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 factors. 

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 counseling online?

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 technology failures.

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 therapy.

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 Manhattan or Beverly Hills would be at a disadvantage in understanding  and helping a person or family in rural Texas

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 solutions available.

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 ensure privacy.

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  
would be to provide such services only to people who live in isolated communities that do not have psychologists or counselors available. 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.