Greetings,
This morning as I peer sleepily at my screen over a steaming cup of sweet chai tea, the first of eight for the day *grins*, I consider what challenges I've faced in online therapy over the past five years. I thought to myself, 'what type of client has proved to be the most difficult?'
It seems obvious that someone with a difficult personality would be challenging to work with through any medium whether that be face-to-face, online, telephone etc, but I think that the online medium intensifies the difficulties faced by therapists with this style of client. I'm reminded of a few cases, which I can not talk about in specifics, but they certainly had a few things in common. (And boy did I learn some lessons :))
1. The clients were demanding.
2. The clients were highly reactive to all their emotions (often threatening to self-harm).
3. The clients were unpredictable and attention seeking.
Your first thought might be 'well, set some boundaries then?' And this would be an excellent point, but when those boundaries conflict with deeply established maladaptive patterns of behaviour (patterns now firmly a part of the personality) this requires time and awareness on the clients part in order for those patterns to be altered.
The obvious question to ask now, is 'how does online counselling (in text) creates further difficulty for this style of client?' The first thing that pops into my, now awake, mind is emailing. The client has a constant link to you, your email.
In a physical setting, you most likely have a receptionist or an answering machine, something you probably won't check several times a day (Well maybe you do?). My point is, email makes getting in contact with you ethically questionable. The difficult client can send you emails about ending their life, self-harm, or anything else that goes on in their day that they deem necessary for you to know about. With messages like this in your inbox, you may be left feeling a little concerned or worried -- well, I would certainly hope so! Of course, your training may have taught you that you should call the police or contact the client directly. What happens if they're overseas? Do you call their phone (if you have that number)? If they're anonymous, how much are you responsible for if something happens to them and you were the last to be informed?
These are all challenging questions to answer.
As I said in my previous blog, you do what you can. The only way clients learn boundaries, is through consistency. Supportive consistency. Address the issue with the client, establish consequences for the continued behaviour in the next session. I don't mean you should threaten to withdraw your support, even if the client is making it difficult for you to help them, the threat of withdrawing support is not helpful whatsoever. I have dealt with this style of client by bringing up a modified version of "The Boy who Cried Wolf." Clients are usually aware that they go through emotional crises which are not always life threatening, make a plan for them that doesn't involve sending you emails (coping skills!). If the client doesn't use these coping skills then that needs to be addressed also. Finally, the best way to ensure you do not put yourself in this situation in the first place is to Screen your clients. And I say it again, Screen your clients! In the few instances where I have agreed to work with these types of clients, I made sure that they would work on their issues and that they would do their homework -- and they did. They demonstrated great enthusiasm to change, and this is the first thing I look for in my clients before I take them on. Deeply ingrained maladaptive coping skills, with hard work, can be changed. The client is more likely to change if they are willing to change. Sometimes these types of clients have terrible living conditions with little social support, and in this case you can make a huge impact on this persons life, whether they are difficult or not.
Know your limitations in this online context. Set your boundaries. Take your time testing whether you can help your clients. Lastly, risk/reward. Will you be putting yourself at risk for a client that you will probably not be able to help? Then don't do it. Helping others requires that we as therapist give so much of our own energy, if you exhaust that energy supply, you and your clients will be affected.
Now, time for a refill.
Tuesday, November 30, 2010
Monday, November 29, 2010
The New Clinic and Ethical Qualms.
Well hello fellow therapists, Second Life-ians and anyone else bothering to read this blog.
I have been particularly busy this week working on my new clinic in Second Life (SL). Yes, out with school work, in with work-work. You might protest at the idea that a job entailing moving around in a virtual world is called "work", but I beg to differ. Anyone who's ever used SL will be aware of the frustrations of searching through endless inventory items, setting objects up in a 3D environment with limited viewing and of course trying to get your scripts functioning without digital hiccups. Despite all the frustrations I've experienced bringing this project to fruition, I'm quite excited about the prospect of holding group therapy and individual therapy in SL.
My previous clinic, which existed digitally last summer (yes Australia has hot Christmases-- haven't you heard 'Hey luv! Put another shrimp on the barbie will ya?' Here's a translation link if you're feeling a little confused about that Aussie Slang ), was mainly an information clinic where clients could make appointments in SL and then flesh out the details through email. From there we would set up appointments using Windows Live Messenger and Skype.
I do have qualms about counselling in virtual environments, at least if I use Windows Live Messenger I can encrypt chat with Bitdefender. Emails can be encrypted, there are ways to make sure you're practising ethically online. SL is not a great environment ethically. You're probably asking 'so why counsel there then?'. The simple truth is that the private IMing system in Second Life is fairly secure. Not completely, but I don't think Linden Labs really cares about what goes on in Private IMs unless you're discussing ways to penetrate the SL mainframe or organising a terrorist attack. Clients can be made aware of the possible consequences of continuing in a virtual environment but still, people I don't know can access the private messages between myself and a client -- I feel uneasy about this.
When I think of ethical issues, I'm reminded of Psychology301 - a psychological testing subject I studied recently at university. When conducting research it is ethical to use people in experimentation provided the possible findings are worth a bit of discomfort. Participants are given every bit of information they need to make an informed decision, I believe this exact protocol should be followed by SL therapists. Anyone entering a therapeutic contract in a virtual world should be made fully aware of the ethical and confidentiality issues.
So what do I do to reduce the risks? Well, I do as much as I can.
I make sure client information is not stored online. In fact, all client information is stored on my password protected external hardrives (that are only connected to my main computer for the retrieving and storing of information) up until 6 months after the conclusion of any therapy, then that information is transferred into a locked filing cabinet in my house.
I make sure clients receive an informed consent document before they begin sessions.
I try to encourage clients to chat over Windows Life Messenger or Skype (or any other chat program).
I do not enter a therapeutic relationships with people under the age of 18.
All counselling is conducted in private IM so that other SL residents cannot 'overhear' our discussions.
The clinic is a Skybox that is very high up in the sky. I allow only one person there at a time so that client Avatars cannot be identified (except for group counselling). I also have moderation rights to the Sim, so that anyone who intrudes will be quickly ejected.
Lastly, I only see people with normal everyday issues. People that, while they're stressed or concerned over an issue, are not usually prone to psychosis or volatility. This can be fairly easy to gauge with a first session where therapists can get a feel for the perceptional and emotional state of a client. And yes, this can be achieved online, and no I will not be discussing this at this point in time (later okay? *grins excitedly* ).
I think the most important thing as a counsellor is to help and support others without putting them in unnecessary risk. Online services are very affordable and have been proven to be just as effective as face-to-face therapy. In my opinion those with more serious issues would be less likely to benefit from online therapy, but many issues people seek help with are problems that can be overcome with a little caring support, problem solving, and coping skills training. It is because of these reasons that I continue to counsel as a SL therapist and advocate online therapy practices.
I have been particularly busy this week working on my new clinic in Second Life (SL). Yes, out with school work, in with work-work. You might protest at the idea that a job entailing moving around in a virtual world is called "work", but I beg to differ. Anyone who's ever used SL will be aware of the frustrations of searching through endless inventory items, setting objects up in a 3D environment with limited viewing and of course trying to get your scripts functioning without digital hiccups. Despite all the frustrations I've experienced bringing this project to fruition, I'm quite excited about the prospect of holding group therapy and individual therapy in SL.
My previous clinic, which existed digitally last summer (yes Australia has hot Christmases-- haven't you heard 'Hey luv! Put another shrimp on the barbie will ya?' Here's a translation link if you're feeling a little confused about that Aussie Slang ), was mainly an information clinic where clients could make appointments in SL and then flesh out the details through email. From there we would set up appointments using Windows Live Messenger and Skype.
I do have qualms about counselling in virtual environments, at least if I use Windows Live Messenger I can encrypt chat with Bitdefender. Emails can be encrypted, there are ways to make sure you're practising ethically online. SL is not a great environment ethically. You're probably asking 'so why counsel there then?'. The simple truth is that the private IMing system in Second Life is fairly secure. Not completely, but I don't think Linden Labs really cares about what goes on in Private IMs unless you're discussing ways to penetrate the SL mainframe or organising a terrorist attack. Clients can be made aware of the possible consequences of continuing in a virtual environment but still, people I don't know can access the private messages between myself and a client -- I feel uneasy about this.
When I think of ethical issues, I'm reminded of Psychology301 - a psychological testing subject I studied recently at university. When conducting research it is ethical to use people in experimentation provided the possible findings are worth a bit of discomfort. Participants are given every bit of information they need to make an informed decision, I believe this exact protocol should be followed by SL therapists. Anyone entering a therapeutic contract in a virtual world should be made fully aware of the ethical and confidentiality issues.
So what do I do to reduce the risks? Well, I do as much as I can.
I make sure client information is not stored online. In fact, all client information is stored on my password protected external hardrives (that are only connected to my main computer for the retrieving and storing of information) up until 6 months after the conclusion of any therapy, then that information is transferred into a locked filing cabinet in my house.
I make sure clients receive an informed consent document before they begin sessions.
I try to encourage clients to chat over Windows Life Messenger or Skype (or any other chat program).
I do not enter a therapeutic relationships with people under the age of 18.
All counselling is conducted in private IM so that other SL residents cannot 'overhear' our discussions.
The clinic is a Skybox that is very high up in the sky. I allow only one person there at a time so that client Avatars cannot be identified (except for group counselling). I also have moderation rights to the Sim, so that anyone who intrudes will be quickly ejected.
Lastly, I only see people with normal everyday issues. People that, while they're stressed or concerned over an issue, are not usually prone to psychosis or volatility. This can be fairly easy to gauge with a first session where therapists can get a feel for the perceptional and emotional state of a client. And yes, this can be achieved online, and no I will not be discussing this at this point in time (later okay? *grins excitedly* ).
I think the most important thing as a counsellor is to help and support others without putting them in unnecessary risk. Online services are very affordable and have been proven to be just as effective as face-to-face therapy. In my opinion those with more serious issues would be less likely to benefit from online therapy, but many issues people seek help with are problems that can be overcome with a little caring support, problem solving, and coping skills training. It is because of these reasons that I continue to counsel as a SL therapist and advocate online therapy practices.
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