To do or not to do, that is the question: an ethical issue to consider when working online with a client

Pip Weitz

In the December 2019 issue of Therapy Today BACP discussed a number of ethical dilemmas concerning working online. Pip weitz picks up the first dilemma and discusses what the BACP team missed in the discussion and why that might be.

Let’s start with the dilemma, which appears relatively straightforward issue at first glance:

‘One of my clients is going to be working away from home for six weeks. She has asked if we could have a couple of online sessions while she is away. She is concerned that she will lose the momentum to make changes if she has such a long gap in the middle of her sessions. My supervisor has asked me to think carefully about whether I should do this as I have not had any specific training in working online. However, if I think about putting my client first, I can see that, for her, it would be good to respond positively to her request. Are there any rules around working online with clients?’

Before you reading on, decide whether you would work with this client or not whilst they were away, and park that decision, given the information provided above.

This dilemma was followed by a very useful discussion by the BACP team:

“Delivering therapeutic sessions online requires additional skills and a different set of competencies to working face-to-face. You can find the telephone and e-competences framework on the BACP website (see details below).

Whether you work face-to-face or online, the relationship is central to the work you do. Ideally, you would undertake some additional training. Some questions to think about are:

·        what do you think the differences might be in working online?

·        what kind of contract or agreement might you need for this kind of work?

·        how are you going to maintain the boundaries of sessions?

·        how are you going to maintain confidentiality? The available platforms for videoconferencing have very different privacy settings, and you will need to ensure the one you use is secure. In face-to-face work, you can ensure that the setting is private, and you need to be able to provide that same level of confidentiality when you are videoconferencing.

·        what impact could working in this way have on your therapeutic relationship?

·        how will you deal with any technological breakdown that might occur?

Your supervisor has expressed concern about you working in this way, and I think it might be beneficial to work through their concerns with them. You are facing an ethical dilemma – you can see the benefits for your client, but you are not sure that you are competent to work in this way. It may be helpful to work through this using an ethical decision-making tool such as the one on the Ethics Hub.

With regard to the Ethical Framework, ‘Putting the client first’ (Commitment 1) is a two-fold commitment:

a) Making clients our primary concern while we are working with them, and;

b) Providing an appropriate standard of service to our clients.

Sometimes, ‘putting the client first’ means explaining why you cannot do something they have asked of you. If you do not feel that you are competent to work in this way, then it is important to say so and to think through what else you could do to help your client maintain progress while she is away.

If you decide that, with support, you can offer her this service, it might be a good idea to have a practice videoconferencing session before she goes away, so that you can iron out any glitches and she can give you feedback on whether this is going to be helpful to her.”

There are two items that I would like to highlight that this discussion completely overlooked and that are critical to consider when working online:

Thinking about where the client is, as any change of jurisdiction requires a great deal of thought. We can’t even talk about UK law. The laws even between Scotland, Northern Ireland, and England and Wales are sometimes different, let alone the different laws in different countries. Knowing where the client is, is critical and not to do so, may even put a person’s life in danger outside the UK. We are not told where the client is, but imagine one of her issues was around her discovering that she is a lesbian, receiving online therapy in another country may put her in danger as being gay in a different country (e.g. Zimbabwe) may be illegal. This is true in a number of middle eastern countries too. Or say she wanted to consider an abortion, this too is still illegal in some countries. As therapists we are required to consider the laws of the county where the therapy will be taking place as opposed to where you are. Ignorance is not a defence and could put a client at great risk personally if the country in question is monitoring internet traffic. As an online therapist I commit to finding out as much as I possibly can about working with a client in the country where they will be going. It is not sufficient to get the client to sign something to say they understand the risks. Clients are by the very nature of them being clients often vulnerable (which a small v) and may at times be a Vulnerable Person. It is always our responsibility to manage this and to make a decision about whether we can work with the client wherever they might temporarily or permanently be.

Let’s further imagine that the client is staying within England and Wales (and the next section will be true of any setting), going on holiday is not like being at home and it may be difficult to have certain internet or for the client to have a private space. It is not alright for the husband or partner of the client (for example) to be sitting in the same room out of sight of the camera whilst you are in a therapy session, even if the client says it is alright – you wouldn’t allow this in face to face practice would you?

The second big issue covers assessment, risk management and safeguarding. In this instance we are presuming that the therapist and client know each other quite well as this is a continuing relationship. However we do not know anything about them, such as risk to self or other. Let’s imagine that the client has in the past made an attempt on her life, and is travelling with her partner and their two young children. Travelling in itself makers people feel vulnerable (with a small v). What would happen if this client suddenly because suicidal or unstable whilst in Lithuania? Assessment in online work is a permanent state of affairs, I use CORE Net which has an excellent tool helping to identify the risk that might arise, but say I, as therapist, had picked up there was a very heightened risk, how could I manage this situation whilst my client is in Lithuania?

In my work with Dr Julian I interview about three therapists a week to work on the platform. I use a case study a bit similar to the one I am using here. Over 80% of those interviewed talk about safeguarding and risk management but fail to pick up how they would manage risk or safeguarding (think about the young children) with a client abroad. How would you deal with a risk or safeguarding incident in this situation? The answer is that it is very difficult and may be impossible in some circumstances.

The point raised by those putting together the ethical dilemma was well made when they said “Sometimes, ‘putting the client first’ means explaining why you cannot do something they have asked of you.”

When I train around these issues I suggest taking advice straight away, by speaking urgently to your supervisor (who will need to be trained on online work, as recommended by ACTO, or they too are likely to miss these essential items), by speaking to your insurer (a good insurer is keen to help, nipping something in early stages avoids a later risk of a complaint), and speak to the client’s GP, preferably after having discussed this with the client where possible. In addition, as far as you can, if the person is abroad, before they go (in this case it is just a holiday) ensure you know where they are going and making some enquiries on the internet about resources and services available should they be required. If the client is permanently abroad you will need their GP or local doctor’s full details before they start therapy with you.

The two issues I have highlighted in this ethical dilemma point to the importance of having a qualified online supervisor and for the therapist to be trained to work online. We have not, to my knowledge, yet have any complaints against therapists that involve online work and you don’t want to be the first one. Ignorance is no defence and getting trained and well supervised for working online is an essential ingredient for an online therapist. There is no such thing as “I only do a little online work”, that’s like saying you only drink-drive on Christmas Day!

I wonder why these two major issues were overlooked, perhaps because no one in the writing ethical team had an online training?

Now ask yourself the same question, would you work with this client under these conditions and with the information provided?

Reference

BACP. (2010). Dilemma: Online working and social media etiquette. In: Therapy today. December 2019 volume 20 issue 10. Lutterworth: British Association for Counselling and Psychotherapy.

Bio

Philippa weitz is an online therapist having qualified in 2015 with both a Diploma in Online Therapy and a Diploma in Online Supervision. She is Vice Chair of ACTO, The Association for Counselling & Therapy Online www.acto-org.uk, Training Director for the Academy for Online Counselling & Psychotherapy www.acadtherapy.online, and Psychotherapy Director for Dr Julian www.dr-julian.com. She can be contacted at info@philippaweitz.com and +44 7880 501 116.