שמי הגרה, נשואה ואם לשני ילדים בוגרים.
אני פסיכותרפיסטית בעלת תואר שני (בהצטיינות יתרה) בפסיכותרפיה קוגניטיבית התנהגותית, ותואר ראשון במדעי ההתנהגות.
חברה מומחית ומדריכה מוכרת באיט"ה בגישה קוגניטיבית-התנהגותית (CBT).
מטפלת ומדריכה בסכמה תרפיה, מוסמכת ע"י ה- ISST (ארגון הסכמה תרפיה הבינלאומי).
מקימה ומנהלת "מרכז ההכשרה לסכמה תרפיה כפר סבא" (מרכז הסמכה המוכר ע"י ה- ISST)
מטפלת במבוגרים בכל הגילאים, כולל בוגרים צעירים מגיל 18.
מלמדת סכמה תרפיה ומרצה בכנסים מקומיים ובינלאומיים.
בעלת נסיון רב שנים בטיפולי אונליין, בישראל ומחוצה לה.
בתפיסתי, קשר טיפולי שבבסיסו אמון וכבוד הדדי, מתן מענה רגשי והגדרת מטרות ברורות - יאפשרו לחולל שינוי.
התכנית הטיפולית נבנית על בסיס הרציונל העולה מההמשגה הקוגניטיבית-התנהגותית או מזו של גישת הסכמה תרפיה, והיא ייחודית ומשתנה מאדם לאדם. בטיפול משולבים כלים טיפוליים באופן אינטגרטיבי, בהתאם לסוג הבעיה ולאישיותו של המטופל.
תואר שני (מוסמך) בפסיכותרפיה קוגניטיבית-התנהגותית. סיום תואר בהצטיינות יתירה.
חברה מומחית ובהסמכה להדרכה בארגון הישראלי לטיפול התנהגותי קוגניטיבי (איט"ה) ובארגון האירופאי EABCT
מטפלת בכירה ומדריכה מטעם הארגון הבינ"ל לסכמה תרפיה (ISST )
מטפלת מוסמכת שלב I בטיפול ממוקד רגש EFT
לימודי תעודה (ביה"ס החדש לפסיכותרפיה) ב- AEDP
תואר ראשון במדעי ההתנהגות.
השתלמויות מקצועיות שונות, כגון: סיוע בעזרת קלפים טיפוליים, טיפול בהפרעות אכילה, סדנאת אימון ועוד.
בעלת נסיון טיפולי רב ומגוון, הכולל טיפול בהפרעות אישיות, קשת הפרעות החרדה, דיכאון, דימוי עצמי נמוך, משברים ומעברי חיים, זהות ואוריינטציה מינית ועוד.
התמחיתי במחלקה הפסיכיאטרית של בית החולים שיבא (תל השומר) ובמרפאת החרדה בבית החולים הפסיכיאטרי ע"ש יהודה אברבנאל.
בעברי עבדתי במרכז שבילים (מרכז טיפולי לילדים בספקטרום האוטיסטי) וכן בבית החולים אסותא, במחלקה לטיפול בהשמנת יתר.
כיום מטפלת ומדריכה במגוון בעיות במבוגרים, בקליניקה הפרטית בכפר סבא, כולל עבודה עם עם ניצולי שואה.
Schema anywhere: The opportunities and pitfalls of delivering Schema Therapy online
By Hagara Feldman (Israel) and Dr Xi Liu (Australia)
Online therapy (also known as Teletherapy, Telemedicine, Remote Therapy, Video Conferencing, etc.) is expanding rapidly as technological advancements allow for more stable and secure platforms for online communication. A PwC Health Research Institute study shows that 72% of American clients ages 18 to 44 and 43% of patients 45 and older, would opt for a virtual mental health visit over an in-office appointment (2015). Current trends suggest that Online Therapy will be routine practice in a few short years. There are many benefits of Online Therapy, including easier access to specialists; reduced travel time and costs; and continuity of care when existing clients relocate. Other reasons seen in clinical practice include seeking specialists with similar or alternative culture/language and experience of phobias that prevent travel or shame-based disorders.
In recent years a number of studies have emerged to demonstrate positive clinical outcomes for Online Therapy (Backhaus et al. 2012). Simpson & Reid (2014) reported that therapeutic rapport can be readily established in one to one video conferencing technology. Despite this, many mental health professionals hold concerns about delivering therapy outside the traditional face to face setting. For those who are interested in delivering therapy online, it is important to acknowledge that it is not simply “business as usual” and it requires consideration and adaptation.
This paper aims to provide: 1) clinical Strategies to enhance therapeutic alliance in Online Therapy; 2) strategies to adapt emotionally focused work (Imagery Rescripting and Chairwork) to the online environment.
Clinical Strategies to enhance therapeutic alliance
(A) The limited perspective: For most Online Therapy setups, both the client and the therapist only have views of each other’s face and shoulders. For clients who only attend online sessions, much information is missing that would normally be readily available in face to face settings. This includes the therapy office decor, the therapist’s dress or body language. For clients with a mistrust/abuse schema, this lack of perspective and physical information can trigger anxiety and discomfort. One client in our clinical experience exclaimed “I don’t even know if you are a real therapist and working in a real office”. A helpful strategy to alleviate this is an audiovisual tour of the therapy room at the start of therapy. The therapist can walk around the room with the laptop, showing small details of the room (even the texture of the sofa or cushion) - a perspective that the client would have had if they were to walk into the room. Further in therapy, the therapist can use this image of the room to create a safe place where they can be together and\or provide comfort via imagery.
For the therapist, the missing information of client’s body language, gait when walking, general appearance and behaviour in the therapy room (such as entitlement, controlling or inhibited behaviours) can be restricting. However, there is also “extra” unique information that the therapist receives only within an online environment. For instance, the client’s pets, family dynamics (a child that insists on entering the room), a display of awards or personal photos on the wall and so forth that can be useful clinical information.
(B) “Nonphysical dimension”: the online environment can trigger emotional deprivation schema, whether it is for clients who start their therapy online or for clients who are in transition from face to face to online. The absence of physical contact means that the therapist won’t be able to offer a hot drink or a pat on the arm when the client is distressed. However, through the use of Schema Therapy strategies, the therapist can overcome this physical barrier through imagery. Therapists can give a sense of physical connection through fantasy - imagining sitting side by side with the client, offering a blanket over their shoulders or any other gesture they would do in a face to face meeting. The imagery place where the therapist and the client meet can also be used as the client's safe place in imagery. It can be a neutral place like the beach, a bench on the street or anywhere else. It can also be the therapist's office, especially if the client has received a guided online tour of the therapy room or has attended a face to face session prior to online meetings. Encouraging clients to prearrange their space to create a ‘therapeutic frame’ can also be helpful. The Therapy Frame is a concept from psychoanalytic literature and is commonly referred to as the ‘container’ from which therapeutic work exists. Most therapists spend considerable time setting up their therapy room to create an atmosphere of stability, safety, privacy so that successful therapeutic alliance can be formed. However, this responsibility in Online Therapy lay with the client. The client can be encouraged to set aside a space that they use each session where a blanket, a glass of drink and tissues are within easy reach. See Appendix 1: “Getting Started with Online Therapy” (Liu, 2019) for further discussion on how to create a therapy frame in the online environment.
(C) Technical challenges: the technological aspect of the online environment may be intimidating for the therapist and the client. Directing the client to use the video conferencing application for the first time, dealing with WIFI disconnections, laptop power outages and so forth, can happen regularly in Online Therapy. These difficulties can also easily trigger almost any schema from all of the five domains. For example, someone with a Defectiveness schema may feel “my therapist must think I’m such an idiot for not being able to use the program”. This may lead to greater unhelpful compliance or overcompensation with blaming or self-aggrandizing. For another client, this may trigger their Abandonment schema and think “oh no, my therapist will get tired of me and leave”. Or an Entitlement schema, “I lost therapy time with the disruption, my therapist better make up for that”. However, by addressing the client’s responses to these technological challenges from a schema activation perspective, the therapist can turn these challenges into therapeutic opportunities. This may enrich the conceptualisation or provide a platform for limited reparenting.
(D) Diversity and Cultural Issues: While it is not uncommon for therapists to have different cultural backgrounds to their clients. When working online, it is more common than not that therapists and their clients live in vastly different circumstances. Combining this with different seasons, time zones and customs, it is easy for the differences to exacerbate Social Alienation or Emotional Deprivation schemas. It is helpful to try and learn some history and cultural values of the client’s home country, especially the way they affect attitudes towards emotions, autonomy and other central values in Schema Therapy. Try to differentiate between one’s own personal schemas as well as those that are embedded within the culture e.g. display of emotions, independence or gender role expectations. It is important for the therapist to maintain an open and curious attitude and work carefully to avoid directing clients to engage in a way that is inappropriate for their social environment.
The possibility of Online Therapy means that therapists can provide greater continuity of care for clients as they move away or are frequently on the move for work or lifestyle. The presence of the therapy relationship as a stable base in their life can be particularly invaluable for clients who have significant attachment trauma. Although the online meetings can address the need for stability, the shift from face to face setting to meeting online, may feel like a loss of warmth and sense of closeness. In order to overcome that, it can be helpful to use a transitional object. A transitional object can be a meaningful object that serves as an external representation of the therapist and / or the connection that took place in the therapy room.
2) Adapting emotional techniques to online environment:
How can therapists safely deliver imagery work that might trigger high levels of emotional reaction, when they are not physically in the same room with their client? How do therapists facilitate Chairwork when the client is not physically with them? This section will address some general ideas and tips regarding adapting emotional focus techniques in an online environment.
Imaginary Rescripting:
Imagery Rescripting when done online is not largely different to what is done in traditional face to face settings. It is recommended to be aware of any risk issues around the possibility of destabilizing a client who is not in physical proximity. Prior to activating unpleasant emotions, move slowly and gradually, start with short pleasant imagery interactions between the therapist (or client’s healthy adult) and the child mode. It is helpful to first meet their needs, without an antagonist, before full rescripts. Clinical reports have seen that clients need to have at least a small Healthy Adult mode for Online Therapy to be successful. It is unclear why this is the case. However, it is likely that it may simply be too unpredictable to do imagery work with a client without a small remnant of a Healthy Adult and if the client becomes destabilized or highly triggered, it is much harder to manage in an online environment. It is also important to pay close attention to somatic changes in the client, particularly as the therapist only has limited view via videoconferencing. It is advisable to spend significant time prior to engaging in imagery work to guide clients to use their senses or objects in the room for grounding and self-soothing.
Chairwork:
Chairwork in Schema Therapy implies, broadly speaking, the externalizing of internal parts, then place these parts onto separate ‘chairs. Movement is an important factor in the efficacy of chairwork (Pugh 2017). When adapting Chairwork to an online environment, the logistics of arranging multiple chairs and enough space for movement can be challenging as the client is not in a space carefully planned by the therapist. The therapists have several options, depending on the limitations of the situation - invite the client to prepare chairs for upcoming sessions or use mobility of the chairs already in the room. For example, moving a single chair to different locations in the room; or moving to the left, center and right sides of a wide sofa. This subtle use of movement allows the ‘stepping in’ and ‘stepping out’ of modes. In addition, objects or mode cards can be used to represent modes, inviting clients to “be” the mode represented by the object.
Conclusions
It is necessary for therapists offering online schema therapy to address issues specific to the online environment. With adequate consideration of the challenges, limitations and opportunities - Online Therapy can be a highly effective form of treatment. This article aims to promote greater understanding of how emotionally focused strategies in Schema Therapy can be an important tool to bridge the ‘physical divide’ when working with clients online. Despite the strong public interest in Online Therapy, there is little empirical research into strategies to enhance therapeutic alliance through different therapy modalities, particularly Schema Therapy. The clinical discussion provided in this paper will
hopefully spark interest in further research.
References
Backhaus, A., Agha., Maglione, M. L., Repp, A., Ross, B., Zuest, D., Rice-Thorpe, N. M. (2012). Videoconferencing Psychotherapy: A Systematic Review. Psychological Services, 9 (2), 111-131. DOI: 10.1037/a0027924
Liu, X. (2019). Getting Started with Online Therapy: A guide to Online Therapy. See Appendix 1.
Pugh, M. (2017). Pull up a Chair. The Psychologist, 30, 42-47.
PwC’s Health Research Institute (2015). Top Health Industry Issues of 2016: Thriving in the New Health Economy.
Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. The Australasian Journal of Rural Health, 22, 280-299.
מדריכה מוסמכת בסכמה תרפיה, שעות הדרכה מוכרות ב- ISST.
מדריכת CBT מוכרת באיט"ה.
