As Rita and I updated the Clinical Interviewing text, we did a little web-searching for online counseling resources and the excerpt below includes our musings on this very interesting topic.
From Clinical Interviewing, 4th ed, updated, SF & SF, 2012
http://www.amazon.com/John-Sommers-Flanagan/e/B0030LK6NM/ref=ntt_dp_epwbk_1
Online Counseling: Ethics and Reality
As a part of reviewing information for this chapter, we perused Internet therapy options available to potential consumers. Previous publications suggested a possible plethora of Internet counseling and psychotherapy providers with questionable professional credentials (Heinlen, Welfel, Richmond, & O’Donnell, 2003; Shaw & Shaw, 2006). Although we hoped that Internet service provision standards had improved, we weren’t overly impressed with our results. Generally, we found that most providers may have more expertise in business and marketing than they do in professional clinical work. Affixed on this foundation of business and marketing, we found two distinct approaches: the more ethical and the less ethical.
The Less Ethical Approach
Many providers offer online services but don’t acknowledge having specific credentials (e.g., a license) typically associated with clinical expertise. For example, practitioners with bachelor’s degrees (or less) made statements like the following:
“I am a counselor, life coach, and spiritual teacher with over 20 years of experience. I have studied the fields of counseling, psychology, personal growth, relationships, communications, business, computer programming and technology, languages, spirituality, metaphysics and energetic bodywork! In addition to my training, a [sic] 18-year relationship with my second husband has deepened my capacity to help others with relationship issues.”
This sort of enthusiastic introduction was typically followed by an equally enthusiastic statement about the breadth of services offered:
“My online counseling services specialties include, but are not limited to: anxiety/panic, self-esteem, highly sensitive people, couples counseling, relationship advice, life and career coaching, emotional intelligence, personal growth, affairs, guilt issues, work and career, trust issues, abuse/boundary issues, communication skills, conflict resolution, grief and loss, emotional numbness, spiritual development, stress management, blame, court-ordered counseling, codependency, problem resolution, jealousy, codependency and attachment, anger and depression, food and body, and developing peace of mind.”
Curiously, we found that the broad range of claims on websites such as these did not move us toward developing or experiencing peace of mind.
The More Ethical Approach
There were also websites that included professional, licensed providers. For example, one website listed and described eight licensed practitioners with backgrounds in professional counseling, social work, and psychology. These professionals offered webcam therapy, text therapy, e-mail therapy, and telephone therapy.
Prices included:
- E-mail therapy: $25 per online counselor reply
- Unlimited e-mail therapy: $200 per month
- Chat therapy: $45 per 50-minute session
- Telephone therapy: $80 per 50-minute session
- Webcam therapy: $80 per 50-minute session
The more ethical professional Internet services also tended to include information related to theoretical orientation. For example, a “postmodern” approach was described as involving: “Staying positive . . . focused on the here and now . . . offering solutions that meet your needs . . . a collaborative and respectful environment . . . quick results . . .”
How to Choose an Internet Services Provider
The National Directory of Online Counselors now exists to help consumers choose an online provider. They state:
“We have personally verified the credentials and the websites of each therapist listed in the National Directory of Online Counselors. Feel assured that the therapists listed are state board licensed, have a Master’s Degree or Doctoral Degree in a mental health discipline, and have online counseling experience.”
The listed therapists and websites are set up and ready to handle secure communication, and offer various services such as eMail Sessions, Chat Sessions, and Telephone Sessions. All work conducted by the professional licensed therapists meet[s] strict confidentiality standards overseen by their professional state board.
Both of these distinct approaches to online therapy emphasize that help is only a mouse click away.
John Sommers-Flanagan 
John and Rita, Thanks for reporting your observations. It might be worth noting also that (a) even though a therapist is licensed, the state licensure board may not condone the practice and (b) even if condoned ed by licensure guidelines, the evidence for effectiveness or efficacy is highly limited!
Paul Silverman
Hi Paul. Good point. I’m aware of some interesting issues on interstate commerce and, as you suggest, given the state-of-the-science in this area, it’s difficult to say much regarding efficacy or effectiveness. I find this whole area to be simultaneously fascinating, mystifying, and frightening. I hope you and Felicia and the family are doing well! John
Hopefully in your search you came across the Online Therapy Institute. We offer an Ethical Framework for the Use of Technology in Mental Health: http://onlinetherapyinstitute.com/ethical-framework/
Hi DeeAnna.
Thanks for alerting me to the Online Therapy Institute. I’ll include it as a resource in the forthcoming 5th Edition of Clinical Interviewing. I’m glad to hear about your Ethical Framework!
All best,
John SF
Actually there are several studies emerging about the efficacy of online therapy- particularly telemental health using video conferencing. A recent Veteran’s Administration study was published with a very large sample (nearly 100,000) and funding of studies regarding online therapy and virtual therapy continue through organizations like SAMHSA. For a thorough bibliography of qualitative and quantitative publications (all peer reviewed or academic book chapters) check Dr. Azy Barak’s wonderful resource here: http://construct.haifa.ac.il/~azy/refthrp.htm
On the topic of state licensing boards, it will take a while but I think there will eventually be a federal mandate that eases license portability issues as telehealth becomes more popular among providers and consumers. While we wait on that to take place, some states are already figuring it out: http://www.healthcareitnews.com/news/more-states-introduce-telemedicine-bills
I hope these resources are helpful!
Hi DeeAnna.
Thanks again for even more info. I’ll check it out!
All best,
John SF
When I’ve spoken to mental health professionals, the response is always negative, but primarily because of the “Wild West” environment. I think most therapists will need to find a way to embrace this movement since I imagine many people would find online counseling far more convenient. Will be interesting to see what the research says in a few years.
Online Counseling Ethics… And the criteria for ethical practice are? How ethical is it really to be advertising ‘unlimited’ email therapy at a per month rate? Surely there must be some limits, because even counselors and therapists need to sleep!
In terms of the question of peace-of-mind, actually I do wonder whether you would not find similar results if you surveyed the websites of in-person practitioners? I suppose that one difference might be that where there is state licensing, there are stricter regulation of the terms ‘counselor’ or ‘therapist’, so those in-person practitioners describing themselves in these ways are bound to the requirements of professional codes of conduct when marketing themselves. But isn’t the question of state regulation of counseling (however it is delivered) a different issue to the online versus in-person practice debate? I can’t help but notice online practitioners coming under a more critical gaze than those who promote themselves as ‘face-to-face’ (a curious term, given that webcam is also ‘face-to-face’ practice). I would not be surprised to find much of the critical focus is born of a sense of suspicion from those ‘in-person’ only practitioners who fear the growing presence of online practice or even technology itself.
But online counseling is here to stay. We need to embrace it, refine it and accept that it is part of the future of counseling and therapy. I practice both online counseling and in-person counseling. I don’t see them as competing but as complementary services. Of course some circumstances and presentations are not suitable for online attention. But there are also clients who would be very reluctant to step foot into a counseling clinic because the threshold is too high, whereas online services might meet their needs. Why shouldn’t people have choice about the services they use? Online services also cater to those who are geographically isolated from in-person practitioners or prefer a different type of service delivery due to being differently-abled or having particular language requirements.
At least to some extent, the question of professionalism is and always will be one of ‘let the buyer beware’, regardless of how much state control goes towards ensuring counseling practitioners meet ethical standards. At the end of the day, it will be up to professional associations to promote their members interests and educate the public about what to look for in the market.
Hi Ash.
Thanks for your very thoughtful musings on online counseling. You ask some interesting and important questions. For what it’s worth, I basically agree with your perspective and found your point that perhaps sometimes more stringent ethical lenses are applied to online practitioners. It seems like, as you suggest, in-person marketing and online marketing both might cross into the gray area of ethics at times.
Thanks very much for sharing your thoughts and have an excellent Sunday evening.
John SF
Online Counseling provides a unique opportunity for people to find help for anxiety, depression and other emotional problems; people who might not be comfortable with in-person therapy or who may not have access to local counselors.
Whenever a client is seeking a therapist to work with, the primary focus should be to find someone that you feel comfortable with and that shares your beliefs and philosophy. This applies equally to in-person or online therapists.
With the advent of Skype, the online therapy experience can be equal to and sometimes better than the in-person experience. People feel more comfortable calling from home.