Tele-psychotherapy during COVID-19 outbreak

Human activities were no longer the same at the time of the COVID-19 outbreak as before. Regulations for working from home, learning from home, social distance, physical distance, etc., have been implemented by different countries in the world (Situmorang, Reference Situmorang2020a). In addition, these changes can ultimately cause symptoms of mental health, such as anxiety, fear, depression, acute stress, insomnia, and delusions of death (Arnout et al., Reference Arnout, Al-Dabbagh and Al Eid2020; Liebrenz et al., Reference Liebrenz, Bhugra and Buadze2020).

In respect to this phenomenon, mental health services can no longer be performed face-to-face and during the psychotherapy process, mental health counselors/psychologists/psychiatrists/therapists and patients/clients must undergo social and physical distancing, but psychological distancing is not required (Situmorang, Reference Situmorang2020a). Ultimately, this has contributed to the introduction of a tele-psychotherapy process, whether by chat, email, video call, or even mobile, for all mental health clinicians/practitioners around the world. The only option at present, during this COVID-19 outbreak, is the use of tele-psychotherapy (Situmorang, Reference Situmorang2020a, Reference Situmorang2020b).

Solution-focused brief therapy approach as the theoretical basis

One of the first therapists to undertake Single-Session Therapy (SST) was Sigmund Freud. Aurelia Öhm-Kronich (“Katharina”) in 1893 and Gustav Mähler in 1910 were both said to have undergone SST. Since then, there have been several references to SST in the literature, with prominent therapists such as Alfred Adler, Milton Erickson, and Albert Ellis being among the early adopters. Furthermore, further researchers improved SST to make it even better (Dryden, Reference Dryden2018; Spoerl, Reference Spoerl1975; Talmon, Reference Talmon1990). In its development, the application of SST can be integrated with Solution-Focused Brief Therapy (SFBT) (Lamprecht et al., Reference Lamprecht, Laydon and Mcquillan2007). As a master philosophy, SFBT helps mental health counselors/psychologists/psychiatrists/therapists to be able to concentrate on solutions to their patients/clients’ issues (Iveson, Reference Iveson2002). SFBT has a particular view that anyone should create solutions to the challenges they face (Bannink, Reference Bannink2007). SFBT claims that understanding the source of a problem to be able to fix it is not very necessary, since it would take a long time. It is not necessary to gather information about an issue for progress to happen. Knowing the dilemma is not necessary, but it is most important to find the “correct” solutions. Some individuals may think about all sorts of alternatives, and what is right for one individual may not be right for another individual. In SFBT, patients/clients choose tasks they want to fulfill in psychotherapy, and no consideration is paid to diagnosis, history, or problem discovery (Gingerich and Eisengart, Reference Gingerich and Eisengart2000; Iveson, Reference Iveson2002).

SFBT is based on the positive hypothesis that stable and knowledgeable individuals are able to develop strategies that enrich their lives. This therapy's essence is to create confidence and excitement in the individual by building optimistic hopes that improvement is inevitable. SFBT is a nonpathological approach that stresses abilities rather than vulnerabilities and strengths rather than weaknesses (Bannink, Reference Bannink2007; Kim, Reference Kim2008).

Single-session therapy as “rapid tele-psychotherapy”

It is appropriate to use the term “rapid tele-psychotherapy” to describe a method of rapid therapeutic assistance with just one meeting. Rapid tele-psychotherapy will use SST in the implementation process based on the current theory (Talmon, Reference Talmon1990), but it is combined with music in this sense. So, SSMT may also be used as the term (Krout, Reference Krout2001). The application of SST based on the SFBT approach should be combined with music on the basis of current theoretical studies and study findings (Degges-White and Davis, Reference Degges-White and Davis2017; Gladding, Reference Gladding2016). In this case, with just one appointment, the psychotherapy process for COVID-19 patients can be performed without having to hang on to several psychotherapy sessions.

Two main techniques that can be applied in rapid tele-psychotherapy

In comparison, SST is an innovative SFBT principle of psychotherapy. The beauty of SST is that, with just one brief meeting, it can be completed easily (Rose et al., Reference Rose, Bisson and Wessely2003). So it can be called “rapid tele-psychotherapy” for this one quick meeting, particularly in the current pandemic situation. In applying this rapid tele-psychotherapy during the psychotherapy process for those in distress in the present pandemic situation, mental health counselors/psychologists/psychiatrists/therapists who work in hospitals/institutions should apply two traditional SFBT techniques. Scaling questions (Strong et al., Reference Strong, Pyle and Sutherland2009) and miracle questions are the two well-known psychotherapy techniques in this approach (Strong and Pyle, Reference Strong and Pyle2009).

1. Scaling questions

For a tele-psychotherapy session, this question may be an opening or closing question The mental health counselor/psychologist/psychiatrist/therapist, for instance, may pose questions such as: “On a scale of 0 to 10, on what scale do you describe your anxiety, fear, depression, acute stress, insomnia, delusions of death, or so on?” (see Table 1). This question will allow the patient/client to gauge the psychological issues he/she is actually experiencing. This question really allows the mental health clinician/practitioner to consider the scale of psychological issues that the patient/client is actually facing, whether the condition is no pain, mild, moderate, severe, or very severe (see Figure 1). In addition, it is possible to pose this question again at the conclusion of the tele-psychotherapy session. The goal is to figure out whether or not the patient/client has experienced a difference in the understanding of psychological difficulties. If, relative to the beginning, the size of the numbers given is decreasing, then the therapy process could be successful.

Fig. 1. Psychological problems scales of scaling questions.

Table 1. The questions of two main techniques

How to apply rapid tele-psychotherapy with SSMT and two main techniques

It has been found that the use of music in the tele-psychotherapy phase decreases anxiety, fear, depression, acute stress, insomnia, delusions of death, and so on (de Witte et al., Reference de Witte, Pinho and Stams2020). Music has also been found to improve feelings of pleasure and well-being (Dileo, Reference Dileo2006). This is really appropriate for helping COVID-19 patients/clients with psychopathological and well-being issues (Situmorang, Reference Situmorang2021a, Reference Situmorang2021b, Reference Situmorang2021c). So, the use of music in rapid tele-psychotherapy is very beneficial in this case. How do you apply that then? The author will clarify below how to use rapid tele-psychotherapy with SSMT using three key strategies.

1. Playing sedative music during rapid tele-psychotherapy session

During rapid tele-psychotherapy sessions, playing sedative music will allow the COVID-19 patients/clients to relax and feel calmer (see Figure 2). It would help the patient/client scale up the psychological challenges they faced at the beginning and at the end of the rapid tele-psychotherapy session where they answered scaling questions (see Table 1). Moreover, the patient/client will answer the miracle questions (see Table 1) more critically in this comfortable and calm state.

Fig. 2. Three key strategies of rapid tele-psychotherapy with SSMT.

The stages of rapid tele-psychotherapy with SSMT

In applying rapid tele-psychotherapy, the counselor/psychologist/psychiatrist/therapist can perform the general procedures of four stages that are usually carried out in the usual counseling or psychotherapy process. However, the difference is this is only carried out in one session, namely:

1. Beginning stage

At this stage, the counselor/psychologist/psychiatrist/therapist can engage in “rapport building” (see Figure 3) by getting to know the patient/client and carrying out short fun activities, for example asking about a song title that is currently very relevant to how they feel at the moment. This song can be discussed at the next stage. After that, the counselor/psychologist/psychiatrist/therapist can provide informed consent forms (see Figure 3) which the patient/client can fill out online. In addition, the patient/client can be given a brief assessment (see Figure 3) of the available measurement tools related to a relevant problem, or by asking questions using scaling questions as pre-test (see Table 1 and Figures 1 and 3). At this stage, the counselor/psychologist/psychiatrist/therapist can start the first strategies, namely “playing sedative music during the rapid tele-psychotherapy session” (see Figure 2) until the rapid tele-psychotherapy with SSMT ends, so that the patient/client can always feel relaxed and calmer.

Fig. 3. The stages of rapid tele-psychotherapy with SSMT.

The advantages of rapid tele-psychotherapy during the COVID-19 outbreak

As we know, growing evidence indicates that many mental health symptoms, including anxiety, fear, depression, acute stress, insomnia, and delusions of death, are common during the COVID-19 outbreak. There are a few advantages of rapid tele-psychotherapy in populations with serious mental illness during the COVID-19 outbreak. Patients/clients and counselors/psychologists/psychiatrists/therapists are not required to meet in a physical location, reducing the need for driving, appointment-related issues, and operating costs (Abney and Cleborne, Reference Abney and Cleborne2004; Cartreine et al., Reference Cartreine, Ahern and Locke2010; Green-Hamann et al., Reference Green-Hamann, Eichhorn and Sherblom2011). Furthermore, patients/clients should seek care in ways that promote greater anonymity, protection, and privacy, thus alleviating any possible negative paradigm associated with seeing counselors/psychologists/psychiatrists/therapists (Barak et al., Reference Barak, Boniel-Nissim and Suler2008; Cartreine et al., Reference Cartreine, Ahern and Locke2010; McAdams and Wyatt, Reference McAdams and Wyatt2010). For King et al.'s (Reference King, Bambling and Lloyd2006) young subjects, anonymity, intangibility, and more time to structure reactions is essential. There is less chance of bias because age, gender, color, ethnicity, and socioeconomic status are often more difficult to detect in a different context (Miller and Gergen, Reference Miller and Gergen1998; Barak et al., Reference Barak, Hen and Boniel-Nissim2009). At the same time, there is a lot more to do in coping with other people who are geographically separated in dealing with a crisis (Green-Hamann et al., Reference Green-Hamann, Eichhorn and Sherblom2011; Holmes and Foster, Reference Holmes and Foster2012).

Tele-psychotherapy patients/clients often converse more unreservedly because they know they are in a secure, non-judgmental atmosphere, and they routinely make more insightful disclosures to counselors/psychologists/psychiatrists/therapists, and share their issues earlier than they would in a face-to-face session (Goss and Anthony, Reference Goss and Anthony2003; Suler, Reference Suler, Kraus, Zack and Stricker2004; King et al., Reference King, Bambling and Lloyd2006; Reynolds et al., Reference Reynolds, Stiles and Grohol2006). Text-based correspondence generates a written document that could help both patients/clients and counselors/psychologists/psychiatrists/therapists (Kessler et al., Reference Kessler, Lewis and Kaur2009), and Goss and Anthony (Reference Goss and Anthony2003) discovered that patients/clients had more influence over the tele-psychotherapy session so they could hang up, log off, or step away from the camera. In addition, the most important thing is that rapid tele-psychotherapy can help COVID-19 patients in a short time.

The disadvantages of rapid tele-psychotherapy during the COVID-19 outbreak

As for the disadvantages of rapid tele-psychotherapy, counselors/psychologists/psychiatrists/therapists have frequently been reluctant to use technical innovations, mostly for good reasons. Although counselors/psychologists/psychiatrists/therapists will currently disregard geographical constraints, questions about time management, jurisdictional licensure, and a lack of knowledge of territorial norms and occurrences have emerged (West and Hanley, Reference West and Hanley2006; McAdams and Wyatt, Reference McAdams and Wyatt2010; Green-Hamann et al., Reference Green-Hamann, Eichhorn and Sherblom2011; Holmes and Foster, Reference Holmes and Foster2012). Miller and Gergen (Reference Miller and Gergen1998), Mallen and Vogel (Reference Mallen and Vogel2005), McAdams and Wyatt, (Reference McAdams and Wyatt2010), and the American Counseling Association (ACA) (2014) have all emphasized the importance of adequate planning, mechanical information, adequate private computer access, and assistance for the uneducated. In the United States, advancements such as the Health Information Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) have prompted counselors/psychologists/psychiatrists/therapists to closely explore the use of electronic communication (Kanani and Regehr, Reference Kanani and Regehr2003).

Finally, the demand for nonverbal evidence, which is normally gleaned by observing body language and other visual and verbal cues, is shifting the therapy dynamic and has prompted others to consider the feasibility of independent tele-psychotherapy (Suler, Reference Suler, Kraus, Zack and Stricker2004; Barak et al., Reference Barak, Hen and Boniel-Nissim2009; Cartreine et al., Reference Cartreine, Ahern and Locke2010). As an example, in Bambling et al.'s (Reference Bambling, King and Reid2008) and King et al.’s (Reference King, Bambling and Lloyd2006) studies, young people agreed that their counselors/psychologists/psychiatrists/therapists often misunderstood the enthusiastic content of their messages. Furthermore, Situmorang (Reference Situmorang2018) and Situmorang et al. (Reference Situmorang, Mulawarman and Wibowo2018a, Reference Situmorang, Mulawarman and Wibowo2018b, Reference Situmorang, Wibowo and Mulawarman2018c) discovered that if music therapy is used in the psychotherapy phase, especially if the counselor/psychologist/psychiatrist/therapist and patient/client play music together online, there would be a sound pause. However, this can be overcome if the network owned by the counselor/psychologist/psychiatrist/therapist and the patient/client are both stable.