Institute Inbrief - 12/04/2016
Welcome to Edition 245 of Institute Inbrief! The multi-faceted challenges of distance professional services can generally be grouped into three categories: those arising for the providing professional, those faced by the industry, and those experienced by the client. In this edition’s featured article, we explore each of these categories.
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E-therapy: Challenges and Ethical Considerations
The multi-faceted challenges of distance professional services can generally be grouped into those arising for the providing professional, those faced by the industry, and those experienced by the client.
Professional (provider) challenges
Have you ever had the experience of receiving an email from someone which seemed either rude or very harsh: perhaps one which seemed not to take your concerns seriously at all? You may have investigated further, following up with the sender in a phone or face-to-face conversation, only to find out that the meaning you took from it was not at all what the sender intended. Unfortunately, the non-verbal language in email and chat communication systems is all but absent. We can include emoticons as non-verbal communication, but still, these convey what the sender is consciously aware of sending, as opposed to the body language which, viewed in person, would convey the unconscious (and generally, emotional) content of a communication. Thus, with text-only therapy sessions, there is potential for misdiagnosis and miscommunication which is not generally an issue when both the therapist's and the client's non-verbal and paralinguistic gestures can be seen.
Similarly, when distance separates provider and client, social norms may be understood out of context and – with asynchronous communication, such as email – time lapses may mean that the professional does not respond in a timely fashion to events which require immediate intervention. Moreover, apart from possible deficits in the communication technologies and etiquettes/protocols associated with using them, providers may not be sufficiently knowledgeable of the political, legal, and/or cultural subtleties of the client's environment. As an example, let's say you are a provider living on the eastern side of the country and your client lives on the western side. When she says she wants to end it all, do you know how to make contact with the crisis team in her area? Or how to call emergency services there? A separate issue is whether you are even legal to practice counselling with people in her jurisdiction.
Industry challenges
The healthcare communication environment is changing at warp speed, in case you hadn't noticed! We experienced this merely trying to find reasonably updated sources of documents such as frameworks and guidelines for ethical practice, updated codes of ethics, and studies recent enough to provide current insights into online counselling issues. Immense is the pressure on the general healthcare industry in Western, English-speaking countries to adapt rules and regulations to the changing environment. More often than not, current legislation simply is inadequate (silent or out-of-date) as regards questions of web-based counseling services, potential for reimbursement from health insurance providers, security and encryption concerns for health records, and the capacity of online systems to safeguard privacy and confidentiality of client health records in an increasingly unregulated medium (meaning, the internet). The industry, moreover, knows that it has responsibility to verify provider and client identities and deal with issues of jurisdictional definition. Little wonder, then, that the general healthcare industry (not singling out mental health care professionals here) has breathed a collective sigh of despair, deeply concerned about its ability to provide safe tele-healthcare.
Client challenges
Members of different social and cultural groups from that of the providing professional (which is typically the mainstream culture) may perceive health information in a way not intended by the e-therapist. Linguistic, cultural, and economic barriers may all prevent such potential (and needful) clients from accessing ongoing online sessions. The potential for misinterpretation of an email, chat remark, or text message in a text-only session is far greater than when the client can immediately query the professional in person – or at least look confused, in which case the counsellor can hopefully address the nonverbally expressed confusion! Finally, online therapy media may not be appropriate for some client groups, depending on their health status, communication, or technology capabilities (Prabhakar, 2013).
Ethical Concerns
Ethical concerns present themselves from many directions to the mental health professional who would engage distance counselling. For start, the various peak bodies tasked with governing counselling in both face-to-face and online environments want to know how to ensure the competency of professionals working in either context, and for those doing distance counselling there is the additional question of whether the professional is/can be licensed to practice in the jurisdiction of a client who may live in another state, or even country. Part of the competence issue is whether the distance professional has the language and interpersonal sensitivity to work in a text-only environment with adequate capacity for clear communication (given that there are few non-verbal clues to support communicated intention).
Similarly to the ethical issues arising from the use of social media in counselling, the distance professional counsellor must deal with threats to informed consent, privacy and confidentiality (with attendant issues of disclosure and identity), and record-keeping. As a corollary issue, some writers have questioned the capacity to get adequate supervision in the online counselling environment. We look at each issue in turn.
Jurisdiction concerns
Let us begin this enquiry – as an ethical distance professional should – by asking whether the professional in question can live in state (or jurisdiction) X and work with a client living in state (or jurisdiction) Y. Haberstroh (2008) offers American counsellors the ACA (American Counseling Association) reminder that, prior to engaging any form of online counseling service, counsellors must check with their state licensing board to determine the scope and legality of online counseling practice. Further, American counsellors must also check, even if the code of ethics they follow does permit e-therapy, that they are licensed to practice in the state in which the client resides. A blog post by the Online Therapy Institute addressed the question of whether an online therapist has to be licensed in every state to offer online therapy. There are no legal precedents (yet) for the answer, but here are some of the standout thoughts related to the question:
- In theory, some officials have suggested that a clinician could be liable for ethics charges or even loss of license if they see a client who resides in another state
- The state of Ohio is suggesting that therapy takes place wherever the client is
- Providers of indemnity insurance to counsellors are generally not happy with the concept of internet-based counselling services, but for the moment at least, they continue to cover such activities
- While there are no legal cases yet, the first person who gets hit with a lawsuit is likely to be hit big (London, 2010).
In Australia, conversations about the ethics of online counselling are shaped differently. Neither the ACA (Australian Counselling Association) nor PACFA (Psychotherapy and Counselling Federation of Australia) codes of ethics discourage web-based counselling activities. Philip Armstrong, the Chief Executive Officer of ACA, commented that to ban someone from doing online counselling in Australia would be considered a restriction of trade and therefore illegal. Armstrong further noted that the American conversations are driven by issues of insurance and litigation at state level, whereas in Australia such concerns are addressed at a federal level; thus Australia does not experience interstate issues concerning distance professional services. The duty of care, best practice, and ethics mandated for counselling in a face-to-face environment are equally applicable when counselling via other platforms. He added, however, that the ACA is currently looking into how to integrate specific, clear expectations for use of cyber technologies, including social media, into its code of ethics (Armstrong, 2015, personal communication).
PACFA acknowledges that more and more online counselling is happening, and specifically refers to such activities in two places in its code of ethics:
Under "3. Guidance on Best Practice for Practitioners" it states that:
"Most work is undertaken face to face but there are also a growing number of telephone and online services. Some practitioners are moving between these different settings and modes of delivery during the course of their work and are therefore required to consider what constitutes best practice in different settings. Practitioners considering moving into alternative modes of delivery, such as on-line or email counselling, are advised to seek supervision and/or consultation about the implications" (PACFA, 2014).
Under "3.1.1.E Good quality of practice and care", PACFA addresses record-keeping, noting:
"Practitioners are required to keep appropriate records of their work with clients. Records include client notes, emails, and transcripts of SMS communication. All records should be accurate, respectful of clients and colleagues and protected from unauthorised disclosure. Practitioners should take into account their responsibilities and their clients' rights under data protection legislation and any other legal requirements" (PACFA, 2014).
An Australian study examining online counselling services in Australia found that, as of 2002, online counselling in Australia was small and largely email-based, with a few chat-based services (Gedge, 2002). The author herself commented that further studies were needed, and certainly an updating one would be useful.
Competency
The question of competency to be an online counsellor has two parts: that of being a competent counsellor generally and that of being a competent professional for distance work. No extra requirements have surfaced in Australia to ensure that professionals can manage competently in the online environment. In the United States, the Center for Credentialing and Education (CCE) offers the qualification of a "Distance Credentialed Counselor", the requirements for which are:
- A master's degree in counseling or related mental health field from a regionally accredited college or university.
- A license to practice counseling or a related field in the state or country in which the candidate resides or works OR certification in good standing as a National Certified Counselor (NCC).
- Successful completion of an approved DCC training course documented by the final certificate.
The CCE includes links to three approved provider websites in order to undertake the training (CCE, n.d.). The tables of Haberstroh's detailed research, however, show how, as of late 2009, "online counseling was rarely discussed at the individual state licensure board level", leaving counsellors with unclear legal guidelines for professional online practice as concerns both jurisdiction and required competencies (Haberstroh, 2009, p 6).
The dearth of legal guidelines notwithstanding, we can examine the concerns and consequent additional skills that should comprise a distance credentialing counsellor program. Most of them revolve around the absence of visual, auditory, or other cues, which affect the delivery of distance mental health services in several ways.
Choice of medium
Before engaging in e-therapy, the would-be distance health professional must become aware of the different technologies available (as we outlined in the section on formats available for distance professional services) and be able to choose from among them the one that will best suit the needs of the client, the technical and interpersonal capabilities of the therapist, and the situation. In addition to understanding how to operate a chosen format, the professional needs to be aware of the advantages and limitations of each medium. For example, asynchronous text-based technologies such as email allow both client and professional the opportunity to reflect and express their feelings with more depth than what the immediacy of face-to-face counselling permits (Dunn, 2012). Because of the time delay when using asynchronous formats, however, the flow of communication can be disrupted (Suler, 2010). Professionals using synchronous communications such as Skype, conversely, can achieve better real-time flow conducive for immediate communication and behavioural observation (Kaplan & Stone, 2013), but not facilitate reflection, deeper expression, or consideration of serious issues (Dunn, 2012; Suler, 2010).
Beyond those concerns, distance mental health professionals need to understand that when clients do not have visual – and sometimes auditory – cues, they have the advantage of increased focus, lowered inhibition, and honest self-disclosure (Suler, 2010). The attendant disadvantages, however, are those of over-disclosure and an increased risk of cultural miscommunication (Richards & Vigano, 2013). Some clients may be uncomfortable without visual cues, and others may not be comfortable expressing themselves in writing, such as through email or chat systems. Finally, there is the situational issue that some clients in remote areas may not have easy access to distance technologies. In Australia, for example, not all communities are likely to have fast enough broadband to accommodate a Skype call. Thus the professional must take into account client preferences, the total context in which the sessions will occur, and the technology that the situation will accommodate.
The requirement for general technical skills in the chosen technologies is summarised well by Nicholson (2010), who remarked that responsible caring did not require helping professionals to become experts in the use of technology. Rather, he noted, they needed to become informed consumers, understanding and appreciating the potential for both harm and benefit in the use of the technology, balancing the risks and benefits to the clients served. Not all of the additional (hopefully supervised) training is technical, however.
Online language and relational skills
Professionals contemplating e-therapy can allow the challenges posed by the technology to become the central focus of the discussion, but the interpersonal aspects of computer-mediated communication are just as important. As early as 2000, expert commentators were observing that online counselling requires the acquisition of a specific set of online communication skills, which include "emotional bracketing, descriptive immediacy, and the use of similes, metaphors, and stories" (Collier, Mitchell, & Murphy, 2000). Those not familiar with the nuances of text-based relationships were deemed to potentially do more harm than good.
Let's unpack that a bit. Clients report significant change and growth when journalling about their thoughts and emotions, highlighting how powerful therapeutic writing can be (Campbell & Pennebaker, 2003). Yet, with so much of the information – that is, the nonverbal, paralinguistic, and body language – missing online, counsellors must be especially sensitive to communicating in an empathic manner in text form. An early study of online suicide prevention reported that email language could seem harsher than intended (Wilson & Lester, 1998). Thus, counsellors must undertake to review their online work, evaluating how their words communicate understanding, warmth, and empathy to enhance the deep-level benefits of clients writing about emotional issues.
One way in which distance professionals can do this is through process observations shared with clients. For example, a counsellor could merely say, "You seem really happy about that". But the client can be more easily in tune with the counsellor if the counsellor adds, "When I read what you wrote, I smiled and wanted to respond right away, but took some extra time to appreciate your growth in this area" (Haberstroh, 2009, p12).
Other strategies may include clarifying previous statements by later adding, say, the intention behind a statement. For example, the counsellor may say, "Peter, when I wrote that things don't seem to be working at all, I realised that sounded a bit like I was blaming you for what is happening in your life. I just want to clarify that I meant that in a supportive way. I know how hard you are working to create the life you want. Actions of others, however, have me thinking that we might want to discuss some different strategies."
In addition, counsellors may wish to engage in the judicious use of emoticons and other text descriptions of emotions. It is a reasonable expectation on the part of users of online counselling that an online counsellor will be familiar with online language while communicating in a professional style. Thus a smiley-face emoticon may convey a lighter tone, while leaving it off the same communication may convey a more serious tone. Health professionals are wise to get occasional feedback on their communicational style and patterns, as there could also be tendencies to overuse such things as emoticons or abbreviations, or habits such as "winking" to the client. Grammar and punctuation count, too, and professionals are reminded that many sentence fragments or run-on sentences only serve to reduce the clarity of a communication.
Cultivating telepresence
Telepresence is the ability of the mental health professional to engage the client with warm, smooth, emotionally engaging, supportive, empathic, nonjudgmental, and reassuring communications. It is supremely important to the success of online counselling (Hanley, 2012). A counsellor with good telepresence avoids fractured or too-brief conversations, fosters emotional bonding and strong support, and facilitates collaborative goal-setting. The distance counsellor must also present him/herself professionally and be perceived by the client as credible. Further telepresence skills include being able to achieve closure with communications, give quality feedback, and provide appropriate follow-up (Haberstroh et al, 2007).
Nonverbal communication
When communicating through text-based media, vocal intonation, eye contact, body posture and language, and other subtle nonverbal cues are absent. To overcome the limitations inherent in text-only communication, counsellors are recommended to incorporate here-and-now physical reactions in sessions (although this must always be balanced with the time limitations of text-based counselling) (Haberstroh, 2009).
Text-based content and flow
Some researchers have noted that, when counselling via chat sessions, the flow and focus of the sessions was markedly different from face-to-face interactions (Haberstroh, 2009). The sessions slowed considerably and focused on narrow topics as both counsellors and clients wrote, edited, and read responses. Clients have complained that sessions felt "scattered" when counsellors quickly typed questions during times of reflection, and too many topics felt confusing. What is needed with the time constraints and slower pacing of a text-only online session is a few, well-thought-out questions and summarisations. For their part, clients should be encouraged to proactively focus on present issues – especially strong emotions or suicidal ideations. It is part of the counsellor's communicative competency to communicate these understandings about content and flow clearly to clients.
Managing expectations with asynchronous text-based counselling (e.g., emails)
Let's face it: email is ubiquitous, a primary communication medium in most developed nations. Counsellors may find themselves responding via email even when they have no intention of using online technologies to work with clients. The first point about emails is that health professionals should not use them as a medium unless the email server is encrypted. Relevant to the question of competency with online interpersonal relationships, however, are the questions of what concerns the counsellor deems appropriate to bring forward via email, the expected response time of the counsellor, and how many emails may be sent/responded to in a designated time period. Counsellors may also preface any email-based work with a recommendation to clients to only write about a few main issues, but in depth. As with any text-based session, the counsellor's responses must communicate warmth and understanding (Haberstroh, 2009).
This article was adapted from the Mental Health Academy’s CPD course “E-therapy: Ethical Considerations”.
References:
Campbell, R.S., Pennebaker, J.W. (2003). The secret life of pronouns: Flexibility in writing style ad physical health. Psychological Science, Vol 14, pp 60-65.
CCE. (n.d.). Distance credentialed counselor: training requirement. Center for Credentialing and Education. Retrieved on 8 July, 2015, from: hyperlink.
Collier, K., Mitchell, D., & Murphy, L. (2000). Skills for online counseling: Maximum impact on minimum bandwidth. In J. Bloom, Cybercounselling and cyberlearning: Strategies and resources for the millennium. Alexandria, VA: American Counseling Association.
Dunn, K. (2012). A qualitative investigation into the online counselling relationship: To meet or not to meet, that is the question. Counselling and Psychotherapy Research, Vol 12, pp 173-187. Doi: 10.1080/14733145.2012.669772.
Gedge, R. (2002). Online counselling services in Australia – the challenges of a new vehicle for an old art. Retrieved on 7 July, 2015, from: hyperlink.
Haberstroh, S., Duffey, T.D., Evans, M., Gee, R., & Trepal, H. (2007). The experience of online counseling. The Journal of Mental Health Counseling, Vol 29, pp 269-282.
Haberstroh, S. (2009). Strategies and resources for conducting online counseling. Journal of professional counseling: practice, theory, and research, Vol 37, No 2, Fall/Winter, 2009.
Hanley, T. (2012). Understanding the online therapeutic alliance through the eyes of adolescent sendee users. Counselling & Psychotherapy Research, Vol 12, pp 35-43. doi: 10.1080/14733145.2011.560273.
Kaplan, D.M. & Stone, A.A. (2013). Mobile technologies for health promotion and disease prevention. Annual Review of Psychology, Vol 64, pp 471-498. doi 10.1146/annurev-psych-l 13011143736.
London, M. (2010). Ethical and legal considerations of online counseling are ongoing. Legal Lines, May, 2010.
Nicholson, I.R. (2011). New technology, old issues: Demonstrating the relevance of the Canadian Code of Ethics for Psychologists to the ever-sharper cutting edge of technology. Canadian Psychology, Vol 52, pp 215-224. doi: 10.1037/a0024548.
PACFA (Psychotherapy and Counselling Federation of Australia). (2014). PACFA code of ethics: The ethical framework for best practice in counselling and psychotherapy. PACFA. Retrieved on 8 July, 2015, from: hyperlink.
Prabhakar, E. (2013). E-therapy: Ethical considerations of a changing healthcare communication environment. Pastoral Psychology, Vol 62, pp 211-218. Doi 10.1007/s11089-012-0434-3.
Richards, D., & Vigano, N. (2013). Online counselling: A narrative and critical review of the literature. Journal of Clinical Psychology, Vol 69, pp 994 – 1011. Doi: 10.1002/jclp.21974.
Suler, J. (2010). The psychology of text relationships. In R. Kraus, G. Stricker, & Speyer, (Eds.), Online counseling: A handbook for mental health professionals (2nd ed., pp 21-53). St Louis, MO: Academic Press.
Wilson, G., & Lester, D. (1998). Suicide prevention by email. Crisis Intervention & Time-Limited Treatment, Vol 4, No 1, pp 81-87.
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Lifestyle, Neurotransmitters and the Brain
Dr Matthew Bambling (2014) approaches the question of why (how?) nutrition might affect our brains by noting that nutrients serve numerous functions, such as energy metabolism, maintenance of healthy mood, protection and growth of neural structures, and the up- or down-regulation of genes involved in healthy brain metabolism. Most importantly, however, nutrients are involved with neurotransmitters. In fact, nutrients help make neurotransmitters. The old saying that we are what we eat is especially true for brains, so looking after them means ingesting optimal nutrition. Bambling sadly observes that many people begin to show cognitive changes that are related to decline by the time they enter their thirties.
Drug Addictions and Group Work
A Support Group had been advertised on the display board of the local Drug and Alcohol Treatment Centre in the City where the Counsellor had been seeing each of the members for private counselling prior to the start of the programme. Ten clients enrolled in the group but by 7:15pm only 5 of the ten group members allocated for the 7pm time-slot, had arrived. Cancellations and rescheduling unfortunately are an issue with people who are challenged with substance misuse.
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Four Study Strategies to Enhance Your Learning
The time of being a student could be one of the most exciting of your life – or it could be just short of torture. Which will it be? Part of the answer to that lies in how successfully you can employ the good study and learning skills which will spell success. In this post, we explore four general study strategies that help improve your learning. These include: preparing the study environment; organising your study schedule; tips for while you are engaged in study; and methods of boosting your reading efficiency.
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