Setting Up Online Counselling: Not Just a Couple of Clicks
The purpose of counselling is generally to help people learn to live in happier, more effective ways, which more often than not means helping them learn how to come together better with other people. In these pandemic-permeated times, however, we are told by authorities that the most effective means of being with others is to keep our (physical) distance from them – at least a little, and sometimes a lot – as region after region engages lockdown. Dealing with that together-alone paradox is the latest challenge for the helping professions and one way of resolving it, while continuing to extend a helping hand, is for counsellors to see clients in online sessions. In this article we look into what must be considered when setting up an online counselling capability.
The current context
E-therapy, or online counselling and psychotherapy, has enjoyed a good growth rate over the last few years (Ratcliffe, 2017), with recent researchers espousing its efficacy (iCouch, n.d.) as practitioners and clients alike have come to appreciate the advantages:
Accessibility. For those who live remotely or who have transportation issues (such as some people with disabilities), single parents with young children, and those who are time-poor and wouldn’t get to session if they had to drive across town, the ability to simply log on and have a session is a great boon to their mental health.
Affordability. Counsellors do not have to rent an office space to see online clients, needing only some privacy, and neither practitioner nor client needs to travel, cutting down those costs. Hence, some counsellors are able to bring the cost of sessions down.
Convenience. As noted, the possibility of a one-minute commute down the hall to where the computer is comes to be a seriously attractive aspect for time-poor people. Some caregivers may be able to still have sessions if they are only engaged for an hour, and only in the next room.
Anonymity. In non-visual forms of online counselling, clients have the added security of remaining anonymous, allowing for less filtering of information and greater honesty in disclosure than the client might feel comfortable with in a F2F session. Perception of stigma and bias associated with face, age, physical appearance, and other aspects is reduced (especially helpful for those with trauma or who have a lot of anxiety).
Communication flow. For the asynchronous, written forms, both parties have time to reflect before responding, which can enhance communication (adapted from Hall, 2020).
As various jurisdictions around the world go into ever-more-restrictive lockdowns, the above advantages remain in play, often intensified. But there is the additional, undeniable upside: mental health support – even more desperately needed now as societal shutdowns create massive unemployment and attendant mental health problems – is possible when an in-person meeting would not have been allowed to happen. So, what forms of communication are we talking about when we say “online counselling”?
The formats of online counselling
In addition to “online counselling”, you may hear terms such as “e-therapy”, “web counselling”, “telepsychology”, “internet counselling” (an older term), “online therapy”, “e-counselling”, and now “distance professional services”. The U.S.-based National Board of Certified Counsellors (NBCC) includes the following as formats:
- Telephone-based, meaning the synchronous distance interaction in which information is received only through audio means.
- Email-based, referring to the asynchronous distance interaction in which information is received through written text messages or email (this can be regular or encrypted).
- Chat-based, involving the synchronous distance interaction in which information is received through written messages.
- Video-based, meaning the synchronous distance interaction in which information is received via video and audio mechanisms.
- Social-network-based, referring to the synchronous or asynchronous distance interaction in which information is exchanged through social networking mechanisms (NBCC, 2012).
- Cloud computing or virtual-reality-based are emergent technologies not included in NBCC’s definition, but add another layer of choice and complexity to the question of distance professional services (Johnson, 2014; list sourced from Mental Health Academy course: “E-Therapy: Ethical Considerations).
What you must consider beforehand
It is one thing to agree to give one existing client one session by teleconferencing once if they and/or you are holed up under lockdown. It is quite another to permanently run a major portion of your practice from the screen of your computer. Here are some considerations to help you determine if you and/or your clients are appropriate for online counselling.
Are you the right person for it?
Jane Evans’ book on online counselling includes a checklist which seeks to establish practitioner suitability for working online therapeutically. She asks counsellors to ask themselves these questions:
- “Would I relate well to lone working using a computer as the vehicle for interacting with clients?
- What proportion of my work would I be comfortable in transferring to an online setting?
- Do I currently enjoy and feel comfortable when interacting with others through an online medium?
- Am I content in working without the actual physical presence of clients?
- Could I manage the administration and practicalities of an online office (more on that in a moment) with the associated responsibilities and appointment system requirements?” (Evans, 2009, p 15).
In addition to a suitable temperament for working physically alone and being online for portions of a day, there is the question of technical competence. The British Association of Counselling and Psychotherapy (BACP) notes that “all practitioners should be sufficiently competent in the use of technology in their work to be able to provide reliable and adequate services to clients and colleagues” (BACP, 2019), a requirement also noted by the Australian Counselling Association (ACA) in their comment that practitioners should be “prudent and conscientious in their consideration of the challenges of any new area of practice”. The BACP goes on to state that this means having alternative ways of providing services for communicating with clients promptly if the primary method of communication fails. Competence also includes having access to technological support that respects the confidentiality of the work being undertaken. The ACA notes that “very few practitioners will be able to engage in online therapy without additional skills, training, and experience. Online therapy is NOT appropriate for novice or inexperienced practitioners” (ACA, n.d.).
Training and supervision
The BACP considers it “good practice” for practitioners to have at least some of their supervision in the same medium in which they are working online. The ACA expressly argues for specialist training in online counselling due to the numerous issues beyond mere competence in providing face-to-face therapy. These include:
- The shift from verbal to written communication skills (for some of the technologies)
- The challenges of building/maintaining an adequate therapeutic alliance online
- The greater potential for miscommunication; thus, the concomitantly greater need to identify misunderstanding
- The ability to do assessment online and to establish the suitability of a client and his/her issues to be addressed online
- Adequate understanding of appropriate administrative practices concerning legal obligations and data storage
- Adequate knowledge about technical issues related to security and privacy in online work (BACP, 2019; ACA, n.d.)
Which choices will be the best for you and your client?
Many issues influence the choice of medium. Most therapists like to see their clients in order to pick up on some of the nonverbal cues; some will automatically be lost in video teleconferencing in that, typically, only the head and perhaps shoulders of the person on the screen are seen. Yet media with video content have more cues than mere audio means, such as telephone. Both video and audio/telephone sessions, in turn, provide more nonverbal information than asynchronous distance interaction (i.e., email or text) or synchronous distance interaction (i.e., chat-based media).
Most of the platforms coming on stream now have multiple options for communication, and so could accommodate the preference of either counsellor or client to see and be seen – or not. This leads to the question of which platform – which particular software or system – is the “right” one to use, which we take up in a moment.
Which presenting issues should use online media?
It is also important to consider which presenting issues can work with an online approach. The so-called “worried well” (clients who are essentially healthy but want to work on certain challenges) may be able to deal well with the therapist being only virtually present. Someone who is suicidal or psychotic is an entirely different circumstance; in all cases that assessment must be made early on, and safeguards put in place for the client if “on-the-ground” support is needed in an emergency situation. Whom should the client call? Whom should the therapist call if the client cannot be contacted and there is concern over their welfare?
Ethical online counselling: what’s required
If you are caught out in the midst of a lockdown and your client really needs to have a session with you, you might just end up on Skype for an hour. But both the ACA in Australia and sources in the United States are adamant that platforms such as Skype or Facetime are not ethical choices for ongoing work. Here is why.
The U.S. HIPAA and the BAA
In the United States, there are two requirements: (1) that the platform be HIPAA-compliant and (2) that the provider of the platform has signed a Business Associates Agreement. Unpacking that a bit, we can explain that HIPAA (the Health Insurance Portability and Accountability Act) of 1996 is legislation designed to protect the privacy and security of health care clients and their data. As a result, the U.S. Department of Health and Human Services has the power to establish national standards for the health care industry when processing electronic transactions. It also requires health care organisations to secure electronic access to health data in order to remain in compliance (Greevy, 2017).
The Business Associates Agreement (BAA) certifies that the service a health provider is using guarantees compliance with the HIPAA and therefore has security practices and policies in place to ensure that client privacy is protected.
Skype is not HIPAA compliant. The owner of Skype, Microsoft, will not sign a BAA covering Skype. Microsoft tells therapists that they cannot guarantee the privacy and security of client data within the requirements of the law. No BAA means no compliance. The fact that Skype is “encrypted” is irrelevant. Similarly, “consumer-oriented” video tools such as Google Hangouts and Facetime are not considered HIPAA-compliant for video conferencing (Dear, 2017b).
In the U.K. and Australia
There is no equivalent (specific) legislation in either the U.K. or Australia which has enforceable requirements for therapists doing distance therapy. However, both the BACP in the U.K. and the ACA in Australia have issued documents setting out what therapists need to be mindful of in order to be ethical when doing online counselling. Australian practitioners must also take into account the 1988 Privacy Act (see Federal Register of Legislation, below). Full discussion is outside the scope of this article, but we recommend having a look at:
- Good Practice in Action 047: Working online in the counselling professions by the BACP, which also encourages its counsellors to read the “Ethical Framework for the Counselling Professions” (BACP, 2019)
- Guidelines for online counselling and psychotherapy (which should be read in conjunction with the ACA Code of Ethics and Practice) (ACA, n.d.)
- The Mental Health Academy (MHA) courses about online counselling, especially E-therapy: Ethical considerations (MHA, n.d.)
- Federal Register of Legislation (Australian Government, 2014)
The platforms for teleconferencing
Given that choosing a video conferencing solution is one of the first things you must do in setting up online counselling, which are the platforms that will best accommodate it? We look at options in the U.K., the U.S., and Australia.
The Human Givens Institute offers online therapy guidelines, expressly noting that Skype is not advised as a platform (although, with certain safeguards and client consent, it can be used). The platforms the Institute regards as more secure, and therefore a better choice, are:
- WebEx. This platform offers a free trial, after which a monthly fee of £15 is payable for the basic package.
- FaceTime. Unlike the U.S. appraisal of Facetime given by Dear (2017b), the Human Givens Institute believes that this platform is “sufficiently secure for online therapy”. It is produced by Apple for Mac users.
- Zoom. Arguably the world’s most popular video conferencing and webinar platform, Zoom offers a multitude of tools and can be used anywhere in the world (Human Givens Institute, 2020).
The Online Counselling Directory (2018) refers readers to several articles which discuss the pros and cons of various teleconferencing platforms for counsellors. Their recommendations for the top four (“the best of the best”, all HIPAA-compliant with a BAA) are:
- Doxy.me. Free, “one of the best”, and “most popular”, Doxy.me is easy to use and has high-quality customer service.
- VSee. Used by NASA and the Navy Seals, VSee claims to be the world’s largest video telemedicine platform. They have video tutorials and several pricing tiers. Their platform is easy to use and they have education available to users.
- Thera-LINK. With a clear connection, easy set-up for both clients and providers, and a 15-day trial, Thera-LINK was designed specifically for therapists. It has an online waiting room, session scheduler, and payments can be accepted through the platform. Tips are offered on how to have the best experience. The first tier of pricing starts at $30 per month.
- Wecounsel.com. With an emphasis toward the behavioural health field, Wecounsel surpasses encryption requirements. Providers can accept payments through the site and there is scheduling capability. After a 30-day free trial, plans begin at $25 per month (Online Counselling Directory, 2018).
Australian therapists are able to use a number of the U.S. sites, but platforms that are specifically for use in Australia include:
- E-therapy.com.au. Offering chat, Skype, and secure emails, E-therapy offers operating manuals to help therapists easily navigate all features. Therapists can edit their profiles; create session times and their own templates and view, save, and search chat logs from sessions or accept/decline booking from clients. No additional software is required and data is secure behind the E-therapy network’s firewalls. Pricing goes from “Free” for a six-month subscription to $180 AUD for a two-year “platinum” subscription. E-therapy can be integrated with existing sites (such as therapist’s website).
- Coviu.com. With a free one-week or two-week trial (depending on the plan chosen), Coviu starts at $19.95 per month, including 1:1 video consultations, in-call payments, a standard consent form, and buttons for the therapist’s website. Upgraded plans add pre-call payments, custom branding, online appointment bookings, local recording (audio only), and free listing with Onlinedoctors.directory. Coviu is seamless across all devices.
- Coreplus. This is not a teleconferencing platform, but “online practice management software for counsellors” which can be used in conjunction with a video conferencing product. It allows interoperability and online execution of many administrative functions, such as hassle-free bookings, easy synchronisation of appointments with the counsellor’s calendar, free Medicare/DVA billing and claiming and the protection of clients’ sensitive personal information. It also allows for Facebook and website bookings; calendar colour-coding; appointment limits; easy invoice creation; the monitoring of billable, cancelled and no-show appointments; and professional letter templates.
Honing in on the practicalities
As you have seen from descriptions of the platforms above, each product offers a different mix of features, but important ones to look for include fit-for-purpose teleconferencing platforms (which Skype is not) that are easy for both practitioner and client to set up, access, and operate, with zero to minimal cost for the client). The teleconferencing product should be accessible for clients who connect with various types of browsers, devices, and platforms, and be able to operate with high-quality audio and visual communications across the bandwidth available in rural and remote areas (particularly important in Australia). Those platforms are best which have the capacity to:
- Schedule appointments
- Accept payments (online billing is helpful, too)
- Make and securely store client notes
- Exchange documents (securely) with the client
- Record the session
- Receive technical support from the platform
- Minimise interruptions and dropouts (the inclusion of instant chat messaging is helpful to re-establish sessions where there are dropouts or lags (Australian Psychological Society, 2020)
Once you have worked out which is the best teleconferencing product for your needs, there are a few aspects you must tend to in order to get going.
- Check the requirements for doing online counselling in both your jurisdiction and those of potential clients, as – ethically speaking – you should be certified in both places. In New Zealand and Australia, there is a general ethical requirement for counsellors to be “competent” in the format used (as we noted above), while in some U.S. states (e.g., Texas) there are specific requirements, such as doing 15 hours of training on technology-assisted services before doing anything related to technology with clients. Always, it is important to state in the contract with the client which jurisdiction’s laws will be followed in the event of a disagreement, and whose code of ethics you will follow. And we reiterate our injunction (above) to be sure to establish early on how you will proceed – who will be called – if the client is in an emergency situation and you are not there in person.
- Check whether health insurance plans will pay for telehealth services so that you can be reimbursed. Most in the U.S. will pay, but the ability to be reimbursed in Australia has only very recently received a boost as a result of the Coronavirus pandemic and the concomitant need for mental health support that will not infect either practitioner or client.
- Get a website and advertise. You don’t need to spend a fortune, but a website is crucial and the cost is worth it. It is how many of your clients will find you. You can think of it as your online “address”. It is your opportunity to “sell” your services by letting prospective clients know about your experience, training, and background, how you work, and what you believe in. It will enable compatible clients to feel some connection with you before they ever arrange an appointment. Adding onto your business card and in other places that you are available for online sessions will help to establish this aspect of your practice.
- Practice doing online sessions. They are different from F2F sessions, and the more experienced and comfortable you become with making therapeutic interventions online, the more your clients will relax and engage the sessions. In the beginning, you may even want to ask friendly colleagues to role-play a session with you online, and do get feedback on how you appeared, spoke, and moved – and which interventions/approaches worked better in a virtual environment.
- Offer online counselling to a few select clients. An online format may not be appropriate for some clients , and others may not be interested, but for those clients who are – or who may have temporary interest because of needing to be away during a scheduled appointment – you can build up your online experience/practice gradually, extending it as you are comfortable and/or as clients prefer it.
- Get listed in an online directory. There are many reputable directories in the U.K., the U.S., and Australia. It is a matter of determining whose volume of traffic, pricing structures, and way of working with therapists will best meet your needs. There is no such thing as too much online presence in terms of attracting clients.
- Be patient. Ha! This could be the most difficult part of all (Thera-LINK, 2020; Thera-LINK, 2018; Dear, 2017a; Dear, 2017b).
Now that social distancing is required for an indefinite period and in many countries, people are experiencing some form of social restriction – if not total lockdown – we would like to say, “No dramas. Just log onto (site) and continue online where you left off in person with your clients; a couple of clicks will get you there.” We would like to say that, but we won’t. The requirement for ethical online counselling is complex, as we have outlined here, involving decisions about which platform and which medium (e.g., videoconferencing or chat) will be secure and most appropriate to use. You need to determine which – if any – clients and which presenting issues to use it with, and to feel satisfied that you are an appropriate counsellor to use e-counselling therapeutically given your experience, qualifications, and temperament. Ethical considerations need to be reviewed, with the ability to feel comfortable online being as crucial as technical competence. Tips for getting started were discussed.
Online counselling is not everyone’s cup of tea, but as many commentators have already pointed out, when we are on the other side of the COVID-19 pandemic, the world might be changed forever. An increase in online therapy may just be one of those changes; now might be a good time to start getting used to it.
Written by Mental Health Academy
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