Therapeutic Presence: The Critical Component in Providing Relationship-Based Services Via Telehealth
By Jennifer DeSchryver, PsyD, IMH-E®
COVID-19 has dramatically shifted how we provide clinical and supervisory services to families and mental health practitioners. Home- and office-based in-person meetings have been replaced with video and telephone calls. Never before has the idea of “how we are is as important as what we do” in our clinical work been so important to remember (Pawl & St. John, 1995).
In this time of social distancing and subsequent provision of services via virtual formats, we are challenged to discover new ways of being present over a screen or the telephone.
We have been tasked with figuring out how to hold onto our core ways of being with others while at the same time to let go of ideas of operating under the premise of “business as usual.” We have had to pull all of our resources for creativity, compassion, flexibility, and adaptability to the forefront of our work over the past several months and the unknowable future for many of us. Meeting virtually no longer seems like a temporary arrangement to help families, but has become part of the fabric of how most of us are working for the foreseeable future. A central challenge before us remains: How do we embody relational principles of “how we are” over a screen when meeting with families and supervisees so that they can experience feeling truly met with by us?
How We Are
Of course we should always strive to consciously embody how we are with others in our clinical work; however, working virtually demands that we be especially mindful of fully and authentically embodying our “how we are” to share with others over a computer screen or the telephone. Our “how we are” includes being fully present, emotionally regulated, safe, reflective, and focused on the centrality of relationships (Pawl & St. John, 1995). We must strive to be open and responsive to each individual’s experience of sheltering in place; tolerate and organize their feelings as they ride an unpredictable emotional roller-coaster; create a sense of safety in being together in whatever way might be available at any given time; continue to seek understanding of how behaviors, feelings, and thoughts shift in response to how things are in the home and the outside world, and keep in mind the critical importance of having a safe and trusted relationship in which to feel held, no matter the format in which it is experienced.
As we stretch to find new ways of maintaining a sense of connection during this time of extended social isolation, we must consider how to help others feel held in mind; to know that they are not alone as they navigate through this frightening time under such extreme stress, pressure, and vulnerability. It is the felt experience of being held in another’s mind that is especially salient here. An important aspect of being held in another’s mind includes being “spoken to over distance … tethered across space and out of mutual sight” (Pawl, 1995, p.5). A sense of connection is created by being consistently held in another’s mind, which is by definition a way to sustain that sense of “not-alone” when physically apart from one another. Current research suggests that irregular, brief, unscheduled contact with clients can strengthen the therapeutic relationship and lets them know that they are in your thoughts even when you are not meeting at a scheduled appointment time (Caldwell, 2020). A quick text to check in with parents or supervisees may be important to consider during these unpredictable times. Of course there are a host of valid clinical reasons to think this option through carefully in reflective supervision, and it may not be appropriate for every family, but from a relational perspective, it may be an important option to consider to help others feel held in mind during extended periods of quarantine and social isolation.
The concept of therapeutic presence is one that not only cuts across theoretical orientations as one of the most fundamental requirements for effective clinical work, but it can also cut across mediums in which therapeutic services are provided. Therapeutic presence is defined “… as having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels — physically, emotionally, cognitively, spiritually, and relationally” (Geller & Greenberg, 2012, p.7). Bringing our full presence to a virtual encounter with a family or supervisee is essential to creating and sustaining the sense of being together that we might otherwise take for granted when meeting in person. By bringing our presence in an open and receptive state and then consciously focusing our sustained and sensitive attention on others, we are able to help them “feel felt with” by us (Furman, 1992; Siegel, 2010).
How do we access our presence and capacity to attune to others when working virtually? We need to actively protect our ability to attend from any outside distractions — phone silenced, email and text notifications on the computer turned off — and to have a designated workspace from where we can sit comfortably. It can be helpful to find a few quiet moments before a session to anchor your feet firmly on the ground and take a few deep breaths to clear your mind so that you can be in that open and receptive state from which you can then consciously turn your attention and attune to the people you are meeting with on the screen or on the phone.
In relationship-based work with families, we aim to bring our therapeutic presence and subsequent attunement to multiple relationships and the complex, interconnected experiences of the parent, child, and provider. We strive to support parents in their relationships with their children and to help strengthen the attachment between them, and offering our presence is a necessary aspect of this process. Siegel and Bryson (2020) emphasize the importance of presence in parenting, what they refer to as a parent’s capacity for “showing up,” and how parental presence is a foundation for developing a secure attachment relationship between parent and child.
By keeping in mind the centrality of presence in fostering healthy relationships and secure attachments, we can strive to provide this relational presence with the clients and supervisees with whom we meet.
Self-Care and Self-Reflection
We can only embody our “how we are” and offer our full attuned presence when we also prioritize our self-care. We need to actively seek out the support we need in order to be truly and fully present in our work with others. Being present for and with others is an active, emotional labor, and being present with others over screens can be even more emotionally labor-intensive. When we are with others in person, we are able to make use of subtle, non-verbal cues that we are not even consciously aware of. We can see the whole person in their whole environment, which allows a more relaxed presence to unfold.
Over a screen, we have to work harder to project our presence to be felt by others. We may end up feeling depleted and exhausted by Telehealth sessions in ways that we didn’t anticipate.
For these reasons, we need to pay close attention to how we schedule our appointments, give ourselves breaks from looking at screens as needed, and be mindful of how we refuel ourselves when not working. In other words, how do we practice self-care?
Self-care can look different for each of us — it can be about finding ways to connect with others or with nature, creating time to get lost in a book, moving our bodies, meditating, practicing yoga, talking with trusted colleagues, and/or meeting with our reflective supervisors and consultants. “Self-care is any action you purposefully take to improve your physical, emotional or spiritual well-being. By making time for self-care, you prepare yourself to be your best so you can share your gifts with the world” (Brownn, 2020).
We need to be mindful of how the change in the contextual frame in which we operate impacts ourselves and our clients and supervisees: how virtual ways of being together can initially feel uncomfortable or awkward, how the felt experience of being together might shift in both tangible and intangible ways, and how our relationships with others might be influenced over time. I would suggest that it is only after we wrestle with and accept our own experience can we then invite supervisees and parents to join us in being curious about how these same shifts impact themselves, their children, and the relationships between them. We need to appreciate what is being asked of all of us — supervisors, direct service providers, and families — to gently and compassionately “name it to tame it” (Siegel & Bryson, 2011) in order to help internally organize the experience for each of us during this unpredictable time in the world, so that all of us have the opportunity to feel held in the mind of another.
Some of our “what we do” needs to be adjusted and altered when working with families over video or telephone, but our “how we are” is a constant, no matter the format we use to meet with others. We truly can offer these ways of how we are in relationships — our therapeutic presence — whether we are meeting with clients, supervisees, and/or students, and whether we are meeting them in their homes, in offices, or over computer screens or the telephone. These ways of how we are with others are as important, if not more, than what we do, and thankfully are not defined by our physical proximity to each other, but by our embodied ways of being fully and therapeutically present when we meet with one another.
Brownn, E. Retrieved May 4, 2020, from http://www.eleanorbrownn.com
Caldwell, B. (April 15, 2020). The Value of Between-Session Contact. Simple Practice. https://www.simplepractice.com/blog/contact-helps-therapeutic-relationship/?utm_medium=email&utm_source=sp-blog&utm_campaign=20200417-paid-trial-leads-blog-update-value-between-session-contact&utm_content=body-link-3-sp-blog-post
Furman, E. (1992). On feeling and being felt with. The Psychoanalytic Study of the Child, 47, 67-84.
Geller, S. M. & Greenberg, L. S. (2012). Therapeutic Presence. Washington, DC: American Psychological Association.
Pawl, J.H. (1995). The Therapeutic Relationship as Human Connectedness: Being held in another’s mind. ZERO TO THREE, 15 (4), 1, 3-5.
Pawl, J. H. & St John, M. (1995). How You Are Is as Important as What You Do. Washington, DC: ZERO TO THREE.
Siegel, D. J. (2010). The Mindful Therapist. New York, NY: W. W. Norton & Company.
Siegel, D.J. & Bryson, T. P. (2011). The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind. New York, NY: Delacorte Press.
Siegel, D.J. & Bryson, T. P. (2020). The Power of Showing Up: How Parental Presence Shapes Who Our Kids Become and How Their Brains Get Wired. New York, NY: Penguin Random House LLC.