Raise your hand if you’re vacillating between radical acceptance “It is what it is. This is the current reality and I can adjust. What I do in this moment is all I have control over and that is okay” AND completely freaking the f@#k out “This is all happening too fast. I didn’t sign up for this. I just want to curl up in a corner and suck my thumb and cry!!!”
Okay, yup, me too!!
So, here we are. COVID-19 is what it is. Many therapists, dietitians, and clients are having to adjust to telehealth rapidly without the typical setup time one might have to prepare for a big change and without their necessarily having wanted to transition.
Teletherapy offers so many wonderful features and, in my experience with it, there are some interventions that actually work better via telehealth than they do face to face (IFS Parts mapping, for example). But, for clients new to meeting via a virtual platform, the novelty, physical and geographic distance, and electronic disconnect of not being in the same room and breathing the same air as the provider they are attempting to attune to, the experience may feel dysregulating and triggering. At least, at first. This may be especially true for clients with histories of complex trauma or event trauma, for whom unclear boundaries, lack of information regarding exits, and virtual communication may feel unsafe.
Like the many therapists, dietitians, and other healthcare providers around the world, our team at Three Birds Counseling has had to transition all of our clients quickly to a telehealth platform. Though we already saw many of our clients via telehealth, we have many clients who are brand new to it. I hope the following tips may help your clients experience more grounding during their telehealth work with you. In addition to the tips below, your clients may benefit from the described grounding techniques that can be found here.
1. Offer a tour of your location
If you’re doing telehealth from your original therapy office and your clients have been in that space before, this may not be as important but if you are meeting with your clients for the first time in a separate location--perhaps your home bonus room or garage--it may be helpful to offer your client a tour of the space you are in. This is similar to an intervention I call Tracing Your Boundaries that I often do with clients who feel dysregulated in a new space (e.g., my therapy office, their new work office, a new apartment, etc). To offer a tour via Telehealth, simply take your computer camera and slowly rotate it around the perimeter of the space you’re in so that clients can see where you are located and feel a greater sense of boundary around the two of you, even if separated by great geographic distance. Teen clients and I have had a good laugh about the pile of clean laundry on the bed to the side of me or stack of legos on the floor and the opportunity to see where I am and what I am surrounded by deflates some of their fear about the unknown.
2. Begin with the here-and-now
Similar to face-to-face sessions, beginning telehealth sessions with an invitation for clients to connect with the present moment is a wonderful way of slowing down their often hyperaroused sympathetic state.
You might do this by asking them to state and finish the following prompts:
I am here.
I am here with you.
It is (time) on (day of week), (date).
I am in my (location).
My feet are touching _______.
My breath is coming in my (nose or mouth) and leaving out my (nose or mouth).
Another way to connect the client to the present moment is to invite them to look around their physical space and find 3 things they have not seen before--a discoloration of paint on their wall, a piece of wrapper on their car floor, a frame that is slightly askew.
A third way of bringing awareness to the here-and-now can be through awareness of their breath--inviting clients to notice their breath, to notice the qualities of their breath (e.g., temperature, smell, length, difficulty level, etc.), to do deep cleansing breaths, to play around elongating and expanding their breath. You can find a couple breathing exercises here and here.
3. Invite them to find the floor
Wherever your client is and however they are situated (sitting, laying down, etc) during session, invite them to locate the floor and/or their feet. This could include inviting them to take their shoes and socks off to add a more heightened sensory input. Invite them to notice what the floor is made up (concrete, carpet, wood), what is feels like (cold, warm, rough, smooth, textured), and how it feels to press down against it. If they don’t want to or can’t remove their shoes, invite them to notice how their feet feel inside their socks and shoes. If they’re laying down, ask them to bring their attention to where the floor is (and where the earth is if different from the immediate surface below). How far away from the floor and earth they are, what they are made of, etc.
4. Invite them to create their own sensory basket
In our offices, we keep a large basket of sensory/fidget/grounding tools, some of which you can see here, and we often encourage clients to create their own sensory/grounding basket of items to use at home. If your client has a basket already made, invite them to have it nearby for your virtual session. If they don’t have one, invite them to create one. Dedicating time to create their own sensory basket of items can be a fun, grounding endeavor, in of itself. And then they will have that basket of sensory items available for times when they need to access them! Some of the items in our baskets, we bought on Amazon (search sensory or fidget items), some we found at the dollar store, some came from treatment centers, some were borrowed from our children’s’ toys, and some are random items you might find around the house (tin foil, pieces of fabric, bottle caps). If your client can’t get out to the stores right now, that last option can work just fine! Encourage them to have items that can engage all of the senses in different ways. Not pictured at the link above are our diffusers, candles, and pieces of chocolate to engage the smell and taste senses, and our couches, pillows, and blankets that are intentionally of a variety of soft or textured fabric. Consider inviting your clients to have blankets and pillows available and even to dress in clothes that feel grounding. They may even get a kick out of you letting them know you’re in pajama pants, yourself! Many of our clients will grab an item or two from our or their sensory basket while they are processing trauma or tackling a new and difficult trigger food, helping them experience more calm, integration, and grounding.
5. Let them know how to hide their face if seeing themself is too distracting or dysregulating
For some clients, the default settings of the videoconferencing program you’re using may be too distracting or dysregulating. We find this can be especially true for many of our clients for whom internalized fatphobia and body dysmorphia may be part of their presenting concern. Most videoconferencing programs will include a setting that can hide their face during the session, so that all they see is your face. If you’re using Zoom, instruct them to click the top right corner of the video box of their face. On the menu that appears, there should be a choice for “Hide Yourself.” We’ve found the best way to introduce this feature is to include it as part of your introductory housekeeping about telehealth (i.e., “It helps to wear headphones to reduce buffer noise, connecting to ethernet can improve the connection, here’s how to hide your face if you just want to see my video.”). This way, you avoid sending an inadvertent message that they *should* hide their face. For some folks in eating disorder recovery, working on increasing their comfort and exposure to looking at themselves in neutral or affirming ways can actually be a helpful intervention to co-construct; here's one exercise that may help your clients work on that.
6. Use the share screen feature
One of the benefits of teletherapy is the ability to share the screen, which can provide grounding in offering clients an alternative to straight talk therapy. Think about this as a virtual whiteboard. You can share a blank word document and map out behavior chains or IFS parts. You can share a worksheet on a particular topic you’re working on. If you have GSuite, you can use Jamboard with your client (share a private link beforehand), working together to draw together, play games, map out family relationships. You can also engage your client in art therapy with Jamboard. There is nothing inherently wrong with straight talk therapy (and I’d advise against including gimmicky interventions just for the sake of doing so) but keep in mind that teletherapy can make a client feel even more focused on and exposed than in your therapy room, where it’s easier to let go of gaze, focus elsewhere, and experience more physical space than just the 19 inch screenview you’re sharing.
7. Acknowledge: “This is different and that is okay.”
This tip comes from Three Birds’ provider Lindsey Umstead, PhD, LCMHCA, NCC and reflects her approach rooted in Dialectical Behavior Therapy. You can follow more of her dialect work on Instagram here. Telehealth IS different and it won’t help to pretend like it is just the same as face-to-face work. Acknowledging and owning that the experience is different--especially for clients whose work began face-to-face--names the proverbial elephant in the room and opens up dialogue to explore clients’ reactions to the difference. It may also open up exploration for ways in which the difference is positive. Though most of our clients have preferred face-to-face therapy, we have had many whose preference is telehealth.
8. Check in at end: “How was this for you? How did it feel? What did you think?”
This one comes from Three Birds’ provider Meredith Nisbet, MS, LMFT and reflects her approach rooted in attachment work and emotion-focused therapy. You can follow more of her work on Instagram here. Just as we might check in with a client about face-to-face work, creating room for clients to share their reactions to the process and experience of telehealth communicates our desire to create a safe and secure environment within which the client can work on healing. If you have a client who tends to be a people-pleaser or has difficulty with asserting and voicing their needs, you may consider alternative ways for them to provide feedback. Would they feel more comfortable putting their reactions in writing to you? Could you provide an anonymous survey link to clients to collect outcome responses? Or perhaps, provide common reactions folks have and let them choose from those.
9. Ask “What can we do to make this more enjoyable and safe for you?”
This tip piggybacks on the last one, coming from Three Birds provider Melissa Carmona, MS, LCMHC, NCC and reflects her approach rooted in helping clients truly be seen and heard as their full authentic selves while experiencing more other- and self-compassion. You can follow more of her work on Instagram here. Notice the “we” in the statement above. Just as in face-to-face sessions, engaging the client in forming a collaborative relationship in which ownership for healing and growth is shared empowers clients to fully engage in the process. Our job is not to *just* entertain or reduce all negative or triggering aspects of life (Spoiler alert: we can’t!). Our job is to provide a space and relationship in which clients can be affirmed as their full selves, grow their resiliency and strength to live in this world, and heal from previous hurts and traumas.
10. Play interactive games with children and teens (and adults!) during sessions
This tip comes from Three Birds provider Emilea Gross, MS, LCMHCA, NCC, who works full time as a high school counselor and whose background is in ADHD coaching. Just as in face-to-face sessions, children and teens (and some adults!) often need a grounding activity to do while talking to create some emotional distance, bonding with therapist, and grounding focus to be able to attend better. Whether using a multiplayer internet game that you can both play from your own computer or using an actual game like Pictionary (you can both draw on your own end with camera facing paper OR via Jamboard), keep in the mind the purpose of the game is to facilitate the session, not to win :). You can find more ideas for interactive activities to do with children and teens here or via the Abundance Practice podcast.
11. Remind your clients that they are capable of doing hard things
This tip comes from Three Birds provider Christina Rush, PhD, who specializes in infertility and pregnancy loss, psychological assessment for 3rd party reproduction, anxiety, relationship concerns, and eating disorders. This tip from her is not one she offered lightly or glibly. Because of the nature of her specialty areas, she sees a lot of folks who are facing or who have faced tremendous loss and medical complications. With the fear and unknown surrounding the coronavirus, many folks are experiencing heightened anxiety, hypervigilance, and fear. Transitioning to something new, like telehealth, during a time of anxiety and fear, may feel too hard for some. Reminding our clients of their resiliency and strength in the face of hardship and trauma is an important part of building their emotional resources for healing, recovery, and living.
Many of our clients also see dietitians as part of their team so I reached out to our colleagues and friends at Lutz & Alexander, a Fat Positive, Non Diet nutrition practice specializing in eating disorders, body image, and child feeding concerns. They are based in Raleigh, NC, but also provide telehealth to clients across North Carolina and in some other states. Here are some tips for telehealth they offered:
Acknowledge and discuss that telehealth feels and is different.
Discuss how telehealth will change your visits - how will you all handle weighing, if that’s been a part of sessions?
Invite your client to sit in a supportive chair with their feet on the floor.
Invite them to doodle or use a fidget if that has helped them in session.
Eat with a client. Invite them to sit at a table with their feet on the floor. Have something to eat on your end, too!
From Antonia Hartley, MPH, RD, LDN, CEDRD, whose work you can follow on Instagram here.
Try the meditation on a raisin (or other food) mindfulness exercise. It’s been a great way to start and bring both my client and self into session.
From Jocelyn Dantini, MS, RD, LDN
Be intentional about naming that there's plenty of time and space to discuss what's coming up for clients around differences in telehealth vs. in-person sessions.
Ask clients if they're feeling comfortable and safe in their environment (i.e: do they have the privacy they need? How can they make their environment feel more private? I.e: turn a fan on outside of the room, humidifier, music, maybe even purchase a sound machine.)
Square breathing is one of my favorite mindfulness activities to use in telehealth and in-person sessions as well :)
From Sara Gonet, MS, RD, CEDRD, whose work you can follow here.
Use the 5-4-3-2-1 method (using all senses)
Name 5 things around you that you see, 4 sounds that you hear, 3 things around you that you can touch, 2 things you can smell, 1 thing you can taste (if applicable) hot tea, cold water....etc
Guide the client through reframing critical thoughts into compassionate observations
Negative thought: I am not being good at recovery right now.
Compassionate observation: I am doing the best I can and it makes sense that my thoughts are heightened right now.
Negative thought: I am lazy
Compassionate thought: It is okay to allow myself to rest.
Consider eating a meal or snack with clients for increased support and accountability as they move through recovery.
I hope these these tips will help your sessions with clients!
Interested in scheduling a telehealth therapy OR virtual clinical supervision session with our team? Contact us here. We'd love to work with you!