Moving from face-to-face therapy to conducting online therapy sessions can seem challenging for both therapists and clients. While studies have demonstrated that well-managed online sessions can potentially be as effective as face-to-face engagements, the whole experience can understandably appear daunting and disembodied.

Unhealed Complex Trauma, maladaptive Dissociation, presence of dissociative disorders or enhanced resistance – can all be ‘complicating’ factors in clinical settings, with a potential to increasing the complexity of our therapeutic endeavours. These presentations and the concomitant therapeutic journey can understandably be even more anxiety provoking for us, as therapists, when we are attempting to conduct therapy in an online environment. Moreover, the symptomatology of such ‘complicated’ cases can be heightened on account of the disquietude created by COVID 19.

Part 1:

Christiane Sanderson considers how we can navigate the challenges of the online format and deliver effective online sessions that allow for deep therapeutic engagement. Using examples, she highlights how the online setting can provide an opportunity for us to practice differently and hone our therapeutic skills, especially with regards to connection and attunement – while opening up doors to long-distance therapy, as well as therapy for clients who may be unable to travel. She explains the best practices that we can incorporate and how we can fine-tune the delivery of our therapeutic techniques to suit the online format.

Specifically, we consider how we can:

• Provide a safe therapeutic space, while reducing the effects of social distancing and the concomitant sense of isolation or exacerbation of trauma symptoms and / or anxieties
• Focus on enhancing our awareness to verbal and non-verbal communication
• Use voice, breath and body language to modulate and regulate emotional states so as to remain present, connected and attuned
• Incorporate a combination of top-down and bottom-up regulation skills that enable our clients to slow down and come into the body, with a view to increasing distress tolerance and improving stress resilience
• Pace our therapeutic approach, including the need to temporarily suspend deeper exploration of past trauma or aversive experiences and focussing on the here-and-now
• Managing the optimal amount of therapeutic contact with regards to the frequency and duration of sessions and the online platforms that can best suit our therapy sessions while ensuring privacy and confidentiality
• Ensure that as therapists we are able to manage and contain our own anxieties and stress through self-care and the specific steps we need to take in the context of online therapy

Part 2:

Dr Jamie March helps us demystify the perceived complexity surrounding ‘complicated’ cases and apparent client-resistance; providing us with a practical and sensitive orientation to the therapeutic approaches we need to follow.

Part 2 starts with a discussion on ‘what makes a complicated client complicated?’ Jamie uncovers common areas of resistance and explains resistance through the lens of trauma-focused and dissociation-informed therapeutic approaches. Jamie then follows an integrative approach, with specific focus on relational attunement, motivational interviewing and grounding skills. Strategies are provided for translating this knowledge to practice settings and making the best clinical decisions possible, particularly in treatment planning, case conceptualisation and working with extreme emotional stress.

Through case vignettes and discussions, we explore:

• The pathways through which unhealed complex trauma can manifest in resistant behaviour
• The ways in which dissociation can present maladaptively and adaptively for an individual client as a response to complex trauma
• The difficulties that both client and therapist can face when working online, especially in the current isolation-inducing COVID 19 environment; and the techniques we can adopt from Motivational Interviewing & Person-Centred, Trauma-Focused therapy to help with these challenges
• Practical steps that we need to take to implement at least 3 different grounding strategies in our online clinical work
• A strengths-based approach that can make our clients well-equipped for dealing with distressing manifestations
• Inventory our own fears, as therapists, about online clinical work, ‘complicated’ clients and apparent client-resistance