Risk Assessment in Online Therapy

Ken Kelly: So managing risk in online therapy. There’s a risk when we work online?

Rory Lees-Oakes: There is. It may be not as apparent as people think if you’re working in the room with a client, and anything goes wrong, you know exactly where the client is and you can call emergency services I used to supervise someone who worked for age concern. A couple of her clients who were older people, became unwell when we were having the counselling session it was just a very easy procedure of calling 999 here in the UK.

But if you’re working remotely, then that becomes a really different proposition because you need the information to be able to point the emergency services to where the clients is.

And that’s the kind of thinking that needs to be in the front of our minds when we work online. Basic safety protocols dictate, that we have contact information for a client. So we know where they are.

Ken Kelly: It’s interesting us having one another’s emergency contact details, and the same is for our entire team at Counselling Tutor because we are a remote working company, pretty much spread across the world, to be honest with you, and we hold emergency contact information on all of our team members. And we have had occasion where we needed to dip into that. So it is real and it does happen, not just in therapy, but just online in general.

And what occurs to me is when we’re working via technology. Whether that be online, via a video app, or if you’re using a telephone, or if you’re texting, you don’t see and feel what you see and feel in a face to face therapy room.

If you’re working on video, you may say, I do, I see my client. But do you? You see a little passport size photo really. So, so much that we rely on in terms of visual cues, nonverbal communication, can be lost when working remotely.

Rory Lees-Oakes: We would think very carefully before working online or remotely with a high risk presentation, we would first of all know that we have the competence to work with that area. But then again, we would revisit it. Is it appropriate to work with that client online?

Ken Kelly: I’m going to give an example of a presentation that I would not work with using remote technology, and this is just me personally.

It doesn’t mean that others don’t work within this area, maybe with different boundaries and a different process. But for me, I would not work with somebody who had an addiction problem or an alcohol related challenge and they were coming into therapy to overcome that. To stop the drinking, to get into what they call recovery.

The reason is, I would find it difficult to ascertain where that client was if they were not in the room. If they were in the room, you have a little hints maybe a smell of alcohol would be a telltale sign but you’re not going to get that in an online setting.

You’re reliant on how that client chooses to share with you.

Rory Lees-Oakes: Yes. And I think that also speaks to psychological contact Ken, because if you’re working with someone who’s in active addiction, you might not be able to get a sense if they’re under the influence.

Certainly in my practice experience, I can think of one or two clients who have presented and clearly they were highly under the influence of something. One was definitely alcohol because I could smell it. And I thought to myself, is this person in a place actually to look at themselves?

Because that’s what therapy is about, isn’t it? Sometimes to look at your own processes in a way that is safe. If someone’s under the influence, then that alters the way people think, and you can’t get a sense of that if you’re working online. So I think, like you Ken, I’d be slightly hesitant to work online with someone who was in active addiction.

The other thing that I’ve worked with a lot of people who are very vulnerable. They’re in very abusive relationships, andit takes quite a lot of both courage and also reflection for people to leave abusive relationships.

It’s very easy to say, why don’t you leave them? But, we all know trauma bonding, financial situations, real fear of violence, can keep people in relationships for years because they can’t find a way to leave. And if I was working with a client or a client contacted me for online therapy and saidI might have to go very quickly because if my partner comes in, I could be beaten up.

I think I’d have to think long and hard about that. Because that could be quite dangerous. If you’re working with someone, and they know that any minute they could be attacked. Are they going to be in a position to be able to process the therapy?

So I think those are things to consider. And maybe talk with your supervisor, talk with your peers, don’t dismiss people out of hand. Neither myself and Ken are saying we should dismiss these two client examples, but it is a safety risk factor that you need to keep in the forefront of your mind.

Ken Kelly: Yes, and the topic is managing risk in online therapy. It’s where we’re identifying that there may be an added risk or a need for really thinking it through.

We’re not suggesting not to work with people at all, but just that we do visit the risk and mitigate that by putting something in place.

Another one that comes to mind is somebody who has a serious medical condition. It could be diabetes, a recent stroke, or a heart attack, they’re now looking at their life and wanting to get a different perspective. But if they are potentially vulnerable to having another episode, it just highlights the importance of having those emergency services.

We would revisit our contract and working agreement with our clients when we see these higher risk presentations. As you were speaking about domestic violence, I was just mindful that you can only see what the camera sees when you’re working as a therapist.

You don’t know if there’s somebody in the room, that person is having to behave in a certain way. So we would work with someone if they were presenting with a domestic violence presentation, a vulnerable person, we would work with them pre the sessions to make sure that they are safe or to make sure that they can in some way give us a sign.

Higher risks such as self harm, suicidal thinking, those would be an added consideration if you’re working online or via a technological interface between you and your client. How would we unearth these risks before we end up in session number three, and then it gets dropped on us, and we realise that we might not have put the preparation in place.

Rory Lees-Oakes: I think before we do that, Ken we’ve talked predominantly about video. And practitioners who can see their clients for those people who are, partially sighted or not sighted at all, all those who work on the phone, it becomes even more difficult.

But to answer the question, how we would mitigate the risk is by having a discovery conversation with the client. The 30 minute introduction session, which, a lot of people, a lot of therapists have, and they find it’s really useful for getting to know clients, but also clients getting to know them so they feel comfortable in working.

It only mitigates risk so much because people may not tell you the truth.

That does happen. But by having a very clear contract, a very clear discovery call where you’re talking to the client, getting a sense of them and what they want to work on, and also, a discovery form, a questionnaire. Which asks about health, where they are, getting their name, and address, and details. Sometimes, even getting a trusted person’s details. So if something goes wrong you can call the friend, with the agreement of the client,

making sure that those are updated. Information shouldn’t be static, it should be revisited and updated. Any risk profiles should be updated and discussed with the client.

They shouldn’t be done in secret. You’ve told me this, let’s have a look at what we talked about initially about risk. It should be an open, honest conversation for the benefit of the client.

Ken Kelly: One hundred percent. This applies to face to face in the room just as much.

Risk management, a risk management plan, or you can have an intake form, that the client can fill in or questions that you might ask, that would highlight if there is an underlying risk. And when you observe an underlying risk, you’re going to build a risk management plan, and you’re going to share that risk management plan with your client.

Let’s say I’m working with a client, they’ve had a life threatening heart attack where they actually died for three minutes, but they were brought back and they’ve got this new perspective on life, they’re wanting to dive into their past and revisit that.

I might recognise that they’re in recuperation. They may be tired. They may be sluggish. High emotions might trigger them off again. I might discuss this with the client and say, I would need to get certain details from you, should you become unwell when we’re in a session.

So we’re contracting that with the client. And that is going to be as unique as the clients that present. You can look to your supervisor if you’re unsure on your risk management plan. There’s a lot of information out about risk management planning for clients, the CPD you can do on it. It does apply in the room as well as online. But online, we take into consideration that distance and the technology that sits as an additional barrier to communication.

Rory Lees-Oakes: Absolutely. And one final thing is that sometimes clients aren’t static. Pay attention. If you’re working on video and the client comes in and they’re in a different room, or location, say oh, I’ve noticed that you’ve changed the room you’re in.

Are you in the same location? That question might elicit actually, no, I moved house. In which case it wouldn’t take very long just to get the new details. And sometimes clients will drive, and park up somewhere. I’ve worked with clients who parked in the car park of some woods because they feel it’s a safe space for them, or a country park. Just to get an idea of where they are.

Just to make sure that we can get help to them when we need them. One thing that sometimes isn’t picked up, but where it’s really essential, is end of life work. Having contact details can be very helpful because sometimes people come to therapy and then they become very unwell because of the medication or the condition and they may need some form of assistance. What strikes me with this conversation, Ken, there’s so much more to think about than when you’re just working in the room.

Ken Kelly: Yes, I like to think that we’re now in an age where a therapist knows that they don’t just graduate with their counselling qualification and go, oh, I’m going to now do this online, we recognise that training is required.

If you look to your ethical body, they will suggest what those additional competences are. There are psychological phenomena that play out online or via technology that don’t play out in the room, it’s different.

So that is our topic today. I’m mindful we can use mental health questionnaires and the paperwork that is available to us as counsellors for unearthing that risk.

And of course, we’ve already spoken how we would then cover that. Make a risk management plan, how this would be covered in our contract, that we’d revisit it on a regular basis, that we would recognise that there are certain presentations that may show as a higher risk. Medical conditions, addiction, domestic violence, anything else as we come to the end of this topic?

Rory Lees-Oakes: I think about keeping the risk profile updated and certainly when it comes to what’s sometimes clinically called suicidal ideation, which I think is a very cold phrase for people considering ending their own lives. Not to rely just on things like PHQ 9.

So PHQ 9 is a questionnaire, sometimes given out to clients where you tick boxes, and give them a score on certain things. One’s on suicidal ideation. Recently, there’s been a change in the use of these questionnaires. If you take one, and the client’s very low score for suicidal ideation, don’t rely on that score all the time, because it might be that the client does it and at that time they feel okay, and then as you’re working through the arc of therapy, things change.

They give you hints and indications, or you pick up themes from the client that they may be considering taking their own life. If you’re ever questioned in a coroner’s court about did the clients ever give you an indication?

It’s not really good enough to say, at the beginning of 10 sessions, I did this form and they said it was low. And then it comes out, that through the arc of therapy they were giving very clear indications they we’re thinking of taking their own life. So all risk profiles should be live, really updated with the consent of the client. It’s a joint venture and work with the clients on that, but don’t just do it and then file it in a draw.

Ken Kelly: Yeah, it’s almost like an audit trail, doesn’t it? It gives you an audit trail that you can use for defendable decision making of why I did what you did at the time.

You did it by saying, every session we checked where that client was. This is where they said they were. When I saw this, and they presented with this, we revisited the risk management plan. And you’ve got a step by step of your entire process of how you help, professionally, that client.