Encyclopedia of Cyber Behavior

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ONLINE COUNSELING


698




Encyclopedia of

Cyber Behavior



Zheng Yan

University at Albany, USA












Volume I


ONLINE COUNSELING


699



Chapter 59

Online Counseling



Derek Richards

University of Dublin, Trinity College Dublin, Ireland


Noemi Viganò

Alliance Counseling: Professional Psychological

and Counseling Services, Ireland
.




ABSTRACT


Online counseling is defined as the delivery of therapeutic interventions in cyberspace
where communication between a trained professional counselor and client(s) is
facilitated using computer
-
mediated communication (CMC) technologies. Research
considers a
spects of delivering therapeutic interventions online, including process and
outcome research, the therapeutic relationship online, the potential benefits and
challenges in working online, client suitability for online counseling, therapists’ and
clients’
attitudes and experiences of online counseling, professional training for working
online with clients, and its very nature and definition as a therapeutic intervention.
Understanding the psychology of online behavior as it applies to online counseling
incl
udes the effects of apparent anonymity and distance, disinhibition, identity and
impression management, writing and emotional expression, presence, and ethical
behavior in cyberspace.


KEY TERMS

Therapeutic relationship online, ethics of online counseling
, experience and attitudes
about online counseling, expression in cyberspace, suitability, cyberbehaviors.

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698


INTRODUCTION


The field of cyberpsychology involves
the study of human experiences
(cognitive, emotional, and behavioral)
that are related to or impacted by
developing technologies, in other
words, the psychological study of
human
-
technology interaction. Subject
areas,
for example, include identity
online, online addiction, and online
relationships. Online counseling, also
referred to as e
-
therapy or cybertherapy,
is another area of study. Online
counseling is the delivery of therapeutic
interventions in cyberspace where

the
communication between a trained
professional counselor and client(s) is
facilitated using computer
-
mediated
communication (CMC) technologies.

The phenomenon of online counseling
has a brief history but, aided by
technological developments, has grown
exponentially in recent years. Research
considers aspects of delivering
therapeutic interventions online. These
include, but are not limited to, the
potential effectiveness of online
counseling, establishing a therapeutic
relationship in cyberspace, potent
ial
benefits and challenges, client
suitability for online counseling,
therapists’ and clients’ attitudes and
experiences of online counseling,
professional training for working online
with clients, and its very nature and
definition as a therapeutic inter
vention.
Research has also been exploring newly
observed phenomena that form part of
understanding the psychology of online
behavior as it applies to online
counseling. Areas of interest include the
effects of apparent anonymity and
distance, disinhibition
, identity and
impression management, writing and
emotional expression, presence, and
ethical behavior in cyberspace.


OVERVIEW


History and Current Empirical
Knowledge


While we have provided a definition of
online counseling, the exact definitions
of in
terventions involving therapists and
clients online are very much in flux and
a continued source of debate. A recent
paper (Barak, Klein, & Proudfoot,
2009) has brought some clarity, yet the
terms are not specific to any theoretical
or technical approach,
nor do they
underscore professionals with certain
levels of training
(Rochlen, Zack, &
Speyer, 2004)
. Synchronous (chat and
video conferencing) and more popularly
asynchronous (e
-
mail) communication
have been used by client(s).
Additionally, online counsel
ing has
been provided as a stand
-
alone service
and as an adjunct to other services.
Virtual

reality environments, allowing
both synchronous and asynchronous
communication, have also been used to
conduct counseling (Nagel & Anthony,
2011). Some web
-
based se
lf
-
administered treatments for a variety of
disorders have included online
counseling support, usually in the form
of asynchronous post
-
sessions feedback,
which appears to increase adherence
and yield enhanced outcomes
(Newman, Szkodny, Llera, &
Przeworski
, 2011)
.

It has been argued (Castelnuovo,
Gaggioli, Mantovani &

Riva, 2003) that
online counseling is a transposition of
face
-
to
-
face counseling online, with
technologies mediating the therapeutic
communication and impacting the
process with their associated advantages
and limitations. From this perspective
online cou
nseling is not perceived as a
new and distinct way of engaging
therapeutically and is therefore not seen
as necessitating a different theoretical
framework from face
-
to
-
face
counseling.

Conversely, it is argued (Fenichel et al.
2002; Grohol, 1999, 2001) t
hat online
ONLINE COUNSELING


699


counseling should be considered a new
type of therapeutic intervention,
characterised by fundamentally
distinctive features. From this
perspective online counseling is not
seen as a substitute to face
-
to
-
face
interventions but rather as a versat
ile
and flexible resource with the potential
to complement and support other types
of interventions

From its beginning online counseling
has been criticized by professionals and
laypeople alike
(Barak, Hen, Boniel
-
Nissim, & Shapira, 2008)
. The roots of
the

criticisms have largely concerned a
number of key areas that have populated
the literature since. Firstly, concerns
have been voiced regarding the impact
of the loss of cues on the process of
therapy. Secondly, ethical issues and
their legal implications
regarding all
aspects of the construction and delivery
of online counselling feature. Thirdly, a
variety of practical issues have arisen
concerning training for conducting
online counseling and concerns about
relying on technology. Our
understanding of the
se issues, while
they still exist, has developed through
research, the development of advanced
technologies, the development of ethical
codes of practice, and specialized
training for professionals.

The goal of counseling is to alleviate
the concerns that

clients can present.
Counseling attempts to foster clients’
well
-
being, building on clients’
strengths, and improving overall
functioning (Mallen, Vogel, Rochlen, &
Day, 2005). Online counseling must
also adhere to the same objectives. The
findings from r
esearch studies in the
area of synchronous and asynchronous
online counseling have positively
evaluated outcomes, working alliance,
helpfulness and impact and report client
improvement and satisfaction (e.g.:
Barak & Bloch, 2006
;
Cook & Doyle,
2002
;
Efstathiou, 2009
;
Hanley, 2009
;
Knaevelsrud & Maercker, 2006
;
Richards, 2009
;
Barak et al., 2008
).

An early study by Cohen and Kerr
(1998) assigned 24 students to one
session of either face
-
to
-
f
ace or online
synchronous (chat) counseling. Both
groups showed a decrease in anxiety
outcomes post
-
treatment. Although the
study is a sure beginning in showing the
potential of online counseling, it
screened out participants with high
levels of distress a
nd had a small
sample.

Another series of studies (Glueckauf et
al., 2002) randomized teenagers and
their parents for family counseling
among video counseling, audio
counseling, and face
-
to
-
face counseling.
Participants in each of the three
treatment group
s report positive post
-
treatment outcomes involving
reductions in the frequency of family
problems.

Day and Schneider (2002) compared
face
-
to
-
face, telephone and video
psychotherapy. No statistically
significant difference was found
between the three trea
tments for either
working alliance ratings or outcomes. A
statistically significant difference was
found with clients participating more
actively in distance therapy than in face
-
to
-
face therapy.

Students using online asynchronous
counseling noted the adv
antages,
namely, ease of use, speed and
anonymity, followed by ambivalence
about traditional counseling
(Efstathiou,
2009)
. Online counseling seems to
reduce the traditional social stigma
toward seeking help and counteract
social factors that may hinder pe
ople in
seeking help such as gender and
physical appearance
(Efstathiou, 2009)
.

Richards (2009) investigating online
counseling with students, highlights the
potential for single session online
contact. He advances reasons such as
apparent
anonymity and distance, the
therapeutic benefits of writing, the
ONLINE COUNSELING


700


cultivating of a zone of reflection, and
the resourcefulness of young adult
students, as supporting the success of
single session online counseling. The
model employed also allows content to
become a resource for all users
(Efstathiou, 2009; Michaud & Colom,
2003)
.

Online counseling has demonstrated its
value for users in accessing services on
time and on demand, including acting as
a gateway to face
-
to
-
face counseling,
and clients reported sa
tisfaction with the
service
(Richards, 2009)
. Efstathiou
(2009) reports that users of their service
were satisfied with the answers they
received. Similarly, Michaud and
Colom (2003) report that 92% of
teenagers felt the professionals had
clearly understo
od them and were
satisfied with the answer they received.

Several randomized controlled trials
that have included a treatment condition
using synchronous or asynchronous
online counseling have reported
significant post
-
treatment and follow
-
up
effects
(Ke
ssler et al., 2009; Vernmark
et al., 2010)
, demonstrating the efficacy
of delivering structured, manualized
online CBT counseling for depression
treatment.

Barak & Bloch (2006) found no
significant difference in clients’
perceived session helpfulness for o
nline
compared with that for face
-
to
-
face
services, despite what they refer to as
meaningful differences in these two
modalities. They have also
demonstrated that perceived helpfulness
correlated highly with impact from both
client and therapist perspectiv
es
indicating that deep, smooth
conversations that yield positive
responses and arouse clients’ emotions
are helpful. Their findings have been
confirmed in another study
(Reynolds,
Stiles, & Grohol, 2006)

that found
session impact and alliances were
simila
r in online and face
-
to
-
face
counseling.

Leibert et al. (2006) reported that clients
are reporting satisfaction with online
counseling but less so than in face
-
to
-
face counseling. The authors found that
the more time respondents spent online,
the more like
ly they were to make use
of online counseling. Noted advantages
in using such a service include
convenience, anonymity and privacy. It
can be speculated that some individuals
with, for example, shame based
problems may need to communicate
without the fear

of the listener’s
reactions. In a more recent survey
(Murphy et al., 2009) the authors
reported that satisfaction

scores of face
-
to
-
face and online clients
showed no statistically significant
difference.

Process and outcome data to date are
positive, but

inconclusive and further
research is needed. A recent meta
-
analysis
(Barak et al., 2008)

reported an
overall weighted mean pre
-
post effect
size of
d

= 0.53 for internet
-
based
psychotherapeutic interventions. More
precisely, the effects achieved for
studies (
n

= 27) that represent work
conducted synchronously (
d

= 0.49) and
asynchronously (
d

= 0.44) were not
statistically different, although chat and
e
-
mail modes were statistically superior
to forum, audio, or webcam. The study
provides evidence for the use of online
interventions, concluding that online
interventions are as efficacious or
nearly as efficacious as face
-
to
-
face
ones. However, the meta
-
an
alysis only
included peer
-
reviewed journal papers,
did not discriminate on the basis of
quality, and was based on a wide variety
of studies with mixed methods,
approaches and objectives.


ONLINE COUNSELING


Research Areas


In many cases the contributions b
y
researchers and clinicians to the
ONLINE COUNSELING


701


historical work and the current status of
empirical knowledge have led the way
in different areas of understanding the
psychology of human
-
technology
interaction with respect to online
counseling, paving the way for othe
rs to
build upon. Many pioneers have been
referenced throughout this chapter.
However, in many cases no systematic
line of research is occurring and
therefore efforts have been largely
individual, or in some cases, such as
with the development of ethical c
odes,
organization
-
led.

In terms of research, Professor Azy
Barak, University of Hafia, Israel,
deserves mention. He has pursued
research in this area for many years,
advocating the benefits of advanced
technologies and their role in extending
the possibil
ities for the helping
professions. Currently, he teaches
courses in research issues in counseling,
counseling applications on the internet,
the psychology of the internet and
counseling skills development.


The therapeutic relationship


At the heart of the therapeutic
endeavour is a belief that the systematic
use of a responsive relationship
produces changes in cognition, feelings
and behaviours (Holmes, 1989). A
significant challenge for online
counseling is establishing the possibility
to create equally meaningful
relationships through CMC.

In an early study
(Hufford, Glueckauf,
& Webb, 1999)

that compared the
alliance in video conferencing and face
-
to
-
face counseling for teenagers, clients
reported significantly higher levels of
allian
ce in face
-
to
-
face. Yet, despite the
lack of social signalling, another early
study (Cohen & Kerr, 1998) reported
similar ratings between CMC and face
-
to
-
face counseling regarding clients’
perceptions of therapists’ expertness,
attractiveness, and trustwor
thiness.
Additionally, while clients rated higher
levels of arousal in face
-
to
-
face
encounters, there were no differences
found regarding ratings of depth,
smoothness or positivity between online
and face
-
to
-
face clients.

A study by Cook and Doyle (2002)
found equivalent alliance scores for the
online and face
-
to
-
face conditions.
Qualitatively online clients reported
experiencing strong bonds with their
therapists. However the study did not
include a face
-
to
-
face comparison group
and the sample was small.
Prado and
Meyer (2004) reported that clients and
therapists created solid working
alliances in online counseling. Mallen et
al. (2005) found that face
-
to
-
face
contact was superior to online
communication in establishing a
relationship, yet no significant
d
ifference was found in emotional
understanding. McKenna and Bargh
(2000) found that individuals who were
socially isolated and anxious and who
had difficulties forming relationships
were more likely to form deep and
lasting relationships online than in
per
son.

A review of the literature concluded that
studies concerning the therapeutic
alliance in online counseling were
scarce, yielding mixed results
(Mallen
et al., 2005)
. Subsequent research seems
to increasingly support the feasibility of
developing ther
apeutic relationships
online with modest to high alliance
scores being consistently found
(Hanley, 2009; Leibert, Archer,
Munson, & York, 2006; Reynolds et al.,
2006). Alliance online appears to be
capable of being equivalent to face
-
to
-
face.

A fundamental

question remains as to
whether the same process variables that
are strong predictors of success in face
-
to
-
face interventions play the same
facilitative role in online interventions.
King et al. (2006) found session impact
to be a stronger mediator in onl
ine
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702


counseling than the working alliance. In
a study on the impact of the working
alliance on outcome Knaevelsrud and
Maercker (2006) found that high
alliance scores correlated weakly with
outcome.

While the research to date is largely
positive further re
search is needed to
understand the nature and dynamics of
online therapeutic relationships.
Whether the therapeutic relationship is
or is not a key facilitative element in
online counseling still needs to be
established. However it would seem that
for an i
nteraction to have therapeutic
value the basic principles of providing a
supportive, empathic, empowering
relationship need to be present.


Behavioural characteristics of
online counseling


The many features and cyberbehaviors
characteristic of online counseling bring
with them associated benefits and
challenges. These have appeared in the
online counseling literature from the
early days
(Childress, 1998)

and many
have been addressed adequate
ly for the
ethical and professional practice of
online counseling.

Dr. John Suler, a clinical psychologist at
Rider University, has written
extensively on features and behaviors
that characterize online counseling,
notably disinhibition, self
-
disclosure
an
d the zone for reflection. He is one of
the founders of the ISMHO and, with
his colleague Dr. Michael Fenichel,
moderated the ISMHO clinical case
study group.

Additionally, John M. Grohol, Psy.D is
a pioneer in online mental health,
publishing one of the first commercial
mental health portals in 1995 and
becoming one of the largest mental
health and online health support
communities. He is a recognized expert
on

online behavior and internet
addiction. He was one of the founding
members and the first president of the
ISMHO. In 2001, he created the world's
first mental health
social networking
community

at Psych Centr
al.


Anonymity and disinhibition


In the online environment users are
often apparently anonymous, using a
fictitious username and not disclosing
identifying information. However, this
is becoming less the case in the
professional practice of online
counse
ling as ethical standards are
bringing about change in how clients
are recruited, assessed and identified.
Features of
apparent
anonymity and
geographical distance in online
interactions have been theorized to
facilitate psychological safety,
disinhibition

and increased self
-
disclosure
(Suler, 2000, 2004)
.

The disinhibition effect is believed to be
a key element in reducing social stigma
and anxieties that some experience in
meeting a professional
(Suler, 2004)
.
This powerful distinctive factor is
believed

to have the potential of
reaching individuals who would
otherwise not access traditional face
-
to
-
face therapy. A qualitative analysis of
clients’ experiences of online
counseling found that clients typically
reported experiencing disinhibition,
which help
ed them express themselves
more openly and honestly
(Cook &
Doyle, 2002)
.

While disinhibition is believed to lead
to higher rates of self
-
disclosure and
honesty, it has also been noted that it
could lead to acting out behaviours
(Suler, 2000)
, including i
dentity and
impression management on behalf of
the client. However, Joinson (2001)
examined self
-
disclosure by comparing
dyads interacting face
-
to
-
face and
online and found that instances of
negative self
-
disclosure were rare and
that participants in the C
MC condition
had significantly higher levels of self
-
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703


disclosure. The author argues that the
decrease in external focus and the
process of having to express oneself
through writing may facilitate and
increase self
-
awareness.


Convenience


A frequently repor
ted advantage of
online counseling is that it can be
accessed anywhere at any suitable time,
is believed to reach individuals who
encounter both psychological and
physical barriers to accessing
counseling services
(Mallen et al.,
2005)
. The nature of these

obstacles can
range from limited mobility due to
geographical isolation or physical
disability, to language barriers, fear of
stigma or time availability
(Rochlen,
Zack et al., 2004)
. Several research
studies have highlighted that both
clients and therapi
sts identify factors
associated with convenience as reasons
for choosing online counseling
(Chester
& Glass, 2006; Haberstroh, Duffey,
Evans, Gee, & Trepal, 2007; Young,
2005)
.

Another facet that has been highlighted
is the potential for online counseling
to
increase the accessibility of specialised
expertise that might otherwise be
beyond the reach of clients
(Young,
2005)
. Simpson et al. (2005)
exemplifies this in treating eating
disorders using video conferencing:
clients were geographically isolated
fro
m specialist treatment and clients had
complete control over whether they
were seen by the therapist.


Time delay


In synchronous communication modes
clients and therapists can check, clarify
and understand in the immediacy of the
interaction. However, in asynchronous
communication a time delay is built into
the counseling process. Clients and
therapists can wonder abo
ut and
interpret the unexplained delays in
messages. This can potentially increase
anxieties; leading to what Suler (2004)
calls the “black hole phenomenon”, i.e.
the ambiguity in the no
-
reply can
become a blank screen where easily we
can project our own e
xpectations,
emotions, and anxieties. (Suler, 2004).

However, because each party can attend
and respond to the other’s message in
their own time, without the urgency of
thinking and responding in the
immediacy, a zone for reflection can
develop; a space fo
r both parties to
reflect on what they want to say
(Suler,
2000)
. This can facilitate the processing
of experiences and emotions as well as
promoting self
-
observation, awareness
and reducing impulsivity. Because the
recipient of communication is not
presen
t in real time and awaiting a
response the pressure that can be
experienced in a synchronous context is
reduced.

Time delay is a potential advantage for
the therapists as it can help with better
observation and management of
counter
-
transference reactions
. Several
qualitative studies found that
participants reported feeling less
pressurized and that the relief from this
pressure enabled them to engage in
deeper reflection and expression
(Haberstroh et al., 2007; Hanley, 2009)
.


Loss of cues



One of the main criticisms and
perceived main limitations of online
counseling is that individuals often do
not know much about each other and all
the visual and verbal cues that convey
subtle information about the person and
their affect in face
-
to
-
face i
nteractions
are missing
(Suler, 2000)
. However,
Suler (2004) argues that this invisibility
can lead to
disinhibition

by removing
any concerns about the other person’s
reaction to one’s narrative and presence.
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704


Practitioners have speculated that this
invisib
ility and the consequent feelings
of psychological safety and
disinhibition have the potential of
reaching clients who are particularly
sensitive to the physical presence of
another person and to cues indicating
disapproval or judgment
(Fenichel et
al., 20
02; Leibert et al., 2006)
.

A qualitative study of clients


and
therapists


experiences of online
synchronous counseling found that the
lack of visual feedback led to a
disinnhibition of self
-
expression and
also facilitated disclosure of more
embarrassing
subjects
(Haberstroh et
al., 2007)
. Leibert et al. (2006)
concluded that the disinhibition effect
reported by participants seemed to be
stronger and off
-
set the impact of the
lack of cues.

Another derivate of the absence of cues
and invisibility is an inc
reased sense of
control by clients over what they
disclose
(Cohen & Kerr, 1998; King et
al., 2006; Simpson et al., 2005)
. For
instance, young clients using online
counseling reported that they liked
having the choice of whether to disclose
that they were c
rying to their counsellor
(Hanley, 2009)
.

While t
ext
-
based communication may
reduce the possibility of
misunderstandings

by allowing time to
formulate the question and the answer,
some
clients may find not having the
reassurance of non
-
verbal visual and
auditory cues distressing
(Alleman,
2002)
.

Presence is the feeling of being in
someone’s presence without sharing
immediate physical space
(Fink, 1999)
.
Riva et al. (2011) considers prese
nce as
an intuitive perception of oneself in
whatever environment one may be in.
Consequently our ability to feel present
in a virtual reality system does not
fundamentally differ from the ability to
feel present in our surrounding physical
environment.
It

is a powerful concept in
terms of its potential implications for
the delivery of online counseling, and
especially the development of a
therapeutic relationship online.


Writing behavior and expression


A distinctive feature of online
counseling is that t
he bulk of
communication is occurring in writing.
The benefits of writing, impacting
positively on psychological and
physical health, have been widely
documented and have been employed in
therapeutic practice in different forms
well before the advent of on
line
counselling
(Pennebaker, Kiecolt
-
Glaser, & Glaser, 1988)
.
The process of
writing can, for instance, be cathartic in
translating emotional experience into
words and this has also been found to be
the case in the use of e
-
mail
(Sheese,
Brown, &
Graziano, 2004)
.

Wright and Chung (2001) point out that
in writing the writer is in control of the
content as well as the pace and depth of
the written material, which can foster a
sense of psychological safety; also the
permanency of the written record c
an
facilitate the benefits deriving from the
process of writing to continue in time.

Cook and Doyle (2002) found that
client participants appreciated the
opportunity to re
-
read the responses
received from the therapist, feeling this
allowed them more time

to process the
content than verbal communication
would have. Beattie et al. (2009)
reported that online clients were
particularly impacted by seeing their
thoughts and emotions in writing, which
also facilitated further self
-
reflection.

Suler (2000) note
s how the use of text,
similar to narrative approaches to
therapy and journal writing, can also
facilitate the therapeutic construction of
a personal narrative. He also argues that
writing may be a preferred or more
suitable modality of self
-
expression for

some individuals who are less
ONLINE COUNSELING


705


comfortable in face
-
to
-
face interactions,
while being unsuitable for individuals
with limited writing skills.


Ethics


Many of the debating ethical issues such
as confidentiality, validity of the data
delivered via computer
networks,
inadequacy of counselor interventions,
misuse of computer applications, lack of
awareness of location
-
specific factors,
digital divide, privacy concerns,
credentialing, and relationship
development issues were identified
early in the literature
(
Sampson,
Kolodinsky, & Greeno, 1997)
. Another
early paper raised many of the potential
legal issues regarding duty of care
arising from the ethical concerns of
online counseling
(Shapiro &
Schulman, 1996)
.

Apprehension regarding anonymity,
distance, and t
he lack of cues in online
counseling raised serious concerns
regarding issues of informed consent,
contracting, confidentiality of records,
privacy, diagnosis, and duty of care
(Bloom, 1998; Childress, 1998; Shapiro
& Schulman, 1996)
. How was it going
to b
e possible for professionals to
practice ethically online regarding such
issues? Skinner and Zack
(2004)

maintain that the many issues that are
posed online are no more
insurmountable than those faced in
traditional practices.

Early

attempts to address the ethical
concerns were the delivery of a general
statement by the American Psychology
Association Ethics Board in 1995 that
described the ethics code applicable to
therapists using telephone,
teleconferencing, and internet services
(Shapiro & Schulman, 1996)
. Another
was the development of standards for
online practice by the National Board
for Certified Counselors (NBCC)
(Bloom, 1998)
.

A further response was the
establishment in 1997 of the ISMHO,
formed with a clear mission to pro
mote
the understanding, use and development
of online communication in mental
health. They too have produced guiding
principles for the ethical practice of
online counseling (ISMHO, 2000).
Other professional accrediting bodies
have followed suit and produc
ed
guidelines for online clinical practice
that are regularly revised as the
evidence
-
base from practice and
research grows (Anthony & Jamieson,
2005; Anthony & Goss, 2009). These
ethical frameworks have been
significant steps in addressing the
important e
thical issues of online
practice.

However, several studies have surveyed
online counseling websites
(Chester &
Glass, 2006; Heinlen, Welfel,
Richmond, & Rak, 2003; Shaw &
Shaw, 2006)

and reported that
credentials varied widely among
practitioners, only 32
% of practitioners
requested that clients sign an informed
consent form, that 42% of participants
did not use any encryption to protect
confidentiality, and they reported very
low compliance with established ethical
standards for online counseling.
However
, a high number of
practitioners provided information
about the limitations of online
counseling.

Dr. Kate Anthony is a leading expert on
the use of technology in therapy. She
has co
-
authored the British Association
for Counseling and Psychotherapy
(BACP)

guidelines for online work
(including supervision) through its three
editions. She is a fellow of BACP, past
-
president and fellow of
ISMHO

and a
co
-
founder of the
O
nline Therapy
Institute

(OTI). She was awarded a
DPsych via public works for her
doctorate: Developing counseling and
psychotherapy in the age of technology
and the internet. Kate Anthony has also
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been involved in training mental health
professionals to wo
rk online since 2002.


Attitudes and experience




Mallen et al. (2005) reported that clients
seem more accepting of online
counseling than are professionals.
Hanley (2006) found that the concerns
expressed by practitioners in developing
an online counseling service for young
people mainly echoed those tha
t would
be considered when establishing a face
-
to
-
face practice, for instance,
contracting, confidentiality, and
informed consent.

A Norwegian study found that the
majority of psychologists held a neutral
attitude and only 3% viewed the use of
the online
medium for therapeutic
interventions as unacceptable
(Wangberg, Gammon, & Spitznogle,
2007)
. The study highlighted that those
who frequently use the internet or had
experience using e
-
mail in clinical
practice were more favourable towards
online counseling
. Chester and Glass
(2006) in a survey of therapists’
attitudes reported that 57% of
respondents believed that online
counseling is as effective as face
-
to
-
face
counseling while 42% believed it to be
less effective.

Therapists have reported concerns
incl
uding technological barriers, the
challenges of counseling without verbal
and visual cues, clinical concerns
regarding the suitability of the medium
for certain clients, and the difficulty
with accurately assessing the clients’
state
(Haberstroh, Parr, Bra
dley,
Morgan
-
Fleming, & Gee, 2008)
.
Therapists have also reported
advantages: lower emotional intensity,
more time to think, the power balance
being more equal, and clients being
more focused, expressive and less
resistant
(Bambling, King, Reid, &
Wegner,
2008)
. In relation to records
being verbatim and permanent, while
potentially useful in supervisory
consultations, it also increases the level
of accountability for therapists
(Murphy
& Mitchell, 1998)
.

Clients appear to have embraced online
counseling wit
h more ease, although an
early study that assessed attitudes
towards online and face
-
to
-
face
counseling noted that respondents had
significantly more positive attitudes
towards face
-
to
-
face than online
counseling
(Rochlen, Beretvas, & Zack,
2004)
. Unlike t
raditional gender divide
in attitudes they found no differences
between men’s and women’s attitudes
towards online counseling, with an
overall neutral to slightly positive
attitude.

Young (2005) reported that the main
reasons clients seek online counseling

were anonymity, convenience,
counsellor credentials, access, and cost.
Conversely, the study outlines some
concerns highlighted by clients such as
lack of privacy associated with the use
of technology including the security of
the technology being used, a
nd being
caught. Several qualitative studies of
clients’ experiences of online
counseling found that most participants
believed it was effective and
advantageous in enhancing freedom of
expression through writing, reducing
costs, and convenient
(Bambling e
t al.,
2008; Beattie et al., 2009; Cook &
Doyle, 2002)
.

In their study looking at clients’ and
therapists’ experiences Haberstroh et al.
(2007) found mixed results with some
clients reporting having experienced a
supportive and helpful relationship with
t
heir therapist while others did not.
Attitudes and experiences toward online
counseling seem to be impacted by the
level of comfort and use of internet
technology
(Leibert et al., 2006;
Wangberg et al., 2007)
. Skinner and
Latchford (2006) found that member
s of
an online support group expressed
significantly more positive views about
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707


the idea of engaging in online
counseling compared to clients
attending face
-
to
-
face therapy.


Suitability


It has been noted that the use of the
medium, as is true for other t
ypes of
communication, may not suit everybody
and that individual factors may be
important in determining the success of
online counseling
(Fenichel et al.,
2002)
. Factors that constitute suitability
for online counseling, for clients and
therapists, are a
bility for written
expression and reading, as well
computer
-
literacy
(Fenichel et al., 2002;
Rochlen, Zack et al., 2004)
. Therapists
should also have an openness and belief
in the therapeutic benefits of online
counseling
(Fenichel et al., 2002)
.

The deb
ate continues regarding the
suitability of individuals and the types
of presenting issues that are appropriate
for online counseling. Some
practitioners advocate for this to be
restricted to less serious issues
(Haberstroh et al., 2008), some note
specific

advantages for specific
populations and presentations
(Simpson
et al., 2005)
, while others advocate that
the medium is adequate to address most
issues at any level of severity
(Fenichel
et al., 2002)
.

Very limited empirical research exists
about the issues presented by online
clients. Most services have dealt with a
broad range of presenting issues, few
have targeted specific issues
(Abroms,
Gill, Windsor, & Simons
-
Morton, 2009;
Alemi et al., 2007)
. App
arently there
exists no difference between the
presenting issues in online compared to
face
-
to
-
face counseling
(Leibert et al.,
2006; Richards, 2009)
.

Barack et al. (2008) reported that while
all age
-
groups showed benefits in online
interventions individu
als in the 19
-
39
age range appeared to benefit the most.


Training


Alongside practitioner guidebooks (see
additional readings)
there are now
training programs that offer certification
in online counseling.
Training
programmes were developed to raise the
a
wareness of ethical issues and promote
the development of specialized skills for
the effective provision of online
counseling
(Anthony & Goss, 2003)
.
Typically, participants are brought
through a variety of theoretical and
experiential modules, learning ab
out the
ethics of practice, establishing a
relationship online, communicating
effectively using CMC, and establishing
an online practice.

Dan Mitchell and Lawrence Murphy,
Canadian counsellors who co
-
founded
Worldwide Therapy Online Inc., have
since 1994 b
een pioneers in the field of
online counseling training and have
authored several professional
publications on the subject. They
developed and instruct online
counseling certification programs
delivered in collaboration with the
University of Toronto.


FUTURE RESEARCH


The research to date is largely
supportive of online cousneling, yet
more

is needed to further explore and
form an empirical knowledge
-
base
regarding the processes and features
characterizing online counseling as well
as its effectiveness

and appropriateness.
These include understand the nature and
dynamics of online therapeutic
relationships,
the type of client or
presenting issues most suitable for
online counseling, and whether it is as
effective as face
-
to
-
face counseling for
client(s)
. Professional training also
needs to evolve as technology develops.
A pertinent example is the use of virtual
worlds for online counseling, still
requiring empirical investigation.
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708


Further exploration the features and
cyberbehaviors associated with online

counseling, including apparent
anonymity and distance, disinhibition,
identity and impression management,
writing and emotional expression, and
presence, are needed to strengthen
empirical knowledge and inform
clinical practice.





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REFERENCES

Abroms, L. C., Gill, J., Windsor, R., & Simons
-
Morton, B. (2009). A process evaluation
of e
-
mail counseling for smoking cessation in college students: Feasibility,
acceptability and cost.
Journal of
Smoking Cessation, 4
(1), 26
-
33. doi:
0.1375/jsc.4.1.2

Alemi, F., Haack, M. R., Nemes, S., Aughburns, R., Sinkule, J., & Neuhauser, D.
(2007). Therapeutic emails.
Substance Abuse Treatment, Prevention, and Policy,
2
. doi: 10.1186/1747
-
597x
-
2
-
7

Alleman, J. R. (2002). Online counseling: The internet and mental health treatment.
Psychotherapy: Theory, Research, Practice, Training, 39
(2), 199
-
209. doi:
10.1037/0033
-
3204.39.2.199

Anthony, K., & Goss, S. (2003). Introduction to online counseling and p
sychotherapy
(pp. 8). England: British Association of Counseling and Psychotherapy (BACP).

Anthony, K., & Jamieson, A. (2005).
Guidelines for online counselling and
psychotherapy, 2nd edition, including guidelines for online supervision
. Rugby:
BACP Publis
hing.

Anthony, K., & Goss, S. (2009).
Guidelines for Online Counseling and Psychotherapy
3rd Edition, Including Guidelines for Online Supervision
. Rugby: BACP.

Bambling, M., King, R., Reid, W., & Wegner, K. (2008). Online counseling: The
experience of coun
sellors providing synchronous single
-
session counseling to
young people.
Counseling & Psychotherapy Research, 8
(2), 110
-
116. doi:
10.1080/14733140802055011

Barak, A., Klein, B., & Proudfoot, J. (2009). Defining Internet
-
Supported Therapeutic
Interventions.

Annals of Behavioral Medicine
, 38(1), 4
-
17. doi: 10.1007/s12160
-
009
-
9130
-
7

ONLINE COUNSELING


700


Barak, A., Hen, L., Boniel
-
Nissim, M., & Shapira, N. (2008). A comprehensive review
and a meta
-
analysis of the effectiveness of internet
-
based psychotherapeutic
interventions.
Jour
nal of Technology in Human Services, 26
(2), 109
-

160. doi:
10.1080/15228830802094429

Barak, A., & Bloch, N. (2006). Factors related to perceived helpfulness in supporting
highly distressed individuals through an online support chat.
CyberPsychology
& Beha
vior, 9
, 60
-
68. doi
:10.1089/cpb.2006.9.60

Beattie, A., Shaw, A., Kaur, S., & Kessler, D. (2009). Primary
-
care patients'
expectations and experiences of online cognitive behavioural therapy for
depression: A qualitative study.
Health Expectations, 12
(1), 45
-
59. doi:
10.1111/j.1369
-
7625.2008.00531.x

Bloom, J. W. (1998). The ethical practice of WebCounseling.
British Journal of
Guidance & Counseling, 26
(1), 53
-
59. doi: 10.1080/03069889800760061

Castelnuovo, G., Gaggioli, A., Mantovani, F. & Riva, G. (2003).
New and old tools in
psychotherapy: The use of technology for the integration of traditional clinical
treatments.
Psychotherapy: Theory, Research, Practice, Training
,
40(1
-
2),

33

44.

Cohen, G., & Kerr, B. (1998). Computer
-
mediated counseling: An empirical
study of a
new mental health treatment.
Computers in Human Services, 15
, 13
-
26.

Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to
face
-
to
-
face therapy: Preliminary results.
CyberPsychology & Behavior, 5
(2),
95
-
105. doi: 10
.1089/109493102753770480

Chester, A., & Glass, C. A. (2006). Online counseling: A descriptive analysis of therapy
services on the internet.
British Journal of Guidance & Counseling, 34
(2), 145
-
160. doi: 10.1080/03069880600583170

ONLINE COUNSELING


701


Childress, C. (1998). Poten
tial risks and benefits of online psychotherapeutic
interventions. Retrieved 24 June, 2011, from
http://www.ismho.org/issues/9801.htm

Day, S. X., &

Schneider, P. L. (2002). Psychotherapy using distance technology: A
comparison of face
-
to
-
face, video and audio treatment.
Journal of Counseling
Psychology
, 49(4), 499
-
503.
doi: 10.1037/0022
-
0167.49.4.499

Efstathiou, G. (2009). Students' psychological web

consulting: function and outcome
evaluation.
British Journal of Guidance & Counseling, 37
(3), 243
-
255. doi:
10.1080/03069880902956983

Fenichel, M., Suler, J., Barak, A., Zelvin, E., Jones, G., Munro, K., . . . Walker
-
Schmucker, W. (2002). Myths and realit
ies of online clinical work.
CyberPsychology & Behavior, 5
(5), 481
-
497. doi:
10.1089/109493102761022904

Grohol, J.M. (1999).
Best practices in eTherapy: definition & scope of e
-
therapy
.
Retrieved 24 June, 2011, from
http://psychcentral.com/best/best3.htm

Grohol, J.M. (2001).
Best practices of eTherapy: clarifying the definition of e
-
Therapy
.
Retrieved 24 June, 2011, from
http://psychcentral.com/best/best5.htm


Fink, J. (1999).
How to use Computers and Cyberspace in the Clinical Practice of
Psychotherapy
. New Jersey: Jason Aronson Inc.

Glueckauf, R. L., Fritz, S. P., Ecklund
-
Johnson, E. P., Liss, H. J., Dages, P., & Carney,

P. (2002). Video conferencing
-
based family counseling for rural teenagers with
epilepsy: Phase 1 findings.
Rehabilitation Psychology, 47
, 49
-
72.

Haberstroh, S., Duffey, T., Evans, M., Gee, R., & Trepal, H. (2007). The experience of
online counseling.
Jour
nal of Mental Health Counseling, 29
(3), 269
-
282.

ONLINE COUNSELING


702


Haberstroh, S., Parr, G., Bradley, L., Morgan
-
Fleming, B., & Gee, R. (2008).
Facilitating online counseling: Perspectives from counselors in training.
Journal
of Counseling & Development, 86
(4), 460
-
470.

H
anley, T. (2009). The working alliance in online therapy with young people:
Preliminary findings.
British Journal of Guidance & Counseling, 37
(3), 257
-
269. doi: 10.1080/03069880902956991

Heinlen, K. T., Welfel, E. R., Richmond, E. N., & Rak, C. F. (2003).
The scope of
WebCounseling: A survey of services and compliance with NBCC Standards for
the ethical practice of WebCounseling.
Journal of Counseling & Development,
81
(1), 61
-
69.

Holmes, J. & Lisndley, R. (1989).
The values of psychotherapy
. Oxford: Oxford

University Press.

Hufford, B. J., Glueckauf, R. L., & Webb, P. M. (1999). Home
-
based, interactive video
conferencing for adolescents with epilepsy and their families.
Rehabilitation
Psychology, 44
(2), 176
-
193.

ISMHO. (2000). Suggested Principles for the
Online Provision of Mental Health
Services. Retrieved 17 Aug, 2011, from https://www.ismho.org/suggestions.asp


Joinson, A. N. (2001). Self
-
disclosure in computer
-
mediated communication: The role

of self
-
awareness and visual anonymity.
European Journal of

Social
Psychology, 31
(2), 177
-
192. doi: 10.1002/ejsp.36

Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., . . . Peters, T. J. (2009).
Therapist
-
delivered internet psychotherapy for depression in primary care: A
randomised controlled trial.

The Lancet, 374
(9690), 628
-

634. doi:
10.1016/S0140
-
6736(09)61257
-
5

ONLINE COUNSELING


703


King, R., Bambling, M., Lloyd, C., Gomurra, R., Smith, S., Reid, W., & Wegner, K.
(2006). Online counseling: The motives and experiences of young people who
choose the internet instead o
f face
-
to
-
face or telephone counseling.
Counseling
& Psychotherapy Research, 6
(3), 169
-
174. doi: 10.1080/14733140600848179

Knaevelsrud, C., & Maercker, A. (2006). Does the quality of the working alliance
predict treatment outcome in online psychotherapy fo
r traumatized patients.
Journal of Medical Internet Research, 8
(4).
doi:10.2196/jmir.8.4.e31

Leibert, T., Archer, J., Munson, J., & York, G. (2006). An exploratory study of client
perceptions of internet counseling and the therapeutic alliance.
Journal of
Mental Health Counseling, 28
(1), 69
-
83.

McKenna, K. Y. A., & Bargh, J. A. (2000). Plan 9 from cyberspace: The implications of
the internet for personality and social psychology.
Personality and Social
Psychology Review
, 4(1), 57
-
75. doi: 10.1207/s15327957
pspr0401_6

Mallen, M. J., Vogel, D. L., Rochlen, A. B., & Day, S. X. (2005). Online counseling:
Reviewing the literature from a counseling psychology framework.
The
Counseling Psychologist, 33
, 819
-
871.

Michaud, P., & Colom, P. (2003). Implementation and
evaluation of an internet health
site for adolescents in Switzerland.
The Journal of Adolescent Health, 33
(4),
287
-
290.

Murphy, L. J. & Mitchell, D. L. (1998). When writing helps to heal: E
-
mail as therapy.
British Journal of Guidance & Counseling, 26
(1),

21
-
32. doi:
10.1080/03069889800760031

Murphy, L. J., Parnass, P., Mitchell, D. L., Hallett, R., Cayley, P., & Seagram, S.
(2009). Client satisfaction and outcome comparisons of online and face
-
to
-
face
ONLINE COUNSELING


704


counseling methods.
British Journal of Social Work
, bc
p041. doi:
10.1093/bjsw/bcp041

Nagel, D., & Anthony, K. (2011) Avatar Therapy.
The Capa Quarterly
, 3, 6
-
9.

Newman, M. G., Szkodny, L. E., Llera, S. J., &

Przeworski, A. (2011). A review of
technology
-
assisted self
-
help and minimal contact therapies for anxiety and
depression: Is human contact necessary for therapeutic efficacy?
Clinical
Psychology Review, 31
(1), 89
-
103. doi: 10.1016/j.cpr.2010.09.008

Penne
baker, J. W., Kiecolt
-
Glaser, J. K., & Glaser, R. (1988). Disclosure of traumas
and immune function: Health implications for psychotherapy.
Journal of
Consulting and Clinical Psychology, 56
(2), 239
-
245.

Prado, S., & Meyer, S. B. (2004).
Evaluation of the
working alliance of an
asynchronous therapy via the internet.

Masters, University of Sao Paulo, Sao
Paulo.

Reynolds, D. A. J., Jr., Stiles, W. B., & Grohol, J. M. (2006). An investigation of
session impact and alliance in internet based psychotherapy: P
reliminary results.
Counseling & Psychotherapy Research, 6
(3), 164
-
168. doi:
10.1080/14733140600853617

Richards, D. (2009). Features and benefits of online counseling: Trinity College online
mental health community.
British Journal of Guidance & Counseling
, 37
(3),
231
-

242. doi: 10.1080/03069880902956975

Riva, G., Waterworth, J. A., Waterworth, E. L., & Mantovani, F. (2011). From intention
to action: the role of Presence.
New Ideas in Psychology 29
(1), 24
-
37.
doi:10.1016/j.newideapsych.2009.11.002

ONLINE COUNSELING


705


Rochlen, A. B., Beretvas, S. N., & Zack, J. S. (2004). The online and face
-
to
-
face
Counseling Attitudes Scales: A validation study.
Measurement and Evaluation
in Counseling and Development, 37
(2), 95
-
111.

Rochlen, A. B., Zack, J. S., & Speyer, C. (2004).
Online therapy: Review of relevant
definitions, debates, and current empirical support.
Journal of Clinical
Psychology, 60
(3), 269
-
283. doi: 10.1002/jclp.10263

Sampson, J. P., Kolodinsky, R. W., & Greeno, B. P. (1997). Counseling and the
information highwa
y: Future possibilities and potential problems.
Journal of
Counseling & Development, 75
(3), 203
-
212.

Shapiro, D. E., & Schulman, C. E. (1996). Ethic and legal issues in e
-
mail therapy.
Ethics & Behavior, 6
(2), 107
-
124. doi: 10.1207/s15327019eb0602_3

Shaw,

H. E., & Shaw, S. F. (2006). Critical ethical issues in online counseling:
Assessing current practices with an ethical intent checklist.
Journal of
Counseling & Development, 84
(1), 41
-
53.

Sheese, B. E., Brown, E. L., & Graziano, W. G. (2004). Emotional e
xpression in
cyberspace: Searching for moderators of the pennebaker disclosure effect via e
-
mail.
Health Psychology, 23
(5), 457
-
464. doi: 10.1037/0278
-
6133.23.5.457

Simpson, S., Bell, L., Knox, J., & Mitchell, D. (2005). Therapy via video conferencing:
A r
oute to client empowerment?
Clinical Psychology & Psychotherapy, 12
(2),
156
-
165. doi: 10.1002/cpp.436

Skinner, A., & Zack, J. S. (2004). Counseling and the internet.
American Behavioural
Scientist, 48
(4), 434
-
446.

Skinner, A., & Latchford, G. (2006). Atti
tudes to counseling via the internet: A
comparison between in
-
person counseling clients and internet support group
ONLINE COUNSELING


706


users.
Counseling & Psychotherapy Research, 6
(3), 158
-
163. doi:
10.1080/14733140600853641

Suler, J. (2000). Psychotherapy in cyberspace: A 5
-
dimensional model of online and
computer
-
mediated psychotherapy.
CyberPsychology & Behavior, 3
(2), 151
-
159. doi: 10.1089/109493100315996

Suler, J. (2004). The online disinhibition effect.
CyberPsychology & Behavior, 7
(3),
321
-
326. doi:
10.1089/1094931041291295

Suler, J. (2004).
The psychology of text relationships
. In R. Kraus, J. Zack & G. Striker,
Online Counseling: a manual for mental health professionals. London: Elsevier
Academic Press.

Vernmark, K., Lenndin, J., Bjärehed, J., Carls
son, M., Karlsson, J., Öberg, J., . . .
Andersson, G. (2010). Internet administered guided self
-
help versus
individualized e
-
mail therapy: A randomized trial of two versions of CBT for
major depression.
Behaviour Research and Therapy, 48
(5), 368
-
376. doi:
10.1016/j.brat.2010.01.005

Wangberg, S. C., Gammon, D., & Spitznogle, K. (2007). In the eyes of the beholder:
Exploring psychologists' attitudes towards and use of e
-
therapy in Norway.
CyberPsychology & Behavior, 10
(3), 418
-
423. doi: 10.1089/cpb.2006.9937

Wright, J., & Chung, M. C. (2001). Mastery or mystery? Therapeutic writing: A review
of the literature.
British Journal of Guidance & Counseling, 29
(3), 277
-
291. doi:
10.1080/03069880120073003

Young, K. S. (2005). An empirical examination of client attitud
es towards online
counseling.
CyberPsychology & Behavior, 8
(2), 172
-
177. doi:
10.1089/cpb.2005.8.172



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ADDITIONAL READINGS

Anthony, K., Merz
-
Nagel, D. & Goss, S. (2010).
The Use of Technology in Mental
Health: Applications, Ethics and Practice
. US: Charles

Thomas Publishers Ltd.


Goss, S., & Anthony, K. (Eds.). (2003).
Technology in Counseling and Psychotherapy
.
UK: Palgrave Macmillan.

Grohol, J. D. (2003).
The Insider's Guide to Mental Health Resources Online
. Guilford
Publications, Inc.

Jones, J. & Stokes
, A. (2009)
Online Counseling: A Handbook for Practitioners
. UK:
Palgrave Macmillan Ltd.

Kraus, R., Stricker, G. & Zack, J. (2010).

Online counseling: A handbook for mental
health professionals

(2 ed.). San Diego, CA: Elsevier

Maheu, M., Pulier
, M., Wilhelm, F., McMenamin, J. (2004).
The
mental

health

professional

and the
new

technologies: A handbook for practice today.

NJ:
Lawrence Erlbaum Associates