As online therapy becomes more popular and mainstreamed, I see a lot of questions popping up in online forums. Counselors are looking for resources, answers to questions about HIPAA, and general pros and cons before taking the leap into online counseling. And now that I am also providing therapy online I had to make sure I was knowledgable about some of these issues.
I've been fortunate enough to connect with many other therapists and businesses who provide resources in these areas so I put this post together in order to share that knowledge with you! Below we'll look at everything from what your options are (there are likely many more than you think) to what to consider ethically and how to document... of course.
Please note that all resources listed below are recommended at your discretion and I do not have an affiliate relationship with any of the recommended sources.
Online Options for Counselors
Video therapy using your own practice
The most seamless transition is to use video software to conduct therapy with your own clients online. There are many services out there that provide HIPAA secure video conferencing tools so you can do this and remain compliant with security standards.
This type of counseling is very similar to the service you provide in your office but your clients may be in a different town or even overseas. I won't get in to the myriad of guidelines around who you can see online but will say that in general, you are limited to clients in your state and need to know your own state laws.
There are a few different resources video conferencing but the one you should absolutely NOT use at this point (if you're in the U.S.) is Skype! For a service to be HIPAA compliant, it must provide you with a Business Associate Agreement (BAA) and even Skype for Business is not providing that currently, so it's a no-go.
For video conferencing you can either sign up for an account that only provides the video or you can sign up for a service that integrates the video with a waiting room and even with your notes and forms for a complete EHR. Obviously, pricing varies greatly based on how much you want from the service but you can check out Vsee, Counsol and WeCounsel.
Contractor for an app based video service
A new wave of therapy has arrived and that's video therapy using apps on your smart phone. Much like video conferencing with your own clients, you simply log in to an app on your phone rather than using a service on your computer.
These apps differ in that you typically contract with the app's company and clients are referred when seeking that specific service. The barrier to entry is very low with these services since you don't pay a membership fee. Once you're included in the listing and a client chooses you, they pay the company and the company pays you a pre-determined rate per session.
Since this system uses a contractor-based model, this is typically only available to licensed counselors and therapists. The fees are also lower than general private practice fees but the risk is very low in that there is almost no overhead for the therapist, other than having a smart phone and a quiet place to conduct a session.
Contractor for a text-based therapy service
Another form of therapy rising is email or text therapy. More similar to email than texting, this type of service allows clients to send secure messages to a therapist based on whatever scheduled is determined. That may be short, daily emails or longer emails once a week. The therapist then replies on a regular basis.
While this form of counseling may go against what we've traditionally learned about the therapeutic relationship, research is finding that it can be quite effective. Obviously, this is not the recommended method for dealing with crisis scenarios, significant trauma or suicidal clients (to name just a few). However, for many people who are used to online text communication this is a great tool.
Personally, I find the opportunity to interact with clients throughout the week more helpful than the traditional method of limiting conversation to 50 minute blocks. I can encourage people to check in if they have an important meeting or if something unexpected happens and we're able to problem-solve in the moment, rather than discussing it possibly a week later.
While you could certainly provide this type of service on your own using personal (and secure) email, many therapists are using online services and apps with clients. There has been concern about certain companies and their ethics but places to find this type of service are BetterHelp and TalkSpace. You can also use a (FREE) service like Signal to text clients securely without using your regular phone texting or messaging settings.
What to Consider
Most of us first consider the ethical concerns with online counseling and our brains automatically go to the topic that has been of utmost importance since day one of our training- confidentiality. Many therapists are concerned with privacy and how "open source" things seem online. And while there is always risk in any interaction (yes, even traditional face to face), there are many ways in which online services are generally secure.
The most important thing is to 1) Understand what risks there are with providing therapy online and 2) Inform clients of those risks, along with other general information related to therapy. This topic could be an entire graduate course so I won't attempt to cover everything in this little subpoint but those are the first things to consider.
Here is a great article from Zur Institute outlining how to conduct a risk analysis (it's not quite as scary as it sounds), what to consider with email and how HIPAA relates to all of this.
Your time is valuable and using email can both save and hurt your time management. Email is great for things like quick notices about appointments but it does leave the door open for more communication. What if your client happens to email very personal information? What if they write a very long email and expect you to read it outside of session?
These are things you must consider with online because whether or not you use text-based or video-based counseling, clients are more likely to email you when your relationship is largely online. Make sure you have very clear policies and procedures around this and have reviewed those with clients from the outset.
Also, consider your time and resources and how that will be a fit for therapy online. This will help guide you in integrating online counseling services into your business plan and making sure it creates more ease rather than more stress in your practice. Make sure you allow yourself time for training or research before jumping in and definitely make sure you've updated your paperwork prior to starting with clients.
How and What to Document
Aside from your regular private practice forms and policies, if you provide online counseling you'll also want to consider some extra things when it comes to paperwork.
Some states require a separate consent form for online services. And if you provide services both online and in the office, you want to make sure you outline the differences in these types of therapy. Some things to include in your consent form are:
- What happens if the client's needs increase beyond what can be ethically provided online
- Procedures to follow in case of poor connectivity or internet outage
- Procedures you'll follow if you feel your client is in any danger
- Communication outside of session
- Expectations for online interaction and the importance of checking in regularly
More specifically, you want to consider how you will respond to clients in emergency situations since you may not be physically located near them. Make sure you have your client's home address, phone number and emergency contacts. Identify the local police and nearest hospital in the area and keep that number handy with your client's info.
Making sure you're prepared will help you to be more confident about the services you provide and ensure you can keep your clients safe when needed.
Resources You Must Follow
There are many resources for therapists who are providing treatment online but here are some of the top ones that I recommend:
Roy Huggins is a licensed counselor and also a "tech guy" so he did everyone in mental health a favor when he started Person-Centered Tech. I recommend every therapist sign up for his newsletter. Roy is great about staying up to date on topics like cell phones, Google apps for business, changes to HIPAA, and everything else you have questions about that no one seems to provide a good answer for.
He also offers an affordable membership where you can have access to him for weekly office hours and provides one on one consultations if you just have a few questions while setting up your private practice. Lastly, he provides CE credits for counselors and therapists for reading some of his articles or taking his courses. I am anxiously awaiting his approval by APA so I can collect some of these as a psychologist ;)
Yes, I spelled that correctly! Clay Cockrell is a U.S. based counselor who provides therapy online and started a podcast to talk about the many issues that arise as a result. He's had some great guests from around the world who discuss new techniques and strategies, legal concerns, tech issues and more. He also runs the Online Counselling Directory where you can list your online therapy practice for a monthly fee.
There are many places where you can obtain CE credit and learn about online counseling services but this site has just about everything you need for training. You can do an entire certification program or take courses piecemeal. Certification is not required by most states but does reflect a level of training, so consider what is best suited for you.
Now what to do...
I hope this article arms you with the tools you need to determine if providing therapy online is right for you and your clients and that you feel better prepared to tackle this new arena. While online counseling isn't appropriate for every client, it can help so many who are unable to leave home, live in rural areas, or frequently travel for business.
Let's continue to support one another in these emerging areas so we can increase the services offered to the public. Comment below if you have additional resources to share and bookmark this page to reference when those questions come up again!