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.