COVID-19: Transferring your therapy practice online temporarily

First up: Don’t Panic. You can do this.

Or, actually – take a moment.

Bring your attention to the part of you that is panicking. This isn’t the whole of you; you are still functioning. Let that part of you that is feeling anxious know that you hear it. Say to it “No wonder”. Anxiety is normal, and it’s OK. And you can hold the anxiety and carry on with other stuff.

DISCLAIMER: I should mention that I’m just a therapist who happens to do a lot of online work. I’m not qualified to train other people to work online, and I don’t recommend switching your practice online on a permanent basis without specific training. This is an extreme situation and I simply want to offer reassurance and practical tips at a time when there is a lot of uncertainty and anxiety.

So here, in no particular order, are some things to think about if you’re planning to transfer your practice online, or even if you’re wondering if you can. I’ll add / update things as I think of them.

Insurance

Check that your insurance company will cover you for online work. They don’t all do this as standard, but even if not, they will probably offer it as an optional add-on – in the current situation even if they didn’t before.

Check registration body guidance

Most of the registration bodies provide at least some guidance around online working. It may also be helpful to check out the competencies published by the Association for Counselling and Therapy Online here.

Supervision

When in doubt – talk to your supervisor! You can discuss your caseload and your sense of yourself working online and explore doubts and fears. Consider whether you have at-risk clients that online working wouldn’t be suitable for. You might want to discuss whether your Clinical Will is up-to-date, at a time when many people are going to get ill. Your supervisor should be able to help you decide on how competent you feel to work in this way from an Adult position.

You could also consider extra supervision from a supervisor who has expertise in working online (if your existing one doesn’t). Check out ACTO-approved online supervisors here. Who do you know that works with clients online who could offer some peer support?

ICO & GDPR

Most therapists are registered as Data Controllers with Information Commissioner’s Office (ICO). If you’re not already then you need to consider whether you should do so at this point as you are likely to have at least some personal information stored / processed electronically.

Added 25.03.2020: You may also need to consider note-taking, particularly if you work for an agency where notes are stored on the premises. Do you have lockable secure storage for your notes in your house? What might you need to consider in terms of secure electronic storage? I use a cloud-based secure client note system called bac-pac, but there are other types of secure client-note software too – ask around to see what other people use.

Platforms / software

It is generally understood in the online counselling world that Zoom is the best choice for working with clients. There are various reasons for this which centre around security of calls and data security,  which you can read more about if you want to here. VSee is another option which is more secure than Skype, but, like Skype, you have a contact list which means client data is at risk if you get hacked. (Note: there has been talk about VSee restricting new free accounts but they still seem to be available as at 19.03.20.)You don’t have this with Zoom. (And if you have clients who ‘don’t like online’ but are happy with phone counselling, you can use Zoom for audio calls too.)

However, I have heard that Zoom has been struggling because of the additional load as everyone moves online. So, we are talking least worst here at least in the short term, and it’s good to have a back-up. My personal preference is to use Zoom and then to let the client know that we will use WhatsApp as a back-up, checking that I have the right number for them; this means I have their number to hand – belt-and-braces if we need to go to phone counselling.

If you work with groups or offer group supervision you will need to pay for at least a Zoom Pro account – the free account only offers group calls up to 40 minutes.

Security

Added 25.03.2020: It goes without saying that you shouldn’t be using the same password for your Zoom account as any other account and if you’re working more online than normal, cyber-security is an important principle to consider. Use different passwords or pass-phrases for every different log-in that you need and don’t write them down. Consider investing in a pass-phrase storage system like Keeper or something similar to ensure that client data isn’t vulnerable.

Added 01.04.2020: There have been stories about people trolling Zoom rooms or ‘Zoom-bombing’ where someone keys a random string of 9 digits into Zoom in the hope that it will just happen to be the ID of a meeting. The chances of finding their way into a meeting that’s actually running at that time are pretty slim, but there are a few things you can do to protect yourself and your clients.

One is, obviously, only send the meeting link to people you want to be there! Another is to enable the ‘waiting room’. This means that your client will have to wait for you to let them join the meeting but crucially, means that you would see anyone else who tried to get into the meeting. You can also set a password which means that someone with the meeting ID – but without the password – wouldn’t be able to access the room. The password is encrypted into the link you send your client, so you don’t need to communicate it separately. And finally, if you set screen-sharing options to host-only, then even if someone was to access the room, they wouldn’t be able to share unwanted images.

Planning and physical set-up

Many of us are used to spending at least some time online or at a device of some sort. Don’t assume that you need to be set up with a PC and camera. You can use Zoom from a mobile device too – phone or tablet. You can make a phone stand out of cardboard like the one below.

It’s important that you consider lighting and background. Your face needs to be visible to the client and you probably don’t want a view of your socks drying on the radiator behind you.

My preference is to use headphones or earbuds because they cut out any noise interference from my end, and ensure no one elsewhere in my house can hear the client. I encourage clients to do so as well – sometimes there’ll be feedback of my voice from the speakers at their end which can be distracting.

The main thing, of course, is that you have a private and confidential space with a good enough internet connection. The easiest thing may be to find a colleague in the same boat, set up your Zoom accounts and call each other, then you can feed back on each other’s ‘space’.

Added 23.03.2020: Remember to account for any ‘smart’ devices you have in your house. Law firms are highlighting concerns with client confidentiality where Alexa or similar devices may be listening in to conversations. Don’t forget to turn devices like this off or make sure they’re out of earshot of wherever you’re working. Think about other potential interruptions like deliveries, house phone ringing etc. Olivia Djouadi has written a helpful article about practicalities here.

online counsellor working from home

Prepare yourself

When I first started working online, I had a check-list that I used to make sure I had everything to hand when I sat down. This included things like ‘shut doors, earphones, pen, phone, diary, water’. This is particularly helpful if where you normally sit at your computer doesn’t feel ‘appropriate’ as a client space, for example you might want to sit on the sofa with your laptop on the coffee table instead, so a checklist can help you have things to hand.  

It’s also helpful to plan what you’ll do if there’s a problem with the technology, to have a back-up plan.

Emma Cameron has created an online therapist daily checklist.

Lucy Hyde webcam counselling

Help the client to prepare

Remember this is new for the client too, to relate to you in this way. They may be used to FaceTimeing friends and family and it’s going to be helpful for them to be reminded that this is something different. Reassure them while acknowledging that you are not an expert – you are modelling being Good Enough!

I send an info sheet to all my online clients before we start working together (and have done so with in-person clients who are moving to online work) to help them prepare their ‘room’. It’s important that they, too, have a private and confidential space. Reminding them of the importance of taking time to ‘get into the space’ before and afterwards can be helpful as they won’t have their usual travel to you.

Re-contract with clients

You should make your client aware that nothing online is 100% secure, even though you are taking precautions. I include a paragraph in my online working contract around the limitations to security and advising clients not to use shared computer equipment or communicate in environments where there is a lack of privacy.

I’m also explicit about online counselling not being suitable for working with certain issues, such as suicidal thoughts or acute mental illness, and that I will support clients to other sources of help if these arise during our online work and we can’t meet. This is a slightly different scenario to when you already have an in-person relationship but it’s still important to talk about what you/they might do if emergency support is required.

Be clear with clients about the difference between face to face and in-person work – that some of the usual sensory cues are absent so that there is a greater opportunity for misunderstanding each other.

And – agree what you’ll do if there’s a technology fail.

Payment

If you normally do cash or cheque, you’ll need to think about how the client pays you. I offer payment by bank transfer or PayPal. PayPal charge commission but some clients are more comfortable with this way of payment so for me it’s worth it to offer the option. Make sure that you communicate to the client that payments by PayPal are subject to PayPal’s privacy policy. There are other options for electronic payment out there so ask around.

Client presentation & online disinhibition

Clients may present differently when you are working with them online and you will both need time to adjust to this. If you’ve ever found yourself marvelling at the ‘flame wars’ that arise on social media, you’ve experienced the online disinhibition effect. The particular relevance in online work is that clients can ‘expose’ themselves more due to the perceived distance from the therapist, that they reveal more of themselves, which can be beneficial.  

However, it can also have a negative impact on the client because they can say more than they later feel they wanted to and feel shame or want to retreat. Here we are talking about someone you are already used to working with and you can help them pace themselves. You can read about the online disinhibition effect here.

Remember self-care!

Be aware of your limitations. Make your workspace as comfortable as you can – it may only be temporary, but if you’re sitting at it for hours a day, it’s going to have an impact on you physically. Take regular breaks from the screen and from your seat.

Remember you’re likely not to be moved around as much, if you’re used to travelling to and from your place of work so be mindful of this when you’re scheduling clients in and make time to move around, go out for a walk or do some crazy dancing on the spot if you’re in self-isolation.

Counsellor self-care

It will be OK

It’s OK to acknowledge that you’re not tech-savvy – your client didn’t contact you because they thought you were a technical wizard. You are not expected to be an expert, don’t be afraid to not know. It’s OK to ask. These are extreme circumstances and you are looking to balance the risk against the benefit. Refer back to your guiding ethical principles to remind yourself what is in the best interests of your client and yourself. Don’t let Perfect be the enemy of Good!

You are going into the not-knowing together with the client in this as with the rest of your work. Allow it to be a bit weird. Bring yourself back to core principles that you work to and to your self-awareness. These will serve you in this uncertainty as they always do.  

And finally – invest in training!

A reminder that there is lots of great training out there for working online with clients. Don’t be tempted to think after a few weeks of working with clients online “Oh, I know what I’m doing know.” Committing to a proper training course is essential if you decide to do this on a more permanent basis. Look here for information about training courses.