Online Counseling: A Primer for Practitioners
Stephanie K. Ferguson, PhD
New Mexico Junior College
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1 Thunderbird Circle, Hobbs, New Mexico 88240
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ONLINE COUNSELING: A PRIMER FOR PRACTITIONERS / 1Abstract
ONLINE COUNSELING: A PRIMER FOR PRACTITIONERS / 1The number of people with reliable access to the Internet has grown exponentially in recent years. With the advent of such connectivity, mental health counseling has expanded into the virtual realm by using online counseling as a means to facilitate the therapeutic relationship. Those in the field who are considering establishing or expanding their practice with the Internet have an obligation to fully explore and understand both the ethical and legal ramifications of doing so as well as the empirical research examining the efficacy and essential skills required of such practices.
Online Counseling: A Primer for Practitioners
At present, approximately 40% (3.4 billion) of the word population has Internet connectivity (Internet Live Stats, 2016). According to Internet Live Stats (2016), 8.4% of the world’s Internet users reside in the United States, which equates to 88.5% (approximately 287 million people) of the United States’ population having reliable access to the Internet. Thus, “a majority of lives are now touched, if not transformed, by having potential access to anyone else in the world with a computer (or smartphone) and an Internet connection” (Fenichel, 2010, p. 6). With an exponential increase in connectivity, many people utilize the Internet as a primary mode of communication with friends, family, colleagues, and services (Barnard, 2010). The ease with which many interact with and through the Internet using computers and smart devices makes utilizing the worldwide web to garner information more commonplace than using a printed telephone directory or brick-and-mortar library stacks. As a mental health practitioner, it is essential to understand not only the ethical and legal implications of leveraging the Internet as a vehicle for therapeutic services (Mallen, Vogel, & Rochlen, 2005) but also the inherent advantages and disadvantages of the medium as well as required essential skills and documented best practices.
What is Online Counseling?
As defined by the American Telemedicine Association (ATA) (2012), “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” (para. 1). With the advent of the personal computer revolution in the 1970’s and 1980’s, telemedicine practiced at a distance appeared in a substantive way with hospitals providing care from a distance to those in rural areas (Sosa-Iudicissa, Wootton, & Ferrer-Roca, 1999). Telemedicine encompasses the use of telecommunication technologies to provide services to patients such as two-way video, email, smart phone applications, and wireless tools.
Online counseling is one component of telemedicine and is a relatively new modality in the arena of mental health care (Kraus & Stickler, 2011). Online counseling, sometimes referenced in the literature as e-therapy, telepsychiatry, telecounseling, and/or telemental health, refers to all clinical interactions and services done via various Internet-assisted modalities such as text, email, chat, video or voice links, forums or message boards, and web logs (Kraus & Stickler, 2011; Barnard, 2010). These modalities can be divided into two groups of online interactions – synchronous and asynchronous.
Synchronous online interaction includes those modalities where two of more people are able to communicate at the same time with no appreciable delay in response. Synchronous modalities could include text, chat, and/or video or voice links (e.g., Skype, Facetime, WebEx, Tango, etc.). Conversely, asynchronous interactions have delayed responses times due to participants accessing the Internet at different times. Asynchronous modes of communication include email, forums or message boards, and/or web logs (blogs). Whichever mode of online communication is used in the therapeutic process – synchronous or asynchronous – it is imperative that the practitioner understand the ethical and legal implications related to online counseling.
Ethical Guidelines
Ethical guidelines have been in place for quite some time to govern the provision of mental health services in person (Hsiung, 2002). However, with almost 90% of the population of the United States having dependable access to the Internet and the demand for health care services on the rise, the need for ethical guidelines specific to online therapeutic service delivery is imperative (Mallen, Vogel, & Rochlen, 2005).
In 2014, the American Counseling Association (ACA) adopted a revised and updated Code of Ethics, which includes a specific section related to distance counseling, technology, and social media. These guidelines acknowledge that “counseling may no longer be limited to in-person, face-to-face interactions” (ACA, Section H, 2014, p. 17). Specific components of this section include knowledge and legal considerations; informed consent and security; client verification; distance counseling relationship; records and web maintenance; and social media.
The guidelines established by the ACA (2014) build upon the Suggested Principles of Professional Ethics for the Online Provision of Mental Health Services developed by the International Society for Mental Health Online (ISMHO, 2000). While many of the same components exist in the ISMHO guidelines document, some notable differences are present. The ISMHO (2000) under the heading of informed consent highlighted the need to expressly indicate expectations for “turnaround time” in asynchronous online communication (Section A.1.b). Another notable difference under informed consent is the mention of the “privacy of the therapist” as well as the client: “The therapist has a tight to his or her privacy and may wish to restrict the use of any copies or recording the patient makes of their communications” (Section A.1.c). The mention of emergencies and what procedures as well as local backup for potential emergencies is detailed also (Section C.1).
Traditional principles of professional ethics should be extended to online counseling (Hsiung, 2000), but such traditional principles need to be modified in order to address the unique opportunities and challenges that online therapeutic relationships pose. While the ethical guidelines of both the ACA and the ISMHO provide parameters for online therapeutic interaction, they lack the delineation of distinct processes by which practitioners could incorporate them into their online mental health services. Just as the landscape of online communication changes at an exponential rate, the ethical principles related to online counseling must be re-evaluated on a regular basis in order to insure “the basic values of professional ethics beneficence, nonmaleficence, and autonomy” are maintained in the field (Hsiung, 2000, p. 151).
Legal Implications
While many professional organizations have established guidelines for online counseling, guidelines are not the same as law, however. According to Zack (2010, p. 108), “Online mental health counseling shares many of the same features as traditional counseling approaches and courts will look to the traditional setting for parallel standards of professional and ethical practice.” In the absence of case law, the court system tends to “interpret existing statutes and precedents from other contexts” and extrapolate rulings applicable to the heretofore uncharted territory (Zack, 2010, p. 108).
Regulatory Issues
The regulation of virtual interaction is a fiercely debated topic attempting to balance free enterprise and personal liberties (e.g., free speech) with general welfare and security. There are federal laws, state laws, and regulations to which face-to-face and online counselors alike must adhere. These include, but are not limited to, licensure and professional legal duties.
Licensure. “State practice laws generally require that anyone providing mental health services to residents of that state be licensed” within that state (Zack, 2010, p. 114). This was rarely an issue when considering face-to-face therapeutic relationships; however, with the advent of online counseling, such lack of reciprocity between states in effect requires the counselor to be licensed in both the state where he or she resides as well as where the client lives since both states “have an interest in controlling what happens in an online counseling interaction” to insure practitioners are qualified and to protect their citizens (Zack, 2010, p. 116). There are those in the field hold the opinion that within an online therapeutic relationship, the counseling takes place within the state where the practitioner resides (Derrig-Palumbo & Zeine, 2005; Hsiung, 2002). Derrig-Palumbo and Zeine (2005) suggested that until more finite parameters are established, practitioners should “proceed and defend, as necessary, that therapy takes place where the therapist practices and is licensed and/or only see clients in the state in which [they] are licensed” (p. 201). The federal government has expressed an interest in addressing the issue of licensure portability in an attempt to promote telehealth services, which include online counseling. However, Reinhardt (2013a) cautioned, “Before offering telehealth services, be sure to consult the licensure laws in [the applicable states] and an attorney” (para. 7).
Professional Legal Duties. Every professional mental health organization or association has its own set of ethics that practitioners are expected to follow (Corey, Corey, & Callanan, 2011). While codes of ethics vary in their semantics and specifics, Koocher and Ketih-Spiegel (2008) noted a number of similar themes across professional organizations including competence, confidentiality, and consent. Zack (2010) identified those same themes as being pertinent to online counseling as well.
Competence.“Just as in face-to-face therapy, an online mental health professional will be liable for negligence if (1) a professional/patient relationship exists; (2) the professional breached a legal duty imposed by the virtue of that relationship; (3) the breach of duty caused injury to the client; and (4) the client suffered damages as a result [57A Am. Jur. 2d Negligence § 71]” (Zack, 2010, p. 117). Providing counseling face-to-face is not the same as establishing a therapeutic relationship online (Zack, 2010; Anthony & Nagel, 2010; Haberstroh, 2009; Barnard, 2010). A way to address the change in modality and the requisite skills needed to be a competent counselor online is to seek additional training and/or certification so practitioners can insure they are within both legal and ethical parameters (Reinhardt, 2013; Zack, 2010; Anthony & Nagel, 2010).
Confidentiality. “Confidentiality refers to the legal rules and guidelines that obligate a therapist not to reveal information about a client” (Derring-Palumbo & Zeine, 2005, p. 203). Most states require mental health professionals to protect their clients’ confidential information as part of their legal duty (Zack, 2010). In an online therapeutic relationship, the same rules of confidentiality apply, but the medium to which they apply – the online environment – affects how confidential information is handled. Could a chat session between a therapist and client be accessed by a third party? Might an email interaction between a counselor and client be forwarded to another person? Could a text message be read by someone who found a lost smart phone? Could a therapists computerized files be hacked? Such possibilities are not necessarily unique to online therapy, but mental health practice in a virtual environment must consider security of patients’ information within the context of cyber threats.
Consent. It is incumbent upon mental health practitioners to disclose to a prospective client the potential risks and benefits of treatment (ACA, 2014, Section A.2). The same standard is applied to online counseling. “Online counselors need to inform their clients of the additional risks due to the online medium that might impact their decision concerning whether or not to engage in online counseling versus face-to-face counseling” (Berger, 2003; Dreezen, 2004 as cited in Zack, 2010, p. 119). Some of those additional risks may include the potential of confidential information being disclosed due to a security breach; the inadvertent outage of service due to technical issues with Internet service providers; the possible misunderstanding that may occur due to inherent limitations of text-based communication; and/or the difficulty of intervention form a distance in the case of an emergency (Zack, 2010). Such informed consent procedures should be a part of the intake process and should be acknowledged by the client in order to insure client understanding of the potential risks involved with online treatment.
Privacy and security.Under federal regulations associated with the Health Insurance Portability and Accountability Act (HIPPA), fines may be levied against anyone who knowingly discloses personally identifiable health information to another person. Since most counselors, including those who practice online, use electronic billing or third-party programs/software to provide services (e.g., email service, chat platform, e-clinic websites), as a “covered entity” HIPPA regulations as well as specifications in the Health Information Technology for Economic and Clinical Health Act (HITECH), which requires a business associate agreement with the vendor of the technology used to process payments or render services, apply (Zack, 2010; Reinhardt, 2013a). Essentially, if a tool is used to create, receive, maintain, or transmit Protected Health Information (PHI), then the vendor of that tool is a business associate and they can be held responsible for following HIPPA law (Reinhardt, 2013b). The use of encryption offers one workable solution where therapeutic communication and payment transactions are secured with encryption keys to which third-party vendors do not have access.
Efficacy of Online Counseling
Barak, Hen, Boniel-Nissim, and Shapira (2008), after completing a meta-analysis of 92 studies involving a total of 9764 clients, indicated empirical research exists supporting the efficacy of online counseling. Barak (2015) later compiled a bibliography of peer-reviewed literature regarding Internet-assisted therapy and counseling containing over 500 articles. “The general conclusion drawn from many studies and several meta-analyses is that online counseling can be as effective as face-to-face sessions” (Kraus, 2010, p. 56). Online counseling was deemed particularly effective in the treatment of depression (Christensen, Griffiths, & Jorm, 2004), anxiety (Kenardy, McCafferty, & Rosa, 2003), and eating disorders (Zabinski, Celio, Wilfley, & Taylor, 2003). Birgit, Horn, and Andreas (2013) found that clients participating in online therapy reread the correspondence from their therapist and used it as a catalyst in their personal therapeutic progress. Similarly, “counselors in training reported facilitating online counseling was easier because they were able to peruse their session transcripts” allowing them to delineate themes that may have been missed in face-to-face settings (Haberstroh, 2009, p. 2). It is clear from the increasing number of studies published that there is sufficient empirical evidence to support the efficacy of online counseling.
Advantages and Disadvantages of Online Counseling
However, it is important to remember, however, that with every form of treatment there are advantages and disadvantages. Understanding both will help practitioners decide whether or not providing mental health services online is appropriate for themselves and their clients.
Advantages
Convenience is one of the primary advantages of online counseling. Since the therapeutic relationship is built via the Internet, clients do not need to leave the comfort of their own home in order to benefit from mental health services. This saves on both time and the expense of travel for the client as well as possible child care costs. Another aspect of convenience is accessibility for those with limited mobility – physical disabilities, physical illness, or mental issues that prevent people from leaving their homes become a nonissue with online counseling. Providing mental health services online also benefits those who live in remote areas without access to such services.
Anonymity and perceived privacy are additional advantages. Since the therapy is experienced within the client’s own space, no one needs to know that the client is actually “seeing” a therapist (Barnard, 2010). Similarly, some people still sense a stigma affiliated with seeking mental health services. “Others may be phobic, trapped in abusive situations, or merely shy and afraid to face someone” (Speyer & Zack, 2010, para. 8). Since the counselor is not physically present, the client’s feelings of fear or shame dissipate with online counseling.
Online counseling can be an educational tool. Since virtual interaction tends to have a disinhibiting effect, clients are more quickly able to identify core issues (Speyer & Zack, 2010; Barnard, 2010). The power differential (Owen, 1995) that often exists within therapeutic relationships is diminished allowing the client to take ownership of the therapeutic process more readily (Speyer & Zack, 2010). When using text-based online counseling, the client is able to read and write their messages at any time. Along with enabling clients to rehearse and compose well-composed responses, they are able to revisit those text-based interactions repeatedly to “reinforce the solutions and resolutions” identified within them (Speyer & Zack, 2010, para. 15; Barnard, 2010).
Disadvantages
Beyond the question of licensure and location of services previously discussed, some insurance companies may not cover online therapy. Without insurance coverage, extended online therapy may be cost prohibitive for some clients. As noted earlier, confidentiality is just as important in online therapeutic relationships as it is face-to-face. Beyond the concerns related to third-party vendors and hacking vulnerability, with online counseling it is incumbent upon “the client to protect their privacy and limit disruptions” during a session as well (Barnard, 2010, para. 72).
While asynchronous communication allows for reflection, it may also increase the likelihood of misunderstandings. Nonverbal signals are not present in text-based online counseling and may be limited when using a webcam. In the absence of such visual cues, practitioners may need to “read between the lines” in order to ascertain the actual crux of the issue at hand (Speyer & Zack, 2010; Barnard, 2010).
Ease of access can be a proverbial double-edged sword. Just because a client has access to online counseling services does not mean that the client is an appropriate candidate for such services. It is important to consider - Who can be effectively treated online and how is such a potential client identified? Internet intake procedures should be structured to promote assessment and screen out clients who would be better served in face-to-face settings (Speyer & Zack, 2010; Barnard, 2010).
Essential Skills and Suggested Practices