939495 APY Australasian PsychiatryChherawala and Gill

Australasian
COVID-19 Psychiatry
Australasian Psychiatry

Up-to-date review of 2020, Vol 28(5) 517­–520

© The Royal Australian and
New Zealand College of Psychiatrists 2020

psychotherapy via videoconference: Article reuse guidelines:

sagepub.com/journals-permissions
DOI: 10.1177/1039856220939495
https://doi.org/10.1177/1039856220939495

implications and recommendations journals.sagepub.com/home/apy

for the RANZCP Psychotherapy

Written Case during the COVID-19
pandemic

Nabil Chherawala   University of Adelaide, North Adelaide Local Health Network (NALHN), Australia
Shane Gill  South Australia Psychiatry Branch Training Committee, Glenside Health Service, Australia

Abstract
Objective: There has been a surge in videoconferencing technology use in response to the COVID-19 pandemic.
RANZCP registrars engaged in the Psychotherapy Written Case are met with new challenges in navigating the
psychodynamic processes that can occur when transitioning from in-person to videoconferencing psychotherapy.
There is also a myriad of videoconferencing platforms to choose from.
Conclusion: It has become necessary to adapt our clinical practice to the current COVID-19 pandemic and physical
distancing regulations. The literature recognises videoconferencing psychotherapy as a valid therapeutic medium
which can facilitate healthy psychological maturation, but there are theoretical drawbacks. A transition to videocon-
ferencing psychotherapy requires patient agreeability, consistency and reflection upon patient–therapist dynamics;
this will aide in the Psychotherapy Written Case submission. Registrars must balance usability, digital security and
patient preferences when choosing videoconferencing platforms.

Keywords:  videoconference, telepsychiatry, psychotherapy, psychiatry training, COVID-19

T
here is growing uptake of videoconferencing (VC) broad range of psychiatric illnesses and patient demo-
technology in psychiatric practice.1,2 This has been graphics.1,2,4,5 Surveys of therapist satisfaction with VC
driven by technological advances and movements and confidence in conducting VCP have also yielded
to make health care more accessible.1,3 In light of the positive results.3
COVID-19 pandemic, there has been a surge of usage in
VC due to regulations mandating physical distancing.
Physical distancing has had a major impact on psychia-
Key differences between in-person
try registrars undertaking the Psychotherapy Written
and VCP
The importance of physical proximity
Case (PWC): a psychodynamic psychotherapy course
and assessment required for RANZCP fellowship. The A powerful therapeutic force in psychodynamic therapy
sudden need to change the setting of therapy has out- is the development of new emotional relationships. In
paced the literature in reporting unique changes to the
psychodynamic process when transitioning from in-per-
son to videoconference psychotherapy (VCP).
Corresponding author:
The use of VC has been widely accepted for use in vari- Nabil Chherawala, University of Adelaide, North Adelaide
ous types of psychotherapy.1–3 VC not only provides Local Health Network (NALHN), 116 Reservoir Road,
accessible psychiatric care and cost-effectiveness, but an Modbury, SA 5092, Australia.
equivalence in outcomes to in-person care, across a Email: nabil.chherawala@sa.gov.au

517

this context, a major argument against VC is the uncer-
tainty of whether a virtual relationship permits enough
feedback to allow correction of distorted images of
another.
For example, Roesler discusses how idealisation of the
therapist – through projections, fantasy and other
processes – can undergo intensification by the nature of
the virtual relationship.1 Therefore, the transforma-
tive process of therapy can be obstructed due to the
absence of reality input that is otherwise inherent in
face-to-face encounters. Roesler further argues that
psychological maturity cannot occur in the imaginary
(virtual) space, and operating primarily in this space
reinforces the difficulties in developing authentic
real-world interpersonal relationships. As Roesler sum-
marises:
Is not the main point in psychotherapy and psychoa-
nalysis to get out from behind our masks and become
fully present with our suffering and our anxieties
about being accepted in the face of the real other?
How can this come about if we can so perfectly mask
our deficiencies technologically? (Roesler 2017: 379)
A counterargument is given by Merchant in 2016, who
described biological mechanisms, such as mirror neu-
rons and ostensive cues, which allow for instinctual
understanding of others, that is not hindered by VC.6
A psychoanalytic perspective, including that of Jung,
has argued that no interaction with another is purely
objective, and that images constructed of others are
always subject to the influence of one’s inner-world
experience.1
Existing literature also conceptualises merits of VCP –
with the virtual space between the therapist and patient
paralleling Winnicott’s Transitional Space. Here, patients
can be creative and experiment with their developing
identities, whilst the therapist (in the role of the signifi-
cant other), is conceptually there but not there, which can
provide sufficient security for the patient.1,7
Adapting the therapeutic frame
Therapists are responsible for ensuring the therapeutic
frame: the environment and relationship which allows
the patient to make a secure connection and use that as
a platform for change.8 A critique seen in the literature is
whether VC permits the therapist to fully manage the
frame,1 and whether there can be adequate containment
of emotions.9 However, history has demonstrated that
the frame is not static, and has needed to evolve with
social and cultural changes.8 Technology-related frame
disruptions can also provide material for further analysis
and reflection.6 From a practical point, registrars might
find that the process of Intentionality, of being purpose-
ful and vigilant in all aspects of the therapeutic endeav-
our, will inform their interaction with the patient.4
518
Australasian Psychiatry 28(5)
Therapeutic alliance
Apprehension in preserving the therapeutic alliance (TA)
via VC is a well-known phenomenon.1,2,4 A small phe-
nomenological study in 2020 found therapists had ini-
tial reluctance in their ability to establish TA via VC.4
This was felt to be resolved by the completion of therapy
courses, and is consistent with earlier studies that have
found TA to be equivalent between in-person and VC.3
An important point of reflection for registrars is that
therapists tend to perceive TA as less strong during VCP
than patients actually do.10,11
Interpreting changes to transference
Registrars should be mindful that a number of case stud-
ies have reported that transitioning to VCP can allow
new transferences to surface. Case reports included a
patient who developed negative transference and aban-
donment affects when the therapist physically moved
overseas, and another where the absence of feedback
when the therapist was interrupted by a door knock, led
to the emergence of violent fantasies that reflected the
patient’s own early experiences of trauma.12,13 Both these
instances allowed for the transference to be examined
and processed as part of the therapy. It has been hypoth-
esised that negative transferences develop because the
physical distance from the therapist allowed those with
harsh super-egos to feel safe in expressing anger and
hatefulness, whilst having a large enough buffer to expe-
rience shame.14
Visual and auditory cues: less
and more
Sensing both subtle nonverbal communications and the
patient’s broader environment is impeded through VC.1
In a severe example, a patient’s spouse sat in on one-to-
one VCP sessions without the therapist’s knowledge.4
Conversely, VC can permit an unhelpful abundance of
input. Consider the option to have a self-image function
on most VC platforms. This would be akin to having a
mirror facing participants during an in-person session.
Consequences here might include a narcissistic need to
monitor one’s own appearance, or a visual prompt to
maintain a composed facade. These vulnerabilities can
affect not just the patient, but the unassuming therapist
as well, and ultimately interrupt the therapeutic frame.
Confrontation and control
Confronting the patient on therapy-interfering behav-
iours can be a necessary and therapeutic process.
However, in VCP, patients have a more readily accessible
‘exit option’ – they can simply close the VC application.
This raises question on how effectively confrontation
can be conducted, how resistance might manifest and
which patients might be less suitable for VCP.
Chherawala and Gill

Table 1.  Summary of common VC platform features

Costa End-to-end Universalityd Patient to install Accessible In-built video

encryption software toolsf recording
Healthdirect, License b Yes Yes No Yes Yes
powered by Coviu
Cisco Jabber License b Yes Yes Yes Yes Yes
Zoom Free Noc Yes Yes Yes Yes
Skype Free No Yes Yes Yes Yes
Facetime Free Yes No Noe No No
Signal Free Yes Yes Yes No No
WhatsApp Free Yes Yes Yes No No
Google Duo Free Yes Yes Yes No No

VC = videoconferencing; PWC = Psychotherapy Written Case.

aFor the purpose of PWC; 1:1 meeting of 60-minute duration. Not including data charge.

bEmployment networks may carry license for use; local registration required.

cZoom is undertaking development of encryption software, and up-to-date information should be sought.

dCan be used on all major devices and operating systems.

eUnless both parties using iOS devices.

fAccess to whiteboard, chat and file sharing capability.

There is also a risk that patients can experience VCP as a
more informal interaction than in-person sessions. As
such, registrars should be mindful of interfering behav-
iours, such as patients who opt to multitask between
computer applications, choose to smoke or invite friends/
family members to ‘meet’ the therapist on screen. These
instances can become boundary transgressions.
Privacy and consent in VC
The safety and refuge of the therapist’s office should not
be undervalued. Registrars will need to consider the
patient’s physical environment, and convey concerns
about unsafe spaces, such as public areas offering free
Wi-Fi or chaotic home environments.
Many registrars may choose to audio-record in-person
PWC sessions, and thus a review of the existing consent
will be required for video-recordings during VCP.
Conversely, patients will also be able to record therapy
sessions via VC features, leaving registrars to consider
their own privacy. Here, consent becomes bidirectional,
especially if patients look to distribute their recorded
sessions.
Choice of VC platform for PWC
Skype is popular in psychiatric literature,6,10 while Zoom
experiences booming uptake. However, both these plat-
forms have seen notoriety in the media for privacy
breach concerns. Social-based platforms offer conveni-
ent options if sharing phone numbers is not an issue.
The authors recommend determining if employer health
networks have licensing with VC platforms adapted for
clinical use. For example, South Australia Health
endorses Cisco Jabber for its enterprise-wide remote clin-
ical services, and conducts its own internal security/
technical assessment. Unless already enrolled, registrars
would need to independently apply for licensing
through governance pathways specific to their local
health network. The relative merits of various VC plat-
forms are summarised in Table 1.
Recommendations for conducting
PWC
Transitioning to VCP can prevent therapy being abruptly
terminated. Table 2 summarises recommendations for
registrars undertaking the PWC via VC. Roesler recom-
mends that the relationship with the patient should
commence face-to-face, and only then transition to VC.1
Numerous case studies inform of positive outcomes
when established face-to-face therapy has necessitated
transition to either telephone or VC mediums.1,6,10,13,14
If the use of technology induces anxiety then regis-
trars should reconsider use of VCP.10 Of ultimate con-
sideration is the patient’s willingness to accept and
adopt VC options, as attitudes and expectations pre-
dict usefulness.2

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 Australasian Psychiatry 28(5)

Table 2.  Recommended domains to address when transitioning to VCP during the PWC
Patient agreeability
-  Patents agreeability with uptake of technology, including choice of VC platform
-  Privacy and freedom to engage in VCP
-  Mutual consent process
Practical therapist skills
-  Process of being Intentional
-  Uniformity in conducting the sessions to allow consistency between sessions
○  Includes location and time of session
-  Establishment of new therapeutic frame
Reflection of patient–therapist dynamic during transition to VC
-  New or changed transference and countertransference
-  Change in quality of the therapeutic alliance
-  The process of confrontation, containment and resistance
-  How audio/visual cues enhance or detract from therapy and how it was addressed
-  Technology hurdles and how this informed or impeded the therapeutic relationship

PWC = Psychotherapy Written Case; VC = videoconferencing; VCP = videoconference psychotherapy.

Conclusions
This review serves registrars engaged in the PWC by VC
as well as psychotherapists for future periods where in-
person therapy may not be possible. It is also aides PWC
supervisors and assessors in ensuring registrars have con-
sidered the breadth of changes that might occur during
therapy.
The increased accessibility via VCP questions whether
this can be used in other scenarios, such as patients relo-
cating or registrars taking maternity leave. There are
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Funding
The author(s) disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: The research has been submitted as part of the RANZCP
scholarly project.
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