Counseling online or psychotherapy online:
Is it safe? Is it effective? Is my privacy
protected? Who is the counselor or psychologist?
How do I know if the on line counselor is competent, ethical, well
trained or a licensed professional?
Counseling online and psychotherapy online are exciting new possibilities as
methods of providing psychotherapy, marriage counseling, family counseling and
relationship counseling. The convenience of being able to get help
in the comfort of your own home, without the bother of commuting to a therapist’s office, without hassling travel, traffic and parking, is certainly
appealing. This is especially true for people with busy schedules, or living at
a distance from the psychologist’s or counselor’s office, or people with
transportation or babysitting problems.
Should you consider counseling online instead
of in a traditional face to face in office visit? We do have some pretty good
guidelines for you to use to answer this question for yourself.
You want to make sure that the elements needed for effective counseling or
psychotherapy are being provided to you. Some elements are so well established
that they are part of professional codes of conduct written into state civil
codes, federal law, or the ethical codes of professional bodies such as the
American Psychological Association.
For example, we know that protecting the privacy of communication in a
counseling or psychotherapeutic relationship is, for many reasons, an absolute
requirement for success. A few other well established requirements for
psychologists or marriage counselors are as follows.
We must start with a
thorough psychological assessment of problems, strengths, weaknesses and risk
We must not only listen to
what is said; we must pay attention to tone of voice and nonverbal cues such
as facial expressions, hand gestures, bodily posture, and leg movements.
Sometimes a slight redness in the eyes allows the therapist to address important
feelings of sadness that a person is struggling to suppress. Jiggling feet,
tapping fingers or slumped shoulders are all very important clues to the
therapist in understanding correctly what a person is experiencing. All of these
forms of nonverbal communication are easily observed in traditional face to face
counseling or psychotherapeutic sessions.
We must adhere to a formal
professional code of ethics as a proven guideline to ensuring the mandate to
“do no harm” and to maximize our ability to provide effective help.
One way of assuring these requirements is licensure by a state board that sets
professionally agreed upon standards for training and knowledge. Different
states have different requirements and examinations to obtain a professional
license to practice in that state. It is both a legal and ethical
requirement that a psychologist or marriage counselor practice only within
the state of his or her professional licensure.
How do these principles apply to the question of doing psychotherapy or
The most promising new technology is the use of video/audio communication. New
computers come with build in webcams and people are “Skyping” each other
routinely. Using this type of technology, the online counselor or therapist is
able both to hear and see the person he or she is treating. Does this mean that
we can now effectively, privately, and safely offer our professional services
electronically? So far, such a technology has major drawbacks.
The confidentiality and privacy issue is a serious problem. The level of
encryption presently available for practical real-time counseling online cannot
ensure that these personal sessions are not intercepted by a third party.
Accidental or intentional invasion of privacy is a danger.
The effectiveness of the therapist or counselor online is impaired because the facial expression,
or the look in a person's eyes cannot be observed
with adequate clarity. Furthermore, the posture, gestures and
body language are completely excluded from the video field. With present technology, the tone of
voice and the video itself is subject to distortion or even interruption at
crucial moments due to
In addition we do not yet have the research results to validate the
effectiveness of such “long distance” counseling online and we do not yet
have training programs established to allow counselors or psychotherapists to
develop the skills necessary to conduct psychotherapy or counseling online
Although it is tempting to provide counseling online, or psychotherapy on
line, these drawbacks raise serious questions about the ethics of a professional
counselor or psychotherapist attempting to provide such services.
Some therapists have decided to “just do it,”
and are providing treatment by e-mail or by webcam video programs right now.
There are plenty of such internet sites available online in a credit card
pay-per-minute format. It is hard to rationalize that such a counseling or
treatment method meets current professional standards for all of the reasons
discussed above. Some of these sites do not even provide the names, training or
licensure of the online counselors and therapists, which prevents the public
from verifying their qualifications. Many such online counselors are licensed to
practice in one state, but are providing services to people in other states or
even across national borders. This is clearly an ethical violation. If a
counselor or therapist is breaking an important ethical rule, one cannot have
much confidence in the quality of professional services he or she is providing
Another concern is the level of knowledge that the
therapist has of the community where the person lives, local social issues,
customs, sub cultural issues, idiomatic expressions and community resources that
are available. A counselor or therapist practicing within his or her own
community is likely to have a good understanding of these issues. On the other
hand, a therapist in
would be at a disadvantage in understanding and
helping a person or family in rural
potential for offering professional services such as counseling online or
therapy online has been of great interest to professional organizations in the
field of psychology, and it has been of great personal interest to me.
I have followed developments in this
field closely and have attended some professional conferences and workshops on
this subject. The information I am providing here is based on presentations by
experts in this field at the American Psychological Association annual Meetings
held August 12 -15, 2010 in
At these meetings, it was indicated that the issue of how to develop the
capability to provide such services effectively and ethically is being addressed
on an ongoing basis, but that we do not yet have acceptable answers and
Telephone, E-mail and Text Counseling or Psychotherapy
Of course, there has always been the option of
offering consultation by telephone, but restriction to voice only communication
has been a big drawback. The obvious disadvantages of communicating verbally
only, without the important visual dimension allowing the therapist and patient
to see facial expressions, body language, gestures and movements have made this
a limited an inferior option. Telephone communication by a land line might meet
the criterion of privacy, but a determined eavesdropper can tap a phone line.
More problematic is the use of cordless phones or cell phones, which certainly
can result in accidental or “hacked” interception of communication.
Some therapists have offered professional advice via e-mail, or by text
messaging, but this eliminates the nuances of meaning communicated by the sound
of one’s voice, limiting communications even further. In addition, email and
texting are unencrypted and can be easily intercepted, thereby eliminating the
privacy and confidentiality of communication between patient and counselor or
therapist. This obviously could make matters worse for the patient and it is an
ethical violation for a psychologist to communicate in a way that does not
Conclusions, Research, Clinical Trials and Future Developments
In this rapidly evolving electronic age it is
indeed tempting to use internet communication for counseling online. However,
professional ethical standards require us to make sure that we are doing
something that has been proven to be helpful, and above all, something that will
not harm our patients.
Research methods testing the effectiveness of new methods of treatment cannot
keep up with the technology, and require time to assess the outcome of new
methods. Some possible research approaches could be based upon the use of
“clinical trials.” This approach is used in medicine to conduct research on
new methods of treatment. Such trials can be used only when all proven forms of
treatment have been exhausted. It would be reasonable to apply the same standard
to counseling online or psychotherapy online.
One clinical trial research possibility Another clinical trial might be to provide such
services to military personal in combat zones where face to face treatment is
not available. In these cases we would not be running the ethical risk of providing
sub-standard professional services when proven methods of service are available.
would be to provide such services only
to people who live in isolated communities that do not have psychologists or