Is Online Counseling Ethical?
By Stephen Snow, June 2001
In an increasingly high-tech world, more and more people are going online. As of the first quarter of 2001, 27 nations and about 429 million people have Internet access, with about 41% of them from North America (Goosley, 2001). As availability of online technology rises, the number of people seeking and providing online counseling via the Internet is increasing (Oravec, 2000).
But while this new technology has attracted many users for counseling purposes, there is extremely little research to show its impact. "Researchers are just beginning to explore questions concerning the effectiveness of online therapy, which makes assessment efforts particularly difficult...such a lack of research is especially problematic." (Oravec, 2000) (APA, 2001).
The combination of the newness of the medium and the lack of substantive research into its efficacy has placed licensing and certifying bodies at a disadvantage. Still, "the novelty of telecounseling does not excuse it from traditional standards of the counseling practice." (Riemer-Reiss, 2000)
That many counselors and clients use the Internet at the present time raises serious ethical concerns about whether this practice is appropriate and, if it is appropriate, under what circumstances. A full examination of the ethical issues is not possible in 10 pages. This paper will explore some key ethical concerns. Among them are confidentiality, privacy, client and counselor identification and competency. The focus of the paper will be online, primarily text-based, Internet counseling. Video counseling and Virtual Reality carry their own ethical challenges, but are beyond the scope of this paper.
My own values place me in the "proceed with extreme caution" position. As someone who has used telecommunications extensively for more than 10 years, I have a firm understanding of its limitations as a communications medium. While I have seen its use result in great closeness and warmth, I also have seen its use result in harm and divisiveness. As a communications medium, it has unique features that must be taken into account by both counselors and clients if it is to be used effectively. One of the most common negative results of interacting online is a phenomenon I have come to call "intimate strangers." Because you communicate with people you don't really know, you can share tremendous amounts about yourself and still not really be known, and vice-versa. Since people often don't really know each other, they might have little compunction about dropping out of even a counseling relationship; online, people can literally disappear without notice, leaving a sense of emptiness, frustration and abandonment. These are more subtle difficulties with the medium but need to be addressed before entering into an online counseling relationship.
I believe the Internet can vest in a person a measure of personal control that can be powerful. It is a tremendously empowering source of information and advice, and changes the dynamic between people and information. It can bridge distances and help overcome a wide assortment of isolations - economic, physical, emotional, geographical - but it has many limitations that should be carefully explored before the technology is used widely. As counselors, our most important responsibility is protecting the welfare of the client (A.1.a). If there is a chance the medium would do harm or not advance the welfare of the client, then it shouldn't be used. So careful assessment is needed at the outset of whether this is the optimum medium to provide care, not merely one choice, or merely a choice of convenience. There are several relevant codes related to the use of Internet technology for counseling, in addition to the welfare of the client.
Confidentiality and Privacy (Section B, ACA Code)
The Internet is an open network, which means it is not secure. Typically, an e-mail message will go though many points on its path from one computer to another. Clients who happen to use a computer at work are subject to corporate policies regarding e-mail being read. "The computer equipment belongs to the employer, and so does everything on it." (Paris, 2001). Paris also notes that the American Management Association "reports that 27% of companies it surveyed monitor employee e-mail." (Paris, 2001). This is one reason the American Counseling Association notes that "to mitigate the risk of potential breaches of confidentiality, professional counselors provide one-on-one counseling only through 'secure' web sites or e-mail communication applications which use appropriate encryption technology..."(ACA, 1999). But even working at home, using a secure connection, does not guarantee lack of intrusion by family members or others. (Paris, 2001). Only the most sophisticated encryption offers a high level of security.
However, e-mail communication "feels" confidential, which makes it all the more important to disclose to clients this limit of online counseling. While the actual likelihood of e-mail being intercepted is small, clients have a priority right to know that it could be, and the counselor has the responsibility to make sure that every possible step is taken to assure that communication remains confidential. "Adoption of digital certificates will quicken over the next years and personal e-mail will be sufficiently protected (but) until e-mail users confidentiality is secured, counselors should not engage in online counseling due to the possibility for interception of the messages." (Riemer-Reiss, 2000).
Confidentiality and privacy also are concerns regarding client information. E-mail creates a permanent electronic record of conversations. Clients need to know how that information is to be handled and disposed of. (B.4).
Client and Counselor Identification and Disclosure (A.3)
One of the attractions of online counseling for some clients might be its anonymity. (Suler, 2001). Yet, without being able to confirm the identity of a client for each interaction, how can a counselor be sure who is being counseled? Preserving anonymity also poses a special problem: counselors would not be able to intervene if a client expresses a desire to harm himself or herself or others. (Grohol, 1997). For clients, there is an equal risk in anonymity, making the "lack of interstate licensure and inadequate policing of online counseling makes the ethical and legal use of this medium somewhat murky." (Haas, 2000). Addressing this, the ACA's standards for Internet counseling call for counselors to "provide a readily visible notice advising clients of the identities of all professional counselor(s) who will have access to the information transmitted by the client...(and)...provide background information on all counselor(s) and supervisor(s) with access to the online communications, including education, licensing and certification, and practice area information." (ACA, 1999). Anonymity poses an additional issue with the lose of visual cues from clients in a text-based environment.
Competence (C.2.a, b)
Like any emerging discipline or practice, "psychologists should work within the bounds of competency." (Stamm, 1998). Many people, including counselors, are only marginally competent when it comes to using the Internet. Technical problems abound. (Riemer-Reiss, 2000). Notes Hudnall Stamm, "To best know when and how to use technology to support healing, I believe that psychologists will need more technology proficiency, particularly with computers, than has been the norm. This is particularly true for those who will be establishing their practices in the coming decades." (Stamm,1998). The ACA Code is very specific about this (A.12) aimed at clients, but is, unfortunately, silent on the issue as it relates to counselors.
Other Potential Stumbling Blocks
Abandonment, dependency and unequal access are additional ethical concerns. While there is little discussion of these issues in the literature, they are no less important. In the case of abandonment, once an online relationship is established, the relationship itself is subject to upheavals because of the technology. The Internet is made up of multiple connections, which connect remote people to each other. All along that path there are potential points of failure that can interrupt the flow of communication and hinder communication. For example, if a mail server at either end of the connection is offline, then that person cannot receive e-mail. Even in e-mail-based counseling there could easily be situations that call for more rapid replies and, if they are not
forthcoming, that could be damaging to the client. Even if the Internet portion of the connection is working all right, there are many possibilities of technical problems that can hinder communication. Any of these mean a lowered standard of care for the client. What is an acceptable level of care in this setting? Does disclosure of this possibility alone make it acceptable if a client agrees to the technology's limitations? I don't believe so. Even if a client agrees to a diminished standard of care, required by the limits of the technology, the counselor still has the obligation to provide a standard of care that "does no harm." It is difficult to see how that can be possible with current technology. It also makes it impossible to keep the promise of timely response, which would be an unacceptable breach of the relationship.
And what of a client's dependence on the technology? For example, if an agoraphobic person cannot come to an office to discuss issues and computer-based counseling is offered as an alternative, does the counselor run the risk of acclimating the client to a life approach that, in effect, supports and sustains the very issue that is causing distress? I believe that a key purpose of counseling is to promote individual autonomy and personal wholeness; the Internet has the potential to promote autonomy but also to encourage dependence, which does not promote good mental health and wellness. If only 41% of North America is online, then for most people, online counseling is not a possibility. This is even more true for minorities, who are twice a likely not to have Internet access as others. (NTIA, 2000). If a counselor has an obligation not to discriminate (A.2), and should strive for justice, then does offering a service only to those who have special technology become a form of discrimination, especially in light of ACA Codes, which state that counselors "provide equal access to computer applications in counseling services" (A.12.c) achieve the required level of fairness? In a word, no. The inability to ensure equal services to all clients undermines the tenet of universality. Internet-based counseling has so many potential pitfalls that it would make me uneasy to offer it as a normal counseling approach.
Potentially Useful Applications
Determining the appropriate setting for a client is of utmost importance. A number of factors enter into this, including location, availability, issues (realizing the presenting problem is not always the core issue), client comfort level and competence.
E-mail, if its limitations are taken into account (especially regarding confidentiality, privacy and availability), may serve some uses for adjunct services (Stamm, 1998). In some unusual situations, such as clients who are deaf, shut in or unavailable, e-mail might be considered if there are no other means. If this is the only option available, then the counselor must assure the highest possible standard of care.
Electronic mailing lists, also called Listservs, serve a different purpose. For group discussion, for support and mentoring, they appear to have significant value (Murray, 1998). At the same time, prudence would indicate extreme caution in considering whether to attempt to conduct online group counseling through this method. The problems mentioned for individual counseling are only multiplied in a group setting.
Future applications
While e-mail-based counseling has severe limits and difficulties, it might not always be the case. Information technology is a rapidly advancing field and new, more secure and easy-to-use applications are being developed regularly. For those with the money, video counseling, also in its infancy, might become another option in the future. Currently, the technology is not reliable or widespread. For e-mail users, the development of embedded encryption, along with spread-spectrum wireless transmission, offer the best hopes of security in the near term.
Conclusion
E-mail, I believe, is largely inappropriate for counseling because it doesn't meet either the standard of care or the confidentiality issues adequately. However, this creates a serious dilemma for counselors. Money drives the growth of the web and the ability to offer these services and make money is one of the things driving counselors to get online (Paris, 2001). If that is true, then the online medium is likely to attract counselors who are driven by financial concerns rather than the welfare of the client. To make sure that there is a counterbalance to this, counseling organizations must make sure not only that they have clear ethical guidelines written into their codes, but they also should create additional credentialing and certification requirements for people who do online counseling. Establishing technical skill proficiency limits as well as requiring technical training would be positive additions.
It is not possible to stop unethical counselors from offering inferior services online. However, organizations such as the ACA must take additional steps to ensure that clients rights are respected and protected. This is not an easy task in the fast-changing realm of electronic technology, and organizations' codes have not kept pace with the changes in the uses of technology. (Riemer-Reiss, 2000).
Because of the nature of technology, certifying organizations need to institute an annual review of standards and codes for online counseling. There also needs to be a serious attempt to create a universally acceptable set of standards. My own review shows there exist now four primary sets of ethical standards for counselors. Of those, the ACA standards are the most rigorous. (ACA, 1999; NBCC, 2000; APA, 2001; ISMHO, 2000). Other than the International Society for Mental Health Online, whose members are online counselors, no mental health organization has endorsed online counseling. (New Therapist, 2000).
In addition, laws will need to be adjusted to accommodate changes in the nature of online counseling delivery and the penalties for violating these laws. Rigorous penalties need to be in place as a deterrent to counselors who might be tempted to sidestep their ethical obligations with clients online. Currently, counselors are governed by state laws and state-level licensure. As online counseling increasingly crosses jurisdictional boundaries, the legal system must address accountability in a more universal manner, which might require the creation of overarching federal legal standards addressing online counseling issues in the United States. But even these do not address issues outside Unites States boundaries. International law will become an increasing issue and pressure point as online counseling expands.
Along with better-articulated and more current standards and a better legal framework, there is a serious research gap into the impact of online counseling. (Stamm, 1998). New therapeutic models may need to be developed to address to unique qualities of the medium. "Increasing evidence, however, suggests that distance counseling will result in substantial cost savings, consumer satisfaction and increased accessibility. Future research is necessary to determine if counseling does improve counseling services." (Riemer-Reiss, 2000).
There is a need for addressing broad, theoretical issues - such as the nature of the counseling relationship in an online environment - as well as the more pragmatic ones, such as the specific steps counselors should take to ensure confidentiality for clients.
That clients will seek this kind of counseling seems inevitable. How counselors respond to the pressure to be online will be increasingly important. For some, it already is considered "a viable mode of service delivery that should be considered to supplement mental health counseling services." (Riemer-Reiss, 2000).
The prudent, responsible approach for counselors is to proceed with great caution. "Just because you can does not mean you should. Before embarking on a tele-health project, small or large, it is important to consider whether or not the program will improve the standards of care. Because of the excitement generated by the momentum of change and technological discoveries, it is possible for the technology of tele-health to outstrip the care-giving of tele-health. ... The first and most important consideration is the need for tele-health services. What are the needs? Is tele-health a market positioning ploy or does it add to the quality of care?" (Stamm, 1998).
As for the future, no one knows. "As technology forges ahead, so too do the opportunities for its adaptation to providing health care. It is important not to be swept up in the excitement." (Stamm, 1998).
One thing is certain, it will be important for ethical, certified counselors to operate in the electronic environment. This is an emerging technology and treatment approach that is gaining rapid client acceptance. Clients will go there. If trained, technically competent, ethical counselors aren't online providing care, then who will be?
References
American Counseling Association (1999). Ethical Standards for Internet On-line Counseling, downloaded from http://www.counseling.org/gc/cybertx.htm on 6/13/01. 8 p.m.
American Psychological Association (2001). APA Ethics Code Draft for Comment, downloaded from anastasi.apa.org/draftethicscode/cfm#toc, 6/13/01, 9 p.m.
Corey, Gerald; Corey, Marianne Schneider; Callahan, Patrick (1998). Issues and Ethics in the Helping Professions, Pacific Grove, CA: Brooks/Cole.
Goosley, Richard (2001). The Nielsen/NetRatings' Global Internet Trends, by way of the Digital Divide e-mail list, divitaldivide@cdinet.com, downloaded 6/12/01, 12:59 p.m.
Grohol, J.M. (1997). Why online psychotherapy? Because there is a need. Downloaded 6/12/01 from the World Wide Web. http://www.grohol.com/archives/n102297.htm.
Haas, C. (2000). Entangled in the net. Counseling Today, pp 26-27.
International Society for Mental Health Online (2000). Suggested Principles for the Online Provision of Mental Health Services, downloaded from http://www.ismho.org/suggestions.html, 6/17/01, 9 p.m.
Murray, Bridget (1998). Mentoring via the Internet is Thriving. The APA Monitor, 29, 11.
National Board of Certified Counselors, Inc. (date unknown). Standards for the Ethical Practice of Web Counseling, downloaded from http://www.nbcc.org/ethics/wcstandards.htm, 6/13/01, 7:30 p.m.
National Telecommunications and Information Administration (2000). Falling through the net.
Oravec, Jo Ann (2000). Online Counseling and the Internet: Perspectives for Mental Health Care Supervision and Education, 9, 121-136.
Paris, John J. (2001). Ethical Issues in Cybermedicine: Patent-medicine salesmen did not go out of style with the Conestoga wagon. America, 184, 15-24.
Riemer-Reiss, Marti (2000). Utilizing Distance Technology for Mental Health. Journal of Mental Health Counseling, 22, 189-206.
Sleek, Scott (1998). Isolation increases with Internet use. The APA Monitor, 1, 29.
Stamm, B. Hudnall (1998). Clinical applications of Telehealth in Mental Health Care. APA Journal, 29, 536-542.
The New Therapist (2000). The ethics and law of online therapy, downloaded from the World Wide Web, http://www.newtherapist.com/ethics.html , 6/13/01, 7:42 p.m.
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