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COVID-19: A guide to providing online therapy in private practice

Introduction…

Hello fellow counsellors. Given the developing situation with COVID-19 it’s really quite difficult to think of anything one can do to help in a meaningful way so here’s my contribution to the cause. I thought it might be useful for some of the less tech-savvy of us out there to have access to some information about how to connect with our clients in an online environment to help reduce the risk of infection and spread. Normally I suppose I would keep this kind of thing to myself as we are all in competition with each other to one degree or another but in the current situation it seems like the right thing to do to share some information about how to do online counselling ethically and efficiently in the hope it will enable some of us to keep working and keep seeing our clients in the face of whatever unpleasantness might be around the corner.

I have been seeing clients online for some years now and have considerable experience in working in this way. I have worked with clients from all around the UK and from various countries around the world using a variety of online platforms and found it to be particularly popular with British people living and working abroad as they often feel more at home speaking to a therapist from their native country, sometimes for reasons of cultural similarity or simply because they can often express themselves more authentically in their first language which isn’t always an option for them depending where they are in the world.

Given the current predicament we face with growing numbers of cases of the Coronavirus in the UK, working in this way brings obvious benefits. In private practice we are reliant on good health to maintain our income so I have created this guide and collated some links to practical and operational information for you to access in the hope that it will allow you to continue your good work without putting yourself or your clients at undue risk and enable you to take secure online and card payments too.


Before you start: Ethics, Safeguarding & Privacy

Before we get into the technical details of online counselling, there are some important ethical, privacy and safeguarding considerations to take into account when moving your client sessions to an online platform. It is a good idea to do as much reading and research as you can, discuss it with your supervisor so they know what you’re up to, and of course you must discuss all relevant considerations fully with your clients and undertake some additional contracting to ensure everything is nailed down and you are both happy with what’s going on.

You can make a good start to the process by checking the guidance offered by your professional body on the matter. In my case, that’s the BACP and they have produced some guidance for online working which you can read here, whether or not you are a BACP member: https://www.bacp.co.uk/media/2162/bacp-working-online-supplementary-guidance-gpia047.pdf

Now, before we go any further you need to check that your insurers are ok with you offering your services online and whether they have any limitations on cover or special requirements around this. Additionally, if your clients have come to you through an EAP or you are working under the stipulations of any other organisation than your own private practice you will need to follow their guidelines and probably obtain their permission to make the change to working online. So, without further ado, go and check that out!

Once that’s dealt with… here’s another important consideration. Before embarking on any online therapy journey, you should carefully contemplate whether the needs of each individual client are conducive with working remotely. You will already be aware that some clients have very complex needs and you must use your professional judgement and the help of your supervisor if necessary to decide whether you have any concerns that working in this way could compromise their emotional or physical safety. If you do have any concerns in this regard at all then my advice is simple – don’t do it.

Assuming your client passes that test and you are comfortable going ahead, from a safeguarding perspective in the sessions themselves it is advisable to ask the client to provide their physical location so should anything untoward happen to them you aren’t left wondering what to do about it with no idea of where they are. You should also be aware that there is no guarantee that the client will be in the same location each time you meet so I ask them for this each time at the start of the session.

If it is a new client, consider what information you want to collect from them upfront – should you ask for anything different from an online client than you would for a face to face appointment? Think about what you might need to know if anything unexpected comes up. If a client becomes ill, upset or tells you they intend to cause harm to themselves or someone else and slams their laptop shut mid-session, you must decide in advance and contract with the client for how you will deal with that when you aren’t physically there with them. Is anyone else around who can help the client and do they have any kind of support network where they are? If the client is in another country, you should familiarise yourself with how to contact the police, healthcare providers and any other relevant authorities in that country just in case and this should be discussed with the client when contracting too. The information you ask for should be requested with all these considerations in mind and if you haven’t already, you should also take GDPR into account and detail how the data you collect is stored and used in your privacy policy.

Whilst we are discussing privacy, we also need to address confidentiality as your existing agreement probably won’t be sufficient when it comes to working online. Both you and your client need to consider your own situation and location during the appointments, for example whether anyone can overhear or interrupt the session, and you should be aware of and make mention of the fact that the internet itself has it’s own inherent security limitations. All the online platforms I mention here are mainstream, from trusted providers and are as secure as they can be but if you have any concerns they all have their own privacy policies which I have provided links to so you can find out what data they collect and why before committing to their use. This information should be highlighted to the client as well in case they want to learn more.


Technical considerations…

So, if you’re partial to a bit of Maslow you’ll already understand the importance of addressing basic needs in order to progress past them and this is the case with online counselling too… it’s just that some of the basic needs are a bit different to those you’re probably used to dealing with. In order for online counselling to be successful it is wise to address the technical side of things in advance and I have written this from the point of view that some readers may not be particularly au fait with matters related to the internet so please bear with me if I’m preaching to the choir.

Firstly you should give consideration to your internet connection – is it generally fast enough to watch a TV programme or YouTube video without interruption? You can conduct a speed test on your current internet connection by visiting this address and clicking the ‘GO’ button: https://www.speedtest.net/ and you can find the minimum recommended internet speeds for Skype here: https://support.skype.com/en/faq/FA1417/how-much-bandwidth-does-skype-need. (You can try restarting your device and broadband router if the speed seems slower than usual). It’s a good idea to make sure you’re ‘up to speed’ so to speak as a slow connection will cause interruptions, will make it hard for you to hear and understand each other and will detract from the work you are doing.

Consider also whether you are using a ‘metered’ internet connection. If you are using a mobile device not connected to Wi-Fi there will probably be a limit on how much data you can use without incurring extra costs so you’ll need to make sure you check that with your provider as you could end up with a big bill if you go over the agreed limits.

As for devices themselves, you will need either a laptop, a tablet or a smart phone with a front-facing camera so that you can see the screen and the camera can see your face at the same time. Most modern devices are set up like this already but it’s worth checking just in case. If your phone resembles an Accrington brick, your tablet came from the doctors and you’ve had offers to exhibit your laptop at the Science and Industry Museum then they’re probably not going to cut the mustard in all fairness and it might be time for an upgrade!

You will also need to think about how you wish to be paid for your online counselling sessions since the client won’t actually be there to hand over any cash. I use iZettle which is an easy to use, cheap and fantastic system allowing you to take card payments from face-to-face clients and send secure payment links to remote clients by text so they can either pay upfront or after their session, depending how you work. I’ll discuss that in more detail shortly.

Finally, and fairly obviously, prior to the session you will need to agree on a mutually suitable online platform to use (more on that in a moment), and of course you must ensure that the basics are taken care of. Your device should be sufficiently charged up or plugged in (video calling will deplete batteries more quickly than other activities), fully working, and connected to a reliable internet connection and I would advise testing your set-up(s) on family and friends before launching straight into a counselling session so that you are familiar with how it all works and that everything is operating as it should be. And of course, as we all know, you should never go into any counselling session without having access to a cup of tea so that will need to be taken care of as well! Once all that is sorted you’re ready to enter the world of online counselling.


Choosing an online platform…

You can think of this in the same way as choosing a physical room to see a client face to face; it has to be suitable, private, mutually accessible and fit for purpose. There are many options to choose from out there but I have a few go-to’s which I will talk about here. Which one you choose depends on a few different factors as some of them are device-specific so not everyone can access them, and I find that clients usually have one which they know how to use so often it’s best if you can go with that to minimise stress on them and make the process as easy as possible. The last thing we want to do is to add pressure to a client by making them download apps and sign up to things if we don’t need to.

Here are my top picks:

 

Offered by Microsoft, Skype is free (some features require credit to be added but video calling is free), available on a Windows or Apple laptop and there is a downloadable app for it so you can use it on smart phones and tablets as well. It is not device specific so no matter what device you or your client are using you should be able to connect and you can even share your screen with the client so if you have resources or handouts in electronic form that you might provide in a session to help you to illustrate a point, you can show it to them on their screen. There is also the facility for the client to share their location with you as well so if you are collecting that information as detailed above they can just send it straight to you. As with most Microsoft products there are excellent documentation and help facilities with it and it’s fairly easy to set up. You sign into it with a Microsoft email account so it could be a hotmail, outlook or live account but if you don’t have one already they are also easy to set up. Here are some links for you to find out more:

 

 

If Skype isn’t suitable for any reason, you could always try WhatsApp which, as you probably know, is a completely free messaging app. Now owned by Facebook, WhatsApp offers end to end encryption for security and is available for download to all smartphones and can also be used on laptops (Windows and Apple) so again it is not device specific. There doesn’t seem to be an option for use on iPads without interfacing through a third party app so you would have to consider the implications of that and check any other privacy policies which would come into play should you use them. I use it on my iPhone without the need for any other apps without an issue. It supports free messaging, audio and video calls and is simple, reliable and very easy to use. With 1.5 billion active users in 180 countries, it is well and truly out there and in my experience clients often already use it, but if they don’t it has the facility for you to invite them as a new user. Even if you don’t use it for your client work it’s a handy one to have as you can make overseas calls to other users at no cost so it’s ideal if you’re phoning home whilst on holiday and can be used if you have Wi-Fi but no mobile signal too. Here’s some more information:

 

 

So, your client has never heard of Skype and doesn’t want to get WhatsApp but you both have an Apple device… well you’re in luck! FaceTime should be pre-installed on your Apple device (if not, get it from the AppStore) and gives you the option to make an audio or a video call for free with any other Apple device using their phone number. It is very simple to use, but the main point about it is that it is device-specific so it’s no use if your client doesn’t have an Apple device. Here’s some more info:


Taking online payments…

Now you’re all set up with an online platform, you have dealt with the various ethical considerations and your client is ready to meet you online it’s time to work out how you’re going to get paid for your sessions without actually seeing anyone in the flesh! Luckily that’s really easy to achieve and doesn’t cost much either.

Historically I have used PayPal for this purpose which is fine for online transactions but I have recently discovered iZettle, and to be honest I have never looked back because it’s fantastic.

Basically, you buy a card reader from iZettle that links to a free app on your phone which allows you to take card payments from your clients either by contactless or chip and pin. There is no recurring fee so you just pay a small percentage of each transaction and you can enter cash amounts to charge to the card reader or set up specific products and services really easily so you can then see how many of each type of service you offer has been sold. And because it works with your phone you can literally take it anywhere where you have phone signal or Wi-Fi and it will work so if you do home visits it can come with you.

For online clients who you won’t actually meet you can use the app to send secure payment links by text so you can request payment upfront for new clients to secure their booking, and you can send receipts by text or email too. iZettle then deposit the money into your bank within a few days (with a small fee deducted). It really is very useful, very easy, very cheap and I wish I’d done it years ago. It even links in with accounting software so it makes your book-keeping much easier too. What’s not to like?

Here’s some further information about iZettle:


To sum up…

Online therapy does come with certain unique challenges and considerations but as long as you are aware of them and try to legislate as far as possible for them it is a very effective approach and in the current climate it’s probably the right time to add it to your practice. It can take a little bit of fiddling about to set up and you have to spend some time getting used to using the various platforms but in my experience it’s very much worth the effort.

Since this article was released a few people have asked about other platforms such as Zoom but I must confess I’ve never used it and find that I can get the job done using the ones listed here which are fairly mainstream and widely used, even by people who don’t really do much video-conferencing and the idea behind this piece is to allow counsellors to connect with their clients quickly and easily without having to learn too much in the technical department. That’s not to say that other platforms aren’t just as good or even better than the ones I have mentioned so I would advocate checking out as many of them as you can.

I’d love to hear any comments and suggestions you have so drop me an email to hello@clivigercounselling.co.uk if you’d like to get in touch. I may even be able to offer further guidance and a short online meeting so you can discuss and test your set up and do some troubleshooting if you are having issues but there would probably have to be a small fee for such activities to cover my time. Feel free to ask if you’re thinking along those lines and we’ll see what we can sort out.

I hope this article has been useful for you. I wish you all the very best with your practice and your online adventures. Stay well and thanks for reading.

By Shaun Reade, Cliviger Counselling.