Disrupting psychotherapy

"It’s time to reimagine how we provide mental health services."

Aaron Balick

‘Keyboard reflection’ by Dave (CC BY-NC-ND 2.0)
‘Keyboard reflection’ by Dave (CC BY-NC-ND 2.0)

These days Psychoanalysis is usually perceived as a turgid, traditional, anachronistic relic: few people outside it realise that Freud was in fact a cutting-edge disrupter and an innovator. He turned the world of psychology upside down and stamped his theories so hard on the Western psyche that the 20th century has been referred to as The Freudian Century. Freud was the original psychological subversive.

It doesn’t stop with him. Several prominent psychoanalysts broke with him to innovate in their own direction. There was Alfred Adler who brought a social element into psychoanalysis; Jung, who challenged Freud’s focus on libido and argued for a more generalised life energy underlying all human motivation; Melanie Klein, who used psychoanalysis to understand infantile states of mind going on to develop child psychotherapy; and John Bowlby who combined psychoanalytic thinking alongside the scientific method to observe and study the behaviour of children and created Attachment Theory. The list of disruptors and innovators in psychoanalysis would go on to fill books (like Cassandra’s Daughter (Schwartz 1999) and Freud and Beyond (Mitchell and Black 1995) for example).

Entirely new strands of psychology would be born out of the minds of disgruntled psychoanalysts who turned rogue. Eric Berne started as a psychoanalyst before going his own way to map out social interactions in what became branded as Transactional Analysis; another recovering psychoanalyst was Aaron Beck who fell out of love with the Freudian unconscious and turned his attention to more tangible things like thoughts and behaviours, ultimately inventing Cognitive Behavioural Therapy or CBT; Albert Ellis was yet another dyed in the wool psychoanalyst who turned rogue and created Rational Emotive Behaviour Therapy; and who can forget Fritz Perls, who started as a psychoanalyst but found it too passive for his personality and went on to create Gestalt therapy?

Other psychologists like Abraham Maslow and Carl Rogers developed Humanistic Psychology as a direct response to the limitations they saw in the more traditional approaches that preceded them.

However conventional and traditional these approaches may seem today, they were controversial when they burst onto the scene. The whole field of psychology was founded by disrupters — and eventually those disruptions became the norm, and in some cases, the orthodoxy. Most talking therapists today borrow a host of ideas from all of the models presented above with very little controversy. In fact, most people don’t know what kind of therapy their therapist practices. Whatever method is used, therapy still pretty much looks the same as it did in Freud’s time — just two people talking in a room.

That is, until recently when technology was given a role. A new set of disrupters started doing therapy by telephone, and later, video conferencing. Suddenly there was no room — just a fibreoptic line. When this tiny minority started to grow, so did the controversy around it. This wasn’t psychotherapy, many argued, because it lacked that important co-presence of two people in a room. Others went even further — conducting therapy via email and text. Where would it go next?

Suddenly coronavirus came and everybody started working online practically overnight and the tables were turned. Those who had experience in online work knew what they were doing and everybody else had to play catch up.

How do I do this securely? What do I need to do differently? Do I have to wear pants?

What was previously a controversial innovation became business as usual for everyone. But it’s not business as usual. The doubters were both wrong and right; working online is not the same thing as co-present psychotherapy, but it is still psychotherapy! Knowing how to work differently is crucial to protecting psychotherapy and ensuring a duty of care to clients.

Innovation is always risky, but that’s why it should be approached critically and with care. When my organisation, Stillpoint Spaces, developed an online therapy platform out of necessity (our community was scattered around the globe), we looked into online work deeply and even carried out our own pilot research project to ensure we were covering all the angles. We learned that when it comes to innovation with technology in counselling and psychotherapy, professionals need ongoing support. For this reason, we initiated regular peer support called “intervision”, where clinicians could regularly debrief with each other about the challenges they face online. This continues as a free benefit to our members.

When it comes to something as precious as the human psyche the “move fast and break things” approach advised by Facebook simply isn’t appropriate.

Innovation comes with responsibility.

Some years ago, I was jolted awake within my own clinical practice when a patient Googled me and I became keenly aware of the role technology plays in mediating our interpersonal lives. After writing a clinical paper about that experience, I followed it up with my book The Psychodynamics of Social Networking: connected-up instantaneous culture and the self (Balick 2014). Off the back of the clinical paper, this book uses psychoanalysis to understand how technology mediates all our relationships, not just those between therapist and client. In short, it uses insights usually applied in the consulting room, and applies them to culture instead.

Understanding our world through the lens of psychology is one thing, but so is its reverse. We should also be asking the question, “what can psychology learn from the world in which it finds itself?”

Whether that’s working online or by other means, we are keen to see where innovation can meet psychology in a way that adds value to the grand psychological project. This is specifically relevant with the use of technology in the delivery of psychological interventions.

Technology isn’t to be incorporated into psychotherapy because it is there, but rather because we can use it to add value in one way or another.

Most psychological services are delivered in ways that in fact disincentivise people to take them up. Most notably, the fact that showing up at a stranger’s office to unburden your most private thoughts and feelings is a big ask! Just getting there is a challenge. In the public sector you may have to wait weeks for your first appointment only to find that your second appointment, often weeks after that, is with someone altogether different. Waiting lists and more demand than supply is equally a problem amongst charities and non-profits. If you can afford to go privately, you may not have to wait so long, but if you want to “shop around” to find the right person you could unload hundreds of pounds before finding who you want to work with.

Recognising this, at Stillpoint Spaces we decided to innovate this initial process by running free “Speed Dating Therapists” events which enable members of the public to experience short ten-minute tasters with up to five different therapists at a time. This gives people an opportunity to see what therapy is like, ask questions, and see what kind of chemistry they may have with potential therapists without any commitment, financial or otherwise. Many in the field are highly critical of “debasing” psychotherapy like this — but the reports are different from the punters who get to ask a variety of professionals a bunch of questions, and getting quick straight answers, without the commitment of a full session.

If we don’t create innovations that make it easier for clients to find us and see us, we may be inadvertently requiring they overcome difficult inhibitions and obstacles just to get to us. It’s incumbent upon the profession to make that easier.

Take men, for example. They are generally less likely to seek professional psychological help, yet they make up three quarters of all suicides. Furthermore, a report by Samaritans indicates that death rates among the under 25s by suicide is rising (Simms et al 2019). Psychological services may be missing an opportunity to reach out to these underserved communities by finding less traditional and more innovative ways to enable people to get started in finding the support they need: perhaps via apps, games, and other ways in.

Just this week, Stillpoint Spaces teamed up with the new “Anyone” app which allows anyone to phone up someone from their directory for short five-minute voice conversations (like in the olden days!). In a joint event, “Anyone” made counsellors and psychotherapists available on their app to offer short and free answers to questions like “What can CBT help with?”, “How does bereavement counselling work?” and “Is Freud still relevant today?” These conversations give anyone the chance to ask important questions without the usual inhibitions that get in the way. It is not a five-minute therapy session, but you could say that it is an important psychological intervention that may ease the way from an app into more formal support.

People, specifically professionals in the field of mental health, get nervous when the idea of “disrupting” psychotherapy is proposed. It’s been well over a hundred years since Freud invented the sacrosanct fifty-minute session, and many are reluctant to break that shibboleth and do it differently. This is with good reason! Especially in a world drowning in social media and ubiquitous technology, good old fashioned face-to-face deep psychological work is absolutely necessary. The benefits of engaging in therapy this way has untold benefits and is still my own preferred way of practicing. While that should remain a benchmark for good practice, it is neither universally available nor is it necessarily the best method for everyone’s diverse needs.

Because of coronavirus, therapists have been forced to move their practices online. However, practicing online is not as simple as copy-pasting what was formerly done in a consulting room onto Zoom. To do so is at best to offer a “less than” service and at worse to actually create a situation that is not safe. Instead, therapists should be taking this as an opportunity to see how they can be more responsive and innovative in this severely limiting environment. And there’s something even better they can do:

Rather than seeing this as a stop-gap until psychotherapy can return to the status quo, therapists should instead see it as an opportunity to rethink the delivery of psychological services altogether.

That means that instead of going back to business as usual as soon as we can, we should think instead about getting back to business as unusual. We can do this by asking how we can emerge better, smarter, more accessible, more nimbly, and more creatively. This doesn’t mean that we leave behind the ways of working that we know and love, but it does mean being open to revisioning psychology itself for a new era: rediscovering its creativity and innovating in directions we may not have previously imagined.

 

This article originally appeared on https://medium.com/stillpointspaces

Aaron Balick, PhD is a psychotherapist, cultural theorist, and author applying ideas from depth psychology to culture and technology.
Aaron Balick

References

Balick, A. (2014). The Psychodynamics of Social Networking: Connected-up Instantaneous Culture and the Self. London: Routledge

Black, M. J. and Mitchell, S. (1995). Freud and Beyond: A History of Modern Psychoanalytic Thought: A History of Modern Psychoanalytical Thought. New York: Basic Books

Simms, C., Scowcroft, E., Isaksen, M., Potter, J. and Morrissey, J. (2019). Suicide Statistics Report. [online]. Available at: https://media.samaritans.org/documents/SamaritansSuicideStatsReport_2019_Full_report.pdf. [Accessed: 18 October 2020]

Schwartz, J. (1999). Cassandra's Daughter: A History of Psychoanalysis. New York: Routledge

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