Presence, absence, separation: reflections on therapy at a distance

By Fiona Turnbull

I hear my client’s voice over the phone.  She is dying.  Not imminently but soon, maybe a few months.  She has been accepting of this.  Despite her prognosis and symptoms, she has been determined to remain as engaged and open to life as possible.  I experience an ever-deepening affection and respect for her over the months I have worked with her as I’ve come to know her through her humour, her profound reflections on life, her glorious use of imagery and her grief. 

And now. I hear her voice on the phone.  She and I acknowledge how glad we are that our therapeutic relationship continues and reflect on how the field has radically changed.  As the weeks pass, five now since we last sat face-to-face in the therapy room, I share how I feel myself increasingly missing her physical presence and we mourn the opportunity to be physically together.  I am all too aware that her health means she is shielding, completely alone in her flat, only able to talk to her family through a closed door or window.  She expresses feelings of injustice about this and an agonising sense of distance and shares her desire to bridge that distance, to sit together again. 

As a result of this radical change in practice over the last month or more, working with clients over the phone or via video calls instead of face-to-face, I’ve become preoccupied by the difference the physical presence of being in the same room as my clients makes to me.  I realise gradually how much this physical separation from clients reminds me of grief: finding myself in that ‘uncanny’ (Fuchs) liminal space between presence and absence and feeling the impossibility of being physically present as when someone has died.  I think to myself that my feelings are likely a faint echo of how it might be right now to be terminally ill and shielding; to be unable to be alongside sick and dying family members and friends, anticipating their death; to be grieving and in isolation; to be dying at a distance from the people we love. 

I know I am still present for my clients.  They and I are not suddenly disembodied: my embodied response still stirs and I still attune to theirs.  And yet I know I am present in a different way as part of a dramatically altered field.  The between is still there but it is stretched in space.  The between persists but is now ‘mediated’, either by a phone or a screen.  I think of the double meaning of the word screen: that which enables me to have visual contact with clients from my laptop but also something which veils, hides, confers privacy. I feel an intangible loss, perhaps of the ‘implicit’, of that which does not need to be said.  That which can be experienced in silences, more easeful when sitting together than remotely.  The holding of the client that both the physical space of the therapy room and my physical presence as therapist can offer. 

As the weeks have gone by, at times, this sense of loss has been powerfully figural for me.  At others, I feel a different figure emerge, one of gratitude and wonder that, despite what appears to be the obstacle of remoteness, meaningful contact, fulfilling dialogue and I-Thou moments remain possible.

Fuchs, Thomas (2018), “Presence in Absence: The Ambiguous Phenomenology of Grief”, Phenomenology and the Cognitive Sciences, Vol 17, pp 43-63.

Fiona Turnbull is a newly qualified gestalt psychotherapist working in palliative care.