Counseling and the Internet

Harper, Sheryl G

During the 1999 annual conference of the North Carolina Counseling, I attended a workshop designed for emerging leaders in the counseling field. As one of our small-group activities, we were asked to brainstorm about how the counseling profession will change by the year 2010. Several ideas emerged repeatedly through this process. One of those ideas was that counselors would be forced to work in an increasingly technological world. This reality is a given. Interestingly though, no one raised the issue of using technology to actually conduct counseling. Perhaps the omission stemmed from a lack of awareness that counseling is occurring already through technological means such as the Internet. Maybe the attendees did not believe counseling on the Internet is really here to stay. Nevertheless, Internet counseling is a subject that the emerging leaders, and everyone in the profession, would do well to explore and understand in greater detail.

This discussion is aimed at understanding how counselors are using the Internet in their work, and the implications. Although corresponding over the Internet for therapeutic intervention is relatively new, people have used writing as a means of getting help with problems for many years. Two well-known examples of this phenomenon are Ann Landers and Dear Abby (Millar & Dunkin, 1997). Introduction of the Internet adds a new dimension to the way in which people can access information and receive help from other people in the United States and around the world. Web sites can be found for everything from selecting the best running shoe to testing left- or right-brain dominance. And some web sites do offer counseling and therapeutic support to people in search of help with emotional and social problems.

Even though "counseling via the Internet has become a reality" (Lee, 1998, paragraph 2), it is controversial. One noteworthy problem is that the professional community does not regulate Internet sites, which leaves people unprotected in their search for help with sensitive issues. To fully understand the reality and issues of counseling and the Internet, we first must gain a basic understanding of the technological options available for counselors and clients. In addition, we should explore the strengths and challenges that a counselor must consider when using the Internet in his or her work. Different types of Internet counseling also will be examined, as well as possible resources on the World Wide Web (WWW) for counselors, clients, and family members. In the next section we will explore the tools the Internet has to offer counselors and their clients.

THE INTERNET AND COUNSELING

To discuss the issues surrounding counseling on the Internet, we have to delineate the ways in which the Internet is currently being used by professional and nonprofessional people alike. Sampson, Kolodinsky, and Greene, (1997) offer a definition of the Internet as "the interconnection of existing commercial and noncommercial computer networks used to transfer information electronically between two or more computer users" (p. 204). Users access the Internet via a web browser, such as Microsoft Internet Explorer or Netscape. The information that is transferred on the Internet can come in many different forms. One method, electronic mail, or e-mail, allows users to send direct messages with or without file attachments to single or multiple users. E-mail can be sent and received around the clock. Users also can "chat" with each other by using "chat mode," a feature that allows two users to simultaneously view the sending and receiving of text messages (Sampson et at., p. 204). Giving out one's e-mail address, for many people, has become as commonplace as giving out one's phone number on a business card.

Another option for conversing with other users online is through video or audio conferencing. This type of technology requires a video camera mounted on the computer monitor that captures the visual image of the computer user (counselor or client). The transmission of information consists of both video and audio signals. This is the closest thing to face-to-face contact that can be achieved over the Internet. Although this technology is available today, it is not the norm. The use of e-mail is much more common for communication via the Internet (Sussman, 1998). Nevertheless, Sampson et al. (1997) note that, in the future, video and audio conferencing will be regular additions to the text available on the existing Internet (p. 206).

In addition to e-mail, Internet users can exchange public text-based information relating to predetermined topics through Bulletin Board Systems (BBS) and list servers (listserv) (Sampson et al., 1997, p. 203). These public forums allow people to share ideas and concerns, ask questions, and discuss issues in an easy-to-access environment. Furthermore, web site addresses are popping up in advertisements for organizations, corporations, groups, and individuals. Each web site is the total collection of WWW information resources, including a home page and links to other web sites, for an organization or individual (Sampson et al., p. 204). These web sites can be accessed through an Internet address. For example, the address for the American Counseling Association web site is http://www.counseling.org.

It is not surprising that, with all these technological advances, some individuals have created counseling services online. These services are referred to in many ways. For example, WebCounseling" (Bloom, 1997, 1998), cybercounseling (Lee, 1998), e-therapy (Grohol, 1999b), and therap-e-mail (Murphy & Mitchell, 1998) are a few of the names given to the process of counseling clients via the Internet. "Cybercounseling" will be used here to refer to the general practice of providing counseling services via the Internet.

Individual, family, and group counseling are all found on the Internet. Sampson et al. (1997) conducted an analysis of web sites to determine how much counseling is actually taking place. In 1997, the authors found that at least 275 practitioners were offering direct counseling services across the Internet (p. 205). Similarly, supervision and consultation are occurring in cyberspace. Before looking at the specifics of these types of counseling endeavors, we will examine some of the strengths and challenges that exist for counselors conducting this type of work.

STRENGTHS OF USING THE INTERNET FOR COUNSELING I

The heading for this section was delibera4ly chosen to read "Strengths" instead of "Advantages." This distinction is made because counselors should not think of cybercounseling as having advantages over face-to-face counseling. It is not a new type of counseling to replace the standard faceto-face methods. Even with the strengths that will be discussed here, cybercounseling should be used only in conjunction with our tried and true traditional methods of counseling intervention (Lee, 1998, paragraph 9). King, Engi, and Poulos (1998) contend that using e-mail in therapy should be done as a last resort, when the decision is between no therapy at all and therapy where some family members are able to participate only by e-mail (p. 44). Similarly, Sampson et al. (1997) note that counseling through videoconferencing should occur only when a qualified local counselor is not readily available and this limited availability is likely to result in clients not receiving needed services (p. 211).

Cost and Speed

With that distinction made, cybercounseling has several strengths that should be examined. One clear strength is found in the cost and speed with which counseling services can be rendered over the Internet. The actual cost of therapy is decreased with the use of e-mail communication. For example, to receive a single e-mail response through some web sites costs $25, but a client could purchase a package that allows unlimited e-mails for one month at a rate of $ 100. Given that some singular one-hour face-to-face counseling sessions can cost $70 or $80, this would save clients a considerable amount of money.

King et al. (1998) discuss cost and speed with reference to using e-mail in family therapy. With a remote family member involved in family therapy through e-mail, communication between family members can be achieved quickly and at a fraction of the expense of using the telephone as a medium. In addition, King et al. point out that family members can write to the remote member about their feelings and issues and send a copy to the therapist at the same time (p. 44). This further adds to the efficiency and ease of communication.

Inclusion

The benefits of cybercounseling extend beyond inclusion of a geographically remote family member. King et al. (1998) raise the issue of eliminating scheduling conflicts (p. 43) with family members and including family members who are unwilling, at least initially, to be present in the same room with each other (p. 43). Those authors contend that using e-mail to communicate in family therapy can make it easier for estranged family members to participate in the process (p. 43).

Outside of family therapy, the Internet can provide access to counseling services for individuals who are geographically isolated or are physically unable to travel to counseling sessions (Murphy & Mitchell, 1998; Sampson et al., 1997; Sussman, 1998). Computers can provide the link to underserved populations who may not seek help because of social stigma or cost (Lebow, 1998, p. 203).

Time

In addition to how the Internet can help reach certain people, many supporters of cybercounseling note the asychronicity of e-mail as a characteristic of its strength as a therapeutic medium (Childress, 1998; Grohol, 1997, 1999b; King et al., 1998; Murphy & Mitchell, 1998). When a client sends an e-mail to his or her counselor, the counselor has an opportunity to read and reflect on the message before responding. This is very different from the immediate response time necessary in face-to-face counseling sessions. This time delay affords both the client and therapist an opportunity to devote more thoughtfulness to their communication, which may encourage greater clarity in their communication (Childress, 1998, paragraph 24).

The time delay also allows for family members to participate in family counseling according to their own schedules, and to consider fully their intended communication before replying by e-mail (King et al., 1998, p. 45). Having a bit more time to respond to comments or ideas from others alleviates the need to "think on one's feet" (Grohol, 1999b). Furthermore, a counselor actually can seek and receive supervision or consultation before responding to a client's email (Murphy & Mitchell, 1998, p. 26).

Writing

Another strength of using e-mail communication is the healing quality of writing. The use of writing as a therapeutic tool is not new. Counselors use both scriptotherapy and therapeutic journal writing to aid in the therapeutic process (Pennebaker, 1990; Adams, 1999). Murphy and Mitchell (1998) use a narrative approach to their practice of therap-email. The authors contend that the very process of writing... externalises the client's problems. As they type, the written representation of their issues appears before them on the computer screen. We believe that this process can enhance the externalisation of problems, and therefore promote therapeutic change. (p. 28)

Murphy and Mitchell also contend that writing allows people to see themselves more clearly and that its "recursive nature ... will lead clients to try and make sense of themselves and their story... in a way that is not demanded of them in face-to-face therapy" (p. 28). This suggests that if email has to be used in counseling, the act of writing can add to the therapeutic value of the process.

Similarly, King et al. (1998) suggest using writing assignments as an addition to family therapy. The authors agree with using the personal narrative as a means of facilitating therapeutic change (p. 48). This personal narrative allows clients to become more conscious of their inner dialogue (p. 48). These benefits of writing add to the strength of using email communication for therapeutic purposes.

Records

With the written word comes a written record. Using email to conduct counseling creates a permanent record of each session that can be reread and reviewed at any time. King et al. (1998) point out that this record allows for review of family sessions and cuts down on arguments that might arise from inaccurate recollections of what has been said previously in therapy. Being able to reread previous messages and responses also allows clients to see their progress and to review the positive and encouraging comments that their therapist has made about them and their behavior (Murphy & Mitchell, 1998, p. 25).

Not only is this written record valuable for therapeutic purposes, but having a verbatim record of counseling sessions could greatly benefit the supervision process. According to Murphy and Mitchell (1998), having a written account of the sessions lets the client be as present for the supervisor as he or she is for the therapist (p. 26). This allows the supervisor to experience firsthand the client's words and to offer his or her own responses (p. 26). Even though the recording of sessions is common for supervision purposes, this actual text of the session allows the supervisor to react as if he or she were the counselor (p. 26). In addition, having a written record of each counseling session requires the counselor to practice at the highest ethical level. This permanent record makes the counselor accountable for every word that is written (Murphy & Mitchell, 1998).

Immediacy

Another benefit of conducting counseling via the Internet is that clients can access their counselor at the time of an emotional problem. Consider the following: Jane, a cybercounseling client who suffers from anxiety and insomnia, is lying awake at 4:00 a.m. ruminating about the stressful events in her life. Jane can e-mail her counselor at that time. She does not have to wait until a scheduled appointment three days later to talk about her feelings. Even though the counselor might not respond until some time later, the email will capture Jane's immediate feelings, not her recollection of those early morning anxieties (Murphy and Mitchell, 1998). Murphy and Mitchell contend that clients are able to gain more control over their situations by being able to take action against their problem (p. 30). Clients know they can work on the problem by e-mailing their counselor: It is a proactive step.

Power

An additional strength of online counseling is the leveling of power (Murphy & Mitchell, 1998, p. 29). Murphy and Mitchell use therap-e-mail to downplay the position of therapist as expert and help clients "be more bold in their behavior" than they might be if the interactions were in person (p. 29). The authors cite examples of the diversity found among listserv members: undergraduate and graduate students discussing topics with established professionals in the field. They hypothesize that individuals are willing to write to, and ask for, information that they would not otherwise solicit (p. 29), thereby creating a more level playing field than existed before. Murphy and Mitchell contend that this leveling effect in the regular e-mail community would be present in therap-e-mail as well (p. 29).

Certainly this list is not exhaustive and other strengths exist. Nevertheless, these characteristics illustrate how email has become popular with some professionals as a means for conducting counseling online. King et al. (1998) highlight the possibilities for using cybercounseling in the following statement: "When implemented in a responsible and ethical manner, electronic communication can enhance the therapist's ability to be effective in facilitating positive therapeutic changes for the clients involved" (p. 51). Many of these strengths also apply to using video conferencing online for therapeutic interventions. The interactions would be different because they take place through visual and auditory means instead of written messages. At this point, some of the many challenges that counselors face when attempting to help clients online will be examined.

CHALLENGES OF USING THE INTERNET FOR COUNSELING

The counseling process includes an infinite number of variables and possible outcomes. Depending upon the client, counselor, situation, and relationship, the counseling process can vary and fluctuate throughout the interaction. With these facts known, we can see how the whole process becomes more complicated if it takes place across cable lines and computer keyboards. These complications involve everything from development of the therapeutic relationship and dealing with crisis situations to insurance coverage and security of information.

Nonverbals

One of the first difficulties to consider is how to build a therapuetic relationship through written words only. What about nonverbal clues? What about using minimal encouragers? What about conveying empathy through nonverbals? The cybercounselor has a whole new set of barriers to overcome before the therapeutic relationship can be built. Lee (1998) expresses concerns over these barriers in the following statement:

In most respects, the notion of counseling via the Internet is counter to everything that we know and hold sacred about our profession. Counseling has traditionally been predicated on the establishment of a working/therapeutic relationship between two live human beings who are ... generally in the same room. This relationship has been fueled by ... verbal interchange.... [and] the therapeutic dimensions of this relationship are further enhanced by the ability of the counselor to observe the non-verbal behavior of the client, and vice versa. (paragraph 3)

For cybercounseling to be effective, the counselor must find ways to work through these barriers. Lebow (1998) echoes Lee's concerns and states that with regard to online groups, "communication can occur only through words on a screen, excluding nonverbal channels and making it more difficult to understand some communication" (p. 203-204).

In response, Murphy and Mitchell (1998) offer some tools for dealing with this problem: emotional bracketing, textual visualization, and descriptive immediacy. Emotional bracketing involves including relevant emotional material in brackets in therapeutic e-mail messages (Murphy & Mitchell, p. 24). An example of emotional bracketing would be as follows:

It has been several weeks since I have heard from you, John (concern, worry), and I would very much appreciate it if you could at least acknowledge this e-mail (feeling pushy, demanding). (p. 24).

This process gives the client an idea of the intended vocal tone in the words (Murphy & Mitchell, p. 24).

Murphy and Mitchell (1998) use textual visualization and descriptive immediacy to give information to the client that he or she would not have otherwise. For example, counselors would add a description of their nonverbal behaviors in the e-mail to give emotional context to the message. All of these techniques are not substitutions for nonverbal information, but are an attempt to bridge the gap that is left by the electronic medium.

Miscommunication

Another facet of these difficulties is the potential for misunderstandings or miscommunication within a text-based interaction. People commonly receive e-mail messages that leave them wondering what the senders meant by their message. Without the nonverbal clues, problems can arise. Email messages can appear colder and more impersonal than the author intended (King et al., 1998, p 45). Counselors need to be aware of, and make their clients aware of, this possibility for miscommunication and how to deal with it (Bloom, 1997). Sampson et al. (1997) purport that video conferencing would help alleviate miscommunication. They state that this medium would allow counselor interpretation of client non-verbal behavior (p. 210. The client also would be able to see the counselor's nonverbal behavior. As stated earlier, however, video conferencing is not the norm for cybercounseling.

Culture

Colon (1996) raises another dilemma for online counselors to consider: culture. E-mail messages reveal only what the sender writes. If the writers do not include cultural information in their messages, readers have ho way of knowing the writers' cultural background. Colon states that users usually are assumed to be White unless and until they announce otherwise (p. 214). Counselors need to he aware of multicultural factors that contribute to a client's experiences.

Consider the following example: Jane (a 33-year-old Caucasian female from suburban Maryland) is a cybercounselor working with a client, Tom (19-year-old American Indian male from suburban Maryland). During the e-mail intake procedure, Jane does not ask Tom about his cultural background. After five weeks, Tom mentions the conflicts he is having with regard to his spiritual life and his occupational decisions. Jane asks Tom to explain more about this conflict. In doing so, Tom discloses his strong connection to his grandfather, who lives on a reservation in North Carolina. Tom struggles with integrating his cultural beliefs with his current career path.

It is at this point, Jane realizes she has made some inaccurate and inappropriate assumptions about Tom and his life experiences. Surprised and embarrassed by her assumptions, Jane thinks that she has been working with Tom from a skewed vantage point. Until this moment, Jane had presumed that Tom is Caucasian and Christian. She realizes that she needs a more accurate picture of Tom's cultural experiences to better understand his viewpoint. Tom's cultural autobiography could provide vital information that directly applies to treatment strategies and interventions. This example illustrates how text-based interactions can allow for inappropriate assumptions that could be detrimental to the therapeutic process.

Access

In addition to cultural concerns, Col6n (1996) raises the issue of availability of online technology to clients. She contends that receiving counseling via the Internet "requires the luxury of time and money; those without either are marginalized again" (p. 214). Sampson et al. (1997) a(ld that counselors need to ensure that less affluent potential clients have some readily accessible public location for connection to the Internet (p. 210). Some people have online service through work or school that is available free of charge (Sampson et al., 1997). Some services are available to the public at locations such as libraries. Moreover, some people gain Internet access through commercial on-line services with E-mail covered by a monthly flat fee or on a per-use basis (Sampson et al., p. 207). Finally, some have limited or no access. The issue of availability and equal access will certainly arise again and again as counseling via the Internet becomes more widely used.

Information

Another area of concern for the cybercounselor is the availability of information regarding the client's local environment and resources. If the counselor lives in New York City and the client lives in rural New Mexico, the counselor has to be aware of the client's local environment and how it influences the client's experiences (Sampson et at., 1997, p. 210). Furthermore, the counselor must be knowledgeable about the resources available to clients in their home area (Childress, 1998; King et al., 1998; Sampson et al., 1997).

In some instances a cybercounselor or cyberclient has to access local resources-for example, an on-call counselor or local emergency personnel. The counselor is responsible for obtaining this type of local information and to inform their clients (NBCC, 1999). Counselors also need to be aware of the local procedures for reporting abuse (Childress, 1998). If a client becomes suicidal or discloses domestic violence or child abuse, the New York counselor would be ineffective if he or she were unaware of the resources available for immediate assistance in New Mexico. Childress (1998) also warns that counselors have to be knowledgeable about local laws and procedures for breaking confidentiality: At this time, it is unclear which laws-those covering the therapist's geographic region or those covering the client's geographic region-are applicable for reporting dangerous situations (Childress, 1998, paragraph 17).

Resistance

In contrast to the earlier discussion regarding the healing qualities of writing, written communication as a therapeutic tool actually can form a type of resistance to the counseling process. Through her experiences with online group counseling, Col6n (1996) explains that resistance can manifest itself in many ways, through textual aggression or joking or silence (p. 215). Therefore, clients sometimes use their writing as a form of resistance. Counselors have to be aware of this phenomenon and be prepared to address this issue if necessary.

Time

Another challenge for counselors is actually the flip-side of one of the strengths discussed earlier-asychronicity.

Asynchronous discussions do allow for more thoughtful responses before responding; however, the trade-off is no immediate feedback (Sussman, 1998, paragraph 6) or, at best, unpredictable response times (Colon, 1996). Unless the counselor and the client are using chat-mode for their email conversations or are implementing video conferencing, there is a lag between message and response. Furthermore, not all e-mail service providers offer chat-mode for their users. Therefore, an automatic response time delay is built into client-counselor conversations. This is a far different environment than face-to-face counseling, where everything occurs in a continuous flow. It will be interesting to see how this delay effects the amount of disclosure and the process of building rapport.

Diagnosis

It is difficult to imagine how accurate and effective diagnosis can take place within the counseling process without face-to-face meetings. Childress (1998) warns that without the ability to adequately diagnose a client, it would be difficult to develop an appropriate treatment plan (paragraph 8). Some professionals readily acknowledge this problem and contend that therapy via e-mail does not diagnose disorders, nor does it treat diagnosed mental or medical disorders (Grohol, 1999b).

Nevertheless, people with disorders are receiving counseling. These people are being treated without face-to-face screening and assessment. This is a fundamental problem that faces counselors who work over the Internet. In an effort to address this diagnostic issue, ethical standards have stated that counselors should state explicitly on their web sites the problems for which they believe cybercounseling is inappropriate (Bloom, 1997). These ethical standards will be discussed again in a subsequent section.

Insurance

Counselors using the Internet to work with clients also will have to face issues with insurance companies for thirdparty payments. Managed-care companies have no set standards to accept claims for Internet counseling. Nevertheless, some progress has been made in the general health-care community for telemedicine coverage. California passed legislation that mandates the coverage of online services that normally would be reimbursed in a face-to-face visit (Sussman, 1998, paragraph 10). Legislation similar to the California Telemedicine Act of 1997 has yet to become a national phenomenon, but it is a start.

Liability insurance is another area that counselors must consider before practicing cybercounseling." According to the American Counseling Association liability insurance company, coverage can be obtained for cybercounseling, but it is dependent on the both the number of clients served and the specific types of disorders that are treated (ACA Insurance Trust, Inc, personal communication, August 10, 1999). Bloom (1997) warns counselors to take responsibility for verifying their insurance coverage prior to engaging in cybercounseling.

Security

During face-to-face contact inside a counselor's office, communication between the counselor and the client is relatively secure. Yet, with communication through e-mail, one can never be sure. E-mails can be tapped into and read by unauthorized individuals from a number of sources without the client's knowledge (Grohol, 1997, paragraph 4). For instance, employers can legally read c-mails written from a workplace (Childress, 1998). In addition, the client and/or the therapist might be sharing a computer with other individuals in the home who can gain access to e-mail messages (Childress, 1998). Precautions can be taken to avoid unauthorized access to e-mail communication, such as placing password protection on files and encrypting messages (Childress; Grohol, 1999b; Sampson et al., 1997). This is another point at which counselors must inform clients of the security dangers and possible ways to address the problem (Bloom, 1997).

Before we look at the different types of cybercounseling interventions, we should note that these challenges could be diminished if cybercounseling were used as an adjunct to ongoing in-person therapy (Childress, 1998, paragraph 29). Consider this example: Joe, a counselor, sees Mark, a client, for face-to-face counseling sessions once a month. Because of Mark's excessive travel schedule for work, he is unable to attend sessions more regularly. Joe and Mark, however, are able to continue their therapeutic work over the Internet while Mark is on the road. This arrangement could alleviate some of the problems previously mentioned, such as building the therapeutic relationship, knowing the client's local environment and culture, and general diagnostic issues (Childress, 1998, paragraph 30).

We should mention that no comprehensive research studies have been conducted testifying to the benefits of cybercounseling or the effectiveness of using e-mail or video conferencing as a therapeutic medium. Currently, only anecdotal evidence or case examples exist to support the claims of effectiveness of these techniques. At this point, we will consider the different forms of cybercounseling that are currently found on the Internet.

CYBERCOUNSELING POSSIBILITIES

Potential clients can access cybercounseling through a simple Internet search for the terms "counseling" and "Internet." This search can be done through a variety of search engines available on the WWW (e.g. Yahoo at www.yahoo.com and Excite at www.excite.com). This type of search will produce a large number of categories and web sites that relate to these topics. The potential client must wade through the web sites to locate ones that fit their needs. This is not an easy process, but the seasoned Internet user can navigate through these options with little difficulty. If the potential client is a less experienced "surfer," this search process can be tedious and frustrating.

For example, I conducted the search described above through Yahoo and accessed 37 web sites related to counseling and the Internet. Similarly, a search thr6ugh Excite yielded 1400 "hits." Not all of these sites provide cybercounseling. Some sites are marketing pages for in-person counseling services. Others provide information about counseling journals and research, online information about counselor training programs, and even personal web pages that mention the word "counseling." Even though the process can become tedious, clients are locating cybercounselors to receive many kinds of treatment.

Counseling

In any counseling process, counselors take steps to begin the relationship and assess what kinds of interventions and treatment strategies might be most helpful for each client. It follows that intakes, assessments, and treatment planning also should be conducted in cybercounseling. Sampson et al. (1997) explain that clients can fill out online versions of intake forms and assessment instruments. These tools can be transferred electronically to the counselor. The counselor can monitor a client's progress or follow-up on these stages through e-mail or video conferencing. The process of online screening also could be used to bring into the mental health system people who otherwise may not seek treatment (Childress, 1998). If potential clients can initiate the process online, without having to venture to a mental health center or locate a therapist, more possible clients might be reached.

Another way to initiate the counseling process is through a telephone call or an in-person meeting with the client(s) to discuss the e-mail process (King et al., 1998). Because of the nature of the information that a client might reveal (e.g. suicidal ideation), in-depth online intakes require that the professional develop specialized skills (King et al., p. 46). Murphy and Mitchell (1998) use a specific method of gathering intake information, called a "Virtually Solve It worksheet (VSI)," which helps begin the therapeutic process (p. 21). The VSI worksheet guides the client through a process of telling his or her story: it is based in narrative and solution-focused therapies (Murphy & Mitchell). The VSI gives the counselor information about the client's experience and what problem-solving techniques he or she has tried previously.

Through the beginning phases of cybercounseling, the counselor should assess the appropriateness of the client's issues for this type of treatment. As previously mentioned, it is the counselor's responsibility to state clearly which problems would be inappropriate for treatment via the Internet (Bloom, 1997; NBCC, 1999). Payment options, approximate response times, crisis resources, and how to reach the counselor offline-all should be explicitly discussed at the beginning of the counseling process. Some of these steps afe highlighted in the ethical code that will be discussed in the next section. In addition to online intake forms, clients should complete informed-consent forms. These should verify that the client is aware of the recency of cybercounseling as a therapeutic method and that little research exists to validate its effectiveness as a technique (King et al., 1998). Depending on the mode of contact (e.g. e-mail, chat-mode, or video conferencing), the counselor and client would proceed with the therapeutic process in ways similar to face-toface counseling.

Individual, family, and group counseling are all available online. Much of what has been discussed to this point has related directly to individual counseling. Family counseling could involve several family members connected through the internet, or most of the family members might see the counselor in-person and remote family members participate through e-mail (King et al., 1998). Some of the interesting facets of conducting cybercounseling with families are the similarities it shares with using the telephone for family counseling. Hines (1994) examines some of the issues that arise when using a telephone as the medium for therapeutic intervention.

For example, the process of joining is common in family counseling, and it becomes much more important when no visual information is available to the counselor or the clients. Hines states that "joining...is more important not just in the first session; the distance inherent in the context necessitates more therapist joining throughout the therapy" (paragraph 18). King et al. (1998) continue that with written word as the medium to engage the family, more challenges exist and the counselor must be inclusive, honest, empathetic, and attentive to decrease any ambiguity in interpreting the written communication (p. 47).

In addition to family work, group counseling on the Internet can take different forms: moderated or unmoderated groups and self-help/support groups. Lebow (1998) discusses some of the possible pitfalls of unmoderated support groups. He contends that online group members can provide support for one another, but without counselor input, "members are left only with encouragement, without new ways of refraining or dealing with their difficulties" (p. 204). Group members, meeting without counselor input, might reinforce each other's negative emotional states.

Information concerning online group counseling is difficult to find and little research is available on the topic. Col6n (1996) discusses her experiences as facilitator or moderator of an experimental online group. She advertised for group members in online public forums aimed at the psychology community. Group members agreed to a 3-month commitment with a minimum of three online postings each week from each member. This eight-person group discussed topics that were important to each member and were able to post messages at any time of day or night. Col6n responded to messages each day and encouraged members to respond to each other's comments and questions (p. 20). In addition to regular postings, real-time chats were scheduled several times during the 3-month period (p. 207).

One area of concern for Colon (1996) is that an online group counselor has to post messages to make his or her presence known to the group. This is very different from face-to-face group work. A counselor in a face-to-face group can sit back and watch the interactions taking place in the group, whereas online counseling requires a different participation pattern from everyone in the group. Also, the group may not have developed beyond the forming stage (to storming, performing, etc.). Thus, the process might actually be individual counseling in a group setting.

Despite these concerns, Colon contends that the informality and the intermittent nature of the online group has advantages over the formal and scheduled nature of face-toface group counseling. These cybercounseling groups may make supportive therapy more attractive to clients who would not otherwise pursue therapy (p. 212). Online groups might provide a sense of community based on privacy, informality, and equality (p. 212). Col6n concludes that the group members were able to build trust with one another and became willing to disclose more, making the therapy more in-depth (p. 212).

Supervision and Consultation

Earlier in this discussion, the possibilities of supervision for cybercounseling were discussed with reference to having a permanent verbatim record of cybercounseling sessions. This opportunity could be one of the less controversial uses of the Internet in the counseling field. Issues of misunderstandings and nonverbal clues are less crucial in the supervisory relationship. Misunderstandings may arise, as they do with any e-mail communication, but these problems will have a significantly less impact on the therapeutic value of the counseling process. In addition, counselors can easily seek supervision at any time through e-mail. lhe supervisor can live in a different country and still be Involved with time-sensitive case concerns.

Some counselors have difficulty finding regular supervision in their working environment, especially in schools. School counselors might depend on direct supervision from a guidance coordinator or a director of student services in the school district, or peer supervision from colleagues within the school counseling community (Myrick & Sabella, 1995, p. 38). With the Internet becoming a more commonly used tool, supervision might get easier for school counselors. The online opportunities allow counselors and supervisors to converse individually and in groups (p. 38). Myrick and Sabella add that supervision can be found by sending questions to the International Counselor Network (ICN) or the Counselor Education and Supervision Network (CES-NET-L) listservs. These networks allow counselors to receive assistance from counselors all over the world.

Similar to e-mail messages for counseling, supervision messages can be read and reread. This allows a counselor and a supervisor to review the comments and respond at their own convenience (Myrick & Sabella, 1995). The information obtained through e-mail supervision also could be given to a teacher or a parent, if appropriate. Unfortunately, typing messages can be slow and tedious and important information could be left out of case descriptions in an effort to be precise (p. 44). Nevertheless, the use of e-mail for supervision could help school counselors feel more connected to the counseling community and provide a means for supervision and assistance not previously available.

Through e-mail communication, consultation with other counselors or professionals from different fields could be conducted with ease. Murphy and Mitchell (1998) illustrate this possibility through the following statements:

I send out a single e-mail to my several colleagues wherever they are, and they respond. There are no long-distance charges, no phone messages, no huge time commitment on my part as the case manager. This in and of itself will change the way that we as professionals consult on cases. (p. 26)

In addition to counselors consulting counselors, e-mail messages could be used so that clients could provide consultation for other clients (Murphy & Mitchell). The therapist asks the client to articulate what they did in overcoming their problems (p. 26). Because there is a written transcript, the therapist could ask clients to share their successes with other clients who might benefit from their insights.

Research Using The Internet

Even though little research exists on the use of the Internet for counseling, counselors and psychologists are using the Internet itself to conduct research. This is cost-effective and easier than face-to-face participation (Buchanan & Smith, 1999; Sampson et al., 1997). There are no expenses for laboratory space or materials, and data acquisition and even analysis may be entirely automated (Buchanan & Smith, 1999, p. 126). All consent forms, testing information, and follow-up communication could be transferred electronically between researcher and participant. Moreover, the number of possible research participants is enormous (Buchanan & Smith, 1999; Sampson et al., 1997). The most common type of cyberresearch conducted today consists of personality tests and surveys that use questionnaire-based designs (Buchanan & Smith, 1999, p. 126).

One of the biggest problems with research over the Internet is validity and reliability issues. For instance, participants in Internet research are active volunteers who sometimes are even seeking experiments; this volunteerism decreases researchers' ability to generalize their findings to the overall population (Buchanan & Smith, 1999). In addition, the researchers lose all control over testing conditions; they cannot even stop volunteers from participating in the same study multiple times. According to Buchanan and Smith (1999), tests given through Internet research must be thoroughly scrutinized as to their validity and reliability in cyberspace. Despite these drawbacks, the authors contend that the Internet offers great potential for psychological research, and specifically Web-based personality assessment is a real possibility (pp. 141-142).

ETHICAL ISSUES

Professionals in the counseling community have differing opinions about the use of the Internet for counseling services. Because it is a reality in today's world, however, the counseling community has to deal with cybercounseling in a way that is responsible and ethical (King et al., 1998). According to Bloom (1997), the counseling profession, and specifically the National Board of Certified Counselors (NBCC), set out to explore the practice of online counseling and to assess the possible existence of any regulatory issues that NBCC might need to address (paragraph 1). Through these efforts, a WebCounseling'" task force was formed and voluntary ethical standards for practicing counseling over the Internet were created. Bloom points out that "NBCC does not advocate the practice of WebCounseling... [but] that these voluntary standards... will give counselors and other behavioral health professionals the direction needed to minimize risk and danger to Web Counselor and WebClient alike" (paragraph 4).

NBCC Standards

The standards that NBCC created are aimed at giving ethical guidelines to cybercounselors specific Co the issues that arise when conducting counseling via the Internet (e.g., see Bloom, 1997, 1998; NBCC, 1999). Thirteen professional standards are presented, along with examples of how to apply these standards to actual practice. The following areas are addressed through this ethical code: (Bloom, 1997; NBCC, 1999):

legal and ethical issues data preservation consent for minors counselor self-disclosure local crisis resources inappropriate problems misunderstandings secure communications identity verification release of information certification and licensure off-line contact technological failures

This discussion will now address some of these and other ethical issues not examined previously._

Confidentiality

One of the fundamental criteria for a counseling relationship is the knowledge that what is said during the interactions is kept in confidence. Clients disclose personal information to the counselor and expect only the counselor to receive this information unless otherwise agreed upon prior to disclosure (such as for supervision). As mentioned earlier, the security of e-mail communication can be enhanced, but there is no way to ensure complete confidentiality because records of the interaction are stored in the computer.

The counselor is responsible for being aware of and communicating to the client the possible threats to confidentiality, and for becoming familiar with and consistently using appropriate security methods (Sampson et al., 1997, p. 209). Childress (1998) highlights four points at which confidentiality can be breached through cybercounseling: "transmission, therapist-end, client-end, and legal subpoena" (paragraph 11).

Encryption is the best way to deal with transmission problems, yet it still is not a guarantee. As previously mentioned, the counselor and the client have to be careful with e-mail storage and access. It still is unclear if communication using the Internet is covered by therapist/client privilege and, therefore, communication may be subject to the legal process of discovery (Childress, paragraph 15). Each of these cases illustrates the need for the counselor to make the client explicitly aware of possible compromises to confidentiality.

Another ethical dilemma for the cybercounselor is record keeping and confidentiality. With a written record of each session stored on the computer, counselors must be sure to secure access to these records. Sampson (1996) offers several suggestions for counselors to safeguard this type of information:

1. Do not keep confidential information on a computer that can be accessed through a network.

2. Treat identifying information for computer accounts as confidential information.

3. Keep account names and passwords in secure locations.

4. Change passwords frequently to limit access if security is breached. (p. 215)

These preventive steps can help decrease confidentiality compromises resulting from computer usage. Counselors also must be careful when discussing cases with other counselors online. According to Sampson et al. (1997), counselors must ensure that case information cannot identify a client when using listservs or BBSs to receive consultation or supervision about a specific case.

Licensure and Certification

NBCC ethical standards state that cybercounselors should provide clients with links to web sites of all appropriate certification bodies and licensure boards to help ensure that they are receiving counseling from certified and licensed professionals (paragraph 22). One web site, www.metanoia.org, is dedicated to checking the credentials of cybercounseling and helping consumers make more educated decisions about cybercounseling (Millar & Dunkin, 1997; Sussman, 1998).

In addition to verification of credentials, there is some debate about how state-by-state licensures relate to counselors in cyberspace. Sussman (1998) raises the question about enforcing legislation on counselors in one state who counsel clients in another state. Who would a client complain to about a counselor practicing from a different state (Sampson et al., 1997)? Sampson et al. (1997) propose that state licensing boards will have to address the possible need for a license to practice cybercounseling. If it is determined that a license is needed, how could this be enforced? The California Telemedicine Act, as previously mentioned, does not mandate insurance coverage for services rendered from another state. As a result, clients in California must receive cybercounseling from an in-state counselor in order for their treatment to be covered under the telemedicine legislation (Sussman, 1998). All of these controversies add to the challenges that cybercounselors face.

Competence

Both Hines (1994) and King et al. (1998) discuss the issue of professional competence in using new technology. They relate the ethical concerns, as stated in the code of ethics by the American Association for Marriage and Family Therapist (AAMFT) and by the American Psychological Association (APA), for using telephones o4 e-mail as the medium for therapy. In this discussion, the concerns for using the Internet for counseling will be related to the American Counseling Association's (ACA) Code of Ethics and Standards of Practice. With respect to compete@ce, the ACA code states the following:

C.2. a. Boundaries of Competence. Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience....

b. New Specialty Areas of Practice. Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and to protect others from possible harm (ACA, 1995, 1997).

These statements illustrate the ethical challenges that cybercounselors face because of the nature of their work and the lack of training and supervision available in this area. Childress ( 1998) purports that the lack of training in this type of counseling intervention may affect both the quality of clinical care provided and the counselor's potential liability (paragraph 16). King et al. (1998) add that professionals can take extra steps to ensure competence by monitoring the client(s) carefully to determine whether or not they remain comfortable with this approach and are in fact benefiting from it (p. 46). Furthermore, counselors should obtain close and frequent consultation to compensate for the lack of available formal training in this emerging area (p. 46).

Premature Termination

Cybercounselors might be applauding the ease with which they can communicate with their clients via the Internet, but the clients can just turn them off. Premature termination remains a possibility with clients, even in face-to-face counseling. The ease with which a session can be discontinued, however, actually may encourage premature termination when difficult issues are identified or in reaction to confrontation (Sampson et al., 1997, p. 211). To try to decrease this possibility, counselors can take preventive measures at the beginning of cybercounseling. King et al. (1998) propose that counselors should secure a commitment from remote family members to remain in treatment until the entire family is ready for termination. But how do you secure this commitment from an individual? Sussman (1998) offers this dilemma as a good argument for obtaining identifying information and contact information about the client prior to beginning the counseling process (paragraph 4).

INTERNET RESOURCES

Cybercounseling is not the only way counselors can use the Internet in their practice. The Internet is a powerful resource that anyone can use to access information. This component of the Internet is an invaluable tool for counselors, clients, and family members to find out more information about specific topics. Jackson and Dacidson (1996) describe the Internet as "the world's largest library and the availability of psychology-related bibliographies, abstracts, full-text journal articles, lectures, research projects, and funding sources is currently a 'mouse click' away from your desktop" (paragraph 4). In this forum, to give a comprehensive listing of available resources would be impossible. Neverthe less, there are some very good places for a counselor, client, or family member to start looking.

The American Counseling Association's web site (www.counseling.org) offers a wide variety of resource for the counselor, including professional news and information, access to the Journal of Counseling and Development, and resources for students and professionals alike. The National Board of Certified Counselors (www.nbcc.org) is another great resource for counselors who are looking for general information. The American Psychological Association (www.apa.org) and the American Psychiatry Association (www.psych.org) both offer a multitude of psychologicallly related information.

Counselors looking for area-specific information can try sites such as the Substance Abuse and Mental Health Services Administration (SAMHSA) (www.samhsa.gov), which offers many free informational resources that can be ordered, and the National Institute of Mental Health (www.ninh.nih. gov). Also, several sites provide a multitude of other behavioral health links: Mental Health Network (mentalhelp.net), the Knowledge Exchange Network (KEN) (www.mental health.org), Dr. Grohol's Mental Health Page-PsychCentral (psychcentral.com), and Dr. Bob's Mental Health Links (uhs. bsd.uchicago.edu/-bhsiung/mental.html). A great site for information about children and mental health is the American Academy of Child and Adolescent Psychiatry (www.aacap.org).

With all web sites available to help clients and family members, counselors should check out the sites prior to recommending them as a resource. In addition to the sites just listed, counselors and clients can access mental healthrelated information by conducting a search of the Internet at sites through Yahoo (www.yahoo.com) or another search engine. Furthermore, clients can become involved in discussion groups or support groups that operate online. As mentioned, the type of support offered in these groups can be helpful, but clients also might receive information or support that does not add therapeutic value to their counseling process (Lebow, 1998).

CONCLUSION

The Internet is an amazing way to access people and information around the world. This tool also has become a medium for conducting counseling, in various forms, without the need for face-to-face contact with a counselor. As the professional community debates use of the Internet to provide counseling, clients currently are receiving help in an unregulated arena. We have looked at some of the positives and negatives of cybercounseling, as well as the ethical issues that cybercounselors face.

This dilemma has no simple solution. At best, counselors are left to their own professional judgment about participating in cybercounseling. Some steps have been taken to increase the professional community's involvement, such as the Ethical Codes and Standards from NBCC. Nevertheless, much remains to be done. The lack of research in this field makes it difficult for counselors to effectively weigh their decisions about cybercounseling.

Despite the pitfalls, the Internet can provide counselors, clients, and family members the ability to receive information and support from globally located sources. The opportunity for counselors to receive supervision and consultation from many resources seems to be a positive step for the profession. Similarly, some benefits exist for using counseling as an adjunct to face-to-face therapy.

Use of the Internet to conduct counseling activities is by far the most controversial of possible uses of the Internet. The issues of relationship-building, miscommunication, confidentiality, and counselor competence are just a few of the challenges facing cybercounselors. But the profession has to be willing to research and fully examine this intervention method (Lee, 1998; Sussman, 1998). With this technology already in place and new possibilities on the horizon, counselors have to take an active role in guiding this new method of service delivery (Sussman, 1998, paragraph 16). As revealed in this discussion, counselors must explore and understand many issues about this technology. Regardless of whether each individual counselor chooses to practice via the Internet or not, the professional community must be prepared to address this topic and explore the possibilities the Internet has to offer.

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Sheryl Harper, MAEd, NCC, is a graduate of the Counselor Education program at Wake Forest University, Winston-Salem, North Carolina. She currently resides and works in Chapel Hill, North Carolina. I

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