Papers

Doing remote systemic psychotherapy during a pandemic – learning from a speedy Quality Improvement Project

By Sarah Helps . . .

Introduction

The past 20 years have seen a gradual rise in research about and practice of video- or tele-psychotherapy. With the worldwide lockdown imposed in response to Covid-19, the practice of face-to-face systemic psychotherapy using the approaches, methods and techniques that have been carefully developed over the past five decades has become impossible. With an unbelievable rapidity, new methods of providing therapeutic services have been devised and implemented to ensure service continuity.  

This practice paper describes what has been learnt in the first stages of a rapid quality improvement project exploring the delivery of remote systemic psychotherapy since the lockdown. Reflections were gathered from early-adopter clinicians, based on 21 remote systemic psychotherapy sessions completed during March and April 2020. These responses suggest that that remote systemic psychotherapy has been acceptable and indeed welcomed by clinicians and families and that robust therapeutic work can be done. Findings indicate that the conversational flow of remote systemic psychotherapy sessions is different to that in face-to-face to face sessions; that it is necessary to do things differently with words and bodies; and that the practice of doing meaningful dialogue when separated by screens requires further exploration.

What was known about doing video consultations before Covid-19

Prior to the Covid-19 pandemic, video consultation by health and mental health clinicians was shown to be an efficient, clinically effective, cost effective, accessible way of providing a service to those who could not travel because of geography, mobility, or conditions which meant they needed to self-isolate, and also kept patients connected to their clinicians (e.g. NHS 2019, Greenhalgh et al. 2016, Greenhalgh et al. 2020, Valentine et al. 2020). Following the increasing acceptance that remote consultations could work, researchers started to examine more subtle, processual similarities and differences between face-to-face and remote consultations, often using naturally occurring healthcare consultations. This body of research broadly showed that the nature and quality of communication changed when meeting by video. For example, there seemed to be a greater need for general context setting discourse and more informal ‘chat’ prior to the actual medical consultation (Pappas and Seale, 2009, Pappas and Seale, 2010, Shaw et al., 2018, Stommel, Goor and Stommel, 2019, Chatwin and McEvoy 2019). Rapport was established differently, with longer greetings and endings, including discussion of how the technology was working, and an acknowledgement of how disruptions to the connection could affect emotional attunement within the conversation (Weller, 2017). Seuren et al (2020) found that once the consultation got underway, questions and instructions needed to be given in a more concrete and repeated way, and that patients and clinicians sometimes wrangled for control of the flow before settling into a practice that enabled tasks to be accomplished – e.g. showing a part of the body or performing an exercise, so that it is visible to the viewer.  

Using a data set gathered in 2016, Shaw et al (in press) found that latency (the lag or transmission delay between one participant saying something and the other hearing it) was common in their set of medical consultations using Skype or FaceTime, but that it was mostly swiftly addressed, often using explicit discussion to clarify who should take the next turn at talk. Their overall opinion was that these technical difficulties did not significantly disrupt the flow of the consultation.

Doing all kinds of remote psychotherapy

The use of digital communication for clinical work, supervision and teaching has crept into our professional lives over the past couple of decades for pragmatic reasons, often gently and without too much thought. The practice of diverse models of remote psychotherapy has been described over the past decade (e.g. Edirippulige et al., 2013, Chipise, Wassenaar, & Wilkinson, 2019, McDonald et al. 2019, Stoll et al., 2020). While there are many good examples of remotely delivering psychoeducative or CBT-informed interventions to families (see Zongh et al. 2011, Boykin et al. 2019, Dadds et al 2019, Kohlloff et al. 2020), there is far less research about the detail of working psychotherapeutically with couples or families, particularly for therapies in which the fundamental vehicle for change is the relational space between therapist and client / patient / family (Borsca and Pomini 2017). Wrape and McGinn (2018) produced a series of case studies illustrating their ideas for working remotely with couples and families. They highlight particular delivery challenges of managing privacy and confidentiality when working with family sub-groups or with people whose screens and talk can be overheard by others; safety of family members during conversations involving high emotions; and the importance of building a meaningful therapeutic relationship with all family members involved in the work.

In a small study investigating differences in presenting problems between couples who requested online couple therapy versus in-person therapy, Roddy et al. (2019) showed that while many presenting issues were very similar for both groups, couples requesting therapeutic support online reported greater problems than did couples requesting face to face intervention with trust and infidelity, with having social time together, and with child / parenting concerns. There are currently no published research studies or practice-based writings about doing remote systemic psychotherapy.

Having to do something different: gathering clinicians’ experiences of remote systemic psychotherapy delivery

While we do not have research or practice guidelines to help us, we must to make changes to the ways in which we work because of the pandemic. This natural experiment provides an opportunity to quickly learn from doing something different. Using quality improvement methodology, involving a Plan, Do, Study, Act (PDSA) cycle, the project was initiated to explore clinicians’ initial experiences of doing remote systemic psychotherapy. In view of the context, the project began in the middle of the PDSA cycle: doing something different was the first step. Reflections on this were then examined in order to learn and to then act going forward.

The trust has used the video-conferencing platform Zoom for a number of years. Many clinicians were well used to using the platform for both teaching and supervision tasks. This familiarity helped the move to using it clinically. Following NHS guidance to prioritise staying connected with patients above detailed assessments of individual platforms, the trust worked swiftly to devise clinical practice guidelines to ensure that Zoom could be used in a way that was safe, confidential and adherent to local governance requirements.

Methods of data collection and analysis

A survey was circulated via email to clinicians within my employing trust who had quickly moved to seeing families via video. Questions focussed on what if any technical challenges clinicians had noted, what worked well, what was tricky and what clinicians thought that they had done differently compared to their usual face-to-face practice. This article reports on clinician reflections based on 21 sessions.

Responses were received from twelve clinicians, including me. At the time of responding, clinicians had completed two or three remote systemic psychotherapy sessions. Clinicians were both qualified systemic psychotherapists (n = 9) or clinicians completing their final training in systemic psychotherapy (n = 3). All worked within children’s mental health services at the Tavistock and Portman NHS Foundation Trust in London.

Survey responses were analysed by me using Braun and Clarke’s (2014) Reflexive Thematic Analysis. An initial draft of the themes that were developed from the data was shared with students on the masters programme in systemic psychotherapy at the Tavistock and Portman NHS Foundation trust and with the respondent clinicians. Feedback from these conversations was used to thicken the description of the themes and strengthen the still tentative practice recommendations.

Clinician’s reflections on doing remote systemic psychotherapy

Overall, clinicians responses indicated that a move to delivering remote systemic psychotherapy had been do-able and clinically effective. One clinician commented:

“The quality of the family therapy session and supervision was maintained. Family expressed their gratitude that therapy could continue and found the reflecting team particularly powerful, perhaps because they were seeing our faces clearly for the first time.”

Four main themes were created from clinician responses: i) an altered session flow; ii) how many aspects of the work are the same and some are slightly different; iii) how doing meaningful dialogue it is hard and iv) the need to do things differently with words and bodies.

Altered session flow

Our trust initially used the Basic version of Zoom which limits sessions to 40 minutes before the session must be restarted. This restriction was frustrating to some clinicians, but others incorporated the time limit into their session structure, using the end of the first 40 minute block to punctuate the therapeutic session and to move into a reflecting conversation space in the second 40 minutes.

Clinicians noted that the initial set-up of remote working took some time, often before the video session as well as at the start of it. Clinicians noted that they needed to more clearly outline the structure of the session, the way in which the recordings would be made, how people might signify that they wanted to say something and the clarity of roles when there were multiple therapists.

Between two and seven devices were used in each session. Clinicians were always on separate screens, but this varied for family members. If families shared the same device there were often challenges regarding how the microphone picked up everyone’s voice. One clinician commented:

“We encouraged family members to sit equidistant to the mic and camera to avoid inequitable access.”

Who was holding the device, and different family members’ distance from the device / microphone, were sometimes hypothesised to involve issues of power and control, i.e. who got to hold the device and orient it to whomever was speaking.

A particular problem was identified when using an interpreter who appeared to have a poor internet connection:

“Family members were not always able to hear the interpreter, which meant that eldest child often stepped in to interpret for dad. This became confusing and the conversation was difficult for family to follow.”

There was some reflection about overlapping talk, both regarding family talk and clinicians’, with one clinician describing the conversation as “stilted” as a result of slight lag.

However, overall conversational flow was considered to be OK. One clinician commented

“To my surprise I did not feel that this was disrupted very much at all. Everyone’s internet connection was working well, and there was no freezing or delay with the speech. The sound and video quality was good and this enabled the communication to flow quite naturally. I had to ask the family to speak up a couple of times which worked fine.”

Another clinician commented:

“The lead therapist allowed every family member a voice in the room, including the youngest member of the family who was more engaged than during the in-person sessions that took place in the months before. The conversation flowed, family took turns in speaking and the lead therapist skilfully placed interruptions when monologues went on too long and punctuated important moments.”

Many aspects of the work are similar but some are a little different

Clinicians noted that families who were already engaged and familiar with a team and screen set-up seemed to adapt particularly well to this remote model. Meeting new families for the first time was experienced as more complex, but not impossible.

Clinicians also reported that the following worked as well as usual: asking risky / tricky questions,  giving bad / unwanted news, hearing from all members of the family, setting teenagers up on their own screens, having teenagers who had been reluctant to attend sessions join in as the session was ‘happening’ in their kitchens.

One clinician commented on how they had been able to continue as usual with their creative practice, for example:

“I was able show previous relational patterns that we drew out previously and brought the paper to the screen to show this.”

In general clinicians felt that the therapeutic alliance could be maintained. However, engaging with teenagers was a very mixed bag. Three clinicians noted that it seemed easier to connect with teenagers, particularly when they were on their own screens, and four clinicians noted that it was hard to engage teenagers, whether on their own screen or sharing those screens with their parents,  due to the lack of visual cues and non-verbal feedback that might usually be noted and commented on.

One clinician noted:

“It was difficult to ascertain whether the young person not wanting to talk was because of the context of a video call, my presence or something else”

Another commented that a teenager had struggled to stay seated on a sofa with his parents while sharing a device between them:

“I feel like I lost the therapeutic alliance I built with this YP in our face to face session. I also lost his voice in the session.”

Two clinicians noted the way they were able to position themselves in more of an observer role than had been possible when physically in the room with families. Clinicians also noted that they left longer gaps after asking a question to see who might respond, and that they used people’s names more frequently to signify who the therapist wanted to answer to the question.

Managing boundaries was noted as a challenging but ultimately engaging issue. For example, one clinician noted:

“One call family was on iPhone and child decided it would be fun to take the phone and show me her house, much to mother’s embarrassment – but all okay and good natured. So, something tricky about boundaries, work/ therapy into personal spaces.”

And another commented:

“There is something about being invited in families’ homes which I find humbling. And also, inviting them in our homes.”

And another noted that:

“I had flowers in my background which the young person had commented on informing that they preferred seeing them as opposed to a beige wall. This made me think about the message I am giving if I choose to present a blank wall in my background.”

One clinician subsequently noted that using written ways of communicating as of behind the screen worked well:

“Communicating between therapists using What’s app [sic] to share hypotheses / ideas as one might if sitting behind a screen. There was unanimous view that work could and would carry on in this way.”

Both clinicians and families therefore revealed things about themselves and their environments that would not usually have come into the therapeutic space.

Doing dialogue is hard

Clinicians frequently commented on how hard it was to engage in dialogue remotely, both between clinicians and between clinicians and family members.

For example clinicians noted that family members sitting together often talked to each other and it was hard to hear or hard to intervene. One clinician commented that

“mother and son talked over each other a lot but this is normal for them.”

Another commented that

“Coordinating reflecting team comments sounded more like three separate reflections, we will work on this.”

Regarding families talking together, clinicians remarked that it was difficult to follow the conversation between family members who shared one screen, for example:

“I found it tricky when the family members who were in the room together (mother and two teenagers) shared comments among themselves that were inaudible and not directed to me. This happened a couple of times, mainly between brother and sister- who would sometimes speak to each other. In the room of course this would be less likely to happen, or if it did you could incorporate what they might have shared into the dialogue however I sometimes felt unsure/ left out of what they were saying and had to encourage them to remain focused with the session.”

There was a worry expressed about what might have happened if emotions had become very high, with comments that practice needed to be slightly different:  

“discussion about risk and safety – trying to gauge how worried to be, needed to ask lots more detailed questions”.

There were notably no reports that this had happened or, where it had happened, that it had been unable to be managed safely.

Doing things differently with words and bodies

Most clinicians reflected that ‘reading’ and responding to a family, a team and their own non-verbal and embodied responses was different and challenging. One clinician described how they had started to use more “verbal commentary” in order to clarify what their and others’ facial expressions might mean. Clinicians noted that reading the room was much harder, for example:

“It wasn’t always easy to see the non-verbal cues (e.g. eye rolls, raised eyebrows etc.) made by family members one to another.”

Another noted how they had

“Struggled to read how my questions landed when taking a risk due to being only able to see the face due to how they were seated and position of the device.”

And another commented:

“Whereas I for instance gesticulate quite a lot in in-person sessions, this may be less useful in a video session. However, describing to the family when we look down – perhaps we are taking notes, when we show our “thinking face” – our faces are more the window and reflection of our thoughts perhaps”.

Other clinicians described using bigger gestures, exaggerated smiles or frowns or looks of puzzlement so as to more effectively communicate  their feelings and their embodied responses.  

The lack of access to the embodied, felt, in the room communication was not necessarily seen as a problem, for example one clinician noted

“I believe I am more succinct and clear in my questions, perhaps due to lack of body language”.

Summary and Conclusions:

What have we learnt about doing remote systemic psychotherapy thus far?

There is clear evidence from the field of health and mental health care that remote video consultations are transacted slightly differently compared with face-to-face consultations, with more potential scope for interactional misattunement but also a good deal of interactional success.

This paper has described a rapid quality improvement project to learn from the experiences of clinicians who swiftly moved their systemic psychotherapy practice online. Four main themes were created from survey responses received from 12 clinicians based on 21 clinical sessions. Thematic analysis highlighted: an altered session flow, how many aspects of remote work are the same as face to face work and some are slightly different, that doing meaningful dialogue it is hard, and that there is a need to do things differently with words and bodies.

Overall, clinicians’ experiences broadly fit with that described in published health, mental health and therapeutic research. These findings contribute to the rapid development of practice-based information about doing remote systemic psychotherapy.

In relation to the published literature, latency or lag was not a significant issue during the sessions. This may be a function of swift developments in technology and perhaps the specific of the platform that we were using. Based on feedback, the trust have now equipped all clinicians in a training context with Zoom Pro accounts so that sessions are no longer constrained by the 40 minute limit. This may well extend to all clinical sessions in due course. This represents a positive development arising from the alignment of technology and working practices (Wherton et al., 2020).

Overlaps in talk both between family members and between team members did happen. Overlapping talk did not generally appear to happen any more than it usually did with the family or the team, but the management of it was addressed differently in this remote environment. Whereas eye contact and hand gestures would have been used in the face-to-face setting to encourage a person to start or stop talking, the challenge of overtalking was solved by clinicians using explicit verbal invitations regarding who might talk next.

The number of participants in a conversation has been generally reported to affect the way in which the conversation unfolds in a variety of ways, one of which being how schisming (Egbert, 1997) can occur when there are four or more participants. Schisming refers to how with four or more people, multiple conversations start to happen alongside and criss-crossing each other. Schisming seems a helpful focus of future inquiry in this remote way of practicing, particularly in relation to the flow of the main conversation and specifically whether family members might be encouraged to use different devices to contribute to the conversation.  

Given the importance that systemic psychotherapists place on being in and doing dialogue, the challenge of doing exploratory as opposed to additive dialogue or even sequential monologue was a concern. This challenge might have to do with technical aspects of lag, which means that it is harder to manage the ordinary to and fro of a conversation or to interrupt, question and build on others’ comments, but given the minimal technical difficulties reported this seems unlikely. It might also have to do to with the way in which intimacy is differently navigated when communicating from different spaces. It might also relate to how all actors, family and clinicians alike, were in the very early stages of relating remotely and so this unfamiliarity might have contributed to the perceived difficulty.  

The primary vehicle for change in systemic psychotherapy is the psychotherapeutic relationship. That relationship is based on exploratory (as opposed to additive) dialogue and on the experience of dialogue, of co-presence, of being heard and felt. Participating in generative, truly co-creative and meaning-making dialogue can be done remotely, but it takes commitment, practice and innovation (Boe et al 2017). Part of that experience relates to how our brains and bodies attune to each other as we act together (Dikker et al 2017). Finding out if and how it is possible to do in-depth interpersonal and intra-personal, dialogical work, particularly when there is no pre-established therapeutic alliance, will be vital in coming months.

It is not yet clear how families will find remote service delivery. Early practice-based experience suggests that families find remote systemic psychotherapy acceptable, accessible and engaging, but it may be that some people are disadvantaged by remote consultation. In her research, Weller (2017) suggested that some teenagers found internet video calls to be both easier and more intense and intimate than they did face to face communication, which led to differences in what they disclosed in the different spaces. More generally, there is a need for more exploration of how issues of age and indeed other issues of social difference can be navigated at a micro as well as a macro level within remote psychotherapeutic conversations.

Using the Zoom platform, and Gallery View, it is possible to see oneself on screen in the same way that one can see all other screens. None of the clinicians made any comment about the affordances and constraints of being able to see themselves as they conducted sessions. This might be because systemic practitioners are used to recording their work and reviewing themselves on video so as to improve their practice. While the remote consultation reduces what we can see and experience of the families with whom we work, that fact that we have this added window into what others see of us warrants further exploration. This would seem to have great utility in terms of learning something new about our practice.

All communication is a complex social interaction, but is particularly intense in the therapist/patient relationship (Iedema et al. 2019). As experts in close observation of patterns of communication, systemic psychotherapists know that the frame of the conversation will affect how both therapist and patient present (Goffman, 1956). The potential for editing the online self, for presenting this rather than that aspect,  affords different possibilities and constraints to that in real-life (Bullingham and Vasconcelos, 2013). Given our current forced context of remote delivery of psychotherapy, the performance of the front-stage self might differ due to circumstance rather than active choice, as we all interact from our kitchens, bedrooms and domestic environments and we might have to work harder, to use additional signifiers (for me it has involved ensuring that I dress formally for work, that I wear earrings and have books and plants around me)  to perform an authentic sense of self.  As a discipline we are increasingly embracing the embodied turn (Nevile, 2015) and now have to find ways of turning embodied responses that might not make it through the screen into language, so that they can be worked with. Finding ways to ‘do’ embodied work when distanced by a screen is therefore a huge challenge.

There are valid concerns that video consultation will not be as ‘good’ as face to face psychotherapeutic work (Russell 2018) and we need to work out when we can and when we should not continue to work in this way. Continuing to learn from feedback from clinicians and families in this natural experiment of remote working is required, as is gathering material about what actually happens as well as what clinicians think is happening within their evolving practice.

What is abundantly clear is that swiftly moving to this new way of working involves bravery on the part of all participants. We might settle into a new normal or we might be caught in further waves of flux. We might provide a mixture of old and new, offering both synchronous (remote or enroomed sessions) and asynchronous contact. As practitioners who privilege feedback, we should be able to effectively navigate these ongoing changes. 

Tentative implications for doing remote systemic psychotherapy

We are not yet in a position to be certain about how remote systemic psychotherapy might differ from face-to-face work, but on the basis of current experience some tentative suggestions are made below:

Issues of similarity and difference: Video working offers a more transparent process as patients see us sitting in our own homes to conduct a session. This will affect the balance of power in the therapeutic relationship. Issues of technological and material privilege will need to be addressed and discussed.

How many screens to use: There is creative potential in discussing with the family whether to be on the same or different screens, particularly if therapeutic issues relate to aggression, epistemic power or voice entitlement. Multiple screens and multiple actors add to the challenge of having proper dialogue. Engaging teenagers, who we might assume to be more used to remote and digital communication, seems particularly complex.

Adapting the flow of communication – in order to manage the additional separations in working remotely, the therapist may need to hold tighter control of the flow of communication, as a way of providing a more solid container for the session. This might involve more tightly conducting the conversational chorus more than usual. Over time, people become very familiar with this way of working, conducting might well be shared again with family members. Spaces between words are as much a part of the therapeutic conversation as are the words between the spaces (Helps 2019). Whether between family members or between members of the team, we will need to work out how pauses will be held usefully, and how therapeutic pauses can be distinguished from pauses as a result of technical glitches.

Re-privileging language while we learn how to read people via the screen– Language has to replace embodied responses, and therefore finding the ‘right’ words can be an exhausting process. Likewise, as we cannot use gaze or gesture to manage the conversation in usual ways, we have to find new ways of doing this. This might involve more explicitly asking members of the family to respond to our interventions. It might also involve creating a repertoire of gestures  to help make sense of the language that we use. Making larger than usual smiles, nods, using thumbs up and down gestures might all help.

We have to find new ways of talking in/to our emotions. We are used to sitting behind the one way screen and reading the emotional temperature of a conversation. We will have to work much harder to notice and find ways of asking and talking about the emotional climate whether families are sitting together or on their separate screens. Again, finding new ways of tuning into tacit, embodied responses and turning these to language will be necessary.

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