Towards the end of March this year, it dawned on me as for so many others, that I would soon be needing to adapt to an entirely new way of working. Traditionally accustomed to delivering face to face therapeutic interventions within a drop-in service model, we began to design a new blueprint that would enable us to deliver support remotely and without any face to face contact with young people or their families.
This service redesign initially involved gathering insight from across the organisation, to understand where we were already delivering digitally and how we could scale this up. We also gathered insight from across the charity sector, reaching out to other services who were already delivering remotely and who might be able to help us establish our new service offer. The response to this from across the charity sector, and the overwhelming collaborative attitude that followed, has been something that has shone through over recent months, and has been one of the greatest things to emerge for our sector as a result of Covid-19. Following insight gathering and large amounts of research, we were in a position to get re-designing, aware that there would certainly be learning along the way that could be embedded and adapted as we went along.
Following several weeks of immensely hard work across the organisation, we were in a position to re-open our service, and we began delivering support remotely to young people, parents, carers and families in the city. Despite much research into the GDPR and safeguarding implications of various web-based platforms, we established a service offer which was to provide support via the phone, using standard mobile communication, and without any use of video technologies. Although the charities research had concluded that Skype, FaceTime and WhatsApp (for over 16’s) met the appropriate standards, we felt telephone delivery was suitable to deliver the support that we needed to.
Over the months since we launched our remote service, I have continually reflected on my own practice, and the general transition of our service to virtual delivery. It felt right to capture these reflections in writing and to document the learning and developments. 1) For many service users, remote delivery is preferable over face to face engagement
One of my overwhelming reflections over recent months, has been when working with clients who have shared that they have known about our face to face service for years, but have never accessed it before now. There have been a range of reasons for this, including being logistically or financially unable to make the journey to our usual base, feeling uncomfortable presenting at a mental health service where they might bump into someone they know, or simply being far too anxious to make the journey, enter the city centre, and walk through our doors to ask for help. As a service, we have greatly reflected on this in recent months, and in particular on those individuals who have previously been unable to access support from us because our service simply didn’t meet their needs. This reflection and our adaptation to remote delivery, has encouraged us to look forward and consider the ways that we might be able to deliver a hybrid service model moving forward, that being one that provides face to face and remote provision, ultimately providing greater choice to our service users.
2) Core therapeutic skills can be comfortably transferred to remote delivery Carl Rodgers (the founding father of person centred counselling) introduced three core principles needed to create an environment where a client feels comfortable, able to engage in therapy and progress forward. These core conditions as they were named, include empathy (understanding), congruence (genuineness or realness) and unconditional positive regard (acceptance/the absence of judgment). Although I have always wondered how comfortably these core skills transferred to remote delivery, it didn't take long to realise they need not be impacted by the fact that you cannot see the client. That being said, it did require some consideration into how these core skills could be transferred to remote engagements. In face to face practice we can rely on an additional layer of verbal cues when working with clients, including nodding, body language and eye contact, but when working digitally without video technology, we must fall back on more explicit verbal statements to communicate our empathy, acceptance and understanding. For this reason, it was necessary to ensure the integration of verbal statements which demonstrate my understanding of a clients experiences; “It sounds like things have been really difficult the last few weeks”, “I can really see how hard that must have been for you” or “I can understand why you’ve been feeling that way”.
Another core skill that became particularly important, was reflecting back to the client what I had heard them say. In the absence of visual cues, and where technology can sometimes reduce the quality of the communication (poor reception being a consistent theme), regularly reflecting back to ensure I had understood correctly became paramount; “So it sounds as though xyz, is that right?” or “You said xyz, have I understood that correctly?”. Using these statements demonstrates that you are listening and checking in with what the client is saying. Even if you have not understood correctly, it gives an open opportunity to address this throughout the call and also demonstrates the congruence within your encounter. Further congruence was often demonstrated through acknowledging the nature of this new situation and new way of working, using statements like; “We usually get to see people when we work with them, but for now we are working on the phones, how do you feel about talking on the phone?”, “I know some people are finding the use of all this digital technology a little strange…how are you finding it?” or “Because I can’t see you at the moment, I don’t know what your facial expression is at the moment, can you tell me a bit about it instead?”.
3) Therapeutic relationships can be established remotely (using core therapeutic skills) I’ve always been slightly sceptical about the ability to build a therapeutic relationship when you do not meet the client in a face to face setting. As someone who believes strongly in the importance and value of this relationship, I have wondered how one builds this without the physical presence, interaction and visual cues that are provided through face to face engagement. However, I’m heartened to confirm that it can be done. I’ve supported a range of young people and adults over the previous months, and in general I’ve found each of these interactions to be positive in terms of our ability to build and establish rapour. I’ve continually (and congruently) addressed this with clients and allowed a space for open conversation and feedback about how they are finding the telephone service delivery. Feedback has continually been extremely positive, with young people consistently feeding back that they are finding the support helpful despite being over the phone. It is of course helpful to reflect that for so many young people, digital technology is their norm, and communicating via these channels is an embedded part of their day to day existence. In light of this, it is my belief that if a practitioner is able to transfer the core therapeutic skills outlined above, to whatever platform you are using, then in theory a therapeutic relationship can absolutely be established between yourself and the client.
4) Working remotely and digitally becomes logistically and legally more challenging the younger the client As a service that supports 0-25’s, we had to prepare and plan for supporting all young people who fall within this age bracket. However, due to safeguarding considerations, the processes became more complicated the younger the client, and required a little more thought to establish an appropriate service offer. When considering the digital platforms that we might use to engage young people, we faced an extra layer of barriers in relation to age, this included WhatsApp who officially require their users to have a minimum age of 16. This immediately ruled out this platform for anyone in the 0-16 age bracket, and finding a digital platform to use with under 13’s became a challenge. We also had to consider the emotional impact when working with younger children, and consider how we would respond if a child became distressed on the phone. For this reason, we decided that as a service, we would require a parent to be present in the room whilst someone under the age of 13 was accessing support from ourselves. Usually this was done by asking the service user to put the practitioner on speakerphone, and we would then speak to both parent and child together. Although 9 times out of 10 this didn’t present an issue, there were some instances where the young person would be less willing to talk with a parent in the room. Where this was the case, we provided a reasonable level of flexibility and suggested that the call be placed on speakerphone, and the parent perhaps leave the room but stay close-by so they could be aware of what was going on and could enter quickly if the young person required support. In regards to consent, our approach did not change much when we transitioned to remote delivery, and we continued to require parental consent to work with anyone under the age of 13.
5) Remote delivery requires an enhanced level of internal communication
Although remote delivery suggests working at a distance from ones colleagues and clients, this distance must only refer to a geographical and physical state of separation. In contrast to what the word distance might imply, it became clear that maintaining effective communication within our internal team and the wider organisation, was more important than ever to survive the months ahead and support one another in our transition to remote delivery. The response to tighten up our internal communications included identifying and responding to any gaps in our internal mailing lists, introducing new communication platforms and necessary training, and allocating work phones to all practitioners. This enhanced level of internal communication has proved another overwhelmingly positive response to Covid-19, and is something that was fundamental in enabling us to deliver remote therapeutic support safely and effectively.
Closing Reflections
Although the last four months have presented some immense challenges for the charity sector, in many ways we have been forced to consider ways of working that we wouldn’t have necessarily considered before. Whilst in a therapeutic setting, this might not have been ideal for all, my overwhelming reflection and response has been a positive one. I am proud not only of our ability to continue to provide a high level of support to young people who would have accessed our face to face service, but also in engaging with some service users who would never have walked through our doors, and consequently, might never have accessed our support. In times of crisis, we are often forced to respond to unavoidable calls to adapt and change, and we must look to capture the learning that emerges during these times so as to enhance our offer in the future.
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