Telephone Therapy by Aviva Keren Barnett

In today’s society ,everything is fast; fast food; hectic life -style, disposable plates to make clearing up, etc . This poses several questions: Is therapy following the same trend too? Does it need to adapt to people’s need to get things done quickly? Is telephone therapy an answer to this issue we face nowadays?

In June, I became a member of a professional reading group. I introduced myself to the group as an existential psychotherapist, my clients are based in the UK, and I work by phone and Skype. Some therapists, social workers and psychologists looked up their noses with a sense of superiority and  promptly said, “Oh, I would never work by phone.”  Shortly after another lady looked at me, and said ,“You just miss too much, I would never do it.” After firstly feeling internally a little bit attacked and not worthy as a therapist, I then switched to being fascinated by this assumption.

Does a therapist working by phone really miss so much? What exactly does the therapist miss? I would like to claim that it is different not less helpful or more helpful it comes down to as always the relationship you have as a therapist with your client.

I have started working with some clients by phone who have honestly admitted on our first session that they are not sure this way will work for them. What interests me is how quickly clients can feel safe in the therapeutic relationship if they are not being seen. Some clients who have only had face-to- face therapy in the past are sometimes wary to begin with, telling me it won’t be for them, but they are willing to give it a try. By the end of the session, they laugh with me and say, “I don’t know why I was worried, it was totally fine. I just couldn’t imagine being in therapy this way.”

Others have told me that they would only work by phone. After unpacking this a little with a client I shall refer to as Tim, I understood a few things more clearly. For Tim, working by phone was more than simply being convenient. Apart from the lack of travel to my consulting room, or even the difficulty of finding time to fit me in to his schedule, Tim gained more from working by phone. I asked Tim on one particular session after he had broken down in tears, “What would it have been like to tell me this face to face?”  Tim replied,” I wouldn’t have been able to.” We explored this further. For a client to share his precious inner world with me, they have to feel as safe and as comfortable with me as possible. Being “looked at” in a face- to- face session can be off -putting and anxiety -provoking for some people. I remember this feeling myself when I saw my therapist during my psychotherapy training at times of emotion. I covered my face in my hands , to hide myself because I felt exposed.

Another client whom I shall refer to as Sally came to counselling for the first time at the age 36years old and was only given five sessions through her employee assistance programme. Sally was so courageous and honest with me. She took a look at herself,  and was able to bring up painful memories and traumatic incidents from her past. When we finished therapy and I asked Sally what it was like to have her first ever experience of therapy, she said:,

“You walked by my side, Aviva, you were the right match for me.”

 She was referring to my approach . I had warned her at the beginning of our work that I am the challenging type of counsellor not the’ sit back and remain more quiet’ type. By challenging ,I mean that part of my style of counselling is to point out any assumptions that the client may be making without them noticing. I find that challenging my clients world –view- , what makes sense to them, and their way of being with others can help the client to better understand themselves, and through this awareness  they are able to change.

  I then further asked Sally  to tell me what the experience of talking on the phone was like for her. She replied  “I am over six foot tall and others feel  intimated by me. Working face- to- face may have put you off me.! ” I learnt from this that Sally also felt safe with me because her physical being was not a part of my initial impression of her, even though I ‘d asked her what she looked like quite early on in our work.

In a nut shell, I need to remind myself when others look down their nose at me and judge telephone therapy as being meaningless , that in fact time and time again I see that telephone therapy can be extremely helpful for those who would not be able to share their way of being with their therapist in any other way. So, I guess it goes back to the wonderful existential notion of not making assumptions!

I need to and want to always remain curious about my clients, and I can still do that by phone, perhaps even more , as I need to work harder because I can’t see the person I’m speaking to. I get a voice, mannerisms, accent, and so much more, but no actual body is present with me. I have noticed that ‘not seeing’ the whole person face- to- face can result in ‘more’ because I have to work harder. I have to work harder to really hear and listen to what the client is saying, so I reflect back to the client more often than when I work face- to face as I feel the need to check with my phone client that I have understood them. I feel that clients may get ‘more’ because the language a person uses becomes more apparent when a client is not seen. By this I mean that I hear a person’s use of language much more clearly than when I see a client face- to face. Perhaps this is due to the fact that it’s all I have as a therapist: a person’s voice and use of language.

When I first started working by phone I was apprehensive, as it was important to me that my clients felt my warmth and care, even though they could not see me. I was quite taken back when clients told me that they felt how much I cared for them nonetheless. I later understood it was about my tone of voice communicating so much more than I realised.

Telephone therapy does have its drawbacks though, and I often laugh with my clients when they tell me they are nodding in agreement to me, but I can’t see them.   A lady said to me “Aviva I’m smiling at what you just said, and just wanted to tell you that.” One drawback for me is that from time to time a client is totally silent on the other end of the phone: in these circumstances , I might ask them in a gentle way, if they could give me some feedback so that I am more able to help them.  I do not always break the silence, but notice that I do so much more often by phone in comparison to when I’m working face –to- face. The other drawback I notice is when I speak to someone with a particularly strong accent , because I have to concentrate on every word so as I do not miss anything. I feel the need to check with the client that I understand what they are saying more frequently than with a client whose accent I understand clearly. I find this especially difficult when the client speaks very quickly. Perhaps it is not a drawback of telephone therapy? Perhaps I am just getting old! It also seems to force me to work more phenomenologically. I need to check that I have understood, so am less likely to run with my assumptions.

One client worked with me face- to -face about ten years ago in the Consultation Centre attached to Regent’s College , and the sessions were open -ended. We both parted ways until she contacted me six months ago to have a few more sessions for a different issue. This time we worked by phone and, as I could not see her, and only had her name, I wanted to check that I had got it right,so I said,“Just so that I ‘m 100% sure you are who I think you are , your name is ....  you came to see me at.... and you wore Tshirts to our sessions with bands logos on them and glasses and spoke to me about relationship issues”.

She laughed ,and said I was spot on. As we continued our sessions, I asked her how she found it working by phone as opposed to face- to -face as she had now experienced both ways with me. She replied, “ It’s still you, so it doesn’t really matter.” This brings me back to my original point, that it is and always will be about the relationship I have with my clients.

 I remember clients after ‘phone therapy’ differently. Without seeing what they wear or how they look, the things that stay in my memory  is their accent, what they said and how I felt about them. I had a client through an EAP who came to counselling after her baby had died. We worked together for six sessions. Around eight months later, she called me and left a message on my answer phone. As soon as I heard her accent, I remembered who she was and what we worked on in therapy. Another client who worked with me for four sessions by phone stopped the counselling as she went into hospital. Five months later she left me a message, and as soon as she said “Hi Aviva”, on the answer phone, I knew it was her. Perhaps that is not so surprising, but, from time to time, I get upset with myself if I can’t remember a client. I worked with a Scottish client by phone once, and after we completed our set amount of sessions ,I heard from her four weeks later and, until she said her name on the answer phone, I couldn’t recall who she was. I was upset with myself for not being able to recall her in my mind.

I had a client who had phone therapy for eight sessions through her EAP who I will call Emma. Emma had only had counselling once before, and that was face- to- face. Emma described her relationship with her first counsellor as cold. She told me of an incident on her last session with her counsellor where she told her therapist that she was going on holiday, and asked her if she was going on holiday as well. Her therapist replied, “I can’t tell you that, we have a professional relationship.” I tried my best to refrain from judging this therapist , but the thought ‘where is the humanness?’ went through my mind.

My relationship with Emma was different, but I wanted to hear from her perspective why this was so. Emma’s reply was thought -provoking for me. She said ,“ You have truly been a life -saver, these phone sessions have helped me so much. I am an introvert, so it’s been controllable and something I can manage.” She went on to tell me what exactly was manageable for her, when she said ,

“I can manage these sessions because I can show emotion with you. I don’t need to acknowledge you in the street, there is no pressure on me, as I won’t know who you are if I saw you.” In comparison to Emma’s previous therapy, she said “I can touch ground with you that I couldn’t with my last counsellor, because we are on the phone and I can truly open up with you.” This was moving for me, and I left that session feeling so privileged to work as a therapist.

Is telephone therapy really less significant or worthy than face –to- face?

My phone therapy tells me that my sessions are worthy, and at times, significant for my clients and me. I will never know if my clients would have been ‘better off’ face- to -face.  But I am more comfortable talking on the phone with my clients now than I was when I first started working this way. I also need to appreciate that others are not comfortable working this way at all. That does not mean though that telephone therapy is worse or better than working face - to - face. I try not to let the phone get in the way of my work with clients, I try to be natural and engage with my clients as best I can. I notice that after a session with some phone clients, I feel more exhausted from the level of concentration I have had to use. If I’d had seen the same clients face- to- face I would be more trusting of myself and what I pick up from the client.  This shows that working by phone forces me to engage more tentatively . As for me, I need to work harder not to miss nuances that I would automatically see if the person was sitting opposite me. I do not think that working by telephone can or should replace face- to- face work, but I do think that working by telephone certainly has merit.

To finish, I would like to say that I am humbled working this way ,I am truly grateful that it is possible as it offers the opportunity  for some clients to have support, who would never contemplate seeing the therapist they open up their hearts to! I think also I need to question my own assumptions and judgements, because if you asked me if I would do email therapy, I would say, for me that is a step to far!