Face to face psychotherapy came to an abrupt halt, with the announcement of Government restrictions, intended to curb the spread of COVID-19. While the effectiveness of online therapy is found to be a viable therapy offering, in certain circumstances, for some clients, when regulated and facilitated by trained professionals (Peelo, 2018), the challenge for practitioners is to decide if online therapy is suitable for them, their clients, and whether or not the additional legal and ethical considerations not normally associated with face to face therapy can be overcome. Having consulted with peers, and supervisors, and completing introductory online training courses, this pre-accredited therapist felt sufficiently confident in using technological means to maintain good therapeutic relationships that are sufficiently safe in working online for the duration of the COVID-19 pandemic. The decision to proceed, was encouraged by the suggestion that the potential benefits of videoconferencing for vulnerable populations can outweigh the additional challenges of delivering psychological care online (Sansom-Daly, Wakefield, McGill & Patterson, 2015).
This article seeks to raise awareness of key elements associated with working online for practitioners considering an unscheduled transition into online therapy during the COVID-19 crisis. Whilst videoconferencing is the most popular medium for working online, the term, working online is used throughout to include all methods of communication using digital and information technology regardless of whether equipment used is a desktop computer, laptop, tablet, smartphone or any other device (BACP, 2019).
Working online is treated as a specialism by the British Association for Counselling and Psychotherapy (BACP) and the Irish Association for Counselling and Psychotherapy (IACP). Both associations having guidance and criteria for the provision of online counselling (BACP, 2019; IACP, 2019a), which strongly informed this article. Acknowledging there are other professional bodies, readers are minded to ensure compliance with the guidance from their own professional body. While recognising there are a number of distinct ethical challenges presented by working online, services are to ‘be delivered to at least fundamental professional standards or better’ (BACP, 2019), with emphasises on adherence to their respective Ethics and Practice policies. Regardless of the theoretical orientation, the skill requirement is consistent; Proficiency in the use of technology; Confidentiality and Client Security; Practitioner Competency; Ethics and Interjurisdictional Practice of Professional Codes and Laws; Crisis Management and Client Safety, (BACP, 2019; IACP, 2019b; and American Psychological Association, 2013).
Confidentiality & Security
Confidentiality, an ethical imperative in psychotherapy, could be compromised in online working, in ways not normally associated with face to face therapy, i.e., potential risks from the client’s own remote environment; unauthorised access by third parties to the digital platform, deliberate or accidental, during an online session (DPC, 2020; IACP, 2019b; APA, 2013; Rousmaniere, Abbass, & Frederickson, 2014). The presence of unknown third parties in the client’s environment, intentional or otherwise, requires an additional check on behalf of the therapist not associated with a traditional face to face (Duncan, Velasquez, & Nelson, 2014). It is important to fully inform participants about potential additional limits to confidentiality, and additional client consent should be obtained if client protected health information is transmitted over any online application, including e-mail (DPC, 2020). These additional risks, reinforce the ethical principle of practicing within one’s area of competence (Duncan et al., 2014). In a study of 93 therapists practicing online, Finn & Barak (2010), expressed surprise that one-third of participants continued practicing when confidentiality was known to be in doubt. Practitioners must be proactive, in guarding against breaches that risk the therapeutic relationship, which in turn could severely damage the integrity of the profession.
It is recognised that absolute security in the digital world does not exist, and so necessitates careful decision making towards taking reasonable steps to ensure adequate levels of security for the type of service being provided. One of the consequences of General Data Protection Regulation (GDPR; DPC, 2018; IACP, 2020) was to restrict the use of hosting platforms to those which comply with security and encryption requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The onus of responsibility is firmly on the therapist to ensure the chosen platform complies with current regulations (IACP, 2019a; BACP, 2019; Dear, 2015; Gamble, Boyle & Morris, 2015; Rousmaniere et al., 2014; and Duncan et al., 2014). And most importantly, practitioners are advised to consult with their insurer, as it is likely to be a requirement for any online work to be conducted via a secure platform. In most instances, if it is a social media platform, it is unlikely to meet the standard for security or confidentiality (Anthony, K., 2020). Training courses in Working Online raise awareness of the unsuitability of social media sites as a medium for delivering therapy online, which aligns with the views of both the governing bodies (BACP, 2019; IACP, 2019b) and the insurance industry (PPT, 2020).
Practitioner Competence and Training
Practitioners are guided to undertake specific training to develop the technological competencies necessary to provide reliable and adequate services to clients, as recommended by their respective associations (BACP, 2019; IACP, 2019b). In response to requests for essential information for practitioners transferring to the online environment as a consequence of COVID-19, a number of introductory online training courses are available, free of charge or donation based (www.otiglobal.pathwright.com and www.thetherapyacademy.ie ). These programmes focus on the key essentials for safe practice and the information most needed by practitioners to work online for a short period (Anthony,2020; O’Carroll,2020). These include having alternative ways of providing services if the primary method of communication fails; keeping up to date concerning new developments in the technology being used in order to provide the safest and most reliable service to clients. A full training programme would include upwards of 80 CPD learning hours as a minimum requirement for full preparation for converting to work online. This is in addition to the practitioner already being a qualified, practicing counsellor, which gives an indication of the complexities and challenges working online presents (Anthony, 2020; O’Carroll, 2020) According to BACP, it is considered good practice to receive at least some supervision online through similar technology. And it is also important for practitioners to ensure the right type of insurance is in place for the service being provided (BACP, 2019).
Contracting & Client Suitability
In an online offering, the practitioner must be cognisant of any legal or ethical limitations and provide clients with explicit and relevant detail of any limitations in advance (IACP, 2019b). Prospective online clients need to have additional information and contractual issues to be presented in advance, such as, the additional risks and limitations to confidentiality (Corey, 2013; IACP, 2019b). Practitioners must continuously be aware of and consider the legal, regulatory, and risk-management issues associated with practicing online therapy, including licensure, malpractice, credentialing, cultural, security and privacy, safety plans and emergency management (Gamble, et. al., 2015;Duncan, et al., 2014), all of which are covered in the introductory courses of Anthony, (2020) and the O’Carroll, (2020).
Another important discussion to be held at the outset and subsequent sessions, concerns the client’s remote environment. Practitioners are encouraged to assess the suitability of the client’s location to ensure it is comfortable and conducive for effective delivery of the online therapy (APA, 2013; Gamble et al., 2015). It is reported that certain mental health issues, including self-harm, psychosis, trauma or severe personality disorders, may prove intractable to online therapy (Anthony, Jung, Rosenauer, Nagel & Goss (2010); APA, 2013; Gamble et al., 2015; BACP, 2009). Additionally, clients who present with ongoing problems of addiction or alcoholism, or those who seem reluctant to comply with the contractual requirements of online therapy may be encouraged to access alternative mediums of support (IACP, 2019b). It is also suggested that some initial in-person contact for initial assessment to facilitate an active discussion on issues such as; clients appropriateness for online therapy; the remote environment; crisis management; and back-up communication strategies in case of network failure (APA, 2013). Faced with such legal and ethical considerations and challenges, it is understandable that both representative bodies, the BACP and the IACP, place such emphasis on the requirements for additional trainings for those intending to work online (BACP, 2019; IACP, 2019a).
The same skills that enable psychotherapists be flexible and adaptable in an ever changing clinical environment, can serve the profession well in the new technological frontier (Rousmanniere, et.at., 2014). This view echoes that of Rogers (1995), in which he states technological advances are not to be dismissed, but as psychotherapists, being open to change is fundamental for personal growth. Although technology will advance, it is imperative that client needs drive the treatment modality (Duncan, et al., 2014). Yalom offers a caution in relation to online therapies and technological advances saying, “if successful, it would be a pleasant and rare instance of technology increasing rather than decreasing human engagement” (Yalom & Leszcz, 2005, p.524), but that was before we encountered COVID-19. Therefore, in an environment of restrictions, online therapy may serve as an adequate conduit for maintenance of the therapeutic relationship when alternatives are limited.
The challenge that COVID-19 have presented are continuing to unfold on a daily basis. As the caring profession in other areas are heroically meeting these challenges, therapists too, are capable of adapting and honing their skills, and learning new skills, in order to deliver effective therapeutic services for the communities they serve. With additional training, good council with supervisors and peers, the COVID-19 pandemic may prove to be the catalyst for positive change in the delivery of therapeutic services for communities. Developing these capacities could serve benefits to many in the future, as the trend towards ‘convenience’ therapy (for whatever reason) could meet unmet needs of those who may not otherwise have sought such services in the past.
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O’Carroll, M. (2020). Introduction to Working as a Therapist Online. An introductory online training course. Accessed on 19th March, 2020 from www.thetherapyacademy.ie
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Sansom, D. U. M., Wakefield, C. E., McGill, B. C. & Patterson, P. (2015). Ethical and Clinical Challenges Delivering Group-based Cognitive-Behavioural Therapy to Adolescents and Young Adults with Cancer Using Videoconferencing Technology. Australian Psychologist, 50(4), 271–278. https://doi.org/10.1111/ap.12112
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American Psychological Association (APA). Available at: www.apa.org
British Association for Counselling and Psychotherapy (BACP). Available at: www.bacp.co.uk
Irish Association for Counselling and Psychotherapy (IACP). Available at: www.iacp.ie
Online Counselling and Therapy in Action: Available at: www.octia.org.uk
Offering courses in Working Online:
Online Therapy Institute:
The Therapy Academy: https://therapyacademy.ie/iacp/details/567