I’ve been offering video sessions for years now, and so when I made the move to mostly telehealth services this week, I knew I’d be in my comfort zone. I already know what wonderful connections can be made this way, and the deep work that can be done. As a somatic practitioner, I’ve been pleased to receive reminders about the ways we can work with the body. It feels like so much is possible. I know we wouldn’t have chosen the situation we’re in now, but given what’s going on, I’ve been thinking of a few of the benefits to telehealth services, and wanted to share what I came up with.
1. Accessibility: I’ve always thought that telehealth would be ideal for people who are otherwise unable to come into the office but still want to prioritize their mental health and access services. It could be transportation issues like you’re in a small Albertan town and the commute is just a bit too far, or you’re here in Edmonton winter and the roads are not worth driving on, or you don’t have access to a reliable vehicle but you still want to access services. I also think about accessibility in terms of chronic pain where sometimes it’s better not to leave the house because you’re more able to take care of yourself at home, and part of taking care of yourself is still having a session. Or maybe you’re sick and staying at home to take care of your health and the health of others, but you really still wanted to connect about that anxiety and depression you’re working through. Or, you’re taking care of young children and today you have no other childcare options. For me, this one is all about reducing barriers.
2. Comfort: Some people really like having the comforts of home around them – like an important animal, a blanket they can curl up with, and being in their most relaxed clothes. When our nervous system can begin from a more settled place, there’s already room for more of a shift to occur. When we’re done the session, you can stay in that comfort and continue to relax into it, rather than worry about dealing with traffic on your commute home.
3. Bravery: This one’s kind of interesting. Over video, sometimes people find themselves able to be a bit braver with what they share or are willing to try out. I’m not sitting in the room staring straight at you (okay, I try not to do that anyway), and sometimes that bit of distance allows people to feel like they can actually be more vulnerable. Also when I invite people to do something they feel silly about, they can move offscreen to do it. Tada!
4. Integration: Sometimes people feel like my office is a magical place where they can self-regulate and feel their boundaries and all sorts of good stuff, but have a hard time translating those skills to home. Doing a session from your home space may allow you to embody self-regulation and other skills into areas of your life that you’re most hoping to take them into.
Dealing with a sinus infection over the last few weeks has me once again thinking about sustainability as a therapist. I was thinking how glad I was that I had room in my calendar to reschedule clients. I was thinking about how gracious everyone was being when I did have to move things around. And this got me thinking about some of the things I’ve done to make all of this possible. For all you emerging therapists out there (and curious cats), please read on…
Schedule for a Realistic Week
There have definitely been times in the past where my schedule has been much more full. I’ve been booked solid for a month in advance, with no room to add in an extra client here or there. I know a lot of emerging therapists who will do this too – we fit in the most clients possible, leaving practically no room for flexibility. I think we plan for the “ideal scenario”, meaning, “if all goes as planned for me, then this number of sessions I’ve booked will be fine”. What we may not always consider is the “realistic scenario”. In a realistic week, I often end up getting an emergency request from a client to book a session because they’re really in crisis. I sometimes get a letter from a lawyer, insurance company, or Victims Services requesting forms to be filled out or paperwork to be put together. I have clients who I need to do research for, make referrals on behalf of, consult regarding, or make ethical decisions about. I also sometimes have sessions that knock me off my feet for one reason or another. I also get sick sometimes, or get stuck on Edmonton winter roads. If there’s no room in my week to recover, fit in, or move around, what do we do?
For awhile, I think the mistake that we make is just to keep adding on to an already full schedule. Many new therapists will work through their lunch hours, stay late to complete their notes and letters, or do the extra work on what should be days off.
I believe all the work I described above is an important part of being a therapist, and so we need to start making room for it within our schedules, not leave it as an extra that can be appended on to a full week. I’ll give you an example. I have about 25 client spots open per week. It used to be that I would open all of those to be filled, banking on the fact that I would get one or two cancellations. But, it just so happened that the cancellations wouldn’t always come when I needed it, and 25 client hours a week every week left me very little room for all those other parts of being a therapist I already described above. Now, I’m leaving 22 spots open on my online calendar. I know it doesn’t sound like much of a difference, but those extra three hours are now mine to be flexible with. I can go home early, add in an extra client if I need to, catch up on client notes, or anything else I need.
Stop Seeing New Clients
In order to have this kind of room in the calendar, I stopped seeing new clients a year ago. I added people to a waiting list if they wanted to wait. In order to feel less guilty about not being able to accept new appointments, I provided them with a list of other therapists in the area who were accepting new clients, as I just couldn’t predict how long it might take for things to slow down. It turns out it took about a year, and things are finally becoming more balanced.
Remember that Being Emotionally Well is Part of the Work
Within my work week, I also had to consider what helps me stay emotionally well. I now see this as a foundational part of being a good therapist, rather than an extra to hope to fit in outside of my work hours. From my perspective, being emotionally well involves seeing a therapist to work through issues that come up in my life and in the therapy room, it involves somatic practices to help nourish my body throughout the day, and it involves connecting with colleagues and peers in consultation and support. In order to provide the emotional care for my clients that my job entails, I need to be present, attuned, and grounded. I take this seriously and I know it’s not just going to happen on its own.
Take Sustainability Seriously
What this brings me back to is what eventually happens when we don’t keep sustainability in mind. I’ve watched some emerging therapists power through very full schedules, and I know that on top of the client hours, they’re also studying for licensing exams and dealing with a steep learning curve.
When we have so much on our plates, we will eventually make mistakes. I have, and I try to remind all the new therapists I supervise that we all will. It’s part of the work. What I have found that clients are generally forgiving if mistakes are made in good faith (accidentally double booking a client because brains are just like that). I think it gets harder when mistakes are made because we’re not caring well enough for ourselves (not consulting when we should have because we ran out of time, overbooking ourselves and then being shorter with a client than intended because we’re emotionally exhausted, or showing up late because we haven’t been getting enough sleep).
By no means is this a call for perfection or a public shaming for those inevitable mistakes we all make. Instead, I’m offering a moment to pause. As we continue in this field, we can ask ourselves if the foundation we’re laying has a strong foundation for sustainability, or if we’re leaning in the direction of burnout. We can notice if what we’re doing has room for our own humanity. We all know that doing this work requires being deeply connected with ourselves so that we can connect with the person in front of us. I continue to believe that the biggest gift we bring as therapists is our own aliveness. So, I’m rooting for that.
It Starts with Connecting to Our Bodies
There’s a theme in my work of connecting back to the body (which I think is already a feminist idea), and I wanted to describe one of the modalities I use to do that. I think a lot of people are used to the idea of therapy as talk therapy, and may not realize that there are other, more body-based forms of healing that can be used by trained trauma specialists to allow clients to move through their traumatic symptoms. I think this can be especially helpful when clients are dealing with more body-based symptoms like hypervigilance, a more sensitive startle response, freeze responses, dissociation, chronic tightness, tension, or pain they feel is related to the trauma, and so on. It may help clients who feel they have already told their story and and looking for the next layer of healing, along with clients who don’t want to have to share the details of what happened to them with anyone.
A Quick Synopsis of Somatic Experiencing
Somatic Experiencing is based on the work of Peter Levine. He wrote Healing Trauma, Trauma and Memory, and a few other books of a similar vein. His work is based on this idea that when we go through a traumatic experience – which could be anything from a sexual assault, childhood abuse, to a car accident or fall, for example– our nervous system responds. It goes into fight flight or freeze – a natural, survival response that allows us to live through a situation. And here, especially coming from a feminist lens (where I recognize that clients can be blamed for their experiences and their survival responses) I want to reiterate that all of these survival responses are equally valid. In less than a second, our body reads a situation as life-threatening and does whatever it needs to do to survive. The body also doesn’t judge one way of surviving as better than another – it just does what it needs to in order to get through. I spend a lot of time working on this with my clients and helping them recognize the ways in which their bodies actually protected them (even when it doesn’t feel like it).
Levine recognizes that sometimes, even after the traumatic event is over, all that nervous system energy gets stuck, or thwarted, and we’re not able to come back down into feeling re-regulated again. Maybe there wasn’t someone safe to run to, or it all happened so quickly. We may end up left feeling still frozen, still stuck. Or constantly vigilant, like there’s something terrible about to happen. Or consistently angry, in fight mode all the time.
When that happens, which is more common for humans than it is for animals in the wild, the therapy is that we slowly, safely, and through containment make space to go back and process those past events. We release any activation so that our traumatic symptoms no longer have such a hold over our current lives.
What Somatic Work Looks Like in the Therapy Room
The way I typically use Somatic Experiencing, if clients want to give it a try, is to start with some grounding and resourcing activities. We could end up spending one session on this, or three, or ten, all depending on each person and what their body needs in order to feel safe. Really important here as a feminist therapist is offering somatic work with consent (“would you like to give this a try?”) and working at the client’s pace.
Once we’re both feeling confident that they’re ready to begin processing the traumatic event, we take the time to ground ourselves, then begin with the part of the experience that is least activating for them. This is known as titration. It basically means doing a little bit at a time (the smallest amount that the client can stay present to) and not just overwhelming the nervous system by diving into the most difficult part of the trauma. Once we’ve processed the least activating part, we move a little further in, and so on, and so on. The entire process can take five sessions, or ten, or …. You get the idea.
That’s my attempt at describing Somatic Experiencing for tonight. Please note I have taken the Beginner and Intermediate trainings but not the advance, which means that though I of course integrate everything I've learned into my work, and do so often, I am not an official Somatic Experiencing Practitioner (SEP). If you’d like to learn more about Somatic Experiencing, Peter Levine has been interviewed a number of times about his work and he's shared some fantastic stories, metaphors, and wisdom, a lot of which is available for free on YouTube.
It’s hard saying no. For a lot of new therapists, we really struggle with the idea of disappointing someone in our care.
It can be easy to feel that because our clients need something, we need to be the one to give it to them. I hear new therapists say things like “but they need evening hours – they can’t make it during the normal workday“ or “they need a sliding scale – they can’t afford the full fee”.
As health professionals in positions of power, we have certain standards of practice we need to adhere to it in order to protect the public. The Standards of Practice of the College of Alberta Psychologists are “the minimum standards of professional behaviour and ethical conduct expected of all regulated members”. These include informed consent, avoiding dual relationships, and acting within our scope, to name a few. These are incredibly important to know and adhere to, and yet it’s not enough to ensure that we’re working in a way that’s ethical and sustainable.
I know some people aren't going to like this post. At the same time, as a Psychologist I think it's important to tackle difficult issues and share what I know from the research and from making a career out of helping people heal and move forward in their lives. Especially for those of us who are mental health professionals or are trusted experts in our communities, we need to make sure that what we tell others about healing and growth is safe, compassionate, and ultimately does no harm. I've been seeing more and more professionals suggesting books like The Secret, and it's extremely worrisome to me.
I wrote this critique while completing my Masters in Counselling back in 2008. Now that I’ve been practicing for awhile, I have different critiques, a more nuanced understanding of the humanistic style of therapy as it’s practiced today, and a more body-based approached to working with people who’ve experienced sexual violence. This critique is aimed at the more traditional style of humanistic therapy, and I've posted just the second half of it. Still, I thought some of you might appreciate the fierce, no-bullshit language of young Nicole and the references to the Garneau Sisterhood. (Who wouldn’t?). Enjoy :)
In the last 5 years I've worked with more and more helping professionals and caregivers, supporting them to be a support to others. It's probably one of the things I enjoy the most, because there are so many good people out there trying to do helping work, and I've actually figured out some things that can allow them to keep doing what they're passionate about, despite the heaviness of the work. I get a little excited about this because I now know without a doubt that it is completely possible to do some amazing things without giving up your life in the process. And actually, it's not only possible, but better for everyone involved - keep in mind that we're able to do more and better work when we can still connect to our own aliveness.
Nicole Perry is a Registered Psychologist and writer with a private practice in Edmonton. Her approach is collaborative and feminist at its heart. She specializes in healing trauma, building shame resilience, and setting boundaries.
About the Blog
This space will provide information, stories, and answers to big questions about some of my favorite topics - boundaries, burnout, trauma, self compassion, and shame resilience - all from a feminist counselling perspective. It's also a space I'm exploring and refining new ideas.