Allie Scott, BACP (Accred), PMCOSCA, ACTO

Within the world of counselling and psychotherapy right now there is an awful lot of pressure on therapists to transition their work to the online environment – this is all very well and good but actually nowhere near as simple as might be hoped! Online counselling consists of a range of relatively new practices, and the implications of its application go beyond simply that of manner of delivery. A Skype conversation is not simply a normal conversation limited by the view, nor is email therapy simply a counselling conversation converted in to text.  While online counselling offers clients greater anonymity; flexibility, and control. Research tells us that client disclosure happens more quickly due to the very nature of online work and that therapeutic writing can enhance self-reflection and this reinforces the message and solutions presented within a session.     

I first undertook my online training a number of years ago and have been managing a tertiary education service within The University of the Highlands and Islands since that time. I converted from a face to face practitioner to an on-line practitioner over a period of months, I deliver both synchronous (face to face via skype) and asynchronous (email) therapy, and am still developing my skills. It took time to find my rhythm working on line, to get over my anxieties and to feel confident and comfortable engaging with clients through the varying mediums. There was a lot to learn and experience, and I had the luxury of time to do this. 

It is important to highlight that online counselling comes in different modalities each with inherent benefits and challenges: synchronous sessions, which take place in real time (e.g. Vsee/Zoom), Instant Messenger, and asynchronous sessions which breaks the interaction in to a series of communications which are passed out and for with a delay e.g. Email.   

Working online presents a number of challenges to even a skilled therapist. The lack of visual cues (unless using video conferencing where even then the view may be distorted), misinterpretations of written communications, the therapists unable to respond to crisis situations – especially suicide behaviour, and that online work is not appropriate for some clients or the issues they bring.  Even practicalities such as ensuring the clients’ insurance covers working in this medium. 

Online communication may also impair the therapeutic skills of an experienced therapist.   This is particularly the case in email counselling which necessitates a unique toolkit in order to work professionally and successfully with client, due to the absence of visual and auditory cues. When in face to face work, we work hard to being rapport by matching the client; mirroring body language, speech pattern and tone, posture, breathing and other cues. With online work you have to have the skills to do the same; paralleling the responses given, especially in the first session, paraphrasing and reflecting what has been said.  You need to also find your own way of expressing self to the client, I often write my thoughts in brackets (smiling at this) or (I notice I am holding my hand to my chest). Online communication/expression brings a different dynamic and therapists need to be highly attuned to their own competency in responding to issues. They also need to be able to provide a sense of containment whilst also facilitating a positive outcome for therapeutic work. The thoughts and feelings of the client have to be held safely within the online exchange, as they would in face to face work.  

I am a pluralistic therapist and feel that pluralism works well in the online environment by responding to client needs, offering collaborative conversations from the outset, drawing on the client’s cultural resources and helping to highlight and develop mechanisms, to ensure safe practice.  This also help to ’hold’ the client in between session exchanges.  Although it should be noted that this process, along with the whole process of therapy, needs to be actively shared and negotiated with the client. Pluralistic Practitioners need to be mindful that this can be facilitated or diminished depending on how the online environment is used.     

One of the key features to be mindful of in online working is how quickly clients may disclose very sensitive information from the outset, where they feel less restrained and able express themselves more openly.  This has been such a pervasive phenomenon that it is now termed the online disinhibition effect.  This can be quite unnerving for therapists and takes a while to get used to.  It also takes skilful practice to navigate the level of detail supplied in a single session to ensure safe practice. 

Each mode of working online requires a different type of skill and takes a while to get used to.  Most online therapists prefer one mode over another. Using a video conferencing platform (e.g., Zoom/Vsee, or other platform such as Microsoft Teams) is the most like face to face work, but it is critical to talk to clients about privacy and confidentiality, ‘netiquette,’ and what will happen in the result of an IT failure of some kind. Instant Messenger, whereby you work in real time with the client is as energising as face to face work and a lot can be covered in a 50-minute session. But again, privacy, confidentiality, and netiquette all need to be clear from the outset. Email therapy offers the client flexibility on how they want to engage and when (which may be particularly important when sharing a home during lockdown). It provides you with a client’s way of being, their character as written, clearly laid out on the page, where their nuances in writing style can help to pick up on what they find compelling, and what is not being said.  But the scope for miscommunication is there, and the therapist is given the opportunity to hold a permanent representation of the dialogue, which can be a far more powerful tool that trying to capture the fleeting meaning of utterance. The email therapist however needs to be confident in expressing themselves online, to be sensitive to the inferences made by their manner of writing, and to be clear and frank to prevent any ambiguities. 

Being an online counsellor is something that takes time to develop. My skills are certainly much more honed and attuned to the ways of working online than they were when I first started.  Entering a relationship with a client online is a unique way of interacting.  Over the years I have developed a way of deciphering text, being able to reflect and write my responses with confidence and without overworking it.  In order to gain a level of authenticity I tend to just write my responses and send – overworking a response is not, in my opinion, the best way to deliver online therapy.  I wouldn’t spend 10 minutes in a face to face session deliberating on the right choice of words, and therefore I tend to write in the same way I would speak in a session… often maybe not finishing my sentences or using humour when discussing something that warrants it.  My narrative character is similar but not the same as my face to face character, and my adaptation to my clients takes on a different frame.  Aspects of rhythm, textual complexity, and sophistication all take on greater meaning, and developing this takes time as you become a therapist in this space. 

Just because you are a therapist does not mean you can be an online therapist; I have known a number of highly skilled therapist who have undertaken online training and subsequently realised that this was just not for them.   

I worry about the use of therapy online by untrained counsellors because there is scope for this to go very wrong. Once something is written down and sent it cannot be retrieved.  Careful and skillful consideration needs to be applied to ensure the client is not left holding something ambiguous or damaging. 

 I think that, given our current situation with coronavirus, lots of therapist will be practicing therapy online which is not in line with ethical guidelines and without a supervisor who is skilled and trained in working within the online environment.   We can assume that all therapists wish to do what is best for their clients, and in the immediate using whatever platform is available might feel like the right thing to do. Therefore, to do the best by our clients; it may be unethical, given the current climate to suddenly cease working with clients and to not engage with any new clients who may be struggling an have no other sources of support.  But we would be complacent to assume that just because we are competent face to face therapists that we are equally able to make the transition to online working. 

I will give you a metaphor, as a result of our current situation I have had to cut my boys hair – to be honest it wasn’t a bad job – they look presentable (if you don’t look too close).  I’ve watched them get their hair cut plenty of times, I read up about using clippers and I spoke to a few friends who are hairdressers – but I am not a hairdresser and cutting my own fringe several times a year doesn’t count!, and although passable it is obviously not an expert job.  I think this sums up how I see counsellors working in the online environment without proper training, that on the surface it looks ok but when you start to really focus in you can see it’s all a bit rough around the edges.

Therefore, I would propose that working via Zoom/Vsee or a similar platform would be an ideal offering, ensuring re-contracting around confidentiality and privacy of working together in a new mode.  I think where possible Therapists who have had no online training should avoid offering therapy via written exchanges.  

I would urge anyone who is thinking about working online, or being asked to work online with their clients to do their research; undertake training to ensure the safety of your clients and following the guidance around working online from ACTO and BACP.  It is imperative to understand the difference and the challenge of working online with clients. 

There are a number of training courses available; Jane Evans is offering one day workshop on Saturday 2nd May for those counselling practitioners are wanting to include online counselling for their clients.  Kate Anthony is also offering a 1-day workshop which has been created specifically for emergency reasons in reaction to Covid-19 to help the mental health profession.