One reflection of the explosion of technology in our lives is the increasing use of technology for delivering counseling and psychotherapy as well as other psychoeducational interventions. An individual can use the Internet to locate a counselor, to gain information about psychological conditions and treatments, to obtain counseling, and to share with others in chat rooms or online support groups. In addition to facilitating the exchange of written or audio content, the Internet can provide individuals with face-to-face contact through the use of video technology.
One of the prime advantages of the Internet in delivering mental health services is that clients who have difficulty obtaining face-to-face contact because of health conditions, remote locations, or other barriers can obtain services that would otherwise not have been available. Examples would be clients living in remote areas where a long drive to obtain clinical services cannot be regularly accomplished; clients whose physical health conditions limit their mobility; clients who live in areas where psychologists, counselors, or other mental health care providers are sparsely distributed; and clients whose psychological condition makes them less likely to seek face-to-face delivery of services but more likely to use the less personal nature of the Internet for chat rooms or support groups. Another advantage of the Internet is that it can be used as an adjunct to regular treatment. An example is that of pain patients who can log on to a Web site where they can enter data about their pain levels, obtain materials about coping strategies they have already been taught, post questions to therapists or other patients, and obtain support between regular treatment sessions.
Ethical and Legal Issues in E-Counseling
However, using technology as the sole or adjunctive means of delivering psychological services poses significant ethical and legal issues. The APA ethical code does not have a separate section on electronically transmitted services. Rather, codes incorporate online treatment as deemed necessary within appropriate categories. For example, the standard on informed consent says that psychologists delivering online treatment must warn clients of the limits of confidentiality inherent in this type of communication.
Mallen, Vogel, and Rochlen outlined several areas where the ethical code may be tested in online formats. One such area is the duty to warn: to protect clients if they pose a danger to themselves or to warn others if the client poses a danger to them. If services are being provided at a distance, it may be difficult to meet this standard. Another example is confidentiality: By their very nature, online interactions are vulnerable to hacking or being penetrated by a third party. If an online exchange is saved by either the client or counselor, the data are equally vulnerable to breaches of confidentiality. Encryption is a possible security step but cannot be relied upon to provide complete protection.
A different type of confidentiality issue is the protection of tests and assessments. Psychologists are ethically obligated to maintain the security of psychological tests and assessment methods. However, if such assessments or tests are transmitted to clients, their security cannot be maintained. In a research setting, when tests are used in online surveys, similar concerns apply.
Legally, psychologists and counselors practice under a license issued by their state. Online treatment tests this limit of practice, because psychologists and counselors may be treating clients in their own state, an adjoining state, a different state, or a completely different country. Mobility issues for psychologists from state to state are being addressed, as are mobility issues for psychologists from country to country. But the advances of online technology have surpassed any advances in mobility in regard to licensure and credentialing.
Training Issues in E-Counseling
In spite of the advances in technology that faculty and students use on a daily basis (e.g., to conduct literature searches via online databases or to download research articles), training in counseling and psychotherapy still adheres primarily to a supposition that counselors will be treating their clients in the traditional face-to-face, office-based, 45- or 50-minute session. Clearly, not all counselors or psychologists are interested in delivering online services, and not all faculty are able to prepare students to do so in future careers. But several training issues apply.
First, at a minimum, students should be competent in computer-aided communication. This competence would extend to chat rooms, encryption, and various hardware and software programs.
Perhaps more important is communication via text. Counselors are skilled at empathy: picking up on client’s verbal and nonverbal cues and recognizing the affect behind them. This skill is much more demanding with text communication. Counselors may need to learn to ask questions in a different manner than they do in person and to convey their responses much more directly than they might usually do in conversation.
Ethical and legal issues that may arise in online counseling must be considered during graduate education in the same way that ethical and legal issues arising from in-person treatment are considered. While practica may not provide opportunities to identify these issues, faculty teaching courses in ethics and issues can include a section on online treatment and might profitably include a panel of local practitioners who deliver online services and have wrestled with relevant ethical issues.
- Derrig-Palumbo, K., & Zeine, F. (2005). Online therapy: A therapist’s guide to expanding your practice. New York: Norton.
- King, R., Bambling, M., Lloyd, C., Gomurra, R., Smith, S., Reid, W., et al. (2006). Online counselling: The motives and experiences of young people who choose the Internet instead of face to face or telephone counseling. Counselling and Psychotherapy Research, 6, 164-168.
- Kraus, R., Zack, J., & Stricker, G. (2004). Online counseling: A handbook for young professionals. San Diego, CA: Elsevier.
- Mallen, M. J., Vogel, D. L., & Rochlen, A. B. (2005). The practical aspects of online counseling: Ethics, training, technology, and competency. The Counseling Psychologist, 33, 776-818.
- Recupero, P. R., & Rainey, S. E. (2005). Informed consent to e-therapy. American Journal of Psychotherapy, 59, 319-331.