Welcome to our new 2020 guide to online counselling. This exciting and ever-evolving field of therapy has never more accessible to both therapists and clients. Here, we look at how to get started and what you should be aware of.
- Introduction to online counselling
- Does online therapy work?
- Benefits of online therapy
- Which platform to use
- Privacy and confidentiality
- Be prepared for delivering online therapy
- Contracting with clients
- Changes to the therapeutic dynamic
- Looking after yourself
- Final thoughts
An introduction to online counselling
While many counsellors have already been seeing clients online for some time, many of us are having to make this shift now out of necessity. In the absence of face-to-face meetings we are moving to platforms like Zoom to continue our work with current clients and also to offer our support further afield.
The BACP may ordinarily recommend lengthier trainings to practice as an online counsellor, they are understanding that right now the priority is continuity of support to our clients. That said, it’s crucial to understand how best to work online – from technology and privacy to changes in the therapeutic dynamic. This will ensure you are best meeting your client’s needs while also alleviating some of your own inevitable anxiety around this new way of working.
But does online therapy work?
When you are used to sharing a room with clients, noticing shifts in energy and feeling the connection between you, it’s easy to be skeptical about online counselling. You may wonder if it’s possible for therapy to continue being effective if it’s via video call, or whether depth is possible.
Relational depth is possible
Reassuringly many therapists and clients report that they quickly settle into online counselling and that the connection remains. Mick Cooper recently shared a blogpost highlighting a study carried out on relational depth in online therapy. The study found that “it is possible to experience relational depth in online therapy, though there are aspects of this medium that may make it less (as well as more) likely to occur” – largely these were related to technology glitches or delays.
Empathy and engagement remain
This article looks at studies comparing face-to-face with phone therapy, finding little variation in empathy and actually increased levels of engagement from clients.
The impact of your mindset
The writer also questions the stories we tell ourselves about whether this kind of therapy “works”, serving as a helpful reminder to not go down the route of a self-fulfilling prophecy.
Benefits of online therapy
Beyond the necessity of moving over to online therapy which we are currently experiencing, there are general benefits to working in this way:
- Flexibility – Working from home means you can choose when to work, selecting hours which suit you best and spreading them through the day rather than fitting into a centre’s availability or fixed slots.
- Cost – With no room fees or travel expenses the therapy is cheaper to provide. This reduction may be carried over to the client. So, new clients may be better able to access therapy and for more sessions than if they were meeting face-to-face.
- No travel time – With no commute to a therapy room you have added time in your day.
- More time to process – With online counselling you don’t have the rush of a ten-minute window to swap with another therapist – instead you can sit and have plenty of time to process the session, with time to reflect and make notes.
- Expand your client base – With online counselling you’re no longer limited by the area you live in, with the possibility of seeing clients anywhere in the country, or even the world!
- Increased honesty – In the relational depth study mentioned above some clients explained how the physical distance between them and the therapist enabled “a more honest dialogue, and therefore deeper levels of communication”. There seems to be a freedom of expression that can come from working online.This sense of disinhibition is something to mention to clients as they may reveal more than they intend to. However, it can be deeply therapeutic. There can be a level of comfort for some clients being in their own home, where the therapy room encounter can feel intimidating to some.
- Increased intimacy – Clients and counsellors alike have also talked about a sense of intimacy that arises through phone and video counselling – feeling much closer than they are in the therapy room with the closeness to the camera, or in the focused dialogue of a phone conversation.
- Self-care and depth of exploration – The client already being at home means that after their session they do not have to navigate a journey home encountering others, instead they can stay with what has come up for them. They may be better able to exercise self-care, with easy access to the soothing comfort of a sofa or bed, and also people or pets that they can connect with. Again, this may affect what is explored – with the potential of it feeling safer to delve deeper – knowing they aren’t having to go through a waiting room or face public transport. If a client lives alone it is worth exploring how they can look after themselves after sessions.
Which platform to use
There are numerous platforms through which you can deliver online counselling. Previously, Skype and email were predominant, but many new platforms are now available, some of which are designed specifically for delivering therapy online.
Zoom is the new Skype
Skype used to be the go-to online therapy and while we accept that many still use it today, it’s not one we now recommend as it does not have a good enough level of encryption and security. Zoom seems to be the preferred platform with a higher level of security and the useful “waiting room” facility. That said, you may have seen some articles explaining how the encryption isn’t as secure as first thought. However, we still think this seems to be the most secure of the various platforms – especially if you are ensuring your room is locked.
It feels like it may be rare to have a video call programme totally free from risk. What’s necessary is to weigh up the risks of a privacy breach versus the risks of not continuing support for clients.
Other options: Vsee, WhatsApp and Doxy.Me
Other platforms include VSee (good for low bandwidth situations) and WhatsApp video – most likely already used by clients and counsellors alike (though some counsellors may prefer to have a platform separate from their social messaging).
Doxy.Me is another option which comes highly recommended for being HIPPAA compliant and no download necessary. With so many people using Zoom it’s good to explore alternative, or back-up, options.
How to make the decision
When researching which platform to use, you can come away with your head spinning and feeling very aware of the various negatives. But we know that these platforms are being used by thousands of therapists worldwide. Our preference is for Zoom or Doxy.Me but what feels crucial is that you find a programme both you and your client are comfortable and confident using. Talk to your clients, and see what their preference may be too. There is no perfect right answer and instead being honest about what you know, collaborating and also being client-led feels important.
Privacy and confidentiality
Privacy isn’t just about the programme you use (though end-to-end encryption is the ideal), it’s also about the environment that both you and your client are in when making the calls. Realistically, this is the bigger risk factor.
How to keep your space confidential
Consider who will be able to hear the calls you are making. Wearing earphones keeps the client’s voice out of the equation, but your side of the conversation will be revealing too. Are you taking calls by an open window where neighbours can overhear? Can you ask family to stay upstairs while you have sessions? Your device will need to be password protected, with the screen locked if taking a break.
Client issues with confidentiality
Some clients may not have a confidential space in their home. One idea for a private space where they won’t be overheard is sitting in a car, if they have one available. This means they won’t be overheard. There is the issue of being seen though once a session is underway this is often forgotten. For those who do not have this option, they may wish to pause their counselling until face-to-face sessions can resume. Counsellors may suggest email counselling or instant messaging as a way to continue support, or else some self-help resources to refer to if appropriate.
With technology, as much as clients need to know how to use programmes to take a call, they may also need to know how to quickly end a call or shut down the programme, if for whatever reason their partner or family can not know they are receiving counselling. This can be explained by phone, or however is best for them to communicate, but again it helps to have a platform they are confident using.
It may also be sensible to switch off any smart devices such as Amazon Echoes. We know that there have been issues with devices making short recordings when they think the trigger word (Alexa) has been heard. You also don’t want Alexa butting in when you’re in the middle of a serious conversation!
Be prepared for delivering online therapy
For many therapists, delivering counselling online is an entirely new experience. It’s challenging in numerous ways, from getting to grips with a new digital platform through to the experience of delivering therapy in an entirely new environment. There are number of ways to get more prepared for delivering counselling online.
Before commencing sessions, ensure you are as prepared as possible. More extensive training can allow you to anticipate any issues you may experience. We recommend Kate Anthony’s short course (approx 8 hours) for a comprehensive look at how to move your practice online.
What is key though is practising with the programme you will be using – make a full-length call to a friend or colleague to get comfortable conversing in this way, but also to navigate any practical issues as they arise.
Get to grips with technology
Use your practise time to understand the technology within a call but also before this – adding a contact or sending an invite to a scheduled meeting, to ensure this is coming from the correct email address.
Suss out how to mute and unmute yourself, and ensure you know how to turn the volume up and down through your keyboard.
Programmes like Zoom and Skype also have the capacity for a test call within their settings so you can check out the video and audio.
Find the right set-up
Practising will also help with finding the best set-up. You will want to stay as close as possible to your wi-fi router (or even connect directly to it) to avoid any connection glitches. Earphones ensure clients don’t hear an echo of what they’re saying through your speakers. Lighting also makes a difference – if you can sit with a window in front of you this is ideal. If not, you can experiment with closing curtains and having lights on or off so you are as clear as possible.
Check this out at the times of day you will be making calls – you don’t want to get a surprise in the evening if the room’s light still leaves you with a dark image. If the quality of your image still looks poor from your device’s inbuilt camera you can look into external cameras.
You also want to get the height of your camera right – if the laptop is on your lap with the screen tilted to see you, you may end up with an unnatural angle of you looking down at the client. If you can have the camera at eye level this will feel more natural. Having the laptop on top of a box, or a sturdy stack of books, can help. If you are using a tablet, ensure you have something to securely lean this on – rather than attempting to hold it steady throughout a session.
Think about your background too, ensuring this is tidy but also that nothing is present that you wouldn’t want clients to see such as family photos (or laundry!). Make sure you have a clock visible so you can keep sessions to usual timings too.
It’s important that clients familiarise themselves with the programme you’re using so give plenty of notice on this so they can have a practise too. If needs be, once you’ve learnt how to use the software yourself you can always guide them via a traditional phone call.
Get into the therapy mindset
Then, when you are ready to go and it comes to the first therapy session itself – give yourself some time to get into the therapy frame of mind. Sometimes, particularly when you first start out, video meetings can feel a little unusual and put you on edge. Practice a few minutes of mindfulness yourself.
It can feel easy to get distracted by the technology but come back to the basics of active listening, really focusing in on your client and breathing in how they are feeling.
When starting with new clients your usual contract (with some adaptations) can be spoken through and then emailed over. A reply confirming they agree to the terms is sufficient in place of a signature.
Whether with new or existing clients, it’s also worth updating the contract to include this way of working. This may include payment and cancellation policies.
Having a back-up plan in case of technology failures is also needed – such as the counsellor explaining they will make a phone or WhatsApp video call to the client if Zoom is not working, for example. Ensure you have the client’s contact details (phone and email) for if this happens, and for arranging appointments.
Explaining the sense of disinhibition that can occur from working this way prepares the client for this possibility, rather than them feeling any regret (or, as Brené Brown calls it – a vulnerability hangover) for sharing more than they meant to.
Preparing for common issues
You can also pre-empt a common issue by explaining that some clients have reported on feeling distracted or uncomfortable because of having their own image on their screen. Zoom lets you turn off your own image being displayed, so this is an option to share with your client.
The changes to the therapeutic dynamic are among the most challenging that therapists experience when moving to counselling online. It’s key to understand how those changes will affect both you and your clients, and how to manage them during the delivery of therapy.
Making the non-verbal verbal
One issue with video counselling can be the reduction in non-verbal cues. It’s still possible to feel connection and empathy but it may be worth checking in more on how clients are responding. Equally, we may need to explicitly verbalise our own feelings and experiences. You may be very moved by what the client has shared but they wouldn’t necessarily know this from seeing you onscreen. Using immediacy to share your own feelings can become increasingly important.
Check in regularly with how the client is finding online counselling and non-defensively share that it’s ok if it’s not working out for them. It may take a few sessions to settle into it, but after that it’s important to support their autonomy in deciding if this is something they want to be doing.
How clients share
You may also find that clients share more of themselves – showing you their home, pets or people in their house. This wouldn’t usually happen but if this is what they’re wanting to share with you at this time then accepting this can be important for the therapeutic relationship. This can also be a benefit – with clients sharing photos of loved ones they have lost, or themselves as a child, for example.
For many therapists, delivering online counselling is challenging. Learning new ways of delivering therapy, and the changes to the therapeutic dynamic can take its toll on us. It’s important to be constantly aware of this, and understand how to manage the changes. Take your time to shift into this new way of working. There are certain measures that you can take to support your journey into the world of online therapy.
How many clients to see
While we may now have the capacity to “see” more clients in a day be aware of the energy this takes, both emotionally but also physically, when deciding your limits. Screentime can be draining, as can the energy it takes to stay emotionally connected.
A comfortable chair
Your chair at home may not be as comfortable or supportive as your therapy room. If you can invest in a new chair or back support this may help, but if not then adding cushions can help.
You don’t have to do this
Also, while many are setting up online or extending who they can offer support to, know that this isn’t something you have to do. Supporting existing clients during this stressful time feels crucial, if they can, and want to, still engage with therapy. However taking on new clients, even it feels necessary for our income, isn’t always the right thing to do. You need to know you are in the right headspace to see clients and it’s ok if you don’t feel you have the capacity to set up online or to see new clients. Right now self-care is crucial – you may be needed later on.
Self-compassion through change
And while you’re going through this process of navigating the change to working online, give yourself some self-compassion. It will take time to adjust. There will likely be things that go wrong and that’s ok. Technology fails. We might not hear quite as well as in person. We’re human and get ill too. Whatever it is – remember self-compassion. You’re doing your best under trying circumstances. And remember, rupture and repair can strengthen the therapeutic relationship.
Equally, if clients don’t feel that video counselling is working for them, you may try other formats such as phone or email counselling, but if they wish to cease counselling – acknowledge with yourself this loss but also that you did your best.
A sense of separation
Giving yourself a sense of separation while working from home can also be helpful. Some counsellors have a particular candle burning or change clothes after sessions, while others time their daily walk after seeing clients.
Check with the provider of your insurance to ensure you are covered for working online. Most seem to include this automatically, as long as your client is also in the UK.
Right now supporting our clients’ mental health and wellbeing is crucial and online counselling allows us to do that. Like with all change, before we know it we will have settled into this new way of working. We may even continue on afterwards. Clients with access needs through chronic illness or disability may especially appreciate having a variety of online counsellors to choose from.
It’s important to remember that every client will respond differently. Some may prefer it to face-to-face and experience deep, intense relating. Others, it won’t be right for – whether through a sense of disconnect and distance, or not feeling comfortable with the technology. Another issue is clients having the privacy at home – with family members or partners present, or children to care for, this may not be possible for all. In which case it may be helpful to signpost to self-help resources, such as those listed below, until they are able to return to therapy.
All you can do is your best. Get comfortable with the technology and ensure it’s working properly, brief your client on what to expect, and check in regularly with how they are finding the experience. You may well be pleasantly surprised.
Don’t forget to update your Counselling Directory, Psychologies Today, website and social media to include that you are taking on online clients if this is something you’d like to do.
If you have any further questions, or own tips, we’d love for you to share them in the comments.
Additional Resources and Training
- BACP resources for working online including information on security and data protection, FAQs, webinars and videos
- Therapist Ruth Allen at Whitepeak Wellbeing has produced this concise yet comprehensive pdf with lots of tips for moving your practice online
- Kate Anthony is offering her 8-10 hour online course on Moving Your Practice Online on a Pay What You Can basis, including those who cannot pay at all.
- Mick Cooper’s blogpost on what facilitates, and inhibits, relational depth in online counselling
- Blogpost from a pluralistic therapist – Working Online – A Practitioner Reflects
- Therapist Elaine Kasket’s video on Audio Tips for Remote Psychotherapy
- Video on how to improve presentation and appearance for video calls
- Advice from the Association of Counselling and Therapy Online (ACTO) for clients and non-ACTO therapists
- “But is it therapy?” article on research around phone counselling
- Christina Sümmerer’s article So Far and Yet So Close: what I’ve learned providing psychotherapy through a screen
Digital resources for clients
- Headspace – specifically their free Weathering the Storm content. NHS workers are also being given a free Headspace Plus membership throughout 2020.
- Anxiety UK’s resources including their own blogs and videos, helpline information and external support services
- Calm’s free resources including talks, meditations and sleep stories.
- Wellbeing pack by an NHS mental health service, incorporating practical advice and CBT-based techniques to manage low mood, anxiety and difficult emotions
If you’ve found this guide to online counselling helpful, then please consider taking a moment to share it with colleagues!