Doing Remote Systemic Psychotherapy during COVID-19: some practice ideas

3 April 2020

As for many other health and social care professionals, the coronavirus pandemic has changed the way that systemic psychotherapists work. With weeks or months of lockdown looming, we cannot practice with families and groups in the ways that have been carefully developed over the last years and decades. In just two weeks, all but essential face-to-face contact between psychotherapists and patients and clients has had to stop. Crisis mental health services have been set up and reorganised to provide services to those most in need and most at risk. 

What follows is guidance developed over this short period by clinical and training staff at the Tavistock and Portman NHS Foundation Trust, regarding practicalities of providing systemic psychotherapy remotely via video link. Organisations across health, education, social care and the voluntary sector are using a variety of platforms to enable staff to connect via video conference. At the Tavistock we are using Zoom via Trust accounts and this has been assessed as secure enough to conduct both clinical and training activities. Recent NHS guidance has emphasised the importance of maintaining a connection over worrying about which platform to use.  

This guidance was written at the end of March, and we are aware that by the time you read this, we may all have gained in knowledge and skills through our use of the new technology in talking with patients, but we hope these thoughts might still be useful to you during this transitional period. And we hope that we can share what is working and learn from each other as we find ways to maintain and build relationships in coming weeks and months. 

Providing medical and general practice consultations online is not new and there has been a large amount of research into how it is ‘different’ to face-to-face contacts. (Greenhalgh et al 2016, Greenhalgh et al 2020, Seuren et al 2020). Likewise, psychotherapists have been providing a variety of forms of psychotherapy for years (see for example Ragusea and VandeCreek, 2003, Chipsie et al. 2019, McDonald et al 2019, Roddy et al 2019). Some systemic practitioners have been providing video-based psychotherapy for years but little has been written about this to date. For many systemic practitioners, working using video consultation this way will be very new. There is a small body of research and practice-based evidence we can draw on to guide our practice in delivering online psychotherapy, which emphasises how online work is different processually and thematically. That body of research informs our thoughts below.  

Initial setup for doing systemic psychotherapy work remotely

Moving to online therapeutic work is likely to be more straightforward with families with whom we have an existing therapeutic relationship than those we are starting to work with. But starting off this way, probably after an initial telephone conversation, is not impossible. And obviously it will be unavoidable in the coming months. 

Issues of similarity and difference have to be considered first as we move online. This relates to familiarity with technology, to ownership of devices that can handle making video calls, and to having the resources to have data or a WIFI connection. Not all staff or patients have these things. Issues of privilege also quickly emerge when we start to see the intimate details of people’s living circumstances. Yesterday a colleague sat on her bed in her shared flat while we had supervision. Her headphones were clearly irritating her head, as she talked carefully and quietly so that her flatmates did not overhear confidential material. I (Sarah Helps) had the luxury of sitting in my kitchen with a newly bought WIFI booster, safe in the knowledge that I could talk freely. 

What follows is a series of recommendations based on the evidence and on practice-experiences to date:

Preparation for clinicians

Access and Inclusivity: Are there any learning, sight, hearing or other issues of disability for staff or patients that need to be taken into account for access? 

Risk assess based on what you know: Are there any indications that it might not be safe to meet via video (e.g. concerns about violence, dissociation).

Setting a containing boundary around your workspace: In both practical and psychological terms, working remotely involves some blurring of boundaries. How can you signify to yourself and those who might be around you at home that you need confidential space and are in work mode. This might involve getting ‘dressed’ for work, putting up a notice on the door of the room that you are working in, wearing headphones to keep the conversations as confidential as possible.  

Changes to what we can see: Video working might offer a much more visible, mutual and transparent process as our patients see us as we sit in our kitchens and studies to conduct a session, and this will affect the balance of power in the therapeutic relationship, which will need discussion. Think about what’s behind you and visible and talk to this different way of being together. Some video packages offer virtual backgrounds so as to create a more neutral-looking space. 

How do you usually establish rapport? What will you need to do differently with your usual ‘script’ in order to establish rapport in this context? 

How do you usually use your body? What might you need to do more or less of? Our nods and head shakes have got progressively bigger and my smiles and frowns have become exaggerated so that they can be seen on a small screen. Waving, thumbs up and thumbs down has quickly become professional parlance. Some recent research suggests that showing more of your body - not just your head and shoulders - can help the flow of communication. Try pushing your camera back a bit. What difference does this make?

Beginnings and endings: I suggest having a different formality and need specific visual and verbal rituals. If you usually have some physical contact with a family at the start or end of a session – a handshake, a touch on the shoulder – what might be a virtual way of creating this? 

Issues to discuss with the family:

Being more active: The therapist is likely to have to conduct the session in a much more active way than they might usually do – for making explicit who might talk next, setting parameters for who can talk for how long. Note that you will probably ask more questions in lieu of being able to ‘feel’ what is going on in the room. Embodied responses might get altered or misread through the screen and might need to be checked. 

Initial questions to ask: Is there a safe space to conduct the call? Who else can hear? Who is ‘in charge’ of the devices on which the call is connected? Is there reliable broadband? Device chargers at the ready? 

Ensure device microphones can pick up all voices: If this is hard – who will be spokesperson? What will that do to the communication?

Using one or multiple devices: Just like a professional team meeting, if family members each have their own device and sufficient broadband capacity, and are able to do so, it seems to work best with everyone on their own separate device, and to manage the session so that everyone can see everyone else’s faces.  

What to do in case of distress or escalation: Establish this as part of the contract very early in the conversation, for every participant. What’s the plan if someone decides to hang up? 

How issues of risk will be managed: How can this plan be discussed and agreed and shared? 

How to ensure voice entitlement for everyone: Make use of the ‘raise your hand’ facilities in some video consultation platforms and develop a virtual talking stick.

What will happen when the call goes ‘wonky': What’s the plan if there is lag? We probably all have experiences that are supposed to be synchronous that are anything but, when there is lag in a video call or when the screen temporarily becomes pixelated and then jumps. Naming and agreeing what to do about this is a vital. 

Length of the session: So far, families seem to like shorter, more frequent sessions. On the Zoom platform, the call ‘times out’ after 40 minutes. 40 minutes may be enough for many families and therapists because the concentration required with video is different to that in the room. Or you may use the 40 mins then have break/ team discussion then reconnect of necessary.

Drawing or mapping activities: If you usually draw in a session, how might you continue to do so and share your positioning compass / genogram / whatever with the family as you go. This can be done by simply holding what you have made up to the screen or via ‘share screen’ if using Zoom. Therapists and families might want to put together a therapy session box where they keep their own materials / toys / drawing tools. 

How reflecting conversations might be managed: Family therapists are used to working in teams, whether the team is in the room or behind the screen. Working over video affords the same environment. Social distancing can be achieved by the team each joining via separate screens, and sitting with microphones muted while the family talk with the lead therapist. Then, the reflecting team can talk while the family are muted and listening. 

Topics that have been common in systemic sessions as the pandemic unfolds: 

  • How to address children’s worry about the virus – being realistic and hopeful, utilising the many videos, social stories and guides that have been published in recent days 
  • How to manage when it gets emotionally hot at home
  • Building safety and attachment at a time of full of fear, loss and disconnection
  • Managing teens who don’t want to stay in
  • Having life and death conversations and talking about advance decision making what people want to happen if they get very sick
  • Getting children to work, now that schools are closed
  • Enjoying the family time
  • Keeping safe in family situations that are not safe
  • Managing issues to do with alcohol and drug consumption, access to illicit drugs, sex 
  • Dealing with illness in those far away – ways of keeping connected
  • Government guidance and concrete thinking – e.g. is it OK to take two short walks rather than a single hours’ exercise?
  • Activities outside the house that take account of physical distancing – walking / running / picnics
  • Resetting family rules about chores, screen time etc
  • Contact between parents and non-resident children
  • Supporting the facilitation of contact between children in care and families: Most contact centres have shut and local authorities are working very hard to find ways of maintaining contact between children and parents. 
  • Giving each other a break and being kind.

Recordings sessions

Recording our work when communicating via video needs discussion. We are in the most part used to being in control of the recording. Now, both patient and family might have the possibility to record. Different video platforms have different settings regarding who can record. Even if there has been agreement about why the sessions are to be recorded, this can often be forgotten about (Brown, Moller & Ramsey-Wade 2013) and needs further discussion about how and why the recording is being made (this will differ for different actors), how the recording will be stored and who it will be shared with. 

The benefits of having a recording are many. Having a recording of the session might be very helpful for patients with additional needs, those who want or need time to process the information discussed or who want to share a session with a person who could not join. It will also help the therapist, whether trainee or qualified, have naturally occurring material that they can discussion supervision. 

Sending email therapeutic-letters has so far proven useful and well-received as a way of recording some reflections and ideas for sessions. It also serves to show that we are keeping people in mind between the contacts. Some teenagers have asked for a list of questions in advance of a video conversation, which takes some careful and tentative planning. 

Looking after ourselves

COVID-19 is a personal as well as a global challenge. Many of us will be affected as we or those we love become ill. It is vital that we look after ourselves and supervision is a key part of this. Giving and receiving supervision via video link is very common and generally effective (Pennington, Patton and Katafiasz 2003). As well as ensuring we stay connected with our supervisors for the personal professional aspects of supervisory conversations, we can also effectively use online tools to share aspects of our clinical work. Sharing recordings of clinical sessions for review and discussion within retrospective supervision is possible using video screen sharing tools. Working remotely seems much more exhausting, partly because of the new and anxiety-filled context and partly because we lack the embodied, intra-active felt experience of the other, on which we rely so heavily. We will need to develop ways of bringing to language this aspect of our practice. 

Further steps in making remote ways of working work

As experts in patterns of communication, we already know that the frame of the conversation will affect how we present ourselves (Goffman, 1956). We know that all communication is a complex social interaction which is particularly intense in the doctor / therapist - relationship (Iedema et al. 2019). When our usual channels of information change, there will undoubtedly be miscommunication and misattunement. We already work with feedback, we are used to reviewing and revising and checking back. These well-honed skills will be crucial in this time of rapid change. 

Within the past couple of weeks, excellent guidance has been published about how to work during the pandemic (see the joint statements from AFT and others, below).

We don’t yet know what the mental health and relational implications of Covid-19 will be. A recent review paper from the NationalElfService unsurprisingly suggests that quarantine can have a range of negative impacts on mental health. We know from our own lives that anxiety has increased as our world temporarily closes in, as exams are cancelled, as routine health appointments are postponed, as we can’t get to see or indeed hug those we hold dear. We don’t yet know whether mental health service use will increase, remain static or decrease as the pandemic evolves. We don’t know if family communications problems will intensify or whether, in this time of crisis people will find different ways of being with each other and managing strong emotions. There are anecdotal newspaper reports that domestic violence is increasing. It seems likely that where there was risk before, this will still be present. 

We don’t yet know how families will cope with online service delivery. Not all therapists or patients will find a fit with online therapeutic intervention. Issues of high risk, dissociation, difficulties using technology are just some of the known barriers. This list will undoubtedly be refined in coming weeks and months. Likewise we can’t yet know what the clinical, practical and ethical issues of working in this new way will be, in the context of what seems like a chronic sprint to achieve change. It is equally possible that some patients, including families and groups from more marginalised communities, or those where there is a person with an autism spectrum condition, might even find online access more flexible and indeed beneficial (Benford and Standen 2009). 

Not all families will want to engage in remote video sessions. Despite the barrier of the screen, an unusual intimacy can be experienced which leads to conversations feeling ‘too’ intense, leading to a switch to just using audio channels. Again, regular discussion of what is working and what is tricky is vital. 

An online way of working will rapidly become ordinary practice. For psychotherapeutic services and specifically within the systemic discipline, future trainees will be taught about the ethics and practice of using telehealth care to provide systemic psychotherapy training and service delivery. Current trainees and clinicians are therefore at the forefront of developing models of what works safely.  This new way of working will have huge impact for the future, for research and practice. Stay well and stay safe. Physical distancing does not mean that you can’t make contact and connection. Be creative and look after yourselves and each other. 

Sarah Helps, Conny Kerman, Carol Halliwell, Heads of systemic psychotherapy, North London.

This blog was originally published on the Systemic Thoughts website.

References

Benford, P., & Standen, P. J. (2009). The Internet: A comfortable communication medium for autistic people?. I: Journal of assistive technologies3(2), 44-53.

Goffman, E. (1956) The presentation of self in everyday life. New York, NY: Doubleday

Greenhalgh, T., Vijayaraghavan, S., Wherton, J., Shaw, S., Byrne, E., Campbell-Richards, D., … & Hodkinson, I. (2016). Virtual online consultations: advantages and limitations (VOCAL) study. BMJ open6(1), e009388.

Greenhalgh, T., (2020) Video consultations: a guide for practice retrieved from https://bjgplife.com/wp-content/uploads/2020/03/Video-consultations-a-guide-for-practice.pdf 24.3.20

Iedema, R., Greenhalgh, T., Russell, J., Alexander, J., Amer-Sharif, K., Gardner, P., … & Roberts, C. (2019). Spoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?. BMJ open quality8(3), e000742.

McDonald, A., Eccles, J. A., Fallahkhair, S., & Critchley, H. D. (2019). Online psychotherapy: trailblazing digital healthcare. BJPsych bulletin, 1-7.

Pennington, M., Patton, R., & Katafiasz, H. (2019). Cybersupervision in Psychotherapy. In Theory and Practice of Online Therapy (pp. 79-95). Routledge.

Ragusea, A. S., & VandeCreek, L. (2003). Suggestions for the ethical practice of online psychotherapy (Vol. 40, No. 1-2, p. 94). Educational Publishing Foundation.

Roddy, M. K., Rothman, K., Cicila, L. N., & Doss, B. D. (2019). Why do couples seek relationship help online? Description and comparison to in‐person interventions. Journal of marital and family therapy45(3), 369-379.

Seuren, L. M., Wherton, J., Greenhalgh, T., Cameron, D., & Shaw, S. E. (2020). Physical Examinations via Video for Patients With Heart Failure: Qualitative Study Using Conversation Analysis. Journal of Medical Internet Research22(2), e16694.


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