Developing the therapeutic relationship remotely 

24/04/2020

Developing the therapeutic relationship remotely  

With the current ongoing pandemic, many of us are managing consults and therapy sessions remotely. Aside from working for Maudsley Learning I also work as a relationship counsellor and have moved my practice web-based. Here I will consider some streamlined general reflections since moving remote, and in respect of the pragmatics of maintaining a therapeutic relationship in a new world under lockdown.  

This article overall contains eight sections:

  1. Recognising General Anxieties and how this may affect remote working
  2. Practicalities of set up 
  3. Preparing therapeutically for remote contact 
  4. Considering Ethical and Safe Practice with the worst-case scenarios from the get-go 
  5. Setting the scene to the consultation
  6. Adapting and responding to non-verbal cues 
  7. Adapting and responding verbally 
  8. Considering Speed and Disclosure 

..and is intended as a starting platform to consider adaptions I have been thoughtful of.

The Royal College of Psychiatrists and therapy and counselling organisations such as UKCP and BACP also have evolving guidance to consider during Covid-19 on how to safely care and alter practice when we are not meeting face to face. I include reference to these resources at the end of this article and a organisation Standing Together who have provided specific advice on working around Domestic Violence. I also include a quick summary checklist.. but first let me start from the beginning of my reflections..

 

1. Recognising General Anxieties and how this may affect remote working 

Use of: Having flexibility and structure/Checking own well-being/Seeking supervision 

Currently we are facing a time of uncertainty, and so any steps that we can take to be empathic to this situation are important. This starts with ourselves, and continues to our work with clients; being curious to what client’s needs may be and how to offer flexible adaptions is essential. Wherever possible, the use of structure can help contain difficult experiences, hence a working checklist has been created at the end of this article– and use of guidance is advised.

Working remotely is not only around the clinical ten minutes or hour spent on the phone or online, and it is important to consider one’s own wider well-being in the new working world, and how this can be supported. You may also like to view ML video on working from home. 

Starting reflections here is only a first step, and considering who may support in one’s wider working life is also relevant. Seeking a relationship to handle managing other therapeutic relationships may mean discussing the move to remote working with a supervisor or manager, for example. 

 

2. Practicalities of set up 

Role in: Selecting a Platform/Trialling a Platform/Advising on a Platform/Collecting Contacts/Using 141 

There are several options for web-based working. Organisations may vary in what package they recommend, so this may be outside of choice for many of us. In counselling and therapy organisations, I know a lot of people have moved across to zoom as a platform – and in the NHS, many are also using Microsoft teams. Thought has been placed into encryption of data to maintain a confidential working practice, and pragmatically this caution remains the same to emphasize with clients.  

Prior to using a platform, it is useful to have a trial run to see that setup occurs correctly, with audio and video checks from your own device. To ensure smooth running it may be helpful to create a few pointers for clients on how to use the service themselves, and how you will manage if you do not connect on the day- e.g. alternatives available with phone. Contact details are helpfully triple checked with email and phone information. 

There may be preference to use a phone, and when outside of organisational use, it is wise to enter 141 prior to a phone number to ensure personal phoneline security. 

 

3. Preparing therapeutically for remote contact 

Reflecting on: What has changed for the client and for yourself by working online 

In counselling, it is often helpful to think through supervision where one is placed with a client to provide care. In preparing for remote contact, it can be helpful to reflect ahead of time what working remotely may mean for yourself and your client. What are each of your potential relationships like with web or phone-based working prior to this contact? How may working this way affect the relationship?  

A tool known asThe Seven Eyed Supervision Model’ was developed by Peter Hawkins and may offer a model to reflect prior to remote work: 

Step of Model 

 

Point of reflection for remote working 

Client Focus 

  • What ideas, concerns, and motivations may the client have to our meeting now remote?
  • How can I ascertain this information e.g. verbal questioning and non-verbal observation? What may be limited in ascertaining this information by remote working?

Possible Interventions 

  • What interventions am I using with my client? Can these be used remotely or how may they be adapted? 
  • Why may I be using certain interventions over others? Is this affected by remote working? Are there other interventions I could use? 

The client- professional relationship 

  • How do my client and I interact with one another? Has this been altered by remote working?
  • How may this interaction vary from other interactions when moving remote?

Your own professional process 

  • What are my thoughts, feelings, and behaviours in response to the client? Has this changed with remote working?
  • How may I become aware of this process? How may my awareness be impacted by working remotely? Do I have other tools at my disposal- e.g. the ability to make notes on the telephone?

The professional- supervisor relationship 

  • What ways may discussions regarding the client with a supervisor (colleague – manager*) echo concerns with the client? Has my relationship with my supervisor * changed by working remotely? 
  • How am I discussing the client? Am I noting how I feel? What may I be omitting to discuss?

The Supervisors process 

  • What may a supervisor * discuss when considering the client? Has this changed in remote working?
  • What may a supervisor feel or notice in discussion? 

Wider Context 

  • What professional contexts may impact on practice currently? E.g., which organisation I work for, ethical guidelines, regulatory bodies.
  • What personal contexts may influence my client and myself? E.g affect of working from home

 

4. Considering Ethical and Safe Practice with the worst-case scenarios from the get-go

Focus on: Awareness and support for cases that cannot work online/Adapting around childcare/Discussing maintaining safety around disclosure

It may not be appropriate to work with certain clients currently by phone or online – e.g., with young children receiving therapy where play is usually utilised. How can these clients be supported otherwise? E.g. signposting to helpful general information and welfare calls to end contact. 

For other clients, what may childcare represent? It would not be ethical to work in certain contexts with a client with a child on their knee thinking with clients on how childcare can be available to enable the consult can be useful. Is there someone at home to look after the child if they are young? If they are older, does the child know to stay away from the room? Can the client wear headphones?

It is of utmost importance to consider how remote working may alter managing safety issues, including disclosures of domestic violence and child protection, or concerns regarding acute risk such as suicidal intent. Therapeutic organisations offer suggestions, and it may be something to consider privately in supervision*. Check with teams, when present, on what process considerations may look like to work remote, and any new policy around this. Who would you consult with now, and how may one hypothetically manage risk by phone or web-based practice locally?

 

5. Setting the scene to the consultation

Checking on: The Environment- both sides/ Use of technology/Awareness of and how to review the process

Prior to a consult, it is helpful to consider what one’s environment may represent remotely on the day. Simple measures on lighting and wearing clothes that are plain may help the visual quality of working with clients through a screen. It’s also important to consider how one can keep the setting as quiet as possible and free from any distraction, and also critically how to ensure client confidentiality.

In opening the consult, consider adding a review of what technology may mean. Reminding clients how to work through any technological concerns as part of the ground rules for the session, both web based or if the phone were to cut out, is crucial

It is also important to check what the working conditions may be like from the client’s side – are they alone or is there anyone else there? How can you try to limit distractions or interruptions for the session? Check again that children are not privy to adult consultations.

Some signposting prompts on how the verbal and non-verbal communication may differ can also set the clients understanding in regard to the differences in practice that may be observed. For instance, in my work with couples or families, I note how I will be using names much more often to direct the conversation, as we cannot see through eye contact and gestures who I may be responding to (see points 6 and 7). 

Lastly, it can be helpful to open with the assurance of how a platform may be working, and use the client in feedback in regard to any difficulties experienced remotely. This can be useful in order to work together on joint frustrations, rather than have technological error be seen as a fault of the consult itself. 

 

6. Adapting and responding to non-verbal cues 

Working with (or without): Eye contact/Body Language/ Pauses

Webbased work still has a benefit of some non-verbal cues to working, but it is interesting to consider how this may differ to being face to face.  

  • Eye contact – as above, one may be unable to use this to direct between clients if more than one person is in the so session, so being explicit with the use of names is helpful. Where possible, making attempts to look at the camera and away from the main screen will give the impression of responding directly to clients. One may find it less easy to interpret a clients lack of eye contact, but this could be observed as looking away further from the screen or looking down. 
  • Wider body language – large parts of the body may not be observed through a screen. Setting a further distance may help with this, but it needs balance to see the clients face. As a client cannot see one’s hands or potential moving of the body that could be therapeutic, the use of facial expression takes further importance, such as nodding or leaning in.  Asking about changes in a clients positioning needs to account for working online. A movement may have a practical rather than observational relevance. Curiousity remains key to note your presence to the client. 
  • Pauses – ensuring here that there is no loss of technological contact is important in addition to acknowledgment. 

By telephone, the loss of non-verbal content can in turn lose a lot of observational input. Prompt to

ask aboutthe use of space, and what the client has at present around them. For example, whether they are sat comfortably and have a drink available can offer lots of additional information, as can getting a understanding of what their day or week has looked like. 

 

7. Adapting and responding verbally 

Managing Silences: Verbally Encouraging/Permitting/Acknowledging

While the same verbal skills are beneficial therapeutically when working remote, e.g. respect of question variety, use of paraphrasing and summaries-core differences fit around the management of silences, which can often increase- or feel to increase.

The following may be useful: 

  • Verbal encouragement, e.g.,mhmm‘, ‘ah’
  • Giving permission, e.g., ‘take your time’ ‘I’m here to listen
  • Own acknowledgement, e.g., ‘I’m just taking time to think about what you said’, ‘Can I check what may be going on for you now?’ 

With the absence of non-verbal cues, these adaptations and responses are even more important for telephone working.  

 

8. Considering Speed and Disclosure 

Understanding and adapting to pace and focus change

By telephone, clients may feel that they need to move faster in a consult and intellectualise concerns, or that they can share more feeling in response to being in a remote environment away from face to face work.  Many counsellors have noted that remote working can move faster, with increased rates of disclosure.

For considering how the pace or nature of work may have altered, it can be helpful to review this with a client,such as whether they have noticed a change, and what this may mean for them.  

When considering moving to either extreme, working mindfully may involvetaking the opposite route in to consideration. Where an interaction has noticeably become process focussed or intellectual, how can one reconnect to the feeling and experience of the client by asking around this? In reference to a self-disclosure, how can one check carefully a client’s comfortability and how it is safe or not to explore? Key points here would also be considering how to end the consult, and grounding activities such as breath work focus. 

On that consideration of ending session I will end my own reflections with a suggestion for a bit of mindful breathing. Good luck on managing all your consults remote, and please also see the checklist attached below with resources and helpful links.

Checklist and Guidance Resources

Article Author: Dr Camilla Tooley