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2 Technological, legal, ethical and practical considerations

2 Technological, legal, ethical and practical considerations

This section discusses the technological, legal, ethical and practical considerations of engaging in counselling online.

2.1 Security and confidentiality

A core ethical requirement of counselling is that it is done securely and confidentially (BACP, 2018, section 55). However, it needs to be understood that ‘absolute security in the digital world does not exist’ (BACP, 2019a, p. 6). What this means is that counsellors need to take steps to maximise the security and hence confidentiality of any data from clients. Activity 4 will help you learn more about what this means.

Activity 4: Maximising data security

Timing: Allow approximately 10 minutes

Match the following security aims with the recommended actions listed below:

Using the following two lists, match each numbered item with the correct letter.

  1. Protection against an electronic data breach by the provider/platform

  2. Protection against an electronic data breach by third parties

  3. Protection against a physical data breach

  • a.Use providers and electronic platforms that meet the privacy and quality standards for healthcare digital communication

  • b.Ensure that communication with clients cannot be overheard or seen

  • c.Avoid using unsecured Wi-Fi; keep firewalls and virus protection up-to-date; use password protection and encryption; work with clients to ensure that they are also taking steps to protect against a data breach

The correct answers are:
  • 1 = a
  • 2 = c
  • 3 = b

2.2 GDPR, contracting and insurance

GDPR compliance with online working

Counsellors and counselling organisations in the UK must already comply with the General Data Protection Regulation and the Data Protection Act 2018 (GDPR) – further information about this can be found in the further resources  section.

One of the requirements of GDPR is that anyone who processes personal data needs to take sufficient steps to protect it from a physical or electronic data breach, as you explored in Activity 4. Another requirement is that clients explicitly consent to the counsellor keeping counselling-related data: this may have implications for counsellors who are moving to working online with clients for the first time.

Consider this further in Activity 5.

Activity 5: Data when working online
Timing: Allow approximately 10 minutes

Answer the following questions in the space below:

  1. What data do you normally collect about the clients that you work with face-to-face?
  2. Is there any data that you might need to collect from your clients in order to work online that you do not normally hold, such as an email address or additional phone numbers?
  3. Are you storing data about clients in a differently way compared to how you would usually? Perhaps you are you storing data electronically rather than on paper, or using your own PC rather than one in the counselling centre?
  4. Is your online therapy creating data that is different or new for your practice, such as text-based counselling content?
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Discussion

If your answer to any of these questions suggests that you might be collecting or storing new or different data, you may need to amend your counselling consent form and data privacy information to reflect this. You may also need to think about taking additional steps to ensure the security of client data: for example, do you have a child who sometimes uses the computer you now use for online counselling?

Do you need to recontract/change how you contract?

As suggested above, you may need to amend existing contracts in order to meet requirements related to GDPR for online counselling. You will also need to discuss with clients exactly how you will engage in online counselling. This includes not only how you will work together (for example, which platform?) but also:

  • ground rules and boundaries for communication (for example, is email contact only for communicating about appointment attendance, and how quickly are counsellors expected to respond to client communication?)
  • agreeing on a ‘plan B’ if the agreed means of communication fails (such as talking on the phone rather than a video call)
  • discussing confidentiality of online counselling, including what the client needs to do to maintain their data security, and how the counsellor manages security and issues related to GDPR
  • how to keep a formal record of consent given by clients to the terms and conditions of the online therapy.

It could be useful to create a written document to send to clients that includes this kind of information, possibly as additional clauses to your existing contract.

Are you covered to work online?

It is also important to check that your professional liability insurance covers you for online work, as well as any limitations to such cover – for example, for clients who do not live in the UK. Organisations that are moving to online working should also check their own insurance.

2.3 Assessing counsellors’ competence for online working

As Fiona Ballantine-Dykes suggested in her welcome message, a critical ethical requirement for all counsellors who are moving to working online with clients is to assess their competence to do so: in other words, are you able to work safely and effectively with clients online? It is important to discuss this with your supervisor.

Activity 6 explores this further.

Activity 6: Working online with clients

Timing: Allow approximately 20 minutes

Listen to this extract of a conversation between online counselling specialist Sarah Worley James and Sally Brown, editor of BACP magazine Therapy Today, as they discuss how counsellors should decide about working online with clients.

Download this audio clip.Audio player: clip_1.mp3
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Transcript

SALLY BROWN:
So how do we assess which clients are OK to work online? Obviously, as I said earlier, it’s extraordinary circumstances at the moment, and I think a lot of our members are in a position where they don’t want to work online, but they want to support their clients. And this is the option that’s open to them, is to complete the work online so they can continue with work for the clients.
And so a lot of the members, they’ve established a therapeutic relationship with the client that you’re working with. And they’re also very experienced therapists. So from that point of view, they are taking their knowledge about how to hold the client safely in difficult times.
They’re taking that and they’re translating that to, admittedly, a new medium. But one in which they’re working with a client who they know – they’ve established a relationship with. But also, the client is also aware that these are extraordinary circumstances.
SARAH WORLEY-JAMES:
Absolutely.
SALLY BROWN:
And I think those factors need to be taken into consideration. I hear what you’re saying about the importance of training. But I guess my concern is: you said most courses are 80 learning hours. We’re in an emergency situation; therapists need to support their clients now. They don’t need to say, ‘OK, well, I hear you’re in crisis, but can you just hang on for the next six weeks while I do this 80-hour training course and then we’ll pick up?’ OK, I’m being a devil’s advocate here –
SARAH WORLEY-JAMES:
Absolutely.
SALLY BROWN:
– I’m wondering what you have to say to members who will say to you – and they will say this – which is, ‘I’m experienced, I know how to hold the client, I have a therapeutic relationship with this client. The client knows that it’s extraordinary circumstances. But maybe when we move our work online, there may be some teething problems and some hitches, but we’re prepared to work through them. In that circumstance, are you then still saying to me it’s not safe to do this?’
SARAH WORLEY-JAMES:
What I’m very conscious of is, absolutely, we need to be flexible while being very considerate of those ethical considerations. Thinking about our own competencies, as you said – our experience level, our familiarity with technology. So what I’m conscious of is, there’s a balance there between being flexible while not feeling, perhaps pressured, to work in a way that feels uncomfortable. And also taking that time to work out with the client what’s going to work for them. What kind of support might they need?
So for example, I’ve had a session this week with somebody who’s normally face-to-face, and we had a webcam session. And obviously what most people would be thinking, well, that’s as close as you can get to you’re actually seeing somebody. But of course there was a lot we talked about in terms of how it felt for that client to not be in the room they’re normally in, which feels very safe for them. ‘Being suddenly at home with other people in the house, am I going to be overheard? Part of my issues that I'm working on are these relationship issues, and actually that person's in the next room. I'm not sure how – I'm feeling inhibited to work as fully.’
So there will be significant changes to be discussed and worked through. Some clients might feel ‘No, this is fine, I‘m not overheard. It feels a bit odd being in my own home when I’m normally in the therapy room.’ And you can work through it, but it might be quite a lot of discussion. Other clients might find they try that and go ‘No, it just doesn’t feel comfortable enough.’
So what you can also be thinking about is, ‘Well, what other ways can I support my clients at this time? Rather than it being therapy, do I want to offer them checking-in support sessions? Focusing on their coping strategies, focusing on how are they maintaining support connecting to their support network. What other online support websites, apps, might they want to start connecting to in order to build a broader range of support around them during this time?’
So it’s thinking more widely beyond from counsellor to counselling sessions. Is that actually appropriate for that client at this point? Is that what they want?
End transcript
 
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Sally argues that counsellors and psychotherapists should – in the emergency context of coronavirus – not be discouraged from working online with existing clients if those counsellors fall into which of the following categories?

a. 

The counsellor is already working with the client.


b. 

The counsellor is struggling financially due to coronavirus.


c. 

The counsellor is being told by supervisors that this is what they need to do.


d. 

The counsellor is experienced.


e. 

The counsellor does not want to abandon clients in a time of national emergency.


f. 

The counsellor has an established therapy relationship with the client.


The correct answers are a, d and f.

Discussion

Abandoning clients is of course ethically wrong (although risk related to abandoning clients must be balanced with the potential risk related to working in a new way) – but this was not mentioned by Sally in this extract. The negative financial impact of coronavirus on counsellors and psychotherapists, as well as counselling organisations, is unknown at the time of publication (April 2020), but it is likely to be huge. However, ethically the decision to work online at this time must be driven by the client’s needs, rather than those of the counsellor or organisation.

What does Sarah suggest that anyone moving their work with clients online needs to consider?

a. 

‘Do I have password-protected Wi-Fi?’


b. 

‘What is my level of competence?’


c. 

‘Do I have a private space at home that I can work in?’


d. 

‘How familiar am I with technology?’


e. 

‘What is my experience level?’


f. 

‘How can I securely process online payments?’


g. 

‘Will my online practice meet ethical requirements?’


The correct answers are b, d, e and g.

Discussion

The practical aspects of providing counselling online are of course important, but Sarah suggests that the core factors that should drive any decision about engaging in online counselling are ethics and competence.

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2.4 Assessing (existing) client appropriateness for online counselling

It is, of course, not just the counsellor’s suitability for working online that needs to be assessed. It’s also critical to consider whether online therapy is the right medium for the client.

What factors might influence this decision? Activity 7 explores this question.

Activity 7: Client suitability

Timing: Allow approximately 15 minutes

Look at the following statements. Are they suitable for working online?

(Don’t worry about the notes that read (T), (P) and (PS) – these will be explained in the discussion at the end of the activity.)

The client has a laptop with a camera and headset that is password-protected and has up-to-date virus protection and secure Wi-Fi. (T)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

The client is not able to easily express themselves in writing, for example due to arthritis or dyslexia. (P)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client has sufficient hearing to manage phone and video conferencing. (T)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

The client is not experiencing any issues with reality testing: that is, they are able to objectively evaluate their own feelings and thoughts against external reality; this is distinct from a state of psychosis. (PS)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

The client is very keen to engage with online counselling and says that the best time to have an appointment is in the morning, while they are looking after their five-year-old twins. (P)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client is not presenting with high risk, for example related to suicide. (PS)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

The client is not able or willing to provide you with GP contacts, emergency contacts and details of emergency services in their area. (PS)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client has difficulty accessing space at home where they can talk without being overheard or interrupted. (P)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client has sole access to a computer, tablet or smartphone. (T)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

The client is anxious about using computers, smartphones and the like. (T)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client’s main presenting concern is their partner, with whom they live; the client talks about how controlling and jealous their partner is. (PS)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is b.

The client and counsellor have agreed clear and appropriate steps about how to proceed in the event of an emergency. (PS)

a. 

Potentially suitable


b. 

Potentially not suitable


The correct answer is a.

Discussion

It is important to assess suitability along several dimensions:

  • (T) = Technological: Is the client open to and comfortable with working online? Do they have appropriate equipment and technical skills?
  • (P) = Practical: Does the client have a suitable space to engage in online counselling – is it private, where they will not be overheard or interrupted, for example by children or partners?
  • (PS) = Psychological suitability: Is the client presenting with an appropriate level of risk for working online? Is there is a clear agreement about steps to take in the event of an emergency? Are there any factors in the client presentation that might make accessing counselling from their home potentially risky?

In relation to psychological suitability for online counselling, the BACP’s competences for telephone and e-counselling (2016a, p. 4) state that it is important to assess for psychological difficulties and presenting problems that may make it harder for clients to make effective use of telephone and e-counselling. These include:

  • clients who need a high level of care and support
  • clients struggling to function
  • clients who present a high level of risk (such as suicide or self-harm)
  • evidence of poor reality-testing
  • evidence of strong transference reactions that may be difficult to contain
  • evidence of a tendency to challenge boundaries and/or present in a fragmented and inconsistent manner across time or medium of communication.

Pause for reflection

Does the current context have implications about how risk might be both assessed and managed for your clients? For example, consider changes in how GPs or mental health services are currently offering services. (This may not be relevant for your work with clients – but if it is, you might consider discussing the implications with supervisors and, if appropriate, clients.)

You should now move on to Topic 3: General considerations for online counselling.