Two cases of Blended Care in a private practice

Last month I received a referral from a general practitioner who wanted me to take care of a patient who suffered from a severe depression.


The use of blended therapy for depression, in which a combination of online components and face-to-face treatment is applied, is becoming more common, but still has its difficulties. Especially when a patient is very passive or agitated a therapist has to deal with motivational problems.


What helped us was that this man, a 49 years old businessman with an extremely busy life, already had a lot of experience with the benefits of the Internet when it comes to communicating from a distance. For him computer-assisted therapy was a sign of dealing with a therapist who doesn’t ignore the novelties in life.


After the initial consultation (in which we came to a diagnostic classification of the symptoms and a shared conceptual frame for the origins of the depression) we sat together to develop a treatment programme in which monthly face to face sessions were combined with online components that we shared once a week by e-mail or Skype.


At first, the online components dealt with psycho education about the origins of depression. Later on we changed to online exercises with mindfulness in order to improve concentration on emotional issues that he tended to ignore. He learned how to make peace with thoughts and feelings that he formerly evaluated as not valuable, proper, correct, decent, etc. He recognised how devaluating he was about his inner life, and how this fuelled for a life of doing still more. This part of therapy in particular had to be supported by personal conversations. Being abroad on business trips most of the time we also had these conversations on Skype. This also applied to the value orientation exercises we selected. This part of the therapy also consisted of writing exercises that he sent to me by e-mail to comment on. So we integrated several components into a blended Mindfulness based Emotion Focused treatment for depression.


In my opinion there always has to be a shared rationale for applying a specific mix of treatment components and treatment procedures for the treatment of depression. A shared conceptual framework for the origins and provocative factors, as well as the factors that nourishes it in the present moment, is as much obligatory, as a shared decision about what the therapy will consist of and what the format will be. Without this no psychotherapy will work, and blended therapy certainly not.


Before moving further into another possible benefit of blended care - lest its installation answers to above prerequisites - let me first share with you another patient of mine. James (as we shall call him) was a young man, 28 years of age, he had been a student for 8 years, studying at a technical university. He was unable to graduate because of recurrent depressive episodes in which his study motivation dropped to zero. The youngest of four children, with two older brothers who were suffering from a severe autism spectrum disorder with serious aggression regulation problems, just like their father. His mother was not able to handle the family affairs by herself, which annoyed his father so that it led to daily quarrels.


Things grew worse when at primary school James became the victim of bullying, while being ignored by his teachers. James’ learning history was really damaged, but he succeeded in finishing high school, after which he left home to study IT in another town. His study was marked by recurrent depressive episodes for which he didn’t seek any help because he didn’t even consider the possibility. Periods of frantically dating were alternated with by periods of avoiding all contact with girls. His relationships with male fellow students were under pressure, because of his habit of complaining and whining about the smallest of inconveniences that came his way.


For me it was clear that blended care would not function, at least not at the beginning of the therapy. We had to take all the time we had to pull James into a holding environment that would be inviting enough for him to share all his pain from the past and his doubts about the future. Because of his study he was very interested in eHealth and it took a lot of persuasiveness to keep him from roaming the Internet for all kinds of solutions for his lack of social assertiveness, as he preferred to see his problem. It was not at all clear to me how we could use technology to increase the benefits of treatment. Actually, I thought it would only worsen things


It took me quite some time to realise that patients can feel highly connected with their therapists, even if contact isn’t face-to-face, and to give in. For his generation it isn’t that strange to build a relationship with the help of the Internet, he explained to me. And as it soon turned out, our contact could even become more personal (and healing) because we were not always in the same physical space. The eHealth exercises helped to prepare him for the real thing. It fostered and gave a feeling of safety that he needed before opening himself in the real life encounters.


So blended treatment can also work the other way around: it can help to accelerate and deepen the face-to-face therapy. As the therapy progressed, the addition of eHealth modules lost their original function as a buffer for his hesitance towards an immediate sharing of emotions. We went on using them for other purposes, like exercising social assertiveness.



By Helen Lionarons