Covid-19 Pandemic: Challenges And Responses Of Psychologists From India by Leister Sam S. Manickam - HTML preview

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AN EXPERIMENT WITH ONLINE GROUP COUNSELING DURING COVID-19

D. S. L. AMULYA

Counseling Psychologist, Bengaluru

Introduction

The COVID-19 pandemic has necessitated that the majority of work and interactions be moved online. This has impacted the field of counseling and psychotherapy as well. There are numerous options currently for individual counseling online. The unique psychosocial challenges of the COVID-19 crisis provide good reason for creating group therapy spaces online too. Group counseling is a distinct format of mental health support and intervention wherein people gather to work together on wellness goals, as the group is facilitated by one or more mental health practitioners. The facilitator of the group is called the ‘group leader’ and the clients or participants in the group are referred to as ‘group members’ (Whittingham & Martin, 2020). Group counselling has unique advantages. Members in a counseling group discuss similar issues within the sessions and benefit from having shared experiences, building relationships, and receiving support from one another (Veder & Beaudoin, 2016). The group becomes a therapeutic space where people can discover commonalities in their experiences and not feel alone in what they go through.  

Amidst the ongoing COVID-19 crisis, there have been drastic changes that demand adjustment, and a difficulty or failure in adjustment can bring about emotional disturbances. A glaring concern that people are encountering at present is the strain of social distancing. Nearly everyone is in some form of distancing or isolation right now, and each person experiences the enormity of this situation in different ways (Epley, 2020). The basic need for connection is compromised for a lot of people during the lockdown. Deprivation of social connection during times of stress and illness can aggravate the stress and illness (Kanter & Kuczynski, 2020). Hence there is great promise in coming together in these times through regular meetings where people can set goals for themselves and support each other in reaching them (Inverso, 2020).

Since face-to-face group sessions are not feasible at this point, such spaces can be created online, to make them available and accessible for people who may benefit from group support. Online counseling groups can provide the necessary opportunities for connection, a sense of community and togetherness. The potential of online group counseling as a novel therapeutic medium is just beginning to be explored (Bellafiore, et al., 2019). Online support groups, counseling groups and psychotherapy groups are gradually evolving.

This paper outlines the rationale and process of providing group counseling online, through a detailed account of an online counseling group held in the month of May 2020. This group was an initiative to create a safe and supportive space for clients to work together on self-care goals. In addition to this, the paper also includes perspectives gathered from interviews of professionals currently running online groups for mental healthcare. This paper records observations and relevant inferences drawn about the potential of creating such therapeutic groups online in response to the ongoing pandemic crisis.

Rationale for Online Groups

Some of the general hassles a client might encounter while looking for group counseling services are, finding a suitable group in an accessible location and one that functions at convenient timings. Since a counseling group extends for a continued period of a few weeks to months, clients also have to consider whether or not they can make that kind of continued commitment to a particular group. Online groups resolve such issues. The group can be accessed from the comfort of one’s own home and offers the convenience of not having to commute or travel to a specific place, making it more economical as well. Moreover, there is the advantage of richness of diversity and variety of experience that comes with people joining from different and distant locations.

Online therapy can be delivered through modalities that are synchronous (chat, audio and video conferencing) or asynchronous and this classification is based on the immediacy of communication and exchange of information (Joshi, 2017). This provokes a thought on what kind of modality might be more suitable for group counseling, especially considering approaches where here-and-now processing of what comes up alive in the moment is important for group therapy work in general.

The Role of Technology

At times like these, when the prescription of the government is to distance oneself and stay indoors, contact with people who stay away has become primarily virtual and over online media. People have been required to make a rather drastic shift to the digital world, for the purposes of work, meetings (official and personal) and just to stay connected. Technology undoubtedly plays a vital role in this process. Mental health professionals are embracing technology by transferring workshops, webinars and therapy sessions online.

Progressively more mental health providers are banking on telehealth services to connect with patients for online counseling. Online counseling broadly refers to professional mental health services provided via the internet through chat, audio and video sessions. It is a great way to avail professional therapeutic support when it is not possible to be physically present for sessions. In response to the pandemic crisis, there has been a surge in private and public helplines that people could reach out to for support. It comes with additional benefits of anonymity, easy access, saving on commute time and expense, and the possibility of reaching service providers located remotely or far away. Having such options can help people assuage the sense of loneliness, lack of control, anxiety and isolation that the crisis creates.

Online counseling services also need to adhere to the ethical and professional standards of practice that are required when providing in-person psychological services (APA, 2013). Mindful use of appropriate technology becomes especially critical for the purpose of defining a safe and reliable meeting space for therapy online. A thorough exploration of suitable online platforms can be helpful, while shifting counseling services online.

Interviews - Online Group Ventures in India

After an exploration over social media platforms and discussion with contacts about existing online group initiatives within the country, two mental health professionals - Anando Chatterji and Shivangi Lakhlani - who have ventured into online group work for mental healthcare with diverse approaches, were identified and interviewed. The interviews were unstructured, tele interviews, with the primary purpose of gathering perspectives about online group work and its implications.

Anando Chatterji, the CEO of Hank Nunn Institute, Bengaluru, is a psychotherapist who works with individuals and groups. His work is primarily driven by the approaches of group analysis and therapeutic communities. He mentioned the term “Scree’lational Psychotherapy” to refer to therapeutic relationships that are developed and processed over a screen. He suggested that adequate planning and preparation to work through challenges and anxieties can ease the shift to online work. (Chatterji, 2020a). Ethical issues such as informed consent and regular supervision become all the more relevant as therapists shift to online work (Chatterji, 2020b; Joshi, 2020).

Shivangi Lakhlani, founder of the social start-up “Her Move-Meant”, is a contemporary dance choreographer with training in expressive arts therapy. She conducted two of her online groups over social media platforms like Whatsapp and Instagram. These projects created virtual communities of sorts, where people could gather and experience a sense of togetherness. Currently she is co-leading a support group with the expressive arts approach. In face-to-face groups, one can provide art resources but in the online group setup, there is a limitation of having to work with what clients can access around them (Lakhlani, 2020).

Both the interviewees expressed concerns about technological glitches, privacy and safety issues, connectivity problems and the loss of personal connection and energy (that face-to-face meetings can foster). On a positive note, people from distant locations were accessing the online groups and some of the clients shared more over the online groups than in the face-to-face meetings.

Online Group Counselling for Self Care

Background

During the lockdown following COVID-19 pandemic, friends and their family members shared about challenges they were facing in looking after themselves and engaging in health-promoting behaviours. Some people expressed difficulty in implementing and adhering to self-care goals, although they had plans in place for the same. In response to this, the counseling group was planned as a safe space online that people could access to work with others on achieving their self-care goals.

After a rigorous exploration of various web-conferencing platforms, ‘Zoom’ (meetings version) was chosen and finalised as the appropriate platform for conducting this counseling group. The rationale for this included, some essential features that the Zoom application provides, including gallery view of all members (so that all members can see one another at the same time), options to share screens (to share and discuss relevant content), and option of a ‘waiting room’ to selectively allow entry of members (to ensure a check on privacy and security). Moreover, the application is widely accessible. The procedure to join meetings is convenient, requiring a simple download of the application on one’s device (laptop or mobile phone). Emails with detailed instructions about joining the meetings, and usage of the platform were shared with the group members before the group began. 

The theoretical approach for the group was primarily behavioral and action-oriented. The group process was planned to involve the stages of rapport building, goal setting, planning for action, acting on goals while tracking progress, feedback, summarization and termination.

Launching of the Online Group

The online counselling group was announced on 27th April 2020 and it was facilitated by the author in the month of May 2020, to respond to the self-care needs and goals of people. The counseling group was designed as a closed group, with space for eight members. The group was conducted for 8 sessions, across a span of four weeks. Two sessions were held every week with a duration of two hours for every session. Innovative methods were applied to explain the idea of a counseling group as well as the purpose, its potential benefits and limitations. The registration process and intake was hassle-free and was made through the use of suitable technology and online applications. The first group session was conducted on 6th May 2020 and the last session was on 29th May 2020.

As the group was launched, pre-group interviews were conducted over a phone call, before finalising the registration of each member. The objective of the interviews was to explain and clarify the purpose of the group to the potential client/member, explore their interest and check for alignment between their goals and the goals that the group is designed to serve. Accordingly, the person was either taken in to the group, or guided to other relevant sources of support.

The first session involved particular focus on gathering informed consent of the members participating in the online counseling group. Time was set aside in the first session to intentionally discuss and address members’ feelings about connecting online for counseling. A brief orientation was done in the session, to familiarize them with the platform. Potential issues that might occur in online meetings and possible options of addressing them were noted. This discussion becomes relevant, especially considering how the group process would involve sharing and responding to one another, and any technical issues obstructing that process could cause inconvenience and may create misunderstandings.

The group then proceeded along the lines of a structured plan. The objectives of the group were made explicit to all, and it was designed for working on self-care goals that members choose for themselves. The emphasis was on behavioural change along with the facilitative interpersonal forces of the group.

Facilitative Forces in the Online Group

Members expressed a sense of togetherness in their experiences and a relief in knowing that they are not alone. Relating to others’ experiences also elicited empathetic responses and altruism from individual members as they acknowledged each other's struggles and conveyed support. Members had the opportunity to connect within the group as they shared information and modelled helpful behaviours. For instance, one of the members defined her goal as communicating her emotions without feeling guilty. This inspired another member to think about how it was relevant for him as well, and he chose that as one of his goals for the future.

Members experienced significant emotional and interpersonal dynamics during the course of the group. For example, after the first session when one of the members expressed his desire to discontinue the group and wanted to proceed with individual therapy, the rest of the group responded with immense care and understanding. Each of them conveyed to him what his presence meant and expressed their wish to have him continue with the group. The love, support and acceptance that the group communicated eventually influenced his decision and he continued in the group. This was a very powerful and heart-warming instance of the therapeutic interpersonal forces of a group. It was enlightening to witness how this was possible in the online group as well, despite people connecting from places apart.

Over the course of the eight sessions, the group displayed the capacity to listen actively, convey acceptance of each-others’ pace and position, positively affirm one another, and also internalize some of the nurturing messages for oneself. They were able to form a bond that was powerful as well as influential, so much so that in the final session, at the very end, none of the members wanted to exit the meeting and they stayed on despite the session ending. The group leader addressed the same and the group requested the leader to end the meeting, as they were not able to. One of the members also highlighted this as an experience of a strong bond, which made the exit difficult at that moment. Hence, it wouldn’t be groundless to say that the facilitative principles of the group process can very much be created and experienced in online groups as well.

Role of the Group Leader

Similar to face-to-face groups, the leader’s role in online group counseling involved preparing a plan for the eight sessions and outlining the structure of the same. The leader played an active and mindful role in encouraging members to share, listen and offer support to each other. The leader spent adequate time on introducing members to the platform (Zoom), and discussing the procedure and implications of using it. In the first session one of the members was not able to access some of the features of the platform. Separate time was allotted by the group leader, outside of the sessions, to explore and fix the issue so that the member could join in comfortably for the remaining sessions.

Conducting the session as per the time and plan, while ensuring that every member had an opportunity to be heard and supported with their experiences was a challenge.  When the audio or video was unclear and members had to repeat what they shared, it disturbed the session flow. Besides, disruptions in internet connectivity created hindrances. In some instances, a member would begin speaking and all of a sudden they would exit the meeting due to network disturbances. The leader would collaboratively decide along with the members about how to proceed in such situations. Accordingly, the group would move on to another member’s sharing or wait together for the member to join back. Despite the possibility of such disturbances being addressed initially, they nevertheless brought abrupt pauses and discomfort within the group. The leader managed the same by checking and encouraging members to talk about their feelings in the moment.

Punctuality and attendance were repeatedly emphasised along with explaining the rationale and when some members joined in late or did not attend a session, it was handled mindfully by the leader. Members who attended regularly and punctually were acknowledged with verbal reinforcements and had the opportunity of sharing first or choosing the direction of an activity.

Tools and Techniques

Ice breakers and other activities were planned and developed for the group, to suit the online sessions. Members shared during the course of the group that they found the activities relevant and engaging. Psychoeducation and sharing of content happened during the sessions through the “screen share” feature in Zoom. Outside of sessions, a google group was created as a space for members to share content and communicate with one another as necessary. The messages and posts on the group were moderated by the group leader.

After action plans were finalized, members were paired with one another as ‘buddies’, to support each other in their attempts at action. Progress was tracked through the use of ‘google sheets’. Discussion of members’ experiences and progress was done with reference to the sheet, and supplementary questions. The group actively participated in the feedback process and moved towards termination.

While outlining the ethical considerations surrounding the termination process, Chenneville & Schwartz-Mette (2020) suggested that psychologists must ensure to process termination fully and adequately in online sessions just as in face-to-face sessions. Further, they need to provide appropriate referrals for clients who need continued support. Keeping such essential considerations in mind, adequate time was spent on the termination process, to address members’ feelings and allow space for communicating messages before closing. In the final session, an activity involving the shared “whiteboard” over Zoom was used to invite members to create a piece of art to depict their feelings and experiences. This feature allows all members to ‘annotate’ on the same board. Each member chose a colour and drew on the board. This activity was fun and allowed members to bond and playfully engage with each other before sessions came to a closure.

Working through Challenges

As anticipated, there were some challenges due to internet connectivity issues and technical glitches which caused interruptions in the flow of sessions. The preparation for the same in the very first session made it easier to address and work through them. During the course of the group, there were occasions when some members were not able to switch on their videos due to low internet bandwidth and hence knowing the attendance of a member in the ‘meeting’ was a challenge. The options of keeping videos on or off during the session creates an additional possibility where a member is technically logged into the meeting, but can physically be away by keeping the video off. It might be helpful to factor in this “present-but-absent” scenario as a possibility in online groups, and to find ways to address the same. Calling out to them and checking from time-to-time became necessary to ascertain their presence and this also disrupted the flow of the sessions. Keeping these aspects in mind, members were requested to keep their videos on to the extent possible, at least at times when they would speak. Members were understanding and cooperative.

A downside noticed with members connecting from home, was the greater chances of distractions and interruptions. Such issues would not arise in face-to-face sessions where the group would meet in a separate physical location that already sets a definite boundary. Confidentiality and privacy were addressed within the scope of these distractions coming up in the online sessions.

Preparation also involved noting and addressing the potential issue of “zoom fatigue”. Zoom fatigue is a novel term used to refer to feelings of fatigue and burnout while video conferencing, due to audio/video disturbances and just the idea of having to stare into a screen for extended durations to communicate and process information (Fosslien & Duffy, 2020). Keeping this potential issue in mind, sufficient breaks were included in each session so that members could ‘switch off’ and look away from the screen for a few minutes.

Outcomes of the Group

The group smoothly proceeded through the stages of forming, norming, performing and closure. Members’ attendance in sessions was recorded. It can be noted from Table 1 that four of the eight members (50%) attended all the eight sessions in full.

Table 1. Attendance of members in the 8 sessions

Note. Members’ names are coded as M1, M2...M8 in alphabetical order of their names.

The remaining members have fully attended at least 50% of all the sessions.  The reasons for the absence (in part or full) included unavoidable personal reasons and lack of internet connectivity. When some of the members had such emergencies, they were able to attend at least a part of the session instead of having to miss the whole session. Flexibility was possible as members could connect remotely for sessions, without the need to travel/commute to the session location. A specific instance of hassle-free adjustments was when a member (coded as M2) joined in late for one of the earlier sessions. The reason was that the lockdown was lifted in his area and his new work timings interfered with the schedule of the group counseling sessions. The group members were invited to respond to the same, and it was mutually decided by all the members that the timings be accordingly revised, to accommodate member M2’s circumstances.

In terms of progress with goals, seven out of eight clients were able to initiate healthy behavioral changes. One of the members (coded as M5) struggled to make the changes she had planned, which was also one of the reasons she was not able to attend some sessions. Upon encouragement, she was able to use the group space to share her concerns and eventually identify the kind of support she needed. This was an instance of how acceptance from the group encouraged the member to trust and share about one’s unique experiences without feeling excluded or judged. Members were able to help one another through goal setting, tracking progress and communicating feedback constructively. There was space for sufficient summarization and the group was terminated with closure.

Feedback from Members

After the closure of the group, members were invited to share feedback about their experience, by responding to a ‘google feedback form (available with the author) to get responses anonymously and 5 of the 8 members gave their responses.

While 60% of the group had responded, it also raises a question as to why the remaining members did not. This might indicate that even though the members expressed positive feedback within the group, they might have had some inexplicable concerns that they were not able to voice out. Some earlier studies on online group counseling have identified themes in members’ negative experiences such as superficial engagement, feeling disconnected from one another or other general risks and disadvantages of connecting online (Kozlowski & Holmes, 2014; Barak et al., 2008). The reasons for not sharing feedback could hence be multifold - in terms of dissatisfactory experiences in the group or some unrelated personal reasons. Diversifying the means of eliciting honest feedback might be helpful in this regard.

The feedback from the 5 members showed that they found the experience of the group to be good or great. All the 5 members have given positive feedback for the group structure and process (content, plan and activities), leader’s approach (style and support), safety and freedom of sharing in the group (no privacy concerns or judgments experienced) and convenience of the platform (Zoom).

Another aspect that was checked was members’ preferences for online or face-to-face meetings for sessions. Studies have generally shown an inclination of members towards face-to-face group sessions than meeting online (Kozlowski & Holmes, 2015; Kit et al., 2014). Majority (60%) of the members shared that both (online and face-to-face meetings) have their pros and cons and that they do not prefer any one over the other. The remaining 40% mentioned that face-to-face meetings are better.

The concerns shared by members included internet issues, disappointment due to the absence of other members in some sessions and inconvenience with some sessions not starting on time (when someone joined in late). One of the members shared that they would have liked the group to extend for longer. Interestingly, all 5 of them (100%) reported that they would be interested in participating in such online group spaces in the future.

Conclusion

The information gathered from the interviews on conducting online group counselling and the online counseling group for self-care initiated by the author seem to have certain parallels. The challenges include the lack of personal connection as in a face-to-face meeting, internet connectivity issues and special attention needed to ensure ethical practice. The advantages are noted to be convenience and accessibility to spaces for connection, support relational growth and wellness. Considering the therapeutic benefits that group counseling offers in general, the kind of difference that online group spaces could make especially during such times of mandatory distancing and restricted travel cannot be emphasised enough. The observations from the documented group process, though not technically sufficient for generalization, still affirm the boundless budding potential for conducting online group work successfully by the psychologists in our country.

The unique advantages that group counseling offers in mental health care, beyond and different from individual counseling, have been widely documented. Creating such space online makes it possible to transcend geographical and time boundaries, allowing an opportunity for people to access supportive and connected space amidst such ongoing uncertainty. Psychologists in India can make use of the online platforms (ethically and appropriately) for creating therapeutic group space (Manickam, 2020). Psychologists in India who choose to venture into online group work, need to document their considerations, experiences and outcomes of online counseling/therapy groups in order to generate evidence base. In the wake of this unprecedented crisis of COVID-19, online group counseling is expected to gain higher traction as we cope with the emerging “new normal”.

Acknowledgments

Special thanks to Mr. Anando Chatterji and Ms. Shivangi Lakhlani for participating in the interviews and contributing relevant perspectives to the content of this paper.

References

APA. (2013). Guidelines for the Practice of Telepsychology. Retrieved from American Psychological Association: https://www.apa.org/practice/guidelines/telepsychology

Barak, Azy, Boniel-Nissim, M. & Suler,