COVID19 has brought about a new normal for many of us. As mental health professionals providing face to face counseling services to victims of violence and trauma, our new normal became tele-therapy. Some of us had done this in bits and pieces over our years of practice but never to this extent, never for a full hour or more and never for consecutive sessions. This blog post is the CSVR Trauma Clinic’s reflections of the process, to share with you what worked well and challenges that arose.
“I recall my first client call, I felt nervous, like an intern seeing her first client, which I found odd, as I have been providing counseling services for a good few years now and so the feeling of being nervous was rather interesting. But there it was, as I thought about it in hindsight, I realized that I relied a lot on my physical being in connecting with people and that a smile, a kind face, soft tone, even the way I dressed to see clients all communicated something that helped me build rapport with my clients from the first meeting. Over the phone, all I had was my voice” Sumaiya Mohamed
The way our operation works is that clients would call our emergency line, give their details to our receptionist who would then forward their details to a therapist. The therapist would then make contact. A few hiccups with this, clients may be called from an unknown number (dependent on a therapist willingness to share their contact details) or be called from a number they do not know. From our experience, they would either not answer the phone or when they do, they interrogate you, as they rightfully should, wondering who is calling me? Levels of mistrust are high in our society, thanks to high levels of violence and low levels of social capital, so these initial reactions are understandable. To manage this, you could:
- Contact the receptionist to essentially make an appointment for you. The receptionist would contact the client and inform the client that you (your name) would call at a particular time and that the number would show unknown or be this number xxxx. Alternatively, you can leave a voice message, informing the client who you are and stating that you will call again this time tomorrow.
- Once your call is answered, it is important to communicate who you are, what you do, where you are calling from and why you are calling them. One has to be mindful that this is not a social call and clients will be distant in the initial interaction. This is where the work starts for the tele-therapist, in terms of building rapport over the phone.
- What we found helpful, was being mindful of tone of voice and pace of speech. Being clear and concise is also very important. Through these elements, containment and holding are communicated.
“I think of clients I have called, who sounded suspicious in the beginning of our calls. Who are you? You said, you are calling from where? And by the end of the call, they are at ease, willing to make another appointment as they tell you about their routine, when they take their lunch break and when you can call again.’’- Charlotte Motsoari
“I have also had experiences where clients referred through the emergency line state it is urgent that a therapist contact them as soon as possible and when you call, the client states ‘I’m not able to talk, can we set another time?’ Be patient, hold in mind that you do not know their context, where they physically are at the time and so it is important to ask after you have introduced yourself, ‘are you able to talk at this time?’ This can give you some indication of the safety to have a therapeutic conversation.”-Gugu Shabalala
“Also very important is being in a quiet space when you make the call. You never know what you are going to get on the other side of the call. Similar to when you walk into a session with a new client for the first time, however, this time, so much is out of your control. You can’t see them, you don’t know where they are and reading body language and behavior is out of the equation. You rely on your hearing senses a lot more, listening for signals of distress, a sigh, a tone, something that can help you get a sense of what is happening for the other person is helpful.” Amina Mwaikambo
Once we move past the initial call, the counseling process starts. Below are a few tips to assist in navigating this process:
- Contracting is important, it helps set the perimeters of your work together:
- Consent forms. As we work with a population group in which not everyone has access to emails, we looked at obtaining verbal consent, written consent via email, WhatsApp or SMS.
- Informing them from the onset the steps you would take should they pose a risk to themselves or others. Getting information about emergency contacts, individuals that they live with or friends who you can contact should the client be at risk.
- What the process entails, what is therapy, what the service you provide is and the limitations to that service. Example: I provide counseling services and I do not provide social assistance. This sets the expectations of the space and limits the experience of frustration for the client and therapist down the line.
- Setting up the space for therapeutic conversations. Informing the client that they should find a space in which they will feel comfortable to talk, space where they will have limited interruptions and there will not be a lot of noise.
- Establish communication pathways, if you are sharing your contact details, can they WhatsApp you? What are your contact times? If you are not sharing your number, what are the avenues that they could use to contact you? If you are conducting therapy via WhatsApp or Zoom, what would be comfortable for you and the client (video on or not)?
- Maintaining some form of the frame:
- Be consistent in your appointment times. Consistency and structure is the foundation for a net of support and holding for the client.
- You are working from home so be mindful of what comes into view, finding a space where the background is neutral (no family photos etc) is recommended.
What we found helps clients engage well within the tele-therapy process:
- Basic counseling skills take you a long way. Being present and listening is your best tool
- Combined with psychoeducation and containment. Clients are really looking for a space to feel supported, heard and understood.
- Going at the clients pace. For example, going too fast can be overwhelming for them; going too deep may leave them uncontained in a situation that you have no control over; going too slow can be frustrating to them, especially if they have limited time to engage with you due to commitments in the home.
- Developing coping skills is very important, for us providing the tele-therapy intervention at this time is temporary, and is really our response to the pandemic. Working with individuals nationally, we are trying to help them create a basket of tools that they can draw on to cope during this time. However, for more in-depth, long-term assistance, we would encourage these clients to seek face to face counselling and therapy when these become available again.
- We found Dialectic Behavioural Therapy and Cognitive Behavioural Therapy homework tools effective to carry the work from call to call. When clients were given homework exercises, they felt like they were doing something and were keen to report on it when we spoke again
- Visuals are very helpful, when homework or psychoeducation was provided we would email or WhatsApp clients an infographic that they found helpful in understanding the exercise and it was executed more often than when information was only verbally relayed.
Tele-therapy allows for a wider reach. Based in Johannesburg we now have the opportunity to engage with people nationally. However, we have found it does have an impact on the referral process.
“Working in Johannesburg and networking has meant that when I make a referral I am aware of where my client is going, processes that they need to follow, even transport routes they need to get there and who they will find on the other side. Referring someone outside of Johannesburg is a lot of harder, as you rely on the internet, look for a resource closest to the client, give them the address and contact details and send them out. To assist this process, writing a referral letter and emailing it to the client may help (it looks official), as well as calling the place you referring them to, to ask about services and inform them of the referral.”-Thembisile Masondo
This journey has not been without its challenges. Below are a list of challenges to keep in mind:
- A common occurrence in our country is load shedding, which has an impact on the cellphone signal, making it hard to make calls. This has led to missed appointments, lack of consistency and when you have load shedding and your client does not, they wonder what has happened to you? Did you forget to call me? We have had to process clients feelings of rejection from a missed session due to load shedding one too many times. Looking at ways to manage this is important, when you know the load shedding schedule you are able to inform clients in advance and reschedule appointments. When it just springs on you, make a note of telling the client in the next appointment that this happened and that in the future if you don’t call, it is assumed to be a load shedding issue and you will make contact as soon as you are able.
- As highlighted before gaining consent is one of the first steps, in some cases clients did not have access to emails or WhatsApp or money to respond to an SMS. In these cases we relied on verbal consent. This is problematic in that there is nothing on record, no paper trail and in rare circumstances could pose an ethical challenge if the client felt you violated their privacy and does not recall giving verbal consent. Try to get written consent at all times and find creative ways to do this.
- Perceptions of the call: Clients may understand the emergency line as a space to off-load some steam and just have a listening ear. Others perceived the space as one where they could get advice and often asked, so tell me what I should do? Some told us their problems and waited for the answer, how can you fix it? Time was spent socializing clients into an understanding of mental health support and therapy services.
- Psychiatric cases and individuals that present as a high suicide risk: This is a challenge when working remotely, as your assessment is based on conversations you had with the client and possibly collateral information gained from conversations with family and friends, if the client allows. The rule of thumb, is to take action and refer if you are concerned. Getting clients to access the service is another challenge, as you have to get their buy-in and understanding of why this is needed. If you are not able to achieve this and the client poses a risk to themselves or others contacting the clients emergency contact to assist and get the client the help they need is worth trying.
Limitations to what you can do therapeutically:
- We found this especially true when doing trauma processing work. Trauma processing work in therapy is a complex and sensitive art when doing this in person, doing it over the phone/zoom etc presents its own challenges. Clients would start talking about their trauma but were not prepared for the intense emotions that it evoked and thus were not in the right space, physically or emotionally, to engage with this depth work.
“It was hard to contain them, as you hear the intense emotion over the phone. One client went silent for a long time and did not respond when I called her name, I was concerned she had dissociated and thus called her alternative contact from another line to check in on her. Fortunately, the client was okay.”- Celeste Matross
The fine line between supportive work and depth work has to be maintained, until the client is able to come into a therapy space in which all aspects of them can be observed and held.
- Another aspect of therapy is clients’ avoidance. When clients feel uncomfortable or want to remain in denial around certain issue, they avoid it. This strategy is easier done over the phone, as avoidance in tele-therapy is hanging up the call, I didn’t hear you, my signal went, I can’t talk right now, I have to go. This makes it hard to work with the client’s avoidance and make a breakthrough in therapy.
Many therapists this year have had to adapt to this new way of providing counselling support –adapt the way they provide therapy, their skill set, their therapeutic approaches to meet the needs of clients during this pandemic. Feelings of being overwhelmed, anxious and helpless have been experienced. Furthermore, the pandemic is experienced by all and those offering support are not immune. It is important to be mindful of transferential issues that arise in the process and our own mental wellbeing. In addition, working from home and providing this service requires us to be aware of the cross pollination of home and work. Creating boundaries between the two in our own ways, such as, set work times, going outdoors during breaks, having lunch with family, stretch breaks during the day and most importantly switching the electronics off after a work day – symbolic of closing your office door.
Something that myself and colleagues have also found is the need to ground oneself before engaging with the family after working. The work we do is trauma focused and trauma has an impact on those hearing it too. In our role, we don’t only hear it but we try to connect to the clients’ experience of it and this does have an impact on us. We can all recall a feeling of heaviness after speaking to someone who has been through something difficult or is feeling a lot of pain and stress. That heaviness does not just leave us and we carry it for sometime. We can carry it with us into our private lives and in interactions with our loved ones. Grounding oneself through supervision support, peer support, mindfulness exercises can be helpful to make sense of the heaviness and experience emotional catharsis.
Those are our reflections and learnings thus far, we are sure as this journey progresses we will discover new insights and challenges. Hope you found this post helpful in the work that you do and wishing you all strength. Let us know what your lessons learned have been during this time.
Compiled by Mental Health Professionals from the CSVR Trauma Clinic