Moving your therapy practice online - Part 1.
Are you a therapist that is having to move your therapeutic practice online due to COVID-19? If so, this article is for you.
Whether you work for a service or for yourself this article will tell you which areas you need to address to ensure you practice safely, ethically and legally online.
Once you have finished this article move to Part 2: Practical tips for your first online sessions, and then Part 3: A tutorial in using Zoom for therapy over video link.
If you are looking for a resource to share with your clients to ease their transition online as well click here.
This article is UK focused, however, it will outline the main points you need to address irrespective of where you work.
Adjust your insurance to include online work:
Call your insurance provider and ask them to update your professional indemnity policy to include online therapy. Ensure you state how you will be providing therapy, i.e. over the phone, text, video link or other.
Check with your insurer which jurisdictions (countries and states) you are allowed to work in as each country has a different law around who can practice there.
If you do not yet have professional indemnity insurance ensure you arrange this now. Recommended insurers in the UK include: Tower Gate, Howden Group and Hiscox although there are others.
If you are working with the NHS, employed or as a volunteer, and starting work online you still need to have indemnity insurance cover. Check with your service to see whether you need to purchase this yourself.
Ensure you meet other legal requirements including data protection:
Online work usually involves a high volume of personal data. You must protect the personal data you receive in line with national legislation.
If you are working in the UK or the EU, you must store all client data in line with GDPR legislation. Go to the ICO.org.uk website to gain more information and to register with them. Registration is essential.
If you need GDPR and ICO compliant software to help you protect and store your clients’ personal data and notes try Write upp or Sugarsync.
If you are not in the UK check the data protection legislation local to where you practice.
Additional measures: Now most of us are on lockdown in our home we have all our client data with us. If you do not live alone you must protect your client data with further steps. For example, don’t leave your laptop or other device open in shared spaces and do not save client’s contact details or identifiable information on your phone.
For people in private practice you are legally required to create a privacy notice that tells your client how you will protect and store their personal data - For guidance on how to create a privacy notice for work inside the UK and EU click here or here. For work inside the USA click here. Share this with your clients and ask them to sign and return it to you before your first online session. Keep a copy in your records.
If you are working from home within the NHS context please check with your service how you are expected to store client’s personal data.
Stick to the ethical standards set out by your profession’s regulatory body:
While working online we must continue to comply with the legislation and guidelines set out by our professional regulatory body, and any other national legislation set out around online practice.
In the UK, the BACP and UKCP have created official guidelines and competencies for online working. Please check with your regulatory body to see if they have specific guidance. You can find additional resources to help you with ethical working online through the Association for Counselling & Therapy Online.
If you are working in the United States of America click here for guidance.
Top tip: Create an information pack for your clients that includes the details of how you work, cancellation policy etc. and importantly, which regulatory body you belong to.
Decide how you will share information and resources with clients:
Arranging appointment times and sharing non-personal information can be done using most email providers. However, risks arise once personal information is shared.
Try an end-to-end encrypted email such as Proton Mail - which is also safe enough to use for email therapy - or GDPR compliant file sharing application We Transfer. Password protect your documents to add another layer of security.
You can also share resources during sessions with clients if you use GDPR compliant software Zoom (video call software) - Zoom offers many functions including video call, integrated direct messaging and file transfer. This will be discussed further in part 3.
Be mindful that current circumstances mean that your clients may not have a confidential space. Consider this before sharing any resources or information.
Choose your medium:
You can speak to your clients over video link, voice call, instant messaging, email and/or text. To choose how you will work you need to consider:
the medium you feel most comfortable using
the software available to you
the technological ability and psychological needs of your client
the level of privacy your client will have access to wherever they are.
If a client has no access to a private space do not opt for video or voice call. Choose instant messaging, text or email.
An overview of each modality:
Therapy over video call - This the most similar to in room therapy. You can see each other, hear each other and share and create visual resources.
Recommended software option includes: Zoom. Skype can be used but there are concerns around security.
Therapy on Voice call - Direct contact but no visuals. This medium poses serious implications for risk assessment. Be mindful about how you assess risk without any visual information, for instance in cases of domestic violence or when a client has undisclosed anorexia. Click here for further resources on therapy by voice call.
Recommended software options: Landline or Zoom (audio only).
Therapy over Instant messaging - This offers direct contact without audio or visuals and may be the safest form of communication if your client is unable to talk confidentially at home. Again, you will need to consider how you will manage risk assessment through this medium.
Recommended software options include: Zoom or Signal
Therapy over email - This option is quite different to in room therapy. Your client will email you and then you respond within the agreed time scale or vice versa. If someone pays you for a 50 minute session once a week then you will spend that length of time reading their email and responding. The benchmark word count for this length of time is 750 words. If you use this medium consider how you will manage risk when contact is not instantaneous. For instance, before you start working with a client gain their consent to contact specific services or chosen people should a risk issue arise.
Recommended software options include: Proton Mail.
Therapy over text - This is similar to therapy over email.
Recommended software options include: Signal.
Whatever software you choose you must ensure they are compliant with your local data protection legislation, i.e. if you are in the UK or EU, your software must be GDPR compliant, or if you are in the United States of America it must be HIPAA compliant.
Additionally, make yourself aware of any safety concerns linked to the software you are using. For example, Zoom has experienced an unexpected surge in users due to COVID-19, and there have been concerns about ‘Zoom bombing’. See this article from Zoom for more information and how to protect your sessions.
Plan for glitches:
The internet sometimes disappears and phone lines cut out. Create a backup plan to manage this before you start seeing clients.
For example, choose a second software option that does not rely on the same form of service to function. If your main medium is Zoom, which relies on internet service, your backup software could be Signal, which relies on phone service. Communicate both options and your plan to your client.
When internet glitches occur it can feel stressful at first. If you plan for them in advance it will be ok. Also, glitches are often temporary. Take a deep breath and see whether they resolve themselves before jumping into your back up plan.
Plan how you will manage risk:
There are issues of risk specific to online work. For example, what will you do if your client hangs up partway through an appointment? Or, what will you do if a risk related issue comes up in the session and you are unable to keep the client in the room with you until the situation is resolved?
Before you meet with someone ensure you know how you will manage this.
Gather clients contact details, GP details, and an emergency contact (the details of a chosen friend, family or relative) before you meet a new client. Explain to your client that you will contact their ‘chosen person’ or GP should you not be able to reach them or should something arise that causes you concern about their safety or that of another. Discuss this again in the initial appointment to ensure that you are both aware of this plan.
Ask your client to confirm their location at the beginning of each session. This way you know their exact address should you need to call someone to your client’s aid.
Create crisis plans for and'/or with each client if there are known areas of risk. Plan ahead of time exactly how you will address this.
Engage an online supervisor who can help you manage this further.
Bear in mind, online therapy can mean you miss certain pieces of important risk-based information. For example, it can be easier for someone to hide information from you in this space. Therefore ensure your risk assessment is ongoing.
Address boundaries early on:
When you start working online you may notice a change in the boundaries between you and your clients.
For example, you no longer meet your client in an office but instead invite them into your home (virtually). Or, you may now be giving people your email address or other contact details usually reserved for friends and family.
These changes can make therapy feel less formal affecting how you or your client show up. You may notice that you or your client sit differently, dress differently, speak differently, reply to correspondence in a less than timely fashion or conversely start messaging excessively, and start feeling it is ok to start sessions late.
Address boundaries early on. For example:
For video calls: ensure that your home office space looks professional and you are dressed in the same way as you would in an office. This will also help you maintain focus and your work mindset if you are working on the phone or text.
Ensure you contract with your client how much contact you will have. E.g. “we will speak over video link at our allotted time once a week. If there are issues around scheduling you may email me however I will not respond to therapy-related issues outside of the session”. Stick to this.
For more information on boundaries click here.
Get online supervision:
To help you transition online effectively and adapt your therapy practice to this new space engage an online supervisor.
If you are in the UK, you can find a list of supervisors with additional qualifications in online work here.
Setting up peer supervision with other therapists using online software can be a great way to skill share and increase your confidence.
Summary
You now have the main points covered for setting up online.
For anyone who is currently feeling deskilled or worried by this sudden need to shift to online work, please remember, you are already a qualified therapist. You already have all the skills you need to connect with and support your clients. Once you understand the technical aspects of online work you will feel confident again.
For specifics on how to prepare and conduct your sessions head to part 2.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I am a Clinical Psychologist trying to get effective psychological advice out of the therapy room and into everyday life.
If you found this article useful and want to learn more about why you feel the way you do, and how to cope with whatever life throws at you… Pre-order my book “A Manual For Being Human”, which is out on July 8th.
Also, connect with me on Instagram for daily posts to help boost your mood. :)