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Issue 9

On Building A Virtual Therapeutic Relationship

Students training to be therapists often wonder how to translate psychotherapy training from one cultural context to another. I find there are two key elements that help a therapist with this process. First, creating a framework for the work of psychotherapy, or in other words, establishing the boundaries and expectations of therapeutic work. Second, developing a relationship with the client. 

These two elements also helped me when I first began working with clients online almost three years ago. My decision to see clients in therapy online was guided by two reasons. One, I was able to offer therapeutic services to those living in parts of India without access to psychotherapy. Two, online work allowed me to continue to work with clients who were likely to face challenges in connecting with another therapist while I was in the process of moving cities. Of course, with the advent of the pandemic, many (if not all) therapists in India have found themselves working across a screen. My colleagues and I conducted a recent survey on a nationwide sample of therapists in India and found that most therapists reported transitioning to video sessions as a result of the pandemic. Well, in the web of all the relationships the world is now negotiating online, where does the psychotherapy relationship fit in? 

It is often more clear to see what we lose through online relationships. There is data to support the presence of zoom fatigue, lack of motivation, challenges in terms of negotiating space during the lockdown, and the difficulty faced by women, especially mothers, in managing family and work-related online spaces. The field of therapy is not free of these issues. Still, one has to acknowledge that online therapeutic work seems here to stay. It offers an important way to tackle the barriers faced by many in India to access mental health care. In efforts to determine how to make online therapy effective, I believe therapists need to consider what they are able to discern through these online experiences. 

Psychotherapy has always been about entering the client’s world. In the traditional face-to-face model, the therapist utilizes the presence of the client in their room to learn about the client’s life. Through online work, the therapist quite literally enters the client’s world and joins the client in a space that is often the very source of their distress. Creating a framework for therapy now includes helping the client virtually enter and exit the therapeutic space, without the physical presence of a therapist’s room. This endeavour becomes a clinically meaningful goal in itself, and it also offers ways for the therapist to understand the client more deeply. In my online work, I have worked with clients who meet with me from the same corner of their homes week after week, highlighting their ability to carve out a consistent safe space even in the midst of chaos. I have others who move from one form of data to the other, one device to the next, and room to room, communicating perhaps the motivation, difficulty and despair to establish a connection with another. What I have learned through these experiences is the need to tend to these issues as meaningful information about clients, and use this to work with the client on creating the boundaries and expectations of our therapeutic work online. 

In psychotherapy literature, the relationship formed between the therapist and client is recognized to be paramount in contributing to favourable therapeutic outcomes. Different forms and models of therapy emphasize different aspects of the therapeutic relationship. I have especially been drawn to the real relationship, one such element of the therapeutic relationship, in my online work with clients. The real relationship captures the extent to which the therapist and client are genuine with each other and are able to perceive each other for who they really are. It makes sense to consider the ways in which one’s authenticity is bound to emerge during the pandemic, not just through online work, but also through the conditions of lockdown. Not only does the therapist see the client in their living environment, the client too gets to engage with the therapist in theirs! At some points during my sessions through the lockdown, my clients have heard my rambunctious toddler on the other side of my study door (despite my best efforts to schedule sessions during nap time). During a session with a young mother, the moment of hearing my toddler laugh was marked by a shared smile and understanding of our identities as mothers, undoubtedly strengthening the real relationship between us. 

However, another client expressed feeling angry as she heard my toddler laugh. She wondered if I could even understand her reports on the struggles she was facing with her children. These reactions too become significant aspects of therapeutic work, often highlighting the client’s patterns and conflicts in close relationships. In this case, the client’s reaction to me was similar to how she was feeling towards others in her life, misunderstood and angry. In psychotherapy literature, these reactions are termed transference and are believed to be an unconscious carryover of how one experiences others onto their relationship with the therapist. I have appreciated the way online work allows therapists to tend to these interpersonal patterns. For example, a therapist might consider if the client feels comfortable with online work because it gives the client the emotional and physical distance they are used to in their other relationships. In another situation, a client’s frustration with connecting with the therapist via video might also be mirrored in their sense of wanting more in relationships outside of therapy. 

Online therapeutic work is challenging and most would agree it does not replace an in-person therapeutic encounter. In my opinion, the more relevant question is not one that pits in-person and online therapy against each other, but rather the one that addresses how we can use online therapy effectively. A step in this direction seems to entail recognizing the privilege of being able to learn more about, and show more to, our clients as therapists. My experiences with online work have made me value the opportunities one has as a therapist to continue to work and connect with others, through these changing and challenging times in the world. 

Avantika Bhatia is an Assistant Professor of Psychology at Ashoka University. Her research focuses on the process and outcome of psychotherapy. She is also drawn to the study of mental health concerns in college students and mothers, and women’s career development in India. As a therapist, she follows a psychodynamic approach and works with college student concerns, trauma, maternal mental health and interpersonal concerns. 

Picture Credits: Paige Stampatori for The Washington Post

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