Online therapy is the fastest growing trend in therapy. As our broadband is getting better and with more people owning smartphones than ever before online therapy is now significatly more practical and reliable.
Counselling online presently comes with distinct advantages for practitioners and clients alike. But to set up a practice online or transition an existing one requires preparation and research. In this guide we want to cover everything that a therapist needs to think about before starting on their own online.
Here’s what is covered.
Therapy online, teletherapy or e-therapy refers to the practice of therapy remotely via the use of telecommunications and ever more frequently, the internet.
In a nutshell, the idea is that you are introduced, hold sessions and transact with your clients over the internet, usually over video.
Similar to traditional therapy, most of the conventions of therapy are kept. With regard to logistics, the client and therapist arrange their meeting, very often keep a regular slot (weekly) with the only key difference being the lack of in-person contact. This makes it more convenient, less time-consuming and usually more affordable for clients since you, the practitioner, enjoy similar benefits.
There are some obvious benefits that come with running your therapy practice online.
Firstly, you don’t need to have office costs. Given that offices gobble up anything from 15% - 40% of a therapist’s revenue per session, you enjoy an immediate increase in your margins.
Secondly, no travel means more peak hour slots for clients. The necessary travel time from one office to another are over, which means peak hours slots freed for clients.
The lack of focus on location is beneficial across other dimensions too. In the ever competitive world of internet marketing, finding a niche is very important in order to rank on search engines, create a personal brand and attract a relevant audience.
The inherent capital costs of renting a room to facilitate sessions comes with the need to attract people locally and a compatible local marketing strategy is unfortunately more expensive. Location based listings are more competitive as directories, clinics or other therapy agencies are capturing the majority of searches.
On the contrary, relying on the internet to conduct your counselling sessions opens up new prospects since you can target an (almost) global population. It follows that instead of competing for local clients, your focus should be on your brand and your counselling areas of interest. Your main selling point to clients is no longer how conveniently you fit into their commute - it is specifically why YOU can help them.
Lastly, running a business online means that you will be extensively using software for client management, payment collection, automated record keeping reducing the manual work. If this is done right, you can free up your time and enjoy some peace of mind.
If you have an existing practice, once you have made the decision to move your practice online, you will need to transition your existing clients as well. Following a considered plan is likely to end with you keeping most of your existing clients. Why? Well because therapy is about the relationship your client want to maintain the trusted relationship you have built. Finding the right therapist is not easy. Your task is to guide them through the new format of your therapy.
Of course, there will inevitably be some cases of clients who will not be willing to follow but that is ok. Here’s a few practical questions you should ask your clients to determine their eligibility.
Assess their competence on an individual case
Depending on the individual's case, online therapy might not be the best option for their recovery. For instance, psychotherapist Eirini Diathesopoulou mentions that "..for a patient suffering from severe depression seeing a therapist in person forces them to get out which can have a positive impact".
Apart from that, the barriers are not prohibitively high. In 2020, a significant percentage of the population owns a debit or credit card as well as a smartphone and can fill an payment form on the web.
A word of caution about communication: whilst you want to ease your existing clients into the new format of therapy, perhaps have one or two trial sessions for them to get familiarized with the new setup. Being firm in your decision is key; ambivalence from your side can deter clients from accepting a change in setup that otherwise would have felt natural to them. So, if this is your decision, be confident about it.
Practicing counselling or psychotherapy online presents certain differences compared to traditional face-to-face therapy. Before you start, here is a list of things to expect with regard to practicing online. An extensive guide by the BACP detailing the competences of therapists conducting teletherapy can be found here.
Inhibition and disinhibition
When your sessions are not conducted in person it can lead to client inhibition or disinhibition. This could mean sharing more or sharing less, faster or slower than intended, or is appropriate. This is something that requires the therapist’s attention to be managed accordingly.
It’s easier to "hide"
The absence of body language and the difficulty to discern, or the mere absence of, facial expressions can lead to wrong interpretations and awkward interactions. And this goes both ways. It is important that the therapist confirms (s)he understands what the client says, means or feels and also to communicate clearly to the client what they have said as clients can misinterpret a cue leading to a dent in the relationship.
It’s easier to get distracted
Boundaries are quicker to dissipate in absence of physical presence. Using one's personal computer for therapy and not properly switching into the therapy context is likely to leave the recipient prone to distractions. Many open tabs or programs running in the background, email coming in and connected devices can interrupt the flow. If a client picked up their phone during therapy where both you and them are physically present in the room, you would probably ask them to look at it later.
However, since this is happening in the background and you don't have that level of visibility these kinds of distractions need to be addressed at the beginning.
Have a contingency plan for technical difficulties
We tend not to think of the cases when things go wrong but since you are relying on external tools, this is something that should be thought through carefully.
Ensure that you always have access to the Internet
This might sound obvious but it’s not that infrequent that connection breaks down. If you are working from home, it might be worth to consider business broadband where resolution times are guaranteed to be as low as 12 hours. As if this is not enough, you will need to take steps to think about your client as well. Because, ultimately, ensuring therapy is effective falls under the practitioner.
Ensure you are in an environment where you internet is stable
Ask your client to do the same. It is not infrequent for clients to take calls from their phones, in their car, etc. This means there might be connectivity issues so it might be good to agree with them from the beginning what the set up of therapy will be like.
Make sure you have secondary access to the internet beyond your wifi
For instance, make sure you can always support video call from your mobile phone (4G, 5G) or have a mobile internet device (e.g. a dongle) and a mobile data plan that does not put you under financial stress to use data continuously.
Agree with the client what is the protocol if there are technical implications
This way your client knows what to do in case of a technical error. For instance, you might agree that if any of you loses reception you will continue your therapy another time or you will use the phone to conclude your session. Setting a plan reduces anxiety and the stress of making decisions whilst in therapy. This is something you should also include in your counselling contract for consistency and clarity.
Run a few tests yourself
Before you start, try having calls with a few friends (ideally test different setups, locations, technologies) so that you know your system is fail-proof.
It is important to make sure that on your end your are comfortable with everything: the quality of the sound, the lighting, the background, noise etc.
So, what tools will you need to get started?
Selecting the right teleconferencing software is an important decision, though luckily one with low switching costs should you wish to change. A lot of model teleconferencing platforms work via your computer's browser and don’t require log-in.
However, it is going to be a key tool for your work so you might need to think about it from several perspectives:
With an abundance of great teleconferencing software apps out there, paying for one seems unnecessary unless you require advanced features.
2. Encryption & Data Security:
Always opt for end-to-end encrypted software. Facetime, Zoom & WhatsApp are end-to-end encrypted. This basically means that not even the provider of the software has access to your data, in this case, the video call. It’s only between you and the client. On the other hand, encrypted software (e.g. Google Hangouts) means that the data is securely encrypted but accessible by the provider.
According to ICO, your responsibility is to inform your client about what use of their data you are making and have them consent to the use of the software as a means of therapy.
3. Accessibility and convenient setup
You want the software you are using to be accessible and easy to use so that any type of client is happy to use it. For instance, if you’re using WhatsApp it is likely that your clients will already have access to it and all you will need is their number to call them. However, that also means that your video call will be restrained to the size of the mobile device used whereas if you are using Zoom, you can both use your laptops which makes it more convenient.
4. Stability and Robustness
The teleconference industry is a very mature one. Consider that WhatsApp has >1 billion users and there were 728 million iPhones in 2017. Both FaceTime and WhatsApp are very stable platforms, optimized for low bandwidth connections and unlikely to experience technical problems. Whilst there are teleconferencing systems made for therapy, I would argue they don’t present enough advantages in order to justify extra cost whilst taking a higher risk by using them.
Now you are set up with the basics. Let’s address the admin and logistics. No one ever started a practice for their love of being bogged down with logistics and counting receipts.
Additionally, no client has a desire to spend time with their therapist spending time on these issues, so your goal here should be a smooth operation for both ends and maximum efficiency for you.
Select a digital calendar
The usual suspects (Google, Microsoft, Apple) do a great job and are used by billions of people. Google Calendar, Apple iCal or Microsoft Outlook are all robust, versatile and ubiquitous - these are tools you can’t go wrong with. My strong recommendation is to go with Google Calendar which after careful consideration we also made a default choice for Assistant.
Your calendar is for your own organisation and you should not keep notes or any personally identifying information for your clients there.
Publicise your availability
A lot of therapists do not like to advertise their available hours online. Others, allow clients to book them.
Whichever way you go, eventually you will end up with a client session and somewhere to store it. This is your calendar.
Turn calendar slots into bookings
Depending on what software you will choose to use, you can turn the events in your calendar in bookings with clients which is very handy as it sequences and streamlines all actions that follow a session with a client.
And this is the essence of scheduling. Do one core action i.e. arrange the meeting and let the rest of the pieces fall into place.
This becomes massively important if your practice exceeds 10 clients where you may be having 40 appointments per month.
When the number of sessions increase, so does the amount of communication required. Changes in scheduled times, cancellations, counselling contracts - it piles up.
So it might be good to employ a system that notifies your clients of their appointments, sends reminders and other therapy related communication without you having to do anything manually.
Payments are a critical part of your operation. Done wrong they can amount to lost revenue, put strain on relationships with clients and even deter new ones from starting out with you.
There are three main things to consider when you're setting up your payment operations.
1. Ensure your clients abide by your cancellation policy
Late cancellations and no-shows are easier and far more frequent online, especially in the first few sessions.
This can be achieved by pre-authorising the client's money which secure the funds but does not charge them up front. Think of hotel check in. Your card is swiped to get your details, make sure you're good for the money (which you might see as non-available in your account) and after the stay is over the funds are transferred.
2. Try to avoid awkward conversations around payment
It is really, really useful for session payments to be automatic. After each session, the client's card is charged and the client is notified so that you dont have to send awkward reminders for late payment and put a strain on the relationship. You can do that by adoping a software solution which can keep the "card on file".
3. Make it as easy as possible for the client
And since you do that you can charge your clients seamlessly without them having to do anything. After every session your fees are charged and they receive a receipt. No need for action on their part, no paperwork on yours.
Last but not least: Record-keeping. When you are just getting started this might not seem important, but it is crucial that you keep a good hygiene with your financial records. And running a practice online can make this more complicated.
Different currencies, timezones, payment providers and fees create additional work for you to report your revenue, profit and costs to your accountant and subsequently to the taxman.
Realising at the end of the quarter that your accountant is asking for all your transactions and expenses will require calculations. Tallying up payments received, from whom, how many times, minus all costs related (e.g. payment fees, referral fees) is no fun.
So make sure that you find a system or a software to automate that. Assistant does this very neatly for you.
One strategy is to create and maintain spreadsheets and develop some good habits of spending let's say 15' - 20' minutes at the end of each to update your records. This is one way of doing it but remember it comes with significant hidden costs. The problem is that in a period of a month where you are working 23 days this quickly amounts to 345 - 460 minutes or 5.75 - 7.6 hours. If you multiply that with the average therapy fee (approximately £58 across the UK) you get a cost of £333.50 to £440.80 per month. Remember, we started of with "it only takes 15' per day".
Online therapy is here to stay. Global culture is slowly but steadily unifying and location is becoming less relevant as a factor of choice. People in remote locations or with physical disabilities can now get access to high quality, affordable treatment.
That said, it comes with certain prerequisites and it is not for everyone. It requires thorough consideration of the implications in the relationship between you and your clients, a significant investment in marketing yourself and some upfront work to start off with smart technical set up.
Then again, you are reading this. Most likely, the benefits outweigh the costs. Good luck!
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