Bridging the distance: Continuing psycho-oncological care via video-consults during the COVID-19 pandemic.

Video‐consults feel distant; patients and therapists miss the non‐verbal contact.

Non‐verbal contact during face‐to‐face sessions helps clients to express what is most difficult for them.

Video‐consults are a good alternative when face‐to‐face psycho‐oncological care is too burdensome for patients.

Therapists preferably would continue with video consults for a mean of 28% of their time.

Tips are provided to improve care through video‐consults.

VIDEO‐CONSULTS

The Helen Dowling institute is a mental healthcare institute specialized in psycho‐oncology in the Netherlands. We offer face‐to‐face individual, couple, family and group therapy, to (family members of) cancer out‐patients (n = 2.302 clients in the last year). Clients mainly suffer from severe cancer‐related fatigue, anxiety, trauma, stress‐related and depressive disorders, relationship problems and/or prolonged grief disorder. Since 2009 the institute offers specific internet‐based interventions for cancer patients, such as Mindfulness‐Based Cognitive Therapy (MBCT) for cancer‐related fatigue , and Anxiety and Depression, , self‐help and blended Cognitive Behavioural Therapy (CBT) for fear of cancer recurrence , within a secure environment.

When it became clear COVID‐19 reached the Netherlands, the management team decided on 12 March 2020 that face‐to‐face care should be continued through video‐consults within the same secured environment that provides the platform for our internet‐based treatments. All clients received a letter explaining this, including instructions how to download the video‐consult app. Two psychologists with extensive internet‐based treatment experience provided two webinars for all colleagues to explain the possibilities of our internet‐based programs and to exchange tips for video‐consults. After 7 weeks we conducted an anonymous survey amongst clients and therapists to learn about their experiences with receiving/delivering mental healthcare through video‐consults. We introduced the following open‐ended questions:

We are interested in all experiences, both positive and negative.

What advantages do you experience from video‐consults (compared to face‐to‐face contact)? For example, you save travelling time or maybe you feel more comfortable to express yourself.

What disadvantages do you experience from video‐consults (compared to face‐to‐face contact)?

When it is possible to have face to face consults again, would you still want to make use of video‐consults? If so, in what way?

How much of the time would you preferably make use of video consults? (0%‐100%)

In the context of improving care, the study was approved by the ethical board of the Helen Dowling Institute.

CLIENTS

Of 274 clients that filled out the survey, 209 had received therapy via video‐consults. They indicated feeling grateful psychological care continued, especially because most of them experienced additional stress due to COVID‐19. Most clients also experienced the video‐consults as more distant. They described it was more difficult to concentrate on the therapy session, because they missed the non‐verbal communication. They also missed their therapist picking up on their non‐verbal signs of distress. This made it more difficult for some to open up and express their feelings.

It's missing depth, seems more formal. I have to concentrate really hard to let the meaning of the words sink in. I'm easily distracted by sounds around the house.

Noteworthy was that some missed traveling time as a moment to reflect on the session beforehand and to process the session afterwards. One therapist, who noticed this, started the session with relaxation exercises to help clients arrive at the session. Clients also missed the physical location as a place where they could leave their distress:

The face‐to‐face contact was outside my house. It was a place that my brain associated with dark feelings. A neutral space where it was easy for me to talk openly about feelings.

Some clients experienced video‐consults from their own place as more quiet and relaxed, because they did not experience the stress of traveling and face‐to‐face contact.

When face‐to‐face contact is possible again in the future, half of the clients would like to make use of video‐consults for about a third of their sessions. It is especially viewed as an alternative when they feel too ill/fatigued to travel.

THERAPISTS

The patient care department has a dedicated team of 34 psychologists and 2 psychiatrists. Thirty of them filled out the survey. Though 15 therapists had prior experience with internet‐based therapy (eg, MBCT, CBT), only two had prior experience with video consults. We provided support by giving two webinars for all colleagues to explain the possibilities of our internet‐based programs and to exchange tips for video‐consults, and we assigned colleagues who were available for follow‐up questions. Furthermore, weekly multidisciplinary team gatherings continued online, providing the opportunity to help each other.

Also therapists described to miss non‐verbal communication, such as “wriggling legs and restless hands” and the informal and physical contact, that usually help to gradually turn towards difficult emotions and to release tension at the end of the session. This might explain why many clients found it more difficult to open up and express their emotions. Therapist noticed they had to work harder and often felt exhausted at the end of the day.

The moment that you walk up the stairs together or gradually end a session are important moments for clients to tune in and regulate emotions, as well as for ourselves.

…not being able to put a hand on someone's shoulder to give some consolation or encourage someone is difficult.

All therapists indicated that they would make use of video‐consults if clients wish to do so in the future. For example, when a client is too ill to travel, or to keep clients motivated to do exercises, video‐consults seem a good alternative. If a good working relation has been established therapists think it is easier, while for more complex therapies they prefer face‐to‐face contact. If possible they would choose to continue with video consults for a mean of 28% of their time (range 1%‐55%). Now therapists have become more familiar with working with the secured environment for video consulting they have also started to use our internet‐based programs more often.

BRIDGING THE DISTANCE

We conclude video‐consults have been helpful to continue therapy. While earlier research into internet‐based therapies (these work through text‐based communication within a developed program with video and audio‐files) showed this could lead to a good working alliance, that was experienced as personal, video‐consults are experienced as more distant by most clients and therapists (see Table 1). It is the non‐verbal contact during face‐to‐face sessions that helps clients to express what is most difficult for them, which is lacking in video consults. At the same time the physical distance from daily life helps clients to make room for their dark feelings.

TABLE 1

Key findings: Positive and negative aspects of video‐consults (compared with face‐to‐face sessions) in a mental healthcare setting

Clients n = 209	Advantages	Disadvantages	Recommendations for clients
	Feeling more at ease at home	Experiencing more distance and less personal contact because non‐verbal communication is missing, which makes it difficult to open up and express feelings	Pay attention to your position on the screen, for example, far enough to show body posture, but close enough to show emotional expressions
	No travel time saves energy	No travel time means less time to reflect, prepare and let go before and after a session	Make time and space for a session. For example, by taking a walk before and after the session or reserving a quiet spot in the house for therapy, where you can leave difficult thoughts and emotions afterwards