Tips related to remote therapy provision

Competence and good practice

Whilst working remotely involves different technology and some specific dilemmas, the underlying therapeutic aspects of compassion, care and professional behavior, and the provision of good quality, evidence-based therapy all still apply.

As with all practice, follow the BABCP Standards of Conduct, Performance and Ethics

And the principles of General Data Protection Regulations (2018)

And as with all usual practice use clinical supervision to discuss your work.

Check your insurance covers remote working.

If you are working as part of a service they are likely to have their own guidelines for remote therapy provision which should be followed. These guidelines may be particularly helpful for independent practitioners and may also have some extra practical tips for those working for services which are usually delivered face to face.

Training and clinical supervision

Make sure you feel competent in the medium you are offering therapy in. Ensure you have supervision from a therapist who has experience in providing online therapy and/or seek peer supervision from colleagues who have regularly offered it. Look for training sessions on managing dilemmas relating to online therapy. If you haven’t used online therapy before, you could practice using the platform with a friend or family member first. Allow extra time before a session to log on if you are less familiar with the technology.

Clear expectations and boundaries

Whichever method you are using, be sure that your client has consented to being contacted using this medium.

Consider having a specific therapy contract for clients that suits online working.

It is important you have access to a safe, private and confidential therapeutic space: a room free of distractions and noises where to conduct the online or telephone session.

Therapists should only focus on the therapy session and not multitask doing other things; for example, looking for CBT resources whilst the session is taking place, or reading materials at the same time the session is happening.

Clients may be tempted to multi-task too. It’s equally important that the client is in a space which feels safe and quiet and free or distractions. It’s a good idea to check where the client is and that they are able to fully engage e.g. not driving or looking after children at the same time, that the TV or radio is off, and that they will not be interrupted by messages or calls. This could be included in a contract.

It’s can also be helpful to think with the client about what they may do after the session e.g. can they do something relaxing to give a bit of space before they go back to their day-to-day activities?

Be clear about the usual boundaries of the session in terms of arriving on time, not taking another call halfway through etc.

Be sure you are talking to the right person before you give any detail, especially if calling a household phone.

It can be useful to have a prearranged word or phrase that a client can say if they are interrupted and want to end the call without saying what the call involves.

Is using text message or email, be clear with your clients about when you will check your emails and messages and how long it may take you to see a message and reply to it. It is particularly important for risk management that a client does not think you are able to see a message when you are on leave or not working. You can use an automatic reply with standard working hours and response times, and/or include within your electronic signature that you are not operating an emergency service and with crisis contact numbers.

As therapists we are generally used to seeing people weekly and having little or no contact in between sessions. If you are concerned about clients calling you or texting you between sessions you may wish consider how you use your phone and video conferencing platforms. If calling on the phone, consider, are you using a specific work phone? If not, consider whether you want to use ‘no caller ID’ so you are not contacted by surprise on your personal phone. If you use this try to let your client know in advance that your number will be withheld so they know it is you.

Alternatively, you may be happy to work briefly with clients between sessions.  This can amplify the effect of therapy meaning that clients engage more readily and make better progress with between session activities. Having some contact with a patient via email or text to explore the change mechanisms is one way of doing this. If you do experiment with this then it’s still a good idea to use a clear work phone or email address and establish clear expectations in relation to when you will reply to their messages.

Make sure you have an alternative way to contact your client if the video call stalls or if you lose reception on a phonecall, e.g. email or another phone number. Agree this in advance and confirm where your client is at the start of the session.

Choosing a video platform

Choose an appropriate platform if you are making video calls. Things to look out for include whether the platform is end to end encrypted, whether video sessions are recorded, and where they stored if so. Who owns any recordings made? Some video platforms record sessions and use them in an anonymised form for big data collection. This may not worry clients but is important to discuss openly so clients are aware of the limitations of whatever software is being used.

For greater security video links that are part of a paid for service are usually better. Some specialist healthcare services have higher levels of security. We don’t endorse any particular platform but ones worth looking into include Doxy, Zoom Pro, VSee, Skype for Business, and Microsoft Teams. There are also others. What’s important is optimum security and workability.

Modifying CBT techniques

During phonecalls it can be extra helpful to use active listening principles, regular summarising back and checking you have understood the client. Use more verbal feedback and consider the pace of your speech to make sure it is extra clear. Pay special attention to tone of voice. Allow silence as you would in a face to face session.

Let your client know you will be taking notes. This might make you go quiet. Consider handwritten notes as especially on video calls typing is very loud and distracting.

You might be used to drawing out formulations in the room with your client. Alternatives for phone sessions could include sending resources in advance of the session, taking a photo during the session and emailing it the client during or after the session, or using a work phone to text an image during the session. Many video call platforms also have have features to enable you to share documents as part of the conversation.

Think in advance about ways to explain metaphors or models e.g. one example from the blog in the resource link uses a clock face to describe a 5 areas formulation, asking people to write ‘thoughts’ at 12 o clock, ‘behaviours; at 3 o clock, and so on.

It is important to think in advance about how behavioural experiments can be planned and implemented when the client is remote from the therapist. The therapist may be able to remain on the phone whilst the patient carries out a behavioural experiment e.g. someone with agoraphobia walking out of their front door, but this will need to be planned according to individual circumstances.

If you are using outcome measures over the phone or online and the client doesn’t have them in front of them, ask them first to write down the scale e.g. for PHQ 0=not at all, 1 = several days, etc)

There are some more specific guidelines, especially but not exclusively in relation to CBT for PTSD, from the Oxford Centre for Anxiety Disorders & Trauma, listed in the resources below. Please do have a look at these

Remote risk management

Managing risk online or over the phone follows similar principles to face-to-face, but if you are working in a way in which you cannot see the client, then you are reliant on other information about risk.

Risk assessment and management is a continuous process throughout therapy. Please seek extra clinical supervision if you have doubts; most clinical supervisors are happy to be contacted between session when issues of risk arise.

You would assess risk by communicating with the client directly using the same questions you would use when working face to face. In addition, you can use information from anu routine outcome measures you are using.

Where risk is identified, but not imminent, you should ensure a risk management plan is collaboratively developed and agreed to. A risk management plan should include contact numbers of agencies, and who to phone first when early warning signs for increment of risk arise. For example Samaritans or other similar organisations.

As in face-to-face work, having a GP contact you can get in touch with if necessary is important to negotiate at the start of therapy. You can then call the GP, if needed. 

If Risk has been identified and is imminent then you need to ask the client to go A&E or you can call the emergency services, this could be the GP, or A&E as above. If the person fails to respond, and you have substantial evidence to be concerned, you can contact the police to conduct a welfare check by phoning 999 or 112 for a mobile phone.

Extra considerations for working with younger clients using remote forms of therapy

When working with young people online it is extra important to set clear boundaries and expectations. You could for example, share a set of rules or ‘top tips’ for the young person to be clear on.

For example, making it clear that online therapy is as important as face to face therapy (only more convenient) and so the young person needs to be in a room free of distractions (not on ipad or phone for example), and where he /she will not be disrupted.

It is important as well, to make clear that online CBT therapy it is CBT not just an online or phone chat.

Young people might struggle more than adults to understand the boundaries of the session. And so they might use other ways of communicating (e.g. emails, messaging) to do ‘therapy’. It requires skill to shape this behaviour to answers messages between sessions within them becoming a mini therapy session.

It is necessary to define parental involvement when working with children and young people online. For example, a young person might get upset during a session. It is a good idea to clarify at the beginning of therapy and to gain consent with the young person whether they would like the parents to be involved/informed or not. This will also depend on the age of the young person. Parents may be present in the session for younger children.

Online presence

Online sessions might mean it’s more likely for you to be googled. It is important you maintain a professional image in social media. Check your digital footprint.

Don’t forget to update your professional sites and referral links to ensure people know you are offering online or telephone options.

Further resources:

Guidance for PTSD Remote Working from the Oxford Centre for Anxiety Disorders & Trauma

Dropbox link: Guidance for PTSD Remote Working

A very helpful blog on telephone working by @notapwpguru

https://notaguru.blog/2020/03/18/ring-ring-telephone-work-at-the-end-of-the-world/

Information Governance Guidance from the NHS

 https://www.nhsx.nhs.uk/key-information-and-tools/information-governance-guidance

BACP have some helpful general information about therapy and counselling online

https://www.bacp.co.uk/media/2162/bacp-working-online-supplementary-guidance-gpia047.pdf

Facebook group CBT in Private Practice

This is set up and administrated by Sarah and Heather, BABCP members. There are lots of resources and advice being shared there.

Some free resources are online here including one on remote therapy

https://courses.clearlyclinical.com/bundles/free-coronavirus-pandemic-ceu-courses

Videos on Remote Therapy Provision

Sarah Bateup, Chair of the BABCP IT SIG, will be doing some Vlogs on this and we will share them as soon as they are ready.

We are exploring options for remotely delivered CPD around this too and again will let you know as soon as this is available.

This resource has been compiled by Dr Lucy Maddox, BABCP Senior Clinical Advisor and includes advice and information provided by: Sarah Bateup, Joanne Adams, Jenny Schiller, Ruth Dennis, Maria Barquin, Sally Tribe, (members of the BABCP IT Special Interest Group Guidelines Working Party), Romilly Gregory (Treasurer of BABCP Equality & Culture SIG), Liz Kell (Co-Chair of BABCP Low Intensity Special Interest Group), Claudia Herrievan (BABCP Independent Practitioner Special Interest Group Committee Member).

BABCP IT Special Interest Group aims to provide members with opportunities to learn about digital methods that are used to deliver and augment CBT.

BABCP Independent Practitioners Special Interest Group represents the interests of full and part-time independent practitioners.

BABCP Low Intensity Special Interest Group promotes and develops evidence-based practice amongst practitioners involved in the delivery of Low Intensity Cognitive Behavioural Interventions .

BABCP Equality & Culture Special Interest Group aims to promote equality,cultural competence and diversity in CBT practice, training and research.

All these special interest groups are free to join for BABCP members.