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Editorial: Reflections on psychotherapy and counselling from COVID-19 lockdown

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Alexandra Bloch-Atefi, PhD, The University of Adelaide, Elizabeth Day, PhD, Auckland University of Technology, Gina O’Neill, Master of Gestalt Therapy, The Relational Institute, Rhys Price-Robertson, PhD, PACJA Editor and Tristan Snell, PhD, Deakin University.

 

In this time of great uncertainty, we can at least be sure of this: the COVID-19 pandemic has changed the field of psychotherapy and counselling, and it will never be quite the same again. In this editorial, we—the Editor and Editorial Board Members of the Psychotherapy and Counselling Journal of Australia (PACJA)—reflect on how our disciplines have been disrupted by this pandemic, and what this may mean for psychotherapists and counsellors, both now and into the future. We are collaborating on this editorial from different areas of Australia and New Zealand during the period of COVID-19 lockdown.

“Trying to predict the future,” Douglas Adams (2002, p. 102) warns us, “is a mug’s game”. “But,” he continues, “increasingly it’s a game we all have to play because the world is changing so fast”. Though a common message is that current events are “unprecedented,” humans have faced innumerable pandemics, each having meaningful and lasting impacts on the psychology and behaviour of societies. Pandemics tend to produce broadly similar social outcomes: they trigger panic responses, challenge the sense of predictability and control offered by dominant epistemological paradigms, and ultimately lead to changes intended to overcome “blind spots” in scientific and cultural understanding (Honigsbaum, 2019). For example, following the Black Death in 14th-century Europe, after a consistent initial response that current treatments were useless for staving off the illness and that humans were paying for their sins, physicians turned away from authoritative historical sources and towards professional experience and experimentation when developing treatments (Cohn, 2002). Predicting the future may be a mug’s game, yet nonetheless history suggests that we can reasonably expect for panic, disruption, and uncertainty to be followed by the establishment of a new normal.  

What will this new normal be for psychotherapy and counselling? In the sections below, we explore three trends that hint at possibilities. First is the move to online services: this is already happening—at breakneck pace—and it seems doubtful that our field’s relationship to digital technologies will ever be the same again. Second is the disruption to business and training, which is causing havoc for practitioners, educators, and students alike. Third is more of a hope than anything else: COVID-19 is uniting us in a shared sense of vulnerability, which provides our field with the opportunity to renounce the remnants of a tendency towards othering that we inherited from our more medicalised allied disciplines.

Going Digital

In the context of global responses to COVID-19, our lives are rapidly being organised online at almost every turn and every level. For psychotherapy and counselling practitioners, this brings sudden change to existing practices that may be welcome for some, challenging for others. We do not have a recent granular snapshot of our workforce in relation to online service delivery. We can, however, deduce that a small proportion of our professional community will already have been engaging clients through online media; notwithstanding various handbrakes within the profession, this will have been a slowly developing shift. Others will have maintained a more traditional line about the centrality of face-to-face work for effective outcomes, eschewing online therapeutic engagement. And then everything changed. Those in agency-based practice may now have become part of the front-line workforce. Some will have lost jobs. Those already engaging clients online may have increased that practice, while for others online therapy is a brave new world of practice that feels unfamiliar, seems second rate, and is to be regarded with suspicion.

What this new world of online service provision is going to look like in a few years is still unsure, though indicators are that our pre-COVID-19 assumptions will have been overturned by the exigencies of the crisis. The public use of mental health apps has been rising steadily, however within our profession these tools may have been frequently presumed insubstantial, and rarely recommended.  In the current crisis, such tools have become a frontline service in support of de-escalating anxiety and depression. While telehealth (i.e., remote consultation by phone or internet) has been used by medical practitioners for years, it was not on our professional horizon until very recently. However, access has now been opened wide: telehealth has experienced a spike in usage since the Australian Federal Government announced a new program as part of its response to the pandemic. In the coming years, telehealth is expected to become a $40 billion industry globally (Globe Newswire, 2019). 

How we as members of the psychotherapy and counselling profession engage with these coordinated online services is currently subject to the results of the Psychotherapy and Counselling Federation of Australia’s (PACFA) ongoing lobbying, along with the Australian Counselling Association (ACA), for formal inclusion of psychotherapists and counsellors into the Australian Mental Health Workforce. As part of this lobbying, PACFA, along with Allied Health Professions Australia (AHPA), has asked the Department of Health to include all allied health professions, including psychotherapy and counselling, in its forward planning around the Government’s response to the COVID-19 pandemic.

Meanwhile, most in our field have been compelled to contemplate their practices in relation to online therapy. Some have chosen to pause client work until the crisis has passed. Others have swallowed hard and moved online. Meta-analyses have found no significant differences in outcome between face-to-face and online therapy (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Berger, 2017). Nevertheless, migrating from face-to-face to online therapy is not as simple as signing up to a web conferencing platform. It requires consideration of what is different, as well as what is the same or similar, through the medium of communications technology. Guidelines for making the shift to online therapeutic engagement began to develop around the start of this century, led by the British Association of Counselling and Psychotherapy (BACP). Resources and training for online therapy abound at present, and PACFA has compiled and continues to update a set of resources for research, information, and training in the online practice space (see: https://www.pacfa.org.au/providing-therapy-using-online-technologies/).  Making time to integrate this information, set up processes, and establish peer or supervisory supports will facilitate what for many of us is a big step in our practice forged by an extraordinary crisis.

Not Business as Usual

Few businesses and institutions have been left untouched by this pandemic. Many in our profession who run private practices are experiencing uncertainty about the viability of their businesses. Like small business operators in other professions, private practitioners may be struggling to maintain a viable practice in the face of multiple challenges: fewer clients, the possibly of contracting the virus, the risk of transmission to clients or family members, increased caring responsibilities for both clients and their own families, a sense of professional isolation, struggles with adapting to new technologies, and difficulties managing their own psychological wellbeing, just to name a few potential challenges.

It is still too early to say what the long-term effects of this pandemic will be on private practitioners. Perhaps the closest evidence we can draw on are previous coronavirus outbreaks in recent history, such as the severe acute respiratory syndrome (SARS) outbreak of the early 2000s (though it is important to note that SARS was not a global pandemic of the same magnitude as the COVID-19 crisis). The research on SARS suggests that health professionals experienced both negative and unexpected positive consequences of the virus. For example, 17% of Taiwanese health professionals developed perpetuating mental health conditions following the SARS outbreak (Lu, Shu, Chang, & Lung, 2006). Physicians in Canada reported disruptions to client care, loss of income, and fear of transmission of the virus, among other difficulties (Grace, Hershenfield, Robertson, & Stewart, 2005). Yet, counter to these difficulties, nearly half of these physicians also reported positive increases in professional teamwork, as well more time for research, reading, and paperwork. Similarly, nurse students in Hong Kong perceived a fortifying of professional identity and personal strengths, considering these key learnings taken from the experience of dealing with SARS (Heung, Kwong, To, Wong, & Wong, 2005). Such research suggests that we should remain alert to the many long-term difficulties that the COVID-19 pandemic poses for members of our professional community, while also remaining open to the idea that there may yet be some “silver linings”.    

We are also witnessing considerable disruption to counselling and psychotherapy training programs, in both universities and private institutions, which is affecting educators and students alike. The most obvious immediate effect of COVID-19 has been a reduction in enrolments from international students, many of whom have been unable to return to on-campus studies in Australia. The rapidly changing Government updates in the early weeks of the virus concluded with the closing of all campuses and the transferal of teaching to online platforms such as Zoom, Google Groups, Microsoft Teams, and Blackboard Collaborate, with many on-campus teachers requiring immediate training in using these platforms. Training organisations’ abilities to meet the professional associations’ course accreditation requirements for minimum face-to-face counselling practice hours have been compromised, and many educators have contacted professional associations for guidance on the implications on students’ eligibility for membership of professional associations such as PACFA or ACA. While these difficult circumstances are understandably contributing to stress and anxiety for both educators and students, professional associations have moved quickly to accommodate creative adaptations to the situation.

The long-term financial loss to universities and private institutions is predicted to be significant. For universities, the biggest risk will likely be a substantial and sustained drop in international enrolments. International education contributes significantly to the national economy. Indeed, recent figures from the Australian Bureau of Statistics (ABS; 2019) show that, in 2017–18, international education was worth more than $32 billion to the Australian economy, making education the country’s third-biggest export industry. The fates of private institutions are perhaps more closely linked to the overall health of the national economy. In the event of a prolonged financial recession or depression, many potential students could have reasons to re-think, reduce, or pause enrolments. Smaller private training institutes are at particular risk of financial stress as students are more likely to pay fees from their own resources rather than using government fee support. Whether or not there are any “silver linings” of this pandemic for educational institutions remains to be seen.

Shared Vulnerability

This is a difficult time for many of us, professionally and as human beings. In addition to containing our clients’ anxieties, we may also be affected by the fears of our friends and families. Many of us will be observing higher-than-normal levels of stress as our daily routines have been disrupted and our freedoms of action restricted. We are likely to be coping with our own personal reactions to the pandemic, given that we too are living in the same unpredictable world as everyone else, prone to the same uncertainties, worries, and stresses.  In line with what we might say to our clients, it is important that we acknowledge these difficulties and give ourselves permission to feel anger, fear, loss, grief, frustration, and so on. It is also important to acknowledge that this pandemic is impacting all of us differently, and each of us differently at different times; for example, some people feel relieved at being able to follow their own rhythms while the world goes into lockdown. While the long-term harms of COVID-19 are more likely to land on the shoulders of those who are already disadvantaged, there is a way in which this pandemic is having a powerful levelling effect, in which everybody—rich and poor, privileged and marginalised—is at risk. We are all vulnerable, and all in this together. Of course, this is often true, but it is usually easier to ignore the fact.

Our hope is that this sense of shared vulnerability carries over into the ways in which we think about, speak about, and define our field. We hope that psychotherapy and counselling further differentiates itself from those positivist disciplines that encourage an othering of those they serve. Othering “implies that the person doing the helping is, and always has been, untouched by difficulties in her own life and that she consequently derives her legitimacy as a helper from never having struggled herself” (Howard, 2010, p. 15). Such othering normally serves to fortify professional identities, defend against anxiety-provoking thoughts and feelings, and enhance practitioners’ own sense of power. Of course, many of us will still find classifications and diagnoses helpful in our professional lives, and it is unlikely we could ever rid ourselves of the tendency to create divisions between “us” and “them,” even if we wanted to. Nonetheless there are vast differences in how different professions and traditions relate to this tendency: some actively temper it, while some have othering firmly built into their philosophies and practices. 

In the field of psychotherapy and counselling, much work has already been done to temper the impulse towards othering. Many of us are used to sitting alongside clients in a shared sense of vulnerability. Yet still there exist forms of psychotherapy and counselling where practitioners are encouraged to sit above, rather than alongside; to see themselves as invulnerable to the kinds of distress and impairment their clients face. If ever there was an opportunity to uproot such tendencies, then surely it now, when our interconnectedness and collective fragility are impossible to ignore. One possible post-COVID-19 future for our field is that it becomes even more strongly defined by a sense of common humanity, which would be evidenced in our language, our practices, our training programs, and our professional policies and standards.

Holding Hope, Making Meaning

The COVID-19 pandemic has made it clear that psychotherapists and counsellors are needed more than ever. We know that one of the main practices that makes counselling and psychotherapy effective across different disciplines and approaches is the mobilisation of hope and positive expectation (Snyder & Taylor, 2000). Aiding our clients in constructing a hope that makes sense for them can be tremendously helpful in making the current difficulties more manageable. We can also play an essential role in helping individuals and groups make meaning of difficult experiences (Wong, 2010), which, at the current time, means adjusting to and making “healthy” meaning from what is, at least historically, an inevitable part of human experience. Though we might feel a sense of unease about the future and our lack of control over it, there is some comfort in knowing that humanity has prospered and grown through innumerable pandemics. The costs are always high, yet each time we come away with valuable lessons that further our culture and remind us of the inevitability of disease, the illusion of absolute control, and our common humanity.

What hopes can we hold for the field of psychotherapy and counselling at this time? What new meanings might our professional community make? What will our new normal be? We hope that this time of disruption and crisis ultimately results in disciplines that have embraced a wider repertoire of delivery options and techniques (both face-to-face and online), with businesses and training institutes that are more robust and responsive to rapidly changing external circumstances, and with a professional community that is more mobilised than ever to resist the urge to maintain sharp lines between “us” (the practitioners) and “them” (the clients). We hope that such positive changes help imbue the challenges of this time with a sense of purpose; that we can transform challenges into opportunities for growth. Such a new normal would take time arrive. And, of course, there are no guarantees it will come. For now, we will carry on in the best ways that we know how: holding hope and making meaning for ourselves, our clients, and our broader professional community.

References

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Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2-4), 109-160. https://doi.org/10.1080/15228830802094429

Berger, T. (2017). The therapeutic alliance in internet interventions: A narrative review and suggestions for future research. Psychotherapy Research, 27(5), 511-524. https://doi.org/10.1080/10503307.2015.1119908

Cohn, S. K. (2002). The black death: End of a paradigm. The American Historical Review, 107(3), 703-738. https://doi.org/10.1086/ahr/107.3.703

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Heung Y. Y. J., Kwong, W. Y. E., To, S. S. T., Wong H. C. D., & Wong, K. Y. F. (2005). Severe acute respiratory syndrome outbreak promotes a strong sense of professional identity among nursing students. Nursing Education Today, 25, 112-118. https://doi.org/10.1016/j.nedt.2004.11.003

Honigsbaum, M. (2019). The pandemic century: One hundred years of panic, hysteria and hubris. London: Hurst & Company.

Lu, Y. C., Shu, B. C., Chang, Y. Y., & Lung F. W. (2006). The mental health of hospital workers dealing with severe acute respiratory syndrome. Psychotherapy and Psychosomatics, 75(6): 370–375. https://doi.org/10.1159/000095443

Snyder, C. R., & Taylor, J. D. (2000). Hope as a common factor across psychotherapy approaches: A lesson from the dodo’s verdict. In C. R. Snyder (Ed.), Handbook of hope: Theory, measures, and applications (pp. 89-108). San Diego, CA: Academic Press. https://doi.org/10.1016/B978-012654050-5/50007-5

Wong, P. T. P. (2010). Meaning therapy: An integrative and positive existential psychotherapy. Journal of Contemporary Psychotherapy, 40(2), 85–99. https://doi.org/10.1007/s10879-009-9132-6

 


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