which takes some careful and tentative planning. Over the past weeks, our trusts have swiſt ly issued governance guidelines to ensure that confi dentiality and safety can be maintained while working remotely.


Looking after ourselves COVID-19 is a personal as well as


a global challenge. Many of us will be aff ected as we or those we love become ill. It is vital that we look aſt er ourselves, and supervision is a key part of this. Giving and receiving supervision via video link is very common and generally eff ective (Pennington, Pat on et al., 2003). Working remotely seems much more exhausting, partly because of the new and anxiety- fi lled context and partly because we lack the embodied, intra-active, felt experience of the other, on which we rely so heavily. We will need to develop ways of bringing to language this aspect of our practice and of giving voice to our behind-the-remote- screen feelings.


Further steps in making remote ways of working work


As experts in pat erns of communication,


we already know that the frame of the conversation will aff ect how we present ourselves (Goff man, 1956). We know that all communication is a complex social interaction that is particularly intense in the doctor/therapist -relationship (Iedema et al., 2019). When our usual channels of information change, there will undoubtedly be miscommunication and misat unement. We already work with feedback, and we are used to reviewing and revising and checking back. T ese well-honed skills will be crucial in this time of rapid change. We don’t yet know what the mental health


and relational implications of COVID-19 will be. A recent review by the National Elf Service (2020) unsurprisingly suggests that quarantine can have a range of negative impacts on mental health. We know from our own lives that anxiety has increased as our world temporarily closes in, as exams are cancelled, as routine health appointments are postponed, as we can’t get to see or indeed hug those we hold dear. We don’t yet know whether mental health service use will increase, remain static or decrease as the pandemic evolves. We don’t know if family communications problems will intensify or whether, in this time of crisis, people will fi nd diff erent ways of being with each other and managing strong emotions. T ere are anecdotal newspaper


Context 170, August 2020


reports that domestic violence is increasing. It seems likely that where there was risk before, this will still be present. Above all, we need to ensure that ordinary distress in the face of this extraordinary situation does not get pathologised. We don’t yet know how families will


cope with online service delivery. Not all therapists or patients will fi nd a fi t with online therapeutic intervention. Issues of high risk, dissociation, and diffi culties using technology are just some of the known barriers. T is list will undoubtedly be refi ned in coming weeks and months. Likewise, we can’t yet know what the clinical, practical and ethical issues of working in this new way will be. It is equally possible that some patients, including families and groups from more marginalised communities, or those where there is a person with an autism spectrum condition, might even fi nd online access more fl exible and indeed benefi cial (Benford & Standen, 2009). Not all families will want to engage in


remote video sessions. Despite the barrier of the screen, an unusual intimacy can be experienced which leads to conversations feeling ‘too’ intense, leading to a switch to just using audio channels. Again, regular discussion of what is working and what is tricky is vital. An online way of working will


rapidly become ordinary practice. For psychotherapeutic services and specifi cally within the systemic discipline, future trainees will be taught about the ethics and practice of using telehealth care to provide systemic psychotherapy training and service delivery. Current trainees and clinicians are therefore at the forefront of developing models of what works safely. T is new way of working will have a huge impact for the future, for research and practice.


Coda In the past two weeks we have been


amazed at community, at the ways in which professionals have shared, pulled together, looked out for and looked aſt er each other. We have also become aware of how people have such individual ways of coping in a crisis and how fear can lead to certainty and a need for control. Despite our love of the not-knowing and the tentative, there are times when we all want to know what to do and how to be. It is very hard to remain curious, to breathe, to step back and step away in order to keep going. And doing these things will certainly help. Stay well and stay safe. Physical distancing does not mean that you can’t make contact and


connection. Be creative and look aſt er yourselves and each other.


References Benford, P. & Standen, P.J. (2009) The Internet: A comfortable communication medium for autistic people? Journal of Assistive Technologies, 3(2): 44-53. Goff man, E. (1956) The Presentation of Self in Everyday Life. New York: Doubleday. Greenhalgh, T., Vijayaraghavan, S., Wherton, J., Shaw, S., Byrne, E., Campbell-Richards, D., Hodkinson, I. et al. (2016) Virtual online consultations: Advantages and limitations (VOCAL) study. BMJ Open, 6(1), e009388. Greenhalgh, T., (2020) Video consultations: A guide for practice. Retrieved from https://bjgplife.com/ wp-content/uploads/2020/03/Video-consultations- a-guide-for-practice.pdf 24.3.20 Helps, S.L. (in review) Doing remote systemic psychotherapy in a pandemic: What do we know, what are we doing and what do we need to learn? Journal of Psychotherapy Integration, COVID-19 Special Issue. Iedema, R., Greenhalgh, T., Russell, J., Alexander, J., Amer-Sharif, K., Gardner, P., Roberts, C et al. (2019) Spoken communication and patient safety: A new direction for healthcare communication policy, research, education and practice? BMJ Open Quality, 8(3), e000742. McDonald, A., Eccles, J.A., Fallahkhair, S. & Critchley, H.D. (2019) Online psychotherapy: Trailblazing digital healthcare. BJPsych Bulletin, 1-7. National Elf Service (2020) Quarantine infection prevention but at what cost for mental health? https://www.nationalelfservice.net/commissioning/ population-health/quarantine-infection- prevention-but-at-what-cost-for-mental-health/ (retrieved 6.4.20). Pennington, M., Patton, R. & Katafi asz, H. (2019) Cybersupervision in Psychotherapy. In: Theory and Practice of Online Therapy (pp. 79-95). London: Routledge. Ragusea, A.S. & VandeCreek, L. (2003) Suggestions for the ethical practice of online psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40(1-2): 94-102. Roddy, M.K., Rothman, K., Cicila, L.N. & Doss, B.D. (2019) Why do couples seek relationship help online? Description and comparison to in‐person interventions. Journal of Marital and Family Therapy, 45(3): 369-379. Seuren, L M., Wherton, J., Greenhalgh, T., Cameron, D. & Shaw, S.E. (2020) Physical examinations via video for patients with heart failure: Qualitative study using conversation analysis. Journal of Medical Internet Research, 22(2): e16694.


Sarah is trust-wide lead for systemic psychotherapy at the Tavistock and Portman NHS Foundation Trust where she teaches, researches and works clinically in the Fostering, Adoption and Kinship Care team. She can be contacted at shelps@tavi-port.nhs.uk


Conny is a systemic psychotherapist and supervisor. She has worked in Adult mental Health and Substance Misuse and currently works as the systemic lead in Barnet CAMHS. Conny runs Kidstime workshops in Barnet and is also a supervisor and trainer for the Tavistock Clinic. Email: armico@outlook.com


Carol is the consultant lead systemic psychotherapist in West London Health Trust CAMHS. She has interests in narrative therapy and the work of the Just Therapy Team in Aotearoa/New Zealand.


5


Ways of working during the COVID-19 crisis


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