The monthly DiS podcast

In response to a suggestion from a person on the mailing list, I have been thinking about a PCP view of the changes from face-to-face sessions to telephone or video consultations. There are a number of issues in relation to the the way the pandemic has affected my working practices, my construing of myself as therapist and my construing of my work and my home. I am hoping that some of this may resonate with your own experiences. Remember that I have a loose construct of therapist so although I use that term here, I am using it to describe all of us who are trying to help young people who would like to change, or who have been told by other people that they need change to change.

Sudden changes

Most services have had to make a very sudden shift from face-to-face, to some form of remote service. Some of us may have relished this, some have been accepting and moved into the the new way of working, but others might have been extremely stressed by the changes. In PCP terms, people will have adjusted in accordance with their personal construing. If they hate using technology, the changes may have been experienced as very difficult, perhaps even threatening. In that case, the individual’s sense of self as a person, or as they are in their role,  is potentially at risk. They might be extremely upset and unable to see how they could c ontinue to work. The sense of invalidation leads to work becoming unbearable, and the remaining option is to be off sick with stress.

Another person might be delighted by the changes, relieved that they do not need to go into the office or clinic. If they are very familiar with the technology already, the shift in construing might be comfortable and consistent with their sense of self. Kelly called this sort of elaboration of sense of self ‘aggression’. It is about moving forward and anticipating that the experience will validate their sense of who they are. Most of us will fall somewhere in the middle, maybe moving between the the two extremes from time to time. There may be aspects of the new therapy world that we are fine with and others that we find challenging. As long as the challenge is not too great for us to reach a position where we are comfortable with the new ways of working, we are likely to adjust over time, gradually elaborating our construing so that the new becomes predictable and familiar.

New interactions

The main tools therapists seem to be using are telephone calls and video consultations. Both of these are likely to be more tiring than a face-to-face sessions because the sessions will require more intense effort on the part of therapist and client. Concentrating on a phone call is more difficult than face-to-face, probably because the communication is more limited. This also applies to video calls where body language is not very visible and we cannot use proximity to convey our responses during conversation. There is a heavier reliance on voice tone and information than there will be in a face-to-face situation. In PCP terms, the opportunities for non-verbal construing are reduced, affecting construing of each other. As a therapist, I love being in the room with clients and I really miss it. I enjoy the interactions in those sessions, noting from the client’s words and body language how the session is going. I can watch and listen and pick up discord between the two. Are they really agreeing with me even though they are saying they do? Does the way they speak and move seem to suggest that what they are saying is not the whole story? I notice changes in eye contact, in facial expression, when the client moves toward or away from me in their seat. I see that their eyes cast towards the door as they become tired in a session. The richness of this non-verbal construing is unavailable on the phone and only partly available in a video consultation. As therapist, my non-verbals are missing to the client so they cannot be as sure about how I am receiving what they are saying. My responses have to be verbalised so they can be clear. I cannot easily use my eyes or smile to show validation - I also have to say it, affecting the flow of the conversation.

Despite what I see as the disadvantages, I am also aware that a phone or video consultation might suit some clients much better. If the client finds it difficult to leave their home and attend clinic session, then this style of delivery is more accessible.

One of the challenges of therapy in the ‘lockdown’ is that some of us would never have chosen to offer the majority of our sessions on the phone or in video calls. Therapy is typically face-to-face in a room. For me, because I prefer face-to-face consultations, the move was uncomfortable. In Kellyan terms, the discomfort I experienced is ‘guilt’ - the experience of being dislodged from a core role. In this case, I was no longer able to be the therapist I had become and wanted to be, and this was somewhat stressful at first. Gradually, I have developed a new way of construing myself as therapist which now includes working remotely and using the phone or video calls almost all of the time. I hold on to the hope that this is a temporary situation and that after ‘lockdown’ I will be able to see people face-to-face again. My construing has been elaborated gradually, a bit more in each session I have conducted, so that now I have found a reasonable way to practice. As my construing has changed, I have found it easier. I now have some solutions to a range of problems that have cropped up so I am more comfortable in my anticipation of the way the session will progress. One of these is to ask the client to have a pen and paper handy for the session, as I do. Writing things down on paper and making diagrams in sessions helps me to make a visual record of our conversation and I do that so the client can see the paper, often inviting them to add to it. That is very important thing to me and it is part of my personal practice style and I realised that this was part of my discomfort. I feel better now that it is added back in. They can also write down my signposting to useful resources, something I would have done and given to them in a face-to-face session.

It is possible to use rating scales in the session, if I ask the client to draw it out in the same way I do. I make sure that we both have the preferred pole on the right hand side of the scale. We can then make a scale along a construct (e.g. between ‘feeling down’ and ‘feeling good’). This will work in telephone and video sessions with the addition of numbers on the scale (perhaps 0-10 with 10 being at the preferred end (‘pole’) of the construct. Generally, I am not a fan of adding numbers to these sort of scales because I find that they can be a distraction. Some people may not have sufficient mathematical skill to place numbers. I think that is why I prefer a scale without numbers - it does not rely on any mathematical understanding, other than  being able to say that x is more or less than y. Nowadays, many clients seem be very used to completing rating scales with numbers 0-10, so as long as the client is able to see it or to visualise it, that should be possible on the phone. I would ensure that they know they can place marks anywhere on the scale, they just need to tell me what the number is.

We are are likely to find that a telephone or video call is easier when we have previously met the client because we can imagine them when we hear them speak. That is likely to be similar for them. When we have not met previously, we might be much more aware that we are working hard to develop a working relationship with the client. We are trying to construe their construing and this is made more difficult by the limited information available. This relates to what Kelly called ‘sociality’ - construing another person’s constructions in order to be able to play a role with them (in this case, as their therapist) and my own experience is that this is a slower process when we are meeting on the phone or in a video session. A client will, at the same time, be construing our constructions about therapy, and about themselves. This makes therapy possible - without sociality, there are likely to be complaints or disengagements.

Another issue with telephone and video consultations is privacy. A planned call will make it easier to manage for both the therapist and client.  It may be difficult to find a private space when other people are in the house.  It is a good idea to give a time frame for the call’s length, so that other people can be asked to keep out of the room. Often parents can help a young person with this, ensuring they will not be disturbed.

These are new arrangements to many of us and will probably also lead to discussions with our own families about privacy and the confidentiality of our work. A therapist will typically have what Kelly calls ‘tight’ construing of confidentiality that has been developed through training and working within the organisation’s boundaries. This tight construing leads to clear implications so that the therapist becomes sure of what can and cannot be shared about their client. When we are working from home we are bringing our work and its relationships into our home. We may not have a space that is only for our work, so separation from work and the stresses of it might be more difficult. Some therapists might have to work from their bedroom, or their children’s room, and the connection may be hard to shake off if what happens in the session is very difficult, such as a disclosure of abuse. If there is no space to work, the experience is likely to become stressful. In this sense, the construing of work is also affecting the therapist’s construing of home.

Professional training is likely to have included the importance of not being over-familiar with clients. This is an issue when the client can see into their therapist’s home in a video call. We have to give consideration to our home and make it work-friendly so that we can limit the client’s knowledge of us. Prized objects might have to be put away - the very things that we have chosen to display because they represent us. Many video platforms will have fake backgrounds which can be used to avoid this.

Loss and new adjustments

The experience of remote working might be include a significant loss of contact with colleagues. Although it is now reasonably easy to stay in touch through the video platforms, all those interactions are changed. It is harder to catch up with someone for a chat, for the conversations we would have at the kettle or the morning office round ups as people arrive. In a group call it is more difficult to negotiate natural turn-taking, to see when someone needs to leave and the conversation will have to end because they cannot start gathering their things to go. So our sense of loss might be related to the change in what is possible, rather than being unable to contact anyone. Again, this relates to non-verbal construing. The sense of ‘being with’, ‘sitting next to’, ‘sharing a space with’ are constructs that we may only have become aware of since we moved to remote working and experienced the contrast pole. These things may have seemed trivial previously and now we realise how important these constructs are. This leads to an awareness of construing that was previously not noticed - Kelly calls this ‘submerged construing’. The construing was happening but it was at a lower level of awareness. Now that might come to the fore and become a source of sadness and loss as our construing of self in relation to ’team’ is changing.

Another loss is the physical sensations associated with being present in our usual workspace. The non-verbal construing of the lighting, the smells and other sensations, the view from the window, the feel of sitting in a work chair and using a desk. These non-verbal experiences help us to adjust from home to work, to know where we are, and because we know, we then enact our construing about a role - our ‘work self’. This can be harder at home, where the shift from home to work is very quick compared with travelling to work, arriving, walking into the workspace - all of which allow for a gentler transition. Now, we might be eating breakfast and playing with our child and ten minutes later we will need to be in full work mode. We will be develop new constructs about the transition, probably making little routine to help us through this change.

Clothing is significant issue. What we wear is an important part of our sense of self. Again, non-verbal construing is relevant. The feel of fabrics, the way they hang when we wear them and the colours are all important to us. For many of us, we will have developed some sort of work clothes/home clothes divide in our wardrobes. Shoes are a part of that too - they change the way we walk and what it is possible to do. Our clothes and shoes support our sense of self in our role and when we put them on, it is part of the transition into the role.  Some of us will be welcome these changes. We have probably all heard of people working in their pyjama bottoms with a more formal top. It is an active experiment for these people - can they be a therapist who is half ‘appropriately’ clothed? Other people might still wear their usual work clothes and change at the end of the working day, helping them to stay in role during the day.

A new construction of self

All these adjustments to our construing have been ongoing since the start of the enforced change and will continue. They may have led to us becoming more aware of what really matters to us about this work and the way we do it. Our construing is continuously developing and adjusting because we will have experiences that validate or invalidate our construing. It might be interesting for each of us to see how it adjusts again when there is a change back to working in clinics and offices. How much of the new or adjusted construing will have become familiar and therefore comfortable by then?  How much resistance might we experience if the shift simply to return completely to the ‘old ways’ of working? It will be an interesting journey into the new world.