Dr. Avigail Lev of CBT Online: “Name feelings more explicitly”

When working with clients via phone or video, it’s important to check in with them more frequently. Check in with them regarding how they’re feeling, check in regarding their nonverbal behaviors and whether you are reading them and understanding correctly. Check in about your relationship and how they experienced you. You can ask questions like […]

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When working with clients via phone or video, it’s important to check in with them more frequently. Check in with them regarding how they’re feeling, check in regarding their nonverbal behaviors and whether you are reading them and understanding correctly. Check in about your relationship and how they experienced you. You can ask questions like these: “How are we doing right now?”, How are we feeling with each other?”, “How did you understand me?”, “Did I understand that correctly?”, “How were you impacted?”.


One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewingDr. Avigail Lev.

Dr. Lev is a psychotherapist, author, and executive coach in the Bay Area. She is the founder of CBTonline, an online platform that connects people with telehealth therapists who specialize in Cognitive Behavioral Therapy (CBT) and offers online CBT resources such as webinars, e-courses, videos, mindfulness audio, and much more. She is also the director of the Bay Area CBT Center, a clinic that specializes in Cognitive Behavioral Therapy (CBT) to help individuals and couples break unhelpful patterns, develop healthier habits, and improve all areas of life. Learn more about Dr. Avigail Lev and telehealth services at https://bayareacbtcenter.com/, https://cbtonline.com/, and amazon.


Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

I’ve always been fascinated by existential questions such as what makes people happy, what makes life meaningful and fulfilling, what drives people, what matters to people, what’s the point of it all. After the first psychology class that I took, I knew that this was the field that I’m meant to be in. I absolutely love being a therapist and I’m so grateful that I get paid to do what I love every day.

Can you share the most interesting story that happened to you since you began your career?

I have many interesting stories because I love my work, therefore it’s difficult to pick just one. The most interesting times I’ve had in my work are moments when I get a new client who is struggling with exactly what I’m struggling with at the time. In those instances, I get to help myself by helping someone else and vice versa. I also recall three situations in which the clients I helped also moved forward into helping professions and helped others. It creates a domino effect in which by helping myself, I help others and by helping others I help myself and they also help others. It’s a beautiful experience of interconnectedness.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“If there is a meaning in life at all, then there must be a meaning in suffering. Suffering is an ineradicable part of life. Without suffering and death, human life cannot be complete.”

Victor Frankl

Being a human being is hard. There’s a lot of pain and suffering for all of us. It’s not because we’re bad or because we’re doing it wrong, it’s just because life involves moments of pleasure and meaning and includes moments of pain and suffering. Like night and day or summer and winter, we can’t have one without the other. It’s not about getting rid of our pain, it’s about learning to relate to it differently, making friends with it, listening to it, learning from it, being guided by it. It’s about practicing being loving, gentle, and kind with our pain rather than resisting it.

The biggest gift that I’ve received from being a psychotherapist is seeing how not alone I am in my own experience. All of us think that we are unique in our pain and that we are alone in it, but when you’re a psychotherapist you get to see how all of us are having very similar experiences and how interconnected we are. Many of my clients who feel deeply ashamed, depressed, or anxious or who struggle with asserting themselves, or with making decisions think that something is wrong with them. They think that they are different or broken, but as a therapist I get to see that life is full of both negative and positive experiences and that all of us are more alike than we are different. We’re all trying to figure out how to live a meaningful life and going through the ups and downs of being a human being and it isn’t easy.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

I am grateful to my mentor, Matt McKay. I wouldn’t be who I am today if it wasn’t for his help and support as well as the faith that he had in me. Him believing in me helped me believe in myself. He is my mentor, my mentee, my colleague, my friend, my supervisor, my therapist, my teacher, my student, my dissertation chair, and we have coauthored many books together. What I love about our relationship, is that we play so many different roles for each other and we don’t feel bound to stick to one. I learn from him and he learns from me, we teach each other, it’s very reciprocal. I also view the therapeutic process in the same way. My clients will never truly know how much I’ve learned from them and how much they’ve taught me. I am grateful to my mentor and all my clients.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

Because I’m a very experiential therapist, one benefit of being in person is that you can engage in experiential exercises and role plays, or exposure work. Behavioral therapy is very interactive, and we may practice exercises like the empty chair technique where you switch seats and talk to different parts of yourself or write down thoughts that are connected to limiting beliefs and act them out. Experiential exercises like these are very powerful in therapy because they take you deeper than insight alone. They help you experience something differently and have a visceral response to a new experience rather than just a rational understanding of it, which is crucial for behavioral change. Other benefits of being in-person is having more access to the clients’ non-verbal responses including their gestures, facial expressions, any tightness, or resistance in their body such as clenching a fist or shaking their leg. All these nonverbal cues are important in understanding the client’s internal experience and bringing attention to those experiences. These observations are more difficult to bring into awareness over phone or video but could still be done effectively.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

The challenge of working remotely is that it’s more difficult to conduct experiential exercise or to notice the subtle changes in clients’ affect and nonverbal behaviors.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)

1. When working with clients via phone or video, it’s important to check in with them more frequently. Check in with them regarding how they’re feeling, check in regarding their nonverbal behaviors and whether you are reading them and understanding correctly. Check in about your relationship and how they experienced you. You can ask questions like these: “How are we doing right now?”, How are we feeling with each other?”, “How did you understand me?”, “Did I understand that correctly?”, “How were you impacted?”.

2. Name feelings more explicitly. Given that there is a screen between the client and the therapist, it’s more difficult to catch subtle nuances of gestures and shifts in emotions and behaviors. When working remotely it’s better to check in too much than not enough. I’ll often say things like, “what’s going on for you right now?”, “what’s that face doing?”, “you seem to be feeling this…. but I’m not sure if I’m reading you correctly?”, “is something happening for you right now?”.

3. Make sure you and your clients bring paper and pen with you to sessions. When you write things down during sessions it helps clients retain the information better. It also allows you to conduct behavioral experiments, do experiential exercises, track thoughts, feelings, behaviors, triggers, and values. Writing these things down will help make therapy more effective, track clients’ progress and clarify barriers.

4. Give clients homework assignments in between sessions. Research shows that the main predictor of whether a client will improve in therapy is whether they practice new behaviors and follow through on assignments outside of session. Giving clients assignments to do between sessions is effective because it helps track clients’ behaviors and it provides information about their progress in therapy and where they get stuck.

5. Practice exposure exercises in the moment. That means that you help clients take small behavioral steps towards their feared situation. For example, if a client is telling you that they are struggling with asserting themself with a friend or asking their boss for a promotion, rather than just talking about it, have the client do it with you in the moment. Work with the client in the present moment to send their friend that text message or work with them to send that email to their boss.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

The main way that Telehealth creates new opportunities that can be more beneficial than traditional office visits is that you get to witness the client in their natural environment, and this creates opportunities for doing behavioral work and exposure exercises in the moment. If a client is struggling with hoarding and has difficulty cleaning their house, you can have them do it right then in the moment. If a client is afraid to make a request of her husband, you can walk them through it right then and there. If a client is struggling with agoraphobia and is too afraid to walk too far from their home, you can talk them through it right on the phone and help them practice coping skills as they walk further away. Phone sessions make present moment exposure exercises more available and easier to do. You can practice coping skills and help them move towards those actions right with them in the moment.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

Zoom and other videoconferencing platforms, apps that help track behaviors, mindfulness audio, heart rate variability, and virtual reality headsets that mimic exposure exercises.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

It would be my own CBT app that incorporates all the exercises I do with clients in therapy.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Clients should be aware of how to pick a therapist that is the right fit for them. One way to do this is by asking the therapist what their formulation of the problem is. The therapist should be able to provide the client with a formulation, which is a hypothesis of why the problem originated, what is driving the problem, how the problem is being maintained, what behaviors are reinforcing the problem, and specific interventions that the therapist will use to work with the client to fix the problem. The client should be clear about how the therapist is thinking about the issue and what treatment will look like. The formulation and treatment plan should be made explicit and needs to resonate with the client. If a therapist is not able to do this within the first three sessions, that is not a good sign. I provide clients with my formulation on the very first session and I get agreement and consent from the client regarding exactly how we’ll proceed with tackling the problem.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

I am excited about virtual reality exposure therapy and heart rate variability tools.

Is there a part of this future vision that concerns you? Can you explain?

It concerns me that with remote work getting more popular and with the isolation of the pandemic that we will become less social and will be less motivated to engage in real life. The fact is that real life relationships will always be better than any technology.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

I would want to create a movement of empathy and authenticity, where we all practice truly seeing each other and witnessing each other. Martin Buber describes an “I thou” relationship where we view others not as a means to an end, but as an end in and of itself. I would want to start a movement that emphasizes this way of relating to others.

How can our readers further follow your work online?

https://cbtonline.com/
https://bayareacbtcenter.com/

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.

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