11.3 Online Client – Therapist Interface: Recognizing and Responding to Ethical Dilemmas
11.3.1 Is e-Therapy an Appropriate Choice for Everyone?
As a therapist, I am often confronted with a dilemma, both clinical and ethical, when there is a referral from a new client for‘long distance’therapy, for something
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like‘depression’, or ‘relationship problem’. The client may be from a geographi- cally distant location, perhaps with limited availability of mental health profes- sionals in that area. If one agrees to take the client on without having had a chance for a face-to-face assessment, there may be possible risk factors for which long distance therapy might be contraindicated. Conversely, refusal to take on the client may be accompanied by the guilt of not helping someone who reached out and has few options available locally.
The overarching ethical principles of beneficence and non-maleficence must be considered while assessing client suitability for any intervention, and this includes the e-therapy modality. In my practice, I almost always agree to work with a client using videoconferencing only after having had an assessment session (preferably face to face) to gauge whether or not the client would benefit from long-distance therapy. Over the years, I have found it useful to educate a potential client that I would need to make an assessment to judge whether or not ‘videoconferencing’ would be beneficial as a primary mode of therapy (Mallen et al. 2005).
The assessment for suitability for e-therapy is based on the following four cri- teria: (1) the nature and severity of presenting concerns of the client (2) the availability and comfort with using technology (3) availability of a private and confidential space in the client’s home/work space and (4) the verbal expressiveness of the client, allowing for a good enough online communication.
The nature and severity of presenting concerns of the client: Are all pre- senting concerns amenable to treatment through online modalities? Possibly not.
One would guess that both the nature as well as the severity of the problem would determine the suitability of a client for e-therapy. Typically clients with psychotic disorders, severe personality disorders and those who are suicidal and homicidal, are not considered to be good candidates for e-therapy (Ragusea and VandeCreek 2003). In addition, victims of sexual abuse and intimate partner violence may not be most appropriate for e-therapy (Bloom1997). Suler (2001) writes,
Tendencies towards poor reality testing and strong transference reactions may become exacerbated in text communication, thereby making them difficult to manage and poten- tially destructive to the treatment. People with borderline personality disorders often challenge the boundaries of therapy, which can be problematic in email communication and when combining different methods of communication (p. 678).
It is also true that any client who has been screened and found suitable for e-therapy, could manifest with suicidal intent or plans at a later stage during the course of therapy. A therapist has to always keep that possibility in mind and be prepared with contact information available for family and identify professionals who could be locally available to the client in such emergency situations (Manhal-Baugus2001).
Availability and comfort with using technology: For online therapeutic interactions to work effectively, it is important to ensure that the client has adequate knowledge of computer functioning, has easy internet access and adequate internet speed available. These may pose a challenge in some locations in India where both
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computer literacy and access might be limited. The use of public‘cyber-cafes’for client–therapist online interface is fraught with ethical concerns regarding confi- dentiality. Usually, younger clients (12-50 year old) are more technologically savvy than older ones (50 years and above). As a therapist, one may need to keep oneself updated regarding the advances in videoconferencing modalities, and be willing to try a medium that his/her clientsfind familiar, useful and stable.
Availability of private and confidential space in client’s home/work space:
During e-therapy, the therapist may have little control over the physical environ- ment of the therapeutic space and in ensuring a physically safe and confidential space. As a therapist, I understood the depth of this only when a client who worked with me face-to-face for two years had to shift to videoconferencing because both of us moved out from the city we met in. During one of the videoconferencing sessions, she cried and shared that she really missed the safety of being in my office during our sessions. Now that she talked to me from her home, she was always aware of the presence of people around her whom she felt emotionally fragile around. In many homes, respecting the privacy of therapy sessions may not be a given. For instance, a parent or a sibling of a teenaged client might not see anything wrong with their being in the same room, while the client is in therapy via Skype.
One of my supervisees once reported the difficulty in having Skype sessions with a woman confronted with issues of subjugation within the joint family, because the family members kept coming in and out of the room, during the session. This client could not explain to the elders in the family why she needed to lock the room for this one hour. Thus, as part of the‘assessment’for suitability of videoconferencing sessions, it might be helpful to ask the clients some very specific questions around what kind of privacy they have in their home while on the call with the therapist (Ragusea and VandeCreek2003). One may also assess the level of assertiveness of the client around being able to ask for privacy, if that is not easily understood or given in their family.
Verbal expressiveness of the Client: Videoconferencing and other forms of e-therapy tend to be much more dependent on verbal expression than a traditional face-to-face session where non-verbal communication is also an essential compo- nent of the interactions. Videoconferencing might not be the best choice for a client who is not very verbally expressive and/or who could use more non-verbal means of expression such as art or sand play to benefit from therapy. This is also another reason why e-therapy has very limited use with young children who need to be able to use‘play’ as a mode of therapeutic work. The risk of missing communication cues is much higher in text-based e-therapy using email, short messaging services or other instant messaging services (Alleman 2002; Mallen et al. 2005), and this could impact the quality of therapeutic services being offered. From an ethical standpoint, these potential limitations should be clarified to the client at the very onset at the initial phase of assessment to avoid later difficulties and hindrances in the therapy process.
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