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Counselling Psychology Quarterly

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Online counseling: The good, the bad,

and the possibilities
a a
Kurt D. Baker & Mike Ray
a
Department of Psychology and Child Development, California
State University, Stanislaus, Turlock, CA, USA

Version of record first published: 02 Dec 2011

To cite this article: Kurt D. Baker & Mike Ray (2011): Online counseling: The good, the bad, and
the possibilities, Counselling Psychology Quarterly, 24:4, 341-346

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 Counselling Psychology Quarterly
Vol. 24, No. 4, December 2011, 341–346

BRIEF COMMUNICATION
Online counseling: The good, the bad, and the possibilities
Kurt D. Baker* and Mike Ray

Department of Psychology and Child Development, California State University,

Stanislaus, Turlock, CA, USA
(Received 1 October 2010; final version received 27 August 2011)

Online counseling is becoming more and more pervasive. Some see this
trend as positive while others are concerned with the quality and ethical
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issues related to providing counseling online. This article reviews the pros
and cons of providing counseling services online, and whether practitioners
and researchers are for or against such practice. It recognizes that it is not
only occurring, but it also will likely increase in prevalence regardless of the
potential drawbacks. The case is made that since it is here to stay, we
should study the phenomenon because, good or bad, it provides a unique
opportunity to study counseling and psychotherapy.
Keywords: online counseling; internet counseling; email counseling;
online psychotherapy

There is little doubt that the internet has ushered in a new era, not just in the form of
an information revolution, but in the business realm as well. The provision of
psychotherapy has also been shaped by the contemporary forces of the internet.
However, an understanding of how the internet has changed the practice of
counseling has not fully emerged; in particular, when it comes to providing services
directly to clients online. This article aims to explicate the benefits and liabilities
related to online counseling and to invite the reader to consider opportunities in
studying this phenomenon.
While the internet is commonly used to obtain information and self-help ideas
about health and mental health topics, this article will focus on the intentional
exchange of information intended to remedy a problem the client presents to the
counselor or therapist. While some would consider it inappropriate to call this
exchange counseling, others find it appropriate at least to compare conceptually the
delivery of services via the internet with face-to-face counseling or psychotherapy
(e.g., Ainsworth, 2004; Andersson, Carlbring, & Grimlund, 2008; Rochlen, Zack, &
Speyer, 2004). In addition, while professionals may see many differences, clients most
likely would not make such a clear distinction.

Features and methods of online counseling

The internet allows for variety of methods to be used in the delivery of mental
health services. The most commonly used method is email (Ainsworth, 2004;

*Corresponding author. Email: kbaker@csustan.edu

ISSN 0951–5070 print/ISSN 1469–3674 online

ß 2011 Taylor & Francis
http://dx.doi.org/10.1080/09515070.2011.632875
http://www.tandfonline.com
 342 K.D. Baker and M. Ray

Maheu & Gordon, 2000; Rochlen et al., 2004; Stofle, 2001). In addition, service
providers use chat, instant messaging, web message boards also described as bulletin
boards or forums (Bewick, Trusler, Mulhern, Barkham, & Hill, 2008), and to a
limited extent, online videoconferencing. Perhaps the economic availability of Skype
makes video-conferencing more appealing and affordable. Mental health services
rendered via the internet can be used as a stand-alone method of treatment or as an
adjunct to traditional counseling. Two major types of online mental health services
are counseling and assessment (Heffner Media Group, 2003). The latter parallels its
real-world counterpart quite closely. That is, completing an online questionnaire is
similar to completing the same questionnaire using paper and pencil.
One of the most powerful arguments for providing online counseling is the
widespread accessibility of such services. As with any online service, mental health
services are not constrained by geography, but rather by access to a computer with
an internet connection. This pervasive availability makes services accessible to
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individuals in rural, under-served areas, as well as giving the client access to

information any time (Alleman, 2002; Sampson, Kolodinsky, & Greeno, 1997).
Some clients might even be more likely to benefit from a remote treatment modality
in initial therapeutic contact (Andersson, Bergström, et al., 2008).
One downside to this broader availability is that the most internet services are not
conducted in real time, meaning that even though the client can send email and read
the reply any time, the lag time for a response could be hours, days, or even longer.
Automated responses are one way to solve this problem, and have been compared
favorably to human online responding (Tate, Jackvony, & Wing, 2006).

The therapeutic relationship

There is no question that the client–therapist relationship is very different when
counseling services are provided over the internet. The most obvious difference is the
lack of non-verbal cues (Liess et al., 2008). While this clearly adversely affects the
techniques used in traditional counseling, some have argued that such drawbacks are
at least partially offset by favorable characteristics of text-based communication. For
example, some have argued that clients disclose at an accelerated rate when making
contact via email (Rochlen et al., 2004) and that online support groups may have a
‘‘disinhibiting effect’’ (Barak, Boniel-Nissim, & Suler, 2008). Apparently, clients are
more likely to get right to the point rather than gradually ease into their statement of
the problem (Rochlen et al., 2004; Suler, 2004). This disclosure may be
emotionally significant despite being text-based (Bar-Lev, 2008). Disclosure may
be enhanced by the perceived anonymity clients may experience by not being
physically seen or by not having to reveal their identity. Disclosure may be further
facilitated by systematic presentation of web-based forms (Joinson, Paine,
Buchanan, & Reips, 2008). Additionally, implicitly requiring the client to articulate
their concerns in written form may create a more reflective stance on the part of the
client (Rochlen et al., 2004). Written communication allows clients to consider what
they are ‘‘saying’’ and revise their statements without worry of it coming out wrong
the first time. This is also true of communications made by the therapist.
While there may, in fact, be positive aspects to conducting counseling via a
written medium, the known powerful effects of the therapeutic relationship (Lambert
& Ogles, 2004; Orlinsky, Rønnestad, & Willutzki 2004) may partially or completely
 Counselling Psychology Quarterly 343

disappear. In addition, because email communications are devoid of their non-verbal

context, they are liable to be very easily misinterpreted or misconstrued. For this
reason, both the therapist and the client must have at least a minimal ability to
clearly articulate themselves via written language (Rochlen et al., 2004). The lack of
cues may itself relate to a higher level of client empowerment, which in turn might
foster a larger sense of client control over their treatment (Barker, 2008).
Additionally, factors such as whether the online moderator is a peer or professional
may also influence client comfort in emotional disclosure and participation
(Lieberman, 2008). Overall, a subjective sense of empowerment seems to be reported
in multiple online support group types (van Uden-Kraan, Drossaert, Taal, Lebrun,
et al., 2008; van Uden-Kraan, Drossaert, Taal, Shaw, et al., 2008).
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Legal and ethical considerations

Perhaps the most difficult issues in providing mental health services via the internet
come in the area of legal and ethical factors. There are several issues related to
jurisdiction, licensing, and regulation that are not easily resolved (Corey, Corey, &
Callahan, 2010). For example, if a client resides in a country or state other than the
treatment provider, in which jurisdiction must the counselor or therapist be licensed?
What if the client resides in one country, but checks her email while traveling in
another altogether? If problems or violations in the course of treatment occur, which
regulatory body has jurisdiction? In addition to licensing boards not being clear on
the parameters of their jurisdiction (Grohol, 1999), most codes of ethics from
professional organizations have very little to say about online counseling and
psychotherapy (Corey et al., 2010).
Beyond jurisdiction and licensing issues, there are numerous other legal and
ethical concerns. At the forefront of these concerns is the very high risk of
compromised confidentiality. Even if a clinician uses encrypted email, how can she
be assured that no one else can access the client’s email account? Additional legal and
ethical concerns include the lack of adequate processes for crisis assessment and
referral by many providers (Maheu & Gordon, 2000), difficulty in accurately
assessing clients in the absence of face-to-face interviews (e.g., suicidal risk,
diagnostic indicators, suitability to online treatment, client’s honesty regarding, for
example, their age, etc.; Heinlen, Welfel, Richmond, & Rak, 2003). While therapists
ethically avoid abandoning their clients, technological difficulties (e.g., broken
internet connection) may isolate a client for extended periods or even force the
termination of treatment altogether (e.g., dead computer).
Although there are numerous online practitioners, there is very little efficacy or
effectiveness data for online treatments (Rochlen et al., 2004). The few studies that
have shown positive results have lacked sufficient controls. In fact, the dearth of
adequate research in this area led Rochlen et al. (2004, p. 280), proponents of online
counseling, to conclude that the effectiveness of online treatments is ‘‘largely based
on anecdotal evidence with limited empirical data supporting their validity.’’
However, some studies have tended to support a variety of positive effects in
psychoeducation and social support, such as reducing binge drinking (Bewick et al.,
2008), providing online psychoeducational support to infertile women (Cousineau
et al., 2008), providing an online support group for problem drinkers (Cunningham,
 344 K.D. Baker and M. Ray

van Mierlo, & Fournier, 2008), an online cancer community (Ginossar, 2008), and
other areas.

Possibilities
In spite of the many liabilities and risks outlined above, mental health services
continue to be offered via the internet. While the exact number of online counseling
practitioners, online psychoeducational websites, social support groups and web-
boards is difficult to assess, estimates are in several hundreds (Sampson et al., 1997)
to hundreds of thousands (Barak et al., 2008). Naturally, it is believed that such
services will continue to increase in number (Sampson et al., 1997). Therefore, there
is a pressing need to adequately address risks to confidentiality, develop clear policy
regarding regulation of such practice, focus research efforts on determining the
effectiveness of online counseling, and establish standards of best practices regarding
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the provision of online counseling. However, there is very little research that actually
addresses any of these issues. In the absence of sound research, policy and practice
will continue to be based on assumptions and historical precedent. In other words,
because such services are rolling forth without these major issues being addressed, it
behooves the research community to examine what is happening in online
counseling.
In fact, the provision of online counseling may provide quite unique
opportunities for research. Researchers have long been searching for the ‘‘active
ingredients’’ in effective counseling. Comparing online and face-to-face counseling is
a ready-made examination of specific components of treatment. Online counseling
opens the door to a new range of so-called dismantling studies, because, by its very
nature, it is a dismantled version of traditional counseling. Outcome studies have
often compared treatment to some form of placebo condition, but it is unclear in the
interpersonal domain of counseling what exactly constitutes a placebo. Could online
counseling be a valuable alternative comparison to what is known as attention
placebo? While most would argue online counseling should not be considered a
placebo condition per se as outlined above, it clearly has aspects of treatment that
differ in substantial ways from traditional counseling. Because online counseling
removes most of the interpersonal features of counseling, it provides new territory
for the study of common factors. Detailing and researching the commonalities
between online and face-to-face counseling could enlighten us about not only the
process and outcome of online treatment itself, but perhaps just as powerfully
provide insight into the process and outcome of traditional counseling and
psychotherapy.

Notes on contributors
Kurt D. Baker is an associate professor of psychology at California State University,
Stanislaus. He earned his Bachelor of Arts degree in psychology from Utah State University in
1984 and his Master of Science degree in 1990 and Doctor of Philosophy degree in 1994 from
the University of Memphis in clinical psychology. He is currently the director of clinical
training for the masters program in psychology at California State University, Stanislaus. He
also works as a part-time licensed psychologist at Kaiser Permanente.
Mike Ray is a graduate student of psychology at California State University, Stanislaus. He
earned his Bachelor of Arts degree in art from San Francisco State University in 2005. He is
 Counselling Psychology Quarterly 345

currently working in the technology field in Sunnyvale, CA at a computer software and

hardware manufacturer while completing his thesis research.

References

Ainsworth, M. (2004). E-therapy: History and survey. Retrieved from http://www.meta-

noia.org/imhs/history.htm
Alleman, J.R. (2002). Online counseling: The internet and mental health treatment.
Psychotherapy: Theory, Research, Practice, Training, 39, 199–209.
Andersson, G., Bergström, J., Buhrman, M., Carlbring, P., Holl, F., Kaldo, V., . . . , Waara, J.
(2008). Development of a new approach to guided self-help via the Internet: The Swedish
experience. Journal of Technology in Human Services, 26, 161–181.
Andersson, G., Carlbring, P., & Grimlund, A. (2008). Predicting treatment outcome in
Internet versus face to face treatment of panic disorder. Computers in Human Behavior, 24,
Downloaded by [Indiana Universities] at 07:13 01 August 2012

1790–1801.
Barak, A., Boniel-Nissim, M., & Suler, J. (2008). Fostering empowerment in online support
groups. Computers in Human Behavior, 24, 1867–1883.
Barker, K.K. (2008). Electronic support groups, patient-consumers, and medicalization: The
case of contested illness. Journal of Health and Social Behavior, 49, 20–36.
Bar-Lev, S. (2008). ‘‘We are here to give you emotional support’’: Performing emotions in an
online HIV/AIDS support group. Qualitative Health Research, 18, 509–521.
Bewick, B.M., Trusler, K., Mulhern, B., Barkham, M., & Hill, A.J. (2008). The feasibility and
effectiveness of a web-based personalised feedback and social norms alcohol intervention
in UK university students: A randomised control trial. Addictive Behaviors, 33, 1192–1198.
Corey, G., Corey, M.S., & Callahan, P. (2010). Issues and ethics in the helping professions.
Belmont, CA: Brooks Cole.
Cousineau, T.M., Green, T.C., Corsini, E., Seibring, A., Showstack, M.T., Applegarth,
L., . . . , Perloe, M. (2008). Online psychoeducational support for infertile women: A
randomized controlled trial. Human Reproduction, 23, 554–566.
Cunningham, J.A., van Mierlo, T., & Fournier, R. (2008). An online support group for
problem drinkers: AlcoholHelpCenter.net. Patient Education and Counseling, 70, 193–198.
Ginossar, T. (2008). Online participation: A content analysis of differences in utilization of
two online cancer communities by men and women, patients and family members. Health
Communication, 23(1), 1–12.
Grohol, J.M. (1999). Best practices in eTherapy: Legal and licensing issues. Retrieved from
http://psychcentral.com/etherapy/best4.htm
Heffner Media Group (2003). Guide to online psychology. Retrieved from http://allpsych.com/
onlinepsychology.html
Heinlen, K.T., Welfel, E.R., Richmond, E.N., & Rak, C.F. (2003). The scope of
webcounseling: A survey of services and compliance with NBCC standards for the ethical
practice of webcounseling. Journal of Counseling & Development, 81, 61–69.
Joinson, A.N., Paine, C., Buchanan, T., & Reips, U. (2008). Measuring self-disclosure online:
Blurring and non-response to sensitive items in web-based surveys. Computers in Human
Behavior, 24, 2158–2171.
Lambert, M.J., & Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In
M. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change
(5th ed., pp. 139–193). New York, NY: Wiley.
Lieberman, M.A. (2008). Effects of disease and leader type on moderators in online support
groups. Computers in Human Behavior, 24, 2446–2455.
Liess, A., Simon, W., Yutsis, M., Owen, J.E., Altree Piemme, K., Golant, M., & Giese-Davis,
J. (2008). Detecting emotional expression in face-to-face and online breast cancer support
groups. Journal of Consulting and Clinical Psychology, 76, 517–523.
 346 K.D. Baker and M. Ray

Maheu, M., & Gordon, B. (2000). Counseling and therapy on the Internet. Professional
Psychology: Research and Practice, 31, 484–489.
Orlinsky, D.E., Rønnestad, M.H., & Willutzki, U. (2004). Fifty years of psychotherapy
process-outcome research: Continuity and change. In M. Lambert (Ed.), Bergin and
Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307–393).
New York, NY: Wiley.
Rochlen, A.B., Zack, J.S., & Speyer, C. (2004). Online therapy: Review of relevant definitions,
debates, and current empirical support. Journal of Clinical Psychology, 60, 269–283.
Sampson, J., Kolodinsky, R.W., & Greeno, B.P. (1997). Counseling on the information
highway: Future possibilities and potential problems. Journal of Counseling and
Development, 75, 203–211.
Stofle, G. (2001). Choosing an online therapist: A step by step guide to finding professional help
on the web. Harrisburg, PA: White Hat Communications.
Suler, J.R. (2004). The online disinhibition effect. Cyber Psychology and Behavior, 7, 321–326.
Tate, D.F., Jackvony, E.H., & Wing, R.R. (2006). A randomized trial comparing human
Downloaded by [Indiana Universities] at 07:13 01 August 2012

e-mail counseling, computer-automated tailored counseling, and no counseling in an

Internet weight loss program. Archives of Internal Medicine, 166, 1620–1625.
van Uden-Kraan, C.F., Drossaert, C.H.C., Taal, E., Lebrun, C.E.I., Drossaers-Bakker, K.W.,
Smit, W.M., . . . , van de Laar, M.A.F.J. (2008). Coping with somatic illnesses in online
support groups: Do the feared disadvantages actually occur? Computers in Human
Behavior, 24, 309–324.
van Uden-Kraan, C.F., Drossaert, C.H.C., Taal, E., Shaw, B.R., Seydel, E.R., & van de Laar,
M.A.F.J. (2008). Empowering processes and outcomes of participation in online support
groups for patients with breast cancer, arthritis, or fibromyalgia. Qualitative Health
Research, 18, 405–417.