Online Counselling Services – Considering the Limitations

online counselling services

Online counselling services – The Limitations

Online counselling has its limits. Psychologists engaging in online counselling services have to consider the impact on the client. In continuation from the previous article which rallied the positive points of online counselling, it is only fair that we point out that like anything in life, an issue has to be considered in its entirety, in this case, the limitations of online counselling.

Some of the circumstances and conditions that may not be best suited for online counselling are:

  • when there is a significant risk factor involved in the patient’s life. Such instances could include a recent:
    • substance overdose
    • suicide attempt
    • suicidal ideation
    • self-harm
  • when there is a real and present threat of the life to the person or another person. Such instances could include:
    • observable characteristics of respiratory failure  (John Hopkins Medicine, 2021) due to overdose such as :
      • being non-responsive
      • being able to hear slow or shallow breathing, choking, coughing, gurgling, grunting, wheezing, snoring
      • being able to observe blueish colouration in the lips or nails, clammy skin
      • being able to observe the change in pupil dilation
      • leaning forward as if they are about to faint or collapse
    • observable symptoms and social behaviours tandem to suicidal ideation include (American Psychiatric Association, 2013):
      • sudden onset of severe sadness or mood changes
      • a strong sense of hopelessness
      • sudden onset of calm or acceptance of their circumstances after the episodes of severe sadness or mood
      • sudden changes in social interaction (social withdrawal)
      • significant and observable changes in personality and appearance
      • engaging in risky and deleterious behaviours
      • being impacted by a significant event or trauma has occurred
      • evidence of making plans such as:
        • preparation of a final will or giving away personal items or property
      • evidence of having made final preparations with loved ones, friends or family such as:
        • requests to take care of children,  pets, passing on guardianship or caregiver responsibilities
    • observable suicidal ideation such as (APA, 2013):
      • thoughts of suicide
      • recent suicide attempt
      • a plan to commit suicide
      • evidence of self-harm
  • when there are challenging self-harm behaviours client involved is a child or a person under the age of full legal responsibility such as:
    • self-harm behaviours in the online counselling session
    • risky or deleterious behaviour is presented while in the online counselling session
  • when the presentation of symptoms by the client requires further examination by a medical practitioner or examination by a multidisciplinary team.

Specific incidents may not be suitable for online counselling and may warrant face-to-face examination:

  • an episode of psychosis.
  • lowered medication adherence in organic disorders such as bipolar disorder, eating disorders, schizophrenia, etc.

The above lists are not exhaustive and it is important to seek advice from a psychologist or medical practitioner. In the case of emergency dial 999.

Scenarios where online counselling can be quite challenging.

Counselling services are currently being offered through the online format for individuals seeking family counselling, couples and relationship issues and even for group psychotherapy by many clinics and practices. While the benefits are clear from our work as psychologists and as observed by Lau et al., 2013:

  • the increased convenience for all parties involved
  • being able to physically distance from the other party involved in the issues during the online counselling session in cases where the interpersonal challenges are challenging or anxiety evoking
  • the ability to open up more with a psychologist guiding online counselling session
  • being able to address particular issues from a location that is more convenient and where the individual feels more comfortable (Lau et al., 2013)
  • enjoying the benefit of being able to learn and reinforcing effective and healthy communication where both parties are located in the same living or work environment and where these skills are practised at the location.
  • aiding situations where physical distance is an issue due to work or life commitments (Lau et al., 2013)

There is a however a debate as to whether counselling services should be offered by this method for more than one person. The potential limitations which have also confirmed by our own work in the field and in academic literature:

  • interruptions or connectivity issues may occur such as mobile phones, not being able to designate a room for the online counselling session, other family members in the household with requests or ongoing needs or simply internet connectivity issues.
  • the ability to speak frankly or clearly about the issue depending on the chosen location for the online therapy session given the sensitivity of the issue being discussed
  • that often important behavioural signals are missed in the session such as fidgeting, tapping of fingers or a shift in one’s posture considering that the screen displays the upper part of the body or face
  • that some may experience the lack or the personal feel in an online therapy session while looking at the screen
  • that when there is more than one individual in the online therapy session, due to some of the reasons mentioned above the direction of conversation can be difficult to control. This is a challenge in face-to-face sessions as well however the distance can be perceived to be an additional issue.

It takes a skilled online psychologist to manage these issues within the session. Troubleshooting issues early on such as,:

  • ensuring your connectivity is properly set up
  • ensuring that family members know that you are engaged for the online counselling session’s period of time
  • securing a location that is appropriate for the online session
  • requesting and providing feedback when it seems the participant sends signals that they are distracted or uncomfortable
  • addressing any concerns about whether the participant feels that an online environment is a place that they can be heard
  • setting up space where healthy interactions can occur and expectations between participants involved

Your online psychologist will assess the suitability for a family, couple or group online session and whether a therapeutic alliance can be established. They will take into consideration extenuating, exceptional or significant factors such as remoteness or distance into consideration as to whether online counselling services may be offered. Taking a comprehensive view of the circumstances particular to your situation, the online psychologist may decide that counselling services in a one-on-one or face-to-face format may be better suited for you where you may be able to better relay your potential issues in confidence.

Finding appropriate services in your jurisdiction

Always be sure to check your local legislation which regulates online counselling services in your jurisdiction. If the services are not legislated in your jurisdiction, always ensure that your psychologist has appropriate professional indemnity in place which serves to protect your well being. With respect to the cost of online counselling services, always check before embarking with any online counselling services with a particular provider that the counselling services or online counselling services are covered by your insurance or government insurance schemes. If you are paying the bill for such services out of pocket then this is not an issue.

While the previous and current article may list the pros and cons of online counselling respectively, rest assured that a significant amount of troubleshooting will be going into improving the provision of online services. As with any disruptive technology, it takes time for adoption, however, the increasing transition towards online-based services which will become a part of mainstream services, be more acceptable and be more readily offered.

On a final note, the counsellor, psychologist or medical practitioner has to consider factors other than just convenience for themselves and the client. This includes doing the necessary due diligence to consider if the patient’s best interests have been taken into account prior to and during treatment. This may involve making a difficult decision of requesting the patient to attend a face-to-face session in the clinic session in spite of the patient’s request to continue the therapeutic relationship purely through counselling services in an online format.

The clients we work with are happy to work with us for the following reasons.

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Note: If this is an emergency, dial 999 immediately.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

John Hopkins Medicine. (2021). Signs of Respiratory Distress. Https://Www.Hopkinsmedicine.Org/Health/Conditions-and-Diseases/Signs-of-Respiratory-Distress. Retrieved May 22, 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/signs-of-respiratory-distress

Lau, P.L., Jaladin, R. A. M., & Abdullah, H. S. (2013). Understanding the Two Sides of Online Counseling and their Ethical and Legal Ramifications. Procedia – Social and Behavioral Sciences103, 1243–1251. https://doi.org/10.1016/j.sbspro.2013.10.453