Interpretative Phenomenological Analysis of Therapists’ Experience of Working Through the COVID-19 Global Emergency using Transactional Analysis

This is a qualitative research study using Interpretative Phenomenological Analysis (IPA) (Smith, 1995) into the experiences of UK-based Transactional Analysis therapists working with clients prior to and during the COVID-19 global pandemic. Aimed at identifying what it is like to transition from working therapeutically in established, predeominantly in-person, relationships with clients to abruptly having to manage major adjustments both personally and professionally in parallel with clients navigating analogous challenges in their own lives, findings suggest that the participants experienced traumatic stress reactions. Participants initially felt unprepared to manage the multiple challenges of moving from in-person to online therapy with clients. In addition to technological and ethical issues, they experienced changes to the quality and nature of the therapeutic relationship. However, they also found positive aspects of online working as time progressed and experienced a sense of professional empowerment. They perceived the role of professional bodies and training establishments as significant. The diversity of online training available across countries and communities was appreciated although the quality of the learning experiences varied.


Introduction
This article describes a research study using Interpretative Phenomenological Analysis (IPA) with three Transactional Analyst therapists before, during and emerging from the COVID-19 pandemic, first declared by the World Health Organisation (2020).
The motivation for conducting this research originated from my own personal challenges home schooling young children alongside working as a therapist and running a busy multi-therapist practice at this time. Juggling work and family life often felt chaotic and stressful. I was acutely aware of my own vulnerability during this period and the idea for this research followed discussions with colleagues, many of whom described similar struggles.
This study aims to document, through the words of the therapists, the feelings and thoughts which arose and different stages of the crisis as it unfolded.

Literature Review
The COVID-19 pandemic was a major global health crisis. The World Health Organisation (2022) stated that as at 13 May 2022 there had been over 517,000,000 confirmed cases, including over 6,260,000 deaths. Such extensive outbreaks are associated with "adverse mental health consequences" (US National Library of Medicine National Insitutes of Health, 2020). At the time of writing (February 2022), available literature related to what these consequences might look like has emerged from only a few of the countries affected by COVID-19 and may not reflect the experiences of those living in other regions.
Existing literature on the COVID-19 pandemic related to mental health was retrieved via a literature search of reputable online sources such as PubMed and The Mental Health Foundation further highlights how mental health difficulties are unequally distributed across society, with some social groups bearing much more of the mental health burden than others. The negative impacts are largely dependent on people's socioeconomic status with groups such as: single parents, the unemployed, young adults, those with long-term disabling health conditions and pre-existing health conditions much more likely to report mental distress than the population as a whole (p.3-4).
This suggests that the COVID-19 pandemic presents an immense mental health as well as physical health challenge to UK society. These needs arise in the context of underfunded mental health services facing a care backlog and long waiting lists. Whilst there is no vaccine to protect us from the mental health impact of the virus, the evidence strongly indicates that funding for mental health should be given equal priority with physical health, as outlined in the UK National Health Service (NHS) Long Term Plan (2019). Governments, public agencies, and communities must also work together more broadly across society to reduce inequalities, support resilience, and protect those most at risk of harm to prevent mental distress from escalating into severe and enduring mental health problems.

Literature addressing the mental health impact of COVID-19 on healthcare workers
Several papers published in China indicate that healthcare workers, including mental health workers, were at a significantly higher risk of adverse mental health outcomes during than prior to the pandemic. Reasons for this included longer working hours, risk of infection, shortages of protective equipment, loneliness, tiredness, and separation from families (Kang, Li, Hu, Chen, Yang, Yang, Wang, Hu, Lai, Ma, Chen, Guan, Wang, Ma and Liu, 2020). This is supported by Professor Sir Simon Wessley, King's College London regius professor of psychiatry, who carried out a study into the impact of COVID-19 on NHS staff (Policy Institute, 2021). Although this study carried out across 20 NHS trusts is still in progress, results so far suggest substantial mental health challenges for many NHS staff during the pandemic, reflective of the general population. The study's preliminary data estimates that in 2019, one in ten people in the UK suffered with depression, and in 2020 this increased to one in five. In the NHS, Wessley reports in a podcast interview that this is also true, although it is "not a single picture … some groups are doing better than others and for example I'm afraid as ever, doctors are doing better than nurses and they are doing better than ancillary staff" (NHS Providers, 2020). Early findings indicate that there may also be differences in the staff's ability to access support. It is suggested that leadership, particularly in frontline supervisor roles -has "an important impact on staff mental health and in creating a supportive working culture within the NHS" and that informal interventions such as 'time-out zones' and 'wobble rooms' appear to be more powerful than more traditional forms of support such as Employee Assistance Programmes (EAPs) (Policy Institute, 2021, p.5-6).
In the USA, Sampaio, Navarro Haro, De Soussa, Melo and Hoffman (2021) conducted a 29-item online survey of American therapists which reported a 39% increase in the number working online with clients during the pandemic versus previously. This study also reported high treatment effectiveness using telepsychotherapy and a significant increase in how burned out the participants felt during this period. The subjects of this research, however, were self-selecting and therefore not necessarily either a representative or objective sample of therapists from across the nation.

Transactional Analysis literature and COVID-19
In addition to the tragedy of the millions of lives lost globally, the rapid spread of COVID-19 has, as previously indicated, highlighted social disparities and injustices in both the UK and globally. To date, transactional analysis (TA) literature related to COVID-19 has focused on describing these as well as other shifting cultural paradigms. Shadbolt (2020) writes passionately of the interconnectedness of politics, society and mental health and introduces the concept of the 'COVID Third' which "accounts for the life-changing impact of the pandemic" (p.1). Whilst opinion-led, rather than research based, her paper serves to both historically contextualise and encapsulate the zeitgeist in portraying the changed nature of the client-therapist relationship during this period and encourages practitioners to "acknowledge, accept and face the shared vulnerability without losing the self-agency of the therapeutic relationship…" (p.10). Campos (2021) further described how the COVID-19 pandemic has exacerbated inequalities -illustrating how the negative effects of ageism has resulted in older persons often being classified "…as having the lowest priority for life-saving treatment regardless of other factors, such as functional health status…" (p.357). In the same issue, Barrow and Pandya (2021) widen the scope of the problem and highlight how the pandemic has drawn attention to 'global inequalities' related to health care, clean water and regional epidemics and the interconnected nature of our planet; "…it has taken this peculiar time…to discover that the deep wound of the Earth itself is our species' wound too, that we are interconnected with everything else that lives on this planet" (p.302).

Study Objectives
The aim of this research was to document the experiences of TA therapists who have worked with clients through the COVID-19 pandemic and to conceptualise their experiences using TA.
The researcher conducted a small-scale qualitative study using Interpretative Phenomenological Analysis (IPA) (Smith, Flowers and Larkin, 1995).
Participants would be invited to describe their experiences focusing on their feelings and beliefs so that a better understanding of the impact of working therapeutically through a global crisis might be achieved.
By focusing on the emotional and cognitive processes of the participants, the emerging themes would be a reflective account of what it is like to work through a social emergency which impacts upon both therapist and client simultaneously.
These themes would be analysed and interpreted using TA concepts, with the intention of supporting therapists in understanding which intra and interpsychic processes might get evoked at such times.
In using IPA, I describe the shared experiences and perceptions of three TA therapists and interpret their experiences using the concepts of TA. I did not set out to analyse the transcripts with a specific TA concept in mind but to let the accounts speak for themselves.

Methodology
Interpretive Phenomenological Analysis (IPA) was selected because it invites the individual to talk about and reflect on their experiences and how they have made meaning of what has happened to them. This is in turn is analysed by the researcher creating a double hermeneutic (McLeod, 2011;Pietkiewicz and Smith, 2012;Smith, Flowers andLarkin, 2009). McQuaid (2015) makes the point that this correlates with the TA concept of script (Berne, 1972) in that each individual's life script is unique to them and may not "necessarily make sense to someone else as they have a different Script and view life through an alternative frame of reference" (Schiff, 1975;cited by McQuaid, 2015, p.32).
Sample sizes are usually small to allow for an in-depth analysis and it is this depth rather than a broad overview across numerous participants which is one of the main strengths of IPA (Hefferon and Gil-Rodriguez, 2017;McLeod, 2011).
Firstly, a web-based demographics questionnaire was sent to participants in order to establish quantatitve factual information concerning, age, living situation, length of time practicing as a therapist, etc. (Appendix A).
Secondly, IPA (Smith, 1995) was applied to data from all three participants who shared their experiences during semi-structured interviews, based on questions shown in Appendix B aimed at prompting the feelings and beliefs that arose from their experience. This method was adopted to ensure participants were asked the same questions in order for comparisons to be made whilst offering the flexibility to pursue specific individual experiences in depth. The researcher asked for further information at relevant points and sought clarification as needed.
The questions were grouped into the three timeseparated categories intended to elicit a perspective of how the therapists' experience changed as events unfolded. The first question invites the therapists to provide a working and familial context pre-COVID. Question 2 invites participants to consider how they thought and felt differently in the pre-lockdown phase of the UK pandemic. Question 3 focuses particularly on the 'precise moment' of the government lockdown announcement to encourage a specific separation regarding how participants felt about themselves before and after this seismic material societal change. Questions 4-6 were intended to explore feelings towards the change in living and working circumstances during the pandemic itself. Finally questions 5-8 invite reflection and consideration of how they are feeling and working now as we exit the pandemic.
The interviews were held online and recorded over a video conferencing platform. All therapists invited were already very capable of working with their autonomic nervous systems (Rothschild, 2000) and returning to Adult (Berne, 1961) to avoid being overwhelmed.
Afterwards, verbatim transcripts were produced and read through multiple times to ensure that a general sense of the whole nature of the participants' accounts were obtained. Notes were made of each transcript to identify any common themes and specific words and phrases were highlighted including the use of metaphor and euphemisms. Attention was also paid to the coherence of narrative, hesitation, and pauses.
Following individual analysis of the transcripts, the researcher compared the emerging themes with the other transcripts. Themes and sub-themes were subsequently defined more precisely, and interrelationships identified to make statements intended to provide an account of both the meaning and spirit of the participants' experiences.
Having completed this initial analysis, the researcher sought for explanations using TA to further reflect upon the data received. These TA concepts were allowed to emerge from the analysis already undertaken, rather than searching for the theory from the outset.

Study participants
Recruitment was carried out through a call for participants in the TA community of the researcher. All three therapists interviewed were recruited from the professional networks to which the researcher belongs. Names have been changed to maintain anonymity. Participant demographics are shown in Table 1.
All participants were selected for invitation based on having worked for a significant length of time in private practice prior to the pandemic. This was to be able to draw comparisons in the study to changes experienced by the participants over time as the pandemic progressed. The invitation to take part was initially sent to several therapists via email.
All participants worked in private practice. Carla and Rachel also worked in a larger group therapy practice.
The material covered was stimulating for all participants as the pandemic had not been declared 'over' at the time the research took place. All three participants reported in conversations which took place after the research had been completed that the reflective process of the interviews was useful for furthering understanding and making meaning (Levine, 1997) of their experiences.

Ethical Considerations
The ethical procedures of The Berne Institute and Middlesex University were followed, including submission of the proposal to undertake this research. This was accepted which meant that the participants were satisfied that the project paid attention to and demonstrated ethical governance in carrying out the research.
All participants were informed of the nature and purpose of the project. This included a copy of the research proposal, details on how the research would be conducted, the amount of time involved for the participant, potential risks, benefits, confidentiality, and possibilities for opting out at any point (Appendix B). A permission request was presented to participants. Interviews were arranged with the participants and time was given for them to discuss and question the nature of the interviews. Confidentiality and anonymity were assured for participants and any clients or family members mentioned during the interviews. Participants were encouraged to gain support through friends and family or from another therapist should any aspects of the research prove distressing.

Participant
It was emphasised that the participants could withdraw from the study at any stage in the proceedings; all were happy to proceed. Permission was gained for recording and details were given of how to raise a complaint or concern with the researcher's supervisor should the need arise.
This project was devised as a result of the researcher's experience of living and working with clients through the COVID-19 pandemic. A balance was therefore required between accounting for the researcher's own experiences, including being open about any prejudice she may have, and the experiences of the participants in the project. As it would not be possible to be aware of all my own preconceptions in advance, IPA was specifically selected for this project for its hermeneutic emphasis in which "reflective practices, and a cyclical approach to bracketing are required" (Smith et al, 2009, p. 35).
Consideration was also given to the potential for positive bias in favour of the participants as this was a piece of 'insider research' (Herr and Anderson, 2005) in which all participants were personally known by the researcher. There are advantages and disadvantages to this position versus research conducted by an 'outsider'. However, I agree with the authors when they argue that "knowledge production from all positions is valid as long as one is honest and reflective about one's multiple positionalities" (p.26).
Ethically, this requires me to acknowledge my own subjectivity whilst accounting for the fact that the interviews will also be subjective from the participants' perspectives as it is the phenomenological experience which is being investigated.
In addition, I sought supervision throughout this project from my Clinical Supervisor and Academic Adviser. Table 2 illustrates the three main themes that were identified: the personal impact of the pandemic on the therapist, with two sub-themes; the professional impact of the pandemic on the therapist, with three sub-themes; and the perceived role of professional bodies and training establishments, with one subtheme.

Themes Identified
Each of these themes is addressed below using quotes of the participants.
Theme 1: The personal impact of the pandemic on the mental and physical health of the therapist This theme addressed how the participants experienced themselves; specifically, the impact on their physical and mental health.

Sub-Theme 1: Physical Safety Concerns
All three participants stated that they felt physically vulnerable and frightened for themselves and their friends and family both prior to (Q2) and at the precise moment when the first lockdown was announced (Q3

Theme 3
The perceived role of professional bodies and training establishments Gains and Losses Theme 2: The professional impact of the pandemic on the therapist This theme relates to the impact of the pandemic on the working lives of the participants. Prior to COVID-19 all three therapists had only ever worked in-person with their clients and felt they were required to transition practically 'overnight' to working online with their clients in order to keep their practices alive. Challenges included both the practical and relational aspects of transitioning quickly to a new model.

Sub-Theme 1: Preparedness
At the start of the first lockdown in March 2020, all three participants reported that they felt uncertain, unprepared and under-resourced to manage not only the technical difficulties of moving to an online model of therapy but also the robust challenge this presented to their frame of reference (Schiff, 1975) in a deeply held notion that working in person was unequivocally "better" than any alternative.

Will They Come?
Initially, for both Rachel and Carla there was uncertainty and anxiety as to whether their income would dry up completely as they were not at all sure that clients would be happy to move to an online way of working. Harry could envisage moving to telephone therapy but also was unclear as to how many clients would be willing to work this way.

"…I thought when I ask them [clients] to go online are they all just going to disappear? I don't know why but I certainly remember thinking, oh am I going to have any clients? Are they all going to want to do this?" [Rachel]
"…there was a little bit of for God's sake, this is completely the wrong time … I'm not going to have any money. I convinced myself I would be on the breadline…" [Carla]

"I'd had no experience of working online with clients … no experience with my own therapist of being online so my knowledge around that was quite limited … my belief was that it would be a lot better face-to-face and in person … I didn't offer that [online] and nobody asked. So everybody I saw was in person." [Carla]
"…you lost a bit of the person to person; I think that there was a lot of fantasy for me around that sort of embodied experience … it raised a kind of not good enough belief in me … a sort of is this [online work] the best experience you can offer? Is this really professional? … I think the potency of being in a room with someone to me feels greater than not" [Rachel]

"I was a bit of a snob about it… I sort of felt like the room had a very nostalgic setting … my office was a really sacred space…the container for a great deal, you know … the room would really get used by clients in terms of their projection … the client would give you lots of information by being in the room…" [Harry]
Technological Challenges

"At the beginning … I was shouting at the screen … sitting forward too much … I felt almost like I was needing to keep the internet up … bolstering the connection by putting more energy into your therapy sessions. So it was exhausting … because I wasn't comfortable with it." [Harry]
"…if I'm with a client, in my private practice, that's upset, I might lean forward or push the tissues, you know, as an example, but you can't do that online. You know, and if I lean forward into the screen, that could be more intimidating …" [Carla] "I think there was another challenge in that sometimes people wanted to introduce you to their whole family and bring in the dogs…" [Rachel]

Sub-Theme 2: Changed Relationship with Clients
Every therapist reported a shift in the nature of their working relationships with clients in moving to online therapy. This included an increase in feelings of anxiety and ethical responsibility as some 'at risk' clients were unable to work online safely at home as well as a material challenge to traditional client/ therapist boundaries. The psychosocial and political contexts also became a more significant and shared aspect of the co-created (Summers & Tudor, 2000) therapeutic frame.

"I felt quite sad … I understood why they wouldn't want to work [online] but I could also see that these two women both needed the support and the help. I felt sad
for them … on a human level. But you know, gosh, also … I was concerned for them … how are they going to manage during this time?" [Carla] "…with the young people that I work with, I think their environment and allowing them that space was a challenge because parents would sometimes come in and just making sure the doors were shut off -things like that they hadn't even thought about …" [Rachel] "

Sub-Theme 3: Professional Empowerment
As time went on the participants become more comfortable working online with clients and able to challenge ethical concerns from a more Adult (Berne, 1961) position which supported their sense of professional growth and empowerment. All therapists reported that they now perceive their future working lives as encompassing a permanently 'blended' model of in-person/online working. Theme 3: The perceived role of professional bodies and training establishments Both Carla and Rachel described how it took some time for guidance to be available for therapists from professional bodies. All participants identified that they needed to work hard to identify gaps in their own knowledge and prepare themselves for transitioning to online work. They found it helpful that training was made available to them online from registered training establishments, especially at the start of the pandemic. However, concerns were raised that competition between organisations seemed to increase during this period and organisational politics sometimes interfered unhelpfully in the learning process. Therapists also identified a lack of speed, consistency, preparedness, and clarity from umbrella organisations such as the British Association for Counselling & Psychotherapy (BACP) and the UK Council for Psychotherapy (UKCP) particularly in relation to the ethics of working online with clients.
"I was aware then that I was moving online with clients … I think I was really nervous. I think I was. I'm also really aware, I'm someone who loves a course and can't do enough training. And, and I think I was really aware of wanting to sort of get some sort of online training and really feel like I was ready to go online rather than I did feel -like I was sort of winging it a bit and not really knowing where to go … particularly around [managing]

Discussion
In addition to analysing the data into the themes described above, it can be considered more directly in terms of the timeline of the pandemic based on the original research questions.

Thoughts and feelings of therapists in the months leading up to the first official UK lockdown
Fear and vulnerability were the predominant feelings experienced by participants at the start of the pandemic. Therapists reported most clients working with similar emotional arousal at this time and framed this as a parallel process (Searles, 1955). For both therapists and clients, their physical safety concerns and strong feelings of shock, anger and anxiety came at a time when the numbers dying from COVID were increasing exponentially in the UK. The specific emotions reported align with emerging research which indicates that traumatic stress symptoms -including traumatic stress and heightened arousal -are a common feature of living through this ongoing global stressor "which could lead to PTSD symptomology" (Bridgland, Moeck, Green, Swain, Nayda and Matson, 2021, p.1).
From a TA perspective, it is important to account for the social and political context of this period. The lived reality of COVID-19 at the end of 2019 and into 2020 included a daily digest of televised messages from the government highlighting caution and propagating an atmosphere of fear and uncertainty. With hindsight, it is possible to consider this as a form of cultural scripting (White and White, 1975) designed to prepare the 'hearts and minds' of the nation and ensure maximum compliance with the lockdown announcement in the spring.
As Shadbolt (2020), identifies, the huge personal human cost of COVID and societal inequalities were brought into sharp focus at this time. Considered within the realm of radical psychiatry (Steiner, 1975) and second wave feminism the slogan 'the personal is political' became a lived phenomenological reality reported by the participants of this study.

Moving to online working when the first official UK lockdown was announced
In the UK, therapists are classified as frontline essential workers. However, as therapists were forced to move their working practices online 'overnight', participants described feeling ill-prepared for the challenges that they and their clients would face. All three were concerned that they needed more skills on how to manage crisis situations during online therapy and were anxious about security, confidentiality, and technological competence. Therapist resistance to working online is a philosophy which should be seen within the context of training establishments and professional bodies, the Cultural Parents (Drego, 1983) of our profession, who had largely discouraged this practice until the pandemic hit and continue to perpetuate the concept of in-person therapy being 'better'. For instance, it was not until Sept 2021 (18 months after the first official UK lockdown) that the BACP updated its guidance for trainees allowing up to 50% of placement hours to be delivered online or via phone. They did concede, however, that if government restrictions continued, they would not place limits on the number of remote sessions allowed "provided you can return to face to face work as soon as is reasonable, practical and safe to do so" (BACP, 2021).
The respondents reported an increase in mental health difficulties and symptoms amongst clients at the start of lockdown as well as concern for some vulnerable clients who could no longer practically attend. This led to an increase in demand on the therapists' own resources. This factor, alongside managing their own home lives and the switch to online therapy which required them to seek out 'just-in-time' training led to therapists feeling significantly more fatigued and overwhelmed than prior to the pandemic.
Professional bodies were perceived as being slow to react in supporting their members in practical ways. Several training organisations offered online training courses more quickly. Many of these were wellreceived although there was a sense of over-reaching and strategic opportunism here which led to a feeling of distrust by one of the therapists. Participants identified a future desire for increased specialised training and education.

Thoughts and feelings of therapists as the pandemic progressed
All therapists reported that their frames of reference (Schiff, 1975) and core beliefs regarding online therapy were challenged. However, all of them became more comfortable working this way as time progressed and they became more familiar with the technology and confident in enforcing appropriate ethical boundaries with clients. The led to an increased sense of competence and professional empowerment resulting in each therapist predicting they would continue with a 'blended' in-person/online model of working even post-pandemic.
All participants reported 'showing more' of themselves to clients during this period and engaged in a shared vulnerability and co-created responsibility (Summers & Tudor, 2000) in new ways which had not been available to them prior to this global crisis. Therapists illustrated how the social and political context of 'out there' demanded to be accounted for (Schiff, 1975) and incorporated into the work resulting in new relational possibilities.

Limitations and Future Research
This was a small-scale study focusing on the experience of only three people; while this is an acceptable sample size for IPA (Smith et al, 2009, p. 51) further studies on this subject with an increased number of participants using an alternative research method such as focus group discussions (FGDs) would provide a larger body of evidence of similarities and differences of therapists' experience. This study also refers only to TA psychotherapists working in the UK; it would be interesting to conduct the research again with therapists from other countries and of different therapeutic modalities.
The researcher kept the questions as open as possible to let the subjective experiences of the participants be heard. Consequently, there is a risk that the data is not fully corroborated because there is no certainty that the recorded perspectives of the participants' did not include any misunderstandings or confused communication. The researcher's own subjectivity will also have played a part in how the data was analysed. In addition, as previously discussed, this is a piece of 'insider research' (Herr & Anderson, 2005) so there is the potential for positive bias in favour of these participants as they were all personally known to me.
It may have been pertinent to ask more probing questions on how the therapists' clients might have described working with the therapist prior to and during the pandemic or how the therapists' families experienced them during this time. However, to do so would have made this research too large and complex for IPA methodology so additional research using an approach such as in person depth-interviews from these perspectives is a consideration for future exploration.

Conclusion
The research has yielded in-depth information which supports understanding of therapists' phenomenological experiences both personally and professionally during the COVID-19 pandemic. The response to the initial questions led to the identification of three themes and six sub-themes as shown in Table  2. From these, it is possible to suggest several recommendations for future action.

Ethical Practice Implications
Therapists raised concerns about equity, as many clients lost access to therapy as their living situation changed and they were no longer able to leave the house to attend in-person therapy. Other inequities mentioned include not having privacy for sessions (living in a small house with other family members, making it hard to speak freely), not having proper access to technology as well as financial and time constraints due to changes in working arrangements, juggling work with children being schooled at home, etc.
Whilst none of the participants interviewed for this research worked during the pandemic for Employee Assistance Programmes (EAPs), this issue of fair pay arose for those who did. At the start of the pandemic many providers reduced their contracted rates of pay to therapists, some by as much as 50%, for those who were delivering phone or online services because of the enforced lockdown. After mounting pressure from professional bodies such as the BACP and the UK Employment Assistance Programme Association, several providers agreed to back track and pay full rates (Banning, 2020).
To better assess increased inequity due to these issues, further research and advocacy in this area is recommended.

Burnout Prevention
Burnout is defined as a "state of mental and physical exhaustion caused by one's professional life" (Freudenberger, 1974, p.159). Although working online has allowed therapists to continue helping their clients during the pandemic, COVID-19 has also increased the number of 'traumatic stressors' they have had to contend with. As well as supporting clients with heightened difficulties and symptoms during this period, all three therapists described a parallel intensification of their own emotional responses including stress, fear, and anger.
Professional bodies should consider offering therapists additional training in their own self-care and stress-management skills during a collective crisis e.g., mindfulness, meditation, and other coping strategies to help prevent burn-out. It is also likely that the number of therapists needed in the UK and worldwide (World Health Organisation, 2020) will need to increase to help mitigate the long-term psychological consequences of the pandemic. This requires investment from governments and improvements to the economic accessibility of therapeutic training. Research is required to determine whether computer-augmented therapy may be an economically viable support option during a crisis in the absence of enough highly trained therapists -"to help increase dissemination of effective psychological stress reduction treatments" (Sampaio, Navarro Haro, De Soussa, Melo, Hoffman 2021, p.13).

Training and Development Implications
All therapists suggested that it would have been indispensable to increase their access to training on how to use tele-health systems with their clients, including training regarding legal regulations and compliance related to online work, the need to use secured online communications, training on how to work with young people online and manage emergencies such as suicidal, self-harming or clients at risk of abuse. None of the therapists interviewed had received any training on working remotely with clients during their academic years, nor had any of their own training been delivered online prior to the pandemic.
In SCoPEd (BACP, 2022), the shared standards' framework covering practice and education for counselling and psychotherapy developed by six bodies accredited by the Professional Standards Authority, including the BACP, UKCP and others, was updated in January 2022. The list of 'core competencies' for therapists now includes six references to "technologically mediated' therapy, including the 'ability to identify and respond to the impact of the technologically mediated environment on issues of identity and presence, including fantasies and assumptions about the therapist and client or patient." This is a six-fold increase on the previous version published in July 2020 in which only one rather perfunctory mention is included of considering the practicalities and ethics of "technologically mediated communication" (p. 18).
It would appear that there is a major philosophical shift occurring at the top level, which is somewhat belatedly accounting for the inevitability that technology will form a lasting and ongoing part of therapeutic professional practice. It is recommended that all therapist training courses include in-depth modules and workshops related to working and delivering training online and that future technologies and preparedness to work with whatever form these may take are included as a core part of this training. Therapists need access to straightforward, accurate information in order to immediately boost their knowledge in areas likely to arise during any future global crisis. For instance, there is growing interest and studies being conducted into the effectiveness of immersive virtual reality (VR) (Sampaio et.al, 2021) -enabling therapists and clients to feel as if they are 'meeting' together in a shared world. Whilst this has not yet been widely adopted into clinical practices, it is anticipated that this will form an ever-larger role in the delivery of psychological treatments into the future. Training and support should come from trusted sources such as therapists' professional membership organisations for them to have confidence that the training they are receiving is both accurate and impartial.
Further research into the effectiveness of online therapy, training, and VR versus in-person work in a post-pandemic society is recommended. Professional bodies should assess the evidence regularly and update ethical frameworks and guidance for training organisations, trainees, and members accordingly.