Introduction

APCP recognises that members of the Association increasingly have queries and concerns about using technology to communicate with their clients. Based on Ethical Guidelines and Ethical Frameworks created by the British Association for Counselling and Psychotherapy (3rd Edition/Information Sheet P6) and the Online Therapy Institute, this document sets out to summarise essential information and give further resources to members.

This guideline focuses on direct counselling or psychotherapy between a practitioner and their clients, and excludes other uses of technology such as software or apps designed to provide or enhance mental health care.

This statement applies to many uses of technology to conduct the therapeutic relationship, including but not limited to:

  •  Email/Forums
  •  Chat rooms/Instant Messaging/Texting
  •  Telephone and Audio (Voice over Internet Protocol)
  •  Videoconferencing

Working within your Scope of Practice

Scope of Practice indicates the specific area to which a practitioner may practice. Scope of practice in many geographic areas also defines where a practitioner may practice; whether the practitioner may practice across various geographical boundaries and within what parameters a practitioner may practice. Practitioners also follow local and regional laws and codes of ethics as applicable.

  • Understanding of boundaries and limitations of one’s specific discipline (knowing when certain elements of one’s discipline are not easily transferable to an online environment).
  • Understanding of specific laws and/or ethics within one’s own discipline or geographic location (practice laws may prevent a practitioner from crossing international borders; professional titles may mean different things across international borders)
  • Respect for the specific laws of a potential client’s geographic location: Practitioners understand that different geographic regions may offer additional limits to practice, particularly with regard to jurisdiction.
  • Knowledge of how online work is covered by insurance carriers.

Having a Sufficient Understanding of the Technology

Practitioners will possess a basic understanding of technology as the technology relates to delivery of services.

  • Encryption: Practitioners understand how to access encrypted services to store records and deliver communication.
  • Backup Systems: Records and data that are stored on the practitioner’s hard drive are backed up either to an external drive or remotely via the Internet.
  • Password Protection: Practitioners take further steps to ensure confidentiality of therapeutic communication and other materials by password protecting the computer, drives and stored files or communication websites.
  • Firewalls: Practitioners utilise firewall protection externally or through web-based programs.
  • Virus Protection: Practitioners protect work computers from viruses that can be received from or transmitted to others, including clients.
  • Hardware: Practitioners understand the basic running platform of the work computer and know whether or not a client’s hardware/platform is compatible with any communication programs the practitioner uses.
  • Software: Practitioners know how to download and operate software and assist clients with the same when necessary to the delivery of services.
  • Third-party services: Practitioners utilize third-party services that offer an address and phone number so that contact is possible via means other than email.

Practitioners seek out training, knowledge and supervision.

Training, knowledge and supervision regarding mental health and technology is paramount to delivering a standard of care that is considered “best practice” within one’s geographic region and within a global context.

  • Formal Training: Practitioners seek out sufficient formal training whenever possible through college, university or private settings. Formal training is displayed on the practitioner’s website.
  • Informal Training: Practitioners seek out continuing education and professional development and conferences, conventions and workshops.
  • Books: Practitioners read books written by the general public and professionals.
  • Peer-reviewed Literature: Practitioners read peer-reviewed literature that includes the latest theories and research.
  • Popular Media: Practitioners are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of mental health and technology on the popular culture.
  • Clinical/Peer Supervision: Clinical and/or peer supervision is sought by all practitioners who deliver services via technology.

Practitioners display pertinent and necessary information on Websites.

Websites provide access to information for the general public, potential clients, clients and other professionals.

  • Crisis Intervention Information: People may surf the internet seeking immediate help and therefore practitioners should display crisis intervention information on the home page (Samaritans, for example)
  • Practitioner Contact Information: Practitioners offer contact information that includes email, post address (PO Box recommended) and a telephone or VoIP number.
  • Practitioner Education, License and/or Certification Information: Practitioners list degrees, licenses and/or certifications as well as corresponding numbers and links to awarding organisations.
  • Terms of Use and Privacy Policy: Terms of Use, often all or in part, synonymous with a practitioner’s informed consent, is available on the website either as a page on the website or a downloadable document. The practitioner’s privacy policy is also available in the same way and offers information about if or how email addresses, credit card information and client records are used, shared or stored.
  • Encrypted Transmission of Therapeutic and Payment Information: Practitioners offer secure and encrypted means of therapeutic communication and payment transactions.

Practitioners conduct an initial Intake and Screening process.

The initial screening and intake process begins with the potential client’s first contact. The practitioner implements formal and informal measures for screening a client’s suitability for delivery of mental health services via technology.

  • Client’s Technology Skills: Practitioners screen potential client’s use of technology through questions at the outset. Questions include but are not limited to an inquiry about the client’s experience with online culture e.g. email, chat rooms, forums, social networks, instant messaging and online purchasing, mobile texting, VOIP or telephones.
  • Client’s Language Skills: Practitioners screen for language skills from the initial contact through the first few exchanges. Assessing for language barriers, reading and comprehension skills as well as cultural differences is part of the screening process.
  • Presenting Issue: Practitioners screen to ensure the presenting issue is within the scope of practice and knowledge base of the practitioner. Screening around issues of suicidality, homicidality and immediate crisis are formally addressed through an intake questionnaire or first exchange.
  • Client Identity: Practitioners incorporate a mechanism for verifying identity of clients by asking for a formal identification number such as Driver’s Licence or other satisfactory method. The client must not be anonymous, offering at a minimum: first and last name, home address, and phone number for emergency contact (if client identity is not required, such as is the case with crisis hotlines and triage settings, limitations of the service are stated clearly). Minors must be identified through parental consent.
  • Clinical Concerns: Concerns regarding mental stability are addressed- e.g. client currently hallucinating or delusional; actively using drugs and alcohol so that insight-oriented interventions would not be suitable; and any other medical or physical issues that might impede the intervention or require a different method of delivery, e.g. disability that impairs typing, rendering a chat exchange cost-prohibitive. Any assessment instruments that are utilised should be approved for online or computer-assisted use according to the test author/publisher.

Practitioners offer an Informed Consent process.

The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information is accessible via the practitioner’s website. The informed consent process includes a formal acknowledgement from the client to the practitioner. This acknowledgement is received via encrypted channels. Informed Consent content is revisited during the course of therapy as necessary and beneficial.

The following topics are addressed within Informed Consent:

  • Possible Advantages and Disadvantages of Online Therapy: Information is disseminated about the pros and cons of online therapy including such disadvantages as lack of visual and auditory cues and the limitations of confidentiality via technology, and advantages that include easy scheduling, time management and a no need to incur transportation costs.
  • Encryption: An explanation about the use of encryption for therapeutic exchanges and lack of encryption if/when unencrypted methods (standard email, forum posts, mobile telephone, SMS texting, social networking) are used for issues such as appointment changes and cancellations.
  • Therapist as Owner of the Record: Unless otherwise specified through law in the practitioner’s geographic location, the therapist remains the owner of the therapeutic record including all transcripts, notes and emails. The client is informed that posting direct information about the therapist or verbatim information from sessions is prohibited.
  • File Storage Procedures: The client is informed about how records are stored (web-based, third party or hard-drive/external drive) and for how long the records are maintained.
  • Privacy Policy: The practitioner’s privacy policy is also included in the Informed Consent process including information about how email addresses, credit card information and client records are used, shared or stored.
  • Practitioner’s Geographical Jurisdiction: The physical location of the practitioner is offered in the Informed Consent and states that the client understands services are rendered under the laws or jurisdiction of the relevant country.
  • How to Proceed during a Technology Breakdown: The client is informed about how to proceed if a technology breakdown occurs during a session.
  • Emergency Contact: Practitioners offer specific information about who to contact in case of an emergency and set specific rules about emergency emails that the practitioner may not be privy to e.g. (suicidal emails in the middle of the night, threatening posts on a support forum).
  • Cultural Specifics that May Impact Treatment: Practitioners discuss varying time zones, cultural differences and language barriers that may impact the delivery of services
  • Dual Relationships and social media: Practitioners discuss with clients the expected boundaries and expectations about forming relationships online. Practitioners inform clients that any requests for “friendship,” business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored to preserve the integrity of the therapeutic relationship and protect confidentiality. If the client has not been formally informed of these boundaries prior to the practitioner receiving the request, the practitioner will ignore the request via the social media site and explain why in subsequent interaction with the client.

Conclusion

This document is designed as a starting point to assist members in developing their services in an online capacity. Online counselling and psychotherapy services will continue evolving, and APCP remains interested in developments and are also actively optimistic about their potential.

Enquiries

http://www.apcp.ie/contact-us/

Further Resources

Anthony, K. & Nagel, D.M. (2010). Therapy Online: A Practical Guide. Sage Publications

Online Therapy Institute – www.onlinetherapyinstitute.com – Training and Consultancy (APCP Member Discount available – please contact kate@onlinetherapyinstitute.com

Therapeutic Innovations in Light of Technology (TILT Magazine) – www.onlinetherapymagazine.com

Azy Barak’s Academic Reference website – http://construct.haifa.ac.il/~azy/refindx.htm

Further Ethical Frameworks of relevance – http://onlinetherapyinstitute.com/ethical-framework/