As we are all coming to terms to the high possibility of working from home or supporting clients needing to self-isolate, many questions have come up on professional groups and in the workplace. Additionally, the announcement in Australia of funding for Telehealth for those affected has also sparked the need for different ways of working. This is where some information is needed to be fully equipped either in terms of skills, possible issues, peer support or online professional development. I already do lots of consultations of online (webinars, group and individual supervisions) and also familiar with this mode of communication due to my global migration journey. I have been fascinated to hear about questions from colleagues so, in the last few days, I collated a number of resources, links and information which I thought would be helpful to share.
Ready to move, be prepared
A number of countries have already taken measures to be working in different ways with many self-isolated. With many school closures abroad, it will also impact on the way parents work. There is no doubt that our ways of working will change so we better be prepared rather than sorry, having all the skills, resources and support to face this challenge.
Issues to Think About
There is quite a lot to think about such as security, confidentiality, privacy, case notes, client’s participation and engagement with an online method. Equipment is vital to be able to get the technology right. Modality such as the type of therapy that can be delivered online also needs some careful thinking. Similarly not all can be done online and some clear communication with the clients may need to take place to inform them of that.
Furthermore, insurance covering and possible restrictions to working online as a psychologist need careful attention as not all is possible. For example, some insurances do not cover from work in other countries. Similarly some countries only allow work online if you are specifically registered in that country. Better check before you launch yourself in this type of work. The Australian Psychological Society (APS) is clear that it is your responsibility as a psychologist to look into all of this before committing to working in the online space.
A must: A reliable device (computer, laptop, phone, iPad), stable internet connection, video camera, videoconferencing software, headsets, etc. (see APS, guidelines).
I am familiar with Zoom and have a group and webinar subscription. It is free for one to one consultation, and groups up to 3. When a fourth person joins in to a group consultation, it is then that it starts to have a cost. Webinars need another type of subscription. I enjoy the Zoom platform for a number of reasons. It is easy to use and has a number of features that are helpful. For example it allows sharing of documents, gives you a chat room to provide links to the client and a waiting room feature. I also recently plugged in my business Google Drive an ‘add conferencing’ feature so that I can send an invite prior to the consultation with the link. It also has a whiteboard function if accessed from an ipad/pen device.
Headsets have helped on some occasions but have not been necessary all the time. With a reliable internet and device, it has not felt vital. I always put the headsets on if I am more in a listening mode such as watching a webinar or a group consultation and I have people in the house as I conscious of people overhearing what is happening online. If I am on my own in the house, I don’t necessarily put headphones on.
I was interested to hear from Dr Stephen Goss about the privacy issues with Skype who claim they can own the data and therefore the data is not yours, bringing privacy issues. In an interview the Good Enough Counsellors and Therapists, Dr Goss explained that Zoom is good and that VSEE is also great as they agree to not share information, see link below for both platforms.
Standards of Professional Practice
Working from home may feel slightly more relaxed, but it does not mean that we should reduce professional standards. Have a think about people may see in the room and also you may need to think about the privacy of the room you are working in. Similarly, working in pyjamas may not be that ideal either so thinking about what you are wearing and how this may be perceived is also important. Have a good think about whether you will be moving during the session and if so what it looks like when you get up and down from the chair. I got caught not looking my best a couple of times on the webinars I lead!
You may want to consider the lighting in the room and the sunlight depending on the time of the day so that you can be well seen without sunshine on the screen. Again I am speaking from a webinar I did where the sunshine was reflecting in the screen and no one could see what I was presenting.
It is just a word of caution and of course some flexibility will be needed along the way as both parties are working from home and there may be unexpected disruptions like the dog barking, the postman or a delivery coming at the door, etc.
Outside could also be considered for a consultation, but again with a need to be mindful as to whether you can be heard (big enough garden or not), the wind, birds and nature, although can be peaceful, can also be unpredictable. It is also being mindful about how the other person will feel if you are outside in a lovely environment and they are not. Perhaps this would need to be discussed beforehand. I am on a 2/3 of an acre and a consultation outside would be possible, but rarely happens due to logistics, shade, weather, etc.
Working With Children Online
This is an interesting area and would love to think about developing this area further in my practice. Children are now digitally native and therefore know devices, technology, etc. so this is an interesting space to work in. However, there are also a number of important considerations to be thinking about. I highlight a few here. There may be many more.
Depending on the age of the child, the ability to comprehend the reasoning behind the session, age of consent, parent in the room and also someone they know or not on a screen and not in the room needs attention. For a child to engage in a consultation online, it is important to consider their developmental stage and cognitive/language ability knowledge and this would be a must before agreeing to sessions online. Having a previous relationship, face to face, may help the child conceptualise the need for a consultation online such as needing to catch up, setting goals, seeing how things are going. It may also be of benefit to share interests and key points from a session before as it may help ground the session and guide the unusual nature of it. Similarly, a young person may need reminders about their right to confidentiality and privacy and how to implement this in their environment- private environment, no distractions, etc. Some issues about who is the client may also emerge so better having some scripts and ground rule/discussions from the onset.
An important issue here is to be able to establish whether the age and abilities of the child allows for an understanding of the purpose of a therapeutic space with a device. There are used to play games or watch something, this is what they know, they are digitally native. Does the child understand the difference between speaking to a relative online or speaking to a psychologist online? Additionally, does the child understand the concept of not being in a room at the same time as another person? For example, I have three children and my husband worked abroad, all our families were living abroad, we have had devices in the house and online chats for a long time. At some specific stages of their development like under 6 or 7 (makes sense with concrete vs abstract thinking and Piaget’s theory), they were unable to detect the other person on the other hand of the device/phone i.e. “just saying look what I have, look what I did today”…and unable to reflect about what I am doing here, how is the other person, it was more about showing what I see, what is in my world. In a therapeutic format, it may be more tricky to engage younger children knowing the stages of cognitive development, as they are in the concrete stage. This may bring the complexity of knowing how to approach a situation and communicate with a client whether it is possible to do online support or not.
What can’t be done online?
As above some support can be offered online and particularly valuable. However, not all can be done online. For example, psychoeducational or neuropsychological assessments may need lots of thinking about completing online as it required a face to face participation. Companies are working on this to me it possible, but there is little research in online test administration. As above, depending on the age of the child, it may be more difficult to engage with younger children. Clinical interviews and diagnostic assessments will also be difficult online as it is important to gain a full understating of behavioural observations and presentation, although some screeners could be done by online questionnaires. Clients should be aware of these limitations so it may be worth having some information on the topic at the ready.
It may also be worth considering rigorous risk assessment processes for online consultations and whether more acute support is needed. Consent forms, contact details, etc. should all be completed beforehand to ensure continuity of care if needed.
What Else Can be Done if Online Therapy is not Appropriate?
Not being able to see someone because of participation and engagement issues as presented above does not mean that support should stop there. Of course, referring to another service may be appropriate, but the support may also need to be slightly changed and be helpful. For example, supporting a parent struggling to understand a child’s needs may be highly beneficial. Similarly, supporting a parent who is finding it difficult to implement a home routine during a a self-isolation context may also be highly relevant. Helping drawing up a behavioural plan, an individualised learning plan, goal setting, monitoring changes, step backs and gains, eliciting views from all involved, are all part of valued and helpful support. Empowering parents and teachers that are assisting the daily routines to support a child is also part of the work of the psychologist.
Working online can be highly valuable and rewarding and offer other opportunities such as suggesting Youtube videos for mindfulness, Zones of Regulation, or Apps to follow up from a consultation. Similarly, developing group support and training programs are an interesting way forward in designing a therapeutic space, and research in this space fascinating. Evidence is emerging and will definitely continue to grow.
Self-Care for the Therapist
Maximising Time at Home for Learning, CPD and Peer support
It is possible that many of us may be required to work from home so it is also a time where one can maximise professional development. I provide below some links to online training programs for psychologists and professionals working in a helping relationship. Similarly make sure you are connected with peers for support and discussions to avoid isolation and loneliness. It is also a good time to catch up with a few things like some accounting, logbooks or building a resource library. It could also bring some new projects your way such as collaborating in writing an article, writing a book review, designing a training course or setting up a professional network group…a challenging situation bringing lots of opportunities…
There may be lots of links that I have missed. I am sure there is so much more out there. Hopefully this will give you a baseline to start preparing for the coming weeks and support you in implementing a few ways of working so that you are ready.
References and Further Readings
Dr Stephen Goss, Online Therapy Institute, https://www.onlinetherapyinstitute.com/
Good Enough Counsellors and Therapists (Facebook) https://www.facebook.com/groups/goodenoughcounsellors/
Online Counselling Platform
Apps and Resources for Parents
Information on coronavirus for children- https://660919d3-b85b-43c3-a3ad-3de6a9d37099.filesusr.com/ugd/64c685_319c5acf38d34604b537ac9fae37fc80.pdf
Information for parents of how to support children though COVID19https://www.who.int/docs/default-source/coronaviruse/helping-children-cope-with-stress-print.pdf?sfvrsn=f3a063ff_2https://www.childrenscommissioner.gov.uk/2020/03/17/supporting-children-during-the-coronavirus-outbreak/
Information for those struggling with OCD www.ocduk.org/ocd-and-coronavirus-top-tips
General information for young people about managing their mental health www.youngminds.org.uk/blog/what-to-do-if-you-re-anxious-about-coronavirus
Information for those with sensory difficulties who struggle with handwashing https://www.sensoryintegration.org.uk/News/8821506
www.twikl – free resource for parents and teachers currently
Online Training and Peer Support
Families in Global Transition group (FIGT), Counselling and Coaching Affiliate https://www.figt.org
www.3ppsychologies.com -Child/School Psychology Resources Webinars Series 1 and 2; Global Migration Training Package; Monthly Group Supervision and Support via Facebook group; Individual Supervision for professionals working with children, families and schools, psychologists including educational and developmental psychology endorsement. Online consultations for parents and teachers are also available. To register to the Working Online Webinars Series, follow the link here