By Sheila Rubin, LMFT, RDT/BCT
Get Sheila's bio in part 2 of this article.
I begin this chapter about the internet with the fact that my clients think I’m a Luddite. I grew up with a wall phone telephone that, by definition, was attached to the wall. At most, we could stand a few feet from the wall, with a few inches of cord linking us to the phone. This was in a time even before answering machines. I came of age and went to study radio and television in college during the time of the black-and-white Portapak video machine that was heavy, where we actually spliced tape using our fingers—just before electronic newsgathering. Response time to a letter was a couple of days to a couple of weeks. I’m fully aware that the words I’m writing here will likely be outdated due to technology changes before the book is out in the world. I have accepted the use of a smartphone into my private practice, along with doing therapy over the phone or Skype if I have met the client at least once in person. I have come a long way!
Who Wants Therapy over the Internet?
People who live far away, people who don’t have time to drive to a therapist’s office, and people who are shy comprise the population of those who request therapy via the internet. I use the word shy to describe people who may feel uncomfortable or even ashamed about what they want to talk about “in private.” This is a great place. The internet provides a safe venue in which shy people may feel safer about seeking help. In working with shy people, I use extra care to welcome them, help them feel safe, and am aware that they may, at some point, reveal their shameful feelings
Therapy on the Phone or Internet
On both phone and Internet, with individuals or couples. I find that I check more often for
feelings that I might be able to sense when working face-to-face. I slow things down and tend to do more somatic work, asking clients to ground and to sense somatically for part of the session. I always ask at the end, “What are you taking from this session? What was helpful?” I also give homework after each session; for example, make a list of the coping skills from the session and put them on your calendar day by day, or take the powerful symbolic objects from this session and put them out in your room at home with a note by each to remind you what each part said to you today. Or, find an object to represent the shy part of you that is afraid to speak and take the card we wrote today and put it next to it. Practice it in the mirror before you talk to your boss.
Concerns about Technology
What about when technology fails, when a person just revealed something that has been hidden and Skype freezes? In the middle of a session, a husband was telling his wife why he had trouble when she touched him. Suddenly the screen froze and this tender moment was interrupted. I was frantically trying to call them on Skype, which would not reconnect. I had to call them on my cell phone; the tender moment had passed and they were fighting again. There was a rupture that had been caused by failed technology that mirrored the rupture in their relationship. I had to slow things down and gently find the words to meet them and name the negative cycle that occurred when communication came to a standstill. I used this as a symbol of what they were both dealing with within the relationship and helped them build a bridge toward each other.
Shame is the rupture of the interpersonal bridge, says Kaufman (1974, 1992). Any disruption in connection with a significant other can disconnect the person from him- or herself, or the therapist, and activate the feeling of shame.
What I realized was I had to let them know ahead of time the constraints and the benefits of using the phone for therapy or skype for therapy. It will save them time coming to my office when they are in a difficult place in the relationship, but it may not be as contained as an in-person session. One couple who was struggling with the husband having an online affair and the wife needing to see his phone to be reassured that he wasn’t meeting the woman. I spoke slowly and carefully to them to get an agreement before we began to talk. “Because we are not face-to-face, I can’t just put up my hand to interrupt you if there is shouting. I am going to do the session slowly and have you repeat what you hear the other person saying so that I can know you heard them and they can know that you heard them. We are going to take turns. Are you both in agreement? And because the phone is not a predictable medium, each of us is on a cell-phone, if one of us gets disconnected for any reason we need to have a plan. Is each of you near a home or office line? If someone’s line dies, we will momentarily stop the session and I will wait for the call of the person who was disconnected. Call me back on your office phone and I will use my phone to accept both calls.
In my chapter in Self in Performance coming out in 2016 or 2017, I write that “Shame can be right there in the shadows. It is easy for misunderstanding.” When I can’t see the emotion on clients’ faces, because we are on the phone or they are looking away from the skype screen, I don’t know what they are experiencing. In the book Shame and Pride, Nathanson (1992) explained that throughout life we are balancing between pride when we are seen in a good light and shame when we make a mistake of being seen in a less than favorable light. Diana Fosha (1992) later wrote that we would call this our “self at best” and our “self at worst.” We strive to be seen as smart or clever or helpful, but when a mistake is made and something is unclear, suddenly the person is risking being exposed and seen as self at worst. This concept is helpful to remember as a client is sharing vulnerable revelations. I know from my own vulnerability how scary it can be to be exposed at the wrong time or without kindness and support.
I have done consultation for colleagues as well as therapy sessions on Skype. The good news is that Skype can serve as a bridge between family members who do not live within driving distance of one another. It can also get in the way of direct eye contact and physical contact those family members long for. It proved very therapeutic for an elder client to see her grandchild over Skype, even though she believed it would not “do the trick.” She had been hurting because her son didn’t call her as often after the baby came and that the other grandparent was invited and she was not. We role-played her talking to her son, but nothing shifted. She still felt left out, like something was wrong with her for not being chosen to spend time with the new family. We unpacked under all the feelings of anger toward her son for not insisting that his wife invite her at the same time as the other grandparents and under that was the feeling of shame. She felt ashamed to not be invited and fought with him on the phone when they did talk. I asked her to role-play talking to her son in a way that invited a solution instead of blaming him for her
frustration. I invited her to role-play the visit with the grandchild. She rocked back and forth.
Finally, I suggested that she use Skype as a way to visit her grandchild. She told me that I didn’t understand. She wanted to pick her up and rock her in her lap in the rocking chair. I invited her to try just one phone visit on Skype with her son and grandbaby. She sat in the rocking chair at her home and rocked during the skype session with her son and his Babby. She was delighted to see her grandchild recognize Grammy over Skype. This experience fulfilled her longing to visit with her grandchild. There were many Skype visits thereafter. Her feelings of shame about being left out decreased and invite to visit increased.
Please note that I only do sessions remotely if I have met with the client in my office and we have developed a solid therapeutic container first. When the client is in my office, I can observe a range of nonverbal cues and get a sense of his or her energy. Over the phone, there are subtle cues I may miss. Here are ways I work with the absence of the visual modality. Because I am not seeing them, there are things I need to do to contain the energy of the session and the pace of the session. Because the client isn’t seeing me, there are ways I want to structure things to help them feel me where they are sitting.
Case Example of Phone Session
This client was feeling dark; her boyfriend was spending time with his ex-lover again instead of going on the date they had planned.
Client: “He’s still in the role of letting his ex rely on him. I couldn’t stop crying for hours.
My emotions got all wacky or something. I see his side when he’s helping his kids. But
every act of his kindness is an act of affection toward his ex. One day its good between
us, and the next day I feel ignored, neglected.”
Therapist: “How about if you choose something in your room to represent your feeling
neglected and ignored.”
Client: “OK, this plant.”
Therapist: “Can you move it near you and look closer at it? And as you are looking at it,
what does it say to you? What does it symbolize?”
Client: “You have to pay attention to a flower. You have to water it or it dies!”
Therapist: “So that’s a very powerful symbol of needing to be tended and cared for.”
(I wanted to pause and have her reflect on the importance of her attachment needs. She really wanted to just rush past them in the session. Choosing an object helped me direct the session to make space for that subject. The act of choosing something took her into another part of her brain where creativity was more open to her. Having a symbol can be a very powerful metaphor. Having it in front of her helped her to focus on it during the whole session).
Client: “Yes! I want to be cared for. But when I feel this way, I don’t feel like myself. It
feels like I don’t exist. It’s too painful when he says he’s coming over and then he cancels
because he’s with his ex-lover. Why am I punishing myself? I could go out and be in
Therapist: “So there’s another part of you that doesn’t want to be punished anymore, that
wants to find another relationship, one where the guy is choosing you instead of choosing
his ex. Can you look around the room and find an object that represents this part of you?”
(This is another place I want to pause the session and give her time to feel the
power of what she just said. I want a symbol for that part so we can talk to that
part as well, maybe have a conversation with both of them.)
Client: “This candle!”
Therapist: “Can you put the candle in front of you and look at it. What does it represent?”
Client: (Surprised) “There’s a light in it! I can attract things…people! But I’m not ready to move on.”
Therapist: “Can you give each a voice? What does the flower say and what does the
candle say to you?”
(The candle told her that she is bright inside when she’s not so depressed
worrying what is going on with this guy she’s dating. It gives her inspiration to
grow herself and step out of the relationship to a real relationship where someone
could really be available for her. As she was expressing this, another feeling
Client: “I feel deep anxiety.”
Therapist: “Where is the anxiety in your body?”
Client: “My diaphragm.”
Therapist: “Can you put some space around it and take some slow deep breaths?”
Client: “I’m not being logical. I should just leave him. But I don’t want to leave him. He
says kind things to me, offers to work it out. I really care about him. He’s clear about his
intention that he wants to be with me!”
Therapist: “There are a lot of conflicting feelings.”
(Because we are on the phone, I want to keep the connection and let her know that
I am here and that I hear her.)
Client: “I’m scared. Lonely.”
Therapist: Yes, there’s a part that’s scared and lonely.”
(I want to support this part.)
Client: “It’s like a pouting child!”
(And it feels like she is putting down that part. It is like some part of her is
shaming that part of her for wanting what she is wanting.)
Therapist: “I wonder, I’m curious if there is some shame around that part?”
Therapist: “Can you look around and find an object to represent the part that comes out
and shames you when you talk about your attachment needs?”
Client: (Apparently looking around her room for a few moments) “A hat.”
Therapist: “How does a hat represent shame?”
Client: “I put it on myself!!! I have a hard time asking him to meet my needs and I’m scared that they won’t get met again. That he’ll cancel plans with me again!”
Therapist: “Maybe the shame comes out to put you down for feeling what you’re feeling?”
Client: “Yes. If I’d recognize those things, logically I would leave.”
Therapist: “That inner conflict is so painful. So one part of you shames you for having normal wants and needs from him and when you think he lies again or cancels plans, then that part shames you again for not leaving.”
Client: “He told me he couldn’t have me over because he didn’t want his neighbors to think I was a homewrecker because his ex just moved out. So now I feel shame for wanting to come to his house. It’s been over six months we’ve been dating. So when is he going to tell people?”
Therapist: “How did you feel when he said that?
Client: “Insecure! Nerves all over my body. On edge!”
Therapist: “What did the nerves say?”
Therapist: “And what did you do when you felt that strong urge to run?”
Client: “I’m feeling shame about my feelings. He’s good with his words, but his actions don’t match. Then I feel shame for wanting to leave.”
Therapist: “I wonder if this current feeling of shame reminds you of anything that happened before in your life.”
Client: “I feel so much shame in this relationship. It reminds me of my last relationship.”
Therapist: “The one where the guy was hiding his porn addiction and hiding his other lovers?”
Client: “Yes. That was terrible. But I want to give this guy more opportunity, more time to show me that he can make the life for us he is always promising. I want to give him the benefit of my doubts. I want this relationship to work.”
Therapist: “Of course you want this relationship to work. Can you turn to the plant that represents your needs? What does the plant say?”
Client: “The plant says, ‘You’re making yourself suffer!’”
Therapist: “What does the hat say?”
Client: “It says that I’m ashamed of my feelings. I’m embarrassed that I want him to visit me instead of his kids. That’s terrible.”
Therapist: “What does the candle say?”
Client: “It says that I don’t need to shame myself for my feelings. I have a light inside me. I need to remember.”
(I’m wanting her to stop here and reflect and to work to understand if maybe there
is something here for her to be shameful for. That would be a form of healthy
Therapist: “Sometimes shame can pull a person out of her deep knowing by cutting off the life force or the light. Sometimes there is healthy shame that tells a person that there is something he or she doing or another person is doing that is actually shameful, that should be shameful. And there might be helpful information here if this is healthy shame. Healthy shame can help a person make new decisions or understand things differently. Here is some homework to do before our next session. Get out your journal at the end of the session and ask yourself, “What did I get from this session?” Please write it down. And please write down some of these questions. Please do some journal writing to answer these questions:
• What does the plant say?
• What does the candle say?
• What does the hat say about how you shame yourself?
• Listen to the shame and feel if there is something of value here or if it is just putting you down.
• Is there part of it that is valid?
• Is there something to listen to that is actually shaming in the situation for a reason?
• Is there something here from a past relationship or situation where you felt shamed?
• Is there something you feel shy about?
• Is there something for you to learn about shame here?
Shame is a primary emotion. The role of shame is to warn us and protect us. Our nervous
system shuts down and we actually lose cognitive ability when we are feeling ashamed.
Two indicators of shame are confusion and stuckness. Shame can freeze both mind and body. Shame is so difficult to see and cope with because it often hides behind other emotions. Shame, like of its functions is to protect us by lowering our emotional intensity and capacity to act. It is important to differentiate healthy shame, which can help us pause and rethink, from toxic shame, which can produce paralysis and leave a person so frozen that he or she is incapable of action and clear thinking. Healthy shame can lead a person to take responsibility for his or her actions, reassess, and make changes.
John Amadeo in The Authentic Heart writes that shame can be instructive and that “properly acknowledged shame and guilt can open a doorway to understanding how you’ve hurt someone.” (p. 64)
While excessive or toxic shame can keep a person in denial, “shame overload paralyzes
your capacity for clear introspection.” He says that “No growth is possible without some
small amount of shame.” (p.65)
In my chapter “Embodied Life-Stories: Directing Self-Revelatory Performance to
Transform Shame” in the book The Self in Performance by Emunah, Johnson and
Pendzic, I wrote:
“When we become significant to another person, as happens when we are therapist,
supervisor, friend, spouse, or parent, then we can induce shame in him or her unconsciously, unintentionally, even without knowing it has happened. Failure to fully hear and understand the other’s need and to communicate its validity—a look in the other direction, a frown, a disappointing facial expression—whether or not we choose to gratify that need, can sever the bridge and induce shame.
Developmental needs that are not met over time can also lead to internalized shame. The child learns to feel shame that his or her needs don’t matter; the rupture is from outside, from the parent who fails to validate the child’s needs.”
I would add that it then is on the inside and the person learns unconsciously to shame themselves. “I am creating attachment through my witnessing, which starts from the first moment: being seen in a positive way, which is counter-shaming.” Daniel Hughes in Attachment-Focused Family Therapy writes about why shame may be a central factor in the development of pathology and a deterrent to getting help: “First, shame places one in a fog, hidden from potentially significant others, actively avoiding the exposure to another who could provide—through intersubjective experiences of acceptance, understanding, and empathy—a pathway toward both effective regulation as well as self-awareness. Second, shame prevents the development of the ability to reflect on and make sense of one’s behaviors and subjective experiences” (p. 184).
In the Eight Keys to Safe Trauma Recovery (2000), Babette Rothschild notes that “shame, quite simply, tells us that something is amiss” (p. 87) and that “Rather than discharge, as an example in yelling or crying, shame dissipates, when it is understood or acknowledged by a supportive other. More than any other feeling, I find that shame needs contact to diminish” (p. 92). Rothschild describes a process for deciding when to address shame, understanding the value of shame, apportioning shame fairly, and sharing shame (pp. 98–100).