Keeping clients and others safe online

"The International Society for Mental Health Online (ISMHO) was formed in 1997 to promote the understanding, use and development of online communication, information and technology for the international mental health community."

The International Society for Mental Health Online (ISMHO).

ISMHO provides information about how to access coaching, counselling and psychotherapy over the internet, safely and securely. This is relevant to the following services:

(1) Internet coaching, counselling and therapy, using Voice Over the Internet Protocol (VOIP).

(2) Video conferencing with your coach, counsellor, therapist.

(3) Using Instant Messaging to contact a coach, counsellor, or psychotherapist.

(4) Email counselling.

To view the ISHMO website, please click here.

I am a member of the International Society for Mental Health Online, and I abide by the guidelines of ISMHO regarding ethical practice in providing coaching, counselling and therapy services over the internet. The basic document which guides my actions is shown below. But first I want to introduce you to an abstracted list of advantages and disadvantages of coaching, counselling and therapy services online:

THE ADVANTAGES AND DISADVANTAGES

This list is not comprehensive, but it will provide you with a good preliminary understanding of the pros and cons of using the internet for coaching, counselling and therapy services.

The advantages include:

1. You may feel freer to be yourself online.

2. You may feel more comfortable receiving coaching, counselling or therapy in the privacy of your home.

3. In the case of using email exchanges or internet relay chat, you may feel more comfortable writing about your problems than talking about them.

4. You may write about what is bothering you sooner than you would talk about it. This can bring faster resolution to problems.

5. Writing may help you to think through your problems and to get in touch with your emotions. It can bring focus, clarity, insight, and emotional relief.

6. You can read and re-read your emails, and chat transcripts, thus achieving greater learning.

7. Writing enhances your relationship with yourself.

8. You can contact your coach/counsellor by telphone, thus maximizing ease of communication, but you do not have to present yourself in their office, or "look them in the eye", which can be an advantage with problems that invoke a sense of embarrassment.

9. There are more coaches/therapists to choose from online. And it is also possible to see them "face-to-face" by using video conferencing if you have a web camera.

10. You can email your coach/therapist any time of day, and especially when you feel the need for help.

11. You can take as long as you want to write.

12. While you can see your coach/counsellor over a webcam, you do not need to be concerned that you will bump into them on the streets of your hometown tomorrow! So there is greater anonymity.

The disadvantages include:

1. Online coaches/therapists don't have access to important information about you without face-to-face sessions (unless you use video conferencing with webcams). (However, having occasional phone sessions as well can provide your coach/therapist with more information).

2. There can be more misunderstandings by email and therefore a greater need to explain things and ask questions. (This can be an advantage too, as it encourages us to be clear and to ask questions, which is something that some people are afraid to do in person).

3. Some problems cannot be resolved online.

4. Confidentiality cannot be *guaranteed* over the internet, (though coaches/therapists make every effort to keep communications private, and would not knowingly or deliberately allow any session information to be made public!) (Skype.com offers secure encryption, which is superior to other systems of encoding).

5. Online coaching/therapy is relatively new - although writing as a form of support is not new - and so it's still in its infancy as a form of coaching/therapy.

If these lists are not sufficient to allow you to make a decision, then please read the Suggested Principles for the Online Provision Of Mental Health Services, which follows immediately below. I advise you to read the Suggested Principles anyway, since they cover some ground which is not covered above.

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Online mental health services often accompany traditional mental health services provided in person, but sometimes they are the only means of treatment. These suggestions are meant to address only those practice issues relating directly to the online provision of mental health services. Questions of therapeutic technique are beyond the scope of this work.

The terms "services", "client", and "counselor" are used for the sake of inclusiveness and simplicity. No disrespect for the traditions or the unique aspects of any therapeutic discipline is intended.

1. Informed consent

The client should be informed before he or she consents to receive online mental health services. In particular, the client should be informed about the process, the counselor, the potential risks and benefits of those services, safeguards against those risks, and alternatives to those services.

a. Process

(1) Possible misunderstandings

The client should be aware that misunderstandings are possible with text-based modalities such as email (since nonverbal cues are relatively lacking) and even with videoconferencing (since bandwidth is always limited).

(2) Turnaround time

One issue specific to the provision of mental health services using asynchronous (not in "real time") communication is that of turnaround time. The client should be informed of how soon after sending an email, for example, he or she may expect a response.

(3) Privacy of the counselor

Privacy is more of an issue online than in person. The counselor has a right to his or her privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. See also the below on the confidentiality of the client.

b. Counselor

When the client and the counselor do not meet in person, the client may be less able to assess the counselor and to decide whether or not to enter into a treatment relationship with him or her.

(1) Name
The client should be informed of the name of the counselor. The use of pseudonyms is common online, but the client should know the name of his or her counselor.

(2) Qualifications
The client should be informed of the qualifications of the counselor. Examples of basic qualifications are degree, license, and certification. The counselor may also wish to provide supplemental information such as areas of special training or experience.

(3) How to confirm the above
So that the client can confirm the counselor's qualifications, the counselor should provide the telephone numbers or web page URLs of the relevant institutions.

c. Potential benefits

The client should be informed of the potential benefits of receiving mental health services online. This includes both the circumstances in which the counselor considers online mental health services appropriate and the possible advantages of providing those services online. For example, the potential benefits of email may include: (1) being able to send and receive messages at any time of day or night; (2) never having to leave messages with intermediaries; (3) avoiding not only intermediaries, but also voice mail and "telephone tag"; (4) being able to take as long as one wants to compose, and having the opportunity to reflect upon, one's messages; (5) automatically having a record of communications to refer to later; and (6) feeling less inhibited than in person.

d. Potential risks

The client should be informed of the potential risks of receiving mental health services online. For example, the potential risks of email may include (1) messages not being received and (2) confidentiality being breached. Emails could fail to be received if they are sent to the wrong address (which might also breach confidentiality) or if they just are not noticed by the counselor.

Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the email account or the computer. Extra safeguards should be considered when the computer is shared by family members, students, library patrons, etc.

e. Safeguards
The client should be informed of safeguards that are taken by the counselor and could be taken by himself or herself against the potential risks. For example, (1) a "return receipt" can be requested whenever an email is sent and (2) a password can be required for access to the computer or, more secure, but also more difficult to set up, encryption can be used.

f. Alternatives

The client should be informed of the alternatives to receiving mental health services online. For example, other options might include (1) receiving mental health services in person, (2) talking to a friend or family member, (3) exercising or meditating, or (4) not doing anything at all.

g. Proxies

Some clients are not in a position to consent themselves to receive mental health services. In those cases, consent should be obtained from a parent, legal guardian, or other authorized party -- and the identity of that party should be verified.

2. Standard operating procedure
In general, the counselor should follow the same procedures when providing mental health services online as he or she would when providing them in person. In particular:

a. Boundaries of competence

The counselor should remain within his or her boundaries of competence and not attempt to address a problem online if he or she would not attempt to address the same problem in person.

b. Requirements to practice

The counselor should meet any necessary requirements (for example, be licensed) to provide mental health services where he or she is located. In fact, requirements where the client is located may also need to be met to make it legal to provide mental health services to that client. See also the above on qualifications.

c. Structure of the online services
The counselor and the client should agree on the frequency and mode of communication, the method for determining the fee, the estimated cost to the client, the method of payment, etc.

d. Evaluation
The counselor should adequately evaluate the client before providing any mental health services online. The client should understand that that evaluation could potentially be helped or hindered by communicating online.

e. Confidentiality of the client

The confidentiality of the client should be protected. Information about the client should be released only with his or her permission. The client should be informed of any exceptions to this general rule.

f. Records

The counselor should maintain records of the online mental health services. If those records include copies or recordings of communications with the client, the client should be informed.

g. Established guidelines

The counselor should of course follow the laws and other established guidelines (such as those of professional organizations) that apply to him or her.

3. Emergencies

a. Procedures

The procedures to follow in an emergency should be discussed. These procedures should address the possibility that the counselor might not immediately receive an online communication and might involve a local backup.

b. Local backup

Another issue specific to online mental health services is that the counselor can be a great distance from the client. This may limit the counselor's ability to respond to an emergency. The counselor should therefore in these cases obtain the name and telephone number of a qualified local (mental) health care provider (who preferably already knows the client, such as his or her primary care physician).

ABC Coaching and Counselling Services.

Jim Byrne’s Email Address.

Back to Voice over Internet page.

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