Now I See A Person Institute (NISAPI) is a non-profit teaching and clinical institute devoted to helping people achieve a complete and sustainable recovery by pairing the normalcy of a horse ranch and the nurturance of horses with a philosophy of postmodern collaborative practice.
Here, people are seen as who they are as persons rather than their diagnoses, and we identify and nurture the inherent positive strengths and self-agency of each client and family member to facilitate their journey of healing. All of our clients are “high risk” individuals who have lost hope after previous therapy, medication, or hospitalization proved unsuccessful, and/or whom previous mental health providers considered unchangeable. As I documented in an earlier blog introducing our practice, we have found our methods to be highly effective. We call these methods “Extraordinarily Normal: A Journey of Breaking Free from the Limits of Labels.”
With the start of the COVID pandemic in March 2020, however, we were forced to change the way we work. Since then, therapy and life coaching interactions have moved from outside (on our ranch or a state park) to inside (over Zoom or via phone). Despite the very different setting and the lack of equine “staff,” we’ve been pleased to discover that our clients have reported similar positive outcomes with telehealth as in person. This blog will describe how we adapted our methods for the pandemic, why we believe it’s been effective, and why we intend to continue to offer this way of working to those who prefer it.
Our Clients and Philosophy
Those referred to us—typically a young person and their family—are mainly those who are ready to give up on living due to trauma and the symptoms that manifest from that trauma. They have usually been given a diagnosis before coming to NISAPI. Diagnoses, unfortunately, can paint a portrait of an individual that leads them to adopt an alternative identity based in deficiency, self-doubt, and the idea of being “incurable.” It can leave the trauma and the person hidden in the picture of treatment. We know that in the face of trauma and severe symptoms, people search for a new self-identity and explanation for what happened.
The meaning of diagnosis has a complex effect on those who suffer. Diagnoses create a world of pathology and deficiency, as marriage and family therapist Harry Goolishian, a pioneer in dialogical therapies, reflected decades ago. And after a person receives a diagnosis, everything that happens to them revolves around the diagnosis instead of the person.
Therefore, clients need to heal from both the “symptoms” caused by life stressors and the diagnoses given them. This is our treatment philosophy and what I teach trainees in our Certificate Programs. It begins with authentically embracing clients as honored guests who are suffering and in need of services that address their urgent concerns. This approach, in turn, spurs dialogues that help to build relationships that produce sustainable change.
The topics of these dialogues and the types of relationships are directed by the client and based on their desires and those of their communities (families, referral systems, judicial systems). As their therapists, our role is simply to aid the client and their community along their journey by participating in transformative conversations. Put simply, we let the clients take the lead to talk about what is happening and guide them, as compassionate yet neutral observers, through the possibilities for growth.
Since the sessions focus on exploring and improving family dynamics rather than assessing or pigeonholing the “identified patient,” there are no good guys or bad guys and no right answers. Everyone’s concerns, feelings, and ideas are heard and discussed, with the goal to find mutually satisfying solutions to the unique challenges they came to us to heal.
Adapting to the Pandemic
At NISAPI, we attempt to get to know the person and their community first and then learn the journey of their symptoms and diagnosis. Rather than draw a distinction between therapists and clients, we all participate mutually as “persons.” For years, we did this in the unique setting of a horse ranch and a state park. The relaxed outdoor settings and the presence of the horses—acting as co-therapists—helped us to create an atmosphere of nurturance and normalcy that aids clients in creating organic and intimate relationships. These relationships, in turn, enable problem-solving in times of significant crisis.
Working at the ranch wasn’t possible during the pandemic. But we quickly realized that our collaborative approach to therapy meant that whatever the location, all of our interactions would still be conveyed in a conversational manner. Therefore, we did not need to be physically present to do the same work. The power of simply “being with” our clients could be transferred to a telehealth format, overcoming the superficial barrier of the screen and allowing the same level of intimacy between clients and therapists as in-person therapy.
In a telehealth setting, we found new ways to create a nurturing environment. For example, rather than artificially recreating a special “therapy room” and trying to eliminate any signs of the therapists’ ordinary lives during sessions, we transitioned our therapy setting from barns and fields to kitchens and living rooms inside our private homes. This arrangement set both clients and therapists at ease and allowed us all to relax and be ourselves, making it easier for us to show each other who we really are. Working via telehealth also allowed both therapists and clients to see details of each other’s everyday lives and communicate person-to-person rather than patient/client to service provider. The home setting also allowed clients to smoothly transfer insights and intentions generated during therapeutic conversations into their regular activities.
Even more important than seeing their home settings, we were able to observe how they physically interacted in their space and with family members, whether these individuals were physically present or participating remotely. We recall many cases where, together on Zoom, it was very helpful for the staff and family members to witness and then reflect upon, say, how a child manifested trauma-driven symptoms in their own bedroom. Or how a parent’s anxiety led to a conversation in a closet. Or how different family members saw and processed anguish in their loved one – all in real time. As participants in each of these dialogues, we could see and hear these events ourselves instead of being told about them after the fact. We became immersed in the evolving pain and the solutions that emerged there.
We also took advantage of Zoom’s breakout room feature to provide individual and relational therapy in both separate and shared virtual spaces, whether we were connecting via video on the Internet or audio via cell phone. For example, children and parents could speak freely to us in their respective, private breakout rooms and then come together for a group discussion that produced new insights. Parents with severe conflict living many miles apart could see via Zoom the homes where their children are currently living, discovering that the two settings and family values expressed there are more similar than they had thought.
Being present together in real-life settings like this allowed all of us to feel an increase in the intimacy of the therapeutic relationship. With less need to “switch gears” from one setting to another or to find a conversation-starter, we noticed a sense of co-creation almost immediately, all of us simply people searching for ideas to build hope.
Some of the themes that have emerged in post-treatment interviews with clients and faculty about the intimate, therapeutic process that occurs via in-home telehealth include:
Comfort and control: The therapeutic dialogues take place in the clients’ “territory,” on their terms, and in a situation where they already feel comfortable. They choose what we (the therapists) see and don’t see and how long they remain on the call. This sense of being in control helps to further level the “playing field” where our relationship, full presence, and sacred conversations take place. As one client told us, “It is great for telehealth. You can be in bed and talk to your therapist, you feel more comfortable and not alone. You can see what I see and experience. ”
Convenience: Sessions can happen wherever and whenever the client happens to be, without the added pressure of having to travel to an appointment in busy traffic—although we have done a session while one or more of us was in a car! One client told us, “I can be in a robe and eating and talking and do not have to worry about getting there, and my stress level is down during the conversations.” Another said, “One of the most convenient things about having therapy over the phone is that I can essentially do it anywhere I feel the most comfortable and it makes my schedule much more flexible.”
Added privacy: Since the client controls the setting, the interactions are self-contained, with fewer distractions and less concern about being overheard by other people coming or going around us. “I felt comfortable talking and the private things I was able to let out,” a client told us. “I was able to get to know you guys better than at the ranch. I do not hide anything; it’s comfortable and I like it. It feels like it is your own private time, we are people talking to each other and are equals.”
Greater insight into clients’ (and therapists’!) authentic lives: We are allowed to observe not only the details of the clients’ home and other environments (depending on where they are when they log on) but also how things operate in those spaces, including how they navigate everyday relationships and the ongoing strains in their lives.
We encourage our clients to contact us when they need us, and sometimes that means children FaceTime us from school. This allows them to talk immediately about what has happened, in context, and not let the problem escalate into further conflict or the placing of unnecessary psychiatric labels. A parent of a teenager with self-harming behaviors told us that this type of access means “they are able to process conflicts before the incidents harm them.” We therapists can also see with our own eyes what the client’s school is like and how they respond to situations, enabling us to better understand the young person’s circumstances.
Following are a few case studies illustrating what witnessing clients’ authentic lives can look like and the benefits it offers.
A Substance-Use Crisis
A family was referred to us due to one of the parents’ substance abuse and how this affected the children. A couple we’ll call Mona and Tom were having therapeutic conversations with our team. Tom had a problematic relationship with a substance that was interfering with both his parenting approach and his marital relationship. Online, we saw each of their teenagers describe to their parents how these events have negatively impacted their lives.
While together on Zoom, the family members were separated: Each teen spoke while in their respective bedrooms, one parent was at home in another room, and the other parent was miles away. The critical solution-based dialogues began after the parents watched each child, independently, disclose and reflect on their self-perceived traumas due to their apparent comfort in what we call their “space of dialogical safety.”
In this conversational arena, filled with the family’s pain, the parents were free to listen with purity—as if hearing each other’s perspective for the first time—and fully process the anguish each child had endured and refused to endure anymore. Almost immediately, conversations about solutions arose: teen with teen, teen with one parent, teen with both parents, and onward. I assume this breakthrough could have been replicated at the ranch somehow, but in cases such as this, we all felt the dramatic impact of the conversations and resultant changes for this family benefited from occurring in the home setting.
I do wonder, though, if the teens would have found the courage to speak so candidly outside of their rooms had the physically distant parent been in the home and physically around them. Would this dialogue even have been allowed to be spoken? And if the parents had been physically together, would they have had the courage and love to listen and make plans to change for their children in that particular session?
A Fearful Child
Another example: “Andrea,” aged nine, who had experienced many traumas in her life, faced a situation in which she was scared when her sister, a source of nurturance and comfort, wasn’t in the home while their parents were in court (for reasons of which she was well aware). This was a case in which one parent had been removed from the home and the child faced isolation and fear alone when the standing restrictions of the pandemic were at their height.
Having a team of caring adult therapists come into Andrea’s room weekly via Zoom while a parent was absent created an environment where the little girl’s isolation was lessened, and her fear gradually left. When possible, one parent working miles away would join us from their job setting, also allowing Andrea to feel safer.
This child, once withdrawn, is now bubbly and has an abundance of friends. Her family continues to participate in our services and in time the therapy process will include additional family members. These family members already “know” us, for they have seen us while this child “Zooms” in her parent’s car. The sisters will even wave hello as Andrea puts on her headphones and prepares for her session.
For many “not-in-person families” like these, we probably wouldn’t have been able to see their anguish in quite the same way had meetings taken place at the ranch. Nor would we have seen the often immediate, significant change right where it happens. Seeing a child go from hiding in their room under the covers to riding in the car with her sisters feeling important was something we were able to witness on Zoom—again, directly rather than just hearing about it from Andrea or other family members.
The Power of a Dog
We not only get to see aspects of our clients’ lives—they see ours, too! One therapist who is also on our faculty, David Abramovitch, has a family dog, Molly, that sometimes appeared in his Zoom sessions. One young person commented, “It was helpful to meet David’s dog. I saw David as caring, as you could see how much he adored his dog with how he spoke to [her] and all the stories he shared ….” Children would playfully compare their own dogs to David’s during the sessions, deepening the therapeutic relationship.
We know the therapeutic relationship is so important to successful outcomes. At the ranch, we knew this relationship was enhanced by the presence of the horses at our meetings during the first and ensuing sessions with clients. In the pandemic, we’ve learned to use our own homes, our rooms, our environments, and ourselves the same way we’ve used our usual natural setting.
Overall, clients’ self-reports about telehealth are similar to what past research about treatment at the ranch has found: The supports we provide and the bonds that we form are therapeutic during otherwise hopeless times. People frequently state that our staff feel more like family than providers. One young person told us, “Talk therapy on Internet or the phone has helped me shift my perspective to be able to manage and control my anxiety. Our conversations have also helped boost my confidence and release shame over the idea of not hitting a certain standard.” We gain confidence in telehealth, too, when we hear client comments like this: “It makes my day. I feel like a ten; that you care about me. Internet therapy is a ten out of ten.”
In considering why the outcomes of telehealth were similar to those of therapy at the ranch or park, we realized that the services we offered were more similar than different. Even when working exclusively in the horse-based setting, we would spend at least an hour talking on the phone to our clients before they came to the ranch. In between sessions, our clients reached out to us via phone or text, so our staff was already used to these forms of communication.
Still, we’ve found that just as telehealth relationships can help build trust faster, it can also sometimes take a little longer than at the ranch, where clients are seeing us with horses and their trust often seems instantaneous. As therapists, we’ve also missed the calming nature of the horses’ presence because we are emotionally attached to them. One could also ask, in not being physically present and moving around in a natural setting, did we miss social cues without realizing it? Or can we feel confident that the online, face-to-face interaction encouraged a new shared experience that made up for that? We may never know: Our new clients had nothing to compare it with.
Ultimately, we plan to stay at the ranch. In the meantime, we are doing a hybrid of in-person and telehealth sessions. Some of our existing clients have chosen to do the in-home therapy, while new clients come routinely to the ranch. One thing is certain: What happens there is amazing, the environment is natural and nurturing, we see people and not traditional pathology, and we believe this is vital to our work and to the field. But we feel the ranch is only one option for those seeking our services—the lessons we were forced to learn from the pandemic have both validated and inspired.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.