Interview with Molyn Leszcz

M = Molyn Leszcz; H = Haim Weinberg H

If you ask me what is one of my conclusions, after doing many online groups and after reading what is written and talking with many colleagues, one thing is that although it resembles face-to-face groups, it is not exactly the same. And the difficulty – because it resembles so much – that most of the therapists ignore the tiny differences, or what looks like tiny differences. And I think this is a mistake.

M

We know that if you are using the group as a setting for an intervention, the process dimensions kind of fade into the background. But if you are using the group as an agent more for the treatment, then the process variables move much more into the foreground.

H

That’s a great sentence. And actually it helps me a lot because one of the difficulties of moving to online therapy is that the setting changes. What you said is actually helping me understand that yes, there might be a problem, but the question is whether we focus on processes or the setting. Say more about that, because I think that this is fundamental and so important.

M

Sure. You may know that I’m focused a lot on the concept of being an evidence-based practitioner. In the work that we’re talking about, in regards to using the Internet, as a vehicle to deliver face-to-face group therapy, the same things that matter – plus matter in the Internet – so, attention to cohesion is critically important. We don’t know yet how cohesion is impacted by a Zoom group as opposed to a face-to-face group. In some ways, there are advantages to the Internet, because there may be more willingness to take risks on the part of the patient, especially when they are texting a response. There’s a kind of subliminal space … we’re face-to-face, but it’s a little different than if we are actually in the same room. Because all you can see of me is my face. You don’t know what else I’m doing. And all I can see of you is your face and … so, we have to be that much more attentive to what is not being communicated manifestly. Using the group as an agent – to come back to my earlier comment – part of why group therapy struggles, is that in the hands of many people, the group is used as a setting to deliver an intervention. Which is fine, if what you are aiming to do is a psychoeducational group, or support group, or learning how to cope with chemotherapy. I think there is great utility and value in that. But if you are looking at this as a vehicle in which the group itself, the processes of the group are intending to facilitate self-awareness, interpersonal learning, self-understanding, then attention to process becomes critically important. By “process” I mean in essence, “why is this happening in this way, at this point in time”. For me, that’s a simple way to remember what is happening, who is saying what to whom, what is being said, who is not speaking. What is not being said. And why specifically is this happening in this way at this point in time. And how does this relate to the two key elements that we know predict better outcome in group therapy: development of cohesion, and the manifestations of empathy.

H

And all these elements of the process and the here-and-now, are not different between online and face-to-face.

M

I would hazard to guess that they are at least the same, plus.

H

Can you say more about the plus?

M

When I do a group in my hospital I am embedded in a particular kind of social, cultural environment. if I feel supported in my work, if I feel my work is valued, if my work is respected, if I work in an environment where people are compassionate in their delivery of healthcare – that influences me. By working in an environment where I feel a sense of inequity or lack of attention to social justice – that also impacts me. And when you’re doing an Internet group, a Zoom group, then you’re open to all of the other forces that surround that dynamic. There are people in different locations. You may have people from different countries. So the larger forces may even make it more complicated.

H

So this is a plus … usually we add the cultural, social component – maybe even the social unconscious issue – clearer when you do a group that’s from many cultures and from all over the world.

M

Right. I would suggest that the more we can make a Zoom group like a face-to-face group and take advantage of the additional properties, the more effective we will make it. so: preparation, selection, a formulation – all are very, very effective.

H

I agree. Going back to the therapeutic factors that you mentioned before, I think that regarding text groups – [forums] – there is already enough evidence that there is developing cohesion … but I think that you are right that there is not enough research and evidence about Zoom or video conference groups. Am I right?

M

I would say so. I mean this is your work; you know this better than anybody. I haven’t found a lot about [online] face-to-face. Most of the work that I’ve found has been about more traditional Internet groups. You’re saying that there isn’t much right now, face-to-face, using Zoom as a platform.

H

Yes. There isn’t much. And that’s why in this book we want to focus more on video conferencing, whether couples or groups or individuals – we hope it will complete and add to the literature.

M

Yeah, I think that would be very important. There’s another variable to talk about, which is … many of the people who are seeking treatment now, in their 20s and 30s are much more comfortable with the Internet, than people in their 40s and 50s. there’s a generational phenomenon as well. Things we might have felt were barriers to engagement are not going to be barriers to engagement for people of a different generation.

H

You might be right. And probably people from a younger generation do it more easily. Maybe even benefit more from that. But let’s also talk about the disadvantage for the younger generation. Doesn’t it mean that … I’m playing the devil’s advocate.… Doesn’t it mean that we support a culture of being there all the time, quick fix, not delaying gratification, by our providing online therapy? What do you think, what do you say about that?

M

I think those are good questions. I think there are ethical considerations with regard to unintended consequences to offering Internet group therapy. For example, how do you deal with a crisis? How do you deal with a situation where one becomes acutely distressed? And they are 400 miles away. What kind of contract must be established to safety. What I don’t know about, but have curiosity about is … we know so many people who are engaged with a kind of surreal life. A virtual life and not a real life. So is a Zoom group bringing people closer together – which we hope – or is it fostering this kind of idea that “I don’t have to leave my house. I can access the world sitting in my chair”. And, on the one hand, I mean a lot of people I see are socially anxious and depressed and on the one hand this is a way for them to access treatment that they might not have access to otherwise, but is it not an inadvertent reinforcement of the idea that they can actually really control their exposure, and not be out in the world at all, at large.

H

You’re pointing out to what I wrote in my book The Internet Paradox – that it’s a paradox. Also actually Sherry Turkle wrote about it in her book Alone Together … so it’s a paradox and maybe, what you said at the beginning, it means that in the session we need to pay attention more than usual to questions of boundaries. And to keeping the setting very clear. Like the agreement that you mentioned. Adding a section about online ethics or norms or rules. And also establishing what we do in crisis.

Something else I would like us to discuss: one of the main questions is what happens in the disembodied environment. Something is missing, which is the body. Anything you can say about that. What are your thoughts?

M

It requires the group leader on a Zoom group to have an extra degree of caution and an extra degree of humility. Because the inference that you are making that what you see tells the story is gonna be that much more limited. Because you’re only able to see a piece. If you’re sitting in a room you can … a skilled group therapist can scan the room pretty quickly. I think it’s a different skill to scan a computer, with 8 faces on it.

H

So you lose something … I think it’s also in the eye to eye contact. It’s another paradox: although you see the person much more closely than you see him or her in the group – you can focus more on the facial expressions, actually you cannot have an eye to eye contact.

M

And if you’re focusing intently on one person, your vision is gonna be obscured with regards to other people on the same time. I would imagine. I know it’s hard to take in everything that’s happening in a group when you’re in the same room. And body posture … I am not as attuned as I should be to the role of body posture but I enjoyed, for example, Pat Ogden’s talk at the AGPA about sensori-motor perspective.

H

So what you actually say is that you might lose something by focusing on one person, lose some attention to the group as a whole.

M

Yeah. I’m imagining that. I would think that everything we do gives us something and takes away something. So the issue here is to be aware of what this gives us and to be mindful of what it takes away. What it gives is access. What it gives is connection to a larger group forces. What it takes away is the potential to really examine someone’s totalistic expression of what they’re feeling. You can see my face but you can’t see my hands. And that’s just you and me. If there are eight other people on the screen it becomes that much more complicated.

H

You’re right. It’s so interesting, I have a process training group of therapists from the US and at one meeting they said that they don’t see the whole body. And then what they did, they showed the leg [and] the shoes, to complete the entire body picture.

M

That’s a concrete enactment. It still doesn’t make it possible, in an ongoing way. But these people wouldn’t be in this process group with you, without the Internet. So again, we have to look at what it brings, and what it obstructs.

H

So, talking about the difference between the concrete and non-concrete, it’s not only not seeing the whole body, it’s the ability to sense exactly what’s going on. Somehow there is some disconnection I think, because … through the mediation of the computer. Do you agree?

M

I agree. I certainly have felt that when I’ve done teaching through Zoom. When you get variation in the technology, in people’s Internet, in people’s wifi, it can be a distraction just from logistics.

H

I agree it’s a distraction, but maybe we can also use it. For example, when there is a disruption, when there is a break in the communication, what do you do with that? Many times, you blame the other: “Your Internet is not strong enough.” So you can use it and say: “Ok, what did you feel? Some people might even be triggered by that. It’s more in one-on-one but you can use it in the group.

M

That’s an illustration, Haim, of how you can take advantage of everything that happens, if you are alive to the process in the here and now. In my group in the hospital, there was a fire alarm. And it was quite loud, and so it led to a discussion about Are we safe? Can we trust Molyn’s determination that we are safe. We haven’t heard a fire alarm before, at this time of the evening. What does it mean? And so it opens up issues around authority, around trust, around safety. It’s all potential material for our work. And the Internet is gonna open up some new avenues. And a skilled group therapist, who is comfortable with technology, I think can probably manage the process of that, in the same way that he would manage the process of doing a group in out of the ordinary situation or circumstance. But you have to know what to be thinking about and what is manifest and what is latent.

H

Yeah that’s another good sentence. And maybe that brings us back to what you said, that as long as you focus on the process and not ignoring things that happened that are not exactly like the regular face-to-face, then you can go deeper and you can work well even online. In my online group contract it’s written, because the group member control the setting in their house, then I ask to have a private room, with the door closed, with no interruption, and no distractions, no looking at emails or iPhone. It goes without saying, but we don’t do it in our regular contract, because I’m taking care of the group’s room. And in one of the sessions, suddenly there was a cat on the table. First we saw only its tail and then (the rest). What do you do with that? Because you don’t have it in the office. Rarely would people bring their cats. So I had to talk about it. It’s actually not exactly according to the contract. We need to pay attention to things like that. Most of the therapists simply ignore it.

M

We know that many therapists in their face-to-face groups also ignore important elements of the process. And aren’t as attuned empathically as they need to be. So the person whose cat comes into the group – what does it mean? Did the person make the decision that the cat … if I close the door the cat will drive me crazy, scratching to get in, and I’ll be distracted. Or, if I bring the cat in, I will feel comforted and be able to take some bigger risks because I will have my pet with me. Or is the person using the cat as a way to create a bit of a barrier to be not alone so there’s two of them against everyone else. There’s a dozen ways to make sense of it. And sometimes a cat is just a cat.

H

So what you say, actually, is that we simply need to explore and not ignore. And there are therapists who will not explore even in face-to-face, in the same room, they might be in greater danger of ignoring while online, because it’s kind of in the background, we don’t think about it enough.

M

I bet you there isn’t a group therapist who hasn’t had the experience of a member of his/her group falling asleep. Especially in an evening group. How do you deal with that? Do you ignore it? Do you, as a group leader, speak to it? Do you, as a group leader, ask how come no one is addressing this? I had this happen in my group recently – it also speaks to the intersubjectivity of our work. Because this is a young father, came to the group, and fell asleep. You can see him struggling to stay awake. So … no one spoke to it, until I said: you know, how come no one is speaking to this? And then he apologized. And someone said to him: this is rude of you to fall asleep. And someone else said: we need to find out why, it’s not typical [of him] to fall asleep. And he said he had to take his daughter to emergency in the middle of the night before. And he struggled, he didn’t get much sleep, and he decided that he would still come to the group. So, is he to be criticized for falling asleep, or is he to be commended for making an extra effort to come. and so it was a kind of useful elaboration about “We need to understand everything from as many sides as possible.” And there will be that much more in a Zoom group because you’re gonna be in ten houses.

H

So I take what you say in two directions. One – again – things happen also in a non-Internet group. And some people will ignore them even in a non-Internet group. And the other: we might need to be more alert in online groups because it’s so easy to ignore something. As if it’s part of the set.… Maybe you’ll try to bring up more things?

M

For me, questions that I have are in the ethical domain: how do you ensure privacy? How do you ensure confidentiality? How do you ensure that no one is making a videotape? I know you have a contract for someone who becomes extremely distressed or suicidal, what are the terms of that contract? If somebody is across the ocean. And the other thing is, from a jurisdictional perspective, are you licensed to be doing this? If you’re in Massachusetts, and you have a Zoom group with somebody from a state where you’re not licensed, I would say you’re exposed to law suit … there’s a vulnerability.

H

Yes, all these things should be considered, and maybe written in the agreement. Let me ask a question: one of the things that we say about groups is that the fact that we arrange the chairs in a circle has some deep mystical meaning: the womb, the container, whatever you want. Here, on Zoom, we don’t see it in a circle, we see squares, do you think that it has some impact?

M

It’s a good question. Again, I think we need to understand cohesion in those kinds of groups. Are there particular layouts that are better or worse. The contract that you referenced I’m sure is helpful in promoting cohesion. I would think a contract is even more important in this kind of group than a face-to-face group. I’m sure you have experience as well: in face-to-face groups people will sign the contract and forget what’s in the contract. They’d say “That really does?” It’s a good question. When you do a group and someone is missing. Do you leave the chair in or take it out?

H

That’s a good point. I leave the chair in, and the presence of the person is there. Actually, online I did not think of doing that. I don’t know how to do it.

M

For me it’s less of an issue because I pull the chair out if somebody is missing.

Just last week my group spent some time looking at the relationship I have with my co-therapist. She’s a resident, and people said “We noticed that you never sit beside one another.” So we discussed the fact that we try to be able to see one another in the group and as a way of facilitating our communication. That was a great interest to members of the group. So I would imagine that when you’re doing an Internet group, you’re doing it by yourself.

H

Usually. But I did a process group for my students in Singapore and in Israel with my co-leader in Israel and what happened was that we felt that we lost something in sensing where the other co-leader is. Usually, when you are working a lot with a co-leader you sense one another, you just have to look at the other to warn him or her … you know what I’m talking about. We lost it online.

M

So let me ask you this question: knowing this is work that you do and that you enjoy. Do you think everyone, every group therapist should anticipate that they should or could do this kind of group work? Or are there some who are better at it and some who should stick to face-to-face?

H

That’s a great question that I haven’t thought about. First of all, let’s begin with the fact that I think that you do need some specific training to make the transition from the circle to the screen. Like for the transition from individual therapy to becoming a group therapist you need a specific training. I think that you need to add some training about groups online. Meaning, understating the difficulties, being aware of all those tiny things that are not so tiny and all that. Now, I don’t think everyone should, for sure, and I also don’t think everyone could. You need to feel comfortable with online communication because some of what Foulkes called “dynamic administration,” online, is the ease of solving technical problems. It’s difficult, when you feel you don’t know what to do when you hear an echo or something like that. So first of all you need to feel comfortable with technical things. And also feel comfortable in the environment, not just the technology – feel comfortable with the online environment. Some people don’t like the online communication. So that’s one thing that I can think about immediately. What do you think?

M

I think that a person to do this kind of work needs that kind of technological security. Because the group requires your full attention. And if your attention is split because you’re worrying about the technology, you’re not gonna be present in the room, that you need to be. I think you need to be even more present doing a Zoom group than a face-to-face group because, I would imagine … this is an assumption, that in a face-to-face group I would frequently say “You know, I noticed earlier tonight there was a moment of distress on your face that we didn’t have a chance to talk about then, but I want to come back to it now.” I don’t know how easy it would be to do that in a Zoom group. I would think that I would miss more cues.

H

I think that you introduced one of the main questions, which is the question of presence: what does it mean to be present? And how to be present online. For me, this is the crucial question in online therapy, whether individual or groups. What does it mean to be present, and how do we make our presence clear online. I think that you said it, I just repeat what you said: we need to put more emphasis, we need to make more effort, we need to find a better way of being present than [with] a group that is in the same room. Do you agree with that?

M

Yes, I think that the demands on the group leader would be greater online, than face-to-face, because there is more that is not directly accessible.

H

Yes. I think that we covered most of the important things.