Assessing Client Suitability for Remote Therapy

Not all clients will be suited to every aspect of remote therapy and may not be able to engage in any support that is provided at a distance. This may be due but not exclusive to, their technical ability, access to technology, personal preferences, writing ability or disability. A client’s psychological state may also make a difference to how they engage or continue to engage in remote therapy. Therefore, it is important that these factors, and others, are assessed prior to the therapy commencing and during the therapy process. An initial way of doing this is to ensure an appropriate intake form is completed at referral stage. The following topics discuss some of the challenges encountered when delivering remote therapy and the aspects that need to be considered when assessing a client’s contextual suitability.  

Psychological difficulties and presenting problems may make it more challenging for clients to make effective use of online therapy: Some examples are:

• complexity of client’s situation – some clients may arrive at their sessions intoxicated. There is more of a risk of this happening when working online due to the disinhibition effect. In situations where the therapist is unable to see the client (email, instant message, and telephone sessions) it becomes more of a challenge to detect whether clients are intoxicated. Although, there are some indicators to be mindful of in terms of their text becoming incoherent, or hearing the client slurring their words. Even with video, there will not be access to smell which removes one of the senses to gain a clue to a client being intoxicated by alcohol. However, it is important to have prior knowledge of whether the client has any disabilities that may explain their difficulty in communicating. 

• levels of risk – careful consideration needs to be given to working online with suicidal clients, or clients engaging in severe self-harm which may endanger their life. Some clients may be struggling to distinguish their thoughts from reality and may need significant psychiatric or emergency medical support. Being able to assess this will be more challenging when working online, particularly when there is a reduction in access to certain indicators such as body language or speech modulation. While using risk assessment forms will help guide decision making, these should not be fully relied upon as they are not an exact science for predicting risk outcome. Due to the safety concerns for clients that are experiencing domestic abuse, it may not be appropriate to provide remote therapy. Some of the issues to consider would be whether the client could be overheard by an abusive partner or whether they have placed hidden surveillance on either the client’s communication device or within the room the client accesses therapy. There are client safety concerns, particularly when working across borders due to surveillance by governments. Engaging clients that want to discuss their sexuality in a clear example. In some countries it is illegal to engage in homosexual acts, or dangerous to disclose sexual preference if it deviates from what is accepted by that government or culture. Engaging in counselling in this context could place the client at significant risk of harm. Therefore, it is incumbent on the therapist to have a sense of the main human rights afforded to people in the countries where they wish to provide remote therapy. 

• levels of functioning ability – as an example, people struggling with depression may lack the energy, motivation, or psychological clarity to operate technology appropriately. This may lead to missed or late attended sessions where the effectiveness of the therapeutic work is greatly impacted. It could also lead to clients not being able to convert their present or lived experience into written words. 

• transference reactions through technology – as with face to face relationships, attachment and rejection issues can also play out in remote therapy. As an example, clients may develop phantasies about their therapist as being the ever-accessible parental figure. Rejection and disappointment can ensue when the therapist does not reply immediately or in the way that meets the unconscious needs of the client. This can also play out when there are technology glitches/failure and the client unconsciously interpret this as another rejection. At times, these transference reactions may be challenging to contain, particularly (but not exclusive to) when there is limited body language, or immediate feedback in asynchronous therapy. 

• challenging boundaries - some client’s may not fully comprehend the boundaries that exist in therapy. Even if these are within the written contract and stated at the beginning of the therapy work, clients in crisis or through a misunderstanding may attempt to contact the therapist outside of the session time for therapeutic assistance. They can perceive the therapist as being an extension of the omnipresent Internet that’s available 24/7. Clients can also challenge boundaries by sending friend requests on social media to the therapist. While it is important to consider the therapists duty of care to clients, it is also important to re-establish the working agreement by restating and clarifying boundaries. However, in some cases, even this may not prevent a recurrence. Further consideration would need to be given on managing this therapeutically or administratively (e.g. working therapeutically with the transference in session, or indicating to the client they can discuss therapeutic material in the next scheduled session and signposting them to a 24hour helpline or emergency services). If instances of crossing boundaries become a common occurrence and the long-term work is continually compromised, it may be appropriate to assess if the medium on which the therapy is taking place is unsuitable, or if remote therapy in its entirety is unsuitable. 

It is important to establish if clients wanting to engage in remote therapy have developed the necessary skills or knowledge to make effective use of the medium on which the therapy will be conducted. Some of these are:

• speed of communication – when conducting therapy using instant messaging, the issue of ‘text lag’ may become apparent and disrupt important aspects of the process. An example of when text lag can occur is when one person is writing faster than the other, and the other is unable to keep up. At this point, there is a possibility of another topic or further detail being introduced by the faster writer. When this happens, the slower writer might have two points to respond to which risks the possibility of two conversations taking place within the same instant message chat, which can become confusing. Another consideration for instant messaging is that some clients may need instant response and find it frustrating when the therapist doesn’t reply immediately. It’s at this point, it may be worth considering either working to understand the ‘urgency’ of the client or a possible move to a medium that is verbal rather than written (i.e. voice or video). It’s also worth bearing in mind that some clients may not be slow writers but need to reflect on what they have composed before sending. This could significantly reduce the amount of material that can be covered during the session. Considering email rather than instant messaging could be more accommodating for this approach.

• emotional expression – some clients may not have the vocabulary so take a lot longer to express themselves. While this can happen in face to face therapy, it can be more challenging in terms of the amount of time taken up to convey in words that takes a much shorter time verbally. Clients may also not be familiar with the meanings associated with or how to use emoji’s (facial illustrations of emotions that have common meanings). Using emoji can convey quickly what would take some time to express in words. Although, it’s worth bearing in mind that emoji meanings can be misinterpreted. 

Some client’s (particularly young people) can be classed as ‘technology natives’. They develop from an early age within an environment that is surrounded by and reliant on technology. This has the propensity to make them very confident in using technology hardware (computers or laptops), and software (applications such as Microsoft Outlook). However, there are also ‘technology foreigners’, people who are not familiar or confident with technology. Therefore, it’s important to assess the capacity of the client and their environment to ascertain if effective use of remote therapy can be made. In some cases, this can be managed by supporting the client with some guidance before they start therapy or managing any issues that come up during the therapy. However, it is worth considering that some of these issues may be out of the client’s hands regardless of whether they are a technology native or foreigner. While the therapist is not expected to be a technology guru, it is important to have familiarity and confidence with the software being used and aware of solutions to some of the common technology issues that may arise. This will enable the therapist to support the client where possible, or assess the environment as not being suitable for remote therapy. Some examples are:

• where the client is unable to access the internet in a private and secure environment. Some clients may want to conduct sessions in work which has implications for organisation snooping software picking up the content of a session or people coming in and out of the office where the client is located. This can also happen at home in terms of interruptions from family members or pets. It is important to discuss with clients from the offset whether they can accommodate a secure and private environment or raise this this with them if the situation develops after a few sessions. 

• where technological factors limit internet access. Wi-Fi reach is one common problem that creates breaks in the connection (particularly with video). Sometimes it is appropriate to discuss with the client the best room to be located in to accommodate a good Wi-Fi signal. It may also be the case that their internet bandwidth is not sufficient to manage video. Signposting the client to a website (e.g. https://broadbandtest.which.co.uk/) that tests the bandwidth of their connection may need to be considered. If the outcome of the test is below the video software recommended bandwidth, then it would not be appropriate to continue from that location and dropping down to voice only may need to be considered. Some clients may connect from within their car and use a phone data signal to connect. Depending of the signal strength, this can have mixed results.

The client’s attitude to online therapy may be influenced by previous experiences, assumptions, or perceptions. These can be:

• previous experiences of therapy – either online, via other support media or face-to-face. A good experience might be that previous a therapist had a warmth about them which enabled the client to feel safe and engage in the process. While a bad experience might be when a previous therapist has been perceived as having an agenda without understanding the client’s needs. This can sometimes happen if the client does not understand the approach the therapist is operating from (e.g. CBT or Psychodynamic therapy). Alternatively, clients may be averse to seeing a therapist but are being influenced or coerced into seeking therapy and have an attitude of resistance to engaging in the process from the offset. Also, clients may have previously engaged in face to face therapy and expect the same relational conditions to apply online (i.e. feeling the same sense of presence with the therapist online as would be when in person). Conducting remotely, even with video, may be a different experience altogether, particularly if the technology failure interrupts the human to human connection. 

• concurrent therapy – where the client is already engaging with other support either online, via other media, face-to-face, couples or family therapy. The therapist may need to conclude that the online therapy could be confusing or conflicting with the other therapy (or the two therapies may actually complement each other).

• clients not understanding the differences or boundaries– some clients have been known to connect into their therapy session from a coffee shop, while driving or with other people in the same room as them. This can sometimes occur if the client applies online therapy with the same attitude as other aspects of life that are carried out online (e.g. social media).

• understanding clients use of the internet – in terms of whether the client has already developed online relationships. This can inform the therapist of the experience the client has gained to build relationships online including the type of relationships, such as brief encounters or more in-depth sustainable relationships. This may be a clue to how to manage the therapy, particularly if the client has a pattern of brief encounters on the internet. The ‘black hole effect’ may occur where the client goes offline during a session and is never seen again. Even when the therapist attempts to reach out to them, no reply is ever received. This could be a common factor in how this type of client engages and disengages with online relationships as cutting off others without notice is no big deal to them. 

• internet communities – can be technical forums, social media parent groups, social media community groups, self-help group for anxiety or self-harm. These can be positive in nature offering lots of supportive and valid advice. However, there are also forums that can be harmful in their very nature. Some self-harm groups can promote the harm and provide further advice on how to inflict greater threat to individuals. It’s also very important and particularly for young people, to be aware of grooming relationships that might be apparent. The case of Breck Bednar was a horrific event where 14 yr old Breck was groomed through a gaming website. He eventually met the groomer in person and was savagely murdered.

It is also important to identify any physical and medical factors that may affect online/other media therapy. These could be factors such as visual or motor disabilities which may make it difficult to see, hear or type. The therapist can provide recommendations for appropriate support software for clients with a disability. Many operating systems such as Windows or macOS have inbuilt accessibility functions for managing sound, vision and typing. It is important to be familiar with the basics of what these functions can provide to appropriately assess and signpost clients to applications that are suitable. There are also external software packages such as Dragon Dictate which converts voice into text and vice versa. However, when suggesting external software to clients, it is important to know and advise clients of the privacy considerations of these packages before suggesting it to them. While clients are responsible for assessing their own privacy, many software privacy policies can be extensive and challenging to fully comprehend the extent to the privacy being offered. This becomes particularly challenging for a client who is already in a distressed state.

Signposting clients to additional information from support websites or self-help apps can aid the process when working remotely with a client. However, where remote therapy has been assessed as not suitable by either the therapist, the client or by mutual agreement, it is important to refer the client to alternative support, if appropriate. In the first instance, it may be possible to engage the client to meet the therapist in a face to face setting. However, if that is not possible due to accessibility for example, it is useful to know a local directory of therapists or specialised services to refer clients to. This could include support services for issues such as:

• drug & alcohol (https://www.gdas.wales)
• anxiety (https://anxietyuk.org.uk)
• sexual abuse (http://newpathways.org.uk)
• domestic violence (https://www.womensaid.org.uk)
• crisis intervention (https://www.samaritans.org)
• bereavement (https://www.cruse.org.uk)

As an exercise, it is good practice for therapists to engage in research and create their own list of the services or online resources that are available nationwide, but also within the client’s local area. 

• Anthony, K. & Merz Nagel, D. (2010) Therapy Online, a practical guide London: Sage 
• BACP (2015) Competences for Telephone & e-Counselling. Lutterworth, BACP.
• BACP (2018) Ethical Framework for the Counselling Professions. Lutterworth, BACP.
• Bond. T. (2015) Standards and Ethics for Counselling 4th Ed. London, Sage
• Bond. T. (2015) Good Practice in Action 047: Ethical Framework Supplementary Guidance: Working Online. Lutterworth, BACP. 
• Bond T. & Mitchels B. (2008) Confidentiality and Record keeping in Counselling and Psychotherapy. Lutterworth, BACP
• Carole Francis-Smith (2014). Email counselling and the therapeutic relationship: a grounded theory analysis of therapists’ experiences. University of West of England
• Dunn, K (2014) The therapeutic alliance online in Weitz, P (Ed) (2014) Psychotherapy 2.0: Where Psychotherapy and Technology Meet London: Karnac books
• Evans, J. (2009) Online counselling and guidance skills : a resource for trainees and practitioners. London, Sage
• Jones, G. & Stokes, A. (2009) Online Counselling; a handbook for practitioners Basingstoke, Palgrave MacMillan 
• Mitchels, B. (2019) Good Practice in Action 057 Legal Resource: Suicide – legal issues when working in the counselling professions in England and Wales. Lutterworth, BACP.
• Suler, J (2004) The Online Disinhibition Effect. CyberPsychology & Behavior Vol. 7, No. 3