The challenges of psychotherapy at a distance: interview with Delia Duccoli

Delia Duccoli is a psychologist and psychotherapist, expert on the relationship and communication between health professional and patient. In the health sector, she follows patient communication and operator’s burn-out management projects.

Q. How can we preserve empathy and humanisation of care in the field of psychology and psychotherapy at a distance?

DD. My experience of online psychotherapy, before the COVID-19, was limited to particular situations, for example, a patient who was on a business trip for a long time. However, even before the health emergency, there was already a lot of international research and studies, guidelines, and good practices to understand both the critical issues and opportunities for online psychotherapy.

This research, which started in the 2000s, showed that there is not much difference in the patients’ perception of empathy and therapist competence; on the contrary, studies have shown that the therapeutic alliance is also a decisive factor in online psychotherapy. Instead, a certain distrust on the part of therapists emerged, since therapy is also a setting, therefore a physical space that is also a place of the mind, a temenos, a sacred enclosure, where the encounter takes place.

Q. What else do we need to preserve in this context?

DD. Psychotherapy is based on the relationship, which is given not only by words but also largely by an emotional communication, we can say “body to body”, transmitted in a non-verbal and implicit way between therapist and patient. And so the question we can ask ourselves is: even in the absence of physical proximity is it possible to create that emotional territory, that affective communication, that “right brain to right brain” communication that serves to lay the foundations for good care work?

The answer came more intensely after this period of forced experience. Even therapists using body mediation therapies – using the body, sensorimotor, for example, EMDR – have tried to answer this question: in online communication, is it possible to create the body-to-body effective communication? Is it possible to create an empathic resonance space?

I think the answer is affirmative: many patients and many therapists have experienced the possibility of creating that secure base, that cooperative alliance, that empathic link from which to explore behaviours, conflicts, memories, suffering.

Q. Could you give us an example of a concrete case?

DD. Since February I have been forced – despite my initial mistrust – to conduct all the support interviews to the health care staff facing COVID-19 emergency at a distance, in online mode and to experiment with them all those body techniques (based on mindfulness, EMDR, sensorimotor therapy) to regulate emotions. I worked with doctors, nurses, sociomedical operators in alarm for the situations they experienced and saw during the COVID-19 emergency: the atrocious sufferings of the patients, the communication of death in solitude to family members, the sense of helplessness and danger.

And not only did online therapy represent the only possible way, but it proved to me first and foremost to be particularly useful. Of course, with some tricks: for example, it isn’t easy to do it with a mobile phone, you need a big screen, a good connection. The ideal would be to be able to get closer (to understand facial expressions), but also to move away from the screen, to see the whole body, to be able to make standing exercises, grounding, relaxation, emotion regulation; you need a space where no one enters to disturb and sometimes all this can be not easy. With some operators, the sessions took place in the car, with the I-pad and the earpiece.

We were able to work on strong emotions – anger, sadness, anxiety, guilt – caused by the situation that many operators were experiencing, also with the possibility to do exercises, to share experiences, to look at each other, to follow gestures, as it happens in therapy in physical proximity. With some caution, this can also be done online.

Q. Also considering techniques such as EMDR, how do you manage the other person’s body and non-verbal language at a distance?

DD. As therapists, we had many prejudices, so at the beginning, many people preferred to suspend EMDR sessions instead of doing them remotely. Often, however, the changes in behaviour are driven by unavoidable needs. Since the emergency did not allow for alternatives, we started to practice EMDR online and, I would say, with outstanding results. You can see the body, the movements, the agitation, the swallowing, the high breath, the muscle tension. The classic bilateral stimulation of EMDR done with eye movement can be replaced by bilateral stimulation done on the shoulders, arms, at the same time as the therapist. Over time we have experienced that the same eye stimulation can be done by video.

There can be some difficulty when people have very violent, extreme emotional reactions in those situations where empathic and protective physical proximity is necessary, and a touch of the therapist can be a relief. There are also situations of people who would never set foot in psychotherapeutic practice and who approach therapy precisely because they feel safer and less embarrassed staying at home.

Whether or not an online therapy is effective depends, I think, also on other variables, factors such as age, familiarity with digital tools, the possibility of having adequate space, a good connection and so on.

Q. From your point of view, what perspectives are there for distance psychology and psychotherapy after the COVID-19 emergency?

DD. For my recent experience, I tend to attribute high effectiveness to online therapy, even though I think there are some aspects to investigate – for example, sometimes it is very tiring to keep the patient’s video attention for an hour so that the times could be reviewed. After the emergency, we should analyse the changes and evaluate the use of the various tools, with the risks and benefits that each one brings. I trust that research will be stimulated to enable us to capture the differences and to address those issues, privacy, for example, that have been left under the radar for the time being.

The normality of before will no longer hesitate: we will live in a different economic and social context, different also from the technological point of view, those “liquid” channels of help will be valued, to tell Bauman, such as chats and applications even for psychological discomfort and self-knowledge. Most likely, online psychotherapy sessions will be far more optional than in the past, both by therapists and patients. New indications and guidelines are already emerging. There will be more choice for the patient and the therapist.

I got enriched by the experience of the bond, also intimate, that is created with video connections, SMS, e-mails, but even more eager to find the meeting in the presence, without screens, that being there for each other in a dedicated space, which nourishes the therapeutic relationship.

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