Despite these concerns, fee based online therapy appears to be
a growth industry. There are strong indications that it is increasing
the current client base for therapy by making services available or appealing
to populations that previously would not use them. John Grohol, past president
of the International Society for Mental Health Online (ISMHO), and a
prominent academic and therapist, told the online journal New Therapist
in 2000 that he expects the number of on-line therapy providers to grow
from the then current 300 worldwide to over 5,000 by 2005. (in Dunaway,
2000). Numbers in Australia are currently small, with the recent comprehensive
search reported here identifying 20 fee-for-service sites.
On line counselling is currently present in three
1. Email question and response - with many sites offering
discounts on multiple emails.
2. Chat programs such as ICQ, in which an appointment is made and generally
paid for before counsellor and client "meet" on line, using solely text
based exchanges for a specified amount of time. This is evolving into secure
Web based messaging.
3. Video or audio links in which counsellor and client are visible
over a web based camera. However, synchronous video based consultations
seems to be more fantasy than reality at present, particularly on Australian
Counselling sites may offer a variety of facilities. Sussman (1998)
reported a diverse range of US based therapy sites. At the most sparse
and probably unethical end was a site with an anonymous "therapist," who
solicits e-mail to which he or she then responds to for $20. Other sites
offer prepackaged intervention programs using workbooks or videos as well
as online interaction. There is at least one site offering this type of
service in Australia, with free email support once a self-help package
for alcohol abuse is purchased. Other sites are extensions of the
physical world practices of registered psychologists, or psychiatrists.
Many sites offer choices of E-mail, private "chat" rooms, telephone, a
few offer real-time audio or video, with one even offering a "virtual
office which adds a dimension of objective presence" (Counselling at Distance).
What factors differentiate on-line counselling from traditional counselling?
Some characteristics of on line counselling are definitely advantageous
to either client or provider, whilst others are either disadvantageous
Practically speaking, online counseling offers accessibility and convenience
to many clients. Costs are usually lower than face-to-face counselling
due to reduced overheads. The lack of travel requirements means improved
access to services for people in remote areas or people who are housebound
due to disability or family commitments. People who travel extensively
and/or who have time constraints may utilize on-line therapeutic services
because they can be accessed from wherever they happen to be.
Others who may prefer on-line therapy are people who are ambivalent
about therapy, or uncomfortable with the traditional model of counselling.
These range from people who are mildly uncomfortable with talking about
their problems face-to-face, to people suffering from serious mental health
conditions, such as agoraphobia, social phobias or anxiety disorders. A
London psychiatrist surveyed patients with obsessive-compulsive disorder
and phobic anxiety disorders and found that 91% preferred receiving services
via interactive voice response, the Internet, or home computer over face-to-face
treatment (Graham, 2000). However, many professionals would dispute
whether it is in the clients best interest to use services which allow
them to continue in possibly harmful behaviours.
In fact, there is widespread concern about on-line counselling in professional
circles, especially regarding issues such as:
- the potential for unqualified individuals to take advantage of vulnerable
- the possibly inferior nature of counselling possible over such a
- the possibility of people with serious disorders such as violent
or suicidal impulses being sidetracked from getting urgently needed help.
It is evident that on line counselling differs from traditional counselling
in many ways. One of the most intriguing aspects of this is that many characteristics
seem to be either good or bad, depending on a variety of factors such as
the nature of the client, the problem, and the expertise of the counsellor.
The characteristics of on line counselling which seem to be significant
are as follows:
Absence of visual and auditory cues.
With the qualified exception of video-conferencing (discussed later), on
line counselling lacks visual and auditory cues. Traditional counselling
relies heavily on characteristics such as tone of voice, facial expression,
body language, eye contact and even silences to communicate information
that words may be unable to. Simple examples of this are the person
who speaks loudly and rapidly, but says they are relaxed, or the person
who slumps in their seat looking dejected but says they are fine. These
are just the tip of an iceberg of non-verbal communications the client
would usually convey. This absence of visual and auditory clues
also produces a strong sense of invisibility and anonymity which together
often produce disinhibition in on-line communications. Grohol stated: "People's
communications on the [Internet] are more disinhibited than they are in
real life…Clients get to the point in e-therapy in the first correspondence."
(in Dunaway, 2000). Invisibility means the client does not have to
worry about how they look or sound, nor do they have to cope with seeing
the therapists reaction. This is an interesting parallel to traditional
psychoanalysis, in which the analyst sits unseen behind the patient, allowing
the patient to say anything they wish without feeling inhibited by
the analyst's reaction. This disinhibition is also reflected in the prevalence
and success of telephone crisis counselling which operates with limited
physical cues. However, in common with the telephone, communicating only
with typed text allows people to suppress or cover up parts of their identity
or even assume an imaginary identity without fear of being "seen through".
Invisibility and disinhibition of course may affect therapists as well
as clients. It has been pointed out by a number of researchers in the field
(eg Pelling, 2001) that it can be very difficult for clients to assess
the legitimacy of on line counsellors. There is some evidence that para-professionals,
often considered unqualified for other counselling positions, are looking
to online counselling for business opportunities. Metanoia , a website
associated with the ISMHO, purports to offer a independent consumer
guide to Internet therapists, and has developed a Credentials
Check for therapists listed through their site.
The counselling environment.
The counsellors office environment will generally ensure privacy and lack
of interruption to the session. A client participating in a session from
their home could be subject to many different interruptions, including
those that will threaten the privacy of the session, such as household
members entering the room. Conversely, clients may be far more comfortable
in their own home, or an environment of their choice over which they feel
a strong sense of control.
Two noticeable feature of many email counselling services are a promised
maximum response time (often a few days), and a limitation on the
number of emails which will be responded to within a certain time frame.
For the client, experiencing delays of days between their possibly momentous
(for them) disclosures or insights and the therapists response may be quite
uncomfortable. This may be accentuated by the perceived immediacy
of Email - that it can be received within seconds of sending. Even using
a chat program , delays of seconds to a minute may be common. Conversely,
the time it takes to type a response, or the knowledge that a response
to this email will cost you $40 may both tend to encourage deeper reflection
than a spontaneous verbal reaction.
The fantasy therapist
Transference and countertransference are important aspects of psychotherapeutic
work. On line this can become even more important and difficult to control.
When clients visit a counsellor in their office, they immediately learn
a lot about them. Physical characteristics such as gender , age, ethnicity,
office décor, qualifications on the wall, and the myriad of other
details give an overall picture of the person. Conversely, often the only
information you have about an online therapist is a name and/or one (self-selected)
photograph. This will tend to result in the client "filling in the gaps"
with imagined qualities and characteristics, shaped by their own
needs. These may create an idealized or even at times a demonized
E-mail, chat sessions, and videoconferencing can be recorded and saved
to a file, and several sites give clients directions on how to save their
chat sessions. This is in marked contrast to traditional therapy in which
the therapist will take notes for their own use, and the client generally
relies on their memory of the session. Whilst clients can and do request
copies of the therapists notes, this is not common practice. Client recordings
of sessions may create new problems such as a client forwarding emails
from their counsellor to others. These emails would very likely be tailored
specifically for the clients situation and may not be applicable to another
person. They also may become effectively public material without the therapist
ever having intended them for a public forum. However, from the clients
point of view, recorded sessions allows them to review the session later
and possibly gain much more therapeutic benefit.
Computers and computer networks often fail to deliver an acceptable level
of service in areas such as response time or error rate and sometimes fail
completely. Whilst an occasional missing email would create some difficulties,
disruption to chat or video sessions would be far more intrusive and potentially
distressing to clients. One Australian site has reverted entirely to email
based counselling, stating that disruptions to the service had made chat
Only one Australian site, Sydney based "Webcounselling"
included a policy on their web site addressing this problem. The policy
allows for the rescheduling (at no cost) of sessions interrupted within
10 minutes of commencement, a discount applying to a subsequent session
if the interruption occurs between 10 and 45minutes, and any time lost
to interruption after 45 minutes is added to a subsequent consultation.
Confidentiality and security.
Client confidentiality is a major concern in the provision of counselling
services. Clients who reveal their most deeply felt and/or possibly shameful
(to them) thoughts and feelings may well fear the deliberate or accidental
disclosure of these. Written records or more recently computer based electronic
records have been subject to exacting ethical requirements with regard
to storage and disclosure to others. Therapists rooms are generally set
up to ensure considerable privacy for the client, with private rooms, locked
filing cabinets, and password protected computer programs. Internet communications
however, are not secure. TCP/IP by design is not a secure protocol, and
all data that travels between the client and counsellor is exposed to potential
hackers unless the therapist and client use additional security measures.
Most commonly used Email and Instant messaging systems do not support
authentication and encryption.
Several Australian sites carry warnings to clients that
forms they submit regarding their problems are not secure. Others assure
clients their system is secure, whilst others do not even acknowledge the
problem. Although secure systems are available for both email and chat
programs, they are not in widespread use. Encryption of Email requires
both client and providers to download and set up the software and this
may discourage users. Some sites utiIize products such as ZixMail
which enables the exchange of encrypted and digitally signed communications
using existing email systems. Some sites use SSL (Secure Sockets Layer)
for forms which provides security for information, including credit card
numbers. However, a number of Australian sites which used this technology
came up with errors such as expired certificate, and messages that the
site name and the certificate name did not match - unlikely to inspire
confidence in a person seeking confidential communications.
Browser -based secure instant messaging systems are becoming available
in response to concerns about confidential communications between and within
businesses, and some Australian sites are using these. Although largely
text based at present, audio and video support also exist. Compatibility
has been a problem with most security solutions - both parties must
be using the same software. However, there are now moves towards standardization
with the Session Initiation protocol for Instant Messaging and Presence
Leveraging Extensions (SIMPLE) standard. This proposed format enables users
to use the Internet for voice exchanges and establish conferences.
Efficacy of on-line therapy
Given the known problems and the lack of studies to date, it is very difficult
at present to make any definitive statements about the efficacy of online
therapy. Many counselling sites carry statements to this effect, some warning
that they do not believe it can be as effective as face-to-face counselling.
However, a few studies of the use of telepsychiatry and interactive
television show comparable efficacy to traditional psychotherapy
(Yellowlees, 2001). It does seem that the biggest single factor working
against on-line counselling is the lack of visual and auditory information.
Instant message software is currently undergoing rapid development, including
video support, allowing the transmission of real-time video. Interestingly,
video mediated web counselling may destroy what is most appealing for some
clients and even some therapists - anonymity and invisibility. As Suler
asks" How will the ability to see and hear other people on the internet
change cyberspace? Will people WANT to give up those spaces that lack face-to-face
cues but are rich in imaginative ambiguity?" (Suler, 2000). Nevertheless,
many therapists see low-cost video conferencing as the complete solution
to on line counseling’s problems (Dunaway, 2000). However, this ignores
the seemingly obvious problem of lack of physical presence. Clasping
a hand, or passing a tissue to a weeping client is a common experience
for many counsellors and one that virtual reality is a very long way from
duplicating. Studies have also shown that many people are uncomfortable
in video mediated communications, even aside from factors such as
video and audio quality (e.g. Fish,Kraut & Root, 1993, Gedge
& Abramson, 2001). Full screen video mediated counselling may not be
the panacea that some counsellors expect.
Ethical and professional guidelines and codes of ethics.
A number of major national and international bodies have produced guidelines
and/or codes of ethics for practitioners providing internet based counselling
services. These include The Australian Psychological Society, the premier
professional body representing psychologists, The American Counseling
Association, the American Psychological Association and the National Board
of Certified Counsellors. A consultative group of the British Association
for Counselling and Psychotherapy in their Guidelines make the point that
rather than requiring less qualifications, online counselling may require
further specialized training and experience.
Globally versus locally focused services.
As with many Internet services, national boundaries may seem somewhat irrelevant
to the practice of online counselling. However, unlike many other businesses
a local presence may be the biggest single factor which causes a client
to choose a service. There have been no studies published to date which
examine this within the Australian context but many on-line sites are extensions
of physical world clinics and practices, and local clients are often
encouraged to seek face-to-face counselling. Familiarity with local culture
and prevailing national situation is probably also an important factor
in establishing a sense of rapport between therapist and client.However,
one Australian site has published an interview conducted with an overseas
client, who had previously had an online therapist based in the US. This
therapist's charges had become prohibitive and the favourable exchange
rate was the major reason for the client seeking a therapist in Australia.
If both client and counsellor are physically located in the same place,
local laws may apply to the counselling relationship. However, counsellors
may be based in different states or countries from their clients, and there
is no international law governing these type of transactions. In the event
that something goes wrong, at the present time, there is probably little
or no legal recourse against the counsellor. One Australian counsellor
specifies that he cannot counsel US resident clients due to laws operating
in the US.
Another major legal issues for both providers and clients is the question
of professional insurance cover and health fund coverage for on-line services.
At present, it seems that unless the insurance cover explicitly excludes
such services, professional malpractice insurance probably still applies.
However, no test cases appear to have been conducted to date. Health funds
are still grappling with the implications of on line health services.
Current situation in Australia
During the early part of 2002, a search was conducted for Australian based
on-line counselling services. Multiple different keywords and search engines,
including Australia specific engines, were used. Numerous free and
fee based services based in Australia were identified. Most free services
are additional new initiatives for existing community or church based services.A
total of 20 fee-for-service sites originating in Australia were identified
(There are probably others, but they are certainly not easy to find). Many
of the sites were identified with a physically based service. Of
these, NSW had the largest number with 7, Victoria had 4, 2 in Qld, one
each in Tasmania, ACT, and S.A. The other Australian hosted other sites
had no location identification.Table 1 summarizes aspects of these sites,
including counselling method, security provision for the clients counselling
data, identification of service provider and statements of qualifications,
the presence of legal disclaimers and ethical guidelines, and the fee structures.
Australian based services varied along many dimensions, from
highly professional sites with strict ethical guidelines and secure session
and payment facilities to dubious sites with no identification of
any practitioner. Most sites offers email exchanges (85%) , with 8 services
also offering chat either solely (15%) or in addition (25%), and
one offering videobased counselling. Several sites promised secure chat
lines and video counselling in the near future, but for several the promised
date of arrival had already passed. Only 4 sites (21%) provided secure
email or chat options.
Of the 20 sites, three (15%) had no identifying details whatsoever
for the providers.
Nearly all Australian providers require payment in advance, although
some offer free initial sessions. Payment was generally by credit card,
but only 8 (40%) specified secure payment options. Many failed to point
out the lack of security to clients, or dealt with it by using normal postal
service. Two providers used an escrow service where payment must
be authorized by the user once they were satisfied with the service. Legal
disclaimers were used by 11 sites (55%), whilst 14 (70%) has some sort
of statement about client rights and or limitations of the online counselling
A couple of the sites specified policies to deal with late/missed appointments.
One highly commercial site specified that the counsellor would allow five
minutes for lateness but will then be obliged to charge a cancellation
fee of AUD $30 if the appointment was missed or cancelled. Another site
specified cancellations must be made at least 1 hr before or full fee charged.
Some sites took considerable pains to distinguish their services from
others . For example one service was directed at the population of
gay , lesbian, cross dressing and sex change clients. The counsellor advertised
themselves as uniquely experienced, being a male to female change themselves.
Other services took a spiritual or holistic approach to counselling. Others
were highly commercial , with one using advertising such as " Accomplish
all your goals" "Transform stress to success". A number of sites had a
global focus, with links to currency converters and tables of International
time zones, whilst others specified Australian clients only.
55 p/h 150 p/m Escrow service
photo, Quals **
Full E. Guide
No ver quals
of client rights
No E. guide
p/ 2 emails
? no security?
id, no address
id, no address
registration + fee
no electronic pay't
no electronic py't
1-4 emails reducing
no electronic pyt
for 7 emails
50 p/h? secure
address, photos, quals
for 5 emails
70 p/h email
Table 1. On counselling services based in Australia.
The following five examples illustrate some of the features of current
on-line counselling in Australia.
WebCounselling, NSW (http://www.webCounselling.com.au/).
Webcounselling is a Sydney based service which appears to take the
on-line enterprise very seriously. They have a page devoted to outlining
the ethics of on line counselling, and address the question of qualifications
very prominently. This site has an international focus, with provision
for currency and time conversions. The counselling method is via chat ,
and the service uses encrypted software Betweenus to protect client session
data. The client also receives a new IP address each time the service is
used. The IP address is e-mailed to the client by the therapist a short
time before the appointment. The software allows the client to save all
of chat session but clients are warned that the material is not secure
(ie not encrypted) once saved. The senior psychologist Bernard Coady
said "We're aiming the service at professional people who feel intimidated
by the thought of going to counselling. The Internet provides the
anonymity and a sense of control over the process which you don't
get in face-to-face counselling," …"We don't see Internet counselling as
appropriate for somebody with a mental illness. It's good for people going
through a life transition"( Coady, 2000) .
Journeys, Tasmania. http://www.ontas.com.au/journeys
The on-line service is an extension of an existing counselling practice
based in Hobart , and goes to considerable lengths to establish credentials.
There is a photograph of the principal counsellor, a description of his
qualifications (social worker), and what this means within the Australian
context. He also includes an extensive explanation of his therapeutic method.
The Hobart practice is advertised as available for local people and organisations
in face-to-face form. Several "stages" of counselling are offered, beginning
with a free downloadable self help questionnaire. An E-mail response to
the questionnaire, described as secure, costs $25.00. The final
stage is an E-mail counselling session of one hour costing $70.00. This
must be booked by appointment. Payment is by credit card only via
a secure encrypted credit card system. The site includes a statement that
a dedicated secure chat line will also be available in the future
McArthur Counselling service (http://www.nswcounsellingservice.org/).
This site had a lot of typographic and grammatical errors, and no address
or identification for any individual or organization. There are three vignettes
of counsellors, with only a first name, no photograph and qualifications
are vague. There was a very brief reference to confidentiality, but no
implementation details. All of this did not inspire confidence. Different
levels of service were offered, including free on line chat with a counsellor.
However, several attempts to register for this service failed and the advertised
fee-based secure chat line was also not operational at time of writing.
Susan Luchich, S.A. (http://users.senet.com.au/~sluchich/ )
This site advertises confidential internet counselling from anywhere,
and face-to-face counselling in Adelaide, South Australia. Qualifications
are specified along with a lot of personal information including personal
references. This was the only Australian site which offered counselling
via video link, specifying that the client must have microphone, web-cam
and supporting software. The site gave information about alternative time
zones for making appointments.
Dr Bob Rich, Vic (http://www.solutions.net.au/~bobrich/intercouns.html)
This site gave a lot of personal information including qualifications.
The counsellor no longer used a chat room as too many attempted sessions
had been disrupted. The site used an Email encryption program, Cryptext
, which the counsellor would send to clients. Payment was either by post
or registration with PayPal. This site was hosted by a commercial web hosting
service, Angelfire which generated advertising banners. This was the only
Australian site which had a WebAssured Seal of Assurance – an Internet
facility that monitors on-line business credentials. However, when clicked
on, it appeared that membership was not current.
On-line counselling in Australia is currently a small and largely email-
based enterprise, with a few chat based services. Further surveys are required
to collect actual usage data. As with many businesses on the Internet,
neither size nor location are necessarily important. Counselling clients
are no longer confined to the service just down the road. The greatly
increased choices of time, place and method in on-line counselling
may well open up this area of human services to a brand new population.
However, strategies specific to the Internet medium are required to encourage
clientele (Patterson,& Byrnes, 2000). It is vital for clients
to feel a sense of confidence and trust in their on-line counsellors. Those
sites with no photographs or identification of any sort seem to fly in
the face of this and look unlikely to succeed. Security for client data
and payment also need to be addressed seriously. It is difficult
to imagine a client talking or typing about their deepest fears or secrets
with no reasonable guarantee of confidentiality. Potential problems exist
for counsellors and clients where serious mental illness or life crises
are involved. Referrals to crisis services and salient warnings about the
limitations of on-line counselling are required on counselling sites. Integrating
a new on-line counselling business with an existing counselling business
is an emerging model and whilst it involves challenges, is probably
generating business on and off-line for some practitioners. Cheap and readily
obtainable on-line video may significantly increase the client base, although
for many people it would still not be the first choice for therapy. However,
increasingly e-therapy is likely to be seen as a significant supplement
to existing services.
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Renee Gedge, © 2002. The authors assign to Southern Cross University
and other educational and non-profit institutions a non-exclusive licence
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