Where Therapy Happens

Freud's therapy room.

More than a year on from lockdown and with Covid restrictions being reduced, where are therapists as a profession and what are my plans?
 
Some therapists working in highly specialised agencies caring for extremely vulnerable clients have moved backwards and forwards between virtual and face to face work throughout the year. A few therapists in private practice have done the same but this hasn’t been the choice for most of us for obvious safety reasons. Perhaps less obvious are the theoretical bases for this decision.

The boundaries of regular, stable, predictable meetings come a very close second to clients’ safety. Knowing where and when you’re going to meet, what’s going to happen when you get there, how things begin and end, allows a trustworthy, reliable  relationship to form. The unconscious mind needs cues to feel secure and predictability of sessions allow the client to enter quickly into a therapeutic mindset, to move from the mundane to the intensely personal and make the most of the session. This doesn’t mean that the content of the session will always be the same, not at all, it means that the client is free to attend to what's on their mind without the distraction of change, of having to reorientate themselves or wonder about and become distracted by what changes the therapist might be going through. It's vital that the client remains the focus of attention, not the therapist.

Therapy develops a kind of ritual flavour: just as we behave one way when we’re at home, another way in the pub and another in the office, so knowing how to be during therapy comes much easier with regularity. It’s why therapists prefer seeing you at this time on this day: a dedicated, stable place and time for this delicate process supports clients getting the best from it.

Professional Advice
The British Association for Counselling and Psychotherapy have useful guidance on deciding whether or not to return to face to face work which includes: 

• consider your clients on a case by case basis – is the risk to the client of working remotely greater than the risk of working face to face? 
• consider whether the space you plan to work from allows for social distancing of two metres or at least one metre with mitigation – this includes any areas such as entrances, exits, corridors and waiting areas
• decide whether you need protective equipment such as masks or visors
• conduct and publish a risk assessment of your premises and create a procedure checklist to mitigate the risk of contamination before, between and after seeing clients. This is a legal requirement.

As I've said before, risk assessments around a virus that remains a bit of a mystery to epidemiologists is not possible for therapists. Infection control is a specialist discipline and one that therapists have absolutely zero teaching or experience in. 

If I begin seeing one client but not another that will set up all kinds of reasonable, entirely avoidable and potentially very unhelpful  dynamics between us. "I'm more or less important to  you" "Do you think my life is less or more valuable?" "Do you not want to see me?" "Do you not trust me?" and so on. This can be valuable, informative material. And it's something that can be addressed without implementing policies based on a pretence of expertise.


Covid
The UK hasn’t done very well in managing the pandemic. The numbers of deaths here are relative to population. It’s worth isolating, say, India from this chart and then the UK to see the graphic difference in numbers of deaths over the year. The new variant which has developed in India has been spreading quickly so that areas of the UK are back under more restrictions. It will soon predominate in London.

While both vaccines cover the new variant they are about a fifth less effective against it than against older variants. It looks fairly certain that the new variant is going to result in us moving back into some kind of national lockdown. This is enough of a risk for me to hold off moving back to face to face work. For me, the therapeutic importance of regularity outweighs my own need to be physically in a room with a client.


Costs
Office rental fees anywhere, let alone in London, were becoming ludicrous before Covid; right now the market is labile and looks to become stupid in the coming year as landlords try to make up lost earnings. These increased costs must be covered and that means increasing fees, something that I very much want to avoid. Many Employee Assistance Programmes (EAP’s) having maintained the same payments for, on average, 15 years, have used the pandemic as an excuse to reduce them. The hourly cost of an office can be the same as many EAP's hourly payments.


The positives of video conferencing
I’ve had the pleasure of working with people from all over the country in the last year and we’ve been able to continue to work wherever the client is, whether that’s at home under lockdown, in a side office at work or from their hotel room. Privacy has been an issue for some people some of the time, particularly over winter, but not yet a reason to end therapy. People with disabilities, with children or other dependents have been able to come to therapy, the flexibility of not having to come to an office has seen therapy open up to a greater range of people.

Overwhelmingly, VC gives clients far greater control over their time. Rather than therapy being another box that must be ticked, often running to and from the office during a precious lunch break, therapy has become much more relaxed, often more profound. People now take at least 10 minutes before and after our work, often a lot more, to prepare for and process it. Their focus can be on therapy rather than on whether the tube is running or when they might squeeze some food in to their day. It’s notable that a large majority of clients have been able to set a day and time to meet and have been able to maintain that rhythm, something that was previously all but impossible. As restrictions ease this is likely to change, but with the extra time that VC makes available it’ll be interested to see just how much.

In time, when this pandemic genuinely comes under long term control and the office rental market stabilises I’ll look again at returning to face to face work but I find myself thinking about where our profession started, with the patient coming to analysis 3 times a week for 5 or so years, reclining on a chaise lounge and free associating while the analyst sat silently out of sight. 20 years ago when the internet was a novelty VC was a strange new world, now grandparents speak to their grandchildren via it, it’s very ordinary, especially for people in their 40’s and younger.

The limitations of returning to face to face work currently outweigh the benefits. I never say never and in this case I’m saying ‘not now’.