Irish Association for Counselling and Psychotherapy
est.1981

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IACP Recommended Approach for Online Counselling and Psychotherapy

Introduction

The guidelines contained in this document are intended for counsellors/psychotherapists who provide therapy and/or supervision using technology or via the internet. The first section of the document (Part 1) deals specifically with the work of counsellors/psychotherapists (referred to throughout as practitioners) who use technology in their work with clients. The second section (Part 2) refers to the work of supervisors who also use distance therapy in their work. They too are referred to as practitioners throughout.

Though the guidelines are primarily intended for practitioners, they are equally relevant to anyone, including service managers, interested in the provision of online therapy. Online provision of psychological therapies is increasingly used by practitioners of various theoretical orientations, and research in the field indicates that many clients value it and benefit from it. This is not to suggest that it can, or should, supersede conventional face to face therapy with clients. Nor does it suggest that all practitioners will wish to pursue technological methods for helping clients, though it is difficult to see how awareness of its potential and usefulness could possibly be avoided. In addition, there are many clients who, for various reasons, find online provision of therapy preferable to the traditional face to face counselling method. There are diverse reasons for this preference, including issues of distance, time constraints or inability to access therapy within a specific area. As technology is evolving at a very fast pace, it would be impossible to provide information here about every facet of it, or to give answers to the many issues which individual practitioners may encounter while using it.

Focus of these Guidelines

These guidelines are of relevance to all practitioners engaging in distance therapy, and should be read and considered alongside the IACP Code of Ethics and Practice for Counsellors/ Psychotherapists/Supervisors.

The following areas are the principal focus of the guidelines:

Practitioner Competence and Training
Contracts and client suitability
Specific issues relating to working online
Professional and legal considerations and issues of jurisdiction
Client confidentiality and security
Protocols for security and appropriate platforms to assure safety and misuse

Methods of communication referred to in the text

As noted earlier, technology and the internet are changing at a rapid pace which means that it is impossible to enumerate the ever-evolving methods of communication it encompasses. However, the purpose of this document is to offer guidelines for good practice in several specific areas and contexts. These include:

Telephone counselling where the context is verbal exchange between client and practitioner, and is conducted in real time
Email: Private written communication between client and practitioner where there is a delayed response. Messages can be composed and sent at any time by either client or practitioner
Generic voice applications: Communication through conversation conducted in real time via the internet
Generic video applications: Communication is both verbal and visual and is conducted in real time via the internet
Instant messaging: Real time programme which notifies when contacts are online. The messages written in return are received instantly
Forums: Delayed response private communication with clients using web based software
FaceTime: A video chat application developed by Apple conducted in real time over Wi-Fi from iPhone or iPad.

Evans (2009) refers to methods of online communication which are conducted in real time as synchronous, and describes communication where there is a delayed reaction as asynchronous (Evans, 2009: 88, 89).

Positive aspects of working online with clients

Online therapy suits some clients, especially those, who, for one reason or another prefer the comfort and seclusion of their own homes. Other clients may value the anonymity certain forms of online counselling provide. In addition, online therapy is by definition, available over a large geographical area which means that clients are offered a wider choice of therapists. The flexibility in terms of timing is also attractive to many clients. Clients with certain problems, including isolation, disability or social phobia, for example, will obviously benefit from the provision of online help. These perceived benefits have certain inherent difficulties for both client and therapist. These guidelines are meant to address a range of issues which are specific to distance technology and the provision of psychological therapies. They are not designed to suggest that this mode of delivery is preferable to conventional face to face counselling and psychotherapy. Most practitioners understand the evolving nature of therapy and concede that it is no longer limited to face to face personal interactions with clients.

1. Practitioner competence and training

1 .1 Online Practice as a specialised area of Counselling and Psychotherapy

Training in the specialised area of online counselling, should, like training in any other specialist area of psychotherapy and counselling, be considered a priority by any practitioner hoping to work in this medium. Weitz (2014) makes the point that ‘both pre-and post-qualification training’ should be regarded as essential for anyone hoping to work in the fast-changing world of online therapy. (Weitz, 2014:14). Courses in pre-qualification training are not readily available in Ireland at present and are limited in number. Post-qualification training is increasingly available and should be considered for all practitioners hoping to work online with clients.

An important point is that some models of therapy appear to work more effectively than others online, this means that the limitations of each practitioner’s theoretical orientation should be a major consideration before making a decision to work in this way. Cognitive behaviour therapy (CBT) appears, for example, to have transferred seamlessly to the internet. It is not difficult to see how this has come about since CBT was well established via self-help programmes, long before it came to be offered in real time by therapists working online. Other theoretical models of therapy may present difficulties and challenges for practitioners hoping to work online. Balick (2014) for example highlights complex aspects of interpersonal communications which may be limited in online therapy ‘in contrast to the myriad of relational cues that provide so much information in real life’ (Balick, 2014:22). This is not to suggest that object relations theory, or any other psychodynamic approach is incompatible with modern technology, but it does point to the multifaceted nature of some theoretical models. It also suggests that the practitioners of these models should consider their suitability or otherwise for online delivery. It highlights too the importance of providing clients with explicit and relevant details about the practitioner’s experience, theoretical orientation and methods of working beforehand. Such information should also focus on any intrinsic limitations a particular approach may have in relation to online working, along with information about what outcomes could be expected if therapy proceeds.

1.2 Practitioner experience

The range of issues clients may bring to therapy online means that inexperienced or novice practitioners are unlikely to be in a position to offer[C1] the kind of support they need. Since online provision of therapy now covers vast geographical areas, potential clients may access any site of their choice, and may do so with a myriad of complex issues. These variables mean that experience and training are essential requirements for anyone wanting to work with clients in this context. Principle 2 of the IACP Code of Ethics and Practice for Counsellors/Psychotherapists makes clear that practitioners are obliged to recognise that their ‘experience and capacity for work are limited, and take care not to exceed the limits’ (IACP, 2014: 1). This stated principle applies to technological ways of working with clients, just as it applies to other, more traditional, approaches in therapy. A diploma level qualification (or equivalent international qualifications) is a desired prerequisite for anyone seeking to work with clients online. However, it is recognised that training in this area is limited in Ireland at present. Experience in face to face practice with clients is also necessary, along with a high standard of competence as stipulated in the IACP accreditation requirements. Other specialist areas of therapy require additional training and experience. These areas include, for example, eating disorders, addictions, and working in a multi-cultural way. Online therapy with clients deserves the same level of expertise and commitment as face to face. It is therefore the practitioner’s duty to be aware of regulatory issues, including complaints procedures, and to inform potential clients of these.

1.3 Specialist training

Specialist training is advisable for any practitioner intending to work online. This training should include the ethical, theoretical and practical dimensions of working with clients online. In addition to the theoretical elements of training, it is more beneficial if such courses also incorporate experiential learning online. Indeed, the delivery online of the training course could have the advantage of permitting trainee practitioners to gain experience of working this way from the outset. Effective work online necessitates proficiency in IT skills, and an awareness of how electronic data and information are stored, along with the ethical and legal requirements of their service delivery. Competence in the maintenance of electronic information and the safeguarding of client records is an essential component of online training courses. Security and confidentiality are basic components of online work, and practitioners should be proficient in the skills necessary to ensure they are never compromised. Evans (2009) describes ‘experience and competence’ in the contracting and assessment of clients from different backgrounds and different presenting issues, as further essential elements of training (Evans, 2009:160). The following is a summary of other essential components of training:

Due to the absence of visual and auditory signals, communication via email presents certain difficulties which are not present in face to face therapy with clients, and necessitates the development of further practitioner skills and training in this context
Understanding of client dis-inhibition: Clients sometimes disclose information and emotion very quickly online. Practitioners need to understand the dynamics underpinning this kind of response so that they can work effectively with clients who exhibit it
Clarification as an aid to understanding. In order to avoid mistakes or misunderstanding, practitioners should be aware of the importance of greater clarification when communicating with clients via email or telephone
Awareness of fantasy and idealisation of the practitioner by the client (which may be erotic or romantic) and stems from the increased transference and projection accompanying online therapy
How to proceed when clients ‘disappear’ through change of email addresses or other contact details
The importance of ‘netiquette’ or the rules of online etiquette, and how this applies to posting messages and replies online
How to maintain a responsible ‘presence’ online, especially in relation to personal practitioner details which may compromise the individual therapist or that of the profession
Some training in the wider ethical implications of working online, especially in relation to the instigation of dual relationships with clients through social networking sites.

1.4 Research

Working in the fast-moving sphere of online technology means that practitioners should keep abreast of ongoing research and development in the field of therapy. Being a member of an organisation or organisations dedicated to the understanding of online mental health research and development is recommended. Examples of these include:

The International Society for Mental Health Online (SMHO)
The Association for Counselling and Therapy Online (ACTO)
The Online Therapy Institute

Familiarity with other online organisations dedicated to providing clients with information about therapy, what it entails and how it can be accessed, is also desirable. One example is:

Counselling and Psychotherapy – Mental Health.ie

All information provided on a practitioner or service provider’s website should be clear, unambiguous and up to date.

1.5 Proficiency in the use of technology

It is the practitioner’s responsibility to ensure that the technology they use is safe and fit for purpose. This includes ensuring that anti-virus, firewall, encryption and spam blocking software are all in place. It also means ongoing maintenance of other technological tools necessary for safe practice with clients. Courses in online practice with clients should include details about the installation of software and maintenance of safety online. In addition, clients should be made aware of system requirements and warned of the risks of technological failure and how to protect against this. As part of the initial assessment procedure, clients should be given all the information necessary to avoid threats to their privacy and to ensure their safety online. This information to clients should include:

The importance of using a personal computer with firewall and anti-virus protection installed
The importance of encryption for ensuring that information received is confidential
The need for password protection for access to computer and email account
To avoid sending or receiving emails at Wi-Fi hotspots unless sure that connection is secure
Checking the ‘to’ address field before clicking to ‘send’

Practitioners are also responsible for ensuring that the technology they use, including all hardware and software, is up to date, stable and capable of functioning efficiently. Though practitioners should be willing to adapt to a client’s preferred software when necessary, this should only be done when the client is made aware of any security difficulties this might entail.

1.6 Accreditation

Training for online therapy is a specialist form of training, and as such should come after the practitioner’s core training is complete. (See sections 1.1, 1.2 and 1.3)

Therapy conducted via technological methods of communication can be used in support of accreditation criteria relating to Continuous Professional Development (CPD) and professional (personal) development. In order to meet the criteria, however, practitioners must demonstrate the following:

Completion of appropriate specialist training and competence to work online with clients; and
Show that work with clients is contracted counselling and not any other activity where counselling skills are used.

It is important to note that courses in online counselling and psychotherapy do not currently meet the IACP eligibility criteria for core practitioner training. However, such training can be used for accreditation application in the same way that other specialist areas, for example, distance learning, can be used. Training for practice online is not recommended for inexperienced practitioners or those without access to continuing support and guidance from experts.

1.7 Supervision and professional support

There are an increasing number of online courses available for trained practitioners who wish to become online supervisors. Some courses offer training to diploma level, while others may be short and conducted over a few days or a weekend period. Practitioners of online therapy have a duty to ensure that their work is adequately supervised in a way that will support their work with online clients. The way in which practitioners receive supervision is a consideration, and may represent a choice between face to face supervision and supervision online. There is currently no firm consensus about which is preferable, though online supervision seems more suitable since it serves to uncover parallel processes and other important dynamics when both practitioner and supervisor are working in the same medium. Supervisors need to have a comprehensive understanding of all the issues, both theoretical and practical, which impinge on the practitioner’s work with online clients. Practitioners too, should understand that they need this level of competence and expertise to support their online work with clients. There are pressures which are unique to online work with clients, which means that practitioners are advised to consider their personal self-care as a valid priority and a necessary prerequisite for maintaining safe practice with clients. Maintaining self-care (and by extension safe practice) includes, among other things, being aware of boundaries, especially in relation to practitioner availability and response to clients. Practitioners should also be aware of IACP guidelines on supervision in their Code of Ethics, which outlines the responsibility of both supervisor and supervisee, with particular reference to the setting and maintaining of clear boundaries. (See also Part 2, Supervision)

1.8 Verification and confirmation of counsellor details

There are certain details which should be available to prospective clients from the outset. These details, which should be clear and specific, are provided in pre-therapy information by the practitioner. They include the following:

The practitioner’s identity
The practitioner’s qualifications and credentials
Information about training bodies relevant to the practitioner’s qualifications
Whether the practitioner works privately or as part of an organisation
Whether the therapy provided is free at the point of delivery or not
Details of affiliation to a professional body for counselling and psychotherapy
Information about which specific guidelines or ethics code for online work the practitioner and / or organisation subscribes to
Verification details of professional organisations should be supplied so that prospective clients may check these. Clients need to know how they can contact professional bodies or organisations to which the practitioner belongs or works
All the information on the service provider’s website should be clear, up to date and accurate.

2 Contracting and client suitability

2.1 Assessment

Service providers of online counselling and psychotherapy have a duty to follow guidelines for identification of clients who are suitable for (and are likely to benefit from) contact online. Some clients may not have the level of computer literacy needed to benefit from online support, while others may lack the communication skills and general literacy required for this medium. Clients, who, because of disability, have restricted access to online support, may not benefit from online provision either. If prospective clients seem unlikely to benefit from this approach, procedures should be in place to guide them towards appropriate help. This rule applies to clients who, for example, may be at risk through self-harm or harm to others, or those who seem beyond the practitioner’s level of competence. Practitioners should be realistic about their own level of competence in certain contexts when assessing clients for online work. Some mental health issues, including psychosis, trauma or severe personality disorders, may prove intractable to online therapy. Additionally, clients who present with ongoing problems of addiction or alcoholism, or those who seem reluctant to comply with the contractual requirements of online therapy, may not benefit from it, but may be encouraged to access alternative mediums of support.

2.2 Informed consent

As there may be difficulties in establishing the truth of certain important client details, including age and capacity to give informed consent, the onus is on practitioners to make reasonable efforts to verify them. This is not to suggest that working online with younger clients is inappropriate. Many practitioners choose this area of work, but when they do they should take extra care to establish additional safeguards about potential clients. Clients who may not be considered minors in one country may, for example, be given adult status in another. When the client is underage the practitioner needs to consider whether, in certain circumstances, a parent or guardian should be informed, or whether consent is required. Anthony and Nagel (2010) point out that payment by credit card or internet payment account is not necessarily proof of adult status, a point that private practitioners in particular should be aware of. Steps should be taken during assessment to ensure that information gained from clients is equivalent to that obtained in face to face work with clients. Assessments may be conducted via online questionnaire or via personal communication or both. Safe practice would suggest that both methods of assessment is preferable, and should be offered free of charge to the client. These guidelines are applicable even when limited services, including, for example, a one-off session, are provided. In this context, it may not be possible to gather comprehensive client details, but adequately informed consent should still be obtained.

2.3 Establishing an online contract

Prospective online clients need to have certain details, including pre-therapy information and contractual issues, and this should be available on the practitioner’s website. In addition, this information should be replicated via email once communication between client and practitioner is established. Clients may quickly scan initial details, including terms and conditions, on a website without actually absorbing all the details, thus the importance of repeating them. To avoid misunderstanding, the language used to convey this information should be clear and unambiguous. If there are financial implications for the client, or for a specific organisation, this should be clearly stated too. The establishment of an online contract can help to reduce the potential for misunderstanding or disagreement between client and practitioner, and can serve as a useful reference point if conflict or misunderstanding arises during the course of therapy. Practitioners need to consider their own boundaries and limitations when working online, just as they would in face to face work with clients. This applies to practitioners working alone, as well as to those working within organisations.

2.4 Contract information

The contract, which sets an agreement between client and practitioner, is the foundation of the relationship. It provides information for the client who will then know what to expect. It also establishes the boundaries of the therapeutic relationship and is designed to ensure that the client understands how the practitioner is going to work. Weitz (2014) considers it an additional and ‘important part of informed consent’ (Weitz, 2014: 175).

The following are specific aspects of working online:

Information about how you work online. Is this done synchronously or asynchronously? Is it done via email, telephone or visual platform?
Details about session booking, dates and times of contact, as well as times of response from practitioner to client. The amount of time per session
Details of security for confidentiality (see section 1.5)
The client’s responsibility in relation to electronically stored or printed material either sent to or received from the practitioner
The ethical framework or code of ethics that you adhere to
Details of fees and how payment is accepted. For example, is payment per session or payment per block of sessions /emails?
What can realistically be expected by the client and what may be achievable through therapy
What should happen in the event of technology failure or an emergency, and what are the alternative means of contact?
What are the arrangements for you or the client if either becomes ill or if someone dies?
The difference between communication used for making practical arrangements, and the content material of therapy sessions. For example, using a mobile phone to confirm or cancel appointments, but not for personal or confidential communication
Policy about sending or accepting email attachments and the use of technological resources including blogging and public forums
General referral procedures and procedures in the event of emergency or crisis and the additional help available in emergency or crisis
Consideration of where the therapy is actually taking place and the applicable law relating to this (See Section 4 inclusive).

2.5 Working with couples, families and groups

There is any number of support groups online which generally operate without a leader. Participants in these groups value the communication, help and shared experience which they receive from other members. In addition, group members tend to value the anonymity which many online support groups provide. However, therapy led online groups is very different, and should not involve the anonymity characteristic of support groups. In fact, the rules of participation and behaviour between members in a therapy led online group, should be just as carefully considered as they are in traditional group facilitation. This applies to all aspects of group facilitation, including intake procedures and the management of conflict within the group as well as the management of endings. Participants should be aware of the terms of membership of the group, as well as the group rules and what happens if there is a breach of these.

It is increasingly possible for practitioners, who wish to do so, to use technological means of working with couples, families and groups. Working online in this way pre-supposes and requires specialist training in traditional therapy with these client group beforehand. Couples, family and groupwork are multifaceted areas of therapy when conducted online and require further in depth training in the complexities of these models. All the ethical considerations which apply to individual therapy with clients, apply also to working online with couples, families and groups.

3. Other issues specific to working online

3.1 Client culture and diversity

Working with clients via email means that verbal and visual cues are absent, a fact that practitioners using this medium need to remind themselves of in their contact with clients. Telephone counselling, which has been available professionally for decades in the voluntary sector help lines, has comparatively recently been adopted for use in contractual therapy, has similar limitations in the sense that non-verbal and visual cues are compromised. This limitation means that highly developed listening skills are essential prerequisites for practitioners working with this form of distance counselling. Practitioners need to understand what verbal pauses or changes in voice tone might mean, for example. These considerations become even more relevant in the context of client difference and diversity.

Technology has made it possible to communicate with clients over wide distances and from diverse cultures both international and local. To communicate effectively with clients in this way means that practitioners have an added responsibility to undertake relevant training in client culture and diversity. The IACP Code of Ethics highlights the central place of respect for the rights and dignity of all clients, including those of different race, ethnicity or national origin, (IACP, 2014:1.1.2). In order to support diverse client groups, practitioners should be willing to question their personal cultural assumptions and the possible impact of these on the people who seek help. Although geographical distance may reduce some practical barriers, cultural issues may be more complex when distance and technology are taken into consideration.

3.2 Crisis situations and client safety

Client safety is of paramount importance in the context of online therapy, and practitioners should address this from the outset by including crisis referral details on their website or homepage. There are a number of organisations dedicated to helping members of the public in crisis, including the Samaritans and Pieta House. The H.S.E.ie also provides a list of out of hours doctors from different areas who are available to help in a crisis. In the Code of Ethics for Counselling and Psychotherapy, IACP indicates that it is the therapist’s responsibility to refer clients to other suitably qualified professionals ‘when it is appropriate to do so’ (IACP:2014:3.3.1). This duty of care applies equally to online work with clients, and practitioners working online need to have sufficient training in this medium to ascertain if a client in crisis needs medical treatment, hospital admission or even Garda/Police intervention. Clients who request online therapy should be given prior information about procedures in place in the event of a crisis, along with details about situations in which these may be needed. (See section 2.4)

3.3 Practitioner responsibility for safeguarding personal information

Along with social networking sites and blogs, the internet encompasses a myriad of possibilities for access to personal profiles and the information they contain. Practitioners therefore, need to be aware that actual and potential clients have access to public profiles and the information which is held on these websites. Practitioners should also consider the fact that they do not have control over personal information written about them. Some of this may relate to their personal as well as professional lives, and can be accessed by anyone sufficiently interested to do so. Those seeking information may include clients and other professionals including colleagues. Bearing these facts in mind, practitioners should ensure that all personal information, accessible to the public, is strictly professional and does not discredit either practitioner or profession. To maintain a responsible online presence implies having policies in place to deal with, for example, client requests for association through networking sites like Facebook, LinkedIn, etc. Policies are also indicated to deal with other situations including the following:

A client who blogs about the therapist and details of the therapy sessions.
Client makes remarks or commentary on the practitioner’s blog
A client posting disparaging remarks about therapy or the therapist
A client visiting, without permission or contract, the practitioner’s virtual reality world or offices, which are specifically designed for therapeutic use. Examples of these virtual worlds include; Second Life, ReactionGrid and InWorldSolutions, though there are many more
A client uses texting in inappropriate ways, regardless of boundaries or contract. This is not to question the usefulness of texting in certain contexts, for example arranging or cancelling appointments

4. Interjurisdictional Practice: Professional codes and laws

4.1 Appropriate standards of practice

Clients do not always live within the same geographical area as the practitioner. The growth of internet technologies means that clients may request therapy from a location outside the practitioner’s professional jurisdiction, and in an increasing number of cases clients may reside in an entirely different country. Provision of therapeutic services across geographical borders means that qualifications, codes of practice and standards may vary from one area to another, and practitioners should be aware of these differences. Regardless of location, practitioners should abide by and uphold the standard of practice required by their own professional organisation. In addition, clients who live outside a practitioner’ jurisdiction should be made aware of these standards and codes of practice. When differences in qualifications, standards and requirements for accreditation do exist across national boundaries, practitioners should take it for granted that both sets of standards apply to their work. Practitioners should review and understand the requirements and relevant laws of the specific jurisdiction in which they wish to provide online support for clients.

4.2 Where therapy is taking place: Applicable law

Section 2.4 points to details which clients should have within a contract and includes consideration of where the therapy is actually taking place and the applicable law relating to this. The British Association Counselling and Psychotherapy (BACP) in their guidelines document (2009) point out that difference of opinion exists as to whether it is at the point of delivery or at the point of supply. Moreover, some jurisdictions stipulate that online therapy is not legal unless both client and practitioner are physically present within state boundaries. As there are differences in requirements for online therapy, practitioners need to be constantly aware of any relevant laws and regulations specific to different areas. Additionally, practitioners should make sure they comply with the requirements or legal stipulations in areas outside their own jurisdiction where they plan to work. This will entail some research into applicable laws and may even require (in some instances) legal advice for added security. (See section 5.1).

4.3 Cases of legal doubt and the client’s responsibility

Clients have the freedom to choose which mode of therapy they feel will be of benefit to them. This range of choice includes distance therapy or technology as a means of accessing therapeutic support. If clients choose to access therapy online they have some responsibility to inform the practitioner (before the contract is formed) about any legal requirements they are aware of, or any other issues applicable to their jurisdiction which exist, and which need to be drawn to the practitioner’s attention. For most clients, especially those apprehensive about embarking on therapy, it may be unrealistic to expect a detailed awareness of legal matters, but it is worth considering their level of responsibility in cases of legal doubt.

4.4 Professional indemnity insurance

Practitioners who wish to work online through distance therapy provision should ensure that their professional indemnity insurance covers their work in this medium, and that it extends to coverage of relevant jurisdictions and the laws which apply in these. Not all agencies which offer insurance for face to face therapy are willing to extend insurance to online practice, which means that practitioners should clarify this before embarking on this type of practice. Many insurers will stipulate certain security conditions that should be met before insurance for online work with clients is granted. It is worth stating that practitioners who engage in distance therapy as part of their practice should understand that they may be subject to regulations and laws in the client’s jurisdiction as well as their own.

4.5 Websites and intellectual property rights

Practitioners need to ensure that their website content does not contravene anyone else’s intellectual property rights. This includes copyright, domain names, logos, art work and trade names. In addition, practitioners should not imply endorsement of their work by a particular organisation, including IACP, except when this is authorised, or trade on the reputation of others.

4.6 Payment for online work

In section 2.4 (contract information) we saw that clients need information about fees and how these should be paid. This information forms part of the contract between client and practitioner. Practitioners need to ensure that online systems provided for payment are secure and reputable.

5. Confidentiality in relation to data protection and storage

5.1 Risks and possible infringement

Practitioners who provide online services for clients must protect and maintain confidentiality, especially in relation to the data and information relating to them. This is an ethical requirement in every model of therapy, it is especially significant in online work. This [C2] mode of delivery is particularly vulnerable to breaches of confidentiality. Maintaining the protection needed pre-supposes that practitioners are well informed about the potential risks to confidentiality before using online technology. Practitioners can only acquire this knowledge through prior training as set out in sections (1.3) and (1.4.). Further information about data protection can be obtained through consultation with technology experts in this field.

Potential risks to confidentiality may occur during use of search engines and participation in social networking sites. Practitioners must be aware that any information on the internet can be intercepted by a third party at any time or by someone (including a relative) with access to their personal computer.

Practitioners must inform their clients about the limits of confidentiality, including the risk of possible access to, or disclosure of, confidential information which can occur during service delivery. Included here is the risk of access to telephone calls or email when practitioner and client are communicating via either of these mediums. Online supervision is another area vulnerable to loss of confidentiality when data and stored information is not adequately protected. Practitioners should be aware of Irish law on data protection: this is included in the Data Protection Act 1988 (as amended by the Data Protection (Amendment) Act 2003) and deals with data protection for phone, email, SMS and internet use. Section 51 of the British-Irish Agreement Act 1999 is also of relevance in relation to cross-border matters of data protection.

5.2 Confidentiality and security safeguards

Practitioners working online need to consider how best to work securely so that confidentiality is not compromised. Online client confidentiality is just as important as it is in face to face consultations with clients. Online clients who are at risk, or those in crisis situations, are covered by the same guidelines as those in face to face therapy. Practitioners must inform their clients about the possibility of disclosure in certain situations, when working with them online. Clients should also be informed and consulted if case material is used in supervision or research. Several other important points arise in relation to client confidentiality and online data, including the following:

Practitioners must maintain electronic records in accordance with relevant laws and statutes. See Risks to Confidentiality (5.1)
Clients should be informed about the way records are stored and protected electronically
Practitioners should assess if a client is aware of any third party who might wish to intercept their communication, and arrange for referral if necessary
Clients should be asked about their computer access and warned that security may be compromised if using a work, library or cybercafé computer
Encryption and other security measures should be assigned to records
Password protection should be in place and changed regularly so that access to confidential electronic messages is restricted. Especially important is the use of password protection for opening email attachments
Practitioners who are in doubt about specific security issues should seek relevant professional help on devising and maintaining online systems which are required for client confidentiality
Organisations have specific systems in place for holding and protecting client data. Practitioners who are employed by organisations should comply with the specific requirements dictated
Websites should include policy detail about the security measures in place, and any circumstances in which data could be shared or disclosed
Practitioners should regularly check that electronic links are working and are appropriate for professional use
All confidential printed material, including emails and client information should be safely stored in line with security measures for client face to face notes as indicated in the IACP Code of Ethics (IACP, 2014 :1.2.8.)

Conclusion

In order to be fully informed about the importance of maintaining client confidentiality, practitioners should be aware of any wider implications which impinge on their work, especially in relation to the possibility of outside access to client information. The Freedom of Information Act 2014 requires the Health Service Executive (HSE) and other public bodies to publish certain information on their activities, and to make the information they hold, including personal information, available to citizens. Legal obligations on practitioners to submit to a court of law[C3] , transcripts of their communication with clients, in circumstances as required by law, must be taken into consideration in online therapy as they would in more conventional methods of therapy. The IACP Code of Ethics and Practice (2014) gives guidelines for situations in which client confidentiality may be broken, and for practitioners working online this is a starting point and guide (IACP, 2014: 1.2.4).

These considerations mean that online practitioners must take special care and exercise vigilance when using distance technology to work with clients. This extra vigilance is especially important when storing and maintaining confidential client information. There is every reason to suppose that technology will become even more advanced and perhaps more complex in the future, which suggests that awareness of its developments, requires ongoing training for practitioners of online therapy. All the advantages of technology should be considered against its possible limitations, especially in relation to client confidentiality.

Part 2: Online Supervision: Guidelines

Introduction

In its Additional Code of Ethics and Practice for accredited supervisors of Counsellors and Psychotherapists IACP defines the nature of supervision, along with many of the functions which supervision provides. This document should be read alongside the IACP Additional Code since much of the information contained in that original document underpins and complements the guidelines for online supervision as set out here. All practising therapists are obliged to undertake supervision as part of their work. This requirement ensures that clients are protected and that supervisors and supervisees develop additional skills and knowledge. There are obvious differences between face to face supervision and distance supervision, and the main purpose of these guidelines is to highlight them, and to point to the unique features of online work which necessitate further discussion.

Online supervision is increasingly the method of choice for supervisors, although training for this approach is still relatively new. On the other hand, there are more courses available for trained online practitioners who wish to become online supervisors. This may be the result of increased demand from practitioners with experience of online work, or it may indicate that experience gained during online therapy with clients is seen as a desirable prerequisite for training in online supervision. Either way, it seems likely that demand for training will result in the provision of more courses for supervisors who wish to specialise in online work.

Earlier (in section 1.7) the way in which practitioners of online therapy receive supervision can mean a choice between face to face work and online supervision was considered. Although there is no firm consensus about which is preferable, there is much to be said for online supervision of practitioners who work online. There are several reasons for this, the first being that supervisors should have an understanding of all the theoretical and practical issues which impinge on a practitioner’s online work with clients. Additionally, online supervision is more likely to uncover, for example, parallel process and other dynamics when both supervisor and practitioner are working online.

1.0 The case for online supervision

Many of the reasons listed in favour of online therapy with clients are applicable to online supervision with supervisees as well. Supervisors or supervisees may be geographically isolated, for example, or supervisees may prefer to work with a supervisor who shares the same theoretical orientation or specialism. Additionally, there are supervisors and supervisees who like to work online because it suits their individual circumstances and affinity with the technology used.

1.1 Training for online supervision

Training in distance supervision is obviously desirable for supervisors who wish to work in this medium. The current IACP Supervision Requirements for Accredited Members includes use of video followed by review, as an acceptable form of supervision. (IACP, 2014:1). Online supervision represents an extension of this basic technology, and increasingly other modes of communication, including audio visual recordings and transcriptions are used by supervisors to facilitate supervisees as well as themselves.

Experience in face to face supervision is a seminal requirement before embarking on distance work with supervisees. As a corollary to this, experience and training in therapeutic work with clients is essential too. Supervisors need to demonstrate competence in the use of technology before they contemplate distance work with supervisees. People who use technology on a daily basis may presuppose they are competent in most areas of it, but online supervisors need to be conscious of the risks as well as the benefits of using technology online with supervisees. Supervisors also need to engage in ongoing training throughout their work in order to keep abreast of emerging technologies and services.

1.2 Forms of online supervision

Online supervision can take different forms and it is important to state what these are. Weitz (2014) lists these as:

Supervision of online therapy taking place online
Supervision online of face to face work
Face to face supervision of a supervisee who usually works online
Group supervision or one-to-one supervision
Asynchronous or synchronous supervision
A mix of face to face work with online work (Weitz, 2014:172).

Group supervision obviously presents its own challenges not least of which is the specialised training and experience it requires, even before online training is undertaken.

1.3 Further factors in online supervision

Online supervisors and their supervisees need to consider a range of factors which arise from the work they do. These factors include many of those described in Part 1 of this document.

Included here are issues of confidentiality and data protection, password security, encryption packages and privacy tools, and the vital consideration of client consent.

2.0 Online identity and Security

Supervisors and supervisees who work online should be confident that they are aware of certain details relevant to their relationship and the work they are doing. Included here is awareness of each others actual identity and credentials. Qualifications and competence to practice must also be clarified, either through face to face discussion between supervisor and supervisee or via telephone link or other media. The relationship between supervisor and supervisee who work together online should be based on transparency and trust. This means that confirmation of qualifications, training, registration numbers and membership details of professional organisations can be verified by either party before supervision begins. Online supervisors should disclose, to the supervisee, their experience and training in online work, as well as any difference or disparity in their training which may prove inconsistent with IACP accreditation criteria. As noted in section 1.2, (Training for online supervision)) specialist training in online work is recommended for supervisors who wish to practise in this medium. Experience of working online with clients is a pre-requisite too. In some situations, online supervision may be used in addition to face to face supervision. This may be alongside other technologies such as telephone or video conferencing. See section 1.3, (Forms of online supervision).

2.1 Legal and ethical considerations

Both supervisor and supervisee should ensure that they understand, and work in accordance with, the legal, ethical and regulatory requirements of the jurisdiction in which they practice. These requirements should be recorded and documented for reference purposes by both supervisor and supervisee. Requirements for liability insurance (and any stated restrictions) should also be noted, along with the requirements of accrediting bodies in different jurisdictions, if applicable. Institutional and legal policies may dictate the way in which sensitive information is recorded and stored in different geographical areas and jurisdictions. This means that supervisors and supervisees should be aware of, and comply with, expected customs and laws governing confidentiality insurance, data protection and storage. See also Part 1, section 5.1 which deals with data protection matters. With the possibility of extending online supervision to more distant geographical areas, supervisors and supervisees may need to research beyond local policies governing data protection and storage. Another area for consideration is the mandatory reporting of criminal activity which may entail different reporting procedures in other jurisdictions. Supervisors and supervisees need to familiarise themselves with these important details.

2.2 Online supervision and contracts

Supervisor and supervisee should discuss and establish an explicit contract, detailing all aspects of the online work they hope to do. As part of the contract both parties should discuss the benefits and limitations of working online, along with how best to maximise its potential while minimising any risks it may present. Contract negotiations should include the following: Goals, fees, payment details, frequency of contact, roles and responsibilities, and dates for review of the contract. Contact details for the supervisor should include address, telephone number and email as well as emergency contact information for the supervisee. Particulars of qualifications held by the supervisor along with details of licences and other relevant credentials should be clarified too. In addition, the supervisor should discuss their particular areas of competence (including distance work) for which they can provide experienced supervision. The supervisor’s approach to supervision and the model used is relevant here; so too is the issue of how potential conflict in the relationship might be addressed. The limits and scope of confidentiality in the supervisory relationship is a focus for discussion. Security and the technology in place to protect it should also be discussed by both parties.

2.3 Methods of communication

Supervisor and supervisee should negotiate agreement about the methods of communication they are likely to use. This is especially important when both parties live in different time zones, where, for example, asynchronous methods of communication may suit both. In addition, supervisor and supervisee should discuss how frequently communication between them should occur, and share their views on what they regard as a reasonable response time. All these details should be written down along with the relevant methods of distance supervision they plan to use. Social media and other methods of communication which are not encrypted are not suitable for conveying confidential information. Both supervisor and supervisee should discuss and differentiate between methods of communication that are acceptable and those that are not. It is the responsibility of both supervisor and supervisee to ensure that their chosen methods of communication are protected from unauthorised access and that the technology used to achieve this is appropriate and adequate for the purpose.

2.4 Technology failure

Working online as a supervisor implies a sound and working knowledge of the technology in use. This is especially important in the event of a sudden or temporary breakdown in connection between supervisor and supervisee. Such an event is likely to cause anxiety to both parties, so an ability to rectify minor technological glitches is essential if satisfactory online communication is to continue. To minimise the possibility of technological problems, therefore, the supervisor should acquire the requisite skills independently of their online work with supervisees, preferably via online training, and the use of technology in other contexts or with colleagues. Evans (2009) points out that one of the difficulties of acquiring new skills in this field of technology is that it necessitates another ‘person or persons to interact with’ in order to develop these skills (Evans, 2009:20).

Perhaps the most important point to make about potential technological failure is that the possibility should be discussed by supervisor and supervisee before it happens. In this way, both parties can agree a strategy for coping, which might involve waiting a certain length of time and then either phoning or texting in order to rearrange suitable contact.

3.0 Arranging contact

Face to face supervision involves arranging explicit schedules for meeting which may be weekly or every two weeks, with little or no contact apart from this. Online supervision is obviously different and in this context instant or random contact is possible, but obviously not desirable. This means that agreement should be reached about levels of contact between supervisor and supervisee before work online begins. (See section 2.3, Methods of communication) Agreement about contact is especially relevant in the context of sudden emergency consultations. Both parties need to agree beforehand about what happens if such a situation arises. One option, as outlined in the BACP Guidelines for online Supervision (2009) is for the supervisee to email an encrypted account of the client’s issues along with suggested focus for a live session.

3.1 Keeping records

The contract between supervisor and supervisee should make explicit how records will be kept and who is responsible for keeping them. In addition, access to records should be discussed along with agreement about how and when they should be discarded. The storing of records and their eventual disposal should be in accordance with data protection legislation. See Section 2.1 (Legal and ethical considerations)

3.2 Security and confidentiality

Confidentiality and security are major considerations in online work. Supervisors are aware of the guideline in face to face work, and these apply equally in online supervision too. However, online work is different in the sense that there is no absolute guarantee that internet communication is always secure. There are some areas of particular importance where special care should be taken. The first concerns client security where details, including names, addresses or any other identifiable information should never be used in communication between supervisor and supervisee. It is possible to identify clients by a code name, and this is one way that supervisor and supervisee can address the difficulty of reference. In addition, communication from clients should be safeguarded and must never be redirected or forwarded to anyone else without the client’s clear and explicit consent.

The second point concerns supervisor/supervisee agreement about the storage and logging of information. Again, communication should never be forwarded to anyone else without the consent of everyone involved in it. This consent should be explicit and clear. There are exceptions to this principle, the first of which concerns grievance procedure as set down in the contract. The second exception involves the risk of serious harm. Any disclosure of communication should be acknowledged and recorded.

We know that online security of communication can be compromised at any time, either through technological mishaps or deliberate unauthorised access. It is important, therefore, for supervisor and supervisee to use safety measures including passwords and encryption to safeguard case material and other sensitive data. If breach of confidentiality does occur, the client should be informed as soon as possible, with the proviso that doing so will not cause irreparable distress or harm. This is a decision that both supervisor and supervisee must gauge carefully, but the general principle is that anyone affected by it has a right to know if confidentiality has been breached.

The IACP Code of Ethics stipulates that client confidentiality can only be broken where there is a risk that clients will cause physical harm to themselves and others (IACP, 2014: 1.2.4). This guidance on disclosure applies to online supervision too when harm to self or potential criminal offending is disclosed. In these instances, information should be shared with the appropriate authorities. If supervision is taking place across jurisdictions, both supervisor and supervisee should be forewarned of legal requirements in relevant areas.

3.3 Looking to the future: Research and training

Research and further training are essential components of conventional supervisory practice, and become even more essential in the context of distance supervision. This is because of the evolving nature of technology, its complexities and the increasing opportunities it provides for those who want to use it. To keep up with these changes, supervisors and supervisees require in as much as possible, not just basic online training, but also regular and ongoing refresher training, combined with research. This requirement ensures that supervisors keep abreast of the technology, but it also serves to inform their skills and knowledge base about the many factors which impinge on distance practice. Included here are legal issues and those relating to requirements for different jurisdictions and training organisations, along with any changes taking place within them. Supervisors who are committed to working online should consider membership of professional online bodies. This will enhance their proficiency and provide contact and support with other online professionals. The Online Therapy Institute is one organisation which fulfils the criteria for support and information, and another is the International Society for Mental Health Online.

3.4 Further Information.

The following reference list contains further information about reading material and online resources which are applicable to both practitioners and supervisors.

References

Anthony, K., & Nagel, D. M. (2010). Therapy Online: A Practical Guide. London: Sage Publications.

Balick, A. (2014). The Psychodynamics of Social Networking. London: Karnac Books.

British Association for Counselling and Psychotherapy. (2009). Guidelines for Online Counselling and Psychotherapy. (3^rd edn) London: BACP.

Evans, J. (2009). Online Counselling and Guidance Skills: A Practical Resource for Trainees and Practitioners. London: Sage Publications.

Irish Association for Counselling and Psychotherapy. (2014). Code of Ethics and Practice for Counsellors/Psychotherapists. Dublin: IACP.

Irish Association for Counselling and Psychotherapy: First Time Accreditation. (2014). Dublin: IACP.

Irish Association for Counselling and Psychotherapy. (2014). Supervision Requirements for Accredited Members. Dublin: IACP.

Weitz, P. (ed) (2014). Psychotherapy 2.0: Where Psychotherapy and Technology Meet. London: Karnac Books.

Online

Ethical Framework for the Use of Technology in Supervision (2014) Online Therapy Institute. Available at: www.onlinetherapyinstitute.com.

International Society for Mental Health Online (2014) Available at: www. ismho.org

Association for Counselling and Therapy Online. Available at: www.acto-uk.org

Data Protection (Amendment) Act. (2003) Irish Law on Data Protection + British / Irish Agreement Act (1999) Available at: www.dataprotection.ie

The Irish Freedom of Information Act (FOI) 2014 + The freedom of Information (amended) Act (2003). Available at: http://foi.gov.ie

The Health Service Executive: For out off hours GP listings. Available at: www.hse.ie

Further Reading and Resources

American Psychological Association (APA) Available at: www.apa.org

(For articles about online therapy)

Untangling the Web: (2014) Available at: www.dailymail.co.uk

(For article about the effectiveness of online therapy)

Adlington, J. (2009). Online Therapy: Reading between the Lines – A Practical Based Guide to Online Counselling and Therapy Skills. London: MX Publishing.

Derrig-Palumbo, K., & Zeine, F. (2005). Online Therapy: A Therapist’s Guide to Expanding Your Practice. New York: Norton.

Jones, G., & Stokes, A. (2009). Online Counselling: A Handbook for Practitioners. Basingstoke: Palgrave Macmillan.

American Resource – www.telehealth.org/ACA

ACA Code of Ethics Preamble

Tele Skills – H.1.a

H.1.b

Software should be HIPAA compliant for contacting anybody in the USA (Facetime and Skype are not acceptable).

Skype, Text Messaging, Chat Rooms, Face Book, Yelp are not recommended as they can provide a written record of the session which may be used in other fora and are not HIPAA compliant.

When you use a particular platform, you can request a Business Associate Agreement or other cloud providers as it makes them liable for hacking.

N.B. When you are dealing with an American Citizen you are governed by the HIPAA protocols even if the Citizen is based abroad.

Last reviewed: June 2017

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