Working with the Nervous System via Telehealth

For many practitioners, it’s been months since they’ve seen patients in person.

Telehealth has been critical during the pandemic, but it also comes with some challenges – not the least of which is working with your patient’s nervous system through a screen.

In the video below, Deb Dana, LCSW will walk you through how she builds a strong nervous system-to-nervous system connection with her clients while meeting virtually.

Have a listen.

Click here for full transcript

Ms. Dana: I’ve been working with lots of my colleagues who have now moved to telehealth, and I want to speak to that for a moment to my colleagues and let you know that yes, you’re being challenged to find new ways to be a regulating resource and it’s even more important that you be that regulating resource for your clients. We have to figure out first, how do we come to our own state of regulation and safety, and then how do we broadcast that to our clients? I know it’s exhausting because I know we’re used to being in a room with another nervous system and feeling the cues that way. One of the things that I do know is that this is a time to teach your clients about their nervous system, because rather than having to guess and look and see what’s going on over there, I can simply ask you, “Where are you right now, what’s your nervous system telling you?”, and you will understand what I’m talking about because we have created this language together. Everything’s different now as therapy has been turned on its head. It’s a wonderful time to stop and dive into the nervous system and educate your clients and take this moment to do that. I also want to say that there are environmental challenges on both ends, you know, the internet comes and goes, kids come and go. I did a session with a client and her two dogs were barking in the background, and it’s okay. Somebody else told me they did a session with their client who was in their pajamas. The thing is, your clients are being invited into your home and we’re being invited into their home and it’s a very different experience. We don’t want to not name that and not experience that together. It’s a way of really connecting. I often will show my clients around this space; you’re seeing a very certain part of the space I created, but I could take you on a tour around this room so you’d get a flavor of the context of where I am. It’s important, and then my clients show me around their space so that we know where we are and we make a deal that when the internet goes out, who’s going to call who back? These things are going to happen, and when a little kid comes busting in, what do we do? It’s really bringing into explicit awareness the need to talk about all of these environmental things that happen. I’m sitting here, I could lean forward and connect, I could lean back, I could do this. . . We have all sorts of ways of bringing ourselves together. I also want to say that everything’s intensified right now, so some clients are finding that what they would say were gains they made over the past couple months are being stressed right now, and I want people to know that, yes, everything’s intensified and your nervous system isn’t getting a break because it’s just coming at us all the time. That moment to take a breath really needs to be built into your day, whatever that looks like for your nervous system. It’s normal to be pulled more easily right now into old familiar patterns, and I’ve been reminding my colleagues to remind their clients that that doesn’t mean you’re going backwards, it simply means that your nervous system knows how to respond to survival threats and has taken you there. We are just anchoring more and more and more in moments of safety and when we come out the other side, all of this practice and anchoring and safety is going to then stand you in good stead. I guess the last thing I’d say about this time for colleagues is, we find that some clients are really enjoying being in a remote session and not being able to go out in the world. I was working with a client earlier today who told me she really feels like she can deepen in and do some of the work that has been waiting for her to do because there’s not so much static going on for her. She just is home and there’s no need to make excuses or have to go out in the world, and she really can just settle in and feel safe at home. I thought that’s a really interesting thing to remember and think about that for some clients, this is the right degree of connection. So, again, we don’t want to make an assumption about any nervous system with that guiding question, “What does your nervous system need right now, where are you, and what do you need to continue to connect and come to ventral?”

You can hear more from Deb Dana, LCSW, along with Bessel van der Kolk, MD; Pat Ogden, PhD; Peter Levine, PhD; Stephen Porges, PhD; and other top experts in the Advanced Master Program on the Treatment of Trauma.

Now we’d like to hear from you. Has coregulating with your patient via telehealth been a challenge? How might you put these techniques into practice? Please leave a comment below and let us know.

If you found this helpful, here are a few more resources you might be interested in:

What’s Happening in the Nervous System of Patients Who “Please and Appease” (or Fawn) in Response to Trauma? With Stephen Porges, PhD

How the Nervous System Responds to Trauma

[Infographic] – How the Nervous System Responds to Trauma

16 Comments

Anonymous AA, Other, Carlisle, MD, USA says

Since March, my experience being in therapy online has been in a very good way. Doing it from home is amazing and help with the long traffic. I am in my late fifties and soon retire from my day job because of extreme fatigue if I stay too long up and walking. Telehealth has been to say to the least the only way to keep therapy going on, and for myself, being in the position of a patient, now that I live alone and far from my children. The thing that appeared to become an struggle for me is to have to talk on the phone and not seeing my therapist in person, which way I can more easily relating to. Besides, isn’t what how therapy should be and supposed to be? This change in how I now see therapy makes me feel somewhat depressed because I have to say more and explain more about my struggles and don’t feel that my therapist even bothered listening as before. I don’t mean to write to complain. It is about bringing a perspective in the profession that I used to do myself.

Robyn Gothelf, Psychotherapy, Huntington Woods, MI, USA says

Thank you Deb
This was very helpful. You are right, for some clients this is the right degree of connecting and it is ok.
Robyn Gothelf LMSW, MEd, IMH E II

Ivana Nedelchev, Teacher, Sonoma, CA, USA says

Thank you. This video was valuable. yes a s a yoga teacher working with the body I like showing my space to the students. Sometimes I set up my mat and light a candle after I connect to create that “natural bond”

Anonymous says

Fabulous.

Sangeetha, Coach, GB says

Teaching clients about the nervous system and how their nervous system is talking to them and what it needs I totally agree is critical via telehealth! As a mindfulness coach rather than psychotherapist, who was working in person and now via telehealth, I find now, that the client knowing their cues when they dissociate or are triggered is even more important although I can mirror and gauge fairly well if I can see head, neck and shoulders without seeing the whole body.

Also doing a quick check in around how the client is feeling and naming what they can feel before doing a mindfulness grounding practice right at the start of the session helps the client focus and me too! It sets the tone for better regulation and I get the client to pause and do more exercises to regulate throughout the session at times they are triggered. I do agree with some clients especially with complex trauma, telehealth would be more challenging even with more education for them on the nervous system.

I believe that shifting position and I also find using more facial cues as Deb says and careful and appropriate humour at times helps create a more warm atmosphere to simulate more how you would be “in person”.

Asking how it is, to be having therapy online and in their home, pros and cons and how you would work together to reduce the cons and reviewing this over time and allowing a forum of communication for this I do feel helps too.

Joanne Chemin, Another Field, CA says

Very nice presentation, but I still need more information. I have not experienced “telehealth” before so I have nothing to compare with. Any help most appreciative!

Deborah Zelisse, Other, Reno, NV, USA says

I find telehealth extremely impersonal. I tried it once, and the therapist misread me, calling me defensive and that my glass was half full. That is not me at all. Did not go back

- Elizabeth OHara, Social Work, Lancaster, PA, USA says
  
  Am sad that you had that experience. Beginning therapy is a risk and to experience your clinician as missing and misreading you would be incredibly frustrating and unsatisfying. I hope that you might be willing to return to therapy with that provider or with another. I believe I understand your discomfort and also want to nite that because therapy is collaborative, its important to try to let the therapist know your experience of them as well. Many of us enter this field with a desire to be present and supportive. If we are not experienced by you as the client in that way, we wont necessarily know until we are given that feedback:) I hope that you will do what feels right for you and if you believe you can, return to give it another try.
  
- Bill poray, Social Work, plains, PA, USA says
  
  Deb is a wonderful presenter. She and PVT has helped me and tremendously, particularly during this period. Her mapping exercises are great regardless of the medium. 2 wonderful sessions. I had a client with complex trauma. Was facilitating body awareness exercise. Her 8 year old son came into room. Rather than ignore this or stop the exercise I suggested she hold her son on her lap and continue with the exercise. It was PVT at its finest. Another session involved another patient with complex trauma. It was second session. I invited her to walk around room and introduce me to some of the objects in her room and tell me about the personal meaning and significance while watching her movements and affect. I processed this with her and she was amazed how relaxed and calm she was. Both sessions done via televideo.
  Bill Poray, LCSW Scranton PA
  
Ryan Mich, Another Field, Albuquerque , NM, USA says

I’m not a practitioner but a patient. In my personal experience I’ve found telehealth to be quite beneficial. I have to drive a long distance to meet with my counselor and this saves on transportation costs at an especially critical time for my finances.
I find that during my meeting I am more open with my doctors simply for the fact that the person to person social anxiety isn’t present. This has led to clearer communication regarding the issues at hand. I simply don’t have to wear the mask that we all do in society. (Not speaking of the surgical variety).
There are most certainly challenges on both sides of the desk regarding this topic but there may yet be some potentiality here that’s worth taking a further look into. Best of luck to all of us involved. We’ll find a way through. It’s what we do.

Timmie Pollock, Psychology, USA says

Most of my practice is neurofeedback and while it can be done remotely, it is not ideal. I however, made the decision early on to find a way to work safely in person.
We wear masks, gloves, have a sanitizer station at the door. I take temperatures and O2 levels of every person who enters my office. The waiting room is closed. We have a covered outdoor area just outside our office, or clients can text me from their car when they arrive. I text when it is clear (and cleaned and sanitized) for them to come in. We have air filters with UV lights in every room. They cannot come after travel, or get togethers for 10 days, and they need to report if they have been near anyone who is even in the process of being tested, which we remind them every visit. College students meet through telehealth only. We have 3 practitioners seeing clients in person and some telehealth, and 2 doing telehealth exclusively. So far so good. . We have not had any problems whatsoever.

Anne Lenox, Counseling, Rochester, NY, USA says

I am finding telehealth very challenging with clients no showing and cancelling more than ever. This is puzzling to me because they do not have do drive to my office yet they are not are showing up. My theory is that they take telehealth less seriously. Also, starting with new clients via telehealth is way more challenging regarding engagement in therapy.

- Alex B, Other, San Diego, CA, USA says
  
  Here’s one reason that might be…for me, I have not been able to connect via telehealth. It’s cold and indifferent. We are human beings and psychology, religion, etc. have for years talked about how we need real, Face-to-face, human connection. Since the invention of television (same with the internet) there has been concern for how it will affect our capacity/ability to connect. It’s all more serious and important than ever, at least for my life, but it does not feel safe or real. I’ve tried for seven months to get even a little of the safety and connection with my therapist but it’s just not really happening. Real human change and growth cannot happen in a vacuum just because it’s watched on telehealth…again that’s my experience but it may be others as well. With telehealth you’ve all basically become Self help videos, not real in the moment flesh and blood. That may work for some, but others with attachment trauma and such often cannot find safety and connection in this manner.
  
Felicity Zwalf, Social Work, AU says

My take away message is “What does your nervous system need right now?”

Thank you for that.

Felicity Zwalf
Social Worker/Counsellor
Melbourne, Australia

Anonymous says

It is more difficult to try to focus with the patient, distractions and not able to engaged closer, to the patient it makes more challenge! We know that Psychotherapy, counseling and Any type of Psychiatric Emotional issues, it takes a long time to address! And via online remote, virtual it makes very difficult to deal with the goal! Honestly I don’t have an specific approach, except to emphasis in my sessions and address this to the patients as clinician!
We are your suggesriousy, advice, or any type of positive outcome! In this matter?
Sincerely
Manuel Sillas MD

Monica Burato, Psychotherapy, IT says

Very useful tips!

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