As part of an assignment for the Online Therapy Institute’s Certified Cyber Therapist course, I have been thinking about the concept of “presence” in online therapy (Lombard & Ditton, 2006). What type of “presence” it is that most resonates with me, or that I would seek to try and create in my online therapeutic work? For me, I think it is/will be about a combination of immersion (engagement) and transportation (“we are together”) – the co-creation of a space which is both novel yet can quickly come to be familiar, therefore allowing both client and therapist to quickly relax into the business of becoming immersed in the process and the relationship. I am less interested in the need to make the experience feel like a traditional therapy environment or encounter (realism) – indeed, because, to many of my autistic clients, that is the whole problem!
The main thrust of the article is about the nature of communicating, forming relationships and effecting change through an artificial medium. It does mention, however, how all our experiences are mediated to some extent through our sensory system, but states that the research discussed applies to external sources of mediation. They talk about how people can usually easily recognise and report the artificially mediated nature of their experiences. They give the example of the Star Trek “Holodeck” as an exception. However, this got me reflecting quite a lot on the nature of mediated experiences – whether through our own sensory systems of something external. Interestingly, I often use the “Holodeck” as a way of explaining to non-autistics why it is important to know someone is autistic – it creates whole new hypotheses when you envisage them operating in and from a whole different sensory environment. It may be that the concept of mediation is even more important in considering different neurotypes, as experiencing the world through different sensory systems is such a key factor. This may be a useful concept that I will be able to make more explicit use of in helping to educate and bridge the understanding between neurotypical and non-neurotypical populations (i.e. it might be just as useful a way to help autistic people understand that neurotypicals do not experience the world the same way as they do – especially given the affinity that many have with Star Trek and science fiction).
For example, what seem like unusual opinions, extremes of distress or behaviour (e.g. shutdowns or meltdowns), no longer seem so unfathomable to the non-autistic person when you conceptualise that person operating within a “holodeck” in which different rules apply – a beautiful but harsh landscape, full of extremes with no middle ground. A place where rain burns, small diversions from the usual route can be life-threatening, and the technology to see into space and therefore discover the existence of other worlds is underdeveloped or absent. A place where there is little atmosphere, so there is no filter from incoming information, so it often makes sense to hide. Just as autistic people may need help to become aware that there are other minds (worlds) out there with different (sensory) environments to them (no, it doesn’t usually make our skin crawl when someone brushes past us; no, we don’t just have a better pain tolerance than you, that noise just doesn’t hurt my ears the way it does yours), non-autistics need a little educating/reminding that theirs is not the only type of (sensory) environment, just because it is the most prevalent. We are always communicating in a mediated way, it just isn’t often obvious.
Leading on then to the use of technology-mediated therapy, it makes me wonder to what extent online therapy might be more or less suitable for autistic clients. As illustrated above, to some extent, they are ALWAYS trying to negotiate social interaction via a differently (to non-autistics) mediated system. Perhaps this levels the playing field, as the therapist now also has to adjust to a less familiar medium and can better empathise with their client’s position. I suppose the answer to this might lie in how closely aligned certain aspects of the particular medium of technology might be to the person’s preferred way of processing information. For example, for some, email or text-mediated therapy may helpfully reduce the need to attempt to process complex nonverbal communication and speech simultaneously. It may allow for longer processing time. On the other hand, for those who struggle with the processing of text or verbal communication, this may prove more problematic. Others (autistic or not) may struggle with text-based approaches and find video chat more acceptable. Again, it highlights the importance of being able to offer a range of options and flexibility for this population.
Dr Fiona McClean
Chartered and HCPC Registered Clinical Psychologist
About the Author
Fiona is a clinical psychologist with over 15 years’ experience of providing psychological interventions for a range of mental health difficulties and in a number of different settings. Most recently she set up and led the Argyll Adult Autism Diagnostic Service in a rural but beautiful area of Scotland before taking up a post within the Neurodevelopmental Services at Your Healthcare CIC, Surbiton, England. She also works in private practice in Scotland, providing specialist autism and ADHD diagnostic assessments for adults, as well as post diagnostic support and a wide range of psychological interventions, for both the neurodiverse and general population. Following graduation from her Certified Cyber Therapist course, she will be opening her online practice by the end of 2018.