First, you might want to play this song while you read. Thanks Patricia for the mood music!
Unfortunately I can’t do hyperlinks within a post in this version of WordPress so I’m sorry for difficulty navigating. There is unlimited room to add to this. If counsellors would like to include any specific learning from their experience please let me know – I can only get my hands on CBT folks at short notice! Roughly the post is organised into:
- Setting up an appointment
- General skills during an appointment
- PWP/IAPT specific notes
- High Intensity CBT specific notes
- Links to online resources
Welcome to the first NaG post written from the self isolation couch. I promise that the cough wont transmit through the keyboard. Please be kind and remember, if there’s anything strange or this is a bit incoherent, I’m writing through a fever. As always please assume that any mistakes are mine. I’ll embed content where I can but some of the most helpful threads will work better as screen grabs, please bare with me if the formatting is a bit off, I’m new to this website malarkey! A link being in this post does not mean that the people at the other end endorse what I write. If I’ve included a link to your site and you want me to remove it then please let me know. Thank you to everyone who has contributed ideas and resources to this post, I hope credit will be clear but if you think I’ve overlooked something please let me know and I’ll fix it.
This is a long post, I don’t think many people will read all of it. If there’s one message to take away its this; grab your nearest PWP/LIT (not physically, maintain 6ft distance please!), make them a cuppa, provide a chocolate biscuit or send a few nice emoijis, and pick their brains about working on the phone and by other electronic means.
We’re in uncertain and fast-changing times and talking therapists are having to change the way they work very quickly. We thought we had weeks, maybe months to adjust to social distancing measures and keep services running when people can’t be in the same place, but it’s all happened much faster than anticipated. There hasn’t been time to run training sessions and put support in place for people who are suddenly plunged into a new way of working. I want to use this post to provide a resource for people who are new to, or uncertain about, telephone and online working. I imagine this is a post that could keep evolving – it’s easy to add, remove and edit content so if you want to contribute anything to this resource please just get in touch in the comments here, or on Twitter.
Low intensity therapists (LITs) have been providing their interventions through a variety of delivery methods for years now. This works well for manualised CBT-based work that has an emphasis on session structure and skills teaching and practice. I can’t comment on how more relationship focussed modalities would be affected by working remotely, I’ve never trained in those therapies but my gut tells me that it’s probably do-able? I’ve suggested to trainee LITS/PWPs that working on the phone uses the same skills as working with someone who has a visual impairment; plenty of non verbal signals don’t rely on sight: pace, tone, choice of words, reflection, summary and verbal empathy, the use of silence.
Setting up and confidentiality
- Make sure you’re comfortable, have a drink to hand, use earphones or a headset if you can. Decide if you’re going to hand write or type your notes as you go.
- Consider ringing from a withheld number. You can let your client or patient know that you will do this so they know to answer a call from a blocked number at the time of your appointment.
- Make sure you block your personal mobile number on outgoing calls if you’re using personal equipment.
- Are you talking to the right person? Check the name of the person you’re talking to and don’t identify yourself or your service until you’re assured you’re talking to the person who your appointment is with.
- If a family member or friend answers the phone and wants to know who you are. ‘I’m [first name], just ringing from the NHS/doctors/just say [first name]. It’s nothing urgent, I’ll try again later.’ Is sufficient and shouldn’t set off any red flags. If someone pushes for more information it’s also OK to say ‘It’s a confidential call, for [name of client]. If they’re not there I can ring later.’ You don’t have to apologise for maintaining confidentiality, and you can end the call at any time. Sometimes people get cross that you wont tell them why you are ringing their friend/partner. That’s not your fault or problem, but do be mindful of your client’s safety if you suspect a controlling or abusive relationship.
- Make sure they can be on the phone for the length of the appointment. If they are fatigued (a common symptom of Covid 19 and many other health conditions!) can they put you on speaker phone or use a headset to talk to you?
- Make sure they aren’t driving or otherwise occupied, that they’re in a private space.
- Encourage them not to have children in the room if they are going to exhibit distress or talk about adult themed difficulties or anything that might be upsetting or harmful for a child to hear; tricky to manage complete privacy when families are self isolating together but safeguarding children is still the first priority.
- Risk assessment is still completed or reviewed at every IAPT appointment. This can feel more uncertain and anxiety provoking for the therapist on the phone. Good use of supervision and robust service policies help a lot.
It’s been lovely to see everyone’s willingness to try to continue to provide access to talking therapies, even in the face of uncertainty about new ways of working. It feels more important than ever to offer safe spaces where anxiety and other emotions can be heard and understood, where people can learn ways to cope and manage the psychological effects of the current situation. Whatever the differences are in our approaches we all share a common skill set; active listening, empathy and the ability to be our wonderful selves. We’re all good at this and can still offer this to our clients and patients.
There seems to be anxiety that the relationship between the therapist and client or patient will be more difficult to establish and maintain when you’re using different methods of communication. I guess one point is that telephone and online working is still communication between two or more people. Loss of visual cues doesn’t have to be the end of meaningful rapport.
When we shifted towards more telephone working a few years ago I noticed that the objections weren’t on behalf of our patients, we all knew that a lot of people would find it easier to access the service if they didn’t have to journey to appointments; in the current climate people might feel much safer at the end of a phone line. What was difficult was a feeling that if we took our physical presence away the patient would lose something vital to their recovery. There’s also a sense that we, the PWPs (and I would imagine therapists in other modalities) would lose something about the work that helped and refreshed us too. We didn’t trust that our interventions – the specific skills and ideas that we offer that are unique to our modality – were helpful on their own, we thought that we were the magic ingredient, and we wanted to keep that sense of connection for ourselves. It’s interesting to reflect on that and discuss in supervision.
Like any CBT based work Low intensity therapies use a formulation to help the patient to describe and understand their difficulty. Typically this will be an ABC or Five Areas model. Formulations are visual, how on earth do you do that on the phone? First and simply you can describe what you’re seeing. ‘So as we’ve been talking there I’ve been drawing a diagram of how things might be fitting together. How would it be if I describe what I’ve got in front of me?…’
There isn’t much else that’s specific to LI CBT that I could add here. Most of us are used to phone work, LICBT works well on the phone and it’s embedded in our training. Some of us have to manage our anxieties about phone calls in general. I used to have quite severe anxiety symptoms when I got phone calls or had to make calls; that subsided after the first few weeks of doing regular telephone assessments! But seriously, if you’re anxious about phone calls generally then use supervision and be gentle on yourself, but don’t let the anxiety stop you.
IAPT specific thoughts
IAPT services have specific requirements for every care episode and every session; these don’t change, however the service is being delivered. We have to collect measures, we have to stick to evidence based interventions and we always work within stepped care. The IAPT standards haven’t gone anywhere either. We’re doing this major shift in service delivery while still trying to meet access, waiting time and recovery targets. It’s going to be interesting to see how that goes. I actually find it easier to do the measures by phone than in person, and I switch the order around a bit: employment questions, the Work and Social Adjustment Scale, the phobia scale, the GAD-7 and finally the PHQ-9 to segue into a risk assessment works well for me.
Some services deliver therapy through the use of email or other text messaging systems and written messages are how most PWP/LITs communicate with their clients on computerised CBT programmes. Some of the same anxieties about safety and effectiveness might arise but, again, it’s another way to communicate and it works really well for some people. You could find out if your service can set up a ‘no reply’ email account that your team can share. It can have a generic name and be used to send resources and information to your patients but it’s not possible to reply to email sent from that account.
If you are communicating with your patients or clients by email then please remember to be personable. You can do reflection, summary, normalising, empathy statements etc by text as well as vocally. Making good choices about the length and depth of your messages will make a difference to how your support feels to the person on the receiving end. It can be a refreshing way to work; looking at the language used and having time to think about what someone has said is a luxury we don’t always have in a ‘live’ conversation.
High Intensity CBT
I have got *gasp* some CBT therapist friends. Nicola Gilkes is telephone working from quarantine this week and this was her reflection yesterday: ‘assessment went really well but explaining a social anxiety formulation did not work well.’ She was planning to get supervision and seek advice from colleagues who have worked electronically in the past.
These are difficult times, please look after yourselves. The work you do as therapists in any modality is important and is going to be in demand, possibly more than ever. It’s a cliche but you can’t pour from an empty cup, keep yourself full. People are getting creative about how they offer and access supervision as well as therapy. Counsellors might be the people to talk to about that because many will have remote supervision for specific approaches via skype/telephone when the expertise isn’t available locally. It’s likely that we’ll all be experts in online conferencing in the next couple of months.
Like I said, there’s space to add to this post, the content I’m posting today is the result of kind responses on social media and my own first thoughts, it isn’t exhaustive. There’s a contact form on this site that will send an email to me. I promise to check the inbox regularly over the next couple of weeks. You can also leave a comment or reach me on Twitter @notapwpguru.
- Connor O’Brian produced this very helpful brief reference sheet for the Association of Clinical Psychologists
- The Psychological Society of Ireland Guidelines on the use of online therapy is available here
- The BACPs guide to Working Online in the Counselling Professions is here
- Some useful online therapy guidelines from The Human Givens Institute are here
- Guides from Digital Primary Care are here
- A great video on GP video consultation skills is here
- The BPS’s digital skills competencies are here
- The Therapist Hub, a lovely online space to share resources and support is here
- A helpful resource from a counsellor who works exclusively online is here
- the Royal College of Psychiatrists guide to digital consultations is here
- The BABCP Tips for Remote Therapy Provision are here
- A helpful list of resources and links is at Psychology tools here
Marshall, D., Quinn, C., Child, S., Shenton, D., Pooler, J., Forber, S., & Byng, R. (2016). What IAPT services can learn from those who do not attend. Journal of Mental Health, 25(5), 410-415. DOI: 10.3109/09638237.2015.1101057
Hammond, G. C., Croudace, T. J., Radhakrishnan, M., Lafortune, L., Watson, A., McMillan-Shields, F., & Jones, P. B. (2012). Comparative effectiveness of cognitive therapies delivered face-to-face or over the telephone: an observational study using propensity methods. PLoS One, 7(9), e42916. DOI: 10.1371/journal.pone.0042916
Irvine, A., Drew, P., Bower, P., Brooks, H., Gellatly, J., Armitage, C., Barkham, M., McMillan, D. and Bee, P., 2020. Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders, 265, pp.120-131. https://doi.org/10.1016/j.jad.2020.01.057
Jones, E. A., Bale, H. L., & Morera, T. (2013). A qualitative study of clinicians’ experiences and attitudes towards telephone triage mental health assessments. the Cognitive Behaviour Therapist, 6. DOI: 10.1017/S1754470X13000226
Rushton, K., Fraser, C., Gellatly, J., Brooks, H., Bower, P., Armitage, C., Faija, C., Welsh, C. and Bee, P., 2019. A case of misalignment: the perspectives of local and national decision-makers on the implementation of psychological treatment by telephone in the Improving Access to Psychological Therapies Service. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4824-4