Back to 1st pageReprinted from the June 1998 Counseling Today
By R.J. Sussman
Counseling on the Internet is alive and, in the opinions of some, well. The question is, as counselors, do we want to take an active role in shaping this new avenue of our discipline, or can we afford to adopt a wait and see attitude? One web site, Metanoia at www.metanoia.org, lists more than 80 sites where some form of counseling or psychotherapy is purported to occur. These sites exhibit a broad range of scenarios. Sigmund, a site with an anonymous "therapist," solicits e-mail which he or she then responds to for $20. Some sites offer prepackaged intervention programs using workbooks or videos as well as online interaction. Other sites offer the professional online services of a licensed counselor, psychologist, or psychiatrist. Some providers ask for a payment in advance, while others offer services free of charge, or ask for payment only if the client believes that they received some benefit. As counselors we have a duty to the public. As a profession we must do our best to offer protection from the chicanery of unqualified Internet "therapists" while still allowing the consumer to exercise choice.
There seem to be some distinct advantages to counseling on the Internet. Certainly one advantage would be the ability to bring mental health services to those in underserved or geographically isolated areas. A game warden or pipeline worker in a remote part of the Alaskan wilderness is prone to face issues and crises just as much as someone in a well-served metropolitan area. The Internet may be a way of bringing counseling to them. Another advantage would be that those who may be better served by specialists would have access to those counselors who may be more qualified to help them, regardless of geographic limitations. Those who are physically disabled or seriously ill would have the option of getting support without having to leave their homes. Instead of arranging for someone else to pick the kids up from day care and fighting rush hour traffic to get to a counselor's office, an individual can have their session after the kids go to bed in the comfort of their own living room. Still another advantage would be that those who are apprehensive about being seen walking into a counselor's office, or who have thought about counseling but are not sure what it's about, may be more likely to seek services if they can do so from the safe and comfortable confines of their homes.
Clearly there exist some disadvantages as well. Confidentiality is one. E-mail may be intercepted by others. Possible solutions include digitally encrypting transmissions, and passwords protecting access to sensitive information on both the counselor's and client's computer. In reality, you are more likely to have your phone conversations eavesdropped on than to have your e-mail transmissions monitored.
Another problem is how to handle emergency situations that arise with clients who may be halfway across the globe. Local authorities may be able to assist the online counselor by contacting emergency services within the client's local area. A proactive way to deal with this quandary may be to get a prospective client's local emergency numbers as well as their physical address and phone number before initiating work. Once a relationship is established, emergency contact with an online counselor may be handled in the same way that it is handled in face to face counseling. The client may be given a home, cellular phone, pager, or voicemail number, or they may be given information on local community resources. A final concern is that a client may more easily terminate a session or a counseling relationship if the counselor touches on sensitive issues. This is a good argument for getting a client's phone number, home address, and e-mail address before beginning work.
Counseling online: Present and future
When we talk about counseling online we are really discussing three very different forms of interaction that use the Internet as a means to transfer information. These three methods of communication are e-mail, text-based chat, and video conferencing. Presently, the most frequently used means through which manner that online practitioners communicate with consumers is through e-mail. Every site on Metanoia's listing of practitioners uses e-mail as the primary route by which the providers interacted with their clients online. Practically everyone who has access to the Internet has an e-mail account. With e-mail there is no need to schedule any appointments. The client or potential client simply sends an e-mail, and the practitioner answers at their convenience.
However, there are also some disadvantages of using e-mail as a way to conduct counseling. One of these is clearly the loss of the dialectical process. In face to face counseling there is a continuous and immediate feedback loop between counselor and client. E-mail precludes this continuous and immediate feedback. Another disadvantage with e-mail is the complete lack of nonverbal information. Many counselors believe that nonverbals are even more important than verbals in some therapeutic situations.
Some online practitioners use text-based chat as a way of working with their clients in real time. This is more cumbersome because appointments need to be set up and there are generally more technical details to be worked out. Although chat provides for immediate feedback in both directions, the client's nonverbals are lost except for the occasional abbreviations indicating emotions (e.g., "lol" means laughing out loud, and " : ) " means happy).
The next logical step would be for practitioners to use video conferencing alternatives. This would be the closest thing to actually being in the room together, and would be a great support to online counseling. However, very few sites offer video conferencing technology and the performance is largely disappointing for those that do.
There are two distinct means of Internet counseling. There is the current formulation, which consists mostly of e-mail with some text-based chat, and there is the real time video conferencing of the near future. Although it may not arrive for another two to four years, video and real time audio may make counseling online the "next best thing to being there."
Legislation and certification
California was the first state to pass legislation affecting the practice of psychotherapy on the Internet. The California Telemedicine Act mandates that mental health services provided online to a resident of California can be administered only by a health care provider licensed in that state. Additionally, managed care must cover online services that would be normally reimbursed in a face to face visit. Other states are currently working on legislation resembling the California model.
The glaring problem with such laws is not just that they restrict consumer choice, but that they are contradictory to the basic nature of the Internet. The online world is devoid of any state or national boundaries. In an evening spent surfing the net an individual may visit a dozen or more countries without a passport or any regard for the specific laws of these nations. For the most part the Internet is a lawless information frontier, and attempts to legislate and restrict not only fall on deaf ears, but can often be impossible to enforce. For instance what happens when a resident of California establishes a counseling relationship with a practitioner in Australia?
How can we protect the public interest without legislation? Several attempts at this feat are already underway. Metanoia has begun to check the credentials of its listed practitioners with their appropriate licensing bodies. In addition, Mental Health Net at www.cmhc.com has rated each of the sites listed on Metanoia. Also, a service called Credential Check has begun certifying practitioners with regard to the legitimacy of their purported degrees, certifications, and licensure.
Last September, the National Board of Certified Counselors (NBCC), with the guidance of its WebCounseling Task Force, adopted its "Standards for the Ethical Practice of WebCounseling" (www.nbcc.org/wcstandards.htm). Officially, NBCC does not advocate the practice of counseling on the Internet. These voluntary standards have been constructed in order to provide direction for the online practitioner, and minimize any potential risks.
Some have accused NBCC of acting prematurely. There has been virtually no research done in the area and it is impossible to ascertain the extent to which online counseling is either helpful or harmful. Due to efforts to control extraneous variables, and the careful scrutiny of Research with Human Subjects committees, psychotherapy outcome studies can be cumbersome. Faculty and graduate students often steer clear of these projects. Perhaps grant money could be earmarked for such investigations given the urgent need on the part of credentialing and governing bodies to make decisions regarding this recent development in our field.
If it is in fact established, after adequate research, that counseling over the Internet seems to be either not at all helpful or in some way harmful, then it is the responsibility of organizations like ACA and NBCC to publicly speak out against such practice. However, if studies indicate that online counseling is in fact beneficial, then a fair and structured approach to certification must be implemented. Clearly, due to the global nature of the online community, any attempt at creating certification standards must be internationally sensitive. Such standards must take into account the different educational systems and credentialing practices of many different nations. Drafting a globally interchangeable certification policy may be a formidable task. It will be necessary not only to encourage the participation of representatives from many countries, but also those from the different domains within mental health. This is not a project counseling professionals should try to take on themselves. It would be beneficial to work as a team with psychologists, psychiatrists, and social workers, to achieve the common goals of protecting the public and increasing the availability of services. In addition to coming to an agreement with other professionals, it is imperative that we consult with managed care companies on this issue. Whether we like it or not, insurance providers have a major role in determining what types of services are performed. With their support, not only will Internet counselors be entitled to third-party payments, but the public can be influenced, through economic means, to seek online services only with those practitioners who possess the requisite skills and have agreed to follow the guidelines necessary for certification.
It is our duty as members of the profession to take an active role in guiding this new method of service delivery. It is important that we take a farsighted approach by conceptualizing online interaction not only in the manner that it normally occurs today, but also in terms of how it will evolve over the next several years. The path toward protecting the public interest and preserving individual choice seems to be paved not with legislation, but with certification. It is important that adequate research be done in the area before certification guidelines are enacted. If research does suggest that counseling over the Internet is or could be beneficial, then it is important to establish international certification guidelines with the input of counselors, other mental health providers, and managed care.
- R.J. Sussman is a doctoral student in counselor education at Southern Illinois University at Carbondale and an Internet fanatic. Correspondence regarding this article should be transmitted via e-mail to R.J. Sussman at sussman@globaleyes.net.
All materials are the property of the American Counseling Association. ACA grants reproduction rights to libraries, researchers, and teachers who wish to copy all or part of the contents of this article for scholarly purposes provided that no fee for the use or possession of such copies is charged to the ultimate consumer of the copies.
Copyright ©1998, American Counseling Association.
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