Shifting to Tele-therapy – Attuning Without Physical Presence
Over recent weeks, many therapists have shifted their practise to tele-therapy. This is in-line with global social distancing directives. Interestingly there is a movement to relabel ‘social distancing’ to ‘physical distancing’. The idea here is that we want to maintain social connection, even when we are physically apart. Of course, this makes total sense, but I must say, there is something very restorative about being physically present with a safe person. Nothing beats it. We can get online and connect as much as we like, but there is no substitute for physical human connection. We simply crave it. So what does this mean in relation to tele-therapy and other online interactions?
Speaking to both therapists and clients about their experience switching to tele-therapy has underlined the importance of our neurophysiological resonance and the ability to attune to one and other. In the therapy room, it is much easier to pay attention to a client’s experience of safety and danger. Both consciously and unconsciously, I tune into my client’s sense of neurophysiological safety, their breath, their posture, bracing patterns in the body, the level of eye contact, areas of muscle tension, the way they associate to their body and orient within the room and in relation to me. I also pay attention to how my own body is responding to the client’s somatic experience. It is a non-verbal conversation where I assess both somatic transference and countertransference. The flow of a therapy session depends on a complex process of listening and responding… It is so much more than a verbal conversation. For therapists like me, who also work with touch, there is the added element of contact; another non-verbal conversation.
As we shift to online tele-therapy, the ability to be physically present and attune so deeply is being challenged. Touch is out for sure. As therapists, it is our job to find ways to attune with our clients without that innate human neurological conversation going on. We can do it; but it is more laboured as we don’t have the power of physical presence. Our processing faculties have to work harder to listen, process and integrate our client’s experience.
Clients may also be finding the switch to tele-therapy difficult. Some are flat out refusing to engage. They want physical presence. It’s part of the treatment; to sit in safety with another. Some are attending tele-therapy but closing off a little, reluctant to engage. I have also found that deep transference may arise; often feelings of being disconnected, helpless, betrayed or abandoned. These are often deep developmental wounds with anguish towards an attachment figure that was not able to listen or help them during their formative years. I am making a point to watch out for this transferred material and work with it. So perhaps there is an opportunity here as we distance and disconnect, to go deeper into childhood wounds.
As therapists, what can we do to attune to our clients when we are not physically present with them and how can we support those who feel resistance to developing and maintaining on-line therapeutic relationships? Here are some strategies that I am finding useful.
1. Taking a moment to arrive
At the beginning of a session, I proactively create a conscious moment where we can arrive together in the online space, to establish the virtual connection. Together we are orienting to this shared non-physical space that is somehow in between our separate physical spaces.
2. Orienting to the client’s room and my room
Because I am aware that many of my clients experience dissociation, I work with orienting to their space before we commence. I often ask for a few landmarks: What room in the house are you in? What can you see around you? Are there other people in the house? And I invite them to tune into their space. Some of my clients like to show me their room with their camera. I will also, in a sentence, let them know where I am (at my clinic/at home). The process of physical orientation can help the client associate to their own body and feel more connected to me, because we have shared our physical landmarks.
3. Base line somatic check in
Often when I am in a face to face session, I take my own read on a client’s body and somatic experience. Sometimes I address it from the outset, sometimes I don’t. Because I often can’t see a client’s full body during tele-therapy, I find it helpful to ask the client to check in and let me know what they are noticing. This will usually decide the first point for processing. It may be that they are still dissociated and require further time to orient, it may be that they notice they are not sitting comfortably, or they may be able to delve right into an experience that is rising for processing. The point is, because I am not physically there, this requires conscious and collaborative assessment.
4. Working with resistance
Working with resistance is a powerful therapeutic approach. When engaging in tele-therapy I look out for it even more. There can be resistance to engaging in tele-therapy in the first place. There can also be resistance that rises during the session when a usually attuned therapist is not able to attune to the same degree. In both these cases, there is material that requires processing. Naming the resistance will actually cause attunement levels to increase. The client will really know ‘hey my therapist really is listening and responding’. Sometimes resistance may lead us deeper to developmental wounding. So, I am always sure to explore the emotions and thoughts that come up with resistance, as well as the somatic sensations. It is important to know if this is isolated to the current experience, or if this is a familiar attachment dynamic that requires exploration.
5. Regular re-centering
Because of the inability to have physical neurological resonance, it is helpful to consciously re-centre and re-attune a few times throughout the call. This is especially important for clients who tend towards dissociation as well as for clients who are prone to experience transference and fragmentation. Re-centering can be as simple as asking a client to check in on how they are feeling, notice their breath, or check if they have having multiple streams of thought. I’ll expand on this last one…
6. Identifying fragmentation
When attunement is not deep enough, it is possible that the client may be engaging with you, but thinking something else; whether its that the session isn’t very helpful, or they are running the grocery list in their head! Fragmentation can occur simply from lack of presence, but it can also occur when developmental material or younger ‘parts’ of self are trying to express beneath the surface. Some tell tale signs that fragmentation is occurring during a session include: change in eye contact, a switch into dissociation, a dramatic change in breathing, bracing, noticeable body movements like twitches, scrunching of fingers or toes, tapping or shaking, or other movements that are ‘new’ from one moment to the next. I find the best way to address fragmentation is to verbalise the change I have witnessed, and ask if there is another feeling or thought process occurring. Usually there is. Just by acknowledging the fragmentation, we are on our way to reintegration.
So, as we shift away from physical presence at this time, we may find that we start to develop new deep listening skills. We cannot take our natural neurophysiological responses for granted anymore. As therapists, this is our opportunity to attune more deeply than ever before.