How psychologists can deliver clinical excellence online - without compromising on outcomes.
2020 will be known as the year video consultation became the norm. Before recently, it felt like only a small minority of practitioners were online.
However online therapy is not new. Back in 2001 Mark Griffiths wrote for the BPS on whether online therapy is a cause for concern - discussing how even then “psychotherapy services such as assessment, diagnosis and intervention” were being provided online.
Back then, services were being offered via email or chatroom, obviously raising questions around security - could you trust the person you were speaking to was an actual therapist?
A number of the disadvantages Griffiths outlined in 2001 are mirrored in our concerns today - as well as therapist qualification, there are legal and ethical considerations around confidentiality, consent, emergencies.
Effectiveness is the next vital consideration. At the time Griffiths wrote there had been few studies on whether therapy could produce the same outcomes online as in person.
In 2020, we have reached a new age of telehealth, where we are able to overcome some or all of these barriers.
It is much simpler to confirm the practitioner is who they say they are with a quick internet search of websites, licencing bodies, social media profiles.
Technology companies are under scrutiny for breaches of data and security, meaning that we see constant improvements in services, assuring practitioners and clients confidentiality is maintained.
However, some practitioners are still uncertain around the effectiveness of delivering sessions virtually rather than in person.
It is understandable. We all prefer face to face contact as it can be easier to build rapport and connection.
There are also fears around confidentiality - because of other people being around. When you’re at home there are other distractions going on, children and partners at home, or if you’re living in a house share rather than with family.
Research has shown that beneficial outcomes can be delivered through teletherapy
In 2018, an extensive review of studies from 2005-16 found psychological intervention delivered by video or telephone had clear and consistent beneficial impact on patients.
Similarly, a French study of 1500 people in 2012 found that online therapist-assisted CBT was as effective as traditional practice - with both effect sizes and recovery rates comparable to or even an improvement on those observed previously in controlled trials.
As these studies show, we are able to achieve the same outcomes through virtual therapy. The question is how.
Best practice for delivering clinical excellence online, from my experience
As an Occupational Psychologist, I have been utilizing virtual solutions for years, with clinical excellence at the forefront of my mind. I also have a background in distanced learning, working internationally, so have been online for a long time.
In recent months this area has exploded and seems to be a much more comfortable space for people.
In the UK, GP appointments and referrals can also be delivered online, so it’s the whole process.
There are three areas I really focus on to ensure clinical excellence:
Security has been a huge factor in delivering sessions online. I would say do your research on the different online platforms available; read anything about them in the news, see what security updates they have made recently, and try to be aware.
HCPC gives guidelines on data protection, reminding us about confidentiality and sharing patient information. Whilst you are working from home or another space, it is vital you ensure that all patient contact is done in a private space where they cannot be overheard, for example working in a separate room with a closed door, and using headphones to ensure there is no opportunity to be overheard. In addition, all notes must be kept securely through an online note-taking system, on a locked device, or in locked drawers, so that they cannot be accidentally noticed by your household.
You also need to consider the environment your client is in - do they have a safe, quiet space without distractions where they can speak openly. Personally, I’ve had instances where clients are sitting in the car as this is the safest space they have to speak without being overheard. You just might need to adapt to what works for your client.
BPS has also published Guidelines in May 2020 on digital approaches, working remotely, and safeguarding - this includes ensuring you have all the correct details for your client and understand their home circumstances, so you have a plan in case any emergencies arrive.
When it comes to building relationships with your clients, you have to do it slightly differently online. This means going a bit further with questions and cues, as non-verbals are different. For me, at the start of each session I check in how they really are and spend a bit more time on this, focusing on some of those non-verbals.
Therapy is emotive and stressful for people so make it less stressful by ensuring they are in the right place before they start. There needs to be preparation and guidance before appointments on the environment a client needs: ensuring they have a comfortable space, where they are not overheard, no distractions, so the client is really in the right space in order to open up and share. Also make sure your space is clear and set up how you like it, that you have no other distractions going on in your home or office.
Get them to test the platforms before you start if possible, even booking a 5 minute test on another day so they can feel comfortable with the technology and you have had another chance to connect, without the pressure of a full session.
The great benefit of teletherapy is that people all over the world can connect with specialists, wherever they are based. As a practitioner, you are able to treat the patients who need you most and will most benefit from your particular expertise. This is certainly the case for another therapist I know, Dr Bijal Chheda-Varma, who told me about her experience delivering online therapy:
“Before the pandemic I was 90% face to face - a few clients might have sessions online if they were traveling or relocated abroad. I swiftly had to adapt my model and find ways to work with patients who were not initially comfortable with the remote options I could offer. “Now it is the dominant choice of therapy, even when lockdown lifted around 60% of my clients stayed online. I mostly only conduct assessments face to face now, psychometric tests to diagnose cannot be done online. I also feel with children and teenagers, adults who struggle with technology, it should be done in person".
Dr Bijal Chheda-Varma, consultant Chartered Psychologist and CBT therapist, and Founder of Foundation For Clinical Interventions
Small issues like technology, perhaps not getting all the body language and personal rapport, are far outweighed by the pros - patients who don’t have to battle with their symptoms to get to the clinic. Those with anxiety, depression, OCD, could be missing appointments due to these symptoms, now those barriers are eased. We can also reach out to people all over the UK and the world who otherwise would not have been ab;le to access the specialist care I offer.
I feel my clinical judgement is exactly as it would be in person and I use the same tools I would do, including risk assessment. Empathy does not stop just because we are on a screen. A little more sensitivity might be needed, knowing that person will be jumping straight back into life.
The main improvement I see now is the clinical forums working online to discuss delivering excellent digitally, of which I am an active member. We also strive to balance care for ourselves as practitioners alongside care for clients.”
We’re all out of our comfort zone right now, however telehealth has been proven to be as effective, if not more so, than traditional clinical delivery. So remember that you can still have an impact, you simply need to try and find your own way.
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