Bulletin: Remote Therapy Debate
We had a most excellent response to this important issue and typical extracts from a selection of respondents, both for and against the use of Skype within hypnotherapy, are now included within this Bulletin. It is perfectly clear that this question divides practitioners to a significant degree and that some form of guidance in the matter would therefore be helpful.
With the availability of the new technologies comes a shift in the way people may want to engage in certain types of therapy and it is consequently easy to see the potential benefits and how it could be used to improve accessibility, especially in regard to those clients who may otherwise have difficulty in travelling to their preferred practitioner. For some, therefore, Internet accessibility has become a major step forward in the provision of therapy services. However, such a move towards increased utilisation of technology raises potential concerns and the hypnotherapist needs to be sufficiently adept at determining whether someone is suited for online therapy in the first place. Furthermore, what might the client’s level of skill be in communicating online?
There are safety and ethical concerns that are brought to bear by technology in general and even assuming that proper client assessment has taken place, there are a number of confidentiality and security issues that need to be addressed. Aside from the usual precautionary computer security measures such as anti-virus and phishing software, how does the therapist ensure that their client’s privacy and confidentiality is protected at all times?
Hypnotherapy, like many other fields, will continue to be affected by new and developing technologies that help people communicate, and the expectation must be that the hypnotherapy profession continues to evolve with it in order to ensure that it continues to provide therapeutic environments best suited to clients’ needs.
Registrant Responses – Selected Extracts
(N.B. All references to ‘the article’ relate to a discussion document submitted by a GHR practitioner and published in the GHR News E-bulletin, October ’12)
OPPOSED to, or GENERALLY CONCERNED about, the use of Skype:
“Rapport is the basis of therapy. I do believe it is impossible to build and maintain a good rapport through remote therapy, which is not an ethical way of offering service. In the event of abreaction, how can you handle this? I wonder if you just let the client be vulnerable at the other end of Skype?”
“What of an abreaction? It is distressing enough if the client suddenly ‘comes out of hypnosis’ in a stressful state despite your best efforts to prevent it. Imagine the terrible stress this would cause to the client and the therapist if it happened remotely. As the article stated, you don’t know who else is in the room with your client, or in the next room. The repercussions and the possibilities of being sued are enormous. In the current litigious society, we, as hypnotherapists, would be leaving ourselves wide open.”
“For me, after 20 years working within mental health as a professional, the most important part of working therapeutically with a client is that the therapist is a ‘container’ for the client’s difficult feelings. Having had to talk to patients over the phone a few times over the years (when they are distressed), I know that remote communication is a very poor substitute for the sheer physical safety that the presence of another human provides. With remote therapy, the person knows that you, the therapist cannot physically get to them so their feelings of being out of control will be left with them until such time as they can make contact (if this is at all possible). In my experience, it is precisely these feelings of being out of control (and alone) that elevate the risks considerably.”
“Re: Disassociated Identity Disorder/Multiple Personality Disorder – Now fortunately I have been in practice for a long time and was able to deal with this. On hindsight I wondered how I would have felt if it had happened a couple of years into my practice – and if this had happened over a Skype session – how would I have handled this situation? Mind you, it is the first time it has happened in my practice in 20 years – but you never know.”
“When I consider some of the issues and problems that my clients have presented with over the last 10 years, I cannot even begin to imagine supporting and enabling those clients in a safe, caring and professional way via the telephone or Skype. In order to properly observe a client and pick up on what can often be a subtle signal, I feel that it is vital to be physically in the same room with them and any hypnotherapist who feels that they are experienced enough to undertake Skype sessions in my view needs to re-evaluate just why they are practicing. Technology offers us some amazing and useful choices but there are some instances when it is simply not the right way to go and this is one of them.”
“I believe there is no way we can give the same level of service. Being in a room with someone and calibrating the response always will have the edge on Skype. How often does a client come for help and believe that it is straightforward with no underlying issues. Quite often this is not the case. That is the whole reason they cannot overcome this on their own. I would be concerned that this could get missed. If a client has an abreaction, it is vital the hypnotherapist is present to give personal support. However, if you have already had sessions with a client, and they merely want to tie in those sessions, that should cause no problems.”
“I agree with a number of points raised against this method of therapy, to include a lack of control of the client’s environment, the possibility of bad sound quality for effective interaction, delays on the audio stream and picture break-up. On a personal level, I have worked in the therapeutic environment as a psychiatric nurse in addition to a hypnotherapist and I would always choose a face-to-face interaction to facilitate picking up the important cues (which could so easily be missed via Skype). I also believe that trust between client and therapist can only be truly established on the former basis. In addition, I have met clients who have not felt on-line CBT to be a valuable method of therapy, although according to The Cochrane Library some people benefit from it, and from a positive perspective it can be provided more readily than the origin method. In my opinion, hypnotherapy should flow smoothly and reduce stress and I feel that the Skype method may prove to be both frustrating and irritating.”
“Hypnotherapy is unique and ‘face to face’ (not face to computer) communication is paramount. However, general telephone support to ‘existing clients’ can be beneficial with small issues. Skype will distract from the whole process of Hypnotherapy and will reduce the influence of hypnosis with our clients, thus reducing empowering results.”
“As a therapist, I would not even think of this form of treatment. It’s against all my beliefs and feelings. There is a Code of Ethics which in my opinion should not be broken. I have read your article and think that Skype is wrong, Phone lines are not for that purpose.”
“My view of the above is that I do think you can indulge in remote therapy and there are certain benefits. However, in respect of hypnotherapy, I believe the only way this could work is through face to face interaction and client exercises, tasking etc, perhaps followed up remotely. My main concerns with providing hypnotherapy remotely are:
1) If a person was experiencing a process of abreaction and there was a technical or connection issue. Such issues are a very common occurrence with online video communication, Skype etc.
2) The other aspect is a degree of concern at the levels of trance the person could go into. This is not a major concern normally but I guess these fears could be exacerbated by the connection issues I mentioned earlier. What if someone was in a deep trance, abreacting, or any kind of state that needed some assistance or attention, and you completely lost connection? Worst possible scenario.
I do not see the issue of remote therapy as being necessarily ‘serious’ but the issues I have mentioned above could easily make it so.”
“In my view, only coaching can be safely conducted in other than face-to-face circumstances. Other approaches require physical presence for the safety and wellbeing of the client and effectiveness of the work being conducted. I was intending to reply to the original article point by point but soon realised that the original actually set out most clearly, in a manner which I cannot improve upon meaningfully, most reasons why remote hypnosis cannot and should not be indulged in. To me it is a non-sense to pretend that it is a safe practise and certainly not a responsible or professional practise. People who may defend it, I suggest simply haven’t been caught out yet!”
“My views are that I do not think it is a good technique as you lose the personal nature of a one to one and body language is such an important factor in these circumstances. There are so many things you might not pick up on, or miss, without face to face communication. I agree with the welfare issues – you will miss the deep emotion and also the ability to contain a situation if the client was to become upset, and I also fear the legalities are in question.”
“There is so much work to do in a session and I can’t rely on Skype or any other technology to replace the physical presence of another. There are ethical and legal issues to be considered as well. In the present age of such fast moving technology, I think that some services like Life Coaching and Counselling or similar might be conducted that way, but I do not think Hypnotherapy should.”
IN FAVOUR of, or NOT NECESSARILY OPPOSED to, the use of Skype:
“Many hypnotherapists, indeed many therapists, offer DVD’s, CD’s and other downloadable digital products online and offline, delivering therapeutic ideas and skills training to individuals. Many of these products include hypnotic inductions and visualisations. Do not similar arguments concerning client care and risk also arise in this case? Is using Skype so very different in reality to offering such products.”
“Is this something to do with Halloween? Because it is too late for April Fool’s Day! If not this sounds to me like blind panic over a situation beyond their understanding. As far as the practice of using Skype is concerned, I feel this is no more an issue than selling CDs for self help and self hypnosis. There are limitations and as long as these are understood by both client and therapist then no therapy will be carried out that cannot be safely undertaken using this medium. In my practice I have found that for some clients therapy carried out in their own home is more beneficial than the client attending my practice premises. Using Skype on the face of it appears to be an extension of this; although, the points made in the article about the subtlety in visual and audible signs (in relation to tone) cannot be easily picked up using Skype. Again, I feel the tone of this article is an over-reaction and a more rational and reasoned response is called for. HSE (Health & Safety Executive) rules dictate that, as long as due diligence is carried out, then legally no blame can be attributed to any therapist if a claim is made against them.”
“I undertook further training in order to work ethically and effectively online, and I believe this is absolutely necessary as it is not a matter, as is widely believed, of just transferring current skills to this medium. One point – the lack of some visual cues is, in my view, compensated for by other indirect information, e.g. paralinguistic phenomena; enhanced connection at the transpersonal level. In normal face-to-face conversation, what we see overrides what we hear.”
“For myself, I’m happy with the contract I currently make with clients via Skype; if undertaking hypnosis with them, I check verbally that they’re comfortable to close their eyes, and I always tell them that I’ll never intentionally disconnect from them. We have an agreed back-up number or text arrangement in case of technology failure, and a third-party emergency contact number.”
“My view is that it could be beneficial if you have previously had face to face contact with the client. Although there are an infinite number of possible pitfalls and detractions from using Skype, overall I believe that in the future its use will become more widespread. I do think though, whether you are using telephone, Skype or other media, it is important if not essential to first have had a face to face consultation so you and the client can gain rapport.”
“There are issues with conducting hypnotherapy via Skype, so hypnotherapists in my opinion need to know about them, like the delay meaning that if you comment on something by saying ‘that’s right’ about a minimal cue (for example), the client hears your comment at a different time. I had feedback from clients when I started to do therapy via Skype and they said it was noticeable that some of my comments didn’t match their experience, so I stopped doing this. The important thing in my mind is for clients to be fully aware of issues that may occur during Skype sessions and not charged if they haven’t received an acceptable therapy session. It is also important that therapists are fully aware of the usual Skype issues as well as what works and what isn’t able to be done so effectively via Skype.”
“The requirement in item 8 (Ed – i.e. within the previously published article) for the client to confirm that they are resident in the UK might not be necessary in those cases where the therapist has professional indemnity insurance that covers on-line therapy with clients resident in other countries. In addition to the items listed, it might also be an idea to include (perhaps within item 14) an understanding that online communication is liable to interruption due to technical issues and that this is beyond the control of the therapist.”
“Whilst I agree that during face-to-face therapy a therapist may, for example, observe the client ‘playing with their ring each time their mother is mentioned’, which would be more difficult to note via Skype and impossible over the phone, I suspect that this issue with their mother may very well crop up through other means. How can this be a conclusive argument against either alternative form of therapy? On the phone it may be easier, for example, to pick up on a slight falter in someone’s voice at a given point without the visual distraction of face to face. I know when I am on the phone with a client with my eyes closed I have a very deep connection which is just ‘different’ from when I’m working face to face, yet equally as effective. The blind person hears or smells rather than using vision, which may well be of more value in certain circumstances. Maybe by having a Code of Ethics along the lines of your author’s suggestions (with appropriate re phrasing so as not to send out scary alarm bells) the client can then ‘tick the box’ to say they have read them. I feel this slightly less intimidating than ‘signing their life away’ on such a dramatic list! My final point is that if we are true to being Solution Focused therapists, we absolutely need to be working on what we DO want our profession to be about and not giving power to problems. Basing policy around fear of recriminations gives our power away.”
Resultant Guidelines for Online Work
After much consideration of all comments and views offered by GHR practitioners and GHSC trainers, together with a review of the Codes of Ethics of other relevant professional bodies on this subject, we have now agreed the publication of a sub-section for the GHR Code as set out below. We fully appreciate that some may feel that remote forms of therapy should be completely outlawed but our view is that it is already too late for such a blanket prohibition, that such services are bound to expand along with the ever expanding possibilities of technology and that it is therefore far more advantageous to all parties to put in place some basic safeguards.
Online & Remote Therapy
1. Be aware of, and familiarise themselves with, the differences between online and face to face therapy and the impact that online work can have on the relationship between therapist and client and on the therapeutic process in general.
2. Possess the ability to carry out appropriate client assessments and shall ensure client suitability for online work prior to commencement of therapy.
3. Obtain appropriate insurance to cover online work.
4. Satisfy themselves that the client has presented their true identity.
5. Ensure that the client has read, understood and agreed their personal contract for working online prior to commencement of therapy.
(N.B. The contract should include, but not necessarily be limited to, confirmation by the client of the following:
i) That they are not suffering from any diagnosed psychiatric condition, psychological illness or epilepsy and are not under the supervision of a psychiatrist.
ii) That they have provided the correct address and contact details of their online location.
iii) That they have provided the correct name and full practice address and telephone number of their GP and that they authorise the therapist to contact the GP if the therapist regards it as essential for either the wellbeing of the client or others.
iv) That they will take part in all sessions free from the influence of either alcohol or drugs and will provide a list of any prescription medicines they are currently taking.
v) That they will ensure that the environment in which sessions are undertaken shall be safe and free from distractions and will inform the therapist if there is anyone else present or monitoring the session.
vi) That they will not record the session (either by sound or visual means) without prior permission from the therapist.
vii) That they understand and accept that the therapist may terminate the session without warning if the therapist should determine that the session has been booked for some purpose other than to receive therapy, and that should this occur, the client will remain liable for any session fee that may have been paid in advance.
6. Obtain an agreed back-up number or text arrangement in case of technology failure, and a third-party emergency contact number.
7. Ensure that the client has a clear understanding of what to do in the event of server or computer breakdown or other loss of communication.
8. Ensure that the client has access to all relevant email transactions and full details of all fees paid to the therapist.
9. Take appropriate measures to protect the integrity and privacy of their computer system and to remove client material from their computer at the end of the contracted work.
Views expressed within GHR published material and any conclusions reached are those of the authors and not necessarily shared by other individuals, organisations or agencies
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