Therapists: How to significantly improve your therapeutic relationships & outcomes

Introduction: Therapy is both an art and a science

Seasoned therapists understand that our practice is a delicate balance of art and science. We mostly employ evidence-based practices, ideally grounded in neuroscience, while also relying on the art of relationships and conversation to help clients reframe unhelpful beliefs and create empowering, joy-filled lives. At the heart of this process is the therapeutic relationship — a dynamic built on trust, authenticity, and honesty.

In my decades of practice specializing in treating anxiety and working with clients who have struggled for years to find solutions, I’ve observed one critical truth:

The quality of the therapeutic relationship is the single most important factor in achieving positive outcomes.

The therapeutic relationship must feel safe, genuine, and deeply attuned, allowing clients to process, grow, and make lasting neurophysiological changes which redefine the process of how they think. In the Western World, we strongly prioritize teaching our children what to think, not how to think, leaving an entire population mostly bereft of the knowledge of how to rewire their own brain. That job is left to us to gift to those who are fortunate enough and willing enough to embark on that journey. That said, as therapists, we have to make sure that the road is prepared effectively by providing a safe therapeutic environment in which the journey can take place. But how exactly do we do this, given that therapy is both an art and a science?

A cornerstone skill to creating a safe and successful therapeutic space and relationship is found in our ability to be present.

Therapeutic presence is not just a nice-to-have—it’s the cornerstone of effective therapy. Neuroscience has shown that humans are constantly evaluating their environment for cues of safety (Porges, 2011). Clients intuitively interpret our body language, facial expressions, tone of voice, and verbal and nonverbal responses and the energy we bring (or hold) in sessions to decide whether they feel safe and understood. Healing happens in presence and attunement

The challenges of building trust, authenticity, and honesty

There are many differing challenges that we face when creating that type of safety and presence. These challenges can be related to the client or us and our own ‘stuff,’ which as professionals we should have processed, or are processing, and be able to keep out of the session. We all come with our own stories and histories. It is our professional responsibility to have worked through that as much as possible in our own therapy, and to grow through any re-emerging edges in supervision.

Administration, which is time out of session, and note-taking, impact our focus on building an authentic and trusting relationship. Structural components such as these impact us all, and note-taking is particularly demanding

Note-taking can empower us to:

• Reflect on our client’s journey
• Craft treatment plans
• Provide quality reports and testimonials
• And, should you have the luxury of time, help ground us to be present with the client by a synoptic review just before the session.

Note-taking is also problematic:

• It can be time-consuming, demanding valuable energy that should be spent with clients
• It can inadvertently challenge our ability to remain fully present in sessions
• It can impact conversational flow
• It can be distracting for our clients

So, how do we reconcile the need for meticulous notes with the imperative to remain fully present? This is where I found Upheal and AI-powered tools come into play.

My search for doing notes differently

“I have a complete love-hate relationship with notetaking!” As with all of the things in my life that I have to do, I’m always looking for ways to make them more effective and joyful. That way, I can minimize my suffering and time investment! This is, in fact, what led me to search for how AI could solve my note-taking challenge. I am fascinated by AI, but since many new AI note-taking apps have emerged, I found myself going on a search for the best tool first – and to do that, I had to create my own set of professional criteria. I then selected half a dozen tools and did significant research by exploring each in real patient scenarios.

I dug in and downloaded 5 different AI-based note-takers and found a tool that checked almost all of my boxes, including the ‘must-haves’ and the ‘want-to-haves.’ Uphheal, I discovered, is more than a re-jigging of Chat-GBT, which has privacy issues. Its feature-rich offering is overseen by therapists and goes through the appropriate product research stages, as well as continuous feedback from community members. When using it, I felt that Upheal was built by those who took the time to ask us, therapists, what we need, and that made a big difference to me. AI has enhanced my therapeutic relationships and improved outcomes, without compromising the authenticity and presence essential to effective therapy.

AI notes have also removed all of the bits about notetaking I do not like, while providing session analytics that I could never have gleaned without the technology.

The solution: AI-powered notetaking

After exploring various tools, I chose Upheal for my practice. It is independently audited regularly (hugely important for me) to ensure compliance with privacy laws and regulatory standards, including those specific to my practice area, Ontario, Canada. In addition, Upheal was very responsive when I asked about who did the independent audit. For therapists navigating strict compliance demands, this level of assurance is invaluable.

7 reasons why an AI-powered app is so helpful:

1. Real-time transcription: Upheal uses AI to transcribe sessions in real time, capturing every word without requiring manual intervention. This allows me to stay focused entirely on my client, without worrying about missing key details.
2. Privacy and security: The app is designed to meet stringent privacy standards, ensuring that client data is protected. This is a non-negotiable feature for therapists practicing in regions with strict regulations, such as Ontario.
3. Consent: When obtaining consent from your client to use an AI notetaker (a process that Upheal has made easy for you to do), you can assure your clients that their privacy will be protected, in writing, if they ask.
4. Customizable summaries: After each session, Upheal generates customizable notes that align with my practice’s specific documentation needs. This helps me save time while ensuring my notes are thorough and accurate, and in a format of my choosing.
5. Session analytics: Upheal provides additional data points for your reflection. For instance, it measures the therapist-to-client speech ratio, and that can be connected to the strength of your therapeutic alliance. Speech patterns more closely resemble each other when the alliance works well.
6. Real-life transcripts: Upheal captures dialogue well and offers speaker recognition. That makes it an excellent tool to use for reference during Supervision and for improving your skills as a therapist.
7. Seamless integration: The app integrates easily into my workflow, requiring minimal training or adjustment. Its intuitive design ensures that I spend less time learning a tool and more time focused on my clients.

As an Anxiety Specialist, my caseload is primarily clients who have often been through many therapists, doctors, and medication regimes. They often have been diagnosed (or, as I like to say, ‘labelled’) with diagnoses such as General Anxiety Disorder (GAD), or one of the many subsets of Anxiety Disorders the DSM defines. They can be a tough crowd – exasperated, frustrated, with little hope and unconsciously committed to living into their diagnosis.

Clients with chronic anxiety have high set-point levels of cortisol, enabling their fight/flight response to trigger fast, easy, and often. This system is our bodyguard of sorts, and what it does best is to activate in the presence of unsafe situations, real or imagined. My therapy space MUST read as safe for these clients, which means I must be as present as I can, ensuring they feel heard, and understood, sense my empathy, and are safe enough to be curious enough to consider the work. Any perceived lack of presence can hinder or even destroy the therapeutic alliance.

I developed and use a process called the Anxiety Release Protocol (ARP)⁽™⁾. ARP⁽™⁾ allows me to get even the most difficult clients to learn how to self-regulate their symptoms over a 12-week program – but when it fails, a post-mortem always begins with me, and how and why they did not engage. And most often in reflection, I failed to be present in a way that made them feel safe. Taking notes in a session is part of that problem.

No matter your modality or specialty, the core of success lies in how present we are as therapists.

When we are wholly present, we can:

● Foster trust: Clients feel safe and understood, enabling them to open up and engage deeply in the process.
● Detect nuances: Subtle shifts in tone, body language, or expression often provide critical insights.
● Respond intuitively: Years of experience and training allow us to respond in ways that feel natural and empathetic.

The use of AI tools ensures that I can maintain this level of presence while also meeting my professional obligations and having notes that help me provide care for my clients.

Final thoughts

Therapy is both an art and a science, and striking the right balance requires us to be as fully present as possible with our clients. The use of AI-powered tools offers an elegant solution to the challenge of notetaking, enabling us to focus on building authentic, transformative relationships while ensuring our documentation is thorough and compliant.

As therapists, we owe it to our clients — and ourselves — to explore innovations that enhance our practice.

Feel free to explore Upheal’s notes and learn more about ARP⁽™⁾. By embracing tools that optimize our workflows, we can remain fully engaged in the art of therapy, fostering relationships that drive meaningful change.

References and Sources

 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation.
Rubinstein, J. S., Meyer, D. E., & Evans, J. E. (2001). Executive control of cognitive processes in task switching. Journal of Experimental Psychology: Human Perception and Performance, 27*(4), 763–797.

Im, S., Jo, D., & Lee, S. M. (2024). Exploring the Impact of Therapeutic Presence on Working Alliance in Metaverse Counseling. The Counseling Psychologist, 52(5), 698-724. https://doi.org/10.1177/00110000241234630 (Original work published 2024)

Stubbe D. E. (2018). The Therapeutic Alliance: The Fundamental Element of Psychotherapy. Focus (American Psychiatric Publishing), 16(4), 402–403. https://doi.org/10.1176/appi.focus.20180022