Therapeutic Presence Therapeutic rapport emerges as the provider and client get to know one another and develop a relationship (Sheafor & Horejsi, 2015). As the client develops trust, an alliance emerges, which helps to create an environment where change can happen. Inside the office, the provider can convey a nonjudgmental attitude, acceptance, and unconditional regard by communicating cues with body language, such as eye contact, body posture, and touch. The physical environment can welcome the client through the use of soft lighting, pleasant aromas, and pleasing aesthetics. When engaging a client in telemental health services, therapeutic presence must be carefully considered. The physical environments, both where the client is and where the practitioner is, must be consciously arranged to maximize visibility over video, yet still convey a sense of comfort. The physical space where the services are delivered must be large enough for the client to feel comfortable (Johnson, 2014; Luxton, Nelson, & Maheu, 2016; Luxton et al., 2014). If families or groups meet for services, the room must be large enough to accommodate them while allowing the therapist to be able to see each of the members. Multiple cameras may be needed during large family or other group sessions (Luxton, Nelson, & Maheu, 2016). The area where services are delivered should be in a quiet area of the building where there are minimal disruptions to the sessions. If teletherapy is delivered to the client in the home, distractions, such as the presence of roommates, family members, pets, or phone calls, should be minimized. If the provider would like to review a written document or report, the provider should send it to the client ahead of time. Telepresence allows for the provider and client to establish a supportive and engaging relationship despite the physical distance between them (Johnson, 2014). Beginning sessions may include a brief check-in with the client to allow time to adjust to the technical restraints of the session. The clinician may want to allow the client time to make adjustments to the physical space and computer setup before beginning a session. Cameras should be adjusted, usually in the center of the line of sight, so that eye contact is maximized (Luxton et al., 2014). Further, there are several things to consider about the provider’s physical space that is visible to the patient within the telemental health session. Small patterns and small stripes can appear blurry on video, so it can be helpful for providers to wear solid colors or larger patterns to ensure that the patient is not distracted by the appearance of blurry clothing because it can strain the patient’s eyes. Additionally, brightness should be tested to ensure that the lighting is not straining to the patient’s eyes. The background can also be important and should be simple, not distracting, and should portray a professional space, just as a provider would do in a traditional office space. Technical failures are an occasional annoyance in telemental health service provision and should be expected to occur at some point in time. The provider and client should discuss Emergency Management Managing emergencies is a vital component of an overall plan to provide telemental health services because the client will not be in the same room as the practitioner. Some examples of types of potential emergency situations include the following: If a client reveals suicidal or homicidal ideation and then leaves the room or turns off the video monitor, if the practitioner witnesses harm to a client on video, or if a health crisis occurs during the telemental health session. The practitioner is not on-site; thus, establishing an emergency protocol is very important.
what will happen if there is a disruption to the service (Johnson, 2014). A provider may inform the client that they will send the client an email about what to do next, such as wait a few minutes for the system to reboot or reschedule in the case of an Internet failure. Clients should not feel that technical failures are a rejection by the clinician, which is why communication ahead of time is important. Similar to in-office sessions, increased compliance and positive outcomes are related to the quality of the teletherapeutic relationship (Johnson, 2014). A clinician who tends to be more reserved with body language will need to practice and improve those skills to establish a therapeutic presence. Because body language is constrained in telemental health sessions, the provider may want to pay close attention to their own body language and make conscious choices about communicating understanding. A provider may want to nod frequently or exaggerate typically minimal movements of the head or arms or other gestures to demonstrate understanding and convey empathy and concern. Eye contact is an important source of clinical information. A client’s eye contact can convey information about the client’s psychological state, such as increased anxiety or depressed mood. In an assessment, eye gaze may be a clue to certain developmental or psychiatric disorders, such as autism or psychosis. For the provider to accurately assess the client’s eye contact, the provider must ensure that their own and the client’s camera are angled properly (Luxton et al., 2014). If eye contact is averted because of the camera position, a provider may mistake this for a symptom rather than a technical problem. If a provider thinks there is a problem with the camera, they must communicate that to the client and allow for readjustments. The following is an example of how to discuss eye contact with a patient. This discussion would typically occur within the first session. Therapist : Some things are different when video chatting than when you are in the same room as a person. Eye contact is a little bit different. I am going to do my best to look at the camera [therapist looks at the camera] so that it gives you the feel of eye contact. However, also please know that when I am looking like this [looking at the patient], I am actually looking at your face and paying close attention to what you are saying. Does that make sense? Patient : Oh yeah, I never really thought about that, but yes, that does happen when I chat with my family. Therapist : Yeah, it can be a little different. So please let me know if it doesn’t seem like I am looking at you because eye contact in a therapeutic relationship can be really important. I can adjust my camera, or we can problem solve in another way. Do you feel comfortable telling me if my eye contact seems to be off due to the technology? Patient : Yes, I can let you know. Therapist : Fantastic, thank you. Let’s get started. This information should also be included in the consent form for treatment. Establishing an emergency protocol should be done prior to starting services (Swenson et al., 2016), as previously outlined. The practitioner may need to include medical personnel at the site where the client is located (i.e., the originating site). If therapy is provided at the client’s home, the therapist should have family and social support contact information.
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