Once your appetite has been whetted for delivering online counselling, you will no doubt have many questions about the practicalities of setting up an online counselling or wellbeing service at your university or college. Going into cyberspace can feel daunting, but it is important to remember that you already provide a professional and ethical service, and do not personally need the technical knowledge and expertise to set up an online provision.1
Platforms and software
The first decision to be made is which platform to use, and here, you can utilise the expertise within your IT and legal departments. There may be an existing in-house system you can employ, or you may want to purchase something more specifically tailored to your service. A prime consideration when making this decision will be what medium you wish to offer your students – videocam, instant messaging (IM) or email – as well as ensuring a high level of security. At Cardiff, I was keen from the outset to provide counselling through synchronous, or ‘real-time’, communication, via IM and webcam, as well as asynchronous, through email. Everyone has their favoured communication style and mode so I felt that offering a range of media was key in creating a flexible service. This is a driving principle that continues to influence my decisions as the service at Cardiff develops.
If you want to focus your online service on email alone, you will most probably use your institution’s internal email accounts, as these will likely run through your own servers, ensuring you have knowledge of where any personal data are stored, and what level of security is in place. This has the added benefit of affording a quick check that the client is indeed a student.
Offering IM and email sessions does not have to mean investing in different software and platforms for each provision. There are many platforms and organisations providing the capability to deliver email, IM and webcam sessions within one secure system.2 At Cardiff University we currently utilise an add-on service provided by Learning Central, our in-house virtual learning environment (VLE). The university’s IT department was keen to purchase and use ‘add-on’ software, Blackboard Collaborate and IM. When the Counselling and Wellbeing team expressed a desire to trial a synchronous counselling service, this presented the perfect justification for that expenditure. It’s worth exploring such possibilities with your IT and legal departments.
Alternatively, you may wish to remove the additional work involved in this process by looking externally at companies set up specifically to provide a secure platform. These include VSee, Zoom and PlusGuidance.3–5 In such cases, however, do remember to involve your IT and procurement departments, who will likely need to approve the architecture and security of the platforms being sold, as well as the viability of the company who is selling them. A key issue to consider and address is having a reliable arrangement in place for occasions when the main platform or software has technological issues. This could involve having a completely separate system available (some of the organisations mentioned earlier also offer a limited free service which may provide back-up for those instances), or simply a clear policy and procedure outlining alternative means for continuing the session, or for rearranging. These arrangements need to be set out in your visible online service guidelines. To ensure all students have access to this information, it is helpful to send them out as part of the setting up process of the first online appointment, thus confirming that the information has been received, even if it has not been read.
Online and face to face: different but equal?
A consideration that was particularly imperative for me was guaranteeing that there was parity with our face-to-face service. I wanted there to be no concerns about students receiving a lesser or greater service by requesting, or only being able to attend, online sessions. The first session in the Cardiff Model, the therapeutic consultation, is 90 minutes long and we offer the same initial session to online clients. But we all type at different speeds, meaning that different counsellors will be able to discuss varying amounts in an IM or email session. Naturally, there will be differences in how counsellors approach their face-to-face work as well, so it is important to recognise that this is just one factor that influences the online therapeutic relationship.
Reflecting on the individuality of online counsellors’ typing skills reminds me how crucial it is for a service, and for counsellors (not just those working online), to consider how online presence, image and identity are managed.6 In this age of cyberspace, all universities and colleges have a website, and potentially an intranet (an internal website, only accessible to students and staff). What you publish creates an immediate ‘feel’ for who you are, how you work, and the range of services and resources that you offer. And it’s not just a case of monitoring your service presence online. Most professionals are already conscious of how they use their personal online social media presence these days, but it is always useful to remind your team about what is and is not appropriate for them to be publishing on Facebook, Twitter, Instagram and other online forums, as some clients will check out their counsellor prior to the appointment. This might be as a way of alleviating anxiety, of making the counsellor known to them, or simply the result of curiosity. I have had several clients begin their first session referring to what I have written in my university profile. So, while working online may be more anonymous for the client, it may be that the client does, in fact, know quite a bit about their counsellor including what they look like and something about their work experience.
Once you have decided what technology, and which media, you are going to use, it is time to develop your confidentiality and security policies and procedures.7,8 This can be the point that raises most concern and anxiety for those who have yet to venture into cyberspace. Stories in the media about hacking, and a lack of familiarity with social media, can heighten these concerns.
It is important to make certain that your online confidentiality policy and ethical approach has parity with that of your face-to-face service.9,10 While the core aspects will remain the same, the points of difference centre on how counsellor and client keep online material safe and secure, be it an email or a transcript from an IM session. (At Cardiff, we have our system automatically set to not save IM transcripts on our computers, while a client may choose to do this as an aide-memoire.) There is a need, also, to be confident about the security level of the platform used to conduct the session and transmit emails. While this will be a central criterion when choosing which platform and software to use, the aspect you have less control over is what a client may do with transcripts or IM logs, as well as where they choose to engage with a session and how securely they keep their computer. It is not unheard of for a client to be having a webcam session, when the counsellor notices people walking past in the background, or the client turning to talk to someone off camera! Clients may leave the room to answer the front door or take a phone call… I have experienced all of these during IM as well as webcam sessions, despite explicitly giving clients information about keeping sessions private.
No matter how explicit and plainly written your guidelines and policies are, these interruptions and intrusions will happen. But again, this mirrors the face-to-face encounters we have with students. I am sure most of us have had clients checking their phone when it pings or vibrates in a session, even if they do not directly answer.
The main point here is to do your realistic best to ensure your clients have received and read your confidentiality policy and online guidelines. Face to face, this collaborative contracting process is clear for both parties. In email sessions, the client has disclosed their experiences, and opened up thoughts and feelings, before the counsellor has even begun to read. In an IM session, the pace is naturally much slower, leading to concerns that potentially a large proportion of the first session is taken up with this process.
Sending a written contract with a request for it to be filled in, signed and returned, ensures it has been read, and a copy can be saved in the client’s file. Including information about how to keep any records of sessions safe, and stressing the importance of creating a private space in which to conduct the session, are also essential. The word realistic is important here. Ultimately, it is the client’s choice about where they will engage with us online, and with whom they discuss their session. Once again, however, the online experience may not be so different from the face to face. Some of us will have worked in buildings where soundproofing was less than adequate, thereby unwittingly overhearing parts of other sessions. One instance I always remember from many years ago was when, during a quiet moment in a session, my client and I could hear every word being spoken in the adjoining room by both counsellor and client.
Explaining online work to clients
It is also helpful to offer guidance about how to make the most of working online. For example, giving a word limit for emails to ensure there is enough time for the counsellor to read, reflect and compose a reply within the allocated session time; describing how to communicate effectively on IM to avoid overlapping of typing, with its ensuing confusion; and guidance about appropriate contact with the counsellor before and after sessions. This information can be sent out in the first appointment confirmation email, along with the confidentiality contract.
As we all know, working with risk, and knowing how to respond to it, are key elements of the work. I am often asked how safe it is to work with risk online, and indeed, some counsellors choose not to work online with anyone who has current suicidal thoughts or substance misuse problems.11 Deciding it would be unethical to deny counselling to someone unable to access our face-to-face service, I developed a robust process that supports counsellors to work with risk. This makes use of online risk assessment tools (Columbia Suicide Severity Scale),12 helps clients to identify and access local support, gives them a range of online websites, app and telephone support resources, and encourages IM and email clients to move to webcam, to gain a visual impression of how they are coping. And of course, good use of supervision with someone trained in working online is essential.
Training and supervision
Online counselling does require a certain skillset and knowledge, focused on how to ethically, appropriately and effectively transfer face-to-face skills and approaches to developing beneficial therapeutic relationships online.13 To this end, training is essential, and you will be amazed at what you learn about yourself on tailored courses, including an awareness that how you express yourself online enables you to relate in new ways to your clients. I notice that many online therapists have a preference for one medium over others, and while I strive to maintain a coherent and consistent portrayal of myself, my own style of writing differs between email and IM due to the need to be briefer and more succinct in IM sessions.
Your online practice will benefit hugely from being supervised by someone who is also experienced in online work, as they will be able to use their specific knowledge and understanding to support the supervision process. Some face-to-face supervisors will be happy to provide supervision for your online practice, but they may be focused exclusively on the therapeutic process within the application of your theoretical approach. Without experience of counselling online, they may tend to miss the significant aspects and nuances of the online characteristics of the relationship.
While there are many issues to consider and address when setting up an online service, in times of ever increasing referral rates, and higher expectations of the level of support, colleges and universities can provide an online service which broadens options to assist all their students. You may be connecting to groups of students who may never otherwise ask for support. A quick look at the 24 Russell Group universities’ websites shows that, at present, only seven of the 24 advertise an online counselling or wellbeing provision. So there is clearly scope for more of us to develop this mode of support.
Working online: diving into cyberspace - is it for us?
In the first of a new four-part series, Sarah Worley-James, from Cardiff University, examines the role of technology in providing a timely, accessible and student-friendly counselling service. University and College Counselling, March 2017
Creating a connection
In the third of her articles exploring online work, Sarah Worley-James discusses transferring face-to-face skills online and how a therapeutic relationship can most effectively be established through the written word. University and College Counselling, September 2017
Sarah Worley-James is Chair of the Association for Counselling and Therapy Online (ACTO). She is a senior counsellor, and Co-ordinator of the Online Service at Cardiff University. Sarah has 20 years’ experience of counselling and training in a variety of settings, the last eight in higher education.
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