Technology in Counselling and Psychotherapy PDF

Technology in Counselling and Psychotherapy A Practitioner’s Guide STEPHEN GOSS and KATE ANTHONY Part II Telephone and video links 91 5 Telephone counselling and psychotherapy in practice...

Technology in Counselling and Psychotherapy A Practitioner’s Guide STEPHEN GOSS and KATE ANTHONY Part II Telephone and video links 91 5 Telephone counselling and psychotherapy in practice MAXINE ROSENFIELD HISTORY It seems incredible that as recently as 1997, some practitioners regarded therapy by telephone, anecdotally, as ‘not real therapy’, and even with some derision. Yet today, many practitioners use the tele- phone for some or all counselling and psychotherapy sessions, and also for supervision (see Chapter 7). The use of the telephone for help in times of crisis has been acknow- ledged for over 40 years. The issue for many in the counselling and psychotherapy world was the precise nature of the support that could be offered by telephone. Rosenfield (1997) defined the spectrum of help that might be offered by telephone and showed the position of counselling within that spectrum. The issues raised by some practi- tioners were concerns about how a client could receive therapeutic help, develop an ongoing relationship with the counsellor, ensure their location for each session was private and pay for the session if there was no face-to-face contact. Given that similar discussions now take place regarding the use of email and other technological innovations, it would seem that, as a profession, we tend to resist the new until external pressures, such as public demand, dictate otherwise. WHAT IS THERAPY ON THE TELEPHONE? Telephone therapy is best described as an ongoing, contracted rela- tionship between the practitioner and client (or clients if a telephone therapy group is established) carried out entirely by telephone. Although some practitioners use the telephone for some sessions, this chapter is written in the context of all sessions taking place on the telephone with no face-to-face contact between practitioner and client. The contracted nature of the relationship sets telephone therapy apart from the work of telephone helplines that typically use 93 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY counselling skills in one-off sessions, to support callers as a ‘listening ear’, perhaps offering information or referrals to other agencies, usually without exploring deeper underlying issues that would require further sessions and more in-depth work. Most people in developed countries have access to a telephone and are familiar with using it. There is no doubt that the telephone is per- ceived to be a safe, confidential environment and that people appre- ciate the privacy it affords, making it a popular medium. The Telephone, Information, Support and Counselling Association in Australia (TISCA, 2000) calculated that in 1999–2000 a call was made to such a service every three minutes, in the state of New South Wales alone. A 24-hour counselling service for teachers in the UK received an average of one call every two seconds, every minute of every day over a 12-month period (TBF, 2001). There are many reasons why a client may find that therapy by tele- phone suits them, in common with other means of distance provision, such as: If a client is feeling vulnerable (perhaps has been the victim of rape), does not wish to go out and meet with a ‘stranger’, or visit an unfamiliar environment. A client with mobility problems might not wish to travel regularly to a face-to-face session or might not find a practitioner operating within an accessible location. A client might have a specific need, be seeking to work with someone from a similar cultural background or wish to work with a specific practitioner who might not live nearby or even in the same country. Attending regular therapy when the nearest town is some distance away (assuming there is a practitioner there) makes the telephone a far more suitable medium for people in rural areas. Clients may not wish to go to a local practitioner, preferring instead to work with someone who they are unlikely ever to meet. For many people, having to travel to a practitioner’s office, spend an hour or so there and travel back makes face-to-face work prohibitive in terms of time and possibly money. For clients who have a chronic, debilitating or degenerative illness, the telephone can enable them to work therapeutically where they might sometimes be too unwell to go to a practitioner’s rooms. In 94  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE addition, it may be easier to use a telephone than it would be to type on a computer keyboard. The immediacy afforded by the telephone enables contact to be made without time delays and at the convenience of both parties. The telephone also provides clients with a degree of safety and control they do not normally have. This is discussed further below. The telephone provides an intimacy as the counsellor and client speak directly into each other’s ears. It is possible to feel cocooned by holding the telephone to one’s ear, which enhances a sense of safety and trust. Practitioners must work somewhat harder than in face-to-face work to convey in their voice, words and contract the values and principles of their work. The obvious lack of eye contact and visual clues and cues means that therapy by telephone is heavily reliant upon the listening skills of the practitioner in particular, in order to be able to note and use in the sessions the variations in the client’s voice, speech patterns, choice of words and so on. It takes some practice for practi- tioners to learn to trust their ‘inner ear’ totally on the basis of what can be heard and indeed some practitioners find they are not comfort- able with the medium and working with so many unknowns. Some practitioners, for whom seeing the client and observing their body language is an essential component to their work, find they cannot concentrate fully on the client when sitting alone in a room with a telephone for up to an hour at a time. There are those who do not like holding a handset for so long or wearing headphones. However, when engrossed in a session, most people do not notice that they are holding a handset for such a long time. Indeed, if they find themselves thinking about the handset or their seating position, it could be useful to reflect on what is happening at that point in the session. It is not ideal to work with the telephone on ‘loudspeaker’ as an alternative, as the sound distorts and this affects the sound of the client’s voice tones. Certain therapeutic orientations are well suited to the telephone. Cognitive-behaviourist approaches and person-centred (experiential) counselling are easily adapted to telephone work, although many eclectic practitioners could enjoy working in this medium. Gestalt and other techniques requiring practical activities are clearly not suited to telephone work (although some therapists may use the telephone for an occasional session). 95 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY ASSESSMENT SESSION During the assessment session both parties can decide if they wish to work together and then agree to a contract. This will include the frequency, length and time of each session and the number of sessions before a review. There will also need to be some discussion about both parties’ responsibilities in the relationship and the confidentiality bond, which includes instances when the practitioner might break confidentiality. In addition, the method of payment and when payment will be made need to be agreed. Fees are generally the same as they would be for face-to-face therapy, the cost of the telephone call made by the client equating in principle to the cost of travelling to a counsellor. Some counselling services operate with a freephone number, in which case the client does not have to pay for the call, but often the client pays, even if the practitioner is working overseas. Although clients may request it, I do not send a photograph, explaining that a key element to working by telephone is not to have the visual image of each other, but rather to work only with what we say to each other, although at times it may become appropriate to explore images and fantasies. It can be likened to the position of a radio announcer whose image is constructed by the listener’s mind. How often has the comment been made on seeing a photograph of a radio announcer, ‘I never thought she’d look like that’? However, this is an area where practice varies. Some practitioners report that their clients tell them they place the counsellor’s photograph near the tele- phone when they are having a session and it helps them to talk. At times I will ask a client to describe to me where they are sitting and how they are sitting and if they ask I will tell them about my office. I have found that this seems to settle a nervous client. Sometimes a little imagination and visualization can go a long way to helping to create the working relationship. A date will be set for the first counselling session as the assessment and contracting draw to a close. In the event of working across time zones, the practitioner must be very clear about the time of the sessions from both parties’ perspectives. After the assessment session, there may be a ‘cooling off period’ for both parties, set as up to five days after the session, where either can decide not to proceed, giving enough notice for the practitioner to use the time that was allocated for the sessions in other ways. Many practitioners offer the assess- ment session free of charge, with the exception of the cost of the tele- phone call. Some practitioners decide to make the call so that the potential client has no expense to bear, others prefer the client to call. 96  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE Often the practitioner will send a copy of the contract by post or email to the client so that both parties can be clear about what has been agreed before the formal therapy sessions commence. During the assessment session, the practitioner has to be able to convey to the client that they will be receiving a professional service and should be prepared to answer the client’s questions. These may be focused on the methods of counselling or on the client’s perceptions of the counsellor – such as age, racial background and expertise in the area for which the client is seeking help. A practitioner working by telephone has to be prepared with answers to direct questions – the medium lends itself to ‘bravery’ on the client’s part (‘I can’t see her/him so I won’t feel judged and I can always hang up if I am not satisfied’). If both parties decide to continue, the sessions will begin, ideally one week apart, at a regular time and on the same day each week. FREQUENCY AND DURATION OF SESSIONS These will depend on the practitioner’s style and the nature of his or her work, but in general a minimum of six sessions on a weekly basis is a useful initial contract to make, as that enables a good relationship to be built. It may be apparent that six sessions is enough or a further contract can be arranged. Session length, which can vary according to the practitioner’s style, should be agreed at the assessment session. Each session should be of the same length so that both parties can work within that clear boundary. TRUST With no face-to-face contact at all and only a conversation or two and the voice he or she has heard, a client places enormous faith in his or her chosen practitioner. A practitioner must acknowledge this and ensure that his or her working environment is quiet, that he or she answers the telephone directly at the time the client is due to call and does not let an answering service or anyone else pick up the call first. The use of mobile phones is not to be recommended for their lack of reliability and privacy. A trusting relationship can develop very quickly with telephone coun- selling clients and, anecdotally, it seems that fewer sessions are needed than in comparable face-to-face work. It would appear that the relat- ive anonymity afforded by the medium enables clients to take risks 97 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY and talk more freely sooner than they might in other settings. This also enables the practitioner to take risks and use all intuitive streaks before he or she might have done if working in the same room as the client. I have found that the disclosure of very painful events or expe- riences often happens within the first two or three sessions by tele- phone, whereas I found it took several more before a similar level of disclosure was reached face to face. Counsellors working by email report similar experiences, which again suggests the privacy that the medium provides is a positive factor in enabling clients to feel free and safe to disclose (Suler, 2002). CONTROL AND EMPOWERMENT One of the biggest advantages of therapy by telephone is that it enables clients to take a fair measure of control of the sessions. Clients can hang up at any time if they wish to terminate a session. What happens in such instances should be addressed in the contract. For example, the agreement might be that the client will recontact when the next session is due or that the practitioner will call the client within a day to confirm that the next session will take place; in the contract there needs to be a clear statement about who will take responsibility to make further contact if the client terminates a session. There is far less intimidation when clients are in familiar surroundings than when they have to travel to a new (and someone else’s) location. The telephone creates a partnership that has some equality in it – both parties are working with many unknowns that face-to-face work would answer and both are reliant on their hearing, the voice they listen to and the words expressed to form the fundamental part of the relation- ship. This can make therapy by telephone more attractive to some people, including those who hold controlling, senior or authoritarian positions in their life and are used to being ‘in charge’ of their situation, on the surface at least, as it can make the concept of their seeking help easier to accept. Equally, those whose self-esteem is not very high may be able to feel more comfortable with a voice and their imagination than with a physical presence. Such clients may feel more able to ‘test’ out things, to speak without feeling they have to behave in what they perceive to be an ‘acceptable’ manner in front of their counsellor. TALK, SILENCE AND VOICES Voice tone, words and pitch of both the client and practitioner are the 98  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE key tools to aiding listening and understanding. Differences in the client’s speed of talking, the presence of silences, the style of talking are all important for the practitioner to note and use. Talkative clients who suddenly become silent may have reached a realization or hit upon a difficulty in expressing themselves. After working by telephone for a few months, practitioners will probably notice that their listening skills become increasingly finely tuned. The slightest trace of a pause, an inflexion of the voice, occasions when the pace of talking changes are all examples of the many ways in which the client’s voice can convey something that his or her words might not. An astute or distressed client will also recognize this in his or her practitioner and it has been my experience to have a client challenge me when I paused after she mentioned something that she found difficult to say. It made me realize how much care I had to take with my voice and reactions, more so than I might have done if we were in the same room and there were other distractions such as body language. Silences can be challenging in their nature and in the context of what the practitioner should do. A client might become silent after stating something that leaves him or her feeling vulnerable, anxious, angry, sad or blocked. The practitioner must decide whether or not to break the silence and if so, when and how. She/he needs to reflect on what had been said prior to the silence to gain a clue as to the reason for the silence and an indication of how to address it or to wait. A silence of 30 seconds on the telephone can feel much longer than it would in face-to-face work. In my own work I find myself timing a client’s silence and if it is longer than a minute I will break the silence; other- wise it can turn into a ‘game’ of who can hold out the longest, which diverts attention away from the cause of the silence in the first place. As this implies, silence on the telephone is immediate, like so much of working by telephone, as the cause is frequently directly related to what has just been said or heard and therefore needs to be explored. Accents can be more pronounced on the telephone and can take some getting used to. A practitioner who has a strong accent should be aware of this and make it clear to the client that it is OK to ask for something to be repeated if necessary. Similarly a client with a pronounced accent may need to be asked to repeat certain phrases. This will usually be discussed quite naturally during the assessment session. It is important to note that the sound of a pen or pencil moving on paper and typing can often be heard by the client. Any note-taking must be agreed to during the contract negotiations. It is important for practitioners to explain that they plan to make one-word notes or jot 99 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY down phrases during the session and add some more detail and thoughts to them afterwards, if this is what they intend to do. Similarly, a client will detect if the practitioner is eating, drinking or smoking. GROUP WORK Group work by telephone is an excellent medium for short-term process work. It is of particular benefit for clients who may be unable to visit a practitioner and join a group, for example those who have a specific illness or disability, are from a particular cultural background or are isolated by their geographical location. Rosenfield and Smillie (1998) document one such telephone group and note the bonds that formed quickly between the participants, who revealed things to the others that they had not discussed elsewhere after just three (out of four) sessions. Essentially, the practitioner needs to have access to the appropriate equipment to enable clients in their own location to join. At the appointed time, the practitioner initiates calls to all participants, one at a time, until the whole group is present. The fees that the clients pay will generally include the cost of the call in this case. The maximum practicable number for such a group is six, as any more than that makes it hard for everyone (including the practitioner) to learn all the voices and get adequate time and space. Facilitating such sessions often requires a practitioner to be proactive in the early sessions, inviting participants to contribute something until they gain confidence in speaking in the group, and it does not take more than a session or two for everyone to work out how to interrupt, how to join in. Often the clients will then ask the other group members to respond, so the practitioner’s role changes to that of the person who summarizes and intervenes to push the group or an individual to look further at an issue and keep time. WHEN THERAPY BY TELEPHONE IS NOT SUITABLE Working by telephone does not suit everyone, practitioners and clients alike. For some, the expectation that counselling must be in a more traditional setting is important. Others may feel that they are less articulate on the telephone or that they have a strong accent that might make it hard to be understood. People who have a hearing impairment may find the telephone too difficult to use therapeutically, 100  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE as may those who cannot hold a handset for a long time, although there are aids to assist with such problems. Other factors may also place restrictions on the suitability of tele- phone work. For example, clients must be able to find a quiet, private room in which they will be undisturbed during their sessions. Occa- sionally clients who wish to have sessions during their working day, such as in their office, find difficulty in remaining undisturbed for the whole time. It is important to consider such matters during the contracting process and find ways of avoiding the problems that they can cause. CASE STUDY ONE Assessment Narelle is a client who finds out about the counselling from her massage therapist. She is intrigued by the concept of never having to meet face to face and spends much of the assessment session referring to how ‘ideal’ for her lifestyle it is not to have to travel to meet me. She is an actor and is on the road with a touring company when we first talk. Narelle is 32 and presents with ‘relationship issues’ with her partner. She says she hopes that I am comfortable talking about a lesbian relationship before explaining that Simone, her partner, is also an actor, but is not with the same company and is presently at their shared, rented home. During the assessment session we agree to talk once a week for the following six weeks in the morning, although she is quick to point out that she ‘is not good in the mornings’ but as she is performing six nights a week and occasional matinees, ‘it has to be mornings’. We agree that sessions will take place at 10.30am for 45 minutes wherever she is for the next six weeks. Because of time differences across Aus- tralia, this means that for me some sessions will be in the afternoon. Apart from establishing the facts we need for the contract, I leave Narelle to do the talking and I make one-word notes of what seem to me to be the keywords she uses. Afterwards I write a more detailed account of the session. She tells me that she and Simone have been involved for about seven years ‘on and off’, living together for the past four years, but the last two years have not been ‘good years’ for them. She sometimes wonders if she is too acquiescent to Simone and occasionally ‘stands up to her’ which causes rows and ‘much grief’. 101 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY First session Narelle calls exactly on time and sounds quite excited. She has been anticipating the session and is curious to know how things will ‘turn out’. She even got up early to ensure that she had breakfast and was dressed – she wondered if she could take seriously a session held if she was in her pyjamas, even though I would not have any idea she was not dressed. I reflected to her the importance she seemed to be placing on the session and she plunged into a long explanation of how she and Simone had been talking since the assessment session and how Simone thinks the idea of counselling is ridiculous unless they are both present but how pleased she is that Narelle is doing this of her own choosing and by herself. We explore more of their relationship and it seems that Narelle is very keen to prove to Simone something of her independence and ability to ‘do this [counselling] by myself, for myself’. I ask her to tell me more about her feelings of wanting to do things for herself and there follows a torrent of examples of when she feels she has let Simone make decisions for them that she is not really happy about. Narelle’s voice remains excited throughout this and she talks fast, barely pausing for breath. After some 15 minutes she slows down and I reflect on some of the things she has said, trying to explore more about the nature of their relationship. For a few minutes Narelle answers, but with less energy than before. I point this out and she says she is ‘feeling a bit strange for talking so much’ and that revealing all she has to me has left her feeling exposed. We spend some time talking of how she might allow other people’s perceptions to dominate her thoughts and that she often has feelings of ‘inadequacy’. She then counters this with ‘but my reviews have been really good’ and with more exploration she identifies that it is only when she is well received on stage she feels like she is a ‘whole woman’, a term which she defines as feeling fulfilled in herself. Session Two Narelle seems quieter, although on time and enthusiastic. She is tired and is not sure what she wants to talk about. She tells me that she felt she ‘talked a great deal and got a load off my chest’ last time but was concerned that I might think she was not a good person. We then explored what it means to her to be a good person’ and why she felt she needs approval from people around her. 102  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE This led to her talking about the sexual relationship with Simone, which she describes as ‘comfortable’. We also discuss the lack of male role models in her life, although she feels that her brother was a good role model as she was growing up. He has also gone on to do ‘the more traditional things – marry, have kids, buy a home and get a good job’. This brings us back to feelings of inadequacy on her part, not being good enough or doing what was expected. Her voice is expres- sive throughout and I am suddenly reminded that I am working with an actor. I find myself wondering if aspects of this session have been a performance, since I did not feel this last session. Session Three Narelle spends most of this session talking about her work and complaining about the accommodation she is now living in and how she is missing home. Her voice tone concurs with her words and when she starts to sound angry it is easy to notice this and explore the emotion with her. I am aware of feeling that Narelle’s acting skills might be more in evidence than her ‘real’ self from the way she uses her voice during this session. There are some pauses and phrases that I feel are being inserted deliberately to create some effect and I mention this with examples and ask her how she feels; what would Narelle the actor be saying compared with Narelle the woman on the telephone? This causes the longest silence we had throughout our sessions. I sensed it was an angry silence. After just more than two minutes, which is longer than I would usually wait, I ask her what the silence is about. She says she feels as though she’s ‘been sprung’ and is not pleased that I seem to be telling her she was performing in our sessions. She acknowledges that she is ‘feeling irritable’ and then changes the subject back to her feeling fed up with life on the road. I am not sure why I left the silence longer than usual but it felt right to do so. The session ended with Narelle sounding flat and even weary. Session Four During the session we explored more about Narelle’s feelings of low self-esteem and patterns of behaviour that might trigger this. At times I felt the session was getting stuck and suggested this might be a reflection of her experiences elsewhere but Narelle rejected the notion of feeling stuck until we were almost at the end of the session. 103 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY In all my sessions I inform the client when there are five minutes left and I always end on time. When I did this, Narelle suddenly rushed into what I felt was an appeasing mode, telling me she was stuck and I was right. I told her that it sounded to me as if she felt the need to leave the session with me being positive about her and our sessions. She tried to prolong the session and I mentioned this, saying that it had to end and we’d talk again next week. Afterwards I became aware that I had not felt she was performing during this session. I did not feel she was performing at any point from this session onwards. Session Five I introduced the session with a reminder of this being the penultimate session before our review. Narelle reacted by saying she wondered if I wanted to get rid of her and then immediately apologized, saying she knew this was my role and that of course she had remembered it was almost the end of our planned sessions. She said she and Simone had had a row and she was thinking of ending their relationship but she wasn’t sure if she could do it. That soon turned into the fact that she wasn’t sure if she wanted to do it. We explored Narelle’s past relationships, their positive aspects and their endings and touched on the impact of ending these sessions. Session Six Narelle had been doing plenty of work between the sessions keeping a diary of her feelings, particularly before and after talking to Simone and she told me some of what she felt were the key points that had occurred to her (the diary was not something we had negotiated as part of the contract but she told me she wrote one at various times of her life when feeling stressed). She talked of not wanting to lose the sessions but also of feeling that she needed to see if she could make things change at home by herself. She was very keen to know if she could have more sessions in the future if she wanted to and explored whether or not Simone could attend as well on their extension tele- phone. I said we could work together in the future and that could be as a two or a threesome. Narelle’s voice was calm and controlled. She sounded like she was confident she could work things out. She was noticeably pleased when I pointed this out. I have not heard from her again, except for a card 104  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE received about six weeks after the last session quoting a passage from Gibran’s The Prophet (1988, p. 10): Then said Almitra, Speak to us of Love… …When love beckons to you, follow him, Though his ways are hard and steep… …And when he speaks to you believe in him, Though his voice may shatter your dreams as the north wind lays waste the garden… with a postscript saying: this is how I think of Simone and myself. We are talking properly for the first time in ages and I don’t know where it will end but at least I now feel more equal in the relationship.Thanks! CASE STUDY TWO Dorothea is a 40-year-old mother of three, girls aged 20 and 16 and a boy of 10 who has severe learning difficulties and attends a special day school. She found out about counselling by telephone from her literacy tutor, having had tuition at home once a week from an adult literacy charity. Assessment session Dorothea was born in Australia of Italian parents and spoke only Italian at home. She married an Italian man when she was 18 and finally approached the literacy charity for help after her husband, 12 years her senior, had a ‘heart scare’. This made Dorothea realize that he might die before her and she became determined to be able to manage on her own and care for her son. Her formal education had been very limited and she had the reading age of an 8 year old. She also could not count change and whenever she went shopping her husband would give her the money and she would hand it over not knowing if what she got back as change was correct. The reason for seeking counselling was to explore her relationship with her husband, which she described as ‘hard’. I found it difficult to understand Dorothea at first. Her accent was very strong and her speech hesitant and unclear. The words she used 105 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY were simple and she repeated herself often. She thought the coun- selling was ‘some time to talk about me and only me’ and she arranged to pay for her sessions by postal (money) order as we did not meet and her husband would not write her a cheque. She told him she was using the money for an exercise class. I asked her if she could understand me fully and she said she could, but I suspected that there were times when she had not fully understood and was instead trying to work out what I meant. We arranged four sessions in total, timed to be the day after her literacy tutoring and she used the tutoring as the way into the session each time. Week One This session began with Dorothea telling me how she had managed to read something and the tutor was pleased. She said she was pleased with herself too. Then she talked of all the things she was not pleased about in her life. It soon became apparent that Dorothea had some notion that coun- selling was like ‘magic’ and that somehow I would ‘make miracles happen for her’. She explained that ‘being Catholic I believe in mira- cles and talk to my figure of Mary’ in her bedroom and she thought that talking to me was a bit like that, only I talk back to her. She talked at length about her husband, his bad temper and how she often had to be in the middle between him and the eldest daughter. She told me she was not scared of him and could shout back just as loud. A few minutes later she told me he ‘is not a bad man really, just like any other man’ and she did not want me ‘to think bad things about him’. I was aware of being very careful in my choice of words, trying to establish what she could understand. By the end of the session, after I had prompted her when I sensed she had not fully understood me, she seemed to feel confident enough in herself and also trusting enough in our relationship to ask me to explain further when necessary. Week Two Dorothea told me that she had not done her literacy homework because she had been too busy and how she felt about that. She spoke at length of how her husband made her angry and how much she does 106  TELEPHONE COUNSELLING AND PSYCHOTHERAPY IN PRACTICE for everyone in the house and no one helps her. Her voice was agitated and she spoke far less clearly than when she was calm. I had to ask her to repeat herself a few times and explained that I could hear she was angry and that it would be easier for me to understand her if she could slow down a little, which she tried to do. She also told me how her son is difficult to look after and how he just watches tele- vision and only the second daughter helps her with him. Her husband hardly spoke to the boy because ‘he is not like a real son’. Whenever I sought to probe a little more into something, she paused and then carried on with what she had been saying. I wondered whether we would be able to make much progress in the four sessions. Week Three This week was initially focused on Dorothea’s wish to lose some weight and how hard it is for her to diet and go to exercise classes. It transpired that she had been watching something on television about being overweight and how a special exercise class had made a big difference to the people on the programme. Then she talked at length of her husband and how she felt about him and their life, much of which she had said previously. He had been asking her how good the classes were since she was not looking any slimmer. I asked her if she could tell him she was using the money to talk to me and she was very definite that she would not do that. She acknowledged that she was feeling frustrated, which was how she sounded to me. I reminded her that the next session would be our last and she said she would miss our chats. Week Four Dorothea’s tutor had brought along play money and they had counted several dollars together although she was not sure if she could do that on her own. She returned to talking of her marriage and its difficulties. She did come up with a few ideas of how she could start off a conver- sation with her husband about her wish to change things a bit and had some clear examples of what she could change. I felt that counselling was unlikely to help her to consider significant changes in her rela- tionship, or explore herself more than she had already done. At the end of the session, Dorothea said ‘thank you for chatting with me. I have enjoyed talking to you and I hope we can do it again later on.’ 107 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY My sessions with Dorothea made me aware of how much we expect of our clients and how articulate they need to be to facilitate building the relationship. On the other hand, it also struck me how trusting Dorothea was in the manner in which she let her feelings come out on the telephone and how she sought affirmation from me as a child might. Perhaps the telephone is not ideal for less articulate people but at the end of the four sessions Dorothea was making an action plan of how to talk to her husband. She never implemented those specifics of which we talked, but she did call me some months later to say that he now trusted her to go out alone and to shop by herself, which was quite a big step forward for her independence and no doubt a measure of the success of her drive towards self-help through the literacy lessons and the counselling. CONCLUSION Telephone therapy can be an effective tool for many clients, especially for shorter term work, although there is no reason why it cannot be used over many months. The medium presents challenges to practi- tioners in requiring excellent listening skills and no visuals to back these up, and it does not suit everyone. There are many advantages of using the telephone for therapy including its near universal availability and the fact that it gives clients a wide choice of practitioners. People talk more freely when they feel they are not being judged and feel safe and this happens quite early on in the telephone counselling relation- ship, thus it may take fewer sessions to achieve the goals of the therapy than would face-to-face work. REFERENCES Gibran, K. (1988) The Prophet, Heinemann, London. Rosenfield, M. (1997) Counselling by Telephone. Sage, London. Rosenfield, M. and Smillie, E. (1998) ‘Group Counselling by Telephone’, British Journal of Guidance and Counselling, 26 (1): 11–19. Suler, J. (2002) he online disinhibition effect’ [Online] Available: http://www.rider. edu/users/suler/psycyber/disinhibit.html. TBF (The Teacher Support Network) (2001), Annual report 2000–2001, Teachers’ Benevolent Fund, London. TISCA (Telephone, Information, Support and Counselling Association of Australia) (2000) Information Sheet.TSICA, Sydney. 108 6 Video counselling and psychotherapy in practice SUSAN SIMPSON THE DEVELOPMENT OF VIDEOCONFERENCING IN TELEHEALTH AND PSYCHOTHERAPY The use of videoconferencing in the provision of psychotherapy is a relatively new one, although it dates back to before developments in email and Internet chat. Historically, however, videoconferencing has been used for commercial, educational and medicinal purposes over the past 40 years or so. Early developments in videoconferencing grew out of a history of rapid growth in electronic forms of communica- tion, which were originally analogue, and most recently digital. In the initial stages, the growth of videoconferencing communications was driven by commercial organizations, such as NASA (National Aero- nautics and Space Administration) in the USA. It only became used for telemedicine when individual practitioners began to utilize commercial-based equipment that was already available. The advent of the television facilitated the development of videocon- ferencing and in the latter part of the 1950s medical professionals began to use closed circuit television and video communications for clinical consultations (Wootton and Craig, 1999). The Nebraska Psychiatric Institute began using videoconferencing for medical consultations, education and training in 1964. The first published study into the use of videoconferencing for psychotherapy was initi- ated at this same site, and used two-way, closed-circuit television for group psychotherapy (Wittson and Benschoter, 1972). Since this time, there has been a steady growth of small-scale studies and evaluations, made possible through the expansion of real-time videoconferencing and the increased availability of low-cost PCs making facilities more widely accessible. Digital communications have also improved markedly, allowing for higher quality transmission of audio and visual data. 109 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY Although the greatest area of growth and research into videoconfer- encing has taken place in industrial countries such as Australia, the USA and Scandinavia, with the advent of mobile video communica- tions and satellite transmission it is becoming increasingly available to developing countries. These developments have facilitated the exchange of communications, education and training to take place across previously impenetrable boundaries. THE CURRENT STATE OF VIDEO THERAPY – RECENT FINDINGS Of the small number of studies that have explored the use of video- conferencing for therapy, most have been qualitative, usually case studies that have focused on user satisfaction and feasibility, or studies which have described video therapy with some face-to-face contact rather than pure video therapy. Some studies have focused on psychi- atric consultations, but few have examined whether videoconfer- encing is suitable for the specific requirements of therapy. Not surprisingly, due to geographical factors, the initial studies exam- ining videoconferencing for therapy have mostly taken place in the USA, Australia and Scotland. These have tested a variety of models and therapeutic methods, including psychoanalysis (Kaplan, 1997), cognitive-behavioural therapy (Bakke et al., 2001), family therapy (Freir et al., 1999) and video-hypnosis (Simpson et al., 2002). In addi- tion, a range of client groups have been involved, including children and families (Freir et al., 1999), adults (Simpson et al., 2001) and the elderly (Bloom, 1996). To date, there has been little investigation into whether certain client groups benefit more or less from videoconfer- encing-based therapies. However, so far, it has been found to hold potential for clients with a range of problems, including bulimia nervosa (Bakke et al., 2001), obesity (Harvey-Berino, 1998) and schizophrenia (Zarate et al., 1997). This chapter includes a compre- hensive review of the literature into the specific field of the use of videoconferencing within counselling and psychotherapy. SETTING UP – TECHNICAL EQUIPMENT AND TECHNOLOGY Although a range of systems exist, most services use purpose-built videoconferencing systems initially designed for business use. The 110  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE lowest cost videoconferencing equipment currently consists of a basic desktop PC with a camera mounted on top. At the other end of the spectrum are self-contained roll-about models which consist of a large (for example 29 inches) screen/video monitor on top of a coding/decoding unit with an internal microphone, tuning unit and speaker and an adjustable camera positioned directly above the screen. A handheld remote control is used to dial up videoconferencing systems at other sites and manipulate the camera view (the view that is transmitted to the screen at the far site). If the systems are compatible, it can also be used to change the angle and magnifi- cation of the view of the far site. In most cases, the upper body of the other person is visible at both sites. Each site has the choice as to whether or not they want to see themselves with a ‘picture-in- picture’ facility, but most users seem to prefer not to, as it can be distracting. Audio and visual data is compressed and passed at high speed through the telecommunication network along ISDN lines (integrated services digital network) or fibreoptic cables. As the bandwidth increases (the amount of information carried by the communication lines), so does the quality of the video images in real time and, usually, the call costs. A number of recommendations are made toward the end of this chapter regarding minimizing difficul- ties in the use of such equipment. VIDEOCONFERENCING VERSUS TELEPHONE THERAPY VERSUS FACE-TO-FACE: WHO PREFERS WHAT? The descriptive data available from studies that have compared the different combinations of technology (videoconferencing, telephone and face-to-face) with therapy have not consistently found that any one approach is superior to the others. In fact, the research seems to point more to individual preferences associated with personality traits, and issues such as control, perception of personal space/ distance and idiosyncratic needs and patterns within relationships. The ability to develop a therapeutic alliance has also been highlighted as an essential factor which may influence preferences of one mode over another, and this will be further examined here. 111 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY Clinical efficacy A number of studies have suggested that therapy conducted via video- conferencing may be equivalent to face-to-face sessions in terms of both client satisfaction and clinical effectiveness. There is a distinct lack of research that has examined the clinical efficacy of video therapy in any depth, with no randomized controlled trials having been completed at the time of writing. The Wittson and Benschoter (1972) study noted above used two- way, closed-circuit television for group psychotherapy and compared this with control groups who received face-to-face group psychotherapy. After six sessions, results showed that the effective- ness of therapy was also unaffected by the presence or absence of technology. Other factors, such as group composition and choice of leader, influenced outcome more than the mode of therapy delivery per se. More recently, Harvey-Berino (1998) compared face-to-face with videoconferencing group behavioural therapy for the treatment of obesity. Both conditions were found to lead to significant changes in eating and exercise patterns and were effective in leading to weight reduction. Most clients were highly satisfied with videoconferencing, even those who were aware that they could have seen a therapist face to face. Although at first over 50 per cent were hesitant about communicating via videoconferencing, with experience they became more comfortable with the technology. Schneider (1999) compared brief cognitive-behavioural therapy via video link, two-way audio and face-to-face with a waiting list control group. Results showed that there was no significant difference between treatment groups across a range of outcome measures, but all were superior to no treatment. Schneider suggests that, in future, it will be essential to consider such factors as presenting problems, personality types and comfort levels in order to determine which clients are most suited to which mode of delivery. A small number of descriptive case studies have also shown promising results. Bakke et al. (2001) treated two clients with bulimia nervosa via videoconferencing using a cognitive-behavioural therapy (CBT) model and reported that both were abstaining from bingeing and purging at the end of treatment and follow-up. Studies carried out by the author (Simpson, 2001; Simpson et al., 2001) also described clin- ical improvement in a sample of clients treated using CBT, as shown by ratings on clinically validated questionnaires, self-report and ratings by general practitioners. Simpson (2002) found that a group 112  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE of eleven clients felt significantly more confident to deal with their problems (including insomnia, flight phobia, social anxiety, binge eating) following a single session of video-hypnosis. Kaplan (1997) described two psychoanalytic case studies, one of whom was seen almost exclusively via videophone, and the other as a combination of face-to-face, telephone and videophone sessions. Videophone sessions were set up so that the analyst could see the client lying on the couch from the same angle as he would have had in his office. His view was that the videophone did not produce any subjective difference to the client’s or his own experience of therapy, and when he examined his progress notes post-therapy, he was not able to distinguish which sessions had taken place with or without the technology. He humorously noted one benefit of videophone sessions by describing an incident whereby after accidentally sleeping late one morning, his client was able to avoid attending the session late by the fact that he could switch on the videophone in his home wearing his pyjamas. Client satisfaction In some cases, clients have expressed a distinct preference for video therapy over face-to-face sessions. However, most have not had any choice over the mode of their therapy, so it is not known whether this represents general satisfaction with the treatment they received or a more specific preference for videoconferencing. Simpson et al. (2001) found that 9 out of 10 clients offered therapy via videoconferencing expressed satisfaction with the service, and some preferred it to face- to-face contact. Clients’ comments indicated that they experienced video therapy as less embarrassing and confrontational than face-to- face contact, and one said ‘it was easier to talk to someone on a screen than having someone invading my space’. Some clients felt that they were more easily able to express difficult feelings via videocon- ferencing and that the extra distance made them feel safer. Similar results were found by Bakke et al. (2001) who treated two women with bulimia nervosa via videoconferencing, using a manual-based cognitive-behavioural model. Results showed that clients valued the privacy and anonymity of video therapy, and they commented that it was less intimidating than face-to-face sessions. They also valued the fact that they were not required to travel to sessions. 113 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY In another recent study (Simpson et al., 2002), 11 clients attended a single session of hypnosis via videoconferencing. One-third of clients preferred video-hypnosis to the prospect of face-to-face hypnosis and one-third had no preference. Even those who expressed a preference for face-to-face hypnosis indicated that they would like further video-hypnosis sessions. A number of reasons were given for prefer- ring video-hypnosis over face-to-face hypnosis, including a greater sense of control, an increased sense of being alone in the room and therefore less under scrutiny and a consequent reduced sense of self- consciousness. On the other hand, the views of those clients who indicated a preference for face-to-face sessions suggested that video- conferencing can lead to a reduced social presence and sense of connection with the therapist. Thus, not all clients may be suited to video therapy. One client who did not experience video therapy in such a positive light reported that he feared that his sessions might be being recorded or watched by others and that this information may be used against him in the future. He described the video therapy as ‘dehumanising’ and ‘unset- tling’, and felt that he would need time to build up a therapeutic rela- tionship in a face-to-face setting in order to benefit from therapy. It was noted that this client’s longstanding avoidant and anxious personality traits, and in particular his difficulty trusting others, may have made it more difficult for him to benefit from therapy in this context (Simpson et al., 2001). Another client found that she missed the intimacy of face-to-face sessions, and often compensated by sitting so close to the screen that only a magnified version of her nose was visible on the therapist’s screen. Although she was frequently asked to sit back a little, she habitually returned to her former position. She also compensated in the form of telephoning the therapist and sending her long letters between sessions. Although this client may have found the closeness of face-to-face sessions more acceptable, she was in fact extremely positive in her ratings of video therapy sessions, and in retrospect it seemed that these may have in fact facilitated the development of a more independent and self-contained aspect of her personality. It may be then that for some clients with issues associated with dependency and lack of sense of self, video therapy may provide additional thera- peutic value, even if it is not their first choice. Simpson (2001) suggested that there was a trend for those clients with more complex problems to rate lower levels of satisfaction with video therapy than those with shorter term, simpler problems. This was also found by Ghosh et al. (1997), who suggested that the self- 114  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE consciousness and awkwardness reported by a client whilst discussing sensitive issues were more attributable to her general character and relationship difficulties than to the technology. This suggests that these difficulties may also have arisen if therapy had been conducted on a face-to-face basis. A number of possible factors may influence clients’ preferences, including their level of previous experience with videoconferencing and the particular nature of their difficulties. For example, those who feel that they lack control in their lives and relationships in general might prefer the extra control offered by videoconferencing. Simi- larly, those who feel intimidated or self-conscious about talking about themselves or their problems may also prefer the distance and control offered by videoconferencing. A sense of control has often been cited as a major factor influencing clients’ level of satisfaction with video therapy. Allen et al. (1996) found that in video therapy clients often perceive a greater sense of control than with face-to-face therapy, due to being able to move out of the camera view or even the room and being able to switch off the equipment if they so desired. According to Omodei and McClennan (1998), this sense of control can be further heightened by giving clients the remote control panel so that they have the opportunity to manipulate sound and picture. Those clients who need a greater sense of control within their sessions may find this particularly appealing, but those who are particularly fearful of using technology for communication may find it confusing or anxiety-provoking. The small number of studies that have compared video therapy with telephone therapy have been inconclusive in their findings. Schneider (1999) compared brief therapy across video, two-way audio and face- to-face modes, and suggested that although individuals may be more suited to one mode over another, most adapt to any given mode with time and experience. Although he found that drop-out rates were higher for the two-way audio and video modes than for face-to-face, he suggested that a longer term therapy may have produced different results by giving clients time to adjust. In comparing video, audio and face-to-face modes of therapy, Kaplan (1997) found videophone to be a more acceptable means of therapeutic contact than the telephone, due to being able to see the other person’s facial expressions and kinaesthetic cues, which enhanced both conversational synchrony and understanding. 115 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY Therapist satisfaction Few studies have examined therapist preference for one mode of com- munication over another. It will be of utmost importance to identify those factors that influence whether or not therapists choose to engage in one mode over another if new forms of technology are to be utilized in the provision of therapy in the future. Those studies which have explored this area suggest that as with clients, individual therapists differ in their attitudes to video therapy. Although thera- pists often tend to be more cautious about video therapy than clients, this initial reluctance tends to recede with experience and practice (Nagel and Yellowlees, 1995). Therapists are often relieved to learn that they can continue to use their usual therapy techniques and strategies, and only need to learn a few minor extra skills, such as the process of turn-taking, in order to become effective video therapists (Omodei and McClennan, 1998). Simpson et al. (2001) reported a high level of therapist satisfaction with videoconferencing sessions, and noted that although some initial adjustments were required in communication style and pacing, adap- tation was relatively quick. McLaren et al. (1996) reported that although some therapists claimed to experience higher levels of fatigue following video therapy sessions, others remarked that they felt more relaxed, and were even able to take off their shoes and put their feet on a stool out of the view of the camera. A recent survey carried out in Aberdeen, Scotland, looked at reasons why certain users are more or less likely to utilize videoconferencing facilities for clinical purposes (Mitchell et al., 2003). Therapists from the psychiatric hospital along with medical doctors from the local A&E department were asked to fill out brief questionnaires and undertake a short interview to elicit their views. Results suggested that people were more confident in the use of videoconferencing for clinical purposes when they had undergone hands-on training in the use of videoconferencing equipment, followed by opportunities to use it regularly thereafter, with the availability of top-up training when required. It was also suggested that self-rating of personality factors such as risk-taking behaviour and openness to new experience may be positively correlated with willingness to use videoconferencing for clinical purposes. At present, most technical training available is through videoconfer- encing manufacturers (for example Sony), who can offer this as part of the deal when purchasing equipment, or in-house training by expe- 116  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE rienced users who are already familiar with the equipment. There is currently little formal training available on the use of videoconfer- encing for therapeutic purposes, although this may at present take place informally at local sites where video therapy is offered. It would seem essential that videoconferencing training programmes be made more available to ensure that the highest possible standards of care are upheld, and so that users will have the skills and confidence to offer these services in the future. VIDEOCONFERENCING AND THERAPEUTIC ALLIANCE The development of a positive therapeutic rapport is a well- documented prerequisite for making insights and changes in psycho- therapy. A small number of studies have examined the way in which the ‘videoconferencing environment’ interacts with certain factors such as empathy and social presence, thereby playing an influential role in the establishment of the therapeutic relationship. Fussell and Benimoff (1995) reported that the establishment of an alliance is dependent on the availability of non-verbal cues such as eye gaze and gestures. Eye gaze is purportedly significant in helping communicators to establish speaking turns and recognize whether or not the other is engaging in the discussion. Gestures may further contribute to conversation, by facilitating speaking turns and providing cues which clarify what is said. It is also suggested that gestures may facilitate verbal fluency and message formulation, and that conversation may become more disjointed when hands are restricted. This may be particularly pertinent for client groups such as the Australian Aborigines whose communication systems include a range of hand gestures whilst speaking (Hodges, 1996). Reservations have been expressed about whether it is feasible to dev- elop a positive therapeutic rapport via videoconferencing. When using low-quality videoconferencing, communication can be compro- mised by sound delays, lack of lip-voice synchronization and poor image quality, which can inhibit appropriate turn-taking and inter- pretation of facial expressions, and thereby detract from rapport- building in the initial stages of therapy (Kirkwood, 1998). Sound delays can disrupt the normal rhythm of speech. For example, when therapists use minimal prompts such as ‘uh huh’ and ‘hmmm’ to facilitate the other person’s speech, this may be picked up at the far site at slightly the ‘wrong’ point in the flow of conversation, thus 117 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY causing confusion. In addition, hand and arm gestures can become pixelated (the screen image becoming interrupted by jerkiness or the picture breaking up) due to the delay in image transmission, thus reducing the quality of this aspect of non-verbal communication. Direct eye contact is also often not possible with videoconferencing, as the camera is positioned above the viewing screen. However, a number of studies (Ghosh et al., 1997; Simpson, 2001) have found that both therapists and clients adjust to these differences, and rate the therapeutic alliance highly in spite of them. Similarly, Simpson et al. (2001) suggest that empathy and warmth can be transmitted via videoconferencing, and that although traditional methods (such as handing clients a box of tissues) may not be feasible, alternatives can be developed through facial expression, voice tone and the respectful use of silences. As the technology develops, picture quality improves and delays in sound are diminished, the precision and clarity of communication will become greater. It may be informative in the future to evaluate whether there is a relationship between the quality of communication and corresponding levels of therapeutic alliance of video therapy sessions. Some have expressed concern that therapeutic rapport may be compromised by reduced social presence and less spontaneity during videoconferencing interactions (Allen and Hayes, 1994). However, in contrast, Capner (2000) found in her review of the literature that clients have largely been satisfied with the social presence in video therapy, and in fact some have commented that they became so used to it that they forgot they were not in the same room as their thera- pist. Schneider (1999) suggested that most therapists are able to use the cues available to them whether they be audio or visual and find ways to develop a positive alliance regardless of media mode. The current author has found that the use of peripheral forms of communication such as email, letter writing and fax can further support the therapeutic alliance, particularly for those clients who require more intense input. Telephone support has been offered occa- sionally, both as a substitute for therapy sessions when technical breakdown has prevented videoconferencing sessions from taking place and as an adjunct at times of crisis. 118  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE THERAPEUTIC PROCESS ISSUES Although the process of therapy tends to be similar for video therapy as in face-to-face settings, it is prudent to consider the ways in which the presence of technology may influence the different elements of therapy. When considering the initial aspects of establishing a therapeutic rela- tionship, there is some variation in the suggestions made by different authors. Gammon et al. (1998) suggest that in psychotherapy supervi- sion, the establishment of a face-to-face rapport over several sessions prior to engaging in videoconferencing sessions contributes to the mutual trust and respect which is required for such a relationship to function effectively. However, Simpson et al. (2001) and Kaplan (1997) reported that it is feasible to develop positive therapist–client rapport after just one initial face-to-face assessment session. There is a lack of evidence to date examining whether it is possible to develop an adequate therapeutic relationship solely through videoconferencing sessions, as most studies have used a combination of videoconferencing and face-to-face sessions. This author is involved in such a study, exam- ining both therapeutic alliance and clinical effectiveness of therapy conducted solely via video link for clients with bulimia nervosa. It is recommended that therapists remain aware of certain boundary issues that may be particularly relevant to working by videoconfer- encing (for example dealing with clients taking snacks and drinks into sessions). In addition, it is important to maintain the normal boundaries which are utilized in face-to-face work wherever possible, to ensure that both therapists and clients alike maintain an awareness of what is expected of them in order for the therapy to proceed effectively. RECOMMENDATIONS Clinical Therapists with ‘at risk’ clients should remain in close contact with the client’s GP (family doctor) or other relevant health profes- sionals; and ensure that adequate support is available to clients between sessions and in case of a crisis. 119 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY Therapists should allow time to adjust to using the videoconfer- encing system, and note that in general any initial discomfort is likely to dissipate with experience. Pre-therapy client information sheets should include information about the therapist, basic details on how video therapy works and how to access the service. Provide information sheets about procedures in the case of tech- nical failure. This should involve the therapist re-establishing the videoconference call as soon as possible, or at the least by making contact by telephone. Telephones should be available for use in all videoconferencing rooms. When sound is lost, or other technical problems occur, these keep both the client and technicians informed (Goss, 2000). Speakers need to learn the etiquette of turn-taking in conversation, such that each person ensures that the other has finished speaking before starting, rather than relying on lip movements which may be out of synchrony with sound (Cukor and Baer, 1994). Clients are most comfortable when therapists use their normal style of communication – attempts to compensate for the extra distance in video therapy can be perceived as artificial (Capner, 2000). Technical Quality of calls are determined by picture size, response delay and frame rate. With lower quality systems, users should keep fast movements or gestures to a minimum. As the quality of calls increase, facial expressions and signs of distress and tearfulness become significantly easier to detect. A solid colour (especially dark) background is best for maximizing picture quality and a dark heavy curtain can achieve this effect and simultaneously improve the room’s soundproofing. Staff should be trained in operating the videoconferencing system, including focusing the camera, using associated equipment, timing speech and turn-taking. In addition, users may benefit from prac- tising staying within the camera view, and in giving feedback to the person at the far site about volume and positioning. Block booking reduces stress associated with the complex logistics encountered with booking videoconferencing systems and per- 120  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE sonnel to operate them at both sites (when needed), and also provides consistency for clients. In order to obtain the best possible balance between capturing body movements and eye contact and facial expressions in the picture, the camera should be positioned to the point where head, shoulders and arms are contained within the image (Fussell and Benimoff, 1995). Lighting should be bright enough in order to produce a clear image for projection to the far site. In the case of video-hypnosis, a balance needs to be reached between keeping lighting dim to enhance client comfort, whilst ensuring that client breathing patterns, facial expressions and so on remain visible. CASE STUDY Presenting problem Peggy presented for therapy with long-term problems associated with her weight and eating, as well as recent health problems including gallstones and chronic pain. Her weight at the time of referral was 120.7 kg, which gave her a body mass index of over 45 (normal range ! 19–25). In order to safely operate on her gallstones she had been advised that she needed to lose at least 25 kg. In addi- tion, over the past year her weight and size had exacerbated her chronic pain, and the combination of these two factors made phys- ical exercise difficult. At the point of seeking help, she lived on a remote island off the south coast of England. She described feeling alone, isolated and in a great deal of pain. Her problems made travel and exercise difficult, and she was therefore largely housebound. Formulation A full assessment of Peggy’s eating patterns confirmed a diagnosis of ‘overeating associated with other psychological disturbances’ (ICD-10 diagnostic system). In addition, her chronic pain, which was caused primarily by gallstones, was found to be exacerbated by stress associ- ated with physical exertion and lack of physical fitness, overeating episodes and boredom. 121 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY Peggy was also experiencing clinically significant levels of anxiety and depression. She believed that she was socially undesirable and unat- tractive, needing to prove her worth through losing weight, and striving for perfection. Her weight and shape became a way of meas- uring her self-worth. Her desire to be more physically attractive led to an attempt to ‘overcontrol’ her eating, through restrictive dieting. Paradoxically, through focusing excessively on her eating and experi- encing sensations of starvation after skipping meals, she began to compensate through periods of overeating and binge-eating, whereby she would lose control and eat large quantities of the foods that she had previously forbidden herself. Treatment Treatment took place over 12 sessions with a clinical psychologist and 8 sessions with a dietician, with follow-up sessions planned on an intermittent basis. Peggy attended her sessions at the local mental health department on the island, where a PC-based teleconferencing system was assembled with a camera on top. The clinical psychologist and dietician used a teleconferencing system, based on site at the hospital in Aberdeen. The client and therapists could see the other person on their screen from mid-torso. Sessions involved a combination of direct therapy work using a cognitive-behavioural therapy (CBT) approach, and hypnosis sessions. The CBT sessions focused on enabling Peggy to recognize and challenge unhelpful thinking patterns and build her self-esteem through learning to value and accept herself. She was helped to re-evaluate her sense of worth and attractiveness by means other than focusing exclusively on her weight and shape. Her eating diffi- culties were addressed initially through developing her awareness of patterns by keeping food diaries (of all food/liquid consumed, and associated thoughts/feelings) which were emailed to therapists on a weekly basis for discussion in sessions. Letters were written and emailed to Peggy by the therapist throughout the course of therapy to reinforce the content of sessions. Hypnosis sessions focused on assisting Peggy in managing her chronic pain through suggestions about the creation and transfer of symptoms of analgesia. It was anticipated that learning to use self-hypnosis would increase her sense of control and efficacy over her pain, and that she would then be less likely to turn to eating as a way of disso- ciating from this experience. 122  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE Peggy was easily hypnotized, and in fact became deeply relaxed in a relatively short time period. Arm levitation was particularly effective as a deepening technique. Her arm could be seen moving upwards on the screen, and signs that she was becoming relaxed (deeper breathing, diminution of body tension) were easily detectable via the videoconference image. Although the sessions were conducted at a low bandwidth, the image of the client was quite still during hypnosis, so the quality of the picture remained relatively good. A large, supportive chair was provided to maximize the client’s comfort during sessions, and the camera was adjusted accordingly to focus on her. Due to the delay caused by using a low bandwidth, some adjustment was required in communication to ensure the other person had finished speaking before beginning to speak oneself (turn-taking). However, during hypnosis this caused little disruption as the client was rarely required to speak and communicated mainly through nodding at relevant junctures. Some improvisation was also required in terms of signalling within hypnosis sessions, in order to convey messages between patient and therapist at relevant junctures. For example, Peggy was asked to signal by nodding rather than raising a finger, which may not have been as easily detectable using videoconferencing. The psychologist spent the first part of the session reassuring Peggy that if any technical problems occurred, or if the tele-link was temporarily lost, she would be able to open her eyes and be in control. She also repeated during the tele-hypnosis session the words: ‘If for any reason you need to open your eyes, you’ll be fully orien- tated and able to do what you need to manage the situation.’ As Peggy’s sessions took place within the mental health department in the local hospital, other health professionals were usually present in the building and the clinical psychologist conducting the sessions would have been able to telephone them if any particular clinical difficulties had arisen in the course of tele-hypnosis sessions. If any concerns had been raised about Peggy’s safety, then it would also have been possible to contact the local psychiatrist or one of the general practitioners to notify them about the situation. Outcome Peggy made a number of significant improvements in video therapy. She lost more than 5 per cent of her bodyweight over the course of 123 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY therapy through an increase in regular healthy eating and physical exercise. Results from Peggy’s questionnaires and self-report also reflected a positive effect of video therapy on her self-esteem, and she was no longer clinically depressed or anxious following her course of sessions. Qualitative feedback: At the post-therapy telephone interview, Peggy commented that hypnosis via videoconferencing was a ‘totally posi- tive experience’ for her. She noted that she actually found it easier to communicate through videoconferencing as she felt it was less personal than face-to-face sessions whereby she may be watched and her body language analysed. As a result, she felt that with videocon- ferencing there were ‘no boundaries’ and she felt more able to ‘say exactly what I felt at the time’. This was also helped by the fact that the therapist was conducting the therapy from outside the local community, and therefore she perceived that there would be greater confidentiality, and little risk of running into each other at community events or the local supermarket. ETHICS AND LICENSING Different regulations and qualifications are required in order to prac- tice between states in the USA and Australia, and between countries in Europe and elsewhere. It may be prudent to consult a legal specialist in order to ascertain responsibility and licensing proce- dures. Seeking client consent which specifies that they accept that all services received from the therapist are considered to be provided entirely at the therapist’s base may protect to some degree from clients who may sue on the grounds of non-residence (Seeman and Seeman, 1999). Reimbursement for services also becomes problematic across state and international boundaries. Private insurers have not yet agreed to pay for video therapy, and the difficulties which therapists may expe- rience in obtaining reimbursement may lead them to avoid offering these services (Capner, 2000). Duty of care has also been highlighted as a potential area for liability, resulting from the establishment of a therapeutic relation- ship. Capner (2000) suggests that when therapists are working in collaboration with other clinicians at far sites, it is imperative to clarify professional boundaries at the outset for professional indem- nity purposes. It may be considered unethical by some to offer 124  VIDEO COUNSELLING AND PSYCHOTHERAPY IN PRACTICE therapy via videoconferencing at such an early stage, when there is a lack of controlled trials to show its efficacy. However, it may also be claimed that withholding therapy services from clients living in remote areas or those who would prefer to work in this way when the technology is readily available may be equally unethical. It is therefore also recommended that client consent be sought on the grounds that there is a lack of evidence into the efficacy, reliability and validity of video therapy. Although concern may be expressed at the level of confidentiality of sessions, given that clinical information is being transmitted via videoconferencing, video therapy is likely to be more secure than face-to-face therapy, as there is usually less likelihood of being inter- rupted, and the probability of being able to break into between two and six ISDN lines is minimal due to the complexity of such an operation. CONCLUSION Until the present time research has been mostly qualitative and self- report in nature, focusing on clients’ and therapists’ experience of the acceptability and feasibility of video therapy. Despite some misgivings and the negative experiences of some, most therapists and clients generally adjust to using videoconferencing within a few sessions. Clients appear to be at ease with video therapy more quickly than therapists and some have even commented that they had forgotten that the therapist was not in the same room. Many clients have expressed a preference for video therapy due to an increased sense of control, feeling less intimidated/confronted and less self-conscious than in face-to-face settings. A minority have reported that the pres- ence of the technology made them feel more distanced and isolated, which may be made worse by the poorer transmission quality at lower bandwidths. Further research is needed to determine whether certain client groups are more suited to video therapy than others, depending on such factors as familiarity with the technology, age, gender, personality characteristics, presenting problems and previous therapy experi- ences. One might predict that the younger generation who have been brought up on text-messaging and email may be expected to feel more at ease with the technology. Larger randomized controlled trials are required to determine the relative efficacy of video therapy 125 TECHNOLOGY IN COUNSELLING AND PSYCHOTHERAPY in comparison with face-to-face therapy, and a multi-centre approach may be needed to recruit sufficient numbers to accomplish this. As the technology becomes more sophisticated and less costly, video- conferencing facilities will be increasingly available to those living in remote areas, both in health centres and peoples’ homes. It is likely that as videoconferencing facilities become more widely accessible, the demand for video therapy services will increase correspondingly and therapists will have more opportunities to develop skills for working in this area. It is also likely to become relevant and applicable in a wider range of settings, such as prisons, large cities with heavy traffic congestion and developing countries. 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