Providing relationship-oriented psychotherapy during COVID-19

COVID-19 has created a world in which physical distancing is either required or recommended. The emotional distancing that accompanies physical distancing can disrupt relationships and lead to isolation and loneliness, which heighten the impact of existing emotional distress and mental health issues. A psychotherapy relationship can be an essential part of managing the impact of isolation during the pandemic.

Videoconferencing and other virtual tools we have during stay-at-home orders, or safer-at-home approaches, are important for maintaining existing therapeutic relationships and for forming new ones. At the same time, these tools aren’t perfect, so psychotherapists should be aware of and attend to the imperfections, for their own sake and for their clients.

Consider these tips when providing relational therapy via telehealth to your clients during this time.

Rapport represents a close and aligned connection reflecting an alliance and agreement on the tasks and goals of the treatment. The client feels safe, respected, and understood.

A key component of the crucible for psychotherapeutic change is the trusting connection between client and psychotherapist. Privacy and confidentiality are essential for fostering openness and trust.

Ensure that both you and your client have secure video connections and are in private physical spaces where you can’t be seen or heard by others who are not part of the relationship. Children or spouses coming in and out interrupt the trusted connection.

You are also entering each other’s space in a new way. You and your client will gain new and different information about each other based on the space in which you work. Pay attention to the impact on the connection.

Accurate attunement to the unfolding experience of both you and your client gives you the foundation you need for responsive matching and mirroring of your client’s emotional experience. Matching and mirroring isn’t copying; it is back and forth communication of physical and emotional attunement — postures, gestures, rhythm, energy level, and voice tone.

When two people are attuned to each other, they automatically reflect what they are seeing and hearing from the other person. Flat screens, distortions, and delays alter the input and interrupt the synchronicity of responsiveness. Eye contact, which is a vital source of information, is dysregulated. Facial cues and whole-body information are missing or flattened.

The missing or distorted information can’t be made up but must be taken into account. You should make special effort to bring those experiences that are often outside of awareness into conscious awareness and discuss together the impact of the disconnections.

As the practitioner, you need to rely on empathy to help you bring the experiences to light. Empathy includes both conscious perspective-taking and automatic and bodily-based emotional processing. Conscious perspective-taking is a largely cognitive process, which is especially important when the non-verbal sources of information are less available or are distorted, as happens with virtual treatments.

Clients may be disaffected, dissociated, and “down regulated”, which also makes them harder to read in both verbal and nonverbal ways.

For the practitioner who is accustomed to eye contact and regulation of closeness and emotional processes through fine attunement to nuances in voice tone and body sense, telehealth can feel tiring and incomplete. It is important to watch for burn-out, detachment, and sluggishness.

Tiredness is common with virtual treatment. You are working harder to capture and reflect the nonverbal aspects of the treatment and use them for empathic connection.

You may also find yourself working harder to bring the nonverbal and nonconscious aspects of the relationship into conscious awareness and use them more explicitly in the treatment.

Because of the pandemic, you, too, are experiencing disruptions in the relationship with your client(s). You may also be feeling the impact of isolation and emotional distancing.

During this time, it is important to protect boundaries between home and work and to allow yourself time to transition from clients to family. Get exercise, eat well, and get enough sleep.

If you are finding yourself overtired, sluggish and burning out, remember what the airlines tell us every time we fly — put your own mask on first, then help others. Make time for self-care so that you can be effective in your own work.