Thank you to everyone who responded to our May Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
May Quandary: I’m offering teletherapy during the coronavirus pandemic, which is working well for most of my clients. Sam, however, who is extremely anxious and suffers from panic attacks, has repeatedly told me that our video sessions aren’t effective because he doesn’t feel grounded enough to work on his issues when I’m not physically in the room with him. How can I change this and the boost the impact of my teletherapy sessions with anxious clients?
1) Cultivate Agency
I can imagine how stressful and frustrating it must be to hear this client say that teletherapy sessions aren’t working for him. It’s easy to get drawn into our clients’ struggles and feel helpless too, especially now that we’re also experiencing uncertainties and anxiety about our loved ones.
I generally find that people with anxiety tend to struggle with feeling anchored or grounded. I wonder if it might help to start Sam’s sessions with 5 to 10 minutes of grounding exercises. This could help him tune into his body, especially tactile senses, like feeling the texture of the chair he’s sitting in or focusing on his feet on the ground, keeping him anchored.
This therapist might also try what I call the 5/4/3/2/1 exercise, where the client looks around the room and identifies five things to see, four things to feel, three things to hear, two things to smell, and one thing to taste. This could help Sam shift his focus from his worried thoughts to the body, and make him more relaxed. As Sam gets used to these relaxation exercises, his therapist might also suggest that he add in something like lavender oil or a vanilla-scented candle—both aromas which help induce calm.
After first calming Sam’s physiological responses to anxiety, I’d advise that the therapist next help Sam name and acknowledge his emotions, which could help him regulate them down the road. Making a list of his fears with him, each assigned a number on a scale to gauge its impact, can also put things in perspective. Giving a shape or form to anxiety can help clients feel like they have agency over it.
Sukanya S., family therapist
2) Ask: What’s Different?
Once, I used a coaster with a client as part of a gestalt experiment, and he actually asked if he could bring the coaster home to remind himself every day of that session and what he’d learned there.
Since Sam is anxious without his therapist’s physical presence, I’d suggest that she send him some kind of grounding item from her office so he can always feel her there. It could be a pen, a coaster from the office, a mug, or simply a handwritten note with something written on it like, “Together, we are stronger than anxiety.”
This anxiety at not having the therapist around could also be something to explore in more depth. Sam’s therapist could ask something like, “What’s different when I’m with you physically? How does that support you differently than when we’re doing therapy online? How am I different? How are you different? What’s changed? What did you get from me in regular sessions that you don’t feel you can get in teletherapy?”
If Sam feels he needs his therapist’s physical presence to feel grounded, this could be explored as well, through questions that examine whether someone wasn’t present for him at some point in his life when he needed them most. Perhaps there’s an underlying trauma here.
Vildana Efendic, EAP-certified gestalt psychotherapist
Sarajevo, Bosnia and Herzegovina
3) Have Fun
As many counselors and therapists find themselves providing phone or online sessions, I too have been curious about how to best engage clients in the most helpful and healing way. With so many unknowns, we can find home environments difficult to navigate, encouraging us to become more creative and adventurous in how we work and connect with clients. This may include having to prompt clients to find private spaces, and developing new rituals for beginning sessions, including similar greetings and wording from the therapist, as we all learn together to find new best practices.
Over the past few months, I’ve begun to invite clients to meet with me, over the phone or video, in comfortable places of their choice. For some, this means in their own homes, allowing me into a space that they may feel uncomfortable sharing. Although I tell clients to find a place they feel open to sharing, I also tell them I understand wanting to keep their home private, and that I’ll honor that. This has resulted in therapy sessions outside, on balconies, on walks, in parked cars, at favorite park benches, and other outdoor spaces. One client meets with me on the riverbank by his home, which allows us space to be mindful, practice grounding, and explore nature in a way that opens up new pathways for healing. I’d suggest Sam’s therapist suggest some of these alternatives to video chatting in the home to see if they help.
We can offer other invitations to anxious clients too, like preparing a cup of tea or coffee together (each at our own homes), listening to calming music together while doing mindfulness exercises, or asking clients to bring specific items to sessions, like pets, blankets, stuffed animals, and other personal items that they may not normally use during in-person sessions. Sam’s therapist could also help bring down his anxiety by suggesting they share an experience together, like tasting chocolate, or a slice of lemon, orange, or grapefruit—anything that connects both people with the here and now. I’ve even worked with a client who shares my love of sharp cheeses, which we tried together during virtual sessions. With another client, who wasn’t feeling connected in our online sessions at first, I suggested we try hunting for household items together, like food items, dry tea, and herbs.
Carla Pauls, Counsellor, BA, MC, CCC, CHyp
4) Create a Shared Space, However You Can
As with all clients, different things work for different people, but here are two things I've done in the past to help anxious clients feel more safely connected and grounded, both in and outside of sessions.
First, I suggest doing calming mindfulness, slowly and gently guiding the client in checking in and connecting with what anxiety feels like in this moment. Where does Sam feel it in his body? Have him close his eyes, switch to belly breathing, and ask how he feels in his torso and stomach, where the breath resides. Belly breathing activates the parasympathetic nervous system. From there, clients can better isolate the thoughts causing anxiety.
Second, I suggest doing visualization or active imagination exercises. Ask Sam to place his feet on the floor, close his eyes, and imagine you sitting in the room across from him. Ask him to locate you in that space. Once he's there, ask Sam what it feels like for him. If he feels a bit calmer, continue to have him sit with this experience for a few minutes, just to let his nervous system integrate this felt sense of safety. Let him know that during teletherapy sessions, or any time between them, he can close his eyes and imagine you being in the same physical space where he is.
Danielle van de Kemenade, counselor
5) Validate, Investigate, Facilitate
It sounds as though Sam could benefit from some mindfulness techniques. If his therapist has already used them during in-person sessions, doing them online should be an easy transition.
If I was Sam’s therapist, I’d begin by acknowledging that Sam has awareness of how grounded he is, which is a great strength to utilize during our sessions. In my mindfulness-based approach, I might say something like, “You've noted that you don’t feel as grounded during teletherapy. What does grounded feel like for you?”
Once Sam has established what grounded feels like, he could begin to embody that through mindfulness techniques, and we’d have a baseline for assessment. Next, I’d encourage curiosity by asking him questions: What helps bring him get grounded? What challenges his ability to ground himself?
Getting to know the parts of Sam that either contribute to or block his groundedness can help us stay mindful and connected while we work together. I’d make a point of dedicating session time to mindful internal exploration, while also encouraging him to stay aware of physical sensations that may arise. For instance, I might ask, “When you imagine a time where you’ve felt fully grounded, what does your breath feel like? Is it deep? Shallow? How does that compare to your breath when you aren't grounded?”
Mindfulness techniques are a fundamental pillar in my work. They’re user-friendly, and put the client in control of his or her healing. The clinician, meanwhile, is simply a facilitator. By assigning mindfulness practices Sam can try at home—and there are plenty of examples easily found online—he can feel more empowered and less anxious, with or without his therapist.
Emberleigh Luce, LMFTA, CCTP
New London, CT
Next Month’s Quandary: The transition from in-person to video sessions was a bit bumpy, but I ultimately found my footing because I was still able to make eye contact with my clients, notice their subtle expressions, movements, gestures. Many of my clients, however, have been requesting phone sessions. I want them to feel comfortable, but without those visual cues I feel hindered as the therapist. What are some tips and strategies that might make phone sessions just as effective as video sessions?
Photo © iStock/simonapilolla
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