Managing risk online
Therapy Today, December 2020

The surreal and unlikely became the very real overnight with the national lockdown in the UK as the COVID-19 pandemic hit hard. With similar immediacy, and perhaps with many of us still in a state of shock, processing our own losses and bereavements, we were transported into an online world. While some of us had been familiar with this context for some time, for others it was a new environment where many of the existing givens of working as a counsellor were put up for question.

Both of us have had an interest in working with risk in counselling for some time, and it was working with clients at risk – and particularly, risk of suicide – that quickly came into question. Indeed, much advice centred around the premise that working with risk was probably too risky online and that generally we should refer such clients on elsewhere rather than engaging with them remotely. But to where, with whom, and why? This article aims to challenge the premise of an avoidance of risk online, and instead takes a position that we can not only work effectively with suicide potential in an online frame; we have an ethical duty to do so.

Challenges

That is not to say, of course, that working with suicide potential is easy. Between us, we have held a position for some considerable time that suicide potential is perhaps one of the most challenging areas of practice. Knowing what to do, when and how can push even the most experienced practitioner. Despite the suicide prediction tools that have been churned out by the risk industry, the science still does not tell us in a reliable way what we hope it will – who is most likely to end their life through suicide, and when.¹ The temptation therefore, is to avoid the potential for risk and, perhaps, an online environment can join the queue of what the literature calls ‘unacknowledged responses’ to support reasons why we have not asked about suicide, or engaged with it in a therapeutically meaningful way. What is therefore expedient for us at this point in time is to offer up some exploratory thoughts of our own about this immediate problem, to ensure it does not become so easily displaced.

That more therapists are working online, and may continue to do so as the lockdown restrictions lift, is, arguably, a good thing. Many clients do not enter therapy services for a variety of reasons but are willing to connect remotely. Often the travelling costs or the challenges of travel, on top of therapy fees (if paid), are prohibitive; being able to log on without having to travel is an important factor. Likewise, online contact can intrinsically feel safer for some, particularly in the early stages of therapy. Building a quality online therapy provision to sit alongside more traditional modes of delivery is perhaps an important social justice issue, where more clients have greater choice about their therapy and therapist. As such, it is a certainty that, as suicide potential has a high presence in our therapy rooms, it will also be present in the online space. If we see counselling as a potential mechanism to help people achieve a greater understanding of their draw to self-annihilation and thus reduce the risk of its likelihood, then there is little reason why we cannot use the same therapy skills and knowledge to do the same in the online space. To consider this possibility, we need to take stock of what ‘risk’ in this context looks like.

Risk in an online environment

The assertion by many, it seems, is that online counselling isn’t suitable for those who have thoughts of self-harm or suicide. A survey of 93 online counsellors found that, while 96% thought that online counselling was suitable for social or interpersonal issues, only 27% thought that it was an appropriate medium for those with suicidal thoughts.² However, a recent study that interviewed online counsellors regarding the possible benefits of offering online support to those in crisis found that many were open to this idea.³ And research has concluded that online counselling can be effective in supporting those with suicidal ideation.⁴

From the client’s perspective, recent research has found that those who are experiencing suicidal ideation have a preference towards therapy online, as opposed to in person.⁵ Taking all of this into account, alongside the understanding that many experiencing suicidal ideation do not engage with therapeutic services, particularly males, where we have seen another tragic increase in the number of suicides, it seems perhaps that counselling should be breaking down barriers for individuals to engage in therapy rather than putting more up. Of course, there are some unique aspects of working online that may require further thought in relation to risk, particularly at this current time.

Risk through an online lens

We know that an integral part of our work with clients is a considered assessment and contracting process. Taking into account the medium in which therapy would take place is a crucial part of this. Working with risk online may present different challenges in relation to this process. Although many online therapists choose to work with a webcam, some do not. So, with no visual picture of the client, information that is gleaned through non-verbal communication and micro-responses to questions, for example, is not available. This would need to be part of the counsellor’s considerations in relation to the assessment and contracting process.

Whether the counsellor’s approach to assessment is to use structured risk assessment tools, a more relational approach or a combination of the two, the process of assessment should endeavour to uncover both risk factors (a factor that makes suicide more likely), and protective factors (a factor that makes suicide less likely) to determine the level of risk a client is presenting with.⁶ However, it is important that counsellors do not see risk and protective factors as the end point in working with risk; they can provide important contextual information, but should segue into, and be informed by, a therapeutic exploration of the client’s suicidal thinking. Sense-making is critical for both the counsellor and client, as it is an important contributory factor in positioning the client to help keep themselves safe at times of crisis. But in what other ways does working online influence or impact client behaviour?

One unique aspect of working online is the online disinhibition effect⁷ – the potential for individuals to behave differently when interacting or engaging online. Disinhibition is categorised into benign inhibition and toxic inhibition: the former encapsulating behaviours such as an increased sharing of private emotions, dreams and fears, and the latter including behaviours such as using inappropriate language or, in more ‘extreme’ circumstances, threats and aggressive communication.⁷ As this can affect an individual’s behaviour for both client and counsellor, it seems important, when working with risk online, to consider the impact this effect may have and be able to find an appropriate way of naming it with the client when it is suspected.

In brief, the online disinhibition effect suggests that clients may be more honest about how they are feeling and, therefore, more willing to self-disclose aspects that feel particularly shameful – such as suicidal ideation. One protective factor identified in relation to risk is the client’s willingness to discuss their feelings and thoughts. In this regard, it seems the online disinhibition effect may assist counsellors not only with their assessment process but also with their continued therapeutic dialogue about risk.

Another protective factor identified in relation to risk is the client attending counselling. It is noted that online disinhibition could have the potential to reduce anxieties, fears and any social stigma the client may feel in relation to seeking professional support.⁷ Therefore, one benefit of online disinhibition is that it may help the client stay in counselling for a longer period of time.

This links to another protective factor in relation to risk – the nature and quality of the therapeutic alliance. One study reviewed 840 pieces of research that looked at therapeutic alliance.⁸ Overall, it was indicated that online therapy was equivalent to in-person therapy in relation to therapeutic alliance. In another recent study, it was also found that relational depth could be achieved when working online,⁹ demonstrating the strength of alliance that can be cultivated, thus helping to provide the foundations for an exploration of the client’s thoughts and feelings in relation to suicidal ideation.

However, there is some scepticism about online counselling. For example, one study suggested that 42% of counsellors believe that online counselling is not as effective in alliance-building as in-person therapy, perhaps due to concerns about the level of therapeutic alliance that can be fostered online. A further concern of therapists when working online, particularly with risk, is the potential for more challenging behaviours to emerge in therapy. However, it is worth noting that this isn’t unique to online counselling. Research that examined self-disclosure found that instances of ‘negative’ self-disclosure were rare, inferring that any negative effects of disinhibition, such as acting out of difficult feelings, are not more common when working online.

If the research is telling us that it’s OK to work with risk online but there is a reticence to do so among practitioners, perhaps the reasons for this are not dissimilar to some existing anxieties that counsellors have already communicated about working with risk in a more traditional in-person setting. These may include personal views on suicide, fears around competence, concerns about litigation and lack of confidence in conducting risk assessments.¹⁰ Working within an ethical framework, using good practice guidance (both available on the BACP website), and using supervision can support counsellors to explore and potentially work through these concerns, if so desired. With these concerns in view, it is perhaps ethical dilemmas and how these are managed that should be the centrepiece of our initial considerations.

Boundaries and confidentiality

Practitioners have highlighted anxieties about issues such as contracting, duty of care and confidentiality, which are all valid.¹¹ However, we believe these are just as surmountable as in in-person work. BACP members have access to various resources (see top tips) to support them in their thinking about contracting, boundaries and working ethically.

Our assertion, therefore, and contrary to some accepted wisdom that suicide potential should be avoided in an online space, is that online-based therapy can be an equally important encounter for those contemplating end-of-life decisions as it is when undertaken in person. Simply put, whether by webcam or sitting in opposite chairs, therapy can save lives if we are willing to ‘go there’ and talk about the often unspoken.

With this in mind we have suggested 10 top tips for working with suicide risk online:

1. Continue to be open and transparent about risk during early contracting, naming it clearly and explaining to the client what the limitations to confidentiality are.
   
   
2. Ensure you obtain, before therapy commences, a clear referral point for your client should you be concerned about their immediate safety, ideally a GP who can trigger mental health services in their locality, especially if the client lives geographically distant from you.
   
   
3. Think about the client’s ‘space’ – can they talk freely or will they be overheard? Be clear about the extent of confidentiality as it applies to the client’s context – you are not in control of it as you would be your own therapy room.
   
   
4. Always be willing to ask the ‘suicide question’: eg ‘How difficult does this get for you? Are there times when you consider ending your life?’ However you phrase the suicide question (which will be informed by you, your client, your relationship and the working context), ensure you name it explicitly and clearly, without using euphemisms, such as, ‘Do you think about getting out of people’s way?’ These can be misleading and end up in confusion.
   
   
5. Talk to your client about how they might take care of themselves at times of crisis, to help them identify their own protective factors to draw on at difficult times. Developing a keep-safe plan (examples of which can be found at Mind and Students against depression) can really help your client support themselves at times of crisis.
   
   
6. Draw up a list of sources of online self-help that you can recommend for people at times of crisis, such as Mind, Samaritans, CALM and the Charlie Waller Trust.
   
   
7. Do your research – source information on crisis support in your client’s locality, should you need it. It’s better to have it and not use it than scrabble around looking for it at a time of difficulty.
   
   
8. Make use of supervision to explore your thoughts and responses to any risk you suspect and to help inform how you will explore this with your client.
   
   
9. If in doubt, act – always with your client’s consent, if that is possible to obtain. Do not delay if waiting would increase the risk. It is always preferable to defend action than non-action when faced with immediacy of risk.
   
   
10. Use BACP resources such as the Good Practice in Action 047 Fact Sheet Working online in the counselling professions, and BACP’s competencies for telephone and e-counselling.

If you take such steps and give due consideration to the client’s needs, as in any therapeutic intervention, online therapy can literally be a life-saver.