Therapeutic Relationships

By Sonia Heidenreich, LCSW

School-Based Mental Health Therapist, Alameda SBS

Recently, I was beginning a telehealth session and opened my back door to get better reception. “I’m just going to step outside so I can hear you more clearly,” I told my participant, and at the same moment, my (indoor) cat darted out the door. “Oh no, my cat ran outside—I have to call you right back, I’m sorry!” I blurted, and abruptly hung up the phone to chase my cat around the yard. I corralled my cat and called my participant back. Her session proceeded; my cat stayed inside. We laughed about how weird this whole situation is, and moved on.

At the start of a different session, I called my participant at our scheduled time, and as her face came into view, it was clear she was in the middle of completing an elaborate, multi-colored eye makeup look. “I’m only halfway done,” she told me, “so I’ll just show you how I do it.” She taught me how to use a blending brush, which is maybe not the most therapeutic conversation I have ever had, but I also gained new insight about the importance of this daily routine for her mental health.

As the coronavirus has made traditional, in-person therapy unadvisable and we have shifted to providing mental health therapy via telehealth, I have taken what feels like endless trainings about how to get better at this new modality. So much of the focus has been on what we, as therapists, can and should do to orient our participants to this new way of working: encourage clients to set up a private space, make sure they understand the new limitations, figure out how to play games with younger kids through a screen. All of this is very valid and very necessary.

More than these logistics, however, I have found myself thinking about the nature of the therapeutic relationship. Most of us who become therapists do so because we like people and we enjoy the process of forging strong relationships with others. Sitting with a client in an office (or on a park bench, or in a client’s home, or in a classroom, depending on the scope of your practice) is a very different experience than sitting “with” them from across the screen of a computer or smartphone. It feels different. It’s hard to put into words, and for some of us, there might be self-doubt involved with admitting this—if we were only better therapists, would this feel better? More natural? Would our clients be more engaged? Would we feel less strange? I don’t think so.

Being a telehealth therapist does feel strange, and new, and different, and unfamiliar—and that is okay. We are allowed to notice that our sessions feel different, or that our relationships with our participants feel different—because they do. Noticing this is, actually, our job; we are engaged in the process of attuning to our clients, and in that process of attunement, we might be sensing discomfort, unfamiliarity, or shifting boundaries. We are still therapists, and we still know what to do with that information—in the same way we would engage, attune, respond, reflect, internalize, join, mirror, and be with our clients in person, we can and are continuing to do all of work now. It is just that it truly does feel so very different, and our own discomfort may have bubbled to the surface as well.

Many of us—myself very much included—have felt that our relationships with our participants have changed as we have had to shift to telehealth, and this can feel disconcerting, incredibly sad, or deeply frustrating. “How do I do this?” I asked a colleague when this all started. “It feels impossible.” And then I remembered a meta-analysis I had read during graduate school (nerd alert!) that found that the quality of the therapeutic relationship is more closely linked to client outcomes than any specific therapeutic techniques. To quote authors Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357–361. https://doi.org/10.1037/0033-3204.38.4.357

“Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others.”

As we try mightily to preserve the therapeutic relationship via telehealth, we must also allow the relationship to shift. We must trust that we are still engaging with our clients in an “interpersonal process” that is foundational to the practice and art of psychotherapy.

Telehealth is a brave new world, and one that brings with it a new awkwardness (darting cats, frozen screens), as well as a new potential for closeness, and an opening into the real worlds and true lived experiences of our participants. At the same time, our clients are now able to glimpse our lives in a new way, which can feel unfamiliar and strange. Amidst all this strangeness and difference, however, there is a very real possibility for genuine human connection. This, I think, is why most of us chose to do this work in the first place, and it is what can help to keep us grounded in our values in the days (or weeks, or months) to come.

For more information on our work at Fred Finch Youth & Family Services, check out our website www.fredfinch.org