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Maximizing the Benefits of Online Therapy

March 1, 2006
by David J. Powell, PhD
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Counselors need new skills to achieve ‘virtual intimacy’ with clients

During the past decade, we have seen explosive growth in modes of communication using computers and the Internet. The reality of online treatment services is unfolding as the behavioral health field, whether willingly or reluctantly, approaches using technology to address addiction and mental health issues.

H. Westley Clark, MD, MPH, director of the federal Center for Substance Abuse Treatment, believes technology can assist in the federal government's larger behavioral health-related goal of ensuring “a life in the community for everyone.” He does not see online ser-vices as supplanting traditional treatment: “The goal is to leverage the impact of people-based services.”

Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), stated in the January/February 2005 issue of SAMHSA News, “At the most fundamental level, electronic access can benefit both the consumer and the provider of services. Consumers can access their own healthcare records and use them to help shape their own treatment. Providers can gain a more complete picture of their patients' overall health as well as have better access to the latest research-based information.”

Online counseling comes in a variety of shapes, sizes, and names, from cyber-counseling to e-therapy, telehealth, and telepsychiatry. It differs from traditional face-to-face counseling by offering services through delivery systems such as e-mail, chat rooms, text messaging, video conferencing, voice-over-the-Internet phones, and interactive Web sites.

A variety of benefits

The strengths of cyber-counseling include the following:

  • It offers the clinician a rich tool in assessing the impact of counseling services. Typically, the weakest link in most treatment systems is aftercare. The Internet now offers the counselor an array of options to leverage the treatment gains realized in inpatient or outpatient care.

  • It provides a means of reaching clients who otherwise might not get help, such as those with physical disabilities, the deaf, people with agoraphobia, ambivalent clients, low-income people without means of transportation, or those for whom distance impedes regular clinical contact.

  • It is cost-effective (with costs expected to continue to decrease while communication speed increases) and, for many clients, it offers much-desired anonymity. For clients uncomfortable with face-to-face therapy, online counseling can offer unique privacy and confidentiality protections.

  • It can offer the client and the clinician a permanent record of sessions, progress notes, self-paced activities, and a personal home page.

  • For youths, who are far more proficient at technology than most older adults are, it opens up a vast new vista for services.

  • In many locations, qualified clinicians are scarce. More than 80% of MSWs and 90% of psychologists and psy-chiatrists practice in urban areas. Meanwhile, more than 60% of rural Americans reside in federally designated shortage areas for behavioral health services. The Internet offers an inexpensive means of providing qualified clinicians right where the client is.

  • The array of tools now available to the counselor through the Internet is mind-boggling, from multimedia presentations to video vignettes, Flash and static slides, interactive slides, group and private text messaging, and personal home pages to assess issues such as self-esteem, anxiety, and sobriety progress.

Barriers to progress

However, with the opportunities afforded by cyber-counseling come a variety of questions that the behavioral health field needs to answer:

  • What are the qualifications of a cyber-counselor? What specialized training is needed for this developing discipline? In the future, cyber-counselors will need to acquire many of the skills possessed by hearing- and sight-impaired counselors: reading and understanding nonverbal cues, in this case when the technologic screen of the Internet shields the client. Furthermore, standards for credentialing of cyber-counselors will be required, in the manner of specialty certification for treating gambling problems, eating disorders, etc.

  • How much time and experience online do most counselors have, given the relative newness of the technology? Along with the needed skills mentioned above, time online will be required to become familiar with the techniques of working on the Internet. I am a “techno-peasant,” as are most individuals in my generation. We will need training and experience online as well as time to learn a new vocabulary.

  • What are the appropriate types of interactions for certain clients? How should the frequency of online “visits” and the cost and payment procedures be assessed? And will payers reimburse for such “visits”?

  • Most importantly, what federal and state laws apply to govern these ser-vices? Under whose jurisdiction and insurance requirements does the online counselor fall? The client might reside in Connecticut while the counselor works in California (in the future, the counselor might be in India). These issues were addressed after the advent of hot lines and after-hours EAP answering services, under which the laws to be followed pertain to the state in which the client resides. Working in this online environment will require the counselor to be familiar with varying state laws in areas such as duty to warn, child abuse, etc. The American Counseling Association has issued ethical standards for cyber-counseling, while the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and CARF are developing standards for the accreditation of cyber-counseling programs.