Pressure to return
I work for a local counselling service that has already reopened for in-person counselling sessions. As one of their counsellors, I am under pressure to return, but I don’t feel ready yet. I have taken the lockdown restrictions seriously as I am the main carer for my elderly parents, and I’m aware that the virus is still at large. I’m not sure how long I can hold out as my job could be threatened and I need the income, but the manager is not sympathetic.
It’s a difficult dilemma – if you go back to work, you are increasing the risk of catching or spreading the coronavirus, but if you refuse, you believe that you might risk losing your job. The immediate course of action, which you may have already tried, would be to speak to the manager of the counselling service to express your concerns and explain your need to avoid unnecessary contact with others. If you have been providing counselling online during lockdown and your clients are happy to continue working in this way, you could reassure your organisation that their service to clients is still being maintained. There is also the issue of what the clients would prefer – if they are also reluctant to meet in-person at the moment, the ethical response may be to continue working remotely with them.
I am wondering why the organisation is putting you under pressure to return. Is there a financial need, perhaps, which raises the question of whether they are making clients their primary concern (Ethical Framework, Our Commitment to Clients, point 1a)? Some counselling services are proposing to continue to offer online sessions to clients who prefer it, to complement their in-person provision.
You have a right to know how the organisation intends to follow Government guidelines. If you haven’t already done so, I suggest you check that the organisation has carried out a risk assessment and ask what protective measures have been taken to mitigate the risk. For example, can social distancing be maintained? Are sanitisation facilities being made available? Are chairs, door handles and surfaces being cleaned between each client appointment? How are the counselling rooms ventilated? Are you or clients expected to wear face coverings? If adequate measures are being taken, you (and your clients) might feel better about returning to in-person sessions.
But it is also important to consider your own self-care. As stated in the Ethical Framework (Good Practice, point 91): ‘We will take responsibility for our own wellbeing as essential to sustaining good practice with our clients by:
a. taking precautions to protect our own physical safety
b. monitoring and maintaining our own psychological and physical health, particularly that we are sufficiently resilient and resourceful to undertake our work in ways that satisfy professional standards.’
As therapists we need to feel sufficiently confident and comfortable in our surroundings to be able to do our job properly and to carry out effective therapy. The therapeutic relationship will be impaired if we are anxious and ill at ease, and our clients are likely to sense our discomfort, as well as their own.
Recontracting
I am in private practice and I am unsure if I need to recontract with clients when moving from online to in-person working. For example, should I require them not to attend if they have a temperature or other relevant symptoms? What other precautions should I be taking?
An addendum to your usual client contract is advisable, to make clear that if your client has tested positive for the coronavirus or has been told to self-isolate or is showing symptoms, they should not attend an in-person session. Similarly, you could confirm that you would do the same if it applied to you. Whether your normal cancellation policy remains unchanged or whether you are prepared to waive cancellation charges in such circumstances will be up to you, but any variation to a pre-existing contract should be made explicit.
At the time of writing, NHS Test and Trace is in operation, tracking those who have come into contact with confirmed cases across the UK. This could require you to share personal data about your clients outside of normal confidentiality boundaries. However small the possibility may be that you will need to reveal their details, clients still need to be made fully aware that their confidentiality may be breached. It is best to check the NHS Test and Trace website (see page 52 for the link) for the most up-to-date guidance to help you decide what information you need to include, and whether you require consent from your client to share the data.
You might also mention that, in the event of a local lockdown affecting either you or your clients, in-person sessions may need to be cancelled at short notice. Other precautions you need to take should be in compliance with the latest Government guidelines and public health advice on social distancing, sanitisation and face coverings. You should carry out your own risk assessment, following the guidance and templates on the Health and Safety Executive website (see page 52 for link). Incidentally, concerns about protection of self and clients apply not only to COVID-19, but also to the many existing (and future) health risks with which we as practitioners work. Our clients come with many different health conditions, some contagious, and so reasonable precautions should always be built into our practice, including checking whether the impact of illness – both yours and the client’s, should they trace infection to you – is included in your personal liability insurance.
Social distancing
My clients and I are keen to return to in-person work, especially those who felt unable to cope with remote working and have been waiting for me to see them again. However, the size of the room in which I work makes a two-metre or even a one-metre social distancing impossible. The Ethical Framework tells us to ‘respect our clients as people by providing services that… make adjustments to overcome barriers to accessibility, so far as is reasonably possible’. So, if I am putting my clients first, surely there is a way I can overcome such obstacles?
At the time of writing you would need to maintain social distancing if you were to see your clients in person. This currently means keeping a distance of at least two metres, or one metre plus precautions to mitigate the risk, including sanitisation, ventilation and the possible wearing of face coverings. If you work for an organisation, they should have carried out a risk assessment, but if you are in private practice, you should conduct this yourself. If you are in rented premises, you should also check what risk assessment your landlord has completed.
If your particular premises make social distancing impossible, however much you and your clients might wish it were otherwise, you cannot yet proceed with in-person working. We are committed to ‘keeping up to date with the law, regulations and any other requirements, including guidance from this Association, relevant to our work’ (Good Practice, point 14f). ‘We share a responsibility with all other members of our professions for the safety and wellbeing of all clients and their protection from exploitation or unsafe practice’ (point 11) and ‘We will do everything we can to develop and protect our clients’ trust’ (point 12).
You refer to our commitment to ‘make adjustments to overcome barriers to accessibility’, so how can accessibility be maximised? What alternatives might there be to resuming in-person contact? If you have been offering telephone or online therapy, might you re-offer this as an option to those clients who are waiting to return to in-person work? Or could you find a safe, confidential way to meet outdoors?
At the beginning of lockdown, we had to put an immediate stop to in-person work, with little warning, but this gradual easing of restrictions gives us the opportunity to take our time to adjust back and ensure that both we and our clients feel safe and confident. So it is wise not to rush into it and, instead, see it as an opportunity to reflect on our boundaries and where they are drawn and discuss it in supervision. Just because this particular boundary may not be of our own making, what are we risking by inviting our clients to breach it and allowing them to come closer than is safe? However highly we hold our ethical values, we cannot let them override the law, and our own personal safety.
Continuing online
Some of my clients want to continue working remotely, but this is not my preferred way of working. Should I insist that they return to in-person work, or should I be more flexible?
This will partly depend on the contract with your clients when you started working remotely. Was it made explicit that it was a temporary arrangement for the duration of lockdown or an open-ended one? Was there a clearly understood intention to return to in-person working as soon as it became possible again?
But a more interesting answer revolves around motives – that of your clients for working remotely, and yours for returning to in-person work. There’s an interesting discussion to be had here with clients. Perhaps they appreciate the accessibility afforded by remote working, enabling them to be in therapy wherever they happen to be or saving them a time-consuming or expensive journey. Perhaps they have valued the different kind of relationship offered online, feeling that they have greater control, or that therapeutic progress has been faster as they have opened up sooner than they would have otherwise. Or perhaps they prefer the neutral territory of cyberspace to coming to see you in your professional premises.
And what is behind your drive to return to in-person work? It could be a useful exercise to take this question to your supervision, to explore together what you have been missing while working remotely with clients. Is it the body language, or the subtle changes of mood or expression that have been harder to detect working remotely? Have technical frustrations got you down? If so, have they been more of an issue for you than for your clients? Do you feel that they are treating the therapy more casually and are not taking it, or you, seriously enough? Do you feel less professional or less effective when working online than with in-person work? In other words, whose issue is this?
In the interests of client autonomy, you might respect your client’s choice, but perhaps you need to be clear about what you are offering, and now might be the time to decide. Has working online been a ‘needs-must’ temporary measure, or are you now willing and appropriately equipped to be offering it to your clients as an acceptable alternative?
Cross-border working
Initially I was quite sceptical about online counselling as I have always practised in-person, but I am now convinced that effective work can be done online, and it is so convenient. I am now receiving enquiries from clients overseas, which would open up a whole new client base for me, and would help to make up for some of the business I’ve lost this year. Is there any reason why I shouldn’t take them on?
Counselling overseas clients may seem convenient and, technically, just as easy as working with clients in your home country. However, you could be stepping into a minefield because of differing legislation. As explained in the BACP Good Practice in Action resource Working online in the counselling professions: ‘The law differs between countries. When working face to face, the applicable law is determined by where the work takes place. When working online, it is possible for the practitioner and client to be located in different legal systems and subject to different laws. This creates uncertainty about which legal system applies. One way of reducing the uncertainty is to explicitly state in the contract that the work is being undertaken in accordance with the laws of the practitioner’s own country and any disputes will be subject to that country’s law. This reduces the degree of uncertainty but does not eliminate it all together. Any contractual disputes would usually be considered in the legal system that applies to the practitioner, provided that this has been included in the contract between practitioner and client. However, any allegations of civil wrongs or crime by the practitioner could still be considered in the legal system that applies to the client’s location.’
Good practice when working with clients from other countries is to establish their location and to be familiar with the legal requirements that might apply to the work, particularly with regard to civil wrongs, including negligence and breach of confidentiality or privacy. Similarly, it is wise to be familiar with any major differences in criminal law. For example, the law in some countries and most states in the US restricts the right to practise as a counsellor or psychologist. The practitioner would have to meet the local professional requirements to be legally compliant. The protection of the title ‘psychotherapist’ is more variable but in some countries may be restricted to medically qualified practitioners. Offering services as a counsellor, psychologist or psychotherapist in these locations without the appropriate licence or legal authorisation may be a civil wrong and/or criminal offence.
Then there’s the question of cross-cultural working, and whether you are sufficiently familiar with your client’s world and the socio-political context of their issues. Counselling and psychotherapy might be perceived quite differently in their country, and some subjects might be off limits.
For these reasons, cross-border working is not straightforward, and should not be attempted without careful consideration. You should check that you are insured for such work, and you might also seek legal advice. Insurers do not cover all countries, and the law can be complex. We are also less likely to be familiar with the support systems available to clients in their country, making it difficult to support the client in getting additional help – for example, in the event of suicidal thoughts or medical need. Your supervisor would also need to feel sufficiently confident to supervise such practice.
Online working has opened up a whole new world of opportunity, but the work still needs to be ethical, legal, safe and contained.