Taking Vagal Virtual

Can Teletherapy Recreate Positive Social Engagement?

Marie-Pierre Cleret

Before Covid-19 upended our lives and practices, I had my first foray into teletherapy with a client who’d moved to Singapore. We’d agreed to hold our sessions over Skype, a technology we both were glancingly familiar with. But despite my willingness to connect in this new way, our first attempt was a miserable failure.

Throughout the call, our faces froze into Edward Munch-like “Scream” masks, and the sound cut out at the most inopportune times. Once, the internet dropped out while she spoke tearfully about her pain over the adoption process she was going through, and she had to repeat herself several times as she tried to convey her frustration at the red tape she and her partner were facing. Meanwhile, I was trying to convey my empathy while containing my own rising frustration. 

As we soldiered on, I began to feel like our therapeutic connection was off even when our online connection was fine; and suspected that it wasn’t just the technical hiccups that were undercutting our work.

Though she was smiling at me through the screen, her smile was less natural and more tentative than usual. I, in turn, felt slightly anxious looking at her. Fundamental aspects of our in-person connection just didn’t seem to be translating from screen to screen.

How We Appear to Clients on Screen

I knew we’d have to put up with the technology to continue to work together, but I was disconcerted by this new hesitation between us. Perhaps there was a way to overcome it. I paused and asked if she’d humor me. “I want to test a hypothesis,” I told her.

First, I had her turn off her video, so I no longer saw her face but still heard her voice. I then focused my gaze on the camera at the top of my screen. 

Instantly she sighed.

“What is it?” I asked.

 ‘You look like you again!’ she laughed.

"How so?”

“Your face, it’s relaxed. The way it usually is. More open and connected to me. Maybe more focused?” 

We then experimented with her turning her video on and off again, and me moving my gaze between the camera and the screen. Each time my gaze went to the camera, she said I looked like me again, and she felt better and more connected. But each time I looked at her when she came back on the screen, she felt a disquieting sense of emptiness. She said my eyes looked “hooded,” and our connection evaporated.

Then it was my turn to study my experience in the moment. When I was looking at the camera with her still on the screen, there was a tightness in my gut and I could feel myself holding my breath. “I can see tension on your face and you seem preoccupied and less attentive to me,” she told me.

Taking Social Engagement Online

Neuroscience researcher and psychiatrist Stephen Porges proposes that during each stage of our evolutionary development—reptilian, mammalian, and now human—we’ve developed a specific way of gauging and responding to safety and threat in our environment, and then regulating our emotions in kind.

His Polyvagal Theory demonstrates how our nervous systems continuously scan faces for visual cues of this safety or threat. We pick up on tension around the eyes, pupil dilation, muscle patterns around the nose and mouth and jaw, facial expressions, and posture and gestures. We also automatically assess vocal tones for tonality, prosody, and pace. We are forever evaluating this elaborate set of data to gauge whether we can relax with one another.

This body-to-body way of relating happens through what Porges calls the social engagement system, and for our dealings with others to go well, our system, and theirs, needs to hum.

When we look at in-person therapeutic experiences, much of this social engagement work involves the therapist regulating the client’s emotions through their embodied presence and nervous system. The entire time we’re in each other’s presence, both client and therapist are gauging threat and safety through cues from each other, directly picked up through the nervous system and placed into a continual feedback loop.

With my Skype client that day, I still hoped to help regulate her dysregulated emotions through my own emotionally regulated presence, virtual as it was. Indeed, she was able to assess my pupil dilation, the muscles around my face, my nose and mouth, and my jaw; as well as listen to my vocal cues.

In relinquishing my own capacity to visually gauge her nonverbal visual cues by focusing my gaze on the camera, I believe I was more able to give her an approximation of what she would have experienced with me had we been in a room together. What I knew about Polyvagal Theory had me suspecting that without the competing stimulus of her face on my screen, my gaze could be directed softly at the camera, and I could devote my attention to her voice, her tonality, prosody, the pace of her words and her breath. This adjustment seemed to work for her.

We decided this would be how we’d go forward, and we managed some sessions this way. There were times when I was still tempted to look at her face on the screen while we talked. But I resisted by reminding myself about the importance of helping her stay in ventral vagal—the state of calm Porges has identified as the one that helps our therapeutic connections hum. 

Vagal Stress

I was determined as we went forward to make myself look into the camera as much as possible and create the simulacrum of gaze-to-gaze connection for my client. But it wasn’t long before I found this process exhausting. I found trying to discern fine facial changes in tone, skin color, micromovements and microexpressions in a context of pixelated images very tiring. Dealing with the asynchronous visual and auditory communication and communication disruption and dropouts on our devices only added to the stress.

Still, given what my client and I had to work with, I reassured myself we could maintain enough therapeutic alliance to create healing. But this effortful, left-brain driven work, made it harder to be present and connected to my embodied experience, and my own right-brain communication. I felt myself more stilted as I tried to work without gaze-to-gaze communication, and the rich material it generates. Nothing I came up with seemed to compensate for that loss. 

On top of all this, I began to suspect that it would always be inherently difficult for my client to truly achieve ventral vagal through a computer. After all, we’ve been conditioned to consider computers work tools or recreational devices, not therapeutic mediums we can readily associate with internal experiences.

It’s Not the Same

Now that we’re all working this way during COVID, some clients have told me they’ve gradually stopped having contact with family and friends over Zoom and FaceTime. They’ve said, “I don’t think it’s worth it,” “It’s not the same,” or “I can’t be bothered.” When I ask them if their experience of me looking at their image on the screen has the same not-the-same effect, they tell me yes.

I’ve begun to worry that in our headlong rush to embrace teletherapy, we’re going to train ourselves out of expecting the depth of connection and intimacy that we receive from body-to-body, gaze-to-gaze, in-person communication. In doing so, we may come to settle for an impoverished version of intimacy and connection; one that could even spill over into our lived, in-person relationships.

Let’s not forget that this conscious, effortful, left-brain focus on trying to get our connection right over computers, disconnects us from our own embodied experience. These days, I feel a sense of emptiness and profound disconnection after a day of “performance” on Zoom, knowing it to be largely a simulacrum.

In the world of business and education, exhausted workers all over the world enduring endless Zoom meetings know it doesn’t remotely approximate in person communication. Though better than no therapy at all, teletherapy is an invitation to clients to not really be present in yet another facet of their lives. This is troublesome for clients and the field, which has long been one of the only places people can receive another’s undivided attention in a safe place. Let’s be honest about that and stop promoting teletherapy as the next big thing.

***

Marie-Pierre Cleret, MSW, has been in private practice for over 30 years; she works with individuals and couples, emphasising embodiment as a key to healing. She lives and works in Sydney, Australia.

Photo © iStock/Tero Vesalainen

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Topic: Professional Development

Tags: 2020 | Alliances | body | body and mind | connection | connectivity | emotion | emotional connection | emotions | online | online therapist | online therapy | polyvagal theory | rapport | Stephen Porges | technology | therapeutic alliance

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5 Comments

Saturday, October 10, 2020 6:00:08 PM | posted by Gillian Solomon
Teletherapy has to have carefully structured guidelines, be mindful of the issues that make not being in the same room quite different. Often folk arrive late in pyjamas . Just unprepared , as it’s different it’s regarded as being very casual. Respects the privacy of the session. That there aren’t other people coming and going. To stick to professional guidelines during the therapeutic hour. To take,the usual data set, to give feedback, ask for it .to ask carefully worded open questions , look carefully for physical responses and leave pauses for affect. To listen, to make sure you know what is being said . To clarify if you aren’t sure. To ask about emotional responses . To ask that the clients look into the frame , be ready on time. That the session is treated as being confidential. That the pacing is kept in line with an online format . The same case conceptualisation and collaboration needs to be respected and used. I have conducted many online sessions , most are very much the same format as normal treatment . A safe therapeutic relationship can be developed. It’s true face to face offers additional benefits. But online is very successful too. Provided one keeps notes, uses them and tracks what’s happening and prepares properly.,

Sunday, August 16, 2020 2:35:40 AM | posted by heather-rose
thank-you Marie-Pierre: absolutely spot-on. yes, zoom etc is a "something", and in some situations is is unequivocally way better than a "nothing", but not necessarily in the therapeutic endeavour. Marie-Pierre points to some possible harms, and some consequences which may not be limited to the individual therapy encounter. i totally agree.

Sunday, August 16, 2020 12:08:26 AM | posted by Didi Rowland
I felt so much relief after reading this! Much to my dismay I have been reading about teletherapy being touted as "the next big thing". I work with children and their parents and it has been mostly via Zoom for the last five months. I've been carried around the house and up and down stairs on kids' Ipads. One five year old even "took" me to the restroom with her before I knew what was happening and plopped me down on the floor next to the toilet. I long to be back in my office and my clients tell me that they do, too. Of course teletherapy is better than no therapy, but the connection (emotional and virtual) just isn't enough for many of us.

Saturday, August 15, 2020 1:19:46 PM | posted by Courtney Pessa
I could not agree M-O-R-E! I’ve tried to make piece with our new Zoom-era but I can not. I can’t accept that freezing faces & dropped connections are the new norm. In fact, I’ve become depressed myself at the lack of emotional contact I have with my clients anymore. Body language is everything to me & now I see just a client’s head that only tells me 1/4 of the total story. Adaptation=survival, I know that. But, after knowing what’s most efficacious for years and years and having honed my skills such that I’m confident in my abilities, this is a disaster. And NO. It’s not the next big thing! Grateful to all who feel this way, too. I’m thinking Support=Survival.

Saturday, August 15, 2020 12:18:12 PM | posted by Tom Bunn, LCSW
It's great you know about Steve Porges. He wrote the "Afterword for Therapists" for my book on exercises that train the mind to automatically activate vagal braking when stressed. The book is "Panic Free." Vagal braking controls panic five times more effectively than CBT.