Tech Topics: Online Therapy: Friend or Foe for Social Work?

by Audrey Morrison, MSW, RSW

     When I visited a fly-in community in Nunavut (a northern territory in Canada) a few years back, I was struck by many things. In addition to the ridiculous price for rotting fresh vegetables, I was saddened to learn that services such as mental health therapy were a scarce commodity. The social context and cultural history put community members at extremely high risk for suicide and a myriad of mental health issues. The Conference Board of Canada (2015) declared that Nunavut residents were completing suicide at epidemic rates (63.9 per 100,000 in 2011).

     The statistics are equally disparaging in the United States. The 2015 annual health ranking (United Health Foundation, 2015) established Montana as having the highest rate at 24.3 per 100,000, and Alaska was a close second at 22.2. The map provided in the document gives the reader quite a startling look at where the most vulnerable are located. One could surmise that isolation, difficulty accessing services, and social context play a role. Remote areas often have difficulty enticing social workers because of isolation, lack of other services, and harsh conditions.  

     It seemed to me that there was a natural marriage to be had between remote communities and e-therapy.  If therapy could be provided early enough, perhaps a mental health crisis could be avoided. 

     E-therapy is simply defined as secure, encrypted communication between client and therapist. The communication can be done by telephone, text (email), or video.

     Although it is not required in my particular licensing area to have a special certification to provide e-therapy, my governing college does clearly state that one must have competencies in the treatment offered. With that in mind, I enrolled in the University of Toronto, Factor-Inwentash Faculty of Social Work to take Cybercounselling Level 1 and 2 certifications. In these courses, I learned the nuances in the distinct methodology used for text (email) counseling, as well as legal considerations and the need for a secure service that operates in the country in which you are practicing.  Just as in face-to-face therapy, you are bound to practice in the areas in which you are licensed and your client must also reside within that area.  

     Initial contact is made by the client, and an initial screening is done. E-therapy of any kind is not appropriate for a crisis call, and it is advisable to be able to provide clients with the number for the crisis line near them.

     A first session is typically an introductory one with some housekeeping items, such as fees, payment terms, insurance claims, and length of sessions.  The therapist may wish to send the client an assessment questionnaire to complete ahead of time. My preference is to do it with them in the first session, so I can ask for clarification where needed.    

     Text (email) counseling can be set up so the client sends the therapist an email and the therapist responds within a set amount of time (generally within 24 hours). This is ideal, because it allows time to formulate responses and access any worksheets or psychoeducational pieces appropriate to attach to the email. The other option is to have an immediate conversation between the client and therapist with back and forth emails done over the prescribed amount of time. Either way is acceptable, and the method used should be based on the best fit for the therapist and the client.

     A benefit of therapy by text (email) is that both therapist and client have a record of the session, which can facilitate easy record-keeping, and the client may review information at any time.  It’s a nice way for the therapeutic direction to be reinforced.

     Many naysayers will bemoan the fact that there is no way to see body language or make eye contact. Although these statements are true, emotion can easily be conveyed by a variety of techniques employed throughout the session. 

     Murphy, Mitchell, and Hallett (2011) found that clients are often uninhibited when utilizing e-therapy. This lack of inhibition may lead to more productive sessions. E-therapy can provide a degree of anonymity that clients may not feel in face-to-face sessions.

     Therapy by telephone allows for instant clarification of meaning. It is important for the therapist to smile while using the telephone, because mood is conveyed through voice. Telephone may be preferred when it is the only private mode of communication for clients or if they don’t have access to Internet service. Most, if not all, encryption services will provide a toll-free number for secure sessions.    

     Video conferencing can be friend or foe of the therapist. Video allows for face-to-face contact, which may comfort some clients and therapists. The therapist must be mindful of what is seen in the background when using a webcam. Light room color, uncluttered background, and adequate lighting are essential both to present a professional atmosphere and to avoid unnecessary distraction from the session. In many instances, the client may also be using a webcam at home. This allows the therapist a unique opportunity to see the client in the home environment.  Just as in face-to-face therapy, it is important to avoid judgment and check your biases at the door of your office. The downside is largely dependent upon the quality of the Internet connection on both ends.

     When operating in a home office, there are additional considerations. E-therapy provides the opportunity for sessions without the overhead and personal risk to safety that can accompany having clients come to your home. There are considerations, however. Even though the therapist is not seen in either telephone or text (email) modalities of therapy, it is important to maintain a professional stance when it comes to choice of clothing. Attire will influence the mindset of the therapist, and as such, it is best to leave pajamas in the bedroom and dress the part for a session.

     Whichever modality is chosen, it is critical to have a private space where there is a sound barrier, so pets and children are not unwittingly interrupting the session. As with any type of therapy, record-keeping and retention is a must.

     Any and all communication must be secure and encrypted. The temptation to use a personal phone, email, or public video conferencing such as Skype or FaceTime should be avoided at all costs, because they are not secure.

     E-therapy can work well in isolation or as an adjunct to sessions. The uses truly are as diverse as the field of social work itself. I like the fact that it offers service to those who could not otherwise access it easily. I also like that I can use it for CBT (Cognitive Behavior Therapy), ACT (Acceptance and Commitment Therapy), and Brief and Solution Focused Therapy. I am particularly excited about the application for adolescent clients who are on the autism spectrum. My peers have been using it for addictions counseling and a host of other applications.

     I have personally embraced e-therapy. However, others have not. I do believe the future of therapy will involve more online, and many Employee Assistance Program providers are already offering some form of online services.

     Where would your vote go?  Is online therapy a friend or foe for social work?

References

Murphy, L.J., Mitchell, D.L., & Hallett, R. (2011). A comparison of client characteristics in cyber and in-person counseling. In B.K. Widerhold et al. (Eds) Annual Review of Cybertherapy and Telemedicine, 167, 149-153.

The Conference Board of Canada. (2015). How Canada performs: Suicides. Retrieved February 11, 2017 from http://www.conferenceboard.ca/hcp/provincial/health/suicide.aspx

United Health Foundation. (2015). America’s health rankings: 2015 annual report. Retrieved February 11, 2017 from http://www.americashealthrankings.org/explore/2015-annual-report/measure/Suicide/state/ALL

Audrey Morrison, MSW, RSW, is a school social worker and has an e-therapy practice.