Opinion piece: A trainee’s experience of virtual psychotherapy
The COVID-19 pandemic had a big impact on the way that psychiatric services work. The essence of psychiatry is about speaking to patients, face-to-face, to formulate and diagnose. However, with infection rapidly spreading across the world, there was a shift towards virtual methods of working to protect the health of individuals and the spread of the virus.
Core trainees in psychiatry are expected to complete two psychotherapy cases, which must be in different modalities. One should be a short-case (up to 20 sessions) and one should be a long case (with up to 40 sessions). These should both be completed by the end of CT3 . There was further information released by the Royal College of Psychiatry (RCPsych), which advised that those trainees who were due to progress to higher training should not be penalised at ARCP due to difficulties obtaining psychotherapy competencies during the pandemic. Trainees would need further training in ST4 to ensure competencies are met. The College also advised that where trainees have started a case, they can continue this work via phone or a confidential videoconferencing platform. They recommended that supervision should continue using digital platforms e.g. Microsoft Teams .
A survey carried out by Mind earlier this year of 2000 people under mental health services reported that half of those people found virtual methods (telephone or online) easy to use. The data was analysed for key themes, and found that waiting times were shorter and there was more opportunity for anonymity, meaning that the patient felt able to speak freely. 15% of study participants found that their mental health got worse using virtual methods, with the key problems being technology, lack of confidentiality, and difficulties finding a private area in their own home .
The opinions of those receiving therapy may vary depending on the modality. A study from 2020 looking at internet-based CBT vs Internet-based psychodynamic psychotherapy for social anxiety disorder found no significant difference in preference. There were slight improvements in symptoms for both online methods .
A thorough study looked at the ethics behind online psychotherapy. It found several points in favour of this method, mainly with regards to flexibility, convenience and cost. The ethical issues against psychotherapy usage online were privacy and confidentiality, the need for specialist training, technology issues and emergencies . This suggests that it is not a straightforward answer when discussing the future of psychotherapy ad psychotherapy training.
In this article, I aim to reflect upon my personal experiences with psychotherapy training as a core trainee, and to discuss and consider the advantages and disadvantages of using virtual methods.
I have recently completed a psychotherapy case in Cognitive Behavioural Therapy (CBT). CBT is based around the link between, thoughts, feelings, behaviours and how they can all influence each other. There is a focus on negative automatic thoughts and how they cause us to be trapped in an ongoing cycle. CBT uses structured work to help to break the cycle . I saw the patient on a weekly basis, over 19 sessions, which therefore meant that it was a short case. This started during the pandemic, and, at this time, the psychological services department were working remotely. Therefore, my supervisor agreed that I would work remotely in line with departmental practices. To maintain confidentiality, I will refrain from providing many details about the patient, but she had a diagnosis of anxiety and depression and had previously undergone a course of CBT face-to-face.
I was given the choice of two platforms, Attend Anywhere or Lifesize. I initially started with Lifesize, as this was familiar to me. However, after using Attend Anywhere during my work in a community placement, I felt that it might be more appropriate for psychotherapy. With Attend Anywhere, the patient could wait in a waiting room. I could also send a text message to the patient with a link for them to join the waiting room. There were options for refreshing the call due to technical difficulties without having to end the call and reconnect which saved time and caused less interruption to the flow of therapy.
With videoconferencing, it can feel like an informal method of conversation. Therefore, it was important to set ground rules (without coming across as dictatorial). We agreed that sessions would be held in private, in a room with no disturbances (tv, phones etc.) Our attention would be focused on the therapy only, with the addition of taking notes where necessary. This carried over to supervision, where I ensured that I was in a private room with no other doctors to maintain confidentiality.
The therapeutic relationship
I started seeing my patient in March 2021, meaning that many people had become accustomed to virtual working by this time. I had attended teaching sessions and training using videoconferencing, but I had only seen one patient in a clinic appointment before using a virtual platform. I felt apprehensive about whether we would be able to build a therapeutic relationship through a screen, having never met in person. For the first few sessions I was worried about a lack of rapport. One of the noticeable issues was difficulty in reading body language. If you are in a room with a patient, you may be able to notice signs of anxiety such as fidgeting or toe-tapping, but here I was only able to see the patients face.
The patient’s perspective
I had a brief discussion with the patient about the use of videoconferencing. She explained that she did not like the video therapy and would have preferred face-to-face therapy as it felt easier to speak to the clinician and to open up. However, she acknowledged the ease of using an online system and the reduced time spent travelling to appointments.
At times, there were issues with technology. For example, slow internet connection, meaning that the screen would freeze, or there would be a delay. This could be frustrating when we were having in-depth conversation, particularly if it was an emotional topic that was being discussed. The headphones that the Trust provided had a very quiet microphone, meaning that I had to switch equipment during the sessions.
An important aspect of CBT is completing exercises both between and during sessions. If the therapy took place in person, then the therapist and patient would work through printouts. I overcame this by using screen sharing and an online whiteboard function, where the patient was able to see annotations of diagrams. Fortunately, the patient had a printer and could print resources if required.
I considered whether the use of videoconferencing affected patient attendance. I held 19 sessions with my client, but 5 of these were cancelled by the client. This was mainly due to childcare problems or other appointments. I communicated with the patient via email, and she cancelled sessions via this method, usually on the day.
Although I had taken part in training and supervision sessions using videoconferencing, I had not received any training regarding how to get the most out of virtual sessions. I realise that there are several courses to enhance skills, but unfortunately as trainees we were not offered this.
I feel that there are several advantages to using virtual methods of psychotherapy. Firstly, in terms of widening access. By being able to access therapy using a phone or computer, this is easier for both staff and patients who have disabilities that may limit their ability to travel to a community site. Likewise for patients who are unable to drive, it removes the issue of travelling on public transport to get to appointments.
Although it may be expensive initially in terms of licensing of video platforms and providing staff with the necessary equipment (laptops, phones and headsets), it may save the Trust money in the long term as less clinic rooms are needed and there will be fewer items printed. Likewise, it will be cheaper for patients, who do not need to pay for petrol or public transport to attend appointments.
Virtual psychotherapy can align well with trainee’s schedules. My psychotherapy patient lived half an hour away from my work base. Taking traffic into account, if I had to travel to the community site local to the patient, this would realistically take up my whole morning or afternoon. With virtual working, I could fit this in around my other appointments, meaning that I could see more patients. This was helpful for my patient, who could arrange sessions around childcare. For some who work 9-5 jobs and struggle to attend appointments which will usually be between this time, it may give them more flexibility to attend, particularly those who work from home.
Despite the numerous advantages of virtual working, there are several issues to be taken into consideration. Firstly, not all patients have internet access, which therefore makes virtual psychotherapy impossible. Some may not have laptops or smartphones, and of those who do, a proportion will have unsuitable internet speeds to facilitate videoconferencing. Therefore, if psychotherapy were to continue to be virtual long-term, a group of disadvantaged patients would be excluded through no fault of their own. As previously mentioned, technology issues can be a barrier to successful virtual working. If there is equipment failure or connection issues, a session may have to be cancelled, whereas this problem would not occur face-to-face.
Patients may feel less responsibility to attend virtually, as missing an online appointment may not feel as important as missing an appointment where someone is waiting for you at a clinic. To counteract this argument, patients may feel more inclined to attend an appointment if they are able to do so from their own home.
Many patients suffer with loneliness which inevitably exacerbates mental health conditions, particularly elderly patients who may have limited social contacts. Speaking to a therapist allows human interaction, which can still be gained virtually, but arguably has a bigger impact in a face-to-face setting where interactions may feel warmer and more sincere.
It is important to consider patient consent when using virtual methods. As clinicians, we would always take informed consent from patients when beginning any treatment, whether psychological or pharmacological, but virtual methods are a newer way of working and it is important that patients are aware of the protocols in place to protect them. As the Mind study suggested, the biggest concerns for patients were around confidentiality and privacy. Patients should be made aware that therapy takes place in a private environment, and that trust equipment should be used with encrypted laptops and trust usernames and email addresses, and they would never be recorded without their written consent. Conversely, a concern for clinicians may be the possibility that the conversation is being recorded, or listened to by another person, which is a factor that cannot be completely excluded with virtual working.
Finally, a lack of training in this area may have a negative impact on the outcomes of virtual psychotherapy. Core trainees are usually new to psychotherapy and there is often little training around the provision of this (depending on the area of training), so alongside a lack of training around virtual working, it can be stressful and challenging for doctors to adjust to.
Although I listed slightly more disadvantages than advantages when discussing remote working, I found virtual psychotherapy training to be an excellent learning experience that gave greater flexibility with my work schedule. My patient was less positive about the experience, which is why it is important to accommodate a mix of both virtual and face-to-face therapy in the future, as patients have individual preferences that vary. It will be interesting to see how the use of virtual therapy progresses through the pandemic. At the time of writing, clinicians are increasing face-to-face working again and introducing patients back into the clinic setting. If there are ongoing lockdowns in future as a result of COVID-19, there would need to be the introduction of a robust, long-term plan for virtual therapy.
 Awal M. CT1-3 Psychotherapy Training Guide for Trainees. [Internet]. 2016 [cited 7 December 2021]. Available from: https://www.rcpsych.ac.uk/members/your-faculties/medical-psychotherapy/supporting-trainees
 COVID-19: guidance for UK psychiatric trainees [Internet]. RCPsych. 2021 [cited 7 December 2021]. Available from: https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/covid-19-and-psychiatric-training
 Trying to Connect [Internet]. Mind; 2021 [cited 7 December 2021]. Available from: 1. https://www.mind.org.uk/media/7591/mind-21014-trying-to-connect-executive-summary-high-res.pdf
 Lindegaard T, Hesslow T, Nilsson M. et al. Internet-based psychodynamic therapy vs cognitive behavioural therapy for social anxiety disorder: A preference study. Internet Interventions. 2020;20:100316.
 Stoll J, Müller J, Trachsel M. Ethical Issues in Online Psychotherapy: A Narrative Review. Frontiers in Psychiatry. 2020;10.
 Overview – Cognitive behavioural therapy (CBT) [Internet]. NHS. 2019 [cited 7 December 2021]. Available from: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/
About the author
Dr Sharna Bennett is a Core Trainee in Psychiatry, working for Kent and Medway Partnership Trust.