Almost overnight, the way we work has been disrupted, changed and, in some cases, halted altogether. In a short space of time, we have found ourselves dealing with multiple challenges, including finding new ways to deliver therapy, while also negotiating changes in what clients are bringing us. And we are navigating this while also managing our own anxieties about the extraordinary situation and its potential impact on our health, our loved ones and our financial security.
It’s completely new territory, but what we are seeing in response from our profession is a willingness to quickly adapt to the needs of both existing and new clients. There is much to consider – do we need to recontract with a client if they are now dealing with severe anxiety when originally they came to us about their relationship problems?
If we adjust our fees, how do we cope financially? How do we find a balance between supporting our clients while also attending to our own self-care?
As therapists, we are used to working with uncertainty and not-knowing but, right now, there are more unknowns than usual. And, as we absorb the new developments that each day brings, we have become acutely aware of the benefits of shared knowledge and mutual support.
In this spirit of collaboration, we asked BACP members to share their strategies and experiences.
The Corona catalyst
The rise in incidence of anxiety and depression seems to have been triggered at least initially by the anticipation of the changes and challenges ahead, according to research from the University of Sheffield and Ulster University.1 On the day after the Prime Minister ordered people in Britain to stay at home, due to the coronavirus pandemic, 38% of study participants reported significant depression and 36% reported significant anxiety. This compared with 16% and 17% respectively the day before the announcement. The study found higher rates of anxiety and depression in those aged under 35, living in a city, living alone or with children, and with lower incomes or health conditions. Not surprisingly, people whose incomes had been hit by the pandemic had higher rates of anxiety and depression.
But the response from many practitioners has been concern that normal reactions to an extraordinary situation will be pathologised. ‘Worry and low mood are a natural response to times of uncertainty, and it does not mean that everyone who feels this way needs help, either through medication or therapy,’ says counsellor Dr Anne Guy. ‘People may need help managing their anxiety, but I think we need to be wary of focusing the problem on the individual, rather than what is happening to society as a whole. What people may actually need right now is practical or financial support rather than medication, or even counselling.’
Psychosynthesis therapist Charlotte Braithwaite describes a need to strike a balance, to ‘reassure clients that what they are feeling is normal, so we are not pathologising normality, but also not normalising pathology’. And what has surprised her is the positive response from clients with a pre-existing condition of health anxiety, she says: ‘One said, “It’s like the world is keeping me company now. This is my every day and I no longer feel alone with it. I feel understood, and that my internal world is mirrored in the external world”.’ She is also seeing a change in the dynamic of sessions, which she has called the ‘Corona catalyst’: ‘I have seen a speeding up of getting to existential issues such as death and what really matters in life. It is making the work very rewarding.’
Counsellor Susanne Barthelmes has seen an uplift in mood among clients she has been working with for depression. ‘The pandemic appears to have put their respective suffering into perspective. There also seems to be a reduction of shame or guilt about withdrawing, not wanting to go out, not wanting to be in contact,’ she says. ‘The fact that everyone is asked to do this appears to normalise the depressive experience. This, in turn, seems to be a motivator to re-engage with life. To my surprise, two seriously depressed clients reported feeling significantly better and that they were no longer experiencing suicidal ideation. They have started engaging in life-affirming activities and looking towards the future with hope.’
Psychotherapist Tamara Howell has noticed a surge in what she has called ‘Corona goals’ among clients. ‘Many people are reacting to the lockdown by setting goals such as an extreme fitness regime, a complete clear-out of the house or learning a new language. It can be hard for clients who are used to a goal-oriented culture to suddenly be faced with this unknown. I hope I am providing space for clients to process challenging feelings as they adapt to this new world.’
There is also ‘Corona guilt’, says counsellor Rachel Jepson – the sense that carrying on with the work they were doing, such as exploring the patterns of their relationship with their parents, seems self-indulgent now. ‘But I say it’s still relevant – you can feel let down by a parent as a child and also feel concerned about how they will cope during the pandemic,’ she says. ‘As therapists, our job is often to explore the impact of past patterns or deeply held beliefs or hurt on day-to-day life, so we can explore with clients who have difficulties with a parent how they are managing that relationship now that they may be involved in caring for them in some way, such as delivering food, or are worried about their health.’
There are growing reports of an increase in domestic violence, says Ammanda Major, a relationship counsellor, sex therapist and head of clinical practice for Relate. ‘Self-isolation in domestically abusive situations is likely to increase the tensions. But identifying domestic abuse within a couple relationship can present serious problems for practitioners who are not fully trained in couples work, as well as potentially increasing risk for one or both of the couple.’
She reports that couples work generally can be impacted when it no longer takes place in the therapy room. ‘With in-person work, we offer couples a neutral and tranquil space away from the pressures of daily life, where they can focus on and consider their relationship, so obviously there is a different dynamic when we “see” clients in their own home via online work,’ she says.
‘Offering confidential sessions for both members of the couple individually can also be difficult to do when they’re at home due to the potential lack of confidentiality. However, the positive side is that therapists gain “access” to the couples’ home situation, which may provide insight and, for some couples, digital delivery of counselling offers more flexibility and helps them to access a service that might otherwise be out of reach.’
Dealing with deskilling
After an initial adjustment period, it may be that much of the work with clients settles back to where it was pre-lockdown. But what won’t go back to normal for several weeks is the way we deliver that work. For the majority of practitioners, whether they work in private practice or for a service, school or charity, that has meant a transition from in-person work to working remotely, usually online or by telephone. For those of us who have not worked this way before, it can mean a period of feeling deskilled.
Sue Balmer, a therapist for an IAPT service, was given 24 hours’ notice to transition her caseload of 20 weekly in-person appointments to telephone work, with no training offered. ‘There was a sense of panic, although I felt calmer after accessing resources on the BACP website,’ she says. ‘But there is still a sense of feeling unskilled, and of having many new factors to be mindful of, including whether a client can be safely held this way. With some clients there was a mutual agreement to pause the sessions because of questions about containing the emotions that sessions can generate.’
It’s been like a ‘CPD accelerator’, says Barthelmes. ‘Never have I had to get trained and skilled up in a new way of working so fast. I have chosen to work by phone, rather than online, due to privacy and Wifi issues at home, and have been open with clients about the fact that phone counselling is not my core competency and that we will learn together how to make it work for us – a kind of co-creation. Initially I felt anxious about sessions in a way I haven’t since I was a trainee. It’s like going back to the drawing board. I am aware that my attention is sometimes on the medium, rather than the content of the session, but I am getting used to it fast. Week three of remote counselling is already a better place to be.’
Counsellors can feel more anxious about leaving silences and find themselves talking more when they are working online, according to research carried out by the international therapy community Stillpoint Spaces.2 ‘There is also the fact to consider that we are moving therapy to the same arena, the home computer, in which we play solitaire, work, watch films, do online shopping – how do we differentiate between that and what we do?’ asks Aaron Balick, psychotherapist and director of Stillpoint Spaces. (How to overcome the challenges to transitioning to online work is explored in detail in this month’s In Practice feature.)
But along with deskilling, for many there is also a sense of wonder at a new dimension brought to the work. ‘I am surprised by how intense, effective and moving telephone therapy is,’ says Balmer. ‘I have noticed that clients who have held back from crying in sessions feel free to cry now. For some, working this way is clearly more difficult, and I am checking in more, asking what they are feeling when there is silence or there is a change of tone. But with others, I feel a sense that they are in their safe place at home, so they are able to go deeper than they have done in sessions.’
The financial impact
Some practitioners are reporting being busier than ever. Susie Pinchin is a counsellor who works for a private girls’ school in London. Although she is contracted to work term-time only, she is volunteering her services to the school throughout school holidays to support the girls. ‘I work with many high-achieving girls and there is a lot of anxiety in particular over GCSEs and A levels, about whether they will get the grades they need,’ she says. ‘The situation is devastating for girls who have never failed or learned to cope with failure. I am sending out regular emails to all the girls and inviting them to contact me. In some cases, this leads to telephone counselling, but in others, it’s just email support. I am aware that I am fortunate to be able to offer this extra support.’
Private practitioners, by contrast, are reporting a loss of clients. ‘I had a caseload of 27 and now have 20,’ says Braithwaite. ‘Seven have paused until the situation changes, due to financial restrictions.’ Some face bigger losses – Barthelmes says she has retained only a third of her caseload. ‘A third have paused their sessions as they did not want to work remotely. For some, it’s about not having the confidentiality they need in the home now they are surrounded by the people who they are coming to therapy to discuss. Another third have stopped due to financial issues. So I am left with the third that, as it turns out, are also those that I have the most established relationships with.’
Whether to offer discounted or even free counselling during this time is often a complex decision. ‘My concerns as a therapist are different from my concerns as a small business owner, and often they are in conflict,’ says Braithwaite. ‘I have grappled with the issue of offering a discount rate, but for some, even that would not help. And I don’t want to get into having to almost “barter” with clients or feel like I am pressurising them to continue, if they would rather pause. For some, the answer has been to move to fortnightly work. If clients do want a discount, I am open to discussing it, but it’s not simple. Do you set a time limit on the discount rate, for instance, or wait for the client to let you know when they can afford full rates? What I have found is that clients are not comfortable with getting a discount and would rather pause until things are back to normal.’
Integrative counsellor Rachel Shattock Dawson notes that working online effectively turns therapy into a level playing field geographically, as online fees are not linked to the economy of the area the therapist works in the same way that they are for in-person work. ‘I have resisted offering fee reductions so far but wonder if I would have kept clients who have left for financial difficulties if I had done,’ she says.
Offering discounted fees can seem like the morally right thing to do during a time like this, but therapists also have ongoing overheads, which may include rental for a room no longer in use, as well as the usual professional membership, directory and insurance fees. And, given that not every client has seen a reduction in their income, it’s best tackled on a client-by-client basis. Alternatively, we could offer clients a fee ‘freeze’ until government support payments come through, but then we put ourselves in the position of being a debt collector. ‘Some members have responded by offering counselling for free. While that reflects good intentions, no one should feel their only option is to work for free,’ says Kris Ambler, BACP’s Workforce Lead.
There is a regularly updated FAQ section on financial support available for members on the BACP website.3 ‘Under the recently announced Self-Employment Income Support Scheme (SEISS), the self-employed who have been adversely affected by coronavirus can apply for a taxable grant worth 80% of their average monthly profits over the past three years, up to £2,500 a month. This scheme will be open to people across the UK for at least three months and people will be able to make their first claim from June,’ says Ambler. ‘If you’re eligible, HMRC will contact you directly and ask you to fill out an online form, and the money will be sent directly into your bank account.
‘It is welcome but it won’t help all our members. Those who trade via a limited company or a personal services company will fall between the cracks. In these cases, the Government has said people should apply for up to £94 a week from Universal Credit, but we are aware of shortcomings in this offer. If the measures aren’t supporting you, please let us know.’
Keeping services going
For counselling services, there can be issues about keeping up rental payments on property while seeing a drop in income. At Stillpoint Spaces, Balick says: ‘We are in the difficult situation of asking counsellors to continue to pay rent for rooms that they are no longer using. But without their support, we can’t pay the landlord of the building. We are looking into the availability of support through a Government grant, but there will be a time lag until that comes in.’
The Grove, a London-based counselling service, has also felt the impact. ‘We rent physical premises for our psychotherapy services and have had to ask for a rent reduction from our landlords as we are getting less income from the therapists who rent our rooms. The other strand to our business is providing counselling in the corporate space, but right now there is no corporate space,’ says co-director Elliot Davis. ‘We fought hard to break into the corporate world and convince companies that employee mental wellbeing is directly linked to productivity. But the world will be changed when we come out of this, and whether that means there will be more willingness to invest in the wellbeing of staff, or whether staff support services will be cut back to save money, remains to be seen.’
Many charities providing low-cost counselling to the community are facing loss of income because clients are suspending sessions due to financial pressure but the organisation is still having to pay for overheads, such as rent, running costs and staff wages. ‘Charities are businesses and are entitled to exactly the same support as local business, such as payment holidays on rent and rates,’ says Ambler. ‘There are also many local authority grants available, and now is a good time to research and apply for them. I will be updating our general advice for charities on the BACP website, but charities needing specific advice can email me.’4
The longer-term impact of the pandemic remains to be seen, but many of us are wondering if we will see an increase in clients preferring to work remotely and, if so, what that will mean for the way that we work. Will funded services see an opportunity to cut costs by continuing with remote working – if it is seen to have worked – rather than reverting to offering in-person sessions? ‘My sense is that an ongoing effect of this situation will be to destigmatise and demystify online work, so it will be more integrated into our profession,’ says Balick. ‘But it shouldn’t be seen as just a convenient alternative.’
We should be sceptical about press reports predicting a ‘mental health crisis’ and a rush of clients seeking therapy after the pandemic is over, says Guy. ‘Public Health England has said that anxiety in the face of a pandemic is normal, and for most of us the best ways of coping are simple and common sense – exercise, sleep, routines, keeping your mind active and so on. It is neither true nor helpful to frame these reactions as a “mental health crisis”. In a shared crisis of this nature, much of the best support comes from each other, as friends, neighbours and citizens. There is a role for therapy in supporting people but we need to be wary of getting sucked into seeing normal responses as a problem of the individual, rather than a collective problem of society that requires practical and even political solutions. While we therapists are well placed to help clients reflect on their responses in that context, what many will need most when this is over is financial support, not emotional.’
Relate’s Major agrees. ‘Counselling is not about giving advice, but that’s what many people need right now. I think, as a profession, we need to think carefully about how we deliver what the public needs in a time like this, while also maintaining our base of traditional counselling work. Clients are looking to access support in different ways – by email, online, by phone and by text – and it is up to us to meet these needs in a responsible way. I think what this pandemic has taught us is that diversifying our core business is essential for us to survive as a profession.’
How have you been affected personally and professionally by the pandemic? If you would like your story to be featured in the next issue, email email@example.com
Sally Brown is a counsellor and coach in private practice and the editor of Therapy Today.
4. Email Kris.Ambler@bacp.co.uk