Knowing your limits

[Art Matthews, MA LPC DCC]

You're in a video chat session with a new client and the discussion becomes extremely confusing. After revealing a history replete with abuse and neglect in her early years, the client's physicality changes, her voice changes and she begins talking about herself in the third person, ridiculing herself and saying, "Alice is such a wimp! It's a good thing she has me to take over when she can't handle life anymore!" A few more shifts and you begin to wonder, does this client have Dissociative Identity Disorder, or are we playing a game here?" This was a case posed to me by a counselor with whom I provide support. The counselor asked me, "Do you think this is legit? Could she really be a true 'Multiple'? What do you think I should do?"

Now, I've watched Sally Field in Sybil, Rosanne Barr on Oprah and have a copy of the DSM-IV R on my shelf, yet I can't say that I've ever met any client who I felt met the criteria for Dissociative Identity Disorder. But that doesn't mean I don't believe it's not possible either. What I am certain of is that treating said client online without proper training, preparation, and experience is not appropriate. I am not qualified to treat such a client based on my experience and training. My basic response to my colleague was: take the client at face value here (accept her presentation as factual and her reality), know your limitations and be prepared before going online for the inevitability that you could need to find a referral anywhere your client may be for any type of condition.

Online counselors have the potential of working with a client literally anywhere in the world. My colleague in this case was working on a mega-site and was going to support the client until the client could get in to see a local psychologist. IMHO: those of you who may not have considered all the possibilities should consider these steps:

1) Pinpoint where your client is and not just where their home is. If you ask where they live, you'll get that information, which may not be where the client is located when they are in the session with you. Try to at least get the nearest city and locate emergency services and referral information for that community.

2) Get information on the client's other healthcare providers (doctors, psychiatrists, etc) as well as past medical history if possible. Find out how to contact their providers if the client is in crisis and/or needs medical follow up. Do a quick search for emergency resources local to the client. Go to: NAMI to locate local offices of the National Alliance on Mental Illness, use your professional associatation's website or do a plain old Google Search for emergency mental health providers local to the client.

3) Get an emergency contact person's name and number and/or a local crisis line number to call if the client is in crisis and they can't connect with other established healthcare providers.

4) Don't allow a client to work with you and another F2F therapist without communicating with the other therapist and clarifying the roles and treatment plan/process. Too many cooks, can diffuse the client's progress. If the client reports being currently engaged with another therapist and they need immediate support, perhaps it's better that they use an 800 number crisis line rather than picking up with an online therapist who might head off in another theoretical direction. Respect the intital counselor and encourage the client to fully disclose if they won't sign a release allowing you to communicate. I might even refuse to work with the client (provided they had other emergency support) unless I saw a copy of a discharge summary.

5) Know how to locate the client's contact information either through the counseling site you work through or using the client's IP address.

6) Network with other online providers so that you have someone to refer to for your own support when you have a difficult client that stretches your capabilities. Look for experienced professionals with training in online counseling. Check out their licensure and credentials, looking for complaints and sanctions as if you were the client.

If you haven't yet discovered a reason to receive training in online counseling provision, try harder. The DCC training taught me there's a lot to know outside of counseling skills before you begin to provide counseling online. Besides the computer equipment, the internet connection and the counseling license; you need to know a lot about computers connectivity and communication.

Yes, counseling over the internet is complicated, but it does provide a valuable service that meets client's needs in a unique way. Many of the suggestions I listed could be considered best practices for F2F counseling as well.

[DeeAnna Merz Nagel]

I think it really comes down to one's scope of practice and areas of competency. I have worked with people who have dissociative disorders in my office and online. I am comfortable using either method of delivery. Thank you for this thoughtful post!