In the past three weeks, we’ve discussed what we know and don’t know about online psychotherapy, and four reasons to move your practice online. As you’ve read, online psychotherapy has a great deal of potential, and may be a good fit for your practice. It does, however, come with some risks to both you and your clients. Here, I’ll address some of those risks and how you can minimize them.
Confidentiality — on both ends
No means of communication is fully confidential. Even in a well-soundproofed office, someone could listen from the outside if they had a powerful and sophisticated enough listening device. Your responsibility is not to find the perfect solution, but rather to take reasonable and adequate steps to protect confidentiality and privacy.
Most therapists give consideration to security and confidentiality when choosing a platform for online work. However, this is not the only place where confidentiality should be considered. In fact, breaches of platforms do not appear to be common. When confidentiality concerns arise in online work, they may be much more mundane.
Consider where you will be doing this work from. If you have a therapy office and will be working from there, then perhaps no more action is needed. But if you plan to work from home, while travelling, or elsewhere, it is worth considering who else may be able to see your screen or overhear your conversation. In addition, clients may mistakenly assume that you are responsible for confidentiality at their end of the conversation. If they are connecting from home, work, or anywhere else, you may want to discuss appropriate measures they can take to protect their own confidentiality.
In a workshop at the 2016 AAMFT Annual Conference, Richard Bischoff and colleagues talked about their work providing therapy via videoconference to clients in three rural Nebraska counties. Despite a great deal of planning and expense in creating secure connections with current technology, that technology still failed with some regularity.
Even if your technology is flawless, that does not mean the network will be. And you have little control over the technology your client is using. For these reasons, it is considered a best practice to plan in advance for technology failure, and to provide guidance to your client about those plans. If your connection drops, who should initiate efforts to reconnect? At what point do you give up on a video connection? Is a phone call a viable alternative?
Inappropriateness for technology-based services
California enacted new regulations for therapy via telehealth in 2016. Among those regulations is a requirement for the therapist to assess the client’s appropriateness for telehealth services at every session. This makes sense: A client who is a good fit for telehealth one week may not be a good fit the next. Their symptoms may worsen. The technology available to them may change. They may have a poor cell signal or network connection. They may have other people around them, making it difficult to talk about sensitive topics.
Assessing appropriateness for online psychotherapy need not be time-consuming at each session, but it should be reassessed to ensure that telehealth services are a good fit for the client’s needs. Clients who are new to online therapy may benefit from being told in advance that this will be a regular element of the beginning of each session.
A common fear among therapists working online (or considering it) is that a client would go into crisis, and the therapist would either not be able to reach that client or would not know how to help them. In an in-person practice, it can be much easier to locate your client and connect them with crisis resources familiar to the therapist.
This risk can be minimized, however, with careful planning at the beginning of online services. Good assessment can indicate what kinds of crisis resources might be most useful. Of course, crises are often unpredictable. So with every client, it is good practice to identify a range of crisis resources local to the client at the beginning of services. Such efforts are in fact now mandated by regulation in California. You may also want to develop a safety plan for every client. Such a plan addresses questions like what the client should do if a crisis emerges and they are unable to reach the therapist.
Ultimately, any therapy practice has risk to it, and any therapy client brings a certain level of risk with them. As with in-person services, these risks can often be managed through careful assessment, strong planning, and good documentation. The AAMFT’s new Best Practices in the Online Practice of Couple and Family Therapy document outlines a number of additional specific steps that MFTs should consider when working online.
Benjamin E. Caldwell, PsyD is a Los Angeles-based Clinical Fellow of AAMFT. He chaired the workgroup that developed Best Practices in the Online Practice of Couple and Family Therapy, which is now available from AAMFT. Have questions about online therapy? Join Dr. Caldwell and Jillian Bashore on May 5, 2017 for a webinar on online psychotherapy hosted by AAMFT. More information can be found here.