Risk Assessment in Online Therapy

The following article is based on principles explored in our Online & Telephone Counselling course.

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Working to professional standards when practising online and telephone counselling is just as vital as it is in face-to-face therapy.

The BACP competences point out that understanding risk assessment for online therapy means we must work within our competence, but one of the challenges of online therapy is that you do not get as full a picture of the client as you would if you were seeing them face-to-face.

Identify Online Counselling Risk Presentations

Clients from certain groups may have behaviours or environments that contribute significantly to a serious risk of harm to self or others.

Traditionally, online and telephone counselling courses do not recommend working with the following client presentations:

• Eating disorders – unless you are an experienced therapist, you need to think carefully about working online with a client with an eating disorder. This is because it can be very hard to assess how the client is doing and – crucially – whether they are at risk.
• Personality disorders – it is challenging to work with people who have personality disorders face-to-face, and this is even more so online, especially if their presentation manifests in missing sessions, being late and/or not responding to messages.
• Severe mental-health conditions – it may be better to maintain contact and provide shorter ‘holding’ calls rather than to engage in deep therapy. However, experienced practitioners may be able to apply much of the same work as they would in person.
• Risks such as self-harm, suicidal thinking or risky behaviours – these can be challenging because we may not be able physically to see cut marks (for example on the client’s arms), so we have to trust their reporting. This can lead to deeper trust, but can also lead to missed signs of risk. In online work, we therefore need to be more verbally explicit and direct, e.g. asking questions such as ‘Have you self-harmed since we last spoke?’ or ‘Have you been thinking about killing yourself?’

• Domestic violence – this area needs lots of consideration regarding risk. Consider what would happen if the abuser found your details on the victim’s mobile phone or overheard the victim speaking with you.
• Addiction – clients with addiction issues are often thought to be unsuitable for online therapy. It can be incredibly challenging because – as with self-harming behaviours – we are again relying on self-reporting, e.g. we can’t smell alcohol, look closely at the client’s pupils or do a drug test (if it’s a treatment programme).
• Serious medical conditions – some clients may have medical conditions that could cause a sudden episode of severe illness (e.g. diabetes or epilepsy).

It is your responsibility as the therapist – with support, as appropriate, from your clinical supervisor – to think carefully about managing risk.

It is also important – just as in face-to-face work – that your skill set is a suitable match for the client’s issues and for what they wish to get from counselling.

Unlike face-to-face work – where you can negotiate with a client to get some help if they disclose a life-threatening situation – working online poses several challenges.

The most pressing of these is how we get help if the client becomes unwell during a session, expresses suicidal intent or poses a danger to others in the household.

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Online Therapy Risk Assessment Management

A risk-management plan, also known as an ‘intake form’, allows you to identify any risks in advance, and so to help manage any clients who may be in danger.

It is important to have a risk-management plan whether you are working face-to-face or online. This should form part of your online counselling contract.

It is best practice to revisit the risk-management plan regularly (as part of your reviews), but always to keep previous versions too, so as to ensure you have a complete audit trail of your actions. This helps protect both the client and you as a professional.

The information provides the basis of a risk assessment if you need to decide whether or not to break confidentiality.

Areas to ask the client about are:

• current medications (researching these if you are not familiar with them)
• underlying health issues
• involvement with mental-health services
• suicidal thoughts/plans/intent

The questions needed to elicit this information may feel very invasive, and it is therefore important to approach these in the right way, paying attention to your tone, and reminding the client of confidentiality and its limits.

It also helps to explain why you need to collect this information.

Using Mental-Health Questionnaires

It can be helpful to use standard mental-health questionnaires.

As well as providing evidence-based information to support your decision-making on whether or not it is safe and ethical to work with a particular client, using a standard tool as part of your assessment for all clients can help reduce the feeling of invasiveness.

As a tool in assessing risk and thus suitability for online therapy, you may wish to use one or more mental-health questionnaires.

These come in various forms, measuring depression (e.g. PHQ-9 and Beck’s Depression Inventory), anxiety (e.g. GAD-7), stress (e.g. PSS) and overall mental wellbeing (e.g. CORE and WEMWBS).

Many of these include questions that relate to suicidality (e.g. in PHQ-9, there is ‘Thoughts that you would be better off dead or of hurting yourself in some way’, assessing suicidal ideation; and in CORE-10, there is ‘I made plans to end my life’, assessing suicidal planning).

There are then specific instruments available to measure suicidality – for example, the Beck Scale for Suicidal Ideation.

These assess how far along the suicidal continuum the client currently is, and so whether it would be more appropriate to see the client face-to-face (if possible) or to refer them to other services (the Samaritans, their GP, acute mental-health services etc.).

As well as providing evidence-based information to support your decision-making on whether or not it is safe and ethical to work with a particular client, using a standard tool as part of your assessment for all clients can help reduce the feeling of invasiveness.

Contact Information

Key to safe and ethical online counselling is the collection of emergency contact details for each client (including their GP practice) before beginning therapy.

Ensure that you then always have the relevant details on hand during every session in case you need to contact the emergency services (for risk of harm, falling over, having a seizure etc.). This is especially useful if you are working with a client abroad.

It is good practice to set your boundaries for information-sharing using the Caldicott Principles.

The BACP (2019: 9) advises:

Care needs to be taken in communicating to clients what assistance can be offered from a distance in situations where the client becomes vulnerable or distressed or requires urgent support outside the scope of the service being offered. It is good practice to have discussed with clients how they might be assisted before such a situation arises.