Therapeutic Alliance Over FaceTime

Therapy in COVID-19

Source: Photo by Volodymyr Hryshchenko on Unsplash

When fellow therapists learn that my entire practice is online, I usually get a look of surprise, followed by the inevitable question: "But doesn't that take away from the work?" Years of experience have confirmed the answer to that is a definitive "no." Providing virtual support during a global crisis like the COVID-19 pandemic is necessary to continue the work with our clients, work that is even more important during this time of collective heightened anxiety and stress.

I frequently hear concern that clients will not continue with virtual sessions, and that this limitation in the work will lead to the end of a therapeutic relationship. This doesn't have to be the case. Here are some useful ways that I have found to make the transition reflective of the great work you already do in your office.

Continue building your therapeutic alliance

• There is no need to overly apologize for the transition to virtual work. This is not a loss for your client; this is an important opportunity for people to remain connected and continue with the work during a time that might otherwise feel quite stressful and alienating for your client.
• A meaningful way to frame this is by expressing your continued dedication to your client through offering comfortable, safe, ongoing, individualized online care. Let your client know how much you value the work and your enthusiasm for continuing it virtually. You can do this in session or in an email, making room for any type of response the client may have.
• Don't make the transition a big deal. It doesn’t have to be and may reflect your uncertainty more than that of your clients.
• Feel empowered to continue delivering care in your typical style. It's normal to feel an increase in anxiety when conducting virtual sessions for the first time, and it can be easy to conflate the new conversational cadence in this format with a clinical problem when this is not actually the case. Learning to adjust to a different setting can actually be a wonderful opportunity to renew our attention to the importance of the therapeutic link we have with clients, seeing that strength highlighted in a new way.
• Use a problem or interruption with the connection in session to provide a new opening to process reactions, acknowledge transference, reflect your feelings if clinically useful, and repair together, deepening the work.
• Acknowledge potential unplanned changes in treatment through a written safety plan you can share with clients. Include any changes necessary if the session is not happening in-person. For example, if a client requires a connection to a higher level of care, and you would normally do this from your office, outline a different way to support this circumstance from their home.

Make the Most of Your "Home Visit"

Generally, your client will be taking your session somewhere in their home. This is a powerful opportunity for you to experience some of what you talk about in session in real-time with your client.

• Imagine your client struggling with insomnia and difficulty with nighttime anxiety who may have listened when you suggested mindfulness or restorative yoga practice in session, but who had trouble implementing this outside of your office. What do you learn about your client's space? Join your client in practicing what this would really look like in their actual home during your session. Listen to your client's feedback, and adapt recommended interventions accordingly.
• Use the client's comfort in their own home to practice different skills that may be less achievable in an office. If you use any guided mindfulness, meditation, or somatic techniques in your work, allowing the client to find the space that feels comfortable for them, to use their own pillows, blankets, and any objects of comfort to help, can be really powerful. Do you work with OCD and use exposures? Use this opportunity to join your client in this work in their home.
• Be open to anything your client may want to share about their home environment. This is a great way to learn more about who you've been working with. Be curious—what might your client be unconsciously sharing with you about their space?
• Pets! In-home therapy animals. My clients respond really well to having their cat or dog pop in and out of session or even curl up on their lap when talking about particularly difficult topics.

Take care of your client by making the tech comfortable

• Create a clear, organized email that has all the necessary instructions for your client to access services, including links to the HIPAA-compliant video platform of your choice. Bullet points are your friend here. Practice first by logging on to the platform as if you were your own client—include instructions based on your experience. Helpful information includes: Does the client need to provide any demographic info? Can they access the video platform on their phone or just their computer? Do they need to download anything first?
• Have a video platform backup. Frequently tech doesn't work the way we intend. Have two video platforms available so that you can switch if needed. Provide this information to the client in the email you send. This is comforting, provides structure and safe boundaries, and lets clients know you care.
• Plan for your first virtual session to start five minutes early. It might take the client some time to get things sorted on their device, and it really helps to have this time built-in, so the session doesn't feel rushed. Demonstrating patience and flexibility through something as small as adding in time during this first transition session can create a new space to deepen the therapeutic link.
• Add a section to your consent form around teletherapy that your client can electronically sign. Outside of this being best practice, this is a good reminder to all of the client's agency.

Get creative

Expanding the ways we are able to connect with clients also opens the door for innovative ways to engage in our work. Experiment with a shared online journal, have your client securely email you an art therapy exercise, try having a session in which your client is able to be by an open window, or even outside in a safe and private space by a patio or balcony if the weather is good.

This is a unique opportunity for you as a skilled clinician to truly meet the client where they are. The online support you provide today can make a profound and lasting change in your clients' lives.

Copyright Laura Federico Holistic Therapy 2020