Shared experience
Private Practice, June 2024

Cast your mind back to March 2020 when the Prime Minister announced the country was going into lockdown and your therapeutic practice had to transform the way it operated overnight. What was that like for you? What was your priority in terms of your practice? Could you separate your personal and professional lives?

When I embarked upon my research project for an MSc in psychology, I felt that the impact of the pandemic on therapeutic practice had to be the focus. I had gone through it myself, as a counsellor in private practice and a team leader in a counselling charity, and I wanted to know how others had experienced this unprecedented event – a collective trauma that we all experienced concurrently; therapists and clients alike. 

I was keen to find out what had been most challenging for therapists and how it had impacted them. I also wanted to know what methods and tools they had used to cope and if they had experienced any benefits from remote work. Now, I would like to share my findings with you and hopefully encourage reflection and perhaps discussion. The background research, summarised below, includes the experiences of counsellors, psychotherapists and clinical/counselling psychologists. 

The initial impact of lockdown 

The World Health Organisation reported that the imposition of lockdown with immediate effect resulted in unprecedented disruption to most therapeutic services. In the face of these unanticipated circumstances, many therapists reported feeling unprepared as they were expected to transition to home working virtually overnight, for an unknown amount of time.¹ There were no clear instructions on how to set up remote therapy² and many therapists had no prior training in it, resulting in them feeling daunted, confused and panicked.³ Some reported feeling more tired, less confident, less connected to clients and less competent, which resulted in higher stress levels and compromised their mental wellbeing.⁴ On top of this, therapists had to support clients, many of whom reported that the stress and anxiety associated with the pandemic exacerbated their symptoms.⁵ Moreover, incidents of abuse, self-harm and suicidality were higher in those who contracted the virus and had an existing mental health diagnosis.⁶ 

Private Practice June 2024

The conditions of the pandemic meant that therapists and clients experienced a major life event and lived through a period of collective trauma simultaneously. As a result, some therapists reported difficulties with over-identifying with clients⁷ and found it hard to suspend their own issues and responses.⁸ Others said they experienced vicarious/secondary trauma,⁹ which was acknowledged as a risk factor for burnout. Others disclosed feeling professional self-doubt, which was found to be higher during the pandemic than pre-pandemic.¹⁰  

Working from home 

Therapists had the immediate pressure to set up a therapeutic space from home, and they reported endeavouring to make their backgrounds neutral and similar to face-to-face settings to facilitate the continuation of the therapeutic relationship.¹¹ One study made the important discovery of ‘structural inequality’, whereby some therapists were at an advantage, due to having more room at home to set up a therapeutic space.⁷ Storage of confidential data was also a source of stress for those who did not have lockable filing cabinets and/or sufficient IT equipment or security.⁸ 

Some therapists found it difficult to hear upsetting stories in their living space⁷ and reported feeling vulnerable and compromised professionally as clients ‘entered’ their homes.¹¹ Some stated that interruptions and distractions were the most challenging part of remote work and found that these got worse with time.¹² Nevertheless, therapists said they appreciated the advantages of working from home, such as increased flexibility and no time or costs related to travel and/or room booking.⁷ They also experienced some clients as more relaxed in their homes and therefore more able to open up.⁸ And sometimes that observing clients’ interactions with others actually enhanced the therapy.¹ 

Challenges and successes of remote working 

Many therapists said that issues with technology, such as connection problems and difficulty with software, were the most challenging factors related to remote working.¹³ Some said they felt a sense of distance, detachment and disconnect from clients, and found it harder to establish trust and a working alliance.¹⁴ Tiredness and ‘Zoom fatigue’ were frequently experienced due to the intensity of the work¹⁵ and the concentration required to compensate for limited sensory perception and the absence of body language.¹³ Perhaps unsurprisingly, behavioural-oriented therapists found remote working more difficult than therapists using other modalities,¹⁶ and effective delivery of CBT, play and art therapies required adaptability and creativity.^1,17 

Despite the challenges, therapists were grateful that therapy could continue thanks to remote options. They also reported feeling more positive and confident than expected, and remote therapy was found to be credible, trustworthy and effective.¹⁸ Indeed, many found it comparable with face-to-face therapy, particularly as the pandemic went on,¹⁴ and they reported feeling strong, competent, authentic and emotionally connected to their clients, who appeared comfortable with the setup.¹⁹ Nevertheless, several studies found that many therapists still prefer, and rate, face-to-face therapy over remote therapy.^20,21 

When therapists’ mental health was compared with that of the general public during the pandemic, it was found that therapists showed lower scores for depression, anxiety, insomnia and stress, and it was speculated that this was related to resilience.²² Indeed, higher levels of dispositional resilience were found to correlate with lower levels of perceived stress in therapists.²³ Perhaps related to this, therapists stated that supervision and connecting with the therapeutic community⁷ and professional bodies,²⁴ facilitated their management of the challenges of the pandemic, as did self-care²⁵ and a healthy work-life balance.²⁶ 

My research findings 

As well as the background research, I gathered my own qualitative data by conducting in-depth interviews online with five UK-based counsellors (details below) to establish how their practice was impacted by the pandemic. The interviews were semi-structured, and the questions were based on the prior research findings to ascertain if the participants had had similar/different experiences. As part of the analysis, I generated themes and subthemes from their narratives, summarised opposite. 

Pandemic as context and influence on therapy 

Participants acknowledged that working in the context of the pandemic impacted therapy. However, this varied depending on client group (children and NHS clients were reported as impacted most). Ann described it as a powerful existential sharing, while she and Katie acknowledged that clients also regularly brought ‘ordinary life issues’. In contrast, Susan said COVID featured greatly; with children drawing pictures of viruses and fearing that they or their families were going to die. She also felt angry about fear mongering in the media as she could clearly see the impact on her clients. Gordon and Tom proactively addressed COVID in sessions. Gordon enquired about it as a fundamental factor in assessment, and Tom said it felt important to acknowledge that ‘we were all living with this unknown and uncertainty’ to address the collective experience. With regard to young people, Tom questioned a possible ripple effect of reduced socialisation due to reports of increased fighting among high school boys, and record numbers of sexual assaults in students that have been disclosed to him since lockdown lifted. 

Professionalism 

The importance of continuing an ethical service was stressed by participants and clearly evident in the descriptions of their preparation and practice, which were guided by BACP recommendations and consultation with other professionals. Participants also relied and drew on fundamental training and knowledge as anchors to ensure the continuation of ‘therapy as usual’ in the extraordinary circumstances. Tom summarised this by saying, ‘There were different barriers, but it was the same core of reaching out and being with somebody and offering the core conditions.’ 

Participants presented as, and made several statements that alluded to their being, particularly resilient individuals, and referred to ‘supporting’ and ‘holding’ the people around them in their personal and professional lives. Furthermore, in relation to converting to remote working, Katie said, ‘There’s definitely resilience that’s been moulded by going through that’; evidencing the development of new as well as pre-existing resilience. 

Regarding the impact on their professional sense of self, in contrast to prior research findings, all participants said theirs was not impacted in a detrimental way. In fact, Ann stated, ‘I think it expanded it because it enabled me to see that there are other ways of working.’ Katie said her experiences during the pandemic increased her confidence, such that she felt able to set up in private practice. 

In line with the background research, all participants said they connected with supervisors, peers and the wider counselling community and expressed a strong sense of collaborative working. Self-care and coping strategies were also vitally important, such as regular walking, cycling, gardening, meditation and connecting with friends and family. Separation and escapism were important for Tom, who swapped his previous hour-long commute for a 10-minute walk to enable him to transition to the working day. He also always wore ‘work clothes’ during working hours and created a social space in the garden for escapism.

All participants appeared to go on a journey with the technology from varying degrees of ignorance, to stress, to embracement; some with great enthusiasm. Ann exemplified this, saying that initially she ‘didn’t even know how to switch on the laptop… it was the most stressful time of my working life’, to now happily working exclusively online. Susan illustrated this further by referring to face-to-face work as old-fashioned, a perhaps unimaginable perception pre-pandemic. In addition, Gordon acknowledged that ‘we’d never have done this if it hadn’t been for the pandemic’, evidencing that while challenging, lockdown has forced the creation of helpful new ways of working thanks to technology.

Challenges of online working 

Despite the enthusiasm, technical issues, such as videos dropping/freezing, time delays and sound issues were said to be challenging and interrupted the flow of clients expressing themselves. Gordon found technical quirks irritating and frustrating, and said he compensated for reduced speaking with increased facial expressions. He also said that the energy felt when working face-to-face with clients is an important part of his work and its absence, when working remotely, impeded his practice. Katie acknowledged that she missed out on body language but said it did not negatively impact the therapy/therapeutic relationship. Ann’s experience mirrored this when she said, ‘I’ve never had a problem connecting with people online.’ 

Participants described challenging situations when clients attended remote sessions while drinking, eating, or lying in bed. Gordon said that it had to be addressed to ensure the professional nature of the relationship. Furthermore, the mobility of technology resulted in clients doing sessions from cars, public transport, work, or outdoors, and participants had to make ethical judgments about engaging in these sessions. These could be challenging but some enhanced the experience as, after realising his client was outdoors, Tom went into his garden and said, ‘There was something really nice about the fact that we were both in the wilderness.’ Susan, in contrast, reported negative experiences, saying a young child client went into their siblings’ bedrooms or left the camera pointing at the ceiling, and she now no longer works with children online as, in her experience, it does not allow for work at depth. 

Interestingly, despite these significant challenges, all participants noted the advantages and opportunities created by remote working with some emphatically expressing their appreciation. Ann and Tom stated that remote working has/will enable them to continue private practice in retirement, and Katie and Tom expressed their appreciation of more accessible CPD. Participants said their client pool has expanded to people all over the UK. Gordon said that working with LGBTQ+ clients in London has been ‘interesting and stimulating and totally engaging’. Katie said her London clients benefit from not having to pay London prices and she likes that remote working removes the awkwardness of handling cash in sessions. Ann noted that clients appear more comfortable and confident in their own space, and she values the self-determination and empowerment related to location being their choice. Susan said she feels bittersweet as she feels unwanted pressure from some agencies to work with children online. However, she also acknowledged that remote working provides scope that was previously unavailable. 

Conclusion 

This research found overall that while therapists experienced great challenge when moving to remote working during the pandemic, they used professionalism and drew on support, resilience and self-care to successfully transition through it; resulting in enthusiastic embracement and improved opportunities with successful outcomes for clients. While there was clear overlap between the background findings and the participants’ experiences, the tone was notably different. Yes, participants acknowledged the stress, pressure and challenges but the overriding feeling was one of positivity; no doubt in part due to the passage of time. I greatly enjoyed the interviews and left them feeling uplifted and energised by the recognition and enthusiasm expressed by the participants about the transition to the new world of counselling. Ann captured this perfectly, saying, ‘The pandemic has changed the counselling world beyond all recognition... and I think in a very positive way.’