Offering Talking Therapies Safely During Lockdown and Tier 4 Restrictions...
It is no wonder that mental health issues have spiralled during the period of the pandemic. The Guardian reports on the fact that calls to mental health helplines and the issuing of antidepressants are at unprecedented levels, at the same time as access to talking therapies has plummeted during lockdown periods.
The article goes on to say that more than 6million people in England alone, were prescribed antidepressants between June and Sept 2020 (Pamela Duncan and Sarah Marsh, Guardian Newspaper 01.01.21). Front line staff have been heavily impacted - in North Cumbria, 400 NHS staff cited anxiety or stress as the reason for sickness absence over the past 12months (News and Star report by Phil Coleman). It's the same story everywhere. Not surprising, when at the time of writing, COVID infection rates are topping 50,000 across the UK on a daily basis. As many as 10 million people, including 1.5 million children, are believed to be in need of new or additional mental health support as a direct consequence of the pandemic, according to modelling data from the Centre for Mental Health.
This article, the first in a series of two, is designed to assist in decisions practitioners are making in respect of continuing in-person/face to face appointments or moving sessions to remote working arrangements (i.e. via telephone or video call). As the need for accessible mental health and counselling services has never been greater, in this piece I've summarised the relevant Covid related guidance from HM Govt. and Professional Bodies, to help inform practitioners and provide a basis for the decisions you may make. The second article, available at https://www.solihullwellbeingclinic.com/single-post/lockdown-and-tier-4-restrictions-to-offer-therapy-remotely-or-face-to-face-that-is-the-question offers guidance on how to choose between remote and face to face working, and how to do either one in the safest, most ethical way.
Responding to Tier 4 Restrictions
Tier 4 legislation essentially states that all "non-essential" retail, gyms, leisure and personal care settings must close. The nation is being told to work from home where possible. There is much confusion as to whether mental health services can operate. Remote therapy working is of course a possibility, but even this seems to require additional training and validation through our respective professional bodies and insurance plans.
Continuing with Talking Therapies, Face to Face
We know intuitively that some presenting needs and personal considerations cannot be managed through remote working practices, and where they can we may be limited in what can be offered. Issues of clients who lack private or confidential space to talk at home is one consideration, but also the possibility that trust and relationship insecurities make 'distance consultations' (another phrase for remote working) even more anxiety provoking than they may otherwise feel. How can we begin working with domestic abuse for instance, without seeing the client outside of their abusive environment?
Sensory needs present further obstructions - where there are hearing impairments or the need for direct facial cues, for example. A lack of technology resources or the ability to use them, can cut out the possibility of online video calls - arguably more often the case for older populations who are less likely to have been exposed to computers or internet services at school or through work, but perhaps also where there are learning needs. Whilst telephone sessions are sometimes a solution, so much is lost when we cannot see each other, or reflect on non-verbal cues. And of course, family, couple or child based therapies can be difficult to extend to the remote working space.
Benefits of Remote Working
Where remote therapies are indicated or possible however, they are very useful indeed. They can overcome practicalities of distance, travel and mobility needs; maintain safety in the face of a pandemic; and for some clients add to the generalisability of skills that may be shared, given they may be delivered and practiced in their own home or familiar environment (albeit, through a screen or headset). I have personally found that relationship based therapies are possible remotely, and in some cases having different members of a family (or each partner) on separate screens, can indeed work. However, audio echo or delay, and internet fall out (screen freeze) can be an issue, and also the usual turn taking cues are missing, when clients and therapists are not facing one another in the same room. It becomes more difficult to manage interactions that compromise the safety people may be feeling in therapy, and you may be at a loss for how to respond if someone walks out of the virtual room, not knowing if they are safe or whether they need further follow-up.
When Remote Working is a Non-Option
Where remote working is not a favourable way to proceed, therapists do have an ethical and clinical responsibility to continue seeing clients in person, face to face - pandemic or not. This is especially so where clients were being seeing in person prior to lockdown; where they have been on a waiting list with the expectation of face to face sessions; or where the psychological and emotional needs can't be managed otherwise, leaving the client at particular risk. However, certain factors may still determine the decision to be made - not least any vulnerability needs for clients who may be in a sheltering group, or indeed therapists who are likewise. We all need to consider our home and family set-up, before making the best decision.
Fortunately, there is provision for therapists to offer 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. I know that many of my colleagues in mental health, especially outside the NHS, have not been at all sure whether they can continue with face to face sessions. Whilst the answer is certainly yes there are some caveats. As the guidance is complex, a summarised version is presented below.
HM Government Advice
The Health Protection (Coronavirus, Restrictions) Regulations 2020 states that no person who lives in a Tier 4 area may leave or be outside of the place where they are living without “reasonable excuse” (or without it being “reasonably necessary”). A number of exceptions to the restrictions on leaving home and visiting certain premises are identified, with those having relevance to wellbeing or mental health needs identified below'
Exception 1 relates to “leaving home necessary for certain purposes to buy goods or obtain services from any business or service listed in paragraph 17* [of the document – see below]” with specific reference to “vulnerable persons” or “persons who have a disability”).
Exception 2 relates to the fulfilment of a legal obligation or to participate in legal proceedings (which for some practitioners may include psycho-legal or medico-legal assessments). Exception 2 also relates to the provision of care or assistance to a vulnerable person or to a person who has a disability or to a person who is a victim (including victims of crime). Exception 2 also makes provision for emergency assistance to any person.
Exception 4 relates to medical need etc. where it is reasonably necessary for a person to leave or be outside their home to seek medical assistance, including to access any of the services referred to in paragraph 17(o)* of the Schedule.
Exception 6 relates to support groups of no more than 15 people gathered at premises other than a private dwelling, and where it is reasonably necessary for members of the group to be physically present at the gathering.
*Section 17(o) specifically identifies that Businesses allowed to remain open in Tier 4 areas include (among others): “audiology services, osteopaths and health services” including those incorporating “treatments required by those with disabilities and services relating to mental health”.
You may see the full guidance at this link: https://www.legislation.gov.uk/uksi/2020/1374/schedule/3A
So, from a legal and legislative point of view, mental health services can be delivered in person, face to face, where it is deemed necessary to do so. Now, let's consider what the professional body guidance is. Sadly, there is nothing at the time of writing from the British Psychological Society (BPS) or British Association for Behavioural & Cognitive Psychotherapies (BABCP), but the UK Council for Psychotherapy (UKCP) and British Association for Counselling and Psychotherapy (BACP) do offer their advice.
Advice from the UK Council for Psychotherapy (UKCP)
At the time of writing this article, the UKCP updated it's Coronavirus Guidance on 20.12.20. The UKCP direction is;
“...under existing guidance, there may be scope across the four nations for therapists who feel they need to work in-person to do so – provided their workplace is Covid-secure...”.
The UKCP also states that in England, restrictions vary by region. Under the strictest ‘Tier 4’ restrictions, public services ‘provided to victims’ are permitted to stay open if following Covid-19 Secure guidelines and ‘support groups that have to be delivered in person can continue with up to 15 participants where formally organised to provide mutual aid, therapy or any other form of support - but they must take place at premises other than a private home.’
So the UKCP does support the provision of in person, face to face therapies. The question is, do you have a Covid-secure workplace, from which to practice? if you are in statutory services such as the NHS, within a Local Authority or mainstream Third Sector (voluntary and charitable) agencies, it is very likely that Covid secure measures are in place. If you are renting a clinical space, for example in the private or independent sector - or indeed if you offer services from home - then you will need to have a formal Covid risk assessment in place, with measures to reduce the risk of infection being clearly communicated and monitored.
To see the UKCP guidance in full please see https://www.psychotherapy.org.uk/ukcp-members/standards-guidance-and-policies/coronavirus/
Advice from the British Association for Counselling and Psychotherapy (BACP)
The BACP offer some of the clearest guidance available, in their document entitled "Coronavirus and your practice : Guidance for members 23.12.20".
This document provides the latest Covid related updates and information for counselling and psychotherapy practitioners. It reiterates what has been said before in this article, that in England, there is an exception under the ‘gatherings’ legislation for providing assistance to a vulnerable person or “to enable one or more persons in the gathering to avoid injury or illness or to escape a risk of harm”. BACP states that meeting in person must be reasonably necessary to prevent a client from harming themselves or suffering physical or mental illness.
Crucially, BACP recommends individual counsellors and psychotherapists check with their indemnity insurers that their practice is covered and that their supervisor agrees with their decision to see clients in person/face to face. This is sound advice, not only to safeguard yourself as a professional but also to be thorough in how you set up services in this unprecedented period of time.
The BACP also echoes the HM Govt. guidance regards support groups summarising it in the following way;
"Support groups that have to be delivered in person can continue with up to 15 participants where formally organised to provide mutual aid, therapy or any other form of support - but they must take place at a premises other than a private home. This includes, but is not limited to, support to victims of crime, people in drug and alcohol recovery, new parents and guardians, people caring for those with long-term or terminal illnesses, or who are vulnerable, people facing issues relating to their sexuality or gender, those who have suffered bereavement, and vulnerable young people, including for them to
meet youth workers."
To read more on this subject, particularly around how to make decisions about working remotely or working face to face, and how to create a Covid-secure counselling and therapy environment for in person appointments during the pandemic, do please read the second article in this series available at https://www.solihullwellbeingclinic.com/single-post/lockdown-and-tier-4-restrictions-to-offer-therapy-remotely-or-face-to-face-that-is-the-question
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.