Lockdown and Tier 4 Restrictions - to Offer Therapy Remotely or Face to Face - that is the question!
What a trying time it has been for us all, since the pandemic hit. To different degrees, we are all contending with worries regards our health and wellbeing, together with that of our loved ones. The usual buffers of social gatherings, family get togethers, down-time at the gym or visits to the pub or restaurant have all been severely curtailed - in many cases, lost altogether. Even in work, we are more isolated than ever before as we busy ourselves remotely, find ourselves on furlough or manage demands of being a care worker, at the coal face. Those more unfortunate still, may have lost their livelihoods altogether.
Saving physical life is of course the priority - but mental health severely impacts quality of life, and in some cases we know it can lead to life-limiting health consequences too. Heart disease and cancer are just two conditions we know can be exacerbated by psychological stress. It is more obvious that eating disorders, suicide and drug or alcohol dependance may lead to actual loss of life, or alternatively, significant and enduring medical needs. Loneliness and isolation are already known to be the silent killers, the world over. How is it then, that Psychologists, Counsellors and Psychotherapists are not seen more definitively as front line workers, in this troubling time?
The Importance of Talking Therapies
The uncertainty and loss of normal routines and support networks during the lockdown period is laying siege to our emotional health. There are issues of complex grief to manage, after the death through Covid of loved ones. Stress levels for students and teachers is debilitating, as they limp between constantly changing sets of demands and expectations. In households characterised by domestic abuse, poverty or conflictual relationships, the world feels less safe or fulfilling than ever before. And, there is also the psychological fall out of long Covid for those in recovery from the virus. Dr Adrian James, President of the Royal College of Psychiatrists. points to the cumulative impact of the disease itself, together with the social consequences and economic fall out that follows an epidemic of these proportions. He is right to do so.
Continuing with Talking Therapies, Face to Face
It has been difficult for many people to access talking therapies, for a number of reasons. Whilst remote therapy has been possible, we know intuitively that some presenting needs and personal considerations cannot be managed through working practices at a distance. Fortunately, there is clear provision for in-person, face to face meetings if this is deemed necessary or reasonable, as per advice and guidance from the Government across all 4 nations of the UK. As the guidance is complex, this has been summarised in the first article of this series, available at https://www.solihullwellbeingclinic.com/single-post/offering-talking-therapies-safely-during-lockdown-and-tier-4-restrictions
Helpful Advice from the
British Association for Counselling and Psychotherapy (BACP)
BACP advises members to read the Government guidance before providing face to face therapy, and recommends working remotely where possible to reduce the risk of Covid-19 infection. What is really helpful about the BACP document is that it offers a decision-making process, which counsellors and psychotherapists are encouraged to adopt for each of their cases/clients, before agreeing in-person / face to face appointments. The decision making should include a review of the following factors:
the client's need and safety
your need and safety
the context of the service
the premises you practise from
whether other options are possible and the ethical and practical risks of any decision
the known risk factors of age and any pre-existing health conditions for both yourself and your client
particular needs of clients who may not be able to engage using online platforms or by phone
whether any risk to the client, either from others or from themselves. can be managed remotely
your supervisor’s feedback
your insurance cover
There is some very helpful additional guidance from BACP if you do choose to offer services remotely;
you should seek and receive dedicated training before working online, to manage the many practical issues that need to be considered, as well as significant implications around how people may (and do) present differently online, communicating and responding in ways that may not be expected.
telephone or online counselling might be an acceptable option if you consider the following points:
that the reason for doing so is to prevent the spread of the virus. If either party is experiencing symptoms of coronavirus the best option may be to take a break from therapy until fully recovered
you are competent to deliver remote therapy
remote working is suited to the needs of the client and the material being discussed, with the proviso that telephone or online therapy may not be suitable for all clients or certain issues
your supervisor is competent to supervise online practice
for older clients who do not have access to, or experience of, video-calling, continuing sessions by telephone may be the best alternative to face to face sessions.
data protection and confidentiality obligations need to be managed, including provision of a safe and confidential space to work from where you can’t be overheard or overlooked during sessions. You'll also need to ensure that you have all the necessary equipment and that the solution you're using is secure
approval from your insurer, after you have informed them of the planned changes to your practice, including working online
consideration of being registered with the ICO (Information Commissioner’s Office)
Creating a Covid Secure Practice for Face to Face Sessions
But as already indicated, there are number of reasons remote therapy is either not a viable option, or contra-indicated for certain individuals and presenting needs. If therapy and counselling truly are collaborative enterprises, we can't offer 'a one size to fit all' approach. Neither would it be clinically ethical or professionally responsible to do so. That's where we need to consider making our face to face environment covid-secure.
Therapists and counsellors who have considered the Covid situation and guidance carefully, may well decide to proceed with in person, face to face sessions. In doing so, there is a need to take certain precautions. You will need a formal risk assessment (contact me if you'd like to see a copy of one I use), in which the measures you are taking to manage risks are detailed and available for users to access. Some of the key aspects of the risk management plan I use include;
signed Covid-free declaration forms from clients and from other therapists/practitioners who may share your space. This declaration should make it clear when clients should isolate or quarantine (seeking medical advice as necessary) and what they should be mindful of when they attend the session
making use of a system of pre-booked and staggered appointment sessions, to reduce overlap and maintain social distancing
clear signage in your practice venue to deter entrance if Covid-19 symptoms are present; to maintain social distance on entry; the compulsory wearing of masks (unless an exemption request is made prior to the session) and the need to sanitise hands (with gel being made readily available at the entrance/exit point)
use of NHS Covid App/QR Code on entry, which will mean having the QR code printed for smart phones to scan, in a visible place
offering psychotherapy and counselling only in rooms that afford 2metre social distancing, and can be ventilated during sessions/between clients
avoiding seeing clients with additional risk factors, where possible
offering separate tissue boxes in consulting rooms for clients and therapists
sanitisation gel being available in the consulting rooms
sanitisation wipes being placed in rooms for all therapists/practitioners to clean touch points and surfaces after sessions (and before, if they are so inclined)
provision of hot water and soap in rest room facilities, with disposable towels and regular emptying of bins
a hygienic building environment in which additional daily cleaning of all surfaces and touch points is undertaken and the regular airing of the building and consulting rooms is managed.
advice that refreshments are not on offer (unless in an emergency), and clients should bring a drink with them, if they may need this.
It seems a lot, but if you have access to a venue like mine at Solihull Well Being Clinic, or you can ask the owners of the therapeutic building you use to emulate these provisions (or if you practice from home, you can incorporate these ideas into that milieu) the risks can be managed and our need to be available to clients in a range of ways (both in person and remotely) can be achieved. Above all, we must keep ourselves and each other safe. Things will get easier in time, as the vaccination programme gets underway. Clients with mental health needs should not suffer needlessly, as we try to square the circle that Covid presents.
Dr Bobby Sura
Consultant Clinical Psychologist and Psychotherapist
Dr Bobby Sura is a Consultant Clinical Psychologist specialising within the field of lifespan and family based mental health needs. He has over 20yrs NHS experience and 16yrs in the private sector, being the founder of Clinical Psychology Direct and Director for Solihull Well Being Clinic. Bobby is Chartered with the British Psychological Society (BPS), Division of Clinical Psychology (DCP), Health and Care Professions Council (HCPC) with eligibility for registration with the United Kingdom Council for Psychotherapy (UKCP) and Association of Family Therapy (AFT). He manages a large service in Hall Green, Birmingham, with a range of Counsellors, Psychotherapists and Psychologists who offer their services on a private, fee paying basis.