Therapy is an indispensable tool to recovery, or in helping one gain deeper insights and achieve self-actualisation. In light of the ongoing COVID-19 pandemic, traditional face-to-face therapy has been forced to take on various forms, including sessions conducted via telephone or through video-calling platforms. Of course, therapy serves the same purpose, regardless of whether it is conducted in person or otherwise. However, there is definitely something restorative about being able to connect with a therapist physically. Humans are innately social creatures after-all, and sometimes when things get tough, a little more human interaction and comfort can go a long way.
Physical presence in therapy certainly provides a deeper sense of connection, in contrast with virtual therapy where one might feel more distant and detached. It may seem bearable at the very beginning, but as you progress through the sessions, having to interact with your therapist through a screen all the time can get frustrating. Similar to how students may have trouble coping with online school and home-based learning, virtual therapy has some form of hindrance when it comes to relationship-building with your therapist. For most psychotherapy methods, it is indeed possible to shift them online. However, for others such as psychodrama, it may not be entirely ideal. How expressive and comfortable can you get, when you’re struggling to follow your therapist’s directives through the small screen and having to deal with technological lags?
Seeing your therapist in person also allows for him/her to detect any subtle body language and somatic movements. These are all non-verbal cues that may be lost through telecommunication. Non-verbal cues are just as important as verbal ones, and can provide your therapist with greater insights. Non-verbal signals can serve to convey your feelings along with what is being said, and can either reinforce or contradict verbal messages. Ignoring them would be very much a failure to be fully engaged in a conversation. Moreover, seeing you in person provides therapists with the ease to identify any form of dissociation. During the session, clients may not necessarily attune well, and may not be fully present in the moment. The client may be engaging with the therapist, but seemingly thinking about something else that is going on in their life at the same time. This does not mean that the session is unhelpful or “boring”. While this could simply be attributed to the lack of presence, it could also point towards other concerns regarding the client’s state of mind. Fragmentation can occur especially when one is recovering from a past trauma and can be brought to the forefront, causing incomprehensive emotional reactions when triggered. Fragments of self are usually suppressed, often attributed to the lack of a sense of safety when it comes to expressing their inner needs or desires. When these feelings start to show during therapy, therapists can identify them through common tell-tale signs such as a switch into dissociation, noticeable body movements (twitching, scrunching of fingers or toes etc.). Body language is not definitive, but can offer clues about one’s thoughts and feelings. With telecommunication, it is more often than not impossible to see the client below shoulder-level, thus making it difficult for therapists to assess any somatic movements that may be occurring.
Another issue with telecommunication is the lack of control over the therapeutic environment. In a traditional face-to-face session, the clinician has considerable control over the environment, and is able to ensure a private, safe and quiet space for the entire duration of the session. This limits the number of distractions and allows for both the therapist and the client to concentrate on psychotherapy. Moreover, in a clinical setting, furniture is often set up in particular ways to facilitate clinician-patient interactions. For instance, seats may be arranged such that the clinician would be facing the client at an angle of 45 to 90 degrees, and approximately 2 to 3 feet away. Facing the client directly can feel somewhat threatening for some, and this angle allows for the client to feel more at ease. Additionally, it allows for both parties to break eye contact naturally (intermittently) without seeming antisocial or distracted by having to do so actively. In contrast, having a session online or through telephone allows for less control over interactions and the client may be more exposed to external distractions or undesirable interruptions. This also leads us to our next point, where teleconsultations also increase the risks of privacy breaches.
Due to the lack of environmental control, having a consultation via telecommunication methods can be a challenge especially for those who do not have access to their own private space. For individuals living with others, there could be situations that compromise client confidentiality, including potential eavesdropping or having others walk in on them. Not only does this make the session extremely disruptive, it can be a huge concern for many considering that mental health concerns are sensitive topics. Clients must make the extra effort to find a suitable place and time for them to speak with their therapists freely and with ease. As such, physical presence in a controlled clinical setting may have the upper hand.
Nevertheless, this article in no way aims at undermining the efficacy of tele-health, nor to allude that tele-therapy is ineffective or pointless. Considering the need for physical distancing during the pandemic, telecommunication is undeniably crucial in limiting the spread of the virus. Putting that aside, traditional in-person therapy can have its barriers too, limiting people from attaining the mental health support they need. Individuals with disabilities may find accessibility to be a significant problem at hand, and find it difficult to travel for therapy without having others to rely on. Others include parents who are unable to find suitable childcare options, all while juggling work and mental health care. For those struggling with social anxiety and agoraphobia, it can also be extremely intimidating and overwhelming for them to step out. In fact, some research has shown that virtual and in-person therapy, depending on the treatment goal, can be equally effective. In adults, cognitive behavioural therapy was shown to be similarly effective both in vivo and virtually (Khatri et al., 2014). There is also evidence that youth with anxiety disorders respond positively via telehealth (Khan et al., 2020). Traditional face-to-face therapy and tele-therapy both have their perks, and we acknowledge that it also boils down to individual preferences. If you’re unsure as to which treatment option to opt for, do feel free to contact us.
Brenes, G. A., Ingram, C. W., & Danhauer, S. C. (2011). Benefits and Challenges of Conducting Psychotherapy by Telephone. Professional psychology, research and practice, 42(6), 543–549. https://doi.org/10.1037/a0026135 (Accessed 06/09/2021)
Khatri N., Marziali E., Tchernikov I., Shepherd N. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: A pilot study. Clinical Interventions in Aging. 2014;9:765. (Accessed 09/09/2021)
Khan, A. N., Bilek, E., Tomlinson, R. C., & Becker-Haimes, E. M. (2021). Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19. Cognitive and behavioral practice, 10.1016/j.cbpra.2020.12.002. Advance online publication. https://doi.org/10.1016/j.cbpra.2020.12.002 (Accessed 09/09/2021)
Ever since people first crushed and fermented grapes, the dark hand of alcoholism has been present. When the first games of chance and competition were born – so too was the addiction to gambling.
We can well imagine that abusing cannabis came, even as it was used for medicinal and religious purposes in the 3rd millennium BC.
And breathing in the toxic smoke from burning tobacco was a daily human habit, well before Christopher Columbus landed in the Americas in 1492 and brought it back to Europe.
But now, in our digital age, technology has accelerated our addictions.
And the stress and isolation brought to us by COVID-19 have pushed many to addictions they never thought they had.
Alcohol and cigarettes can be delivered to our doors from digital orders placed on mobile phones. The Dark Web and chemistry have conspired to create hazardous new psychoactive substances that pose as cannabis, available with a few keystrokes on a laptop. An Internet poker or roulette game can be found 24 hours a day, every day of the year. The Internet has sped us down the path of over-shopping, over-eating, and over-playing competitive games.
Ever adaptable and flexible, the Internet has even created new addictions – such as Internet pornography and anonymous sex “dating”.
If we are unlucky enough to fall down these digital “rabbit holes”, what are the results? Alice’s Wonderland? Or: failing health and finances; anxiety; depression; isolation, fractious and failing relationships, lost schooling and jobs; self-harm; and suicidal thoughts. “Jails, institutions and death” – as Alcoholics Anonymous warn us. A life without meaning, purpose or dignity.
But just as addictions have been accelerated by technology and new ones invented, technology has also enabled us to make recovery more convenient, available, cheaper, effective, and timely.
The longest journey for people suffering from addictions has been from the “bottle” to the therapy room. Any number of “barriers” stood in the way. Not enough time, not enough money, not enough knowledge of which therapist to see or what recovery involves.
But the biggest barrier of all to entering recovery was shame.
Now, therapy can be done on the Internet: information about therapists can be Googled; prices compared; social service agencies offering low-cost therapy or even free therapy can be found, and rich information and video testimonies on the recovery journey can be reviewed.
Best of all, Zoom therapy can be conducted with a therapist “once removed” from the personal space of the client by computer screens – and in the comfort of the client’s own living room or bedroom. Clients could even maintain much of their anonymity. In this safe space, shame may deign to take a back seat.
With digital recovery free from barriers, even if the sufferer is still reluctant to seek help, they may be more inclined to reflect on why they remain reluctant to get and receive help. If they do start to reflect honestly – they have started their first step on their recovery journey.
But more can be done with digital recovery.
I would submit that the next significant step in using the Internet to accelerate recovery is to bring the therapist to the clients where they are – on the sites that feed their addictions and perpetuate their suffering.
A therapist could join as a “player” in Animal Crossing, Fornite, a poker or roulette game. They can then engage suffering players in unthreatening and therapeutic conversations. Perhaps PornHub will produce an avatar “ambassador” – a therapist who guides users through a porn compulsiveness assessment? Perhaps the GrabEats avatar therapist will help customers with alcohol and calorie counts, consumption and portion control, alcohol use and dietary information – and motivational conversations to help customers build their resolve.
Engaging suffering people in their digital space opens a whole new avenue for the helping professional to guide someone towards a path of meaning and purpose.
Therapists may wish to think “Digital” – and harness the power of technology to enrich people’s lives – even if technology can also impoverish them.
If you’re considering seeking help from a mental health professional / psychiatrist, there’s a pretty good chance that you’ve realised there’s help out there that can assist you with whatever concern you have on your mind. Your mind may be in disarray, but remind yourself that whatever stigma against seeking mental help may exist in your mind, it’s there because of your lived experiences – created by the culture you live within. There’s absolutely nothing wrong with wanting to get better, or better yourself, and to feel constrained by some vague idea of what it means to be “a man” or “a strong woman” is unwarranted.
If you’re fearful of revealing your innermost thoughts and feelings to a stranger (by virtue of it being your first visit), keep in mind that your psychiatrist is first and foremost a doctor, bound by the Hippocratic oath, and second, believes in the value of offering a non-judgmental listening ear through their training and moral code. If that doesn’t comfort you, you should be aware of legal constraints that exist in your favour to protect the information that you share with them. Notwithstanding of course, if there is reason to believe you intend to injuriously harm yourself or another.
Because of the anxiety that may roil your thoughts, it may do you well the night before to sit in silent contemplation and pen down the reasons or thoughts you intend to divulge. Having a concrete list to bring into your psychiatrist’s office will help you ground yourself and serve as a reminder that you’re there for good reason – to get help. Nothing to be ashamed of, nothing to hide, nothing to unconsciously lose behind a preponderance of mistrust or other self-serving attitudes. Your psychiatrist’s office is a safe space.
If you feel that all this is a hard ask, consider bringing along someone whom you trust and knows you well, with your best interests in mind. They can serve as a calming influence that soothes your inner turmoil. Furthermore, they might be able to helpfully point out if there are discrepancies between what you tell your psychiatrist and the truth of the matter.
When you step into your psychiatrist’s office for the first time, you will most likely be greeted with an open-ended question such as “How may I help you today?”, or “What’s been bothering you?”. It’s normal to feel overwhelmed by the variegated ways you can choose to answer their greeting, especially if you have issues with how you are perceived by others. But remember, this is their way of getting to know you, especially since they have nary a clue of why you may have decided to make good on your appointment.
Because of the time constraints on your visit (your psychiatrist’s office is a place of business after all), you can expect them to try their best to elicit responses through a line of inquiry that their best judgment will allow them to evaluate and cohere into an accurate as possible diagnosis of your mental condition, if you are indeed suffering from one. No psychiatrist is a soothsayer or mind-reader, and you should be aware that the help you receive will very much be preponderant both the truthfulness of your responses and the skill of your psychiatrist, who is also trained in reading cues and tells that they feel will help them make a diagnosis.
As your visit comes to a close, based on the personal proclivities of your psychiatrist, you can expect a number of permutations to happen. They may prescribe you medication, if they feel confident in their diagnosis. They may point you towards psychotherapy or counselling (the difference between the two we will delve into in another post), they may prescribe both the former and the latter, or they may hold off on either if they feel that they cannot in good conscience do so.
Of course, it is very much your right to evaluate for yourself if the synergy between your initial choice for a psychiatrist is optimal for you. If you feel comfortable with them, do feel encouraged to continue on course, or if not, seek out another psychiatrist per a trusted friend’s recommendation, or look online for one that seems more promising in terms of a potential therapeutic alliance.
Ultimately, don’t forget that your psychiatrist has your best interests in mind. They are committed to formulate a treatment plan for you that runs parallel to your values and is in line with your goals.
Promises Healthcare is committed to providing mental health services to those in need, and has realigned how we provide these services in light of the current COVID-19 pandemic. Not only do we practice strict social distancing in the clinic, we have a new teleconsultation service up and running. This may be a blessing for those who are not yet comfortable with in person visits. Simply visit our main website and visit our teleconsultations page.
Alternate services of help are also provided by the Ministry of Health & National Council of Social Services in the public health and non-profit sector respectively. The Minister for Health has also written in response to a question regarding the use of Medisave for mental health therapy and counselling treatment: “No Singaporean will be denied access to necessary and appropriate healthcare because of an inability to pay.”
COVID-19 has posed a challenge to everyone, and those more physically vulnerable in our community clearly need our care and attention.
There are also people whose mental vulnerability deserves equal care.
Mental illnesses such as depression, anxiety, and addictions are exacerbated by a pandemic crisis in multiple ways.
Collective family and community fears are (in themselves) contagious; and the constant bombardment of medical and financial bad news, can leave those with mental illnesses lost in a cascade of negative rumination and catastrophising.
The mentally ill and people with addictions commonly have compromised immune systems, and suffer stress or substance, tobacco and alcohol abuse related diseases – leaving them wide open to severe pneumonia with acute respiratory distress symptoms – and other complications from COVID-19.
Isolation, separation and loneliness – caused by working at home and social distancing – are perhaps the worst contributors to: low mood; agitation; irrational fears; moments of panic; self-disgust; resentment; anger; and even rage.
People whose ability to pause, use reason and find practical solutions can be severely compromised. They may find themselves bereft of the motivation, and ability to engage in even the simplest tasks of self-care.
Added to this, listlessness, boredom and frustration can lead to despair. Then self-harm and suicidal thoughts may arise, take hold, and even overwhelm them.
Those in recovery or active addiction may also turn to their compulsive and impulsive behaviours of choice, to sooth and find momentary respite from the moods and thoughts that have hijacked their mind. Triggers, urges and cravings may become relentless and unbearable.
The solution may begin with finding a way out of isolation.
Starting the journey out of this darkness can start with talking to people who can demonstrate unconditional positive regard, show kindness and compassion, and help reframe the situation. Such people can assist those suffering to put a name to and validate their emotions.
In short – therapy can help!
In times of COVID-19, working with a therapist via teleconsultation can be effective using ZOOM, Skype, WhatsApp video and FaceTime.
Although the calming and soothing sensation of the physical presence of a therapist is absent, for those in isolation – distraught with shame and despair – Internet enabled therapy can prove a lifeline.
Isolation can be further broken, using similar Internet methods, by attendance in recovery groups such as Alcoholics Anonymous, Narcotics Anonymous and Sex and Love Addicts Anonymous – all of whom now hold Zoom meetings in Singapore.
These Zoom opportunities in Singapore are supplemented by Zoom, Skype and telephone conference meetings in Hong Kong and Australia (in Singapore’s time zone) and in the U.K. and the US (during our mornings and evenings).
Having broken the isolation, the second step therapists can provide is guidance and motivation towards self-care. This would include tapering or abstinence from the addictive substances or behaviour. A well thought through relapse intervention and prevention plan, specifically tailored to a person’s triggers, will also assist.
Triggers may be particular places, situations, people, objects or moods.
The acronym “HALT” is often used by those in recovery; which stands for the triggers of being: Hungry; Angry; Lonely; or Tired.
When these triggers arise, people are encouraged to
HALT their behaviour;
breathe deeply, with long outward breaths;
think through consequences;
think about alternatives;
consult with others; and
use healthy tools to self-soothe.
Daily mindfulness, meditation, exercise, sleep hygiene, healthy eating and following a medication regime are important aspects of self-care – and for some suffering mental illness – these actions – and time – may be all they need to find their footing again.
Luckily, the Internet gives a vast array of possible self-care options, including things to distract us, soothe us and improve us.
Everything is available from: calming sounds and music; guided meditations; games; home exercise, yoga and tai chi; self-exploration and improvement videos; video chats with loved ones; to healthy food delivery options. They can all be had with a few keystrokes.
Today we live at a time when suffering from mental illness and addictions is commonplace. But we also live at a time when the solutions are literally at our fingertips – if we only reach out for them.
With COVID-19 forcing many of us to practice social distancing and to work from home; isolation and the constant access to Internet devices makes staying in recovery from compulsive sexual behaviour a very tall order.
There are many reasons why COVID-19 is interrupting recovery from sex addiction. Restless, irritability, and discontent will inevitably arise for all of us, when our routines are disrupted – but there is more to it than that for people in recovery for addictions.
Some will experience acute urges and cravings to act out because:
isolating at home, away from colleagues and friends leaves a recovering person lonely, and without the support of recovering others;
if they are now living 24 hrs a day with traumatised partners and disrupted families, tensions may reach flashpoints;
some may already be very anxious and depressed, and the additional worry about health and contracting the virus may prove too much;
some may have suffered financial problems from their acting out, and may be dismayed by their financial future, given the impact of COVID-19 is having on savings, jobs and salaries;
they may now repeatedly look at electronic devices for work, COVID-19 news and distraction – and those may be the very devices that caused or exacerbated the problems in the first place;
unstructured time will inevitably lead to both the distress of ruminating about the consequences of the present, and the triggers of fantasising about past acting out.
When people are struggling with an addiction, their mind can play tricks on them. COVID-19 can present a series of excuses to put their recovery “on hold”.
One person in recovery said:
“I started to tell my wife that I was looking out for the family when I decided not to attend recovery meetings and therapy. She then asked whether there were other things I could do, that didn’t involve meeting others.
I told her, pretty emphatically: “no, recovery requires the support of others”.
Then she Googled and found recovery meetings online by Zoom, Skype, and telephone conference. I was stumped. I realised that my mind was once again leading me astray.
I checked with my therapist and found that I could do therapy by Zoom, and he also gave me lots of online recovery videos to watch, information to read, and exercises I could do.
My sponsor and I now do our recovery work using WhatsApp video.
Calling my recovery friends and supporters was what I was doing before COVID-19 anyway.
I found that some of my recovery work, like meditation, prayer and daily gratitude lists is solitary work any way, and that I now have plenty of time to do that – if I chose to.”
Many people had to finally admit that they could either work hard on their list of excuses – or they could work hard on their recovery – but not both.
One of the greatest problems that people find preventing them from finding and staying in recovery from sex addiction is shame. Online connectivity platforms like Zoom, WhatsApp and other online social platforms can help with that.
People feel safer engaging online – which is one step removed from physical interactions. They feel greater comfort being at being home, in a familiar and secure space. They can also control whether and when they are seen or heard, and they can leave a meeting at any time.
Partners and family of those in recovery may also feel more assured. Their loved ones are not outside the home visiting triggering locations. They are also demonstrating their commitment to staying the recovery course – virus or no virus.
Partners and the whole family may also have more opportunity to join in healthy recovery activities – daily meditation, exercise, healthy eating, and good sleep hygiene.
Being at home gives people in recovery a unique opportunity to initiate family activities like games, puzzles, movie watching, making meals, arts and crafts, walks and swims. In recovery, this is called: “making living amends”, to the loved ones who have been hurt.
So at this isolating and stressful time, consider individual therapy and the STAR group therapy delivered by Zoom – and remain on the recovery path.