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Running head: ONLINE COUNSELING: A PRIMER FOR PRACTITIONERS 1

Online Counseling: A Primer for Practitioners

Stephanie K. Ferguson, PhD

New Mexico Junior College

Author Contact Information:1 Thunderbird Circle, Hobbs, New Mexico [email protected] (mobile)575-492-2643 (office)

ONLINE COUNSELING: A PRIMER FOR PRACTITIONERS 2

AbstractThe 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

According to Fenichel (2010), “the clinician who works entirely online needs a new skill

set that includes privacy safeguards for the client, methods of clear communication

(compensating for absent verbal and visual cues), a framework that is structured yet flexible, and

processes that allow for means of validating the results” (p. 7). Speyer and Zack (2010)

highlighted the need for practitioners to understand the limitations of the online medium while

leveraging the benefits. At a minimum, practitioners should:

assess the suitability of clients via an intake process;

work within ethical parameters;

educate clients and provide informed consent;

advise clients of limitations related to online counseling;

have resources in place to address potential emergencies; and


provide verification of professional qualifications (Speyer & Zack, 2010).

It is also essential for both the practitioner and the client to be confident and competent in

their computer usage skills (Anthony & Nagel, 2010; Speyer & Zack, 2010). Having knowledge

of specific computer programs, platforms, firewalls, and other security needs to insure privacy

concerns are being addressed. Likewise, both the practitioner and the client should be reasonably

proficient in writing and typing. Text-based counseling “is essentially a letter writing process”

(Speyer & Zack, 2010, p. 3) simply using an electronic medium rather than pen and paper.

Reinhardt (2013a) as well as Anthony and Nagel (2010) and Haberstroh (2009) agreed working

online is a specialty area that requires additional skills unique to the virtual therapeutic

relationship. “Training, knowledge, and supervision regarding mental health and technology is

paramount to delivering a standard or care that is considered ‘best practice’” and may be gained

through both formal and informal training, books, peer-reviewed literature, popular media, and

clinical/peer supervision (Anthony & Nagel, 2010, p. 67).

Closing Thoughts

The methods and scope of online counseling as well as the ethics and regulations

governing it are still evolving. At its best, online counseling enables both practitioner and clients

to experience telepresence – “the illusion that a mediated experience is not mediated” (Lombard

& Ditton, 2006, para. 1). When such conditions exist, practitioner and client are able to engage in

a satisfying and productive virtual therapeutic relationship. Understanding both the rewards and

the risks of such an undertaking, however, is essential for all participants. Approaching the

potential benefits with enthusiasm tempered with caution in relation to the challenges of the

medium will serve practitioners well.


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