Providing medical and general practice
consultations online is not new and there has been a certain amount of research into how it is ‘diff erent’ to face-to-face contacts (Greenhalgh et al., 2016; Greenhalgh et al., 2020; Seuren et al., 2020). Likewise, psychotherapists have been providing a variety of forms of psychotherapy for years (see for example Ragusea & VandeCreek, 2003; McDonald et al., 2019; Roddy et al., 2019). Some systemic practitioners have been providing video-based psychotherapy for years but to date very lit le has been writ en about this (Helps, in review). For many systemic practitioners, working using video consultation will be very new. T ere is a small body of research and practice-based evidence we can draw on to guide our practice in delivering online psychotherapy, which emphasises how online work is diff erent in process and thematically. T at body of research informs our thoughts below.
Initial setup for doing systemic psychotherapy work remotely Moving to online therapeutic work is
likely to be more straightforward with families with whom we have an existing therapeutic relationship than those we are starting to work with. But starting off this way, probably aſt er an initial telephone conversation, is not impossible. And obviously it will be unavoidable in the coming months. Issues of similarity and diff erence have
to be considered fi rst as we move online. T is relates to familiarity with technology, to ownership of devices that can handle making video calls, and to having the resources to have data or a WiFi connection. Not all staff or patients have these things. Issues of privilege also quickly emerge when we start to see the intimate details of people’s living circumstances. Yesterday, a colleague sat on her bed in her shared fl at while we had supervision. Her headphones were clearly irritating her head, as she talked carefully and quietly so that her fl atmates did not overhear confi dential material. I (Sarah) had the luxury of sit ing in my kitchen with a newly bought WIFI booster, safe in the knowledge I could talk freely. What follows is a series of
recommendations based on the evidence and on practice-experiences to date.
Preparation for clinicians
Access and inclusivity: are there any learning, sight, hearing or other issues of
Context 170, August 2020
Conny (on screen) and Sarah (smaller)
disability for staff or patients that need to be taken into account for access? Risk assess based on what you know: are there any indications that it might not be safe to meet via video (for example, concerns about violence, dissociation)? Set ing a containing boundary around your
workspace, in both practical and psychological terms. Working remotely involves some blurring of boundaries. How can you signify to yourself and those who might be around you at home that you need confi dential space and are in work mode. T is might involve get ing ‘dressed’ for work, put ing up a notice on the door of the room you are working in, wearing headphones to keep the conversations as confi dential as possible. Changes to what we can see: Video working might off er a much more visible, mutual and transparent process, as our patients see us as we sit in our kitchens and studies to conduct a session, and this will aff ect the balance of power in the therapeutic relationship that will need discussion. T ink
about what’s behind you and visible and talk to this diff erent way of being together. Some video packages off er virtual backgrounds so as to create a more neutral-looking space. How do you usually establish rapport? What will you need to do diff erently with your usual ‘script’ in order to establish rapport in this context? How do you usually use your body? What might you need to do more or less of? Our nods and headshakes have got progressively bigger, my smiles and frowns have become exaggerated so they can be seen on a small screen. Waving, thumbs up and thumbs down has quickly become professional parlance. Beginnings and endings have a diff erent formality and need specifi c visual and verbal rituals. If you usually have some physical contact with a family at the start or end of a session – a handshake, a touch on the shoulder – what might be a virtual way of creating this? Likewise in relation to our colleagues, as we feel disconnected sit ing at our kitchens or on our sofas, kisses have been blown and hugs
3
Ways of working during the COVID-19 crisis
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