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Delivering psychological therapies during Covid-19

Dr Thomas Richardson

The current Covid-19 pandemic has affected everyone’s life, and is putting huge pressure on the NHS; this is especially the case for those working directly with Coronavirus such as paramedics and nurses and doctors in intensive care units. The lockdown has also impacted many different NHS services, and as part of Solent NHS Trust’s ‘rapid evaluation’ of this impact, I thought I’d briefly share my thoughts and reflections on how it has impacted my work.

I’m a Clinical Psychologist; I work in the Mental Health Recovery Teams for Solent NHS Trust in Portsmouth. My usual working pattern involves working with a multidisciplinary team of other psychologists and therapists, nurses, social workers, psychiatrists, occupational therapists, support workers as well as various students and trainees. In my usual week I would normally run a Dialectical Behaviour Therapy (DBT) group for those who have problems with emotional instability, impulsivity and suicidal. I have several meetings and supervision session with colleagues and a number of one-to-one therapy sessions at my base at St Mary’s hospital. My clinical work varies from trauma focused therapy, work with those with psychosis, complex depression and bipolar disorder.

Embracing technology in lockdown

I’ve always embraced using technology in my role: I led the development of our online mindfulness resources on YouTube, and used the Solent Dragons' Den funding to purchase Virtual Reality equipment to help support exposure work in therapy. I like my gadgets! I also often work from home on Fridays when I’m working on the research part of my role. The current pandemic has made these occasional instances become the everyday norm. As with the rest of the UK, we went quickly from 'business as usual' to being told to work from home and only come in if requested. Face-to-face appointments were only allowed for emergencies, so I have to work remotely for my therapy cases. I’m very much used to talking to service users over the phone, but these calls are usually brief, not a full on 50 minute therapy sessions.

I have personally had therapy as a service user via Skype and found that I got used to it quickly, but I have never used video therapy in my clinical role and the thought of only doing it online with my service users was anxiety provoking. Over the past few weeks I have found myself going back and forwards between thinking "How can we possibly go on with business as usual?" and just having quick catch-ups with my service users over the phone, to "I guess we have to try to keep going as much as possible; we don’t know how long this will go on for" and starting full therapy sessions video link software such as zoom.

Some of my clients have been happy to continue therapy online and it is generally going well. There were initially some technical issues but we've quickly adapted. We have a Zoom session at a regular time, and the functions of Zoom mean that I can share my screen to show hand-outs and draw diagrams. For other clients it has been harder, and I think it’s difficult for some service users to remember appointments when they don’t actually have to come into the hospital for them. Perhaps it feels less formal for them. There’s also the broader issue, as one of my clients put it, that with lockdown each day merges into the next, so it is hard to remember what day it is and when your appointment is! For my trauma cases the ‘memory processing’ stage is hard to do remotely, and for two of my clients we agreed to pause until face-to-face therapy could resume. Another is done via an interpreter, I thought this was perhaps a step too far to do this remotely, so we have decided to pause. My colleagues are in largely the same situation; some clients paused, some carrying on remotely.

This unprecedented situation has led us to adapt and try things we wouldn’t usually consider. Kudos in particular to Dr Helen Courtney, who successfully completed an Eye Movement Desensitisation Reprocessing Therapy (EMDR) session remotely with the client watching a video of a dot moving back on forth on his TV via YouTube, whilst Helen observed and spoke to the service user from their computer.

When adapting to technology is difficult

For some service users technological worries play a part in not wanting to do therapy over video and for others there are deeper reasons. Some feel it is intrusive and anxiety-provoking for me to be able to see into their home. Some see the separation of 'clinic' and 'home' as invaluable and I can understand this; having the place you go for therapy, and then being able to go home and continue with your day. When we are all stuck in are homes, there is no separation between the place you go to discuss your worries in detail, and the place you try to relax and watch TV in the evening. In the same way that I am struggling with the lack of separation between my work time and personal time now that I am working from home, some clients are struggling with this in therapy. I have found it hard working remotely from home with three small children in the house; equally some service users understandably are either unable to get a quiet place for a video call, and do not want their children to overhear what is discussed in therapy.

We have tried to do our DBT group online via Zoom. Before we set this up rather than a weekly group we started to record videos discussing the group content, uploading them to YouTube and then texting the link to our clients; not ideal, but the clients said they appreciated the effort we had gone to. The current situation has forced us to innovate, and I hope we will keep these innovations; having the videos of skills online will be useful even when the group meets at St Mary’s as normal as they can be used to help catch up for those who miss a session, or as a ‘taster’ for those who are on the waiting list. 

But it’s not just about the physical distance which can interfere with therapy. When lockdown was first imposed, myself and my family had just emerged from a week of self-isolation having all suffered with suspected Covid-19 symptoms. It was a scary time, and I thought about little else. In a similar way the worries and fears some will discuss in therapy may be eclipsed by the pandemic. Not talking about it feels like not mentioning the elephant in the room, but equally if I do talk about the impact of it on mental health I find myself feeling like a hypocrite; I am at least as anxious about the current situation as my service users. I have moments of feeling helpless, and it felt hard to help my service users cope whilst I was feeling like this.

There are of course some simple psychological strategies for coping with the lockdown; taking one day at a time, planning a structure, using mindfulness, doing activities that you enjoy, keeping in touch with people. However, a lot of us are very much in the ‘same soup’ as our clients, as we are sitting with a lot of worry and uncertainty. We can validate how hard the current situation is for them, whilst also being honest and self-disclosing how the lockdown is impacting us at both a personal and professional level. Our usual goals for therapy are often now not possible as a lot of my work is helping those who are highly anxious to get out more and engage with others (not a helpful goal right now!) Instead, encouraging people to get out and embrace the world has been replaced by supporting them to stay in and cope without others.

Translating virtual body language

So, we continue to take people off the waiting list for therapy; some are happy to start therapy talking to their computer, others want to wait for face-to-face appointments to resume. I can understand opting for remote therapy is easier if you have already met the clinician and have built up a solid therapeutic relationship. But, just like our services users, we are uncertain about when things might go back to normal. 

I am going into St Mary’s occasionally to help with ‘Intensive Case Management’ which is our duty desk. This is another change to my normal role and I have really appreciated being able to connect with colleagues again, and learn more about the challenges of this role. I have also been able to drop off medication and check-in on vulnerable service users during this time; it feels good to do something more practical and hands-on. Doing home visits with full Personal Protective Equipment (PPE) is new to me though, and it can make some service users feels anxious. I can’t imagine doing a therapy session with a mask over my face as the normal automatic facial expressions to communicate empathy and caring are hidden (they are still there on video therapy, although harder to see). According to a BBC article I read, it is much harder to read body language remotely, and this is perhaps why, despite not having to commute each day, I am feeling really tired. My eyes sting after staring at a screen all day, but I know this nothing compared to those Covid-19 frontline staff that I applaud every Thursday at 8pm.

So I and my colleagues in psychological therapies continue trying to adapt and innovate to keep working in the current lockdown. When life goes back to something resembling normal, we shall see what has permanently changed in the way we work. For example, students who go home for the summer but want to continue with therapy - might we be able to offer them remote therapy as we have been doing for the past few weeks?

My work continues; busy as ever, in some ways the same, in other ways completely different. I know that I certainly will appreciate being able to see my service users and colleagues face-to-face again. For now, well, it’s a good thing that I like technology!

About the author

I am a Principal Clinical Psychologist working in Mental Health Recovery Teams in Portsmouth, as well as a visiting academic and lecturer at the University of Southampton in the Department of Psychology. I have a range of clinical responsibilities there, delivering evidence based psychological therapies to adults with severe and enduring mental health problems. As part of my role I lead research and service evaluation within the psychological therapies team and work with the research team.