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Rosemary Parkinson, 2020. From face to face to online: thoughts on the experience of a rapid change of practice. Reformulation, Summer, pp.12-14.
I went into isolation earlier than other people. My partner has health issues, so it seemed sensible. It is always a hard decision to prioritise one’s own needs over one’s clients’. As therapists we know how important it is to make sure we look after ourselves so we can work best with our clients. But in time-limited work it is rare to have to talk to clients about our needs or to change pre-existing contracts for our benefit.
I have occasionally worked online with clients before now. Clients have unexpectedly had to move away or become housebound during our work together. However, there has been a total shift of all my client work online, a shift we have now all had to make. When I was making this decision, there was little advice available about a rapid change from face to face to online working. I had to work out what to do myself.
I contacted my supervisors and told them my plans and discussed with them how clients might be affected. I looked into different online platforms. Those less intuitive led to some hilarious false starts as I practised with colleagues. I debated how to get the best balance between ease of use and security, as these don’t always seem to go together. In the end I decided to use Zoom as many have since. But I do give clients the option to use something else if they prefer. I adapted my client information sheet to reflect the changes, adding some suggestions as to how clients might like to prepare their therapy space. It asked new clients to send an email consenting to the contract to work together as they wouldn’t be able to sign it in person in the session. I then contacted clients, giving them the opportunity to work on video or phone or to postpone sessions. I offered to call them to discuss the practicalities if they had concerns. I guess all therapists in private practice have navigated their way through these issues in the past few weeks. However, when I did it there were no guidelines and, as a private therapist, no organisational protocol to follow.
I realised I was attempting to manage clients’ anxieties about the changes by making the transition as smooth as possible for them. I felt like a parent scaffolding a dramatic change in their child’s life. It felt important to me to show my clients that the frame remained secure, that I was secure, and that they could continue to feel safe to access their emotions.
The power dynamic
This need to make a change came upon me with the speed of an accident. I dealt with it in the moment and just got on with it. In making all the changes I hadn’t had much time to think about what the actual sessions might be like for me. As they approached I realised I felt anxious both in terms of the technological challenges and the potential impact on therapeutic relationships. Once I started though, I began to feel quite excited. Not only did the therapeutic relationship seem to work similarly, I quickly saw that this way of working could reduce the power imbalance between therapist and client.
CAT has always been a collaborative therapy. It is a joint endeavour embarked on by therapist and client working together towards a shared goal. Even the concepts within it such as Reciprocal Roles offer a restating of complex concepts in an accessible way, enabling clients to engage with them rather than defer to an expert who has all the knowledge. Over the course of my career as a CAT therapist I have noticed that I have become increasingly collaborative in my therapeutic style. I have gradually changed my practice to enable this, such as inviting the client to reply to the Reformulation letter.
As therapists we all know how important the therapeutic frame is. This includes not just the boundaries of sessions but the layout of our rooms and even the pictures on the wall. Historically, most therapy sessions have been conducted in the therapist’s space. We get to decide on all the practical aspects of our sessions with clients. There are good reasons for this from a transferential standpoint and many’s the reciprocal role or procedure that has emerged from the client’s behaviour towards these boundaries. However, it can also feel to both client and therapist that it reinforces the therapist’s occupation of a powerful, controlling position and pushes the client further into a powerless, controlled role.
In beginning to work online I have seen that it offers an opportunity to change this reciprocal role. Previously clients entering my space might be reminded of earlier experiences where they felt uncertain and powerless. For example, visiting distant relatives, attending appointments with professionals one perceives as powerful, inequalities embedded in society and sometimes of course, more extreme, overt, abusive relationships. Whilst their re-experiencing of this can assist in eliciting transference it can also interfere with developing the necessary therapeutic relationship needed to embark on therapy together. Clients can have their anxiety levels heightened by this perceived repetition of earlier powerful relationships and this can interfere with their ability to think, to feel and to connect.
Working online can reduce this experience of the therapist as powerful and reduce the resultant anxiety. There is academic support for this. In 2018 Kocsis and Yellowlees reported on various research into telepsychotherapy and the therapeutic relationship. They found evidence of a reduction in both clients’ anxiety and in their perception of a power imbalance between them and the therapist. When working online clients are able to choose their own space, set it up to be how they will feel most comfortable, have more choice in when and how they move about, what they wear and have with them. Anecdotally I have found that particularly for initial sessions this can enable a lower level of anxiety and a quicker development of therapeutic rapport. Therefore when I explain CAT to clients they are more able to hear what I am saying. They seem to engage with the therapy more as co-investigators. Even at the start I can feel a Reciprocal Role of ‘inviting co-curious observer to invited co-curious observer’.
Yellowlees’ own research also found that the ‘virtual space’ which occurs between the therapist and client when working online allowed clients to open up faster and share more intimate details. It seems that by reducing their anxiety about the process, clients’ adult selves can be present in the therapeutic relationship from the start and this can make a difference to the therapy as a whole. Potentially clients’ reduced anxiety, increased cognitive capacity, and more constant access to an adult part of them will enable a faster development of their own compassionate internal parent.
Reciprocal Roles in Action
As my online work has continued, I have become aware of ways in which it offers greater evidence of clients’ reciprocal roles in action. Seeing my clients in their own space gives me access to different information about them. When clients log on to their virtual sessions they intend to show us some things. Why have they positioned themselves there? What do they want us to think about them? A client with an admiring to admired reciprocal role may be showing their extensive book collection, their priceless antiques, or beautiful garden. A client who fears that if they are seen they may be attacked may show a featureless background or even show us their mess as if to say ‘See, you don’t need to envy me’.
They are also giving me a lot of unintentional information. How do they manage trying to create a private space for a therapy session? What happens if there is someone else in the space, or someone who intrudes during the session? A client who doesn’t feel entitled to have their needs met may not have been able to ask clearly that other household members don’t interrupt this time. Another client who has described how they feel contemptible in relation to others might demonstrate their flip into the top end of the pole when they speak contemptuously to someone who interrupts them.
Sometimes I have noticed that clients can feel as if they are only half in the therapy session as they sit at home. Being at home rather than having to travel to a therapy location can lead to their metaphorically as well as physically being only partially in the therapy room with me. There are many reasons for this from fear of being overheard to being distracted by the cleaning they haven’t done. But whatever the reason it can make them less available in the session. This too will be demonstrating a reciprocal role in action and we can make use of this information as we engage in our co-curious observing.
However, I have also noticed that when I gain information in this way it can feel more difficult to share it with a client. When in our usual face to face work we may observe the client who laughs when telling us a tragic childhood story, the client who tells us they feel confident to speak up while cowering in the back of the chair with their arms and legs crossed and simply describe these incongruences. In thinking about differences in my countertransference when in a video therapy session I wondered about how the traditional social rules of respecting someone’s space might be making a difference in how I make these kinds of observations. If a client is showing us their day to day life through online working we may feel we are intruding and not know how to comment on the information we observe. As in all therapeutic work we can reflect on the information our countertransference gives us and what it tells us about our own reciprocal roles and our client’s.
When home isn’t safe
Much of this article assumes a client’s home is a safe space which they have some control of, where they will feel more relaxed and more confident. This will not always be the case. We know there are various reasons for this both practical and more dangerous. The incidents of physical domestic violence have increased and no doubt many are living with increases in non-physical abuse. The new ACAT guidelines on working online (2020) include the statement
‘Be aware that online CAT is not necessarily suitable for every client. Think carefully with the client about risk issues and discuss with your supervisor if in doubt.’
Clients may not be able to continue with therapy if this is the case and yet be even more in need of support. This will take thoughtful supervision to untangle. The link at the bottom of this article gives some practical suggestions should you need them.
Conclusion
These are just my thoughts on my rapid move from face to face in person working to online video sessions. I have, like most of us, had to adjust and learn fast. This involved anxiety and uncertainty, both about my capacity and the impact on my clients. However, I hope I have shown how the work has been easier than I anticipated and that I have seen benefits both to the client and the therapist. I am excited to have discovered that working online offers opportunities which enable a reduction in client anxiety, a potentially speedier engagement and a new way of eliciting reciprocal roles. In some ways it seems to offer benefits over in person work. I am enjoying my work online. I am feeling comfortable in our virtual space with each client. They too say they are feeling ‘at home’ working together in this way. I suspect that in the future I may continue part of my practice online even when it is not a necessity.
Afterword
In moving to online working there was a lack of information about the practicalities, the skills needed and little research to look at. This too has changed fast. ACAT was quick to produce its guidance which can be found here https://www.acat.me.uk/page/policies+and+official+documents. There are still a number of things which are up to us, however, such as which platform to use, checking our insurance provision, working out how to administer data gathering forms, and of course making choices about how we manage risk. These decisions will be helped by talking to our CAT colleagues and supervisors.
As therapists we will need the safe space of supervision more than ever to allow us to reflect. Those of us who are also supervisors have additional new skills to learn to enable us to continue to offer this safe space online. In doing so we give therapists the chance to continue to do a ‘good enough’ job as the world around us changes. Altogether, through our thoughtfulness, reflection and supervision, our responses to these changes will help both our clients’ self-development and our own.
If you know someone is at risk staying at home there are a number of routes to support listed on the gov.uk site. The household isolation instruction does not apply if someone needs to leave an abusive relationship:
https://www.gov.uk/guidance/domestic-abuse-how-to-get-help
References
ACAT online CAT guidance April 2020 https://www.acat.me.uk/page/policies+and+official+documents
Corbridge, C., Brummer, L and Coid, P. (2017) Cognitive Analytic Therapy: Distinctive Features. London: Taylor and Francis Ltd.
Jenaway, A., (2011) ‘Whose Reformulation is it Anyway?’, Reformulation 37 p.26-29
Kocsis, B. J. and Yellowlees, P. (2018) ‘Telepsychotherapy and the Therapeutic Relationship: Principles, Advantages, and Case Examples’, Telemedicine Journal And E-Health: The Official Journal Of The American Telemedicine Association, 24(5), pp. 329–334.
Russell, G.I., 2018. Screen relations: The limits of computer-mediated psychoanalysis and psychotherapy. Routledge.
Ryle, A. and Kerr, I. B. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester: John Wiley and Sons Ltd.
Yellowlees, P. M. (2017) ‘Telepsychiatry’, in Dewan, M.J.S., Steenbarger, B.N. and Greenberg, R.P. (eds.) The art and science of brief psychotherapies: An illustrated guide. 3rd edn. Arlington, VA: American Psychiatric Association Publishing