See Me, Feel Me: An AEDP Toolbox for Creating Therapeutic Presence Online

Here are some other tools:
a) Slowing our own breathing, then verbally inviting the client to slow down. Let’s both slow down.
b) Using exclamations and statements instead of questions. Statements are often as easier way to make contact than to ask questions: I can see you are thinking and feeling and processing. Brave of you! That’s really something!
A big smile! Ow! Your foot is talking… You’re reacting!
c) Statements can start with fragments: Pain here… feelingful here…. a lot of
feeling… I’m here… I get it.
d) Some useful “continuers” that invite the client to put words on their
experience: tell me… say more…. please continue… put a lot of words on
that….finish that. Always ask patients to complete sentences if they trail off:
Cognitive disruption often comes right at the “juiciest” emotional point.
e) Saying, your thought/your reaction/your turn…This is said as a statement but
is a question! You are feeling….. you are reacting.. and the feeling as you are
talking.

Mirroring and Beyond. A quick way to get in synch is to notice the breathing of your client and match and mirror it. If your client takes a big breath or lets out a sigh, you can do it too and make it explicit: That was a big sigh…. phew I just did it too……how is it that we are taking breaths together? Mirroring helps make the relationship and relatedness explicit.

However, going beyond mirroring is particularly useful on a video call. Suppose a patient is talking without much affect about something his parent did that was problematic. The therapist can use this moment to speak up to the unspoken feeling: I feel angry on your behalf when I hear how your father behaved and criticized you.

Intention and attention: Therapist presence creates client presence

Lipton in his volume writes: “Intention refers to the directionality of many of the qualities that make up the therapeutic stance in AEDP. In AEDP therapists, our intention is to lead with authenticity, delight, affirmation, and privileging of our client’s transformance strivings.” We encourage you to ask yourself the five questions in Lipton’s PAIRR model, in an effort to cultivate therapeutic presence when you are online.

1. Presence: Am I in my body and open to my own physical and emotional experience? 2. Attunement: Am I open to tracking my own and my patient’s moment to moment communications verbal and nonverbal?
3. Intention: Am I explicitly converting my care, concern and openness to deep engagement?
4. Resonance: Am I slowing down and allowing myself to be impacted by my client and to explicitly communicate this when helpful?
5. Reflection: Am I actively and explicitly reflecting with my client on their experience with and of me? (Lipton, this volume).

We would add Danny Yeung’s conceptualization of contemplative presence as a useful thing to cultivate online:

Contemplative presence is an all-encompassing awareness and openness to existence in the here and now, while embracing existence with appreciation, admiration and reverence. These mental qualities within contemplative presence share the same family of resemblance with simple “presencing” and dyadic mindfulness. At the same time, contemplative presence goes beyond with three distinct characteristics: First, contemplative presence is facilitated through a stilling of the body (Yeung et al., in press). Second, contemplative presence includes intuition, defined as a non-discursive, direct, immediate embodied knowing. Third, contemplative presence could be practiced as a way of life (Yeung & Zhang, this volume).

Danny Yeung’s deep engaged presence is transformative in the transcript he shares in his article. Let us look at the specific language he uses as he invites his patient to orient to his internal experience, and lets the patient know that his story is important, and that there will be space for that while making explicit:

I am here with you. I have reverence for you. I honor and accept your defenses, and you have come to me for help with these very defenses… What’s it like to sense me with you?

In the “training at the AEDP gym” of moment-to-moment tracking, it is important to stay with whatever is emerging, to notice the experience, and to stay present in the here and now. Over time both therapist and client change in this process week to week. Therapist presence creates Client Presence.

Returning to Yeung and Zhang’s transcript, we see how the therapist explicitly remembers why the client has come to him for therapy: To change the way he keeps people out:

T: (tender, firm) We will go to the story…sometime. [focus on process not content] I am sure we will go to the story sometime. But if we were to draw your attention inwardly
[somatic focus]… Slowing down [down regulating anxiety]… Making room for that pain [focus on affect]…And I understand you definitely had the need to keep people out [empathic acceptance of defenses]. At the same time…as you shared with me before…this keeping people out – such as your wife…is keeping you very alone inside [the cost of his defenses]. So, let’s just take this moment, and I’m curious …what’s it like for you…too…and what’s it like for you to sense me being with you. [undoing client’s aloneness]

C: (eyes closed. Attention inward) It’s good and safe. [confirming client receptiveness oftherapist’s presence; assuring co-creation of inner sense of security]

T: (tender, slow, firm) Where do you notice the sense of goodness and safety? [somatic focus]

C: (eyes closed, gesturing with both hands) All around us. Sense of protection all around.

T: (very tender, very slow) Sense of protection all around…Right…And feel free to .. in addition to my gratitude and also…you have my utmost reverence for you…here’s your turn to be cared for. That’s why I’m here. [Therapist intuitively guessed client’s shame, hence needing to defensively “hide” in an inner chamber. “Utmost reverence” is the beyond mirroring and honoring of client as Reverend, undoing shame.]

Now re-read this transcript with us, absorb what the therapist does in a very short opening contracting ‘pitch’ to the client: to stay with his therapist, to avoid using the defensive strategies that have been so costly to him with other people and for which he has come to therapy; Yeung’s presence and his language may be inspiration to enter a resonant, present but actively working place in your own next sessions:

We will go to the story…sometime. I am sure we will go to the story sometime. But if we were to draw your attention inwardly Slowing down … Making room for that pain… And I understand you definitely had the need to keep people out. At the same time…as you shared with me before…this keeping people out – such as your wife…is keeping you very alone inside. So, let’s just take this moment, and I’m curious …what’s it like for you…too… and what’s it like for you to sense me being with you?

As we slow down and invite our clients to notice their internal experience and their somatic experience, and gently notice how it is to be with us – their therapist – we are entraining self awareness and dyadic relational mindfulness. Our presence and ability to hold our seats through emotional closeness and distance; through waves of emotion as well as disconnects or blocks to feeling; and then our ability to reflect on all of this together grows and expands our client’s presence:

Everything you are saying is so important, and I want to know all, and would it be okay with you if just for a few minutes now, we slow down and notice what’s inside while we talk, and I will do the same.

Creating therapeutic presence before the session begins

Shari Geller’s article in this volume offers ways to center ourselves before each session. In addition, consider beginning each meeting with a few moments of a guided “internal awareness” exercise (see Appendix 2 for a brief example). This invites the client or trainee to go inside the felt sense in their body in the moment and to explore, phenomenologically, what they find, without judgment. This has multiple purposes for the client, but in considering Therapeutic Presence (TP) it can definitely be stated that the practice “jump starts” each session for the therapist herself by priming her nervous system and heart to a position of receptivity, greater calm, and awareness. Her experience aligns with the assertion made in Yeung and Zhang (this volume): “….the AEDP therapist, embodying contemplative presence or the open, loving, appreciative attention toward clients, could enhance the intuitive ability and accuracy to land the right intervention with a client, in just the right time and in just the right way.”

Using imagination online

In our YouTube episodes about portrayals we teach how to summon creative imagination to activate bodily engagement in the dyadic exchange. The use of our imagination is a great resource online. Our ability to imagine lights up almost as many neural networks as actual experience. (Pally, 2000). Online we can use portrayals to light up and enliven our relationship: Imagine us together.

Imagine me with you… Can you imagine us together right now? Imagine me with you this week: see my face, hear my voice, feel my hand on your shoulder for support (if that feels right), Imagine us side by side.

A portrayal is an imagining or a visualization but it is more than that—it is a multi- sensory experience. Although the visual component is important, so are the other senses:

• Visual- Use your sense of sight to see pictures, images, and movies.
• Auditory- Use your sense of hearing for listening to sounds.
• Kinesthetic- Use your sense of touch to feel tactile sensations, emotions and energy. • Olfactory- Use your sense of smell.
• Gustatory- Use your sense of taste.

Other routes to activate imagination

In imagination the therapist may invite a shared felt sense of sitting together in the same physical space; explore the client allowing a kind hand on his back; or the sensation of sitting shoulder to shoulder with his therapist, looking at things from the same physical as well as emotional perspective. This harnesses an AEDP therapist’s bravery to her therapeutic presence: openhearted and emotionally courageous in service of emergent need in the client.

Use of guided imagery can be easier to initiate online; people tend to feel less constricted when in their own environments. Try inviting your clients to “go to” places of calm and beauty in their mind’s eye, and even to imagine meeting you there, to discover what emotions might emerge in a conversation they could have in such a place. For some, the prompt is fertile and reassuring; for others it stimulates painful awareness of yearning. The AEDP therapist whose line of exploration results in such an experience takes the opportunity to metaprocesses the distress, and this is often a pivotal relational moment in the treatment. The lesson here is that teletherapy can support a felt sense of being together; it may also stir feelings of greater longing and aloneness. Either road taken by the client requires a True Other who is present as guide and companion and whose feet are firmly on the road: TP is the necessary and healing ingredient. We can make explicit the “medicine” in these shared experiences: “whatever we can do/ feel/ live together will change your internal world so that you will have portable change to have these experiences you want with others over time.”

Teletherapy summons creative imagination to activate bodily engagement in the dyadic exchange. One supervisee reports that during an intense moment she grasped the sides of the computer screen, and told her client that she was doing so, as a way to convey that she is actively with them. She asked the client “can you see how my arms are framing the picture you are in? It’s my way of holding you.” In this manner she conveyed her presence, and then checked in with a round of metaprocessing, “How is it to hear and see me express my holding?”

Always powerful, metaprocessing is ever more crucial in teletherapy

Metaprocessing, whether employed in person in session or remotely in teletherapy, is involving, relational, and transformance-promoting. Metaprocessing makes the implicit explicit and brings present moment experience to life: “In response to a moment of transformation or of change for the better, the therapist explores the emergent positive experience, urges the client to focus inward on what the experience of that moment of transformation is like…” (Fosha, Thoma, & Yeung, 2019, p. 21).

One of the qualities of an AEDP session held online must be to make room for healing experience to settle and root in the heart and mind of the client. Embedded as it often is in everyday life; the client may be in their home, workplace, or even their car; a session online requires that the therapist bring an added layer of presence and vitality to make new experience “stick.” Inviting the client to make space for the absorption and reflection upon immediate emergent events through body as well as mind, and to enjoy relational and celebratory moments is one of the activities which differentiates AEDP from other models of treatment.

How to close an online session

Below we list a few things that can be said at the end of an online session that can help sustain the session until the next time:

Carry me with you and I will carry you with me. How would it be for us to use the screen – take a snapshot of us smiling together here? A Hug! Can you take it in?

Wrapping arms around our own bodies simulates a sense of connection in the nervous system, and doing it dyadically potentiates the benefits. Other explicit uses of body in session also promote TP and CP (Client Presence!): placing our right hand over our hearts, either with the explicit invitation to the client to mirror us, and models self calming as well as being a gesture of care. One hand on the forehead and the other on heart center has the same effect. Such invitations to include somatic present-moment experience help keep the session “alive”, and metaprocessing such moments makes the experience real and relational. It creates an impression that we could step out of the screen and into the felt sense of being in one another’s presence.

Such shared moments of somatic experience increase affective receptive capacity for client and therapist; they also “hold” them between meetings.

I have always wanted to make house calls!

As much as some therapists and clients miss coming into our offices for psychotherapy, there are advantages to the client feeling the comfort of a home environment supporting their experience. The softening of a client with their toddler on his or her lap is an entry point not to be missed as is the delight of having cats, dogs, and even pet birds entering the scene either in passing or to join the client. The use of the unconditional regard offered by a companion animal is an internal attachment-promoting opportunity. It may give the client a chance to explore allowing a kinder self-view than he usually allows himself.

“Lance”, whose poodle puppy begged to be picked up in the session and who then fell asleep on her owner’s shoulder, was able to experience present-moment body sensations of a young animal surrendering to comfort and affection. Lance was invited by his therapist to bring the sensation inside his own body as he imagined being held in a similar fashion by his girlfriend. The opportunity to “use” a physical experience of a friendly animal is one rarely possible during sessions in our offices, but it happens quite frequently when the client is in their own environment. An AEDP therapist is a therapist alert to glimmers of transformative experience. Sometimes there are disadvantages to a house call. Lack of privacy or even of safety due to the presence of family members needs to be assessed. Advance planning with our clients may help circumnavigate such problems

Creating a holding environment online

A word here about environment as an important aspect of Therapeutic Presence: Making energetic, somatic, emotional, and cognitive space for therapeutic connection and processing in remote sessions also rests, for clinician and client alike, upon a sense of calm and consistency. Most therapists intentionally configure their workplace offices to be healing environments that enhance the client’s sense of safety and amplify the therapist’s own presence; the frame of the “sacred space” of our offices to help us hold the work when in person. The authors have noted that establishing routines for themselves as well as setting up a dedicated space from which to “meet” clients online helps both halves of the therapeutic dyad relax into connection more reliably.

In “setting the stage” for a meeting it also helps to consider possible technical interruptions. Consider making explicit at the outset of a session that should the WiFi connection be interrupted you will remain present, looking at the screen and holding the client in heart and mind until service is resumed. Or explicitly state that you, as the attachment figure, will make the phone call to the client to resume connection. This is a particularly AEDP formulation adapted to meet a technological challenge; it is another way to make TP alive for the client in real time.

Self-consciousness vs self-awareness

Members of one of Kate Halliday’s training groups noted that until the 2020 pandemic changed the ways many of us in the US and elsewhere do business and socialize, the stimulus of the screen had been a means of escape from everyday life. 21st Century humans have almost universally been acculturated to respond to movement on any screen within view, and to do so from a fairly passive stance. Years of exposure to movies, television, and even social media trained the brain to look at objects on a screen as just that: objects to “consume” and even evaluate. The consumer is expecting to assess and to be at a distance from the “other” on the screen. In fact, we had been trained to objectify people presented in the media, judging their conformity to standards of beauty created by those very media.

In our training group we noted how uncomfortable most of us are with the “self-view” function of tele communication; unable to avoid assessing ourselves, we are self conscious at a time when we are explicitly called to be self aware. In our role as an AEDP therapist, internal awareness is paramount; the gaze needs to be from inside, rooted in awareness of the internal processes mediating that gaze. We work to respond with authenticity from that inner “truth”.

If the distraction of self-view has a pull for us as therapists, recognition of that pull illumines a barrier to presence on the part of the client. It accentuates the necessity that we “summon” them into the dyad with our own presence, explicitly and implicitly, even though this invitation to join us in the intimacy of a present-moment relationship may be a departure from their usual mode of response to a screen.

Teletherapy also offers distinctive benefits as a byproduct of this phenomenon. One colleague stated that he has noticed that he can find a glance at his own face useful in the present moment as a way to be certain that his facial expression is conveying what he is feeling. Another said that she uses the small “self” in the corner of her screen to steady herself when the session gets rough. This self-to-self connection is one of ways we support TP in ourselves, through a grounded reliance on our own “older, wiser, stronger” self.

One colleague suggested that we invite our client to close their eyes to help explore inner experience more, with us, for a moment or two. This seems to break the “spell” of the screen if it feels the client is losing emotional track of their internal process.

Research has demonstrated (Majid, et al., 2018) that for English speakers it is easiest to speak about things that we see. It is important to note that their paper shows how for non-English speakers, this is often not the case. Cultural diversity requires that we avoid making ethnocentric assumptions. For English speakers, bypassing the dominant sense of sight may help access internal non-verbal experience; it is common for people to close their eyes when they are examining a body sensation or accessing an emotional memory. This requires extra presence on our parts during the moments their eyes are closed; we anchor them, much the way we do dissociating clients.

Radical presence promotes secure attachment in teletherapy

Presence is requisite in any attachment relationship, including that of an AEDP therapy. The AEDP clinician is an attachment figure who is willing for the purposes of the therapeutic relationship to be “emotionally engaged, affectively competent and confident and self-discloses affect …. in the service of the patient” (Prenn, 2011) Our colleague Ben Lipton writes in this issue of Transformance that TP includes the stance of the therapist and also much more; he identifies an ineffable quality in the presence of the AEDP clinician: “the foundational therapeutic driver of transformation for (my) clients…. (is) radically relational” (Lipton, this volume) (emphases ours).

A radical (rooted) relationship is one that can encounter adverse conditions and survive, or even (as with young plants in the Spring) benefit and strengthen from exposure to such challenges. Therapists report the benefits of intensity of focus on the attachment relationship required online, and the pitfalls attendant on it.

For example, a colleague who works with children reported a poignant experience that illustrates both: His client is a boy with significant early attachment loss. In sessions in the office “Jerome” had rarely made eye contact and was skittish about any interventions that focused on the relationship with his therapist, “Alan”. Since the necessity to work remotely during the Covid-19 pandemic has meant that all sessions are online, Jerome has allowed himself to begin to look at Alan in his sessions, and the content of each hour is radically different. It is apparent to Alan that the attachment longings in Jerome have been awoken by the enforced separation, but also that his reliable presence week after week has allowed Jerome to expand his capacity for their connection.

However, this experience of “feeling felt” and “seeing himself being seen” has awoken a fierce desire for the focused attention of his “True Other” therapist. Alan reported recently that he looked away from the screen for a moment because he heard the vibration of his cell phone. Jerome said “Mr. Alan, you’re looking away!” with alarm in his tone. He noticed and was able to address the brief hiatus in his therapist’s presence. For Jerome’s therapist it was a reminder of how an anxious attachment radar is always finely tuned to such ruptures, and even more so in remote sessions. We are required as attachment therapists to center ourselves solidly in our present moment experience with the client; in sessions where the cues to that presence are all held in our gaze and our eye contact, any shift in visual focus may be read as distraction and lack of TP.

Alan’s honesty in metaprocessing the rupture detected by Jerome’s “attachment radar” opened an opportunity for repair; it also made room for deeper but careful exploration of the attachment they felt for one another.

Ironically, avoidant attachment strategies come into their own in “remote” therapy. People for whom the intense TP of in-person therapy can prompt overwhelm and arouse defenses sometimes seem to thrive in the more diluted intensity of online work. Making the recognition of this explicit (in a celebratory, non-shaming way) is an attachment strategy in itself; a way to say “See, I know you. We can be connected in ways that feel safe for you.”

A disorganized attachment system needs extra reassurance, and the therapist’s own awareness of his physical expressions and smallest gestures became even more important. The effort to avoid defensiveness, to self regulate, and to stay steadily present even in difficult moments may feel amplified in online meetings. Starting from a place of TP as described by Geller (2017), and invoked even before the session begins, is essential when the client’s attachment needs call for extra layers of awareness and care. Recognition of our own attachment vulnerabilities is, as always, central to our capacity for TP. The self/other triangle provides a perspective on this: “self other interactions provide a set of dynamics that become internalized, shaping psychic structure, and also generate the affective background that strongly influences what state configurations come to the fore”. (Fosha, 2000, p.121) Therapeutic presence demands that we not only monitor our internal experience in the moment, but also hold in awareness our own embedded tendencies created by our historical attachment experiences.

Capacity for deep transformational work in teletherapy

When clients drop down into State 2 and allow the presence of their therapists to accompany them through waves of affect, the mutual experience of post-breakthrough affects and then of States 3 and 4 is frequently one of deep, mutually contemplative experience. As experiential therapists, our ability to work with emotional experience relies upon our own capacity to be emotionally present. This is never more the case than when we are engaging the process with a client many miles away. However, there seems to be a potential for added depth to the process when it takes place remotely.

Perhaps a “willing suspension of disbelief” akin to what an audience brings to dramatized stories offers some explanation for this added depth. The “drama” of AEDP experience, accessed dyadically through affect and relational experience and leading through Transformational affects to States 3 and 4, directly accesses the limbic system, and asks the pre-frontal cortex to wait its turn. In that interregnum, similar to that experienced when we are engrossed in a televised drama or a compelling novel, we surrender to affective experience. The structure of teletherapy, entrained by years of relationship to the screen as a source of such experience, may be especially suited to help open these channels. This in turn may facilitate access to the “trance” state familiar in AEDP. These intuitive leaps feel valid and validating; they activate the “click” of recognition and spontaneous expressions of secure attachment and self awareness:

…clinical intuition can be understood as a direct and immediate embodied knowing mediated by right brain receptiveness, relatedness and responsiveness to non-verbal affect. The immediacy of intuitive information processing, occurring prior to any leftbrain discursive reasoning, guides the therapist as to when, what and how to intervene moment-to-moment (Yeung & Zhang, this volume).

Transformational experiences associated with quantum change emerge organically from these affective and relational moments, when the therapist, like a professional “actor”, has fully entered his character, and embodied it mind, body, and spirit.

What follows is an example of this phenomenon:

Thousands of miles separate client and therapist, but when the “curtain rises” on the session, we are already into Act 3 (Metaprocessing, and the reaping of the harvest of our work). For several months, the client has been processing early attachment wounding, and in doing so has been “reclaiming her sense of entitlement to exist”, as she had stated at the conclusion of the previous session. What follows is a brief transcript of “Acts 3 & 4.”

C: Well, I had a real challenge this week…..(describes a professional experience where she felt off balance)… but then I woke up in the night last night and the words ‘you’re OK, even when you’re not getting everything right’ came to me. OK! Like deeply here and enough…(takes a breath, and begins to talk more about the work situation)

T: Whoah! can we stop a moment? This ‘being OK’ feels really important! Let’s give this enormous statement lots of room to percolate through…..can you go back to those words as you felt them, and allow yourself to really feel, now, how they take effect in your body as you stay with them?

C: …… mmmm. yes. It’s an energy. Feels as if it’s rooted in my uterus. Female. It feels kind of grounded (gestures with her hand, up and down the midline of her body; therapist mirrors the gesture) “I am here! ….It’s not about performing…..I have an image of sort of plonking into an embodied sense of it!

T: Can you say more about ‘it’? (Client goes on to describe a spontaneous experience in the present moment of being both a powerful indigenous healer and a powerful animal. She names the qualities each represents; the narrative has a “magical” tone to it; using language, but experienced for us both at a somatic, out-of-body level.)

T: Oh…. (reverently)…. I can ‘see’ you in each of those beings as you describe the images!

C: Probably I DO have power!….I don’t have to be scared of it. I like connecting with people on a deeper level… I like helping….I can stay connected and be powerful! We have entered State 4. She is naming her new truth; she sits straight in her chair; her eyes glow with vitality. This State 4 awareness of connection to the ALL of life sparks in both of us. We have completely forgotten the miles between us; all we know is the present moment.

Conclusion

Online teletherapy sessions require therapist presence in active and explicit ways: it is not always enough that we be present (although sometimes it can be); it may also be essential that we make our implicit presence explicit with our words and our breaths and our faces and our embodied selves.

AEDP therapists practice from the inside out and the bottom up; this involves lending ourselves wholeheartedly to our clients’ felt awareness in the present moment and being willing to trust emergent co-created experience. Especially in the practice of online therapy, a clinician whose therapist presence has been honed by hours of deeply focused relationally engaged practice will be equipped with the stamina required for sustained engagement, even during unprecedented times. Recent experiences have shown that not only can teletherapy “hold its own” as a viable mode of therapy, there are powerful and surprising benefits to the work possible even at a distance of many miles (Callahan, 2020). The AEDP therapist who leans into the experience with deep therapeutic presence will reap the benefits for him or herself in added vitality and enjoyment.

In summary, for some clinicians and their clients the opportunity for intimacy and immediacy as well as the flexibility offered by tele-therapy has proved surprisingly appealing. Online psychotherapy is here to stay, and AEDP skills, interventions, maps, schemas and ways of being fit the screen just as well as they worked in your office up until now.