The eCounseling Controversy: Advantages and Disadvantages of Telephone and Internet Therapy
Raul is a Hispanic American looking for a counselor who speaks Spanish, and who understands first-hand his cultural perspectives. There’s no one like this within 50 miles.
Dave can never seem to make his appointments. Because of no-shows, he’s been “blackballed” from two dentists and one counselor already.
After an hour, Judy feels she’s just beginning to get to the heart of what she needs to say—then the session ends.
The last counselor Jamie saw made a pass at her. She vows never to put herself into that situation again.
Ken has always felt that he doesn’t articulate himself well verbally. However, he expresses himself quite well in writing.
Jordan works 9 to 5, Monday through Friday, the same hours the counseling center is open. “People in therapy must not have jobs,” she thinks to herself.
Brian is so ashamed he could never look a counselor in the eye.
John lives in a small town. Not only does he not want his neighbors to know he’s been having panic attacks, the only counselor is his daughter in-law.
Sayward is a Licensed Professional Counselor with medical conditions that make her unable to leave home. She wishes there was a way she could still use her 20-plus years of clinical experience.
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These persons come from different walks of life. They have different stories. They struggle with dissimilar circumstances. But they have one thing in common—they all could be excellent candidates for eCounseling.
Did you know that only 10% of depressed people who are referred by a physician to seek mental health services ever receive those services? Why is this? Is it because they do not want to get well, or are there other factors? As you might guess, the reasons are many; and include the problem that acquiring counseling is too difficult. Consider this, a man suffering from depression, to receive counseling must:
1) Overcome his apprehension, embarrassment and fear of seeking counseling 2) Come to terms that people in his community might find out he is in therapy 3) Research and locate reputable local counseling services 4) Make contact with a service (usually by phone) to schedule a session 5) Accept, if insurance is to be used, that he will be diagnosed with a psychological disorder that will go in his health record 6) Maintain motivation and courage while waiting for a scheduled session—the wait is often weeks or longer 7) Execute his intentions of arriving at the counseling appointment (which may necessitate taking time off work).
For a person battling even the most common life-issues, this is quite a series of tasks! And what is more, we—as counselors—cannot do much to make it easier. We often have long waiting lists for new clients, business hours that conflict with client work schedules; we allow clients to suffer social stigma, require them to travel to an unfamiliar place, and to arrive promptly and presentably; all while battling depression, anxiety, agoraphobia, grief, psychosis, or perhaps the greatest personal crisis of their life.
And all the while we wonder, “why is the compliance rate only 10%?”
In response to these tasks that reduce compliance so remarkably, several thousand counselors across the country are taking on the challenge of providing eCounseling. They are using distance communication technologies like telephone, email, online text chat, and even videoconference (see “eCounseling” column in 2007 issue of CCT). To these persons, eCounseling is more than a back-up service for clients who just “can’t make it in” for therapy (see table 1). Practitioners and researchers contend that, in numerous ways, eCounseling can be superior to in-person counseling. These proposed advantages include a series of client-related factors presented below.
Proposed Advantages
Safety and Assertiveness eCounseling may increase clients’ sense of safety, for they are able to receive help from within their home environment. This may help clients express themselves more fully. For example, a study investigating Thai women in a co-ed online discussion found that females who took a passive role in face-to-face (FTF) interactions spoke more assertively and frequently online.
Anonymity While some counseling ethics codes regard client identification as necessary, eCounseling may still benefit from anonymity. For example, although a client may be required to provide their name and location, the Internet is a phenomenon where persons “communicate without the distractions of race, gender, age, size, or physical deformity or impairment.” One of the first online counseling services, called “Dear Uncle Ezra”, was developed in 1986 by Cornell University. This service allows queries from anonymous students, and a counselor responds via a public internet post. After 21 years this program is still active and users confirm that if it were not for the anonymous format, their problem issues would never have been revealed.
Social Stigma eCounseling assures clients they will not encounter their counselor in public , nor will they risk meeting persons from the community in the counselor’s waiting room. Therefore, eCounseling may be effective in eliminating the social stigma of receiving therapy. One study investigating the use of phone counseling services by Arab Israeli callers found the stigma-free medium “may be a culturally appropriate modality of providing helping services to people who conventionally underutilize other forms of professional mental health intervention.” With similar ideas, the University of Wisconsin’s counseling center allows therapists to be contacted by email, and George Mason University provides counseling by videoconference.
Selection eCounseling may provide clients a greater selection of therapists to choose from. This is especially beneficial for persons looking for a counselor with specific experience, or with particular language, religious or ethnic understandings. Similarily, online support groups and forums dedicated to a variety of emotional problems have been present since the 1980’s, and they have allowed persons to reach others dealing similar issues from across the world.
Accessibility eCounseling is advantageous to individuals residing in areas where counseling services are not available and with clients who are unable to leave home. Also, while in-person counseling may be incompatible with a client’s work schedule, eCounseling possesses potential for 24 hour service availability—this is apparent with some crisis and eCounseling services currently available 24 hours-a-day. Even if counselors are not online or at a phone at all hours, counseling by email creates the perception of a counselor’s perpetual availability. A client can communicate anytime, instead of waiting for a weekly or bi-weekly session. And since sessions do not have a defined beginning or end, a more intense psychological holding environment may be present between counselor-client exchanges.
Affordability eCounseling may be more economical than in-person counseling due to lower overhead costs of counselors who do not need to rent commercial space, and the elimination of client and counselor commuting expenses. Concerning the value of time, the hours invested in counseling may be less with eCounseling due to elimination of travel, lack of a waiting room, and the goal-directed dialog that often ensues with distance communication. Regarding the latter, studies show that when communicating through phone and internet, “small talk” is greatly lessened and individuals address important issues faster.
Proposed Disadvantages
In contrast, opponents of eCounseling present these issues of concern—whether eCounseling is ethical and legal, clinically effective, and financially viable.
Ethical and Legal Concerns Similar to FTF provision, there are numerous ethical and legal issues in eCounseling. Areas of particular concern include confidentiality, dealing with suicidal or dangerous clients, crisis response, and counseling clients across state lines. While the latter is an issue most state boards have no formal position or legal precedent, a number of articles have been published concerning the ethical issues of eCounseling, and they are commonly found to be challenging—but not impossible to resolve (a detailed investigation is outside the scope of this article, but will be tackled in a later article with George Ohlschlager; see endnotes).
Rapport Traditional views contend online communication (text-based) is an inferior modality for developing rapport, due to the inability to read body language and hear emotional cues. However, other empirical studies have found eCounseling technologies to be effective rapport building mediums. Today, the debate of how well rapport builds through distance communication continues.
Clinical Efficacy According to ethical standards of the ACA, NBCC, and others, counselors are ethically obligated to provide viable treatment. With eCounseling, while some studies contend efficacy to be inferior to in-person sessions, others have found client improvement with various online and telephone modalities to be equal, and in some cases greater, than in-person services (see endnotes for a list of studies).
Financial Viability Financial issues include the cost of beginning and maintaining a practice; receiving training, marketing, acquiring clients, and receiving payment. Currently, literature does not show clearly whether eCounseling is advantageous or disadvantageous to counselor financial viability.
Text-based eCounseling: The Plot Thickens
The Clinical Social Work Federation states in reference to text-based counseling, “… psychotherapy services cannot be delivered online [specifically via text] because of the inherent nature of the service and, therefore, the federation is opposed to the practice of Internet-based treatment.” However, others involved in the research and practice of online counseling disagree. Proprietors of text-based counseling identify numerous intrinsic advantages to the modality—in addition to those of eCounseling in general. These proposed advantages are described below.
Attention and Reflection Text based interactions (especially those with a time delay) allow both client and counselor to pay close attention to their communication exchanges, and reflect on their own thoughts and feelings, while still in dialogue.
Confession and Framing A client’s need to confess is automatically framed through the process of writing. For example, journaling is sometimes assigned as homework to persons participating in in-person counseling, partly because of its framing and cathartic effects.
Objectivity and Externalization Writing often invokes one to reread and review what was written, a process that promotes increased objectivity and externalization of a problem on the part of the client.
Associations and Insight New associations, insights, and the recovery of old memories are common benefits of the process of writing out one’s story. Further, it has been said that while with in-person sessions a client may speak for an hour and not reach the heart of a matter, with email eCounseling a client can communicate more in one sentence written after an hour of reflection.
Accountability Text-based interactions allow participants to comment on and directly quote pertinent excerpts of previous exchanges. This heightens the accountability of both client and counselor to their statements.
Ownership and Control Clients might communicate in a less restricted manner by text, for they are less affected by positive or negative leads of a therapist. Clients also possess heightened ownership of the counseling process for they set the pace and tone by controlling both the frequency and content of disclosures.
Maximum Anonymity While all eCounseling methods increase client anonymity, text-based counseling offers more anonymity that even telephone counseling, for clients need not even share the timbre of their voice with a counselor.
Testament of Treatment Progress Discussions are easily saved or printed with text counseling, allowing clients to reread therapeutic guidance years after the termination of therapy. This may strengthen old resolutions, and be a testament of the client’s treatment progress.
The Debate Continues
The aim of this article was not to advocate for, or oppose, eCounseling practices; it was simply to introduce the proposed advantages and disadvantages. Though it is difficult for me to hide some of my bias, I will denounce neither the pessimism nor the over-enthusiasm that exists in the field (though I may want to). To do this would make me a politician either for or against—another voice of opinion, not of legitimate conclusion. In order for authoritative assertions to be made, there are many meaningful studies that remain to be conducted on the various counseling factors, the proposed advantages and disadvantages mentioned. For now the debate continues. However, if good research, honest appraisals, legitimate concerns and open attitudes continue in the manner they have for the last several years, eCounseling may soon stand as an accepted and invaluable tool to bring help and healing to persons with a spectrum of needs, in a variety of settings.
Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is an Adjunct Graduate Professor for the Center for Counseling and Family Studies at Liberty University. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony is author of The Clinical Training Guide for Online Counseling and Telephone Counseling. Anthony practices counseling in Boston and Cambridge, Massachusetts. See ThriveBoston
References
Rosenfield, M. (2003). Telephone counselling and psychotherapy in practice. In S. Goss, K. Anthony (Eds.), Technology in counseling and psychotherapy: A practitioner’s guide (pp. 93-108), Great Britain: Palgrave Macmillan; Suler, J. (2004). The psychology of text relationships, In R. Kraus, J. Zack, G. Strickler (Eds.). Online counseling: A handbook for mental health professionals, USA: Elsevier Academic Press.
Panyametheekul, S., & Herring, S. (2003, November). Gender and turn allocation in a Thai chat room. Journal of Computer Mediated Communication, 9(1).
American Counseling Association Governing Council. (1999, October). American Counseling Association code of ethics. Author.
Worona, S. (2003). Privacy, security, and anonymity: An evolving balance. Educause Review, 38(3), 62-63
see http://ezra.cornell.edu Umefjord, G., Petersson, G., & Hamberg, K. (2003). Reasons for consulting a doctor on the internet: Web survey of users of an ask the doctor service. Journal of Medical Internet Research, 5(4):e26. Retrieved October 1, 2005, from http://www.jmir.org/2003/4/e26/
Al-Krenawi, A., Graham, J. R., & Fakher-Aldin, M. (2003, October). Telephone counseling: A comparison of Arab and Jewish Israeli usage. International Social Work, 46, 495.
Carlson, S. (2002, November). As campus psychologists go online, they reach more students, and may also risk lawsuits. Virtual Counseling, 49(12), Retrieved April 01, 2006 from http://chronicle.com/free/v49/i12/12a03501.htm
Carlson, S. (2002, November). As campus psychologists go online, they reach more students, and may also risk lawsuits. Virtual Counseling, 49(12), Retrieved April 01, 2006 from http://chronicle.com/free/v49/i12/12a03501.htm; Anthony, K. (2003). The use and role of technology in counselling and psychotherapy. In S. Goss, K. Anthony (Eds.), Technology in counseling and psychotherapy: A practitioner’s guide, Great Britain: Palgrave Macmillan.
Umefjord, G., Petersson, G., & Hamberg, K. (2003). Reasons for consulting a doctor on the internet: Web survey of users of an ask the doctor service. Journal of Medical Internet Research, 5(4):e26. Retrieved October 1, 2005, from http://www.jmir.org/2003/4/e26/ ;Rosenfield, 2003; ; Speyer, S. & Zack, J. (2003). Online counselling: Beyond the pros and cons. Psychologica, 23(2), 11-14.
Childress C. A. (2000). Ethical issues in providing online psychotherapeutic interventions. Journal of Medical Internet Research, 2(1): e5. Retrieved February 20, 2005, from http://www.jmir.org/2000/1/e5/
Rosenfield, M. (1997). Counselling by telephone. London: Sage ; Tidwell, L. C., & Walther, J. B. (2002). Computer-mediated communication effects on disclosure, impressions, and interpersonal evaluations: Getting to know one another a bit at a time. Human Communication Research, 28, 317-348. Kraus, R. (2004). Ethical and legal considerations for providers of mental health services online, In R. Kraus, J. Zack, G. Strickler (Eds.). Online counseling: A handbook for mental health professionals, USA: Elsevier Academic Press.
Short, J., Williams, E., & Christie, B. (1976). The social psychology of telecommunication. London: John Wiley; Parks, M. R., & Floyd, K. (1996). Making friends in cyberspace. Journal of Communication, 46, 80-97; Michailidis A., & Rada, R., (1997). Activities and communication modes. International Journal of Human-Computer Studies, 46, 469-483.
Lea, M., & Spears, R. (1991). Computer-mediated communication, de-individuation and group decision-making. International Journal of Man-Machine Studies, 34, 283-301; Lea, M., & Spears, R. (1995). Love at first byte? Building personal relationships over computer networks. In J. T. Wood & S. Duck (Eds.), Under-studied relationships: Off the beaten track (pp. 197-233). Thousand Oaks, CA: Sage; Spears, R., & Lea, M. (1994). Panacea or panopticon?: The hidden power in computer-mediated communication. Communication Research, 21, 427-459; Walther, J. B. (1992). Interpersonal effects in computer-mediated interaction: A relational perspective. Communication Research, 19, 52-90; Walther, J. B. (1995). Relational aspects of computer-mediated communication: Experimental observations over time. Organization Science, 6(2), 186-203; Walther, J. B. (1996). Computer-mediated communication: Impersonal, interpersonal, and hyperpersonal interaction. Communication Research, 23(1), 3-43; Childress, 2000; Manning, T., Goetz, E., & Street, R. (2000, November). Signal delay effects on rapport in telepsychiatry. Cyber Psychology and Behavior, 3, 119-127; Nowak, K. L., Watt, J., Walther, J. B., Pascal, C., Hill, S., & Lynch, M. (2004, January). Contrasting time mode and sensory modality in the performance of computer mediated groups using asynchronous videoconferencing. System Sciences, 29-38.
Champion, 1988; Parks & Floyd, 1996; Michailidis & Rada, 1997; Michailidis & Rada, 1997; McGrath, 1990; Hain, Chuan, Trever, & Detenber, 2004 (See eCounseling.com/static/board for full references) Barak & Wander Schwartz, 1999; Weinberg, Shmale, Uken, & Wessel, 1996; Lynch, Tamburring, & Nagel, 1997; Reese, Collie, & Brossart, 2002; Consumer Reports, 1995; Reese et al., 2000; Ben-Ari and Azaiza, 2001; Hornblow & Sloane, 1980; Celio, Winzelberg, Wilfley, Eppstein-Herald, Springer, & Taylor, 2000; Robinson & Serfaty, 2001; Winzelberg, Eppstein, Eldredge, Wilfley, Dasmahapatra, Dev, & Taylor, 2000; Zabinski, Pung, Wilfley, Eppstein, Winzellberg, Celio, & Taylor, 2001; Klein & Richards, 2001; Lange, Van de Ven, Schrieken, Bredeweg, & Emmelkamp, 2000; Stroem, Pattersson, & Andersson, 2000; Tate, Wing, & Winett, 2001 (See eCounseling.com/static/board for full references)
Grohol, J. (1997). Why online psychotherapy? Because there is a need. Retrieved July 12, 2005, from http://psych-central.com/best/best4.htm; Slavich, S. (2003). The status of online mental health services. Unpublished doctoral dissertation, Wichita State University. Wichita; Gladding, S. T. (2004). Counseling: A comprehensive profession. (5th ed.). USA: Prentice Hall.
Lonner, R. B., Trimm, S., Phillips, D. G., Amey, B., & Jean Synar, B. (2001). CSWF position paper on internet text-based therapy. Clinical Social Work Federation. Retrieved February 22, 2005, from http://www.cswf.org/www/therapy.html, para. 1 Fenichel, M. (2001, July 24). A Response to the Clinical Social Work Federation Position Paper on Internet Text-Based Therapy: A response from the president of ISMHO. Retrieved December 12, 2004, from http://ismho.org/issues/cswf.htm
Suler, J. (2000). Psychotherapy in cyberspace: A 5-dimensional model of online and computer-mediated psychotherapy. CyberPsychology and Behavior, 3, 151-160; Suler, 2004 Speyer & Zack, 2003 Childress, 2000 Speyer & Zack, 2003 Suler, 2004
