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Online Therapy: The Practitioner’s Definitive Guide

Everything therapists, counsellors and coaches need to know about practising online, from platforms to privacy, training to technology

Online therapy, sometimes referred to as e-therapy, distance therapy/counselling or tele-therapy, has become an increasingly popular choice for individuals seeking care.

Clients and therapists alike are embracing this new modality because it fits with today’s electronic, on-the-go lifestyle. In fact, online therapy is becoming one of the fastest growing areas of therapy and the demand for services is coming from both clients and therapists alike.

But while it opens new possibilities, mastering this new method of communicating with clients can be challenging…

Online therapyFor many practitioners, climbing the steep learning curve can make
online therapy seem daunting

We’ve developed this guide for therapists, counsellors, and coaches who are considering delivering therapy online, to answer all your questions in one place.

Here’s what this guide contains:

  1. What is Online Therapy?
  2. How Do I Get Started?
  3. Infographic: What Equipment Do I Need? What Are The Pros And Cons Of Online Therapy?
  4. Why All The Concern About Privacy?
  5. Where Can I Go For More Information?
  6. FAQ Section

So, what is this new frontier and why is it becoming so popular?

  • Online therapy is convenient. Because it is electronically based, services can be provided anytime or anywhere eliminating the need to drive to an appointment, parking and then being seen in an office.
  • The cost per session is often significantly lower because of the accessibility and flexibility this mode of service delivery offers.
  • The increased flexibility makes therapy available to those who may have limited mobility or are geographically isolated. Under-served areas can now receive services not previously available.
  • This new mode of service delivery is offering therapists a new revenue stream and a new way to reach potential clients previously inaccessible to them.
  • The low overhead means that therapists can spend more time on service delivery and be more likely to be able to sustain a practice.
  • Some third party payers are starting to recognize the need and value of electronically-based counselling in some instances.

Some therapists were early adopters and jumped in with both feet. Others have been more hesitant, wanting to understand more about the risks, benefits, and how-to’s of such a new way of providing care.

Let’s be honest, when many of us were in training, the idea of conducting therapy online was not even an option. Even with the birth of the internet and subsequent availability of real-time online communication (like Skype), the idea of online therapy still evokes some ethical and procedural questions.

Licensing boards have been scrambling to put standards of practice in place and distance counselling training programs are popping up all over the place.

This article is not intended to debate the pros and cons of online therapy. It is clearly not for every therapist or for every client. However, it is a new reality in therapy practice.

This article is intended to pull the curtain back on online therapy and provide the reader with some of the best resources currently out there and a few things to consider.

You, as the therapist, can read, evaluate, and decide what is right for your practice.

What is Online Therapy?

For many therapists, this is the number one question. Online therapy is a relatively new treatment option and one which is only now beginning to get attention in graduate school programs.

For those of us trained before the age of the Internet, it sounds like a whole new treatment universe. And in some ways it is.

Simply put, online therapy is the provision of mental health via the Internet.

These services may be delivered using a variety of electronic mediums including video chatting, texting, emailing or voice messaging. And these services may be provided through any number of systems or apps.

Some services have proprietary systems. Others use traditional web-based services such as Skype, text or designated email.

Studies have found that more and more clients are willing to enter into Internet-based therapy and in fact, may actually be more compliant with that modality than with face-to-face sessions (Day & Schneider, 2002).

What’s even more interesting is that text-based therapy may result in even greater compliance and positive therapeutic outcomes (Hull, 2015).

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How Do I Get Started?

This is usually the second most common question that therapists have. The truth is you can’t just find yourself seated at your desk one day and say, “Hey I think I will try online therapy with this client.”

The reason is because the next question will be, “How do I do that?” This is where it can get dicey if you’re not prepared.

A quick tour around some of the Internet therapy sites and discussion forums yields this short answer: get some training in providing online therapy. The reason for that is two-fold.

First, you want to make sure you understand the nature of providing this type of therapy and which clients may be suited to this approach. It’s not for everyone.

Second, you need to make sure you have the knowledge and expertise, equipment, applications, and security to provide those services. You have to be sure that your Internet-based services meet the privacy and security requirements necessary to avoid a breach of confidentiality and privacy for your client. More on that in a minute.

Another thing to consider is whether or not you have adequate malpractice coverage. Does your current policy cover the provision of online therapy? If you’re not sure, then you need to find out. Every policy is different and you may need to add coverage.

One last caveat: before you even attempt to embark on this journey, make sure you check with your licensing board. In general, the provision of distance counselling is dependent upon where you are licensed and/or where the client resides.

For example, if you are licensed in the state of Louisiana, you can provide online therapy but you have to be licensed in the state in which the client resides.

If you are contacted by a client in Texas you may not be able to legally provide online therapy services to him/her.

Your licensing laws may differ. Make sure you do your homework. The last thing you want is to be sanctioned by your licensing board. “I didn’t know” is rarely accepted by review boards.

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Infographic: What Equipment Do I Need? What Are The Pros And Cons Of Online Therapy?

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What Equipment Do I Need?

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A Reliable, Well-maintained Laptop or Desktop Computer

It’s often recommended to avoid using mobile devices when using audio and/or video-based applications so as to maximize audio/visual resolution.

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High-speed, Reliable Internet Connection

You don’t want to spend the session trying to reconnect or waiting for buffering.

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A Good Quality Headset

You want to be able to hear and understand each other well. A handheld device will become uncomfortable quickly in an hour long session.

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A Quiet, Private Area In Which To Conduct Your Session

Privacy guidelines still apply. You don’t want people walking by or overhearing your conversation.

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Appropriate Video Or Audio Software

While the types of applications you can use may depend on where you are in the world, the main consideration here is protection of the client’s privacy and confidentiality. Not using your electronic media correctly or using the wrong tools can place you in legal and ethical jeopardy and potentially breach the client’s confidentiality.

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A Formal Policy That Protects Patient Information

You need to lay out exactly how and when technology is to be used and the reasonable safeguards you will take as a therapist to protect the client’s electronic patient health information (often referred to as ePHI).

What Are The Pros And Cons Of Online Therapy?

Pros

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Low Overhead

Whether you use free applications like Skype or opt for a proprietary application, the relative cost of providing online therapy vs. face-to-face can be significantly less.

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Greater Access To Potential Clients

Barriers such as lack of mobility, transportation or geographical isolation are removed. Clients can be “seen” where they are.

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Flexibility

Both client and therapist have greater flexibility in scheduling sessions.

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Affordability

With lower overhead costs, online sessions may be less expensive than an in-office session.

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Variable Communication

Online therapy can offer clients various ways to interact with the therapist. Email, text, voice or video may be used to accommodate the client’s communication style and needs.

Cons

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Not Being Able To Read The Client

This is one of the issues most often mentioned by distance therapists. When conducting online therapy, it is much more difficult to read behavioral cues and micro expressions that might be more apparent in a face-to-face session. This becomes even more of an issue when using email, text or audio.

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It’s Not For Every Client

Some clients are not appropriate for online therapy. As tempting as it might be to have a 100% online therapy practice, there will be times when you have to decide to either see a client face-to-face or refer them to someone else. It’s important to adequately assess each potential client prior to starting online therapy. This is where your training in this modality is crucial.

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Technical Issues

The fact is, technology isn’t perfect. There will be times when the Internet will go down or the app won’t open. Maintaining good connectivity and equipment will minimize this risk but even the best laid plans are sometimes foiled. However, this con speaks more to the need to have good training and technical skills so that you can competently conduct your online sessions. You don’t want to be fumbling around during your session. That becomes detrimental to the client.

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Legal and Ethical Issues

Be very careful not to assume that because the Internet is worldwide, standards of practice for Internet-based counselling are too. These issues will largely be determined by your own licensing agency. It’s important to know what is accepted and legal practice in your jurisdiction.

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Therapist Competency

This falls into the “just because you can doesn’t mean you should” category. Just because someone is a licensed therapist doesn’t mean they are adequately trained to provide online services. Could they? Probably if their licensing board allows it. Should they? Probably not. Online therapy requires a specific skill set and knowledge. To avoid violating standards of practice and practicing outside of your competency, take time to get adequate training. Your practice will thrive and your clients will benefit from your expertise.

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The Definitive Guide to Online Therapy

Why All The Concern About Privacy?

It’s generally assumed that if you and a client are video-chatting, it is just the two of you and when the conversation is over it’s over.

Well, maybe not. Not all applications are the same and not all provide the same level of privacy with regards to protecting information.

If you take a quick spin around the Internet, you’ll find a lot of discussion about encryption and debate about using certain applications for online therapy.

Without getting overly technical, encryption refers to the “conversion of electronic data into another form, called ciphertext, which cannot be easily understood by anyone except authorized parties” (What Is Encryption, 2016).

Essentially what you need to know is whether your application protects your client’s information from being accessed inappropriately and without their consent.

As the therapist, it is your responsibility to be sure that whatever technologies you choose meet or exceed privacy requirements for your therapy practice.

In some places, the types of acceptable applications are mandated by regulatory agencies and policies.

For example, in the U.S., applications for use in telemedicine, online therapy and such must meet HIPAA (Health Insurance Portability and Accountability Act of 1996) standards for encryption and privacy.

There has been some debate as to whether the more popular free applications are compliant or not. Those applications may be perfectly fine for your intended use or for your place in the world.

The take away message here is to know your regulatory and licensing requirements before you choose a platform. Again, this is where training can make all the difference for you.

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Where Can I Go For More Information?

Now that you know what online therapy is, what you need and what some of the issues are, what’s next? More information of course! Depending on where you are in the world, you may have access to training locally. In some places, there are certifications for distance therapists. Here are some of the best resources for more information about becoming a distance therapist, training and certification.

American Distance Counseling Association – ADCA is a professional association for counselors who provide distance counselling. The site has information and links to a number of helpful resources. http://www.adca-online.org/

BetterHelp – provider of online therapy services. This site has good information about the provision of services and offers opportunities to apply to become one of their providers. www.betterhelp.com

Talkspace – provider of online therapy services. This site has a blog about online therapy services, as well as an opportunity to apply to become a provider, alongside over 1,000 professional licensed therapists. www.talkspace.com

Training & Certification

In the US:

Center for Credentialing & Education (NBCC)

http://www.cce-global.org/dcc

CCE offers the Distance Credentialed Counselor (DCC) certification for professional counselors. They maintain a list of approved training providers for the DCC credential.

In the UK:

The Online Therapy Institute

http://onlinetherapyinstitute.com/online-therapy-certification/

The Online Therapy Institute offers certification in cybertherapy. They provide a variety of methods for completing training.

Local Workshops – With the increasing interest in online therapy, workshops are popping up everywhere. Some of the online continuing education providers offer programs on this topic periodically. Online therapy content sessions are also becoming quite popular at professional conferences.

Your licensing board – before proceeding with any significant change, it is always a good idea to check with your licensing board to be sure what you are about to do does not conflict with your practice standards. Some licensing boards moved quickly to adopt standards for online therapy. Others are still early in that process.

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We hope you have found the information in this guide useful. Please let us know in the comments below what your experiences with online therapy have been, and feel free to share any advice you may have for other practitioners.

FAQs

Collecting Payments

How do I get paid for delivering therapy online? What are the technicalities? What software/hardware do I need?
In order to get paid online, at a minimum you need a computer with a high-speed, secure connection; a bank account; and a user account with whichever payment processor you choose.

Having an online business presence means that you must have a verifiable bank account into which your payments will be deposited. Some companies may issue paper cheques but this increases the wait time for your money and the service fees are generally higher.

You should choose a user-friendly payment processor. Your client needs to be able to easily select the service for which they are paying and enter their credit card information. If the process is too confusing, then clients will go elsewhere.

If you are in the US, you also need a valid tax ID (Employer Identification Number or Social Security Number depending on your type of business). You can contact the IRS at www.irs.gov for information about the type of tax ID you will need.

If you are outside the US, your country/region may require a similar ID of some sort, such as the UTR (Unique Taxpayer Reference) in the UK. Requirements will vary depending on the country in which you are operating and the base of your operations.

How do I get paid without using PayPal?
Whether or not you need PayPal or another payment processing account will depend in part on whether you are an independent therapist providing online services through your own company website or a contracted therapist providing online services for an online counselling company.

One thing to know about payment processors is that they almost always charge processing fees. These vary quite a bit. When choosing your provider, consider the cost of doing business with them so that you can price your services accordingly.

Payment is generally made via an online portal such as PayPal, Square, Google Wallet or Stripe, among others. Here is a great article about some alternatives to PayPal: http://www.makeuseof.com/tag/online-payments-PayPal-alternatives/.

PayPal is probably the largest and most used payment processor. The main reason seems to be ease of use and name recognition. They also do business in most countries. Their fees are generally not the lowest, but nor are they the highest.

Concern has been expressed about PayPal’s security in various forums. PayPal is probably fine for small amounts of money, but there may be safer options if you are going to be processing larger amounts.

If you are using your own website, you probably use a “shopping cart” type of software. The platform your site is built upon will partly determine what type of payment processing model will work best. It might be PayPal, but you might have other choices. Make sure you collaborate with your webmaster or web designer.

Some online therapy companies using proprietary software use their own payment portals. If you choose to be a provider for one of these companies, you may not need a PayPal or similar account. You may simply need a verifiable bank account and tax ID number (if required in your country). Some companies do require a payment account, and it might be PayPal. Again, it depends on the provider.

Here are some alternatives to PayPal:

Google Wallet – https://wallet.google.com/

A strength of Google Wallet is that payments can be made from any mobile device. It’s user-friendly and generally reliable. Sending or receiving money is free but there is a $500 monthly limit. Users can use credit or debit cards, which can be a plus for clients who don’t have access to a credit card. There is the usual credit card fee (currently 2.9% per transaction), which can change over time.

The biggest downside of Google Wallet is that it is US only. If your business includes international clients, then this payment processor is not for you. The $500 limit may also be an issue if you do a lot of online business.

Amazon Payments – https://payments.amazon.com/merchant

This is one of the stronger alternatives to PayPal. A nice thing about Amazon Payment is name recognition – almost everyone uses or at least knows of Amazon. Amazon’s login and pay system allows users to use their Amazon credentials to make payments to businesses. Because payment is made through Amazon, clients can access their account and make payments on their mobile devices.

Amazon has a good reputation for service and for security. They also offer a number of integrated solutions. It’s definitely one to consider, especially for expanding businesses.

Apple Pay – www.apple.com/apple-pay/

This payment option is similar to Google Wallet. It’s a viable alternative for some Apple users, but it is only available in the US and is only compatible with certain iOS devices. Hopefully accessibility will improve in future.

Stripe – https://stripe.com/

Stripe Checkout is an online payment system that is becoming popular. It is an embeddable payment form for desktop, tablet, and mobile devices. It works within your site – customers can pay instantly, without being redirected to complete the transaction.

Stripe requires an account and charges pay-as-you-go processing fees, like many other payment systems. Some international business is supported. Check the website for details.

Square – https://squareup.com/

Square started out as the mobile payment processor that gave everyone a card reader. They have since grown and now offer a full array of mobile and online payment processing options. Their platform is user-friendly and their per-transaction processing fees are in line with all the others.

Square is currently available in US, Canada, Japan, and Australia but availability changes often with these companies as they grow.

What about international payments?
Beware: Some companies charge different fees for different services and for international payments. Depending on the payment processor, your international payments may incur a larger service fee and may be subject to additional hold and release times.

Some processors don’t accept international payments at all, while others accept payments only from certain countries. The bottom line is that if you are planning to work globally using your own platform, then you have to do your homework and read the fine print.

If you even think you might do international business, look for a payment processor that will support your business. The biggest mistake you can make is to choose a company that doesn’t do international processing only to be offered the opportunity of a lifetime… in another country.

Changing processors can be a headache and can take up way too much of your already limited time. This is where having a good business plan and thinking strategically makes all the difference.

Insurance

What do I need to consider when choosing an insurance provider?
The Golden Rule of working with insurance is this: Just because an insurance company provides a card and benefits (even out-of-network benefits), it does not automatically mean that they cover for all forms of service. Counselling may be covered, but it may be face-to-face only, or it may exclude things like hypnosis, family counselling, or group counselling… the list of exclusions can be a long one.

Another thing to remember is that a list of covered benefits generally will not include the list of exclusions. Again, the covered benefits may say ‘counselling’, but the exclusion of e-counselling, pet therapy or whatever it may be is stated in the separate exclusion of benefits document. Every insurance company has this document, so ask for it if the answers you are getting are vague. Be prepared to read lots of jargon and fine print.

A few insurance companies are starting to recognize the benefits of online counselling. However, this practice seems to be more accepted for telemedicine than for mental health at the moment.

Because there are literally hundreds of insurance companies, each with their own policies and exceptions, the best practice is to contact each insurance provider with whom you are contracted. Ask about e-counselling, or online therapy. Be prepared to use multiple terms to describe it, as there is currently no universally accepted term for e-counselling.

Expect that you may have to work a bit to get to the right person. A customer service representative is not likely to have all the information you need. Your first stop should be the provider relations representative. If they cannot answer your questions, the next stop is the company’s quality improvement or quality assurance representative.

Even if there is a general policy exclusion for e-counselling, the policy may allow geo-access exceptions for providing services when a client is in a severely underserved area or geographically distant location. If you have a potential client who cannot come to you (for example, if they are housebound) or you practise in a severely underserved area, ask for an exception. They may say no, but you won’t know until you ask.

If there are other online providers in your area, they can be a great resource. Ask them if they have had any success with insurance and online counselling.

Anecdotal evidence suggests that a few companies are starting to pay for e-counselling, but the hard evidence is scant. It does happen, but it appears to be more on a case-by-case basis as opposed to routine payment.

Are there limitations around insurance dealing with overseas clients?
Again, in terms of coverage and payment, it is really a company-by-company, client-by-client issue. In general, covered services can be provided to insured members by contracted providers (or out-of-network providers if the client has these benefits). However, some types of insurance have service area requirements. The exception is emergency services, but e-counselling is not considered an emergency service.

Best practice is to check the benefits summary and call the insurance company directly.

*** Regarding your own insurance: before engaging in any kind of online therapy services, you need to check your own professional liability insurance to be sure you are adequately covered to provide such services. Your policy may need upgrading.***

Platforms/Apps

What are the most secure HIPAA-compliant teleconferencing platforms/apps?
Skype and FaceTime are all fine and good for general contact but when it comes to online therapy, the same rules apply to privacy and confidentiality as in face-to-face therapy. The issue of internet security must be first and foremost. While Skype is probably the easiest and most recognized online talk platform, it is not appropriate for online counselling. FaceTime falls into this category as well.

The main issue with platforms like Skype and FaceTime is that they are not HIPAA compliant. Until they are, using them violates HIPAA regulations and calls confidentiality and privacy into question.

There are several sites that are designed for online therapy and offer a variety of service options. Three of the most popular are Thera-link, VSee and CounSol. Doxy.me is another less well-known option. They are all HIPAA compliant and use secure technology.

Thera-link – https://www.thera-link.com
VSee – https://vsee.com/
CounSol – https://counsol.com
Doxy.me – https://doxy.me/features

There are also a number of online therapy services that therapists can become affiliated with. These companies use their own proprietary platforms, are generally HIPAA compliant, and use secure technology. The advantage of being on one of those platforms is that they manage the security of the site. Be wary of any company that is not HIPAA compliant (or similar for your country/region) or does not have a clear security/privacy policy.

How do I ensure security and protect my client's privacy?
Proprietary online therapy programs have security and compliance mechanisms in place. If you are on your own, you have to make sure you have a secure connection and you are using an application that adheres to HIPAA, or whatever the regulatory standard is for your country/region.

Just as in conventional therapy settings, you as the therapist are responsible for maintaining the security of your client’s information. Because you are using the Internet, there is an added risk of leakage or hacking. Privacy cannot be absolutely guaranteed. Always make sure your client is aware of that risk.

To minimize the security risk, make sure your online counselling accounts are password protected and that your computer is secure at all times. Best practice is to use your e-counselling equipment for e-counselling only. But not everyone can afford two computers, and if you fall into this category then you must take extraordinary care to make sure no one can access sensitive information.

Can you conduct group sessions online using these apps?
With some programs you can conduct group sessions. Thera-link, VSee and CounSol all have group session capability.
Is there a suitable online platform designed for therapists that includes an appointment booking system and client database and records?
Yes. Counsol (https://counsol.com/site/package/list/) seems to offer a complete, Cloud-based system. They have lower-level packages available as well.
How do I set up for an online therapy session?
Most newer laptop computers have built in webcams that actually have good resolution. If you are using a desktop or older computer without a camera, you will need to purchase an external webcam. These usually come with the necessary software for installation, and the installation process is generally easy.

There are several moderately priced webcams. Be sure you purchase a camera that is compatible with your particular computer and operating system. Look for one that is HD. You may also want to look for features such as autofocus, video recording capability, and a microphone if your computer doesn’t have one. Some reputable brands to look for are Logitech and Microsoft LifeCam.

In terms of lighting and setting, you want a quiet and secure location. E-counselling requires the same privacy as a face-to-face counselling session. Set your equipment up and take a look at your screen. You should see yourself and a background. This is what your client will see. You can adjust your lighting and background as desired. Pay attention to what is on the wall behind you.

Logistics

How do I get a client to sign consent forms and releases?
Some therapists keep their forms on their website and the client accesses them there. Some therapists email or text the forms. It all depends on how you connect with your clients.

Best practice is to make sure those forms are complete BEFORE you conduct a session.

Always have your client sign an online disclaimer.

Because you are conducting online therapy, you need to make sure that your informed consents and declarations of practices or consents clearly outline the risks of online therapy. It has unique risks and considerations that face-to-face therapy does not.

Make a point of checking with your particular licensing board to be sure you are in compliance with regulatory and licensing requirements.

What's the best way to get a client to sign a document online?
A wide range of platforms are available. Docusign and Signable.co.uk are popular options that both offer pay-as-you-go or monthly payments.

Docusign: https://www.docusign.com/esignature/electronically-sign-documents-online

Docusign is probably the best known document signing service. It works with mobile devices, Google, and Dropbox. There is also a Docusign app and the service is very user-friendly. The cost is $10 per month for the basic package, which includes five documents.

Sign Now – https://www.signnow.com/

Sign Now is similar to Docusign. It works with mobile devices, OneDrive, Google, and Dropbox. It is compatible with both Android and iOS devices. The basic business package is $5 per month. Other packages are available and they offer a free trial.

Hello Sign – https://www.hellosign.com/info/tour

Similar to the other services, Hello Sign also works with Google Docs, Gmail, and other Google apps. Their services description boasts bank-level security. The basic package is free and includes up to three documents per month and full integration with Google Drive. Other packages offer a free trial.

Signable – https://www.signable.co.uk/features

This service offers a pay-as-you-go service as its basic level. Each document costs about £1. The service works with all major browsers (Firefox, Chrome, IE, etc.). It is also compatible with Dropbox. Signable is compliant with the Electronic Communications Act 2000.

Can you put in your own custom terms and conditions on the online therapy platforms?
It depends. Some of the platforms allow for some customization but in general you have to operate within what they offer.

Unless you are connected with one of the online counselling services, you can for the most part set whatever practice parameters you want. If you are operating as part of the service, you are obligated to follow their guidelines.

Hypnosis

Is hypnosis a good idea online?
Hypnosis is currently being offered online by some therapists. Opinions on hypnosis online seem to be mixed. For some cases, it may be appropriate and even helpful. In general, any client who is not a candidate for hypnosis face-to-face is certainly not appropriate for online hypnosis.

As with any potential online therapy client, you want to do a thorough assessment to determine whether online therapy – and possibly hypnosis – is appropriate.

One of the challenges to control for is location. Your location has to be calm, quiet and private. The online client needs to be in a similar location. You may need to have a discussion with your client prior to setting up a hypnosis session.

Because it is different to face-to-face therapy, your client may need some education about e-counselling and its effectiveness, utility, etc. It’s a new way of doing things and some clients are apprehensive.

Is it necessary to tailor scripts accordingly?
The short answer is maybe. Depending on the specific issue and purpose, there may be instructions you need to give for which you cannot see the client’s response due to camera angle and such.

Having a contingency plan for what to do if the connection is lost is a really good idea. It is a very real risk. Especially if you are working with clients in other parts of the world, spotty or unreliable internet service on their end may be an issue. Technology has glitches that we cannot predict and contingency plans are a necessity. One option is to add to your script a sentence such as “If we lose connection you will enjoy a comfortable rest for X amount of time, and then awaken feeling refreshed.”

Safety

What is online therapy particularly good for? What it is less effective with?
Online therapy has been found to be effective for depression/mood disorders, anxiety disorders, stress, PTSD, phobias, relationship issues, adjustment issues, and grief.

A University of Zurich study found that online therapy was more effective for clients with depression than face-to-face therapy (Journal of Affective Disorders, 2013).

A pilot study compared the effectiveness of online Cognitive Behavioural Therapy (CBT) and face-to-face supportive therapy with service members suffering from Post Traumatic Stress Disorder (PTSD) after the September 11th attacks. Those receiving online therapy showed greater improvement. A 6-month follow-up showed that they continued to improve, unlike those who participated in the face-to-face therapy group (American Journal of Psychiatry, November 2007).

Online therapy may also help to reduce recidivism and hospital re-admissions. A Johns Hopkins study of almost 100,000 veterans found that online therapy lowered the number of hospital visits among veterans, by 25%. This was slightly higher than the number of hospital visits experienced by those who used conventional therapy. (Psychiatric Services, April 2012)

Online therapy is generally not appropriate for high-risk clients, including those with severe mental illness or highly acute symptoms such as suicidality or psychosis.

Online therapy may also be contraindicated for clients with certain comorbidities or issues that require intensive monitoring, such as eating disorders or self-injury.

Here is an informative article about assessing for online therapy: http://users.rider.edu/~suler/psycyber/suitability.html

What do I need to be aware of when managing high-risk clients?
The general consensus is that high-risk clients or those with severe pathology are not appropriate for online therapy. You do not have the benefit of the face-to-face interaction to be able to gather non-verbal information. You also run the risk of a suicidal client or a client with an adverse reaction simply disconnecting. You then have to decide how to respond to ensure safety.

If you choose to take on high-risk clients, you should have very detailed and specific safety plans with multi-layered safeguards and contacts. You also need to have clear, identified emergency contacts for wherever the client is. You may never need to use them, but you need to know how get help to your client or execute Duty to Warn if you need to. Emergency numbers (police, emergency medical services, etc.) are easy to find and should be a part of your client’s file.

As part of your online intake, you may wish to have clients provide you with an emergency contact (and consent) to be used if an emergent situation arises.

How do I work with an abreaction – and who would be liable?
Whether you are conducting therapy face to face or online, your liability is the same. You are providing hypnotherapy services as a licensed/certified clinician and have the same level of legal and ethical responsibility.

Anyone who is going to provide hypnosis/hypnotherapy service, whether face-to-face or online, needs to be trained to deal with abreactions. In the case of online services, you must have a protocol in place for dealing with unexpected situations (e.g., if the client disconnects in distress).

How do I reassure clients about the benefits of online therapy?
Clients are very wary about having hypnosis over a virtual medium. It’s useful to have a list of points to cover with them to assuage their fears. This is a really good resource for client-focused information about online therapy in general: http://www.metanoia.org/imhs/.

Share your credentials and training information with your client. You do not want to practise beyond your scope of practice.

Here is some additional information that may be helpful for clients when considering online therapy.

1. Online therapy is not for people who are in crisis. They are in need of more immediate, direct crisis help.

2. Online therapy, just like face-to-face therapy, has risks as well as advantages.

3. Advantages of online therapy:

  • Makes access to therapy easier for disabled or housebound people, and those in remote or underserved areas
  • Generally more affordable that face-to-face therapy
  • Scheduling tends to be more flexible. Some therapists allow clients to schedule their own appointments online.
  • Has been shown to be as effective as face-to-face for many clients, including hypnotherapy.

4. Disadvantages of online therapy:

  • Often not covered by insurance, depending on the individual company and benefits
  • Concerns about confidentiality and privacy. The legal and ethical standards for online therapy are just as high as for traditional therapy. Communicating via the internet does add a layer of risk that information could be hacked.
  • Online therapists are not immediately available to respond to crisis situations.
  • Online therapy is not appropriate for high-risk clients or those with serious psychiatric illnesses.
  • Unexpected reactions, while not common, can result from any type of therapy. Being distant from your therapist means dealing with those reactions may be more difficult or require additional intervention.

5. Working with a therapist via the internet is different to face-to-face. Working with a therapist online means that you need to be comfortable with video conferencing or phone contact and, if using email or chat, you need to be willing and able to express yourself clearly in writing.

6. Honesty is very important in therapy. Whether face to face or online, the therapist cannot help if you hide or omit important details. Share your feelings or any concerns with your therapist.

7. Hypnotherapy online is most often conducted via video conferencing so that you and your therapist have the benefit of visual contact.

8. Your therapist is credentialed and trained in the services being provided.

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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Notes:

References

Day, S. X., & Schneider, P. L. (2002). Psychotherapy using distance technology: A comparison

of face-to-face, video, and audio treatment. Journal of Counseling Psychology, 49(4), 499-

Hull, T. D. (2015, June). A Preliminary Study of Talkspace’s Text Based Therapy. Retrieved

January, from http://talkspace.com/online-therapy/wp-content/uploads/2015/06/Talkspace-

What is encryption? – Definition from WhatIs.com. (n.d.). Retrieved April 20, 2016, from

http://searchsecurity.techtarget.com/definition/encryption

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