Words Can Hurt

Bower Place Director’s Notes – Catherine Sanders October 2020

More people have died during the pandemic than those directly infected by the virus. Lockdown, fear, isolation, and containment with a dangerous family member has also seen an escalation in deaths from murder and suicide. Vulnerable groups, like LGBT youth, marginalized cultural groups and those already struggling with mental health are particularly at risk.

In recognition of this, Dictionary.com in partnership with the Trevor Foundation is reviewing the words used to describe suicide. Traditionally the term was ‘to commit suicide’ which carries with it the historical view of suicide as a crime. St Augustine framed suicide as an arrogant refusal to submit it to the will of God, in consequence the bodies of those who died were often desecrated and their possessions confiscated leaving devastation for remaining family. In Victoria, suicide only ceased to be a crime with the alteration of the Crimes Act in 1958. Little wonder it is hard to speak about.

Words reflect attitudes and influence the views, feelings, and opinions of those who listen. Speaking openly about the desire to die is protective and we need the right words, that support not add to the hurt. Dictionary.com recommends the term ’died by suicide’ just as we would refer to someone who has died from cancer as ‘died from cancer’. When a person does not die the terms ‘non-fatal suicide attempt’ or ‘suicide attempt’ are suggested.

Changing our language is challenging but insignificant compared to the pain of those who seek death and those they leave behind

When Time Stops – The Value of Ritual in a Time of COVID

Bower Place Director’s Notes – Catherine Sanders August 2020

Ritual, Evan Imber Black writes, ‘hold us, shape us, sustain us, and connect us’. Through the pandemic many of our traditions and ways of marking time have become impossible. No leaving the house, no gatherings of more than 10 people, no hugging, no singing, no way to mark the annual and extraordinary transitions of our lives in the ways that we have traditionally done.

Rituals connect us, from the incidental greetings of leaving and returning to the once in a lifetime events of 18th birthdays, weddings, and funerals. In her paper ‘Rituals in the Time of COVID-19: Imagination, Responsiveness, and the Human Spirit’, Imber Black details the ways we have found to continue to mark time and retain connection from the reinvention of major holidays, Easter, Ramadan, Nowrus and Passover to the  major life cycle transitions of  graduation, weddings, funerals and protests. She urges us as family therapists to address this with our clients to encourage creative construction of new ways to retain relationship and embed memory. In conclusion she writes ‘Rituals bent but did not break during COVID-19. New rituals were created, designed, and invented that captured and expressed the current moment. When the shutdown finally becomes a memory and some of the newly invented rituals slip away, I predict that many will maintain as discoveries of our creativities, our capacities, and our requirement for the human connections rituals provide.’ A joyful addition to our practice in a dark time.

Imber-Black,E. ‘Rituals in the Time of COVID-19: Imagination, Responsiveness, and the Human Spirit’ Family process x:1–10, 2020

Guidelines and protocols in the delivery of family therapy in the telehealth world:

AAFT has received many enquiries from our members asking for any guidelines and protocols in the delivery of family therapy in the telehealth world.  The Bouverie Centre; Victoria’s Family Institute, has generously shared the guidelines they have developed for this very purpose.
Click HERE to access the Guidelines

As the mental health field is producing a plethora of information and resources each week at this time we know that this list is not exhaustive, but we trust it is useful in responding to some of the enquiries the AAFT office has received in recent days.

Be well and stay connected with our national Family Therapy Association as we adjust to service provision during these challenging times. Email us with your stories, questions and ideas. We love to hear from you and we are committed to supporting our members.

For our Australian members the relevant privacy legislation for agencies and organisation with an annual turnover of more than $3 million is the Privacy Act 1988. Visit the Office of the Australian Information Commissioner site here for relevant information. Even if your place of work falls under this threshold, the Australian Privacy Principles should still guide you. And of course we encouraged all family therapists (and we require clinical members) to adhere to The AAFT Code of Ethics (2016) in all of their work.

Additionally, from The Canadian Association for Marital and Family Therapy: “Please let your members know that if they would like to join our discussion forum they are more than welcome to. https://www.facebook.com/groups/CAMFT.COVID19discussionforum/”

If AAFT members wish to ask specific questions around managing telephone/zoom/skype sessions with families during this time please direct enquiries in the first instance to the AAFT office by phone on 0499 078 211 or by email at admin@aaft.asn.au and we will put the request/issue up on the AAFT website or in the newsletter for others to answer their query.

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One of the most prominent enquiries we have received at the AAFT office has been from members seeking information, resources and training in delivering family and systemic therapy by telephone or video conferencing means. For many people based around metropolitan or regional centres the delivery of services in this manner is the exception and not the rule. But times have changed, and rapidly too. Many practitioners tell us they feel anxious about delivering family therapy with clients who aren’t in the room, that they aren’t sure how best to determine when it is appropriate and how they navigate the ethics of this delivery method.

  • The absence of a physical context for therapy, such as administrative operations, the room, office procedures and the ritual of entering and exiting the room mean that with telephone counselling the engagement ritual must be adapted. The therapist does not control the location and setting of a telephone call and has little idea what these conditions are. The physical context contributes to the setting of boundaries for the therapeutic process. Telephone counselling still requires these boundaries which now need to be explicitly negotiated with the client. How will the client contain their emotional space at home during the session and then resume back to “the norm” when it is finished. These conversations are often less explicit in the therapy room but are vitally important when therapy is being delivered in the client’s home.
  • Always remember to discuss confidentiality and ethical limitations and be clear how these will be recorded if you are unable to obtain client signatures for associated documents
  • Know your client’s expectations and check if they are the same or different between face-to-face and telephone/video conferencing counselling – this is essential to positive therapeutic outcomes as client expectations influence the quality of the alliance and activates their engagement
  • Know your own expectations. Often therapist’s preference interventions while clients consider that secondary to experiencing a meaningful connection. Holding in mind this difference of expectations keeps the therapist mindful of potential misreading of cues during the session.
  • Negotiate an agenda to minimise the chance of misunderstanding. Mutual understanding of short and long-term goals and a shared understanding of their perceived attainability helps to forge therapeutic alliance. Therapists can do this in the same way they do in face-to-face sessions. Invite the client to identify a specific problem and, where needed, try to help them limit the parameters of the topic in order to fit within the constraints of the telephone therapy. Tensions felt in telephone counselling can often arise when it is unclear what is on the agenda for that session.
  • Gathering background information is different in telephone counselling and typical tools used by family therapists are suddenly limited, such as developing a family genogram. If you can access video-conferencing this limitation is somewhat moderated but if you are restricted to the telephone therapists may not gather as much clear detail. It is worth noting the “gaps” so that these aren’t overlooked – “What don’t you know that you would like to know”
  • Core skills in telephone counselling are the same as with face-to-face including empathy, curiosity, and unconditional positive regard, a non-judgemental/impartial enquirying presence. In the absence of non-verbal cues provided by body language in face-to-face sessions, telephone counselling requires therapists to rely on other information such as voice, language and vocal responses. Practitioners may also use their own voice to communicate their qualities to clients. For example, they may adjust their tempo, slowing down their speech to provide clients with assurance of their attentiveness.
  • Be mindful of generational and cultural mismatches which clients will likely perceive as empathy breakdown. Mismatches like this may result in therapists falling back on platitudes or emphasising technical aspects of “doing therapy” with practitioners essentially going through their paces offering automatic and rigid technical interventions
  • Therapists may also want to notice if they have shifted into autopilot employing rigid technical interventions as this can be a sign that the therapist is not feeling confident in the unknown space of a telephone session. Catching themselves in this and pausing to be open and curious again to prevent alliance fractures
  • Without any visual focus, therapists may find their mind wanders and they find it more difficult to maintain attentiveness. Practitioners not used to telephone counselling may find this delivery more cognitively taxing.
  • In the absence of body language therapist providing telephone counselling may find they need to use more minimal verbals prompts (such as “mm” and “ok”) to encourage clients that they are being listened to.
  • Attending to client’s affective processing remains an important aspect of counselling when it shifts from face-to-face to telephone. Some practitioners can be anxious about emotional processing with clients over the telephone, worried that a client may be too disregualted and lost in their emotions. Shifting to a more directive problem solving approach and exploring and defining coping strategies may assist in containing client’s emotional distress.
  • Therapists may also find silence more challenging in telephone counselling, again in the absence of visual feedback to explain the client’s silence. Practitioners should remain curious about silence and not always seek to fill it.
  • Equally so clients may be more verbose on the telephone, which again becomes an opportunity for the therapist to be curious, especially if this is different to their face-to-face presentation. For clients that therapists anticipate a greater challenge in containing and focusing the therapeutic work over the phone, the practitioner may consider including this in the boundary negotiations at the beginning of the session, “How will we ensure we can stay on track today so that we can help you get the most out of our time together?”
  • In face-to-face sessions interactions naturally conclude in line with office schedules and pre-determined session times that structure times and appointments. While the structure may still technically exist, for the client in their home during a telephone session this may not be experienced in the same way so winding up the call is am important skill. Typically this is facilitated by using particular questions that invites the client to collaborative wrap up the process such as asking the client “what are you going to now after this session?”. Allow a little time for the wrapping up process with the client. In face-to-face session clients have the ritual of leaving the counselling room and moving into a reception space, each step shifting the client one step closer to their outside “lived” real world. Allow the conversational wrap up with the client act of this transitory space to move them back to their ”lived” real world.

These reflections are in no way meant to be comprehensive, so please use them as a point of discussion with your colleagues and in clinical supervision to support you in exploring and developing your telephone counselling skills. And let us know your thoughts and innovations, we would love to share them with out members.

References

Florence.E. & Lowe.R. (2005) Solution building approach to telephone counseling: Implication and integration. Queensland University of Technology.

Introduction to telephone counselling (2010). Australian Institute of Professional Counsellors. Accessed online 29/3/20 (https://www.aipc.net.au/articles/introduction-to-telephone-counselling/)

Young,H.R.(2000) Exploring the dynamics of telephone counselling: A qualitative study of Lifeline, Melbourne (doctoral dissertation). Victoria University, Melbourne.