Cyber Counseling

Online counseling comes in a variety of shapes, sizes, and names, from cyber counseling, to e-therapy, tele-health and tele-psychiatry. It is differentiated from traditional face-to-face counseling (FTF) by offering counseling through email, chat rooms, text messaging, video-conferencing, voice-over-the- internet phones, interactive websites, and a variety of resource delivery systems.

The strengths of cyber counseling include the following:

§  It offers the clinician a rich tool in leveraging the impact of counseling services. Typically, the weakest link in most treatment systems is aftercare and follow-on counseling. The Internet now offers counseling a broad array of options to leverage and maximize the treatment gains in
in-patient or outpatient care.

§  It provides a means of accessing clients who might otherwise not get help, such as those with special needs, the handicapped, deaf, non-ambulatory, agoraphobics, ambivalent or pre-contemplative clients, low income patients without means of transportation, clients with hectic lives, those who need daily follow-on contact, or those where distance prohibits regular clinical contact. It offers help to those needing an instant response when no resources would otherwise be available to them.

§  It is cost-effective, accessible, affordable, and, for many of our clients, it offers a much-desired anonymity. For clients who are uncomfortable with FTF therapy, it offers unique privacy and confidentiality.

§  It provides the client and the clinician a permanent record of the sessions, progress notes, self-paced activities, and a personal home page for all clients, etc.

§  For youth, the generation who are far more proficient at technology than those of us older adults, it opens up a vast new vista for services, and clinical procedures. Whenever I want to know something about the Internet, to whom do you think I go? Of course, to my 20-something daughters! While I am still learning how to use my cell phone, they are proficient at text messaging, IMing, video- and picture phones.

§  In many locations qualified clinicians are a rarity: more than 80% of MSWs and 90% of psychologists and psychiatrists practice in urban areas. More than 60% of rural Americans reside in federally designated shortage areas for mental health services. The Internet now offers an inexpensive means of providing qualified clinicians “right in the client’s town.”

§  Over time, costs for online services will continue to decrease, and through high-speed broadband connections, the speed of communication will dramatically increase. Advanced encryption will further ensure security of information. And the Internet and computer systems will be readily available to most U.S. citizens.

§  It is a non-sexist means of communicating, as 50% of those using the Internet are male, 50% female.

§  The array of tools now available to the counselor through the internet is mind-boggling, from multi- media presentations, video vignettes, flash and static slides, interactive slides, group and private text messaging, personal homepages to assess issues such as self-esteem, anxiety, sobriety progress. Personal journaling is not enhanced, as are homework assignments, and synchronistic and a synchronistic communication (Gross, 2002).

Some of the barriers or issues that the mental health field faces with cyber counseling are:

§  What are the qualifications of a cyber counselor? What specialized training is needed in this new, developing field? In the future, cyber counselors will need to acquire many of the skills possessed by hearing and sight impaired counselors: how to “understand” and read non-verbal cues when the client is shielded by the technological screen of the Internet. Counselors will need to develop a “third ear” as blind counselors have done. Further, standards for credentialing of cyber counselors will be required, even as there is specialty certification for gambling, prevention, eating disorders, etc.

§  How much time and experience online do most counselors have, given the newness of the technology? It is easy to “hang out one’s shingle,” professing experience in cyber counseling. However, along with the needed skills addressed above, time online will be required to become familiar with the technology and techniques of working on the Internet. For example, I am a technopeasant, as are most individuals in my generation. We will need training and experience online as well as learning a new vocabulary. This only comes with experience and time.

§  What are the appropriate types of interactions for what clients, ranging from chat rooms, email, video-conferencing, etc? What about the frequency of online “visits” and the cost and payment procedures?

§  Most importantly, what federal and state laws apply? Whose jurisdiction and insurance requirements does the online counselor fall under? For example, the client might reside in Connecticut and the counselor works in California. Do the laws of Connecticut or California apply? (In the future the counselor might reside in India). These issues were addressed thirty years ago with hotlines and after-hours Employee Assistance Program (EAP) answering services, often operating across state lines. Hotlines resolved that the laws to be followed pertain to the state in which the client resides. What are the different state laws concerning duty to warn and protect, dependent and child abuse, etc? This requires the counselor to be familiar with the various state laws in which their cyber client resides, not a simple task. Most likely, the same ethical standards that apply to hotlines can be utilized for cyber counseling as well. The American Counseling Association has recently issues ethical standards for cyber counseling. JCAHO and CARF are also developing standards for the accreditation of cyber counseling and accredited the first substance abuse online program, www. egetgoing.com (Hsiung, 2002).

§  If relationship and therapeutic alliance is so important in counseling (see The Heart and Soul of Change by Hubble, Duncan and Miller), how does a counselor establish rapport when there is reduced interpersonal contact, when there is an absence of physical closeness? When the counselor cannot “see” or “hear” the client? How can the clinician ensure the true identity of the client? How to avoid avatars? (An avatar is when I get online in a chat room, for example, and pretend to be twenty years old and with a full head of hair).

§  How does the clinician deal with counseling emergencies, especially if the therapy is offered across state lines, or even national boundaries? Again, hotlines and Employee Assistance Programs have developed nationwide resource lists to respond in clinical emergencies. Cyber counseling programs need to tap into these existing lists and networks.

§  How does one avoid misuse of the website or online system, such as pornographic communication, cyber-infidelity (cyber affairs), and most importantly, internet addiction (see more below)? This is a much larger question that the Federal Communications Commission and other regulatory bodies will surely address.

§  What about privacy and confidentiality? How can the counselor protect against a hacker getting into the system? Who has access to the information obtained online? This is the most often raised concern I hear about cyber counseling. Technology, though, has answers for this: through improved broadband capabilities and firewalls, improved encryption methodologies, confidentiality can be assured. Voice printing, finger printing before one can log on, and other tools are emerging that can assure that the person online is in fact the client. People will always voice concerns about technology and confidentiality, even as I did twenty years ago with fax machines, answering services, and now the internet. A facetious answer I give when the question of confidentiality is raised is “What makes you think anything you do, even paper-and-pencil forms and charts, is confidential when seventeen sets of eyes and hands touch every claim form you send through for third- party reimbursement? How often have you gone around in a clinic and found charts lying around on desks? This does not release cyber counseling from concerns about confidentiality. Two wrongs don’t make a right. However, questions about confidentiality hav

e always been relevant and should be raised regardless of whether the counseling is performed face-to-face or online.

§  Is there an inherent issue of classism, where the poor again might not have access to care and treatment? Are there cultural, ethnic and racial issues unique to the internet?

§  How can online systems be tailored to the unique issues of the substance abuse field? For example, how does a cyber counselor deal with an online client who is obviously intoxicated when “in” group counseling? How does a counselor assess if the client is intoxicated? How do we deal with mandated clients and “sign-in” procedures when logging onto an online group session?

Issues Counselor Face

Mental health professionals will need to acquire not only a new vocabulary but also core skills, such as:

§  How to establish rapport with clients over the Internet. This is not a new skill as a hotline and Employee Assistance Program counselors have been able to do so, often in high-risk situations;

§  How to maintain a professional “tone” when there might be no verbal communication; again, this is not a new issue as hearing impaired and blind counselors have been able to “see and hear” clients in different and unique ways;

§  When the counselor is visible onscreen, issues such as the counselor’s make-up, nuances of facial expressions, body language, voice inflection, etc. Although obviously in FTF communication these issues are relevant as well, the internet and monitor make these issues more obvious, visible, and important to the client/counselor communication.

§  Online group etiquette needs to be taught to counselors and clients (Kraus, et al, 2004).

Preliminary results of internet counseling seems to point to higher percentages of people completing the treatment program, higher abstinence rates for alcohol and drug abusers, the vast majority of cyber clients state that it was beneficial. A new term has been coined: virtual intimacy. It seems, from early research, that people are more comfortable talking online than FTF. There is something reassuring and safe about the technological shield under which we can communicate online.

There seems to be more uniform treatment results, more personal attention given to clients through the use of personal homepages, and other tools. There is greater client involvement and interaction in online treatment than in traditional FTF counseling.

So where do you go if you are interested in cyber counseling? First, contact the reputable firms who have pioneered the use of the Internet in counseling, such as www.egetgoing.com, www.webMD, and others. Second, contact your trade association (ACA, NAADAC, APA, NASW) concerning training programs available and the ethical standards that apply. Finally, contact CARF and JCAHO concerning programs they have reviewed and accredited to see the standards being used and what programs are viewed positively.

Conclusion

The Internet is a reality in our lives. By getting into the net early, the alcohol and drug abuse professional can play an important role in defining the standards for e-therapy.

Resources

K. Derrig-Palumbo, Online Therapy, New York: W.W. Norton, 2005
Freeman, John, The Tyranny of Email. New York: Scriber, 2009.
B. Gross, Online Therapy: Annals of the American Psychotherapy Association, Washington, DC: 2002 Hubble, Duncan, Miller, The Heart and Soul of Change, (2nd edition) Washington, DC: American Psychological Association, 2010.
R.C. Hsiung, E-Therapy Case Studies, New York: W.W. Norton, 2002.
R. Kraus, J. Zack, and G. Strickman, Online Counseling, London: Elsevier Academic Press, 2004.
Morosov, E. The Net Delusion: The Dark Side of Internet Freedom. New York: Perseus, 2011.