There is no doubt that online counseling has improved access and opportunity for individuals to obtain counseling and mental health services. Some clients may continue to utilize traditional, face-to-face clinical services and use various forms of online counseling as an addition or supplement.
Logistically, online counseling can offer aid to various segments of the population who might otherwise not seek mental health services due to physical, psychologic, geographic, personality, or financial barriers. For example, online counseling services are generally less expensive than traditional face-to-face counseling.
In a systematic review of 16 studies on the economic implications of Internet interventions, Internet interventions facilitated by a therapist or counselor were more cost-effective than a wait-list, traditional interventions, or placebo.
Those who are physically disabled may not be able to travel to a mental health agency or a counselor’s office; online counseling allows them the option of accessing services from home . These populations may be at risk for not receiving necessary care, but online counseling may reduce this risk. Even those who may not necessarily face geographic barriers may experience time barriers.
In a study of online counseling services provided by a college, 77% of the online inquiries to counselors for assistance were submitted after working hours (i.e., after 5 p.m.) and 29% were submitted during the weekend. Those who have psychologic disorders that may preclude them from traveling or having contact with large groups of people may also benefit from distance counseling.
Geographic constraints impede some from seeking traditional mental health services; for example, those who live in rural areas or geographic regions where there are minimal mental health services or those who have difficulty accessing transportation may not have access to care. During the COVID-19 pandemic, online counseling has been necessary, particularly in states with shelter-in-place and social distancing guidelines .
Additionally, individuals who are more introverted may find the online environment more appealing . It is also possible that younger individuals (“digital natives”) may naturally find online counseling more amenable than traditional counseling. Finally, compared with traditional face-to-face contact, online counseling is less expensive.
This could promote greater access to counseling services as finances could be a major barrier to access of mental health resources. Online counseling tends to be less expensive than traditional face-to-face therapy/counseling.
Unfortunately, there is still a tremendous amount of stigma attached to psychiatric and mental health services. Mental health consumers experience an array of stigma and prejudice, not only from outsiders but also from family, friends, co-workers, the community and church. Individuals may try to conceal their disorders for fear that someone could discover their psychiatric status and treat them unfavorably. Thus, course and recovery can be adversely affected by the stigma.
The relative anonymity offered in online environments allows feelings of stigma to be reduced. It is speculated that if the level of stigma is reduced and level of anonymity increases, then the clients’ amount of self-disclosure increases. Indeed, there are some studies that indicate greater client self-disclosure with online counseling.
The perceived anonymity associated with online environments coupled with the ability to reread and edit messages is thought to produce more thoughtful and insightful responses [57,189]. Some experts argue that the psychologic anonymity of online counseling is therapeutically beneficial as “it facilitates what seems incompatible in ordinary life: to make contact with a stranger over very personal topics, with a degree of self-revelation that overcomes inhibitions regarding the portrayal of one’s problems much more readily than would be the case for a meeting in person”.
In a study exploring online counseling for problem gambling, participants stated they preferred online rather than traditional face-to-face counseling because the anonymity made it “less daunting” and they felt less “exposed.” For some, it was the first time, they were able to talk about their problem gambling and the related despair .
However, other studies have found a preference for in-person counseling due to the greater potential for relationship building. Parks and Roberts, for example, compared online and face-to-face communications and found that participants were equally comfortable and confident in sharing information. However, participants stated that knowing the identity of the person from whom they were receiving information promoted a greater sense of commitment in maintaining the relationship . Obviously, there are characteristics of traditional face-to-face counseling that are difficult to capture in an online environment.
Given the geographic mobility and transient quality of society, online counseling can offer continued support and services if a client or counselor relocates. According to the U.S. Census, 37.5 million people in the U.S. have relocated within the past year. While the majority (69.3%) stay within the same county, 16.7% move to a different county in the same state and 11.5% move to a different state. This can make continuity of care difficult to achieve unless Internet technologies such as online counseling are used.
Social support is vital in positively influencing individuals’ subjective well-being, particularly for those who are diagnosed with a clinical disorder. For those who feel psychologically and/or physically isolated, the Internet has opened opportunities to obtain social support either for themselves or for family members. Online support groups create communities that allow individuals to connect with each other based on common experiences, such as similar diagnoses, life situations, stressors, or psychosocial issues.
Another advantage of online counseling is that communication in the form of text can be more therapeutic, and for some writing and putting abstract emotions into words can be a cathartic experience.
It can also be more efficient, as a client might be more concise in writing than during verbal conversation . Certain online media, such as e-mails, chatrooms, and threaded discussion forums, allow administrative convenience in providing an automatic permanent record of the client/counselor interaction. For example, one can scroll through e-mails to see the beginnings, middle, and conclusion of messages.
In discussion forums, one can see the threads of responses. This can be beneficial from a clinical standpoint, as a client can see the evolution of thoughts and feelings. Counselors can go back to clients’ verbatim text communications to highlight incremental changes, challenge cognitive assumptions, and monitor progress. These archives of permanent records can also be utilized for clinical supervision.
Finally, some argue that online interventions might be advantageous as a supplement to traditional, face-to-face interventions. Supplemental online interventions can be used to expand on any topic or information covered in face-to-face sessions, alleviating time constraints for practitioners and patients [116,179].
During the week, clinicians can e-mail their clients to reflect on a particular issue, either prior to the next session or after a session as a follow-up. Having e-mail archives can also ensure that permanent records are available, which may be useful for clinical supervision. Consequently, the Internet can serve as a complement to provide more elaboration on issues discussed, or it can be used as a supplement to monitor tasks or homework assignments given to clients .
Online counseling could also be viewed as a preventive strategy for certain mental illnesses. For example, if a client has mild depression, online counseling can mitigate symptoms before they become more severe.
LIMITATIONS OF ONLINE COUNSELING
As a result of the relatively recent phenomenon of online counseling, some are concerned that most counseling theories apply specifically to face-to-face counseling, not online counseling. As a result, it may not be easy to apply traditional counseling theoretical frameworks and principles to online counseling.
However, as online counseling and interventions become more commonplace, more studies will be conducted to evaluate their effectiveness. Over time, a more advanced knowledge base will be in place for clinicians, professionals, and researchers to utilize.
To date, one of the main challenges with the delivery of Internet counseling and mental health services involves the mechanisms for monitoring quality of services and accountability. There is no established monitoring system to track the credibility and legitimacy of counselors’ advertisements. There is also no accountability structure to review and monitor the quality and accuracy of information on websites.
Some have also wondered about how to monitor the quality of the clinical process. These concerns may be amplified in cases of chat rooms or support groups, which may or may not involve a licensed and trained counselor. Even when trained counselors are involved, clear competencies and training standards and guidelines are often lacking.
The lack of nonverbal cues (e.g., displayed diploma) may also negatively influence clients’ perceptions regarding a therapist’s credibility. Just as there are concerns about the identity and the credential of the counselors, there is also concern about the identity of the client. Some have recommended that code words mutually developed by the counselor and client be used in the beginning of each session to verify both parties’ identities; requiring the client to summarize the last session can also be used to verify identity.
Another concern with online counseling is based on security and privacy issues. Computer hackers, for example, can access particular websites and compromise the confidentiality, privacy, and security of clients’ disclosures, as well as payment information, such as credit cards. As online counseling websites become more sophisticated, there is a move toward using the same message security systems utilized by banking institutions. It is important not to use personal e-mail accounts or insecure platforms (e.g., FaceTime).
Online counseling may not be conducive and appropriate for clients with severe emotional problems or who have serious psychiatric problems. In an emergency situation in which a client expresses suicidal or homicidal thoughts, counselors may not know where the client is located and be unable to implement emergency plans. In addition, they may not be able to warn vulnerable third parties.
However, similar challenges exist with telephone counseling or crisis hotlines. Counselors may also have difficulty referring clients to appropriate local resources and services. Even when clients share their locations, counselors may be unfamiliar with the range and quality of services in any given geographic area.
Another concern is the absence of nonverbal cues in online environments, such as chatrooms, e-mails, and discussion forums. Counselors have traditionally relied on nonverbal cues to assist in diagnosing.
Due to the lack of nonverbal cues, there is a greater likelihood for counselors to misread and misinterpret text messages; therefore, counselors must be careful in interpreting latent meanings. When conducting online counseling through text-based technologies (e.g., instant messaging, e-mail), direct communication is relied upon, and this can have drawbacks.
Crying, irritability, and other signs of distress may not be detected, and side effects of medications such as tremors or akathisia are not evident. The online environment for counseling may not be conducive for certain clients who require visual and auditory cues, including clients who have paranoid tendencies or poor ego strength.
The lack of nonverbal cues is also a concern in the formation of a therapeutic alliance and establishment of rapport between the counselor and client . Some argue that the anonymity offered by online counseling offsets this concern, as anonymity can promote greater rapport building and self-disclosure. Furthermore, engaging clients in writing is beneficial in setting clear expectations and goals for both parties. Others believe it is impossible for an effective working alliance to be developed in an online environment.
In a 2013 study examining clinicians’ ability to develop a therapeutic alliance in an online format, few participants stated they were not confident in relationship-building in online therapy. These same clinicians were self-assured in their ability to develop a therapeutic alliance in face-to-face therapy; not surprisingly, greater years of experience were related to increased confidence . In a 2017 meta-analysis, there was no difference in client-rated scores of the therapeutic alliance in Internet interventions and traditional face-to-face therapy.
At this point, the results are mixed at best. As noted, one of the potential advantages of the online environment is the time delay for both client and counselor responses. It can provide both parties the opportunity to think before they converse, and as a result, the responses may be richer and more thoughtful. However, the downside of this time delay is that some clients may misinterpret the delay as abandonment or inattention, which can trigger anxiety.
It may also promote the use of defense mechanisms because clients have more time to think about their responses. Again, online counseling is not suited for everyone. Counselors must properly assess its applicability for each client.
Another limitation of online counseling is the potential for technical problems. In a study of graduate counselor interns, participants were asked to engage in online supportive counseling .
Some participants had difficulty getting online and were frustrated with the delays resulting from various technologic barriers. Some technologic delays stemmed from the participants’ lack of proficiency in using the technology, while others were caused by technical problems. Regardless, the participants felt that the technology interrupted the relationship with the counselor. Online counseling assumes that clients have a certain level of technologic ability and financial means to access and easily utilize various programs.
Finally, there are many ethical and legal issues associated with online counseling. Because the Internet is available across state and country boundaries, state and legal jurisdictions by which the counselor practices may not apply. At present, there are minimal regulatory and legal guidelines, which raise many questions that cannot be easily answered. The topic of ethical and legal issues will be discussed in detail later in this course.