Delivering psychotherapy by video conference in the time of COVID‐19: Some considerations

Abstract

In New Zealand, we have been far less affected by COVID-19 than many other countries. To put our discussion in some context at the time of writing (10 May 2020) in a country of nearly 5 million people, we have had 1,144 cases of COVID-19 with 1,371 people recovered and 21 deaths. At the same time, the United Kingdom has had 215,000 cases and 31,587 deaths; and the USA has had 1,034,000 cases and 79,696 deaths. While our case numbers have not been particularly high the government's response has been to institute four types of lockdown. We have had just over four weeks of level 4 lockdown (stay at home unless essential worker and only allowed out for groceries, pharmacy and exercise within neighbourhood) and are now in Level 3 lockdown (work at home, businesses using delivery or click and collect and many trades back at work). It is anticipated we will go to Level 2 over the next couple of weeks (can return to work if able to keep distance and most businesses open) because the case figures are now down to between 0 and 2 per day. This upheaval has had a big impact on our research and clinical work. We are involved in a research project that delivers Interpersonal and Social Rhythm Therapy (IPSRT) over 12 months for people discharged from mental health services with a diagnosis of a mood disorder (Major Depressive Disorder or Bipolar Disorder). IPSRT has a strong emphasis on Social Rhythm Therapy (Crowe, Inder, Swartz, Murray, & Porter, 2020) which focuses on maintaining regular social rhythms (sleep, diet, exercise, social interaction), particularly relevant during lockdown. All the therapists (4 mental health nurses, 2 psychologists and one social worker) have been able to continue delivery of therapy and attend regular clinical meetings and supervision via Zoom. Ethical approval was attained for this change in mode of delivery by Zoom which is now password protected for security purposes. While there are many positives about this mode of delivery, a few unanticipated issues that have arisen that are worth considering. The positives in the use of Zoom (and probably other video teleconferencing platforms) is that it provides a viable alternative to the provision of continuity of care in times of social, economic and health upheaval. Most of the participants in our research project engaged very well in IPSRT sessions delivered by Zoom. This enabled regular contact during a stressful situation, and all participants were appreciative of the opportunity to continue therapy. A few people chose to have phone-delivered therapy. There is fairly limited evidence on the use but a meta-analysis of synchronous tele-health technologies in psychotherapy for depression found that they were as effective as in-person delivery (Osenbach, O'Brien, Mishkind, & Smolenski, 2013). The use of such technology potentially provides more flexibility and equity of access than in-person therapy. While not everyone in NZ has access to a device that can connect to Zoom this has been boosted by the government's funding and delivery during lockdown of in excess of 25,000 devices and internet connections throughout the country for educational purposes in low socio-economic areas. All our current patients had access but not all patients wanted to interact via Zoom, some requested to have therapy by phone. There are two principal issues that our patients have identified. The first is that the use of Zoom can be perceived as the therapist entering into your house and some may experience this as an invasion of privacy. Many of our patients do not live alone, many have children or are in shared flatting arrangements which make it difficult to find a private space in which they will not be interrupted or their conversations overheard. For some, the only private space they could access was their bedroom and since one of the basic tenets of good sleep hygiene in Social Rhythm Therapy is to only use the bedroom for sleep and sex, this was not a tenable option. Tied into this issue related to a therapy space is the Māori concept of manaakitanga which relates to the tikanga (protocols) around entering into another person's space. While it is useful to be reminded of the process of invitation into another's space, it is not always feasible in a teleconference situation. Different cultures will have different protocols around becoming part of their private space. The second issue the patients in our studied identified was that when they usually come into the department for a therapy session they go through a process of transition and preparation for the session on the way from the car to the office. They also missed this reflective space post-therapy when they had used the time between to reflect on what had been discussed or shift their emotions for their next situation. When we as therapists pop into their lives via Zoom, this important element of the therapy process was missed by many. They had no warm-up or warm-down transition space when the therapy was delivered in their own home. Now that we are aware of these issues, we can be mindful to mitigate them when setting up the delivery of our therapy sessions. We can defer to patients about what they would expect from people entering their personal space. We can check if they have a suitable space rather than assuming this. We can talk with the patient about what would work as a warm-up and warm-down for them. There are probably other issues encountered while delivering mental health services, including psychotherapy, during a health crisis and social lockdown but these are the issues we have identified with psychotherapy. Video teleconferencing provides an accessible option for many but not all people. It requires access to broadband and an electronic device or a smartphone which many of the most disadvantaged do not have. We were able to support all the participants in our study during this time because all had access to a device or smartphone but those entering a psychotherapy study do not represent all those with a mood disorder. Everyone's context will be different—nurses in other countries will face other social and cultural issues in the delivery of care in these times of pandemic. New Zealand has been relatively lucky to date but as we move back into the new norm we need to be mindful of the effect of new modes of care delivery for the patients to whom we deliver care.