Theory and Practice of Online Therapy Internet delivered

Interventions for Individuals, Groups, Families, and

Organizations 1st Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/theory-and-practice-of-online-therapy-internet-deliv
ered-interventions-for-individuals-groups-families-and-organizations-1st-edition
/

Click Download Now

Contents

List of contributors viii

Acknowledgments xi

Introduction 1
HAIM WEINBERG AND ARNON ROLNICK

SECTION 1
General Considerations for Online Therapy 11
EDITED BY HAIM WEINBERG AND ARNON ROLNICK

1 Introduction to the General Consideration Section: Principles

of Internet-based Treatment 13
ARNON ROLNICK

2 Interview with Lewis Aron and Galit Atlas 23

3 Empathy in Cyberspace: The Genie Is Out of the Bottle 34

LOU AGOSTA

4 Sensorimotor Psychotherapy from a Distance: Engaging the

Body, Creating Presence, and Building Relationship in
Videoconferencing 47
PAT OGDEN AND BONNIE GOLDSTEIN

5 The Clinic Offers No Advantage over the Screen, for Relationship

is Everything: Video Psychotherapy and its Dynamics 66
GILY AGAR

6 Cybersupervision in Psychotherapy 79
MICHAEL PENNINGTON, RIKKI PATTON AND HEATHER KATAFIASZ
vi Contents
7 Practical Considerations for Online Individual Therapy 96
HAIM WEINBERG AND ARNON ROLNICK

SECTION 2
Online Couple and Family Therapy 101
EDITED BY SHOSHANA HELLMAN AND ARNON ROLNICK

8 Introduction to the Online Couple and Family Therapy Section 103

SHOSHANA HELLMAN AND ARNON ROLNICK

9 Interview with Julie and John Gottman 111

10 Internet-delivered Therapy in Couple and Family Work 123

KATHERINE M. HERTLEIN AND RYAN M. EARL

11 Digital Dialectics: Navigating Technology’s Paradoxes

in Online Treatment 137
LEORA TRUB AND DANIELLE MAGALDI

12 Practical Considerations for Online Couple and

Family Therapy 154
ARNON ROLNICK AND SHOSHANA HELLMAN

SECTION 3
Online Group Therapy 159
EDITED BY HAIM WEINBERG

13 Introduction to the Online Group Therapy Section 161

HAIM WEINBERG

14 Interview with Molyn Leszcz 166

15 Online Group Therapy: In Search of a New Theory? 174

HAIM WEINBERG

16 Transformations Through the Technological Mirror 188

RAÚL VAIMBERG AND LARA VAIMBERG

17 Practical Considerations for Online Group Therapy 205

HAIM WEINBERG
 Contents vii
SECTION 4
Online Organizational Consultancy 209
EDITED BY RAKEFET KERET-KARAVANI AND ARNON ROLNICK

18 Introduction to the Online Organizational Consultancy Section 211

RAKEFET KERET-KARAVANI AND ARNON ROLNICK

19 Interview with Ichak Kalderon Adizes 223

20 All Together, Now: Videoconferencing in Organizational Work 228

IVAN JENSEN AND DONNA DENNIS

21 A Reflexive Account: Group Consultation via Video Conference 244

NUALA DENT

22 Practical Considerations for Online Organizational

Consultancy 258
RAKEFET KERET-KARAVANI AND ARNON ROLNICK

Epilogue 268
ARNON ROLNICK AND HAIM WEINBERG

Index 270
Contributors

Gily Agar is an Israeli clinical psychologist, founder of an online video-

therapy service for Israelis abroad, and teaches therapists and other health-
care providers how to create close and engaging relationships in video.
Lou Agosta, PhD, is an empathy consultant and psychotherapist in private
practice, delivering empathy lessons (psychotherapy interventions) as a
professor of medical education at Ross Medical University at Saint
Anthony Hospital, Chicago, IL. He is the author of three peer-reviewed
academic books on empathy, including A Rumor of Empathy.
Lew Aron is an internationally recognized lecturer on psychoanalysis who
has made significant contributions to relational psychoanalysis. Unfortu-
nately, he died in 2019 before the publication of this book.
Galit Atlas is a psychoanalyst known for her rethinking of the place of
sexuality and desire in contemporary theory and practice.
Donna J. Dennis, PhD, is a leadership development professional, specia-
lizing in solutions for leaders working in virtual and remote teams. She
has conducted research on working virtually for the Gestalt International
Study Center.
Nuala Dent is a systems psychodynamic researcher and practitioner with an
interest in understanding group dynamics at the intersection of face-to-face
and online ways of working.
Ryan M. Earl, Ph.D, is a Clinical Lecturer, Department of Psychology,
at Northwestern University.
Bonnie Goldstein, LCSW, Ed.M., PhD, is founder and director of the
Lifespan Psychological Center in Los Angeles, specializing in individual
and group therapy for children, adolescents and families. She teaches at
USC’s School of Social Work and is on the faculty at the Sensorimotor
Psychotherapy Institute, where she teaches internationally and has co-
developed their child, adolescent and family treatment training program.
 Contributors ix
Shoshana Hellman finished her doctorate at Columbia University,
Teachers College, NYC, in counseling psychology. She currently
works in private practice both in Israel and the USA with individuals,
couples and families, and is a licensed couple and family therapist – the
only certified Gottman couple therapist and consultant in Israel. She
worked as a senior supervisor for the Ministry of Education, psycholo-
gical services in Israel for over 20 years and was a faculty member at the
University of Wisconsin in Madison. She has several publications in the
area of supervision and professional development of counsellors.
Katherine M. Hertlein, PhD, is a Professor in the Couple and Family
Therapy Program at the University of Nevada, Las Vegas.
Ivan Jensen, MD, has worked with, taught and researched leadership and
organizational development for more than 30 years, with a special
interest in complex and virtual organizations. He is a founding partner
of GestaltPartner in Sweden where he teaches, as well as provides
consulting to organizations.
Ichak Adizes is an international consultant. He is the developer of the
theory and protocols of the organizational therapy that bears his name.
Heather Katafiasz, PhD, is an Assistant Professor at the University of Akron.
Her professional interests include expanding the systemic understanding of
Intimate Partner Violence and its intersection with substance use.
Rakefet Keret-Karavani has been practicing organizational consultancy
since 1994, focusing on leadership development. Her doctorate disserta-
tion researched leadership in virtual organizations, as manifested in video-
conference meetings.
Molyn Leszcz is president-elect of the American Group Psychotherapy
Association. With Irv Yalom he wrote the 5th edition of Yalom’s book
The Theory and Practice of Group Psychotherapy.
Danielle Magaldi, PhD, is an Associate Professor at the City University
of New York. Her research focuses on two areas: the effects of
technology on human relationships and spirituality in psychotherapy.
She maintains a private practice treating adults and children.
Pat Ogden, PhD, founder of the Sensorimotor Psychotherapy Institute,
is a clinician, consultant, international lecturer and trainer, and ground-
breaking author in the field of somatic psychology.
Rikki Patton, PhD, is an Associate Professor at the University of Akron.
Her professional interests include improving treatment for marginalized
populations with a focus on addiction work.
Michael Pennington, M.A.Ed., is a doctoral student in the Marriage and
Family Counseling/Therapy program at the University of Akron. His
x Contributors
professional interests include technology use in therapy, therapist self-
care and cybersupervision.
Arnon Rolnick is a licensed Clinical Psychologist with special interest in
the usage of technology in psychotherapy. He is a certified supervisor
in CBT and biofeedback and has written numerous articles on these
subjects. Arnon is the head of a clinic in Tel-Aviv which integrates
various psychotherapeutic approaches.
Leora Trub is an associate professor of psychology in the school/clinical-
child PsyD program at Pace University where she trains doctoral
candidates in clinical work and runs the Digital Media and Psychology
lab, which explores the intersection of technology and human connec-
tion. She is also a practicing psychologist based in New York City,
working with adolescents, adults and couples.
Raúl Vaimberg Grillo is a Psychiatrist, Doctor of Psychology and
Psychotherapist. He is the Director of the ‘Postgraduate Course in
Group Psychotherapy and Psychodrama’ at the University of Barcelona.
Lara Vaimberg Lombardo has a Master’s Degree in General Health
Psychology, a Postgraduate degree in Group Psychotherapy and Psy-
chodrama (University of Barcelona), and has participated in research
projects on childhood, therapeutic groups and Autism Spectrum
Disorders.
Haim Weinberg is a licensed psychologist, group analyst and Certified
Group Psychotherapist in private practice in Sacramento, California.
He co-edits a series of books about the social unconscious, wrote a
book on Internet groups, and co-authored a book on Fairy Tales and
the social unconscious.
Acknowledgments

As the editors of this book, we are pleased to acknowledge the help and
contribution of our two co-editors who took a major part in editing two
sections of our book: Shoshana Hellman who co-edited the Family and
Couple section, and Rakefet Keret-Karavani who co-edited the Organi-
zational Consultancy section. We are grateful for their work and patience
with our many requests for revisions.
We are very grateful to our families and friends for tolerating our
continuous preoccupation. Without their support and patience, we
would have never been able to finish this project.
Last, but not least, we are grateful to our online patients who taught us
so much about how to do online treatment properly.
Haim and Arnon
Introduction
Haim Weinberg and Arnon Rolnick

Ocean separates lands, not souls.

(Munia Khan, a Poet)

It is almost outdated to write that we are in a dizzying process of changes

in a rapidly changing world.
Nobel prize winner Daniel Kahneman (2017) believes that the world of
medicine, consultation and organizational behavior is going to change sig-
nificantly due to technology in general and artificial intelligence in particular.
We, as clinical psychologists and psychotherapists, look at the changes
that are taking place with a curious eye, examining cautiously but also
with enthusiasm how these changes affect our lives. This book is edited
and written from the same observing position, enthusiastic on the one
hand and critical on the other.
One of the unique features of this book is that it is not only about one-
on-one interaction and individual psychotherapy, but also on multi-
participant interaction. Quite a bit has been written about remote
treatment at the level of one-on-one (Scharff, 2018), and later in the
book you will find reference to the knowledge accumulated in various
articles and books. Human interaction and psychotherapy often exist in
more than one-on-one format. Couples and family therapy is one example
that we have chosen to expand on. Another unique challenge of this book
is to discuss the possibility of remote group work. Group therapy is clearly
less expensive and also effective, however, group therapists know the
technical and practical difficulty of bringing a group of people together
in one place at a time. We therefore found it very important to discuss the
possibility of group therapy from a distance.
One of the sections in this book is certainly innovative and perhaps not
classical to be included in conjunction with psychological treatments: this
is the section of organizational consulting from a distance. The reasons for
introducing this part are twofold. First, we have to acknowledge that the
prevalence of group work in organizations is much greater than group
therapy in clinical practice, and even more so, in organizations there is
a tendency to neglect the importance of the interpersonal aspects of team
2 H. Weinberg and A. Rolnick
work in general and from a distance in particular. Not neglecting the
interpersonal dimension in organizational online work is one of the tasks
of this book.
We want to emphasize that in this book we mostly focus on online
videoconference therapy. Although there are some chapters that discuss
text-based therapy, our main interest is in the more advanced technologies
that make the sessions “closer to reality”. Phone sessions, for example, has
been practiced for several decades. However, their use was very limited,
and they were always perceived as adjunct to the in-person therapy. This
is not the case in videoconferencing, that threatens to replace the tradi-
tional face-to-face (f2f) meetings.

Theoretical and Practical Questions

In this book we aimed to encompass both the theoretical and practical
aspects of online therapy and consultation. Some of the existing books and
articles, focus only on one of these aspects (e.g. Essig & Russell, 2017 on
theory, while Derrig-Palumbo & Zeine, 2005 on practice). We think that
practical considerations stem from theoretical understanding and the
specific school of thought. For example, in f2f group therapy, the question
whether the group leader should always sit in the same chair depends on
the theoretical orientation: In a psychodynamic one, a stable setting is very
important, and the group therapist should stay in the same chair to allow
for projections, while in humanistic approach, modeling and flexibility is
more important, hence changing seats is recommended. What seems to be
a simple practical question is influenced, in fact, by theoretical considera-
tions. This same question, considered online, might affect the technology
chosen for group work. Most of the programs nowadays do not enable the
group therapist or consultant to choose the “seat” of the leader and
participants on the screen.
The position of the editors and authors throughout the pages of the
book is an observing position. We try not to fall into the following
dichotomy: Is remote therapy good or bad? Are these treatments similar
or different from conventional psychotherapy? Moreover, as researchers,
we are interested not only in the question of whether tele-therapy is
effective, but also the question: what can we learn about the mechanisms
that work in treatment in the light of the existence of “non-body”
treatment or treatment that is in different locations? The transition to
remote treatment allows for dismantling the various therapeutic factors.
The fact that disembodied therapy is possible, questions traditional
assumptions of necessary conditions for therapy. Holding, for example
(Winnicott, 1971), a major term in psychodynamic psychotherapy, is
based on the actual maternal hands, hugging and encompassing the baby.
In remote therapy not only “real” hugs are impossible, sometimes it seems
that the therapist is a handless mother.
 Introduction 3
If we look at the changes that have taken place in the field of
psychotherapeutic theories in the latest decades, Bowlby’s theory of
attachment stands out, as almost every psychotherapeutic approach nowa-
days uses some of his conceptual approach. Sroufe et al. (2005) claims that
“Attachment can be considered ‘perhaps the most important developmen-
tal construct ever investigated’.” Proximity is the keyword in Bowlby’s
theory. Children seek closeness with a parent who can protect and take
care of them. From here derives the assumption that the therapist should
also be close in order to help the client repair the attachment ruptures.
The question is whether being close means only physically. When Bowlby
talked about proximity, did he mean “in the same location”? While
interpretation-based theories did not place much emphasis on the element
of physical closeness, in some of the attachment-based approaches this
element cannot be ignored, thus questioning the validity of remote
treatment. To sharpen this question, can we think of caring for small
children without physical proximity? While we do believe that remote
therapy is possible and effective, we hardly believe that it is suitable for
very young children.
The question of physical presence is even more relevant in the frame of
reference of interpersonal neurobiology modern theories. These theories,
by Alan Schore (2003), Daniel Siegel (1999), Louis Cozolino (2013) and
others, emphasize the importance of mutual regulation based on physical
presence. For example, these theorists claim that what works in therapy
are not just the words but the mutual regulation of brain to brain, body to
body. Sometimes these theories focus on right brain to right brain
communication and sometimes on the peripheral nervous system. Stephen
Porges (2011) for example, argues that therapy is based on the experience
of safety that a therapist provides to the patient. In Porges’ opinion, two
people in physical proximity immediately activate a mechanism that
checks whether it is safe to be close with the other person. A major part
of his Polyvagal theory is identifying the nervous system mechanisms that
focuses on the other person’s voice and face for that purpose. Ostensibly,
these theories will question the adequacy of remote therapy as there is no
body present to regulate the body of the other, so mutual regulation is
impossible. A closer look shows that one of the important variables for
Porges is the face (especially its upper part). However, facial expression
becomes clearer and in higher resolution online – perhaps even more than
in treatment in the same room. On the other hand, in remote treatment,
usually only the face is seen while important information about posture,
sitting, breathing, and various motor movements disappears. Smell and
pheromones are also important and are missing online.
Some of these theoretical issues have clear practical implications. Several
writers suggest solutions for creating a bonding experience in online
family, group and organizational settings. For example, some recommend
sitting more distant from the screen. To this end, we have attached a few
4 H. Weinberg and A. Rolnick
pages to each section dealing with some possible best practice solutions for
remote work, again from an observing and insightful position, discussing
the advantages and disadvantages of any proposed solution.
We tried to summarize the main theoretical and practical issues that
online therapists should deal with. Here is our list of topics to take into
consideration:

1. Presence. All the authors writing about online therapy (e.g. Lemma,
2017; Russell, 2015; Weinberg, 2014) focus on the question of
presence, wondering whether it is possible to create it in cyberspace
and how much presence necessitates a body. Presence is actually
essential for positive outcomes of psychotherapy. Nevertheless, it is
quite an elusive term. In their book about therapeutic presence, Geller
and Greenberg (2012) argue that it is the fundamental underlying
quality of the therapeutic relationship and, hence, effective therapy.
They describe therapeutic presence as the state of having one’s whole
self in the encounter with a client or a group by being completely in
the moment on a multiplicity of levels – physically, emotionally,
cognitively, and spiritually. Therapeutic presence is defined as bringing
one’s whole self to the engagement with the client and being fully in
the moment with and for the client, with little self-centered purpose
or goal in mind (Craig, 1986).
The term ‘face-to-face’ means ‘to be in each other’s sight or presence’.
Traditionally we mean the physical presence, since the participants in the
communication are in the same physical space. However, when we move
to cyberspace, and especially when we use video conferencing, presence
acquires a different meaning. What is this online presence that is so crucial
to therapeutic relationship? The presence of the other is usually felt
through hearing the other’s voice and seeing the other’s face and body.
Although traditionally, presence involves the body, actually this physical
presence only supports subjective presence.
The presence of the therapist involves his/her immersion, passion,
attention, emotional involvement, reverie, and a readiness to be drawn
into enactments (Grossmark, 2007). This can still be done online. Lemma
(2017) writes that presence is the perception of successfully transforming
an intention into action, and actions are not restricted to ones that we
discharge physically. This can clearly occur in Cyberspace as well,
although it might need specific focusing on how to transform the
intention into action taking into consideration the limitation of online
communication.
2. Terminology. We wondered what the right term for online therapy
should be, especially one that is using video. Is it e-therapy (not
exactly, as it implies using email for therapy), or online therapy?
Certainly not “virtual therapy”, as it implies that this therapy is only
virtual. And how do we term therapy where all the participants are
 Introduction 5
physically present in the same room? Calling the latest f2f ignores the
fact that in video therapy we also see one another face-to-face (and
sometime better, due to the fact that the face is shown in a close-up).
We noticed that the chapters’ writers for this book struggled with this
question as well, and we decided not to force a unified term, but allow
each writer to use their own term. Thus, Ivan Jensen and Donna Dennis
(Chapter 20) called it collocated work. Katherine Hertlein and Ryan Earl
(Chapter 10) used a general term for online therapy and called it “Inter-
net-delivered service”. Leora Trub and Danielle Magaldi (Chapter 11)
related to it as “in-person treatment”. Nuala Dent (Chapter 21) chose
‘face-to-face’ to denote a group meeting in the same physical place and
‘online’ to denote a group meeting via technology specifically. She wrote:

I search for words to distinguish these different face-to-face meet-

ings. I could identify them as “physical” and “virtual” but this
implies one is real and the other not-real. To describe a video
conference meeting as “online” suggests that a meeting where all
members are in the same room is “offline”.

3. Is it the same therapy or a different one? A continuous debate in the

literature about online therapy focuses on the question whether it is
the same therapy as we do in-person or a different one. Sherry Turkle
in an interview with Essig and Russell (2017) says: “Technology
creates a new state of the self …. Online intimacies are real but operate
with new dynamics” (242). Todd Essig (personal communication,
2017) agrees that online therapy is working but claims that it involves
processes that are different from in-person therapy. Specific processes
fundamental across psychodynamic therapies, such as analytic listening
and attention to implicit processes, are inevitably changed and mod-
ified when subject to technological mediation. He is worried that we
are lowering standards so that what takes place on screen qualifies as
working. He and Russel suggest that the alluring convenience of
remote treatment should not cause clinicians to either lose sight of or
undervalue that which is unique to what we call “local therapy.”
We think that the split between “is it the same” or “is it different” is
unproductive, and we prefer to look at both similarities and differ-
ences. For example, Weinberg (2014) argued that online relationship
involves a different kind of intimacy and termed it E-ntimacy. It is not
the kind of into-me-you-see that is praised in Hollywood movies and
is based on self-disclosure and on privacy. As privacy cannot be
guaranteed in Cyberspace, we should rethink of intimacy in new
ways: “Intimacy without privacy reinvents what intimacy means” (Turkle,
2011: 171). Online E-ntimacy is more similar to the kind of intimacy
that develops in Large Groups (see Chapter 15) and is based on an
atmosphere of cohesion, “we-ness”, and belonging.
6 H. Weinberg and A. Rolnick
Another example to different processes in online therapy is its
meaning to ending and termination of therapy and relationship. We
can continue therapy in circumstances that were unavailable in the past
(such as moving to another country). Thus, online therapy and online
connection perpetuates the fantasy that we can overcome human
limitations of time and space, as we can continue our relationship
whenever we want and wherever we are.
4. Making it more “real”? Related to the previous question of how similar
or different online therapy is from in-person treatment, is the question
how much we want to make it as closer as possible to the “real”
experience. An approach wanting to replicate the circumstances in our
clinic would insist that in online psychoanalysis the patient still lie on the
couch even when the analyst is behind the screen. In our opinion this is
a too rigid and even ridiculous. This question affects the decision
whether to sit close to the screen, so that only our face is shown, or
maintaining some distance from the computer, thus seeing our bodies as
we are used to in our offices (we will address the distance from the
screen in the practical guidelines). We believe that on the one hand we
should try and replicate the basic conditions that exist when we see
a patient in-person, but always taking into consideration the fact that it
is a different media that dictates some different circumstances.
5. The need to focus. We agree that “an online environment may require
a greater investment of time and energy to create and maintain
a psychic space that supports learning through experience” (Nuala
Dent, Chapter 21). In order to maintain presence, to stay focused and
not be distracted by other stimuli (whether on the screen or in the
therapist’s environment), the therapist should be keenly aware and
make a special effort.
6. The disembodied self. Many authors pointed out to the disembodied
interaction online. This is only partly true, as each participant still have
a body, and can sense it while sitting in front of the computer, which
is not different than while sitting in our office with a patient (who is
sitting or lying on the couch) in the same room. Lemma (2017) refers
to therapy mediated by Skype as embodied presence because “in cyber-
space we are still embodied. What changes is our experience of our
own and the other person’s embodiment” (92). All the members in
online communication can feel their emotions, pain, body ailments
and bodily needs while they communicate. What is missing is the
body-to-body communication. It is missing because of two reasons: 1.
Only part of the body (usually the head and shoulders) is seen, and
most of the body is hidden. 2. The screen creates a barrier, so that we
cannot smell or be sensitive to bodily cues that we are aware of
(consciously or unconsciously) when we are in the same physical
space. It reduces the communication from a full body, three dimen-
sions, to a flat, two-dimension communication. So, indeed, something