The following article, by Phillipa Weitz, was published here in the e-Beratung journal in October,and she has kindly allowed us to replicate it on our website. Please bear in mind that this was written for a European audience.
Tomorrow never comes! That’s the trouble with looking into the future. And tomorrow is all too quickly yesterday. In e-consulting (guidance, counselling and psychotherapy) the pace of change is so quick that we are permanently playing catch-up with the regulations, our practice when working online and understanding and implementing the ever-changing technology. Within this context, I wish to emphasise the importance of the client or patient. We can discuss the academics as much as we want but the important thing for our client or patient is that he or she gets the care he or she needs.
This article is couched within a number of challenges. I was truly inspired by Rogers’ 1972 address to the American Psychological Association (Rogers, 1972), entitled “Some New Challenges”. It inspired me to radically challenge my thinking and open my mind to new ways to working in online counselling and psychotherapy. I hope this article may inspire you to think about some of the issues and challenges of working online therapeutically.
To put the present into context, in 2005, ten years ago the internet was Web 1.0, where we simply went for information. Web 2.0, where we are now, has moved us into a world of social media, social exchange, thanks to the ubiquitous smartphone, the world of internet superhighways, and a comfortable internet speed. And tomorrow, Web 3.0 the Internet of Everything is where we are going, a world with robots and intelligent digitally based exchanges. For me as a mental health practitioner no matter how many robots may exist there is a completely unreplaceable quality to human interaction, something we psychologists, counsellors, psychotherapists, coaches, guidance experts etc. know to be central to our work. This statement says a lot about my style of therapeutic interaction online, and how I view the online therapeutic relationship as key in the success of the therapy, but I do accept we can now have the possibility of providing support of an entirely different kind, to many people who might find that helpful and who have been otherwise excluded from receiving the help they so desperately need. This can include online bibliotherapy, automated self-help, programmed CBT – freeing up clinicians to work with those who really need our help.
Before going any further, I would like to pay tribute to those within the UK, who were the pioneers. We owe a huge debt to this group which includes: Kate Anthony , Jane Evans , Steph Palin , Gill Jones  and Anne Stokes  to name but a few. They have worked tirelessly and passionately to create and train the first cohorts of counsellors and psychotherapists to work online. We would not be in such a strong position without their tireless, selfless dedication. Other countries have similar pioneers and I hope we will not forget them as we start to become a mainstream profession.
I see a number of challenges for the next ten years for e-consulting, counselling and psychotherapy online or la psychothérapie en ligne.
2. Challenge 1: Clarifying internationally, how does each nation use the terms “counselling” and “psychotherapy”?
Whilst writing this article I have been mindful of the international, certainly European, readership. Identifying how we use terms differently is important if we are to ensure that we are aiming for the same outcome – successful therapeutic work with clients. Not to do so will lead to a catalogue of disasters and misunderstandings. I am of course speaking of the terms “counselling” and “psychotherapy”. Within Europe, we do not have a common definition of “psychotherapy” and “counselling”. In the UK the British Association for Counselling and Psychotherapy state:
“BACP, as an Association, has not distinguished between counselling and psychotherapy. Counselling and psychotherapy are umbrella terms that cover a range of talking therapies. They are delivered by trained practitioners who work with people over the short or long term to help them bring about effective change or enhance their wellbeing. Counselling and psychotherapy are services sought by clients to help them resolve emotional, psychological and relationship issues within a context of confidentiality and clear ethical boundaries using evidence-based interventions to foster long-term recovery, increased resilience and wellbeing. BACP sees no evidence of any difference between the functions of counselling and psychotherapy.” (British Association for Counselling and Psychotherapy, FAQs)
For our German and Dutch colleagues, for example, counselling and psychotherapy have separate roles within mental health care. And where does counselling and psychotherapy end and guidance begin? The word “Beratung” translates into English as consultation or advice . I understand guidance to mean guiding a person along their psychological journey, not the same as advice. Some psychotherapists might take exception even at including guidance within the way they work.
BACP clarifies this: “Therapy is not advice giving or persuasion orientated to the therapist’s point of view, although therapists may offer information and some therapeutic approaches may ask you to do homework as part of your therapy.” (British Association for Counselling and Psychotherapy, What is Counselling and Psychotherapy)
For the purposes of this article, I take the BACP version where psychotherapy and counselling are seen as the same. But a goal that we must pursue over the next ten years is to come to a greater understanding and cohesion globally about the use and role of these terms as borders are crossed regularly when working online. Not to do so will put our entire profession at risk through assumptions, as Henry Winkler says, “Assumptions are the termites of relationships”.
3. Challenge 2: Working better together cross-border, integrating EU law
Working online in counselling and psychotherapy in 2015 is exciting and leaves me full of hope for our clients in terms of service delivery. But it is also full of challenges, contradiction, ignorance and muddle. There is little uniformity or cohesion at an international level. Many of us are blissfully unaware that only several hundred kilometres away others are doing the same, or similar in another country. A priority must be for us to work better together, as Europeans, to make a more cohesive European profession that crosses state borders. This is critical to the future of psychotherapy, as we know it, where we have a very rich and diverse profession.
Fighting for this liberty is very important, otherwise, the UK may be reduced to the same issues as France and Germany where psychotherapy is limited to psychologists and medically trained doctors. A sweep of an EU pen in the middle of the night could deliver this result without us even being aware of it. Working in a more co-ordinated way in Europe online cross-border will truly enrich the profession.
However, a word of warning lest we think that we can do what we like cross border in counselling and psychotherapy: this is not true. We will always need to think about the jurisdiction issues of another country. I foresee that, in Europe, we will become closer as a profession using our online tools to achieve this in a way face-to-face colleagues have failed to do previously. As an example, we will need to think about EU law. On 15th June 2015, the European Council agreed on a unified approach on general data protection. This will eventually, when confirmed, replace national data protection regulations within Europe. We need also to consider “the rest of the world”. The EU itself is already negotiating data protection with other countries. For us in the UK we particularly look to both Australia and the USA. There are specific issues in northern America where it is a minefield to work unless you have a state license, and where every practitioner is bound by the requirements of HIPAA . Africa could receive so much support online, and is already doing so through a number of programmes such as the WHO, and Interhealth, to name but two.
However, what are the consequences of the laws of those countries? Over the next ten years, these issues will be more widely discussed. By then jurisprudence will be available for us to draw on for guidelines.
Without delving into the laws of each country, some countries have rules regarding working online, some don’t. Some of the rules relate to a general digital policy, such as the importance of storage of servers. (Question for you: do you know where your online data is stored?). In Europe, it is required to remain in Europe, in Australia it is required to remain within Australian territory. What happens when we don’t know the laws relating to that country? So often, these matters are a grey area and show the importance of working only with a qualified online supervisor. In the UK The British Association for Counselling and Psychotherapy has been very clear on this, stating within the Online Ethical Code (Anthony & Goss, 2009 and in press), that online therapists should have a supervisor who is qualified to work online, otherwise they leave themselves open to a complaint to their professional body.
4. Challenge 3: Overcoming the vague, unhelpful and conflicting data protection guidelines that have not helped our cause
I cite here the current issues around security and confidentiality e.g. the Skype issue, the Snowden effect, and currently security issues with Windows 10. Therapists all take their own views on security and confidentiality, some saying they don’t care so long as the client is happy, others taking security and confidentiality to a high level. I believe that the national professional membership organisations need to lead the way in these matters as the implications are well beyond the required understanding for individual practitioners – a European Association for online counsellors and psychotherapists could really help here.
The problem with such vague guidance is that we each interpret it differently, and so far, this has not yet been tested in court. Germany, for example, has a far more prescriptive approach to Data Protection, which I personally find refreshing, as we just need to know clearly what we can and can’t do. However, we need also to recognise that no matter what military grade security we implement, if a hacker can get into the White House computers they are going to get into your computer, and secondly the various secret services are always going to have the facility to monitor an individual’s digital activities. We need to be sensible and take reasonable precautions. I believe that in 10 years’ time there will be a more unified approach, certainly within Europe, reflecting the new 2015 EU data protection regulations. Greater collaboration will iron out national differences, and help us to reflect, as one nation, Europe, on how we as mental health professionals can best protect our clients’ security.
Our current challenge for the forthcoming years will be to interpret the EU data protection regulations and implement them. By 2025 these issues will be considered as standard. This will take a great burden off the individual mental health practitioner.
5. Challenge 4: Working out issues of jurisdiction
This involves the ongoing challenge of working cross-border and how this impacts our work. Each nation, even within Europe, also has its own laws, leading to many a dilemma.
Dilemma: We are not allowed to practise psychotherapy online in Austria (Hintenberger, 2012), but in the UK this is fine. So what happens if I, as an English therapist, take on an Austrian client?
Dilemma: Tonderai, a young Zimbabwean man has contacted me via my website and has requested to work with me online. He give me an outline of his problems, depression, family and work based problems, and we contract to work via text-based chat, for an initial 6 week period. In Week 3, he tells me that he is secretly gay and has a gay lover, Lawrence who lives in the next village. It is illegal to be gay in Zimbabwe, what should I do? If I agree to work with him, online I may be putting him and his family at risk if the Zimbabwean secret services are monitoring his internet activities.
Dilemma: I have an English client who goes on holiday to the USA for two months and wants to continue to see me online whilst away. Can I do this?
All these are grey areas, as yet untested in court. It will be really important for the therapist to discuss such dilemmas and issues with their supervisor and their professional indemnity insurer before embarking on therapy and confirming in writing what they decided and why, so that if, later on, there were to be an issue, you have a full paper trail that demonstrates that you thought clearly through the issues before embarking on the therapy with the client.
The current guideline given by professional indemnity insurers (and here I cite Steve Johnston of Oxygen Insurance, Weitz, 2014) is that the mental health practitioner should make it clear that the jurisdiction they are working under is that of the home country of their mental health practitioner – so in my case, the UK.
A European Association would help us to coordinate national regulations and laws, and to reflect on the impact of these, and where necessary give some guidelines. By 2025, I would expect this to be more standardised, certainly for Europe.
At the moment, many countries take very differing views towards face-to-face psychotherapy. For online work, Austria, the birth country of our revered father of psychotherapy, Sigmund Freud, has rejected online psychotherapy as impossible! What would Freud say about that?! I think he would have been the first to engage with technology. He already used forms of remote therapy, i.e. using the telephone and writing letters (another form of distance therapy).
6. Challenge 5: Training to work specifically online
Within the UK at the moment, training to work online is a post-graduate specialisation, but I don’t expect this to last. The United Kingdom Council for Psychotherapy is already changing its pre-qualification minimum syllabus requirements to incorporate more digital matters (UKCP, 2015). Here’s an extract of the documentation that is currently out for consultation (Autumn 2015) – click the image to expand it:
In the UK, there has been quite a lot of resistance amongst mental health practitioners about training to work online, despite the recommendations of UKCP, BACP and ACTO for all therapists working online to do so. I never cease to be amazed by the ignorance of very senior therapists who think they know all about working online without any training. The problem is because they can use Skype they think it’s just a matter of turning on Skype. And they don’t even know that they don’t know! Over the next 10 years we will sadly begin to see complaints filtering through, where a client’s confidentiality has not been respected, for example through using Skype, and it will only be once complaints start that the majority, as opposed to the current minority, of mental health practitioners will undertake at least some training to work online. In the UK this amounts to around 100,000 mental health professionals needing some skills updating and specialist online training organisations will need to be ready.
Linked to training, there are two distinct populations in the online world: digital immigrants, those born before the advent of computers, social media and Information Technology (IT), and digital natives, those for whom the online world has always existed. Within the UK the majority of our counsellors and psychotherapists have learned IT skills in adult life, but it won’t be long before the next generations of counsellors and psychotherapists will be digital natives.
This will have a transformational effort for working online, and training, and this will inevitably have an impact of the delivery of pre- and post-qualification training. In ten years’ time, nearly everyone will be digital natives, and no one will want to wait until they have their professional qualification before specialising in working online. It would be like telling a child who can write with a pen that he has to go back and write with a pencil.
Getting the training right, developing a career structure for the online counsellor and psychotherapist will be important challenges for the future of the profession, and I hope we can do this in a collaborative way within Europe, making a more powerful lobby, academically and clinically.
7. Challenge 6: As online practitioners, fitting into the provision of mental health services in our various countries
This chart, drawn from the research of Theo Vos et al. (2012), demonstrates the high level of mental health problems globally. Seven out of twenty conditions relate to mental health, with major depressive disorder coming out only second to low back pain. Depression is a condition that could so easily be treated online.
There is a massive need for appropriate health and support to these client groups, and digital methods are one route to provide this support. In the UK, psychotherapy and counselling have faced huge criticism and problems to be accepted to work in the NHS, as the government demands evidence-based research to prove their efficacy as treatment methods. In face-to-face work, CBT and mindfulness are examples of two therapeutic modalities that have demonstrated this, and are, commissioned for services as a result.
Large amounts of money are currently being poured into mental health services in the UK, and some of this will filter through to the use of technology, for example through apps. If we are to provide services, we need to provide rigorous evidence-based research.
MindTech Healthcare Technology Co-operative has been leading the way in the UK in such research and is advocating a move away from randomised control trials (RCTs) as taking too long to complete; the app or technology being investigated is likely to be obsolete well before the completion of any RCT. There has, as a result, been a call for people-driven research, and examples of this within the UK include Leeds mHealth Habitat and Berkshire Eating Disorders Service.
The challenge for counselling and psychotherapy online is that over the next 10 years the online profession must demonstrate its efficacy. Other countries will have varying political influences on the funding of mental health services, but, in the current financial climate, we can expect all countries to struggle with budget deficits in the health sector. It will be important to demonstrate that we can help clients to feel better about themselves and help them get back in to work, where appropriate. Depression in the UK is the second highest cause of lost work time, and this is something we can really help tackle with clients able to access this help from the comfort of their own homes.
We need to undertake research that will lead both the public and our own professionals to realise that therapy can be effective online – we know this, and in fact, there is already plenty of evidence of this – for example, Susan Simpson and her team in South Australia carried out a meta-analysis on nearly 10,000 articles on the online therapeutic relationship. The evidence was overwhelming that online was at least as effective as face-to-face. Interestingly, it was the clinicians who were initially more doubtful that it could be effective (Simpson & Reid, 2014). I am hoping that by creating a European Association for Online Counselling and Psychotherapy that we can pool our research together to provide this evidence base.
8. Challenge 7: Having consistent technology to ensure high quality delivery of online care
At the moment, within counselling and psychotherapy, we are using a variety of online tools and apps but they are not integrated and many of them are of dubious quality in terms of security and confidentiality.
Regarding smartphone apps, next year the ISO 14971, an ISO standard for the application of risk management to medical devices, is being modified to include all smartphone apps, and any app being used to support mental health will be considered as a medical device and will be subject to these regulations. This is probably a very good thing as there are legions of relatively useless apps for mental health available, and if they are to be successful in helping patients and clients to feel better about themselves, then it is right that these apps should come under scrutiny. This is one example of how over the next ten years the technology will become far more slick and integrated.
Already within the UK in the last few months, I have come across three platforms that are very close to launching, that include at least a secure asynchronous email type system, a chat system and video-conferencing – and often a lot more too. All this is very new, but in ten years, this will be standard. In fact this last item is high on the list of the trained qualified online counsellor and psychotherapist who understands the importance of a fully integrated, secure platform and it has been frustrating, to say the least, that to date, we do not have one available to us, at least in the UK, and this is set to change.
Quality of ADSL/broadband speed and reliability is crucial. It does seem incredible that I can get good quality broadband/ADSL up a country lane in France whilst some areas of the UK, a country half the size still has large areas on dial up internet. This is a major challenge for us as a profession, and whilst these issues continue we will need to adapt our style of practice to less videoconferencing and more therapy delivery via chat, which takes less bandwidth, or via email where and when the internet may be down for days at a time. As a profession, we have the opportunity to work worldwide, but our ability to, and our method of delivery of therapy, will be dependent on these technical issues. I would not wish either of these two methods of delivering therapy to be seen as “also rans” and I personally find “chat” to be the most effective format for psychological support online.
Susan Simpson and her team, based in Adelaide in South Australia, have struggled over the years to deliver a video service because of technology issues. Obviously, a country such as Australia is huge and the delivery of quality broadband is a challenge, as identified in earlier research projects. In a recent article (Simpson, Rochford, Livingstone, English & Austin, 2014) focussing on a tele-psychology project in Port Augusta, 256km north of Adelaide (South Australia) Susan talks of the great advances made in terms of the technology with a CISCO level technology provision.
I have used Australia as an example, but we are currently in a world crisis with refugees fleeing in many directions. PTSD and trauma are by-products of this, and far more work is still needed. There are projects and counselling being delivered online, for example, in Africa where there are bandwidth and technology issues. One possible alternative route is to use the mobile phone technology, but few people in the third world have smart phones because of their expense. I forecast a dramatic increase in mental health aid online internationally, despite the technological issues.
Whether we are in the UK, Europe, or elsewhere in the world technology will determine how we can deliver efficiently online. Where bandwidth issues continue there are the two other options of text-based chat, or email. Technology is changing at such as rapid pace that the problems I have described above will gradually improve, ensuring that our delivery of provision is better quality.
Most of our mental health colleagues see us online counsellors and psychotherapists as a minority (slightly eccentric) specialism. But in ten years’ time, I foresee this will have changed dramatically, perhaps led by client demand rather than therapists. But we have a long way to go, there are technological challenges, legal challenges, professional challenges, and downright ignorance to overcome, but overcome these we will, as we become the beacons of online counselling and psychotherapy over the next ten years. Just as you cannot put toothpaste back in the tube, our online profession is alive and well and will continue to grow. With the passion, that we all have for it, and the digitalisation of everything, counselling and psychotherapy is here to stay.
Carl Rogers in his 1972 address to the American Psychological Association entitled his address “Some New Challenges” – an essential read to open the mind to the possibilities. His final words were “Do we dare?” Let’s take his lead and dare together!
 Kate Anthony: https://en.wikipedia.org/wiki/Online_Therapy_Institute, Retrieved 12/09/15
 Jane Evans: www.linkedin.com/pub/jane-evans/3a/673/4b2, Retrieved 12/09/15
 Steph Palin: www.linkedin.com/pub/stephanie-palin/6/2b4/a15, Retrieved 12/09/15
 Gill Jones: www.linkedin.com/pub/gill-jones/a7/b54/7b2, Retrieved 12/09/15
 Anne Stokes: http://counsellingassociates.org/organisational-services/anne-stokes.html, Retrieved 15/10/15
 http://www.linguee.de/deutsch-englisch, Accessed 15/10/15
 The Health Insurance Portability and Accountability Act of 1996 (HIPAA). http://www.hhs.gov/ocr/privacy/index.html, Retrieved 12/09/15
Anthony, K. & Goss, S. (2009 and in press). Guidelines for online counselling and psychotherapy. British Association for Counselling.
British Association for Counselling and Psychotherapy. FAQs. http://www.bacp.co.uk/student/faq.php, Retrieved 15/10/15
British Association for Counselling and Psychotherapy. What is Counselling & Psychotherapy? https://www.bacp.co.uk/crs/Training/whatiscounselling.php, Retrieved 15/10/15
Hintenberger, G. (2012). Die Internetrichtlinie für Psychotherapeutinnen und Psychotherapeuten in Österreich. Eine kritische Würdigung. eberatungsjournal. net 8(1). http://www.eberatungsjournal. net/ausgabe_0112/hintenberger.pdf, Accessed 20/10/15
Rogers, C.R. (1973). Some New Challenges. American Psychologist, 28(5), 379–387.
Simpson, S.G. & Reid, C.L. (2014). Psychology in the Bush, Original Research, Therapeutic alliance in videoconferencing psychotherapy: A review, Psychology Clinic, Australian Journal of Rural Health 22, 280–299.
Simpson, S.G., Rochford, S., Livingstone, A., English, S. and Austin, C. (2014). Tele-web Psychology in Rural South Australia: The Logistics of Setting Up a Remote University Clinic Staffed by Clinical Psychologists in Training. Australian Psychologist, The Australian Psychological Society 49, 193-199.
United Kingdom Council for Psychotherapy (2015). UKCP Standards of Education and Training, The Minimum Core Criteria, Psychotherapy with Adults. http://www.ukcp.org.uk/news/standards-of-education-and-trainingconsultation, Accessed 15/10/15
Vos, T. et al. (2013). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010, The Lancet 380(9859), 2163–2196.
Weitz, P. (ed) (2014). Psychotherapy 2.0: Where Psychotherapy and Technology Meet, p207
About the Author
- Philippa Weitz, BEd, MSc, MBACP
- Qualified teacher, trainer, psychological counsellor with more than 25 years in the mental health sector
- Clinical & Security Advisor at HealthBridge Technology
- Commissioning Editor for UKCP Book Series
- Director of UK Counselling Online and Online Counselling 4 Brits
- Managing Director of Philippa Weitz Training Ltd. and PWT Academy for Online Counselling and Psychotherapy
- Standards and Ethics Officer for ACTO
- Author/Editor “Psychotherapy 2.0: Where Psychotherapy and Technology Meet”
Mail: firstname.lastname@example.org / Web: www.philippaweitz.com