try to talk to me. In this scenario, I should take some time to process my anger...".
During this process, the client and I build a simple theme analysis of the client's traumatic experiences. The method identifies defense mechanisms, cognitive distortions, common triggers, and the positive outcomes and resources related to the trauma.
In figure 1, the main themes are organized as defense mechanisms, triggers, and resources. This process is iterative and evolves session by session. In this case, the client's anxiety and panic attacks were triggered by the fear of being rejected or abandoned by her new romantic partner. Another trigger was the awareness of gaining weight. Both triggers and the lack of awareness of her beliefs and values related to traumatic experiences allow the symptoms to develop and stay.
In her words: "when I'm at the mall or public spaces, I start thinking that I'm not well dressed, that I look fat or stupid... and my boyfriend is so beautiful... I think he will leave me... or that others can see that he should not be with me... I hate my skin and fat...".
This process requires a good therapeutic alliance and trust between therapist and client, which may vary among different clients and therapists, so don't be afraid if it is hard to open up with your therapist or define the problem.
Now we are ready to set a change objective or goal. The problem is understood and we know the resources she counts on to face the issue.
Session 4 and on
Objective:
In this case, she was a good writer so we exploited that. She started writing stories of good moments like when she felt beautiful, or others confessed having feelings for her. All the little victories and beautiful moments were "ignored" because of her maladaptive defense mechanism.
The act of talking out the problems, exploring them together, and re-define them by integrating other good moments usually gives "perspective" and "awareness" of bad habits such as catastrophizing, avoidance of the mirror, or obsessive solutions like trying to be always "fit and beautiful".
The sessions usually are about talking and exploring these worries, expressing them somehow into art or symbolic objects, followed by a commitment to act differently in front of the trigger.
Afterward, progressive exposure to the fear is key: going shopping, finding a new job, looking and touching her body in the mirror, challenging the ritual of "perfect dressing", practicing self-love, and sharing / helping others with similar issues. The trauma turns into a "cool - dramatic story of surviving" instead of something to be afraid of.
Other details:
- some sessions at the beginning were without the camera.
- most sessions were in the morning, while she was in pajama on her bed.
- She missed many sessions during the process of finding ways to love herself.
- The entire process took 20 sessions.
When the therapy finished she was very aware of her patterns and confident about how to handle them. Life also put some challenges on her way (conflicts with her boyfriends and family members), that she managed to handle without triggering anxiety disorders, self-agression, or isolation. I could tell she was very proud of her achievements, improved her grades, and even set more boundaries in her relationship that she would not dare to set before.
The last time I followed her up she mentioned that would manage very well most problems. Still experience insecurities sometimes, but never lasting long enough like to come back to therapy.
She knew what to do and how to do it, and life could be seen as balance place between "good and bad" that was very worth living.
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