Mallen, M. J. (2005) - Online Counseling, Reviewing The Literature From A Counseling Psychology Framework.

THE COUNSELING
10.1177/0011000005278624
Mallen et al. / ONLINE-COUNSELING
PSYCHOLOGIST RESEARCH
/ November 2005
Online Counseling:
Reviewing the Literature From a
Counseling Psychology Framework
Michael J. Mallen
David L. Vogel
Iowa State University
Aaron B. Rochlen
University of Texas–Austin
Susan X Day
University of Houston
This article reviews the online-counseling literature with an emphasis on current appli-
cations and considerations for future research. It focuses on primary themes of counsel-
ing psychology including the history of process-outcome research and multiculturalism.
It explores current gaps in the literature from a counseling psychology framework,
including the field’s focus on normal and developmental challenges and tasks, client
strength and resilience, education and career development, prevention and wellness, and
multiculturalism. In general, current evidence indicates that online counseling may be a
viable service option for some clients, especially those who are typically isolated; how-
ever, questions remain regarding the effectiveness and appropriateness of online
counseling.
Online-counseling services are currently being provided in a variety of

formats and are expected to increase in the next 10 years (Norcross, Hedges,
& Prochaska, 2002; Stamm, 1998). Clients are using videoconferencing,
synchronous chat, and asynchronous e-mail with professional psychologists
in place of or in addition to face-to-face (FtF) counseling. Yet the majority of
counseling psychologists are not involved in the provision of these services
(VandenBos & Williams, 2000), and few have investigated whether the ser-
vices are a viable means of client treatment. Several considerations arise
from these trends. First, other professionals or even quasi-professionals
online may provide mental and behavioral health services, and counseling
psychologists may be missing opportunities to reach new clients. Second, an
increasing number of individuals are exploring the Internet for mental and
Correspondence concerning this article should be addressed to Michael J. Mallen, Department of

Behavioral Science, Unit 1330, University of Texas M. D. Anderson Cancer Center, P.O. Box
301439, Houston, TX 77230-1439; e-mail: mjmallen@mdanderson.org.
THE COUNSELING PSYCHOLOGIST, Vol. 33 No. 6, November 2005 819-871
DOI: 10.1177/0011000005278624
© 2005 by the Society of Counseling Psychology
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820 THE COUNSELING PSYCHOLOGIST / November 2005
behavioral health services and information, and counseling psychologists are

not involved in ensuring that this mode of psychoeducation and prevention is
accurate and safe. This review of the available literature has shown online
counseling to be beneficial for some clients, but the body of knowledge has
not yet established online counseling as a truly effective mode of service
delivery. Counseling psychologists are in a unique position not only to
extend their services to online modes of treatment but also to conduct
research in this area to determine whether online-counseling practices are
therapeutically beneficial for clients. These new modes of service delivery
may offer counseling psychologists an innovative context for furthering the
field’s process-outcome research. This article begins to outline specific areas
of investigation that may allow counseling psychologists to further their
knowledge of what is and what is not therapeutic for clients.
Subsequently, this article’s purpose is to discuss online counseling (i.e.,
asynchronous e-mail, synchronous chat, and videoconferencing), to outline
and evaluate the research in this area, and to provide guidelines and a context
for future research from a counseling psychology framework. We offer a
brief overview of the telephone-counseling literature to provide a foundation
for the subsequent review of the online-counseling literature. The latter
begins with research that has examined online support groups and the poten-
tial for computer-mediated communication to facilitate emotional responses
and a sense of alliance among group members. We discuss studies that have
assessed client and clinician satisfaction with new modes of service delivery.
Next, we review the process-outcome research that has been conducted on
online counseling. Then, we review studies related to multiculturalism and
the access to new treatment modalities. Finally, we conclude with a section
regarding what is currently known about online counseling and a discussion
of important gaps in the literature from a counseling psychology perspective.
Specifically, we use counseling psychology’s focus on normal and develop-
mental challenges or tasks, client strength and resilience, education and
career development, prevention, consultation, psychoeducation, and
wellness to frame this review. By linking the available literature to counsel-
ing psychology’s unifying themes and the scientist-practitioner model, we
hope to integrate and synthesize the research while stimulating the reader to
consider how counseling psychology can define the future practice of online
counseling. We use the term online counseling throughout the article to
encompass the growing variety of therapeutic services currently offered. A
definition of online counseling can be found in the previous introductory
article (Mallen & Vogel, 2005 [this issue]).
Importantly, our goal with this article is not to advocate or to oppose
online counseling but to organize the relevant research findings into an acces-
sible format for counseling psychologists. Several articles have already sum-
Mallen et al. / ONLINE-COUNSELING RESEARCH 821
marized the debate and the various obstacles and challenges associated with
online counseling. For example, Rochlen, Zack, and Speyer (2004) listed
potential benefits and challenges of online counseling. Benefits included
convenience and increased access (Finfgeld, 1999; Jencius & Sager, 2001;
Pomerantz, 2002), the therapeutic effects of writing (L. J. Murphy & Mitch-
ell, 1998; Pennebaker, 1997; Wright & Chung, 2001), and the ability to link
clients to limitless multimedia resources (Grohol, 2002). Challenges
included lack of nonverbal cues (Alleman, 2002), possible minimization of
cultural static (Suler, 2001), misreading cues, time delays, technological
glitches (Griffiths, 2001), crisis management (Childress & Asamen, 1998),
and potential client or therapist deficiency in computer literacy (Manhal-
Baugus, 2001). The goal of this article is to synthesize and consider online
counseling specifically from a counseling psychology framework. We begin
with a discussion of the telephone-counseling literature to provide a founda-
tion for this analysis with a more commonly used technology of counseling
psychologists (VandenBos & Williams, 2000).
THE TELEPHONE IN COUNSELING
Although Internet-based technologies are currently increasing the

amount of services provided outside of the traditional FtF setting, the use of
distance technology in practice has been discussed in the literature for more
than 30 years. The telephone has a strong historical record in serving clients
and is a precursor to more sophisticated distance technologies. This discus-
sion, about the usefulness of the telephone for counseling services, has a
direct bearing on the issues related to online-counseling services. Today, the
telephone, also a distance-communication technology, has become a stan-
dard tool for most practitioners for tasks such as scheduling, consultation,
payment, crisis management, and even psychotherapy. In a survey of nearly
600 doctoral-level practicing psychologists who were members of the Amer-
ican Psychological Association (APA), 98% reported providing services by
telephone (VandenBos & Williams, 2000). The five primary health care ser-
vices for which practitioners most often reported using the telephone were
referrals (91%), emergency care (79%), consultation and education (71%),
individual psychotherapy (69%), and clinical supervision (58%). Thus,
today, the majority of practicing APA psychologists report using the tele-
phone not only to conduct routine business activities but also for the direct
provision of client care (i.e., crisis care and individual psychotherapy).
Despite the telephone’s being a common and relatively uncontroversial
method of communicating with clients, earlier writers vigorously discussed
the possible applications of the telephone including pitfalls and limitations
(Lamb, 1969; Rosenblum, 1969). Below, we review the literature related to

mental health and behavioral services provided by telephone, using the coun-
seling psychology framework and serving to highlight the current issues that
counseling psychologists must consider when using distance-communication
technologies to deliver these services. Our major topics involve research that
relates to effectiveness and beneficiaries, access to counseling and behav-
ioral services, and the ability to foster client strength, resilience, prevention,
and wellness.
Effectiveness of Telephone Counseling—Learning From the Past
One of the main debates in the telephone literature is whether telephone

counseling can be effective or as effective as FtF treatments. Sangha, Dircks,
and Langlois (2003), for example, studied the effectiveness of genetic coun-
seling by telephone with a sample of 24 pregnant women, finding that partici-
pants did not significantly differ on measures of their understanding of the
information presented and that both groups experienced a similar reduction
in reported anxiety on a 10-item questionnaire. The trial, however, was
nonrandomized. Because the study allowed patients to choose either tele-
phone or FtF counseling, it may be that patients who selected telephone
counseling were somehow different from those who chose FtF counseling;
however, demographic variables demonstrated rather homogeneous groups,
and no significant differences were found during the posttest evaluation,
indicating that the sample was representative of the population.
A second study by Reese, Conoley, and Brossart (2002) also compared
data from a nonrandom sample of 186 adult clients who received telephone
counseling to data from the Consumer Reports (CR) effectiveness study of
FtF psychotherapy (Seligman, 1995). The results from the telephone study
were significantly lower than the CR study in regard to how helpful the cli-
ents thought the intervention was but slightly higher in regard to their satis-
faction with the services provided. Yet, as the CR results are not a true com-
parison group to the individuals involved in the telephone-counseling study,
these findings need to be interpreted with caution.
As these studies demonstrate, one of the issues facing researchers examin-
ing the effectiveness of counseling through distance technologies is the diffi-
culty in directly comparing telephone counseling to the traditional FtF mode
of treatment. As such, several studies have investigated the effectiveness of
telephone counseling as an adjunct to traditional FtF treatments. For exam-
ple, Lovell, Fullalove, Garvey, and Brooker (2000) followed four middle-
aged patients diagnosed with obsessive-compulsive disorder. Patients were
delivered a single 45-minute FtF treatment session, eight weekly telephone
therapy sessions, and a final FtF session. Three clients improved with the
remaining one making minor improvements. The brief phone calls appear to
have facilitated client growth, but the small sample size reduces the power of
these findings. Research, however, has also demonstrated that the telephone
can be combined with FtF treatments to increase the likelihood of success.
For example, telephone counseling used in conjunction with FtF counseling
has been successful for clients attempting to quit smoking (Lichtenstein,
Glasgow, Lando, Ossip-Klein, & Boles, 1996; Mermelstein, Hedeker, &
Wong, 2003; Míguez, Vázquez, & Becoña, 2002; P. M. Smith, Reilly, Miller,
DeBusk, & Taylor, 2002). An example of this research comes from 664 indi-
viduals that participated in proactive telephone counseling after nicotine-
replacement therapy (Zhu et al., 2000). Patients who received multiple tele-
phone counseling sessions as an extension of their physicians’ efforts dem-
onstrated a significant decrease in level of nicotine use when compared with
patients who received only a single telephone counseling session. This has
led some researchers to suggest that telephone interventions should not
replace FtF contacts with health care professionals but may be used as an
adjunct to improve the lives of patients and their families (Friedman & Grant,
2003).
Researchers have also tried to examine which types of clients would most
benefit from telephone-based mental health services. For example, Hugo,
Segwick, Black, and Lacey (1999) reported the results of a telephone coun-
seling program that targeted women with eating disorders. In all, 26 patients
completed the program, consisting of 10 weekly telephone sessions, fol-
lowed by a call 1 month later, and then calls every 3 months for 2 years from a
therapist. Out of 26 patients, 18 returned follow-up self-report ratings of
bulimia (BITE; Henderson & Freeman, 1987). They reported fewer
instances of vomiting, laxative abuse, and binge-eating frequency. The
majority of client change was reported between the program enrollment and
the end of the 1st week, indicating that patients’ desire and readiness to seek
help, not the mode of treatment, may be the biggest factor in the effectiveness
of the treatment. In the study, Hugo et al. present a case that structured tele-
phone counseling for bulimic patients may offer a viable alternative to
conventional FtF treatments.
Case studies have also demonstrated that telephone counseling could be
effective in helping individuals deal with the psychological effects of cancer.
Rosenfield and Smillie (1998) directly examined the usefulness of tele-
conferencing, a telephone conference call, for providing group counseling
for women dealing with cancer. In their study, the researchers formed a group
of six women with various forms of cancer from different geographical
regions. The group was conducted through teleconferencing 1 hour per week
for 4 weeks. The researchers concluded that the telephone group formed a
solid working bond, with the group dynamics and development being similar
to FtF groups in terms of support given and received. They provide a detailed
week-by-week analysis of the group sessions to support these claims but do
not provide outcome data. The authors conclude that the telephone could be
an excellent tool to bring together isolated individuals for short-term work.
Finally, Grant, Elliott, Weaver, Bartolucci, and Giger (2002) investigated
the usefulness of telephone interventions to train family caregivers of stroke
survivors in problem-solving skills, which are derived from the field of coun-
seling psychology (Heppner, 1978). In the Grant et al. study, 74 stroke survi-
vors and their primary caregivers participated in an initial 3-hour visit from a
nurse and in ongoing telephone calls during the following 3 months. The
comparison groups were a control group and a sham-intervention group. The
sham intervention consisted of the same amount of telephone contacts from a
graduate research assistant who was blind to the purpose of the experiment.
Instead of supplying treatment through the telephone contacts, only informa-
tion about health services received by the stroke survivors was logged during
the phone calls. Compared with the sham-intervention and control groups,
the family caregivers who participated in the telephone intervention had
better problem-solving skills, greater preparedness, less depression, and sig-
nificant differences in vitality, social functioning, and mental health as mea-
sured by a variety of instruments, including the Medical Outcomes Study
Short Form Health Survey and the 20-item Center for Epidemiological Stud-
ies Depression Scale (Radloff, 1977). The researchers stated that telephone
interventions designed to teach problem-solving skills may be useful for
family caregivers of stroke survivors. In a response to this study, Friedman
and Grant (2003) stated that it was the flexibility in scheduling that may have
been one of the main reasons for the intervention’s success.
Fostering Client Strength, Resilience, and Wellness

Lester (1974) suggested that the unique qualities of telephone therapy,
including the client’s ability to control the pace of treatment and to remain
anonymous, may allow individuals who would not otherwise seek treatment
to feel more comfortable. Williams (1971), however, suggested that anonym-
ity could be a disadvantage because the communication may become devoid
of personality. In addition, anonymous callers may not be able to benefit from
interventions that require the counseling psychologist to know their identity,
such as involving local police and crisis intervention services. Lester (2002)
countered that personality is not lost and that we know today that one of the
main applications of the telephone is, in fact, the crisis hotline. Crisis tele-
phone lines are common and can be found in most phonebooks or directories.
Hotlines are a help-seeking service that adheres to the central counseling
psychology principles of support, prevention, and wellness (Conyne, 1987;
Gelso & Fretz, 2000; Kiselica & Look, 1993; Myers, 1992; Vera & Reese,
2000). As such, counseling psychologists often rely on telephone crisis inter-
ventions in their practices and refer clients to 24-hour hotlines that provide
services when others are not available.
The telephone’s usefulness in fostering resilience and wellness has also
been discussed with regard to whether telephone counseling is useful for
only short-term crisis work or whether a meaningful long-term therapeutic
relationship is possible. For example, Spiro and Devenis (1991) discussed
the possibility of conducting long-term psychodynamic psychotherapy
through a telephone. They present a single case illustration of an 18-year-old
female. They state that the client experienced greater equality in the sessions
because the power differential was diminished, which resulted in increased
intimacy and presence during the sessions. In a recent study, Donnelly et al.
(2000) presented findings from a pilot study in which 14 cancer patients were
provided long-term interpersonal psychotherapy by telephone. The small
sample size eliminated the possibility of pretest and posttest analysis, but
participants responded to the program with ratings of excellent or good,
indicating that they perceived the experience to be beneficial.
Prevention, Consultation, and Increased Access to Services

The possibility of increased access is another main issue that telephone
counseling has raised. Distance-communication counseling may be used to
reach individuals who otherwise could not be reached or would not come to
an FtF session. As already mentioned, counseling psychologists use crisis
phone lines and other hotlines to make services available when they are out of
the office. Ranan and Blodgett (1983) also provided two case examples to
illustrate the potential of the telephone to deliver long-term therapy. They
focused on reaching unreachable clients, such as those who are paranoid,
phobic, or borderline. In a related study, Shepard (1987) followed the experi-
ence of two women who received telephone therapy for more than 1 year and
hypothesized that the telephone may make therapy possible for some clients
who are isolated or might not otherwise pursue treatment. Specifically,
Shepard suggested several potential benefits of working with clients through
the telephone including lower costs, increased convenience, and perhaps a
greater sense of control on the client’s part. As such, Shepard suggested that
the telephone could be a catalyst for individuals to seek treatment if they are
unwilling or incapable of attending FtF sessions.
Summary of the Telephone-Counseling Literature
It is apparent that researchers have used the telephone for goals such as
outreach, prevention, short-term treatment, and relapse prevention, all
important enterprises and initiatives in counseling psychology. Thus, it
seems promising for future research on new modes of treatment to consider
and use the previous research on telephone interventions. Counseling psy-
chologists can build from this work and use these studies to guide their
research methods and design. Telephone services are effective for certain
populations, including those looking to learn specific skills and those having
a strong desire to commit to change.
Yet, despite some evidence of telephone counseling’s usefulness, it is
important to emphasize that the services have not replaced (or threatened to
replace) traditional FtF meetings with trained professionals. Practitioners
and researchers have combined modes of treatment in attempts to offer new
or extended forms of therapeutic services. Similarly, it is our perspective that
the development and the potential rise in popularity of online counseling do
not signal the end of FtF counseling but create opportunities for new forms of
communication to supplement mental and behavioral health services. Yet, as
is reviewed in this article, the studies analyzing these distance-communication
technologies suffer from small sample sizes and an overreliance on case stud-
ies, limiting the generalizability of the findings. Therefore, as with any new
intervention, it is important to continue to conduct studies to investigate new
modes of service delivery.
Most important, for this discussion, the line of research and debate regarding
the telephone’s usefulness for counseling services has a striking resemblance
to the issues presently being discussed pertaining to online-counseling ser-
vices. The discussion of the telephone-counseling literature offers a histori-
cal context for current efforts to analyze the suitability of online counseling
for a wide variety of mental and behavioral health treatments. The online-
counseling literature is currently progressing through similar questions,
although at a very early stage. Counseling psychologists can rely on this
background as they research new modes of technology, such as asynchronous
e-mail, synchronous chat, and videoconferencing. Counseling psychology can
examine whether computer-mediated communication (CMC) services reach
new populations that would be unwilling or unable to pursue FtF treatments.
This could be approached in several ways.
First, counseling psychologists providing mental and behavioral health
services online can evaluate whether their clientele consists of individuals
who would normally avoid FtF treatments. Second, researchers can deter-
mine whether typically underserved populations, such as prison inmates,
individuals with physical disabilities, and those residing in rural areas, are
more likely to obtain mental and behavioral health services through CMC.
Third, researchers could implement experiments that compare FtF and
online counseling for specific populations, such as international students or
students of color on college and university campuses. Researchers could then
compare FtF and online services to determine if students of color favor one
mode of treatment over the other. Counseling psychologists have a clear
understanding about populations that are underutilizing mental and behav-
ioral health services and can analyze if online counseling could be beneficial
for clients who are not using FtF services. Next, we discuss newer forms of
technology and how they have been used to provide mental health and
behavioral services.
COMPUTER-MEDIATED COMMUNICATION IN COUNSELING
The following review of the online-counseling literature includes all

known, relevant, published articles or chapters in professional journals
through December 2004. Dissertations and online journals without a peer-
review process were not included; however, because the online-counseling
field is in its infancy, all other published articles were included. As detailed in
the previous article, there have been numerous terms used to describe online
counseling, but there has not been a clear set of terms associated with the new
modes of service delivery (Mallen & Vogel, 2005). Therefore, we used
PsychINFO to search for the following keywords: online, Internet, computer-
mediated communication, counseling, treatment, and therapy. We also found
studies by reading articles on online counseling and by searching references
to ensure that studies were not overlooked. We used studies that examined
mental and behavioral services with some form of communication between a
therapist and a client, including those related to online support groups, as
they are applicable to counseling psychologists even though they do not
always include communication with a therapist. The search results yielded
27 studies, which were both favorable and unfavorable regarding online
counseling’s effectiveness. The appendix lists these articles and summarizes
the current findings related to online counseling.
Below, we provide a review of the research relevant to online counseling
and attempt to connect the literature to a counseling psychology framework.
Specifically, we have organized studies into topic areas that concern the field
of counseling psychology, and we highlight gaps in the literature. First, we
discuss studies that have investigated how individuals use CMC to gain sup-
port. We review these studies because they evaluate CMC’s potential to facil-
itate emotional responses and a sense of alliance among group members.
Second, we discuss studies that have assessed client and clinician satisfaction
with new modes of service delivery to demonstrate the current research on

how readily clients and professionals accept these treatments. Third, we
review process research from online-counseling studies to discuss the unique
issues of delivering mental and behavioral health services without both par-
ties’ being together in an FtF environment. Fourth, we review outcome
research from online-counseling studies to present what is empirically
known about the effectiveness of new modes of treatment. Last, we discuss
studies related to multiculturalism and access to new treatment modalities to
explore how online mental and behavioral health services may be extended to
new populations. These sections are organized to guide the reader through
important components of the online-counseling literature and to connect cur-
rent findings to core themes of counseling psychology. We then evaluate this
literature from a counseling psychology perspective and discuss the
conclusions and gaps in the literature from this perspective.
The innovations of computer technology led to several new forms of com-
munication, all with implications and applicability for the counseling and
psychotherapy practices. CMC began to gain momentum in the 1960s and
can be defined as any type of communication between two or more individu-
als facilitated by computer hardware or software, with e-mail being the most
common form (Kraut, Mukhopadhyay, Szczypula, Kiesler, & Scherlis,
1999; Walther & D’Addario, 2001). Current examples of CMC include send-
ing an e-mail to a family member, posting a message on a professional
listserv or bulletin board, having a conversation with a friend in a chat room,
or using a videophone and webcam to send pictures and sounds to a friend.
The first well-documented example of a computer program’s being used
for therapeutic purposes was the software program ELIZA, originally
designed as a language program (Weizenbaum, 1976). ELIZA was not strictly
a form of CMC because it did not link two individuals together. Instead, it
was designed to generate certain language patterns as a response to input
from an individual. This commonly used language-generation program is
noteworthy and closely associated with counseling psychology because it
was meant to replicate a Rogerian therapist’s statements during an initial
therapy session. The curious reader can interact with the original ELIZA pro-
gram on several Web sites (e.g., http://www.manifestation.com/neurotoys/
eliza.php3).
Online Support Groups—Demonstrations of Empathy
Counseling psychologists work to convey empathy and support to clients

so that their strengths and coping abilities can flourish. Consistent with this
notion, some researchers have suggested that one of the Internet’s main bene-
fits is that it is a way for individuals to connect with others and to gain support
and information (e.g., Barak, 1999; Zelvin & Speyer, 2004). The Internet
may be a way to receive social support particularly for individuals who feel
isolated, leading them to find new ways to handle problems. However, the
question is whether online counseling can effectively accommodate the com-
munication of therapeutic empathy and support without both parties’ being
present at the same location.
The research has frequently investigated the use of online support groups
and has typically found benefits for participants (e.g., Grohol, 2004; Mallen,
2004). Online support groups consist of messages on discussion boards
available 24 hours a day, and these groups have been shown to yield benefits.
Because these messages are available to anyone with access to the Internet,
researchers have lurked on discussion boards to analyze their content. By
lurking, the researchers do not participate in the group but are capable of
reading each message that is posted. The ethics of such research are not yet
clearly defined, as members of online support groups are not typically guar-
anteed privacy or confidentiality. Researchers interested in collecting data
this way should be aware of potential ethical questions related to publishing
data without the knowledge of participants. The following article (Mallen,
Vogel, & Rochlen, 2005 [this issue]) elaborates on the numerous ethical
issues of collecting data through CMC. Despite the controversy involved in
lurking on online support groups to collect data for publication, the research
exists and the results warrant review.
To begin the review of the online-support-group literature, Braithwaite,
Waldron, and Finn (1999) analyzed 1,472 social-support postings from 42
unique members of a computer bulletin board for persons with disabilities.
Social-support messages were broadly defined and included any posting that
offered caring, belonging, esteem, or assistance to the recipient. Messages
were coded into five categories classified by Cutrona and Suhr (1992): infor-
mation support, tangible assistance, esteem support, network support, and
emotional support. Two independent coders were used to analyze the data,
with interrater reliability of .76 after being corrected for chance agreement.
The results found that the most common form of support that members of the
bulletin board offered was emotional support (40%), which was often in the
form of understanding or empathy, encouragement, or physical affection. An
example of this emotional support is a message responding to a member’s
recent discouraging round of physical therapy: “I know! I just got my first
symptoms on July 22nd and I still have problems when I move in certain
ways” (Braithwaite, Waldron, & Finn, 1999, p. 137).
In another study, Finn (1999) also investigated an online self-help group
that focused on disability issues. The researcher analyzed 718 messages from
42 unique users in 33 states and developed 14 categories for the messages,
derived from the therapeutic self-help group mechanisms found in the group-
work literature (e.g., Katz & Maida, 1990) and from the social-support cate-
gories that Cutrona and Suhr (1992) developed. Two research assistants
coded the messages and reported a mean agreement of .82. Messages catego-
rized as providing support and empathy (21.2%), providing information
(15.3%), being devoted to problem solving (14.4%), and involving expres-
sions of feelings or catharsis (12.3%) were the most common on the bulletin
board. Although the authors coded the messages into categories, it is
unknown whether group members themselves perceived the messages as
being emotionally supportive; however, messages on the bulletin board
would often be posted in sequence, and the recipient’s response would con-
firm that he or she felt supported. Future research should not only look to cat-
egorize messages posted on these types of computer bulletin boards but also
strive to obtain outcome data from the participants to determine how they
perceive the conveyed support and whether it is effective.
Sharf (1997) analyzed messages posted to a listserv titled the Breast Can-
cer List. Listservs differ from computer bulletin boards in that an individual
needs to subscribe to receive messages. Anyone who finds the Web page
hosting the messages can typically access bulletin boards. The exact mem-
bership of the group is continuously in flux because individuals can continu-
ously subscribe and unsubscribe to the board. At the time of the study, the
author reported that membership exceeded 825 participants, most of whom
resided in the United States or Canada. The author became a lurker on the
listserv, meaning that she did not actively participate in sending messages but
viewed messages sent by others. Similar to other findings on online support
groups, she identified three main categories of messages: information, social
support, and personal empowerment.
Another study investigated an e-mail group of parents with autistic chil-
dren (Huws, Jones, & Ingledew, 2001). An analysis of more than 6,000 mes-
sages over a 3-month period, using the qualitative data-analysis package
QSR Nud•ist (Gahan & Hannibal, 1998), indicated that chat-group partici-
pants were able to convey and gain a sense of interpersonal warmth by using
the CMC. The core category that emerged from analyzing the messages was
making sense of autism, which was composed of messages related to search-
ing for meaning, adjusting to changes, providing support and encourage-
ment, and sharing experiences narratively. Similarly, Winzelberg (1997)
focused on an electronic support group for individuals with eating disorders.
Two independent raters analyzed the content of 306 messages and coded it
into four categories: searching for meaning, adjusting to changes, providing
support and encouragement, and sharing experiences narratively. Members
of the group were found to use similar helping strategies to those employed in
FtF groups. The members provided emotional support, information, and
feedback.
Finally, Bresnahan and Murray-Johnson (2002) analyzed more than

2,000 messages from an asynchronous women’s health discussion group,
which focused on menopausal issues. The authors provide several examples
of participants’ commenting on the social support they received from the dis-
cussion group. One woman wrote, “I know where you are coming from and I
have a lot of empathy for you. It was really hard for my head to adjust to my
changing body. I think informing yourself, being active, laughing, being pos-
itive and having support groups like this one really helps” (Bresnahan &
Murray-Johnson, 2002, p. 405). The authors concluded that participating in
an online support group could result in feeling supported and developing a
sense of community with other group members.
One of the problems with these previous studies is that they have not
included the guidance or support of a counseling psychologist or another
type of trained practitioner. A professional can prevent some of the negative
consequences of online support groups, such as proliferation of misinforma-
tion, conflict among group members, and possible development of Internet
addiction (see Young, 1996; Young & Rogers, 1998). Hsiung (2000), how-
ever, studied an online self-help group that was monitored by a mental health
professional. In an 8-month period, the Psycho-Babble group (http://www
.dr-bob.org/babble) had more than 20,000 messages posted (an average of 94
per day) by more than 1,500 members. Members of the message board indi-
cated that the forum was effective in their efforts to educate themselves about
various mental health and behavioral issues, as well as to gain support. An
examination of more than 20,000 messages also provided evidence that the
group was effective in terms of participants’ giving and gaining support for
their mental health issues. The study analyzed examples of messages and
grouped them into categories, such as education, support, and feedback.
Summary of the Online-Support-Group Literature

Importantly, the studies of online support groups have not tested the effec-
tiveness of online counseling directly; however, they provide some evidence
that individuals can receive general support over the Internet. They also dem-
onstrate that consumers are willing to seek help in an online environment,
and online support groups may be a first step toward change for many people
(Grohol, 2004). Of course, there are several limitations with studies of this
type. First, the voyeuristic nature of the group examination does not allow the
research to confirm whether the participants of the online support groups
intended or interpreted the categories that emerged in the messages in the
same way. Second, because the individuals in the message group are not
knowingly participating in a research study, it is impossible to obtain out-
come or follow-up data other than what is available in the online messages. It
may be that individuals who are comfortable with online communication

gravitate to this form of support, and it may be that these groups are not bene-
ficial to the entire population. Online counseling is not unique in this respect
because FtF services are not uniformly effective for everyone and one size
does not fit all.
Initial evidence indicates that members of online support groups can con-
vey empathy through text-based CMC, which has implications for counsel-
ing psychologists interested in researching or practicing online counseling.
Future research should examine if empathy from a counseling psychologist
can be effectively conveyed and perceived through online-counseling envi-
ronments and if this therapeutic alliance translates to positive outcomes,
including reductions in client symptoms and positive behavioral changes. It
may also be valuable to assess how empathy and support are experienced
when delivered by peers instead of professionals, including differences in the
ability to communicate empathy and support across various training levels
among professionals.
Satisfaction and Acceptance of Services

Traditionally, outcome research on a new intervention is conducted by
comparing the new treatment to a no-treatment control or to an established
intervention. Thus, online counseling’s effectiveness is established by com-
paring the relative changes in client symptoms after participation in online
counseling with the relative changes in those not treated or treated in FtF
counseling. However, it also important to measure clients’ satisfaction
because they are ultimately the ones who do or do not benefit from the ser-
vices that counseling psychologists provide. Seligman’s (1995) CR study, for
example, gathered nearly 3,000 participants to respond to 26 questions,
which focused on the participants’ experiences with mental health profes-
sionals. These questions were organized into three subscales: specific
improvement, satisfaction, and global improvement. Overall, participants
reported that treatment from a mental health professional resulted in feeling
better. Counseling psychologists’ attempts to investigate online counseling
should include efficacy and satisfaction measures to develop a more
complete understanding of online counseling’s potential effectiveness.
Several studies have examined client satisfaction with CMC services. In
one of the first studies on distance technologies, videoconferencing was
examined as a potential way for professionals to work with psychiatric
patients (Dongier, Tempier, Lalinec-Michaud, & Meuneir, 1986). In this
study, 50 patients underwent a closed-circuit TV (CCTV) interview and were
compared with 35 matched controls who received an FtF interview, which a
psychiatrist conducted for the purposes of consultation on diagnosis, treat-
ment planning, and case management. All of the patients were asked to rate
various aspects of the interview, such as feeling at ease during the interview,
ability to express themselves, quality of interpersonal relationship, and util-
ity of the assessment interview. No significant differences were found in
patients’ satisfaction ratings between the CCTV (videoconference) and the
FtF condition; however, the psychiatrists or consultants rated the CCTV con-
dition as significantly inferior in usefulness of the interview. The local staff
or consultees also rated the CCTV interview as significantly inferior to the
control interview in terms of global assessment and diagnosis. The authors
interpreted the results as demonstrating that professionals, such as counsel-
ing psychologists, may be more critical of new modes of treatment and ser-
vice delivery than clients are. Meanwhile, patients responded to the CCTV
interviews in a similar fashion to patients in a matched FtF control group,
indicating that patients were equally satisfied with the new mode of
treatment.
Stevens, Doidge, Goldbloom, Voore, and Farewell (1999) analyzed gen-
eral psychiatric assessments conducted by psychiatrists through either FtF or
videoconferencing conditions. First, 40 clients were diagnosed using the
Diagnostic and Statistical Manual of Mental Disorders, Third Edition,
Revised (DSM-III-R) and randomly assigned to an FtF or a videoconferencing
condition. Five psychiatrists, blind to the initial diagnosis, performed the
assessments. Clients and psychiatrists were asked to complete the California
Psychotherapy Alliance Scale (Marmar, Horowitz, Weiss, & Marziali, 1986)
and the Interview Satisfaction Scale, a 12-item measure developed by the
authors. No significant differences were found between the FtF and the
videoconferencing conditions for the client or psychiatrist on the California
Psychotherapy Alliance Scale or for the client on the Interview Satisfaction
Scale. A significant difference was found on the Interview Satisfaction Scale,
with psychiatrists reporting less satisfaction in the videoconferencing group
than in the FtF group.
Videoconference technology has also been used to conduct neuropsycho-
logical assessment interviews. Schopp, Johnstone, and Merrell (2000) ran-
domly assigned 98 participants with a wide range of neuropsychological
problems to two modes of evaluation: videoconferencing or FtF interaction.
The study used nine interviewers, including four neuropsychologists, three
neuropsychology postdoctoral fellows, and two neuropsychology interns.
Interviewers and clients rated their satisfaction, how relaxed or stressed they
felt, their ease of communication, how caring they perceived the interviewer
to be, and whether they would repeat the experience. No significant differ-
ences were found between the conditions on measures of client satisfaction,
ease of communication, and level of relaxation during the interview. In fact,
clients in this study reported a greater willingness to repeat the experience in
the videoconferencing condition than in the FtF condition; however, inter-

viewers expressed significantly lower satisfaction with the videoconferencing
condition than with the FtF condition.
In another example, correctional psychologists used videoconferencing
technology to consult with prison inmates. On a six-item questionnaire
developed by the authors (Magaletta, Fagan, & Peyrot, 2000), 75 inmates
reported that they were satisfied with various aspects of the online-consultation
process and were willing to return for a follow-up to the consultation. Fur-
thermore, inmates with severer pathologies still reported that they were satis-
fied with the process, although some problems did arise when inmates
became angry or frustrated. At times, the early signs of frustration and anger
were not readily apparent to the psychiatrist because of the technology’s slow
transmission speed and low resolution. The authors stressed the importance
of audio quality during videoconferencing sessions and suggested that future
research and practice should use more advanced technologies. A limitation
of this study is that the authors did not evaluate the psychologists’ attitudes.
As previously mentioned, psychologists’ attitudes and satisfaction with
online modes of treatment may not be as forgiving as clients’, and this dispar-
ity may lead to negative therapeutic outcomes in long-term treatment. Also,
the authors acknowledged that the six-item measure they created for the
study was too simplistic. Future research should use more rigorous measures
to evaluate the overall satisfaction with online modes of treatment.
These studies show a similarity between the satisfaction ratings of partici-
pants in videoconferencing versus FtF sessions. Videoconferencing, where
one can see and hear the other person, is more similar to FtF than are other
forms of CMC that rely on synchronous chat. The studies looking at text-
based online counseling have yielded mixed results. For example, two stud-
ies have examined member satisfaction with online group counseling and
found different results. Meier (2000) investigated an online support group for
job-related stress. The group members (52 master’s-level social workers)
reported a high level of satisfaction with the overall experience in the group,
the group leader’s presence, and the range of topics discussed during the
group. These variables were assessed by an 83-item satisfaction survey
designed by the author. Members also commented that they enjoyed the con-
venience and privacy of being able to participate from home. Although group
members reported high levels of satisfaction, they did not demonstrate
changes in levels of stress, which indicates that client satisfaction may not be
associated with a reduction in symptoms. The author noted that most of the
sample (95%) reported having good to excellent computer and Internet skills,
perhaps contributing to their acceptance of the online group.
Sander (1996) examined couples group therapy, which shifted from ses-
sions held in an office to sessions conducted from home through synchro-
nous chat. The shift in the mode of treatment was initiated after several cou-
ples could not attend FtF sessions because of child care conflicts. The study
participants reported less satisfaction with the chat sessions compared with
their previous FtF encounters, suggesting that clients from an established FtF
setting could downgrade the quality of the relationships when placed into an
online environment. The therapist also expressed his frustration with the text-
based mode of treatment, which may have been communicated to the clients,
perhaps making them more negative about the process. The author acknowl-
edges that “clumsiness and disjointedness” characterized his efforts to trans-
port his FtF counseling group to an online environment (Sander, 1996, p.
309). Although the report is mostly negative in terms of the usefulness of
online couples group therapy, the author predicted that as technology
advances, the practice of online mental and behavioral health services will
likely increase and become less cumbersome.
In line with the previous study, Rochlen, Beretvas, and Zack (2004) sug-
gested that when presented with a choice, people might prefer FtF treat-
ments. In an instrument-development project of comparable measures of
online- and FtF-counseling attitudes, it was found that participants expressed
more favorable attitudes toward FtF counseling than online counseling in
regard to perceived value and discomfort level. The primary limitation is that
it was an attitude-comparison study, and attitudes might be based on familiar-
ity and expectations, particularly because these were general college students
and not actual clients or individuals experiencing distress. Yet the research
finding suggests that the implementation of online-counseling services may
need to pay particular attention to potential client attitudes and comfort levels
with computers and distance communication. This study merits mention
because it assesses potential clients’ interest level in online counseling. The
research could be considered a preprocess study because it measures atti-
tudes and expectations about treatment. The study also serves as a bridge to
begin discussing the literature that has investigated the process of online
counseling.
Summary of the Satisfaction and Acceptance Literature
Thus far, research has demonstrated that according to clients’self-reports,

they perceive forms of online counseling as satisfactory and useful. It appears
that professionals are less likely to accept new modes of treatment. Profes-
sionals may not accept new modes of treatment because they possess knowl-
edge and training in the effectiveness of traditional treatments; however, Day
and Schneider (2000) found that over time, therapists’ comfort level increased
with counseling delivered through videoconferencing. Clients, on the other
hand, may simply appreciate the services provided and may not scrutinize
outcomes in a similar manner as professionals. Research should investigate

the possible disparity between clients’ desire for and acceptance of online
counseling and professionals’ lack of acceptance of online counseling.
Process, Interventions, and Working Alliance
While some studies have started to examine the outcomes of online coun-
seling, fewer have attempted to measure process variables. This is an impor-
tant omission as one of the most significant challenges for online counseling
is whether it is possible to meaningfully connect with a client through
distance-communication technologies. Without the benefit of contextual and
nonverbal cues, the therapeutic alliance might be significantly hampered,
and because the client and the counseling psychologist are not in the same
location, it might be difficult to really explore the person-environment inter-
actions. This could be problematic as the therapeutic alliance is one of the
critical factors related to counseling’s efficacy (Gaston, Piper, Debbane,
Bienvenu, & Garant, 1994; Gelso & Carter, 1994; Hartley & Strupp, 1983;
Horvath & Luborsky, 1993; Krupnick et al., 1996; Robbins, 1992; Wampold,
2000), and if a therapeutic alliance cannot be formed through CMC, then
online counseling is unlikely to be efficacious for most clients. Yet only three
studies have attempted to examine the type of relationship or therapeutic alli-
ance that can be formed during online counseling. They have produced
mixed results. In a Hufford, Glueckauf, and Webb (1999) study, in which
they compared videoconferencing with FtF counseling for families with epi-
leptic teens, the teens in the videoconference condition reported significantly
lower alliance levels than did those in the FtF condition. This is interesting
because we may expect that younger individuals more readily accept new
technologies. In turn, though, participants in a study by Cohen and Kerr
(1998) provided similar ratings between the CMC and the FtF condition
regarding the therapist’s expertness, attractiveness, and trustworthiness as
measured by the Counselor Rating Form (Barak & LaCrosse, 1975). These
findings are notable given possible concerns that clients in the CMC would
rate their counselors lower due to lack of visual or nonverbal cues to use in
their judgments. Participants also responded to the Session Evaluation Ques-
tionnaire (Stiles & Snow, 1984) to rate the depth, smoothness, positivity, and
arousal of the counseling sessions. Participants expressed higher levels of
arousal in the FtF condition, and there were no other significant differences
between groups.
Other research has shown that a working alliance can be adequately estab-
lished during online counseling (Cook & Doyle, 2002). Cook and Doyle
(2002) compared differences in the ratings of the working alliance from 15
online therapy clients with normative data from a comparable FtF-counseling
sample. The participants completed at least three counseling sessions, which

were conducted through either asynchronous e-mail or synchronous chat.
The findings were that clients participated more in the distance modes and
had equivalent working alliances with their counselors as measured by the
Working Alliance Inventory (Horvath & Greenberg, 1989). This study is lim-
ited because it did not have a strict FtF comparison group and was composed
of a small sample. Future studies should include larger participant samples
and randomly assign participants to an online, FtF, or control group. Studies
of this type will give the counseling psychology field more specific answers
on the process and outcome of online counseling.
The process of online counseling needs to be further explored in future
research. For example, it would be useful to directly examine how the
absence of verbal and nonverbal cues, such as speech, clothing, skin color,
and appearance, changes the dynamics of the session (Mallen, 2004). Clients
might dislike the treatment because therapists miss important social and cul-
tural aspects of the presenting problem and the relationship because only
typewritten messages are transmitted during the sessions (Zelvin & Speyer,
2004). Culturally sensitive counseling psychologists may be able to inquire
about these issues online in the same way as in FtF therapy; however, the
potential for misunderstandings is present. One example of the potential for
increased problems is that without the presence of nonverbal cues, the use of
common stereotypes may be more likely. Preliminary research has found dif-
ferences in the way therapists in training approach male and female clients.
In a Mallen and Vogel (2002) study, therapists in training conducted an
online session through synchronous chat with a client who they thought was
genuine; the client was a confederate. Information about the client’s back-
ground and presenting issues was standardized so that each therapist in train-
ing met with the same client. The only difference was that therapists in train-
ing were randomly assigned to have a male client or a female client, while the
rest of the identifying information was kept constant. The therapists in train-
ing reported being significantly more satisfied with the female client and
assessed the male client as being significantly more hostile and proud. With
the lack of nonverbal cues, counseling psychologists and their clients may fill
in the blanks with stereotypes or idealized versions of their online partners.
Future research should investigate the likelihood and implications of this
process.
Future research may also need to further examine the types of messages
exchanged in online counseling. One previously mentioned study (Meier,
2000), which investigated the feasibility of an online support group for prac-
ticing master’s-level social workers to discuss job-related stress, also started
to examine specific process variables that occur among members of an online
group. Qualitative analysis of 209 comments made by members throughout
the life of the group found that 54% of the comments offered emotional sup-
port and validation, 29% expressed encouragement, and 17% offered infor-
mation advice. Although the listserv could have stunted emotional communi-
cation and led to a question-answer cycle, members of the group mainly
chose to offer emotional support to other group members. But we know little
about what transpired between counselors and clients.
One way that counseling psychologists can directly examine the process
variables of online counseling would be to analyze online-counseling ses-
sions with the Counselor Response System and Client Behavior System
(Hill, 1978; Hill & O’Brien, 1999). Investigations into the online-counseling
process should use these classification systems to code the interventions used
by therapists and the responses offered by clients during online-counseling
sessions. Researchers could compare therapist intervention tendencies and
styles, along with client responses, across different modes of service delivery
to determine if there are differences between forms of online counseling (i.e.,
asynchronous e-mail, synchronous chat, and videoconference). Such analy-
ses would go a long way in furthering our understanding of what happens
during online counseling.
Summary of the Process, Interventions,

and Working-Alliance Literature
The current knowledge base concerning the process of online counseling
is not extensive. Only a few studies have examined process variables through
online interventions for mental and behavioral health issues, and these have
demonstrated mixed results. For example, Cohen and Kerr (1998) and Cook
and Doyle (2002) found no significant differences in reported therapeutic
alliance between CMC and FtF interventions; however, Hufford et al. (1999)
found that teenagers reported less therapeutic alliance in CMC compared
with FtF. Given these mixed findings, future research needs to build on these
studies and further examine the process variables in online counseling.
Online-Counseling Outcome Studies

The main goal of counseling is to alleviate the distress, anxiety, or con-
cerns experienced by a client when he or she enters therapy. Counseling psy-
chologists also focus on building on a client’s strength to improve overall
functioning. As a result, it is important to directly examine whether online
counseling is effective. In our review of the literature, we found several stud-
ies that have directly examined the effectiveness of CMC technologies such
as synchronous chat, asynchronous e-mail, and videoconferencing in deliv-
ering online-counseling and behavioral services. Cohen and Kerr (1998)

assigned 24 undergraduate students to either one semistructured session of
FtF counseling or one semistructured session of CMC counseling delivered
through synchronous chat by a counseling psychology graduate student. Par-
ticipants showed significant decreases in anxiety in both modes of treatment
as measured by the State-Trait Anxiety Inventory (Spielberger, Gorsuch, &
Lushene, 1970), with no difference in the level of change in the two modes.
These results provided some initial support for the use of CMC in delivering
mental and behavioral health services, but it should be noted that individuals
with severer presenting issues, such as major depression or substance abuse,
were screened out of the study. It may be that the clients allowed to partici-
pate were experiencing very little distress before the study, and thus, CMC
counseling may not have been as effective as FtF counseling for severer cli-
ents. The low number of clients used may have also limited the ability of the
researchers to find significant differences.
To address these issues, Day and Schneider (2002) randomly assigned 80
clients, who volunteered to participate through numerous media and referral
sources, to three modes of psychotherapy: FtF, videoconference, and two-
way audio. They also used a wait-list group as a control condition. The clients
presented a variety of issues, including weight issues and personality disor-
ders. The most common problems the clients reported were body image or
weight, family relationships, other relationships, and work or school. Before
treatment, clients in each condition had similar averages on the Global
Assessment of Functioning (GAF), with each group’s having a mean GAF of
either 69 or 70. The outcome measures included the Brief Symptom Inven-
tory (Derogatis & Coons, 1993), GAF, Target Complaints method (Battle
et al., 1966; Mintz & Kiesler, 1982), and modified versions of the Client and
the Therapist Satisfaction Scales (Tracey & Dundon, 1988). The authors
gave 16 doctoral students in a counseling psychology program training in
cognitive-behavioral therapy but also flexibility to reproduce conditions sim-
ilar to FtF-therapy relationships. A MANOVA comparing the treatment
groups to the control groups on outcome measures demonstrated the effec-
tiveness of treatment over the control condition. For example, after complet-
ing five sessions, clients in the treatment groups reported less severe target
complaints and were assessed as having a higher GAF than those in the con-
trol group. The authors explored possible differences between the treatment
groups with a MANOVA on this set of outcome measures and found no sig-
nificant differences among the three modes of therapy. The authors reported
that “the similarities among the three treatment groups—face-to-face, video
teleconference, and audio conference—came through more strongly than
any differences” (Day & Schneider, 2002, p. 501).
In a series of studies (Glueckauf et al., 2002; Hufford et al., 1999; Liss,

Glueckauf, & Ecklund-Johnson, 2002), Glueckauf and colleagues compared
videoconferencing to FtF counseling for families with epileptic children. In
one study, the authors randomly assigned 39 teenagers with seizure disorders
and their parents from the rural Midwest to the following conditions: home-
based family video counseling or audio counseling through speakerphone,
traditional office-based family counseling, or wait-list control. The authors
provided six sessions with an integrative family-therapy approach to the par-
ticipants and collected data twice at 1 week and at 6 months after the conclu-
sion of treatment. A total of 22 families completed the counseling program
after 17 families dropped out early in the study; dropouts were usually in the
office-counseling group, which required long-distance travel for the partici-
pants. The outcome measures used in the study were problem-specific scales
from the Family and Disability Assessment System (FDAS; Glueckauf et al.,
2002; Glueckauf, Whitton, & Nickelson, 2001) and the Social Skills Rating
System (Gresham & Elliott, 1990). Process measures included a modified
version of the Working Alliance Inventory (Horvath & Greenberg, 1989) and
Homework Completion Ratings and Missed Appointments (Glueckauf et al.,
2002). Across all treatment types, participants reported significant reduc-
tions in both severity and frequency of family problems as measured by the
FDAS; mode of transmission did not affect the outcome of the treatment. The
overall level of therapeutic alliance was moderately high across the three
conditions, although teens’ perceptions of this alliance were significantly
higher in the office condition than in the videoconferencing condition; par-
ents did not report significant differences in the alliance. Also, no significant
differences were found between groups on measures of treatment adherence.
This study demonstrates videoconferencing’s usefulness in providing ser-
vices to clients. These results are limited in their applicability to the most
common types of online counseling (i.e., asynchronous e-mail and synchro-
nous chat) in which messages are typed back and forth between the client and
the therapist. Text-based modes of counseling do not allow as much
information to be transmitted between parties, and future research should
examine the differences between these modes of service delivery.
Wright and Chung (2001), in a review of literature related to therapeutic
writing, suggested that therapeutic writing has been beneficial for those who
perceive themselves to be powerless, who are not using their first language in
FtF therapy, who are silenced by shame or other inhibiting emotions and feel
unable to speak, who need to disclose stressful or traumatic events, and who
are at particular stages of life (e.g., adolescents, hospice-care patients) asso-
ciated with experiencing strong feelings. Because text-based online counsel-
ing includes written communication, this review is relevant to the likely
effectiveness of services provided through asynchronous e-mail and syn-

chronous chat. Online counseling may be able to work by using this type of
writing component. Directly examining the effects of writing through a com-
puter, Lange, van de Ven, Schrieken, and Emmelkamp (2001) randomly
assigned 25 undergraduate students who were experiencing post-traumatic
stress to either a computer-based treatment group or a wait-list control condi-
tion. The computer-based treatment was composed of biweekly writing ses-
sions over 10 weeks. During the 45-minute writing exercises, one of seven
clinical psychology graduate students responded to people’s writings half-
way through the sessions to give them feedback about their progress and
instructions on how to proceed. These graduate students followed advanced
courses in behavioral and cognitive psychotherapy, received special training
in applying writing assignments in the treatment of post-traumatic stress and
pathological grief, and were closely supervised during each phase of
treatment.
Results from the study demonstrated that the participants in the computer-
based writing treatment showed larger reductions in post-traumatic stress
symptoms than did control-group participants The control group was not
kept waiting until the treatment group had completed the follow-up but
received treatment directly after the experimental group had terminated treat-
ment. These reductions in stress symptoms were measured by the Impact of
Events Scale (Horowitz, Wilner, & Alvarez, 1979); the anxiety, depression
somatization, and sleeping problems subscales of the Symptom Checklist–
90 (SCL-90; Derogatis, 1977); and the Profile of Mood States (Wald &
Mellenbergh, 1990). These results remained stable 6 weeks after the treat-
ment’s conclusion. Limitations of the study include the fact that the partici-
pants were college students who received extra credit for their participation.
As a result, the findings may not be generalizable to general or clinical popu-
lations. Although there was a follow-up at 6 weeks, future research should
evaluate the effects of online counseling over a longer period to determine the
long-term effects.
Two other studies, generating mixed results, have also examined the effec-
tiveness of online counseling for group work. Meier (2000) investigated the
effectiveness of an online support group for practicing master’s-level social
workers to discuss job-related stress. For the online-intervention group,
Meier randomly assigned 52 participants to a discussion listserv or a no-
treatment control group. Participants completed the standardized Occupa-
tional Stress Inventory (Osipow & Spokane, 1987) before and after the inter-
vention. A group leader facilitated the discussions, which included encour-
aging members to explore their work-related stress in more depth, raising
new concerns, and trying to enhance the experience for the members to
increase their satisfaction with the group. While members of the group
expressed satisfaction with the experience, they did not show any significant
changes in their levels of occupational stress, psychological strain, or coping
resources. The authors suggested that the small sample size and “weak inter-
vention” (Meier, 2000, p. 259) did not allow for the detection of differences.
In addition, the participants may have only been experiencing mild levels of
stress.
In turn, however, Hopps, Pepin, and Boisvert (2003) found evidence for
the potential usefulness of goal-oriented, cognitive-behavioral therapy deliv-
ered through synchronous chat to 19 individuals with chronic physical dis-
abilities in Canada. Using a pretest-posttest design with a wait-list control
group, the authors found that participants reported less loneliness at posttest
than the control group. In the study, loneliness was measured by a French
translation of the University of California at Los Angeles Loneliness Scale
(Russell, Peplau, & Cutrona, 1980), Emotional Versus Social Loneliness
questionnaire (Russell, Cutrona, Rose, & Yurko, 1984), and personal defini-
tions of loneliness. The participants maintained the reduction in loneliness at
a 4-month follow-up. A main limitation of the study, noted by the authors, is
that the sample was relatively homogeneous and may not represent all people
with physical disabilities. Specifically, participants were most likely more
educated, independent, and less impaired than the general population of indi-
viduals with physical disabilities. In addition to this limitation, the sample
size was very small: Groups were composed of only 9 or 10 participants.
Summary of the Outcome Literature

The findings from studies that have evaluated the outcomes of online
counseling have been mostly positive, generally reporting significant client
improvement (Cohen & Kerr, 1998; Day & Schneider, 2002; Glueckauf
et al., 2002; Hopps et al., 2003; Lange et al., 2001). Taken as a whole, these
studies provide preliminary evidence that online modes of counseling can be
effective in reducing clients’ presenting problems. As a result, these findings
provide the foundation for future research to determine whether online coun-
seling is a useful treatment option for counseling psychologists and their
clientele.
Multiculturalism and Access to Services
Online counseling may be useful for reaching persons of color, who have
typically underutilized FtF mental and behavioral health services. For exam-
ple, research has demonstrated that Asian Americans underutilize counseling
services (Matsuoka, Breaux, & Ryujin, 1997; S. Sue, Fujino, Hu, Takeuchi,
& Zane, 1991), are more likely to prematurely terminate psychotherapy
(O’Sullivan, Peterson, Cox, & Kirkeby, 1989), and are less likely to disclose
emotional and interpersonal issues (Tracey, Leong, & Glidden, 1986) when
compared with European Americans. It is unknown at this point if online
counseling would be effective in bringing persons of color to therapy because
research has been so sparse in this area, but counseling psychologists can use
their expertise to answer this question. A potential problem associated with
online counseling is that those who might benefit most from its services may
be without access to CMC.
One such population is African Americans, who have an elevated rate for
several stress-related diseases and must overcome the negative influence of
racism (Utsey, Bolden, & Brown, 2001). One reason that African Americans
have less access to CMC is their poverty rate, nearly 3 times as high as White
Americans’ (D. W. Sue & Sue, 1999). These statistics demonstrate that Afri-
can Americans are a population that would potentially benefit from new
modes of mental and behavioral health delivery, although they may not have
the tools to access these services. Online counseling may be useful for Afri-
can American clients, who sometimes display a differential response accord-
ing to the individual’s race with whom they are communicating. In text-based
online counseling (e.g., asynchronous e-mail and synchronous chat), obvi-
ous differences in race, such as skin color and speech, are not visible, and the
therapist’s racial anonymity may allow clients to be more natural during
online sessions. It should be emphasized that this is a tentative and specula-
tive assumption that warrants further empirical investigation. Another issue
with extending services to African Americans is their traditionally negative
view of mental and behavioral health services, which may be a response to
their mistrust of American society (Vontress & Epp, 1997). There is currently
no research that has investigated if African Americans would feel more com-
fortable meeting online with a therapist, but counseling psychologists are in a
unique position to begin addressing these and other questions.
Other populations underserved by traditional FtF mental and behavioral
health services are Latinos and Hispanics. They are also overrepresented
among the poor and have high unemployment rates. This is witnessed by a
discrepancy between the annual income and the poverty rates between His-
panics and White Americans, with Hispanics earning a smaller salary and liv-
ing in poverty more often (D. W. Sue & Sue, 1999). A challenge facing Hispan-
ics interested in mental and behavioral health services is that few counseling
psychologists are bilingual, presenting a hurdle for those who speak English
as a second language. A potential of online counseling is that therapists who
can speak two or more languages can extend their services through distance-
communication technologies to populations that need their expertise and

multilingual abilities. Potential obstacles for online counseling to be effec-
tive with Latinos and Hispanics may include limited access to CMC technol-
ogies, language proficiency, and uncertainty about or distrust of the new
mode of service delivery. D. W. Sue and Sue (1999) recommended that thera-
pists should carefully explain the roles of client and therapist in counseling
and discuss the goals for the counseling relationship. The explanation of ser-
vices, roles, and goals may take on greater importance in online-counseling
relationships, as contextual cues are lost when parties are in different locations.
One population that has been studied is Asian Americans. Chang, Yeh,
and Krumboltz (2001) randomly assigned 32 Asian American male under-
graduate students to either an online treatment group or a no-treatment con-
trol condition. The online treatment group was composed of 16 participants
and was moderated by a clinical psychology doctoral student who was super-
vised by a licensed psychologist. The results indicate that the online support
group was a viable means of providing support to Asian American male stu-
dents. The participants found the service to be convenient and posted the
majority of their messages (75%) in the evening or early morning hours
between 5 p.m. and 9 a.m. This finding lends more support to the notion that
online services may be an attractive option for individuals who need services
outside the normal business hours of 9 a.m. to 5 p.m. The authors state that
online support groups moderated by counseling psychologists may be an
option for university counseling centers to provide new means of outreach
services. Specifically, these services could target persons of color who may
underutilize mental health services, and counseling psychologists have been
committed to ensuring that they extend their services to individuals from
minority cultural groups.
Shernoff (2000) detailed his use of the Internet to provide therapeutic ser-
vices to lesbian, gay, bisexual, and transgendered (LGBT) clients. The article
does not present empirical data to support the effectiveness of the services
provided but provides anecdotal reports regarding the delivery of counseling
services to LGBT clients. The author states that e-mail was incorporated into
the FtF treatment for some of the clients who were highly anxious and desired
additional contact between weekly sessions. The author also suggested that
the Internet was beneficial for LGBT individuals who sought services online
when feeling too stigmatized to seek out counseling or who were isolated in
remote areas. Although the article does not present empirical data, it is an
interesting commentary on how counseling services can be provided to a
population that is at risk because of discrimination (DeAngelis, 2002).
Finally, Rochlen, Land, and Wong (2004) investigated males’ attitudes
toward cognitive- and emotions-based counseling vignettes from online and
FtF conditions. Overall, participants’ evaluations of online and FtF counsel-

ing were fairly positive and similar. However, there was some evidence sug-
gesting that men with difficulty expressing their emotions responded more
favorably to the online-counseling vignette as opposed to FtF counseling,
indicating that online counseling may be useful in reaching out to males, who
typically underutilize counseling services (see Addis & Mahalik, 2003).
One of the primary goals of counseling psychology is to reach out to dis-
enfranchised or underserved individuals (e.g., Brammer et al., 1988;
Pearson, 2003). As access to distance-communication technology increases,
online counseling may also provide a link to treatment for individuals who
might otherwise avoid FtF treatments. For instance, some individuals may
not seek assistance from an FtF therapist, out of concerns related to fear,
stigma, availability, or convenience. The field of counseling psychology may
be missing opportunities with these clients (Alleman, 2002; Barak, 1999;
Kraus, Zack, & Stricker, 2004; Suler, 2000), and researchers may want to
investigate whether online counseling can reach these populations. One of
the shortcomings of the online-counseling literature is that most of the partic-
ipants have been college aged and predominantly White. There has been little
research including individuals from other cultural backgrounds. For
instance, a 19-year-old gay teenager living in a rural town is likely to have
few outlets for counseling services. The young man may not see the local
therapist because of the stigma attached to receiving therapy or perhaps
because of the therapist’s lack of experience with LGBT clients. Online
counseling is an avenue for him to pursue services that he otherwise would
not. A further discussion of the practical aspects of working with diverse
clients can be found in the next article of the Major Contribution (Mallen
et al., 2005).
One of the most useful aspects of online counseling may be the ability to
use new technologies to conduct assessments, evaluations, and therapy in
remote locations and for individuals who might not otherwise be able to seek
treatment. Reaching disenfranchised clients is one of counseling psychol-
ogy’s key tenets. By working with clients through CMC technologies, coun-
seling psychologists may be able to extend their expertise to new areas that
they could not reach without extensive travel. They could accomplish this
through direct interventions with underserved clients or through a consulta-
tive role by offering advice to local physicians and therapists who may be
struggling with a particular case. Clement, Brooks, Dean, and Galaz (2001),
for example, described a neuropsychology clinic for Army personnel. For the
purposes of conducting a screening interview, discussing the results of
neuropsychological evaluation, and participating in ongoing psychotherapy,
32 patients were seen for 87 videoconferencing sessions. The authors
reported that the clinic was able to coordinate care easily with superiors, fam-
ily members, and soldiers in the study because of the videoconferencing sys-
tem. Similarly, in a previously discussed study (Winzelberg, 1997), which
focused on an electronic support group for individuals with eating disorders,
two thirds of the messages were posted between 6 p.m. and 7 a.m., which is a
time when members would least be able to obtain support from FtF
professionals. As a result, the members were able to receive support and
information around the clock.
Summary of the Multiculturalism and Access-to-Services Literature
Currently, there have been limited efforts to systematically evaluate if

online mental and behavioral health services are effective for clients from
different cultural backgrounds or if the process and the outcome of these ser-
vices are different from experiences in traditional FtF therapy. The studies
reviewed offer preliminary support for the notion that online counseling may
be useful for populations that underutilize clinical services, such as Asian
Americans, men, and LGBT community members. Future research also
could investigate online counseling’s ability to accommodate counseling
psychologists’ focus on multiculturalism. Because nonverbal cues are lost in
text-based communication, certain characteristics may be overlooked during
the course of service delivery, and it will be important for future researchers
to incorporate the study of this issue into their online-counseling investiga-
tions. Conversely, it may be beneficial for there not to be visual cues to race or
ethnicity, equalizing the counseling situation (Day & Schneider, 2000). In
fact, some researchers have suggested that distance technologies can lead to
the client’s experiencing greater equality in the sessions because the power
differential is diminished. Yet these assertions need to be directly tested, and
counseling psychologists should be actively involved in this process.
COUNSELING PSYCHOLOGY AND ONLINE COUNSELING—

CONCLUSIONS AND GAPS IN THE LITERATURE
As the above literature review suggests, many unanswered questions

regarding online counseling remain; however, the review does provide coun-
seling psychologists with a basis of knowledge. For instance, studies of
online support groups provide some evidence that individuals can receive
and give general support over the Internet, and as demonstrated by client self-
reports, research has also demonstrated that new modes of service delivery
are perceived as satisfactory and useful; however, it appears that profession-
als are less likely to accept or be satisfied with these new modes of treatment.
The literature related to process variables in online counseling is sparse, but
the findings of studies evaluating the outcomes of online counseling have
been mostly positive, reporting significant client improvement on a variety of
outcome measures. These results provide preliminary evidence that online
modes of counseling can be effective in reducing clients’ presenting prob-
lems and symptoms. Research has also offered preliminary support to the
notion that online counseling may be useful for populations that underutilize
clinical services, such as disabled or rural individuals.
Furthering the quality and quantity of research in this area should provide
critical information on both the positive and the negative aspects of online
counseling. Limitations that exist in the literature at this point include the fact
that many of the interventions detailed in the literature are limited in terms of
time. Although counseling psychologists primarily focus on short-term
interventions, the current literature does not allow for any type of long-term
analysis of the outcome of mental and behavioral health services delivered by
CMC technologies. At this point, research suggests some potential uses of
online counseling but more is needed to directly examine differences across
various process and outcome variables between FtF and online-counseling
conditions. In addition, some potential limitations exist including issues
related to the therapeutic alliance, who is most appropriate for online treat-
ment, the ability to intervene during a crisis, and the lack of nonverbal cues.
Future research efforts should investigate elements of process and outcome
that have already been explored in FtF modes of treatment. Common factors
of effective FtF counseling have been identified (Wampold, 2000), and these
factors should be examined to see the degree to which they are present during
an online-counseling session. Preliminary research has suggested that these
important common factors can be achieved in online counseling (Cook &
Doyle, 2002; Day & Schneider, 2002), but future research efforts are needed
to continue studying the setting of online counseling, such as working with
clients without the assistance of nonverbal cues and how it affects the process.
For instance, research on the therapeutic alliance, the critical factor
related to outcome in counseling (Bachelor, 1991; Eckert, 1993; Henry,
Strupp, Schacht, & Gaston, 1994; Horvath & Symonds, 1991) is crucial. If a
therapeutic alliance can be formed through CMC, then online counseling
may likely be efficacious for certain clients. In an online environment, how-
ever, it will require researchers to determine the best way to measure a thera-
peutic alliance in the absence of traditional FtF cues. Because process and
outcome research has a long history in the field of counseling psychology, it
seems natural that counseling psychologists would be involved in evaluating
new modes of treatment. In addition to measuring process and outcome vari-
ables from the client’s perspective, it will also be important to measure thera-
pists’ evaluation of online mental and behavioral health services. Research
has demonstrated that therapists have been less favorable toward online ser-
vices than have clients, and this dynamic should continue to be evaluated.
Future research also needs to build on the existing literature on FtF coun-
seling (see Heppner, Kivlighan, & Wampold [1992] for a discussion of
research design in counseling). Analogue studies, for example, could be use-
ful in comparing online counseling to FtF counseling to determine the effec-
tiveness of the new mode of treatment. Before treatment begins, participants
could be given pretests (e.g., Beck Depression Inventory; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961) to assess baseline functioning. Subse-
quently, researchers could use process and outcome measures to determine
significant differences between FtF and online counseling. For example, it
would be useful to gauge clients’ responsiveness to treatment as well as the
therapists’ attitudes to the new mode of treatment. An instrument used often
in counseling research is the Counselor Rating Form (Barak & LaCrosse,
1975), which measures client perceptions of the therapist in terms of attrac-
tiveness, expertness, and trustworthiness. This type of study would provide
the field with an indication of the benefits, risks, and effectiveness of online
counseling in comparison to traditional FtF counseling. The advantages of
analogue studies include increased experimental control, degree of specific-
ity of operational definitions, and ability to isolate specific processes in the
complex activity of counseling. Disadvantages include generalizability and
external validity (Heppner et al., 1992). Analogue research can be beneficial
because the increased experimental control can minimize potential ethical
dilemmas related to online treatment (see Mallen & Vogel, 2002).
Several areas of interest for counseling psychology specialists should be
considered in future online-counseling research efforts. Areas of emphasis
for counseling psychologists yet to be addressed in the literature are normal
and developmental challenges or tasks, client strength and resilience, educa-
tion and career development, and issues related to prevention, consultation,
psychoeducation, and wellness. There are several gaps in the literature
regarding these topics, and counseling psychologists can determine how
online mental and behavioral health services might help or hinder these core
components of the field.
Normal and Developmental Challenges or Tasks
Counseling psychology has focused on normal or developmental chal-

lenges and tasks with short-term interventions. The current literature review
reveals numerous holes in the knowledge base regarding which specific pop-
ulations are best suited for specific online mental and behavioral health ser-
vices. Counseling psychologists interested in delivering online mental and
behavioral health services likely desire information about the types of clients
that respond best to online treatments. Also, information detailing the most
effective forms of online interventions would be helpful for professionals
delivering these services. At this time, there is not enough research to make
firm and specific conclusions or suggestions regarding which clients and
interventions are the most successful.
One of the most important questions that pertain to the effectiveness of
online counseling is who would most benefit from online-counseling ser-
vices and who may most likely be harmed. It is believed that online counsel-
ing would benefit individuals functioning at a moderately high level (e.g.,
Stofle, 2001; Suler, 2001). For example, individuals who have more severe
issues that require close attention and supervision may be better served
through traditional FtF methods. Specific populations that fall under this
heading might include clients who express suicidal ideation, reveal a recent
psychotic episode, or admit to substance abuse (Suler, 2001; Zelvin &
Speyer, 2004). Future research efforts should establish if online treatment
yields positive outcomes for clients with a wide range of presenting issues,
from developmentally appropriate issues to severer presenting concerns.
Client Strength and Resilience

Counseling psychologists seek to empower their clients by finding areas
that the client can control and successfully manage. From that point, counsel-
ing psychologists can build from a client’s strengths instead of focusing only
on negative affect or behaviors. By allowing an individual to receive treat-
ment without coming directly to a counseling psychologist’s office, online-
counseling methods may result in the client’s feeling less dependent on his or
her therapist. Not only may a client feel more comfortable in his or her nor-
mal environment, but in some modes of online counseling, the client may
also have more control over self-presentation and can think through what he
or she wants to say. However, control over self-presentation may not always
lead to a positive outcome if the client were holding back from openly com-
municating with the therapist or if the therapist were overlooking certain cli-
ent assets because they may not be evident in an online setting. Looking at
online counseling from this vantage point reveals the need to research issues
such as how dependent or comfortable clients feel in an online therapy ses-
sion versus an FtF session, as well as what they are willing to self-present in
the different formats. It also reveals the need to understand what counseling
psychologists are able to pick up in an online session and what they may miss.
Education and Career Development
In addition, counseling psychology has been at the forefront of studying

academic decisions and providing career counseling services. Vocational
counselors have already infused technology into their services by often
directing clients to computer-assisted programs for career exploration.
Counseling psychologists can begin to conduct research on the effectiveness
of current online career interventions, such as the online version of the Occu-
pational Outlook Handbook (http://www.stats.bls.gov/oco) or O*Net data-
base. O*Net takes the place of the Dictionary of Occupational Titles (DOT)
as the nation’s primary source of occupational information. This database
organizes occupations in terms of knowledge, skills, abilities, job family, or
job codes from databases such as the DOT (Converse et al., 2004). The inter-
ested reader can find more information about the creation and implementa-
tion of O*Net in Baughman, Norris, Cooke, Peterson, and Mumford (1999).
Counseling psychologists are well trained to assist the development of
Internet sites devoted to career guidance, which can be used at times when
FtF professionals are less likely to be available. We are thus able to educate
the public about various career-related issues and to assess the impact of
these education and training efforts.
Another important function of counseling psychologists in terms of
online career interventions is to eliminate or minimize the vast amount of
misinformation available on the Internet. For example, a search for the terms
career and counseling on Google.com yielded more than 9.7 million Web
sites. Numerous online career inventories can be found on the Internet, but
most are questionable at best. The measures are not proven assessment tools
and have not been psychometrically validated. Many of these career
resources are put together by individuals with no training in counseling psy-
chology, or any other professional psychology training. There are also ques-
tionable career consulting services, which offer assessment on their Web
sites. Clients who find these services may not seek out FtF career counseling
services, and when they do arrive for FtF services, they may bring in the out-
put from these assessments, which rarely have any meaningful value for a
counseling psychologist because of the absence of psychometric informa-
tion. Counseling psychologists have the training to provide accurate infor-
mation about career services and psychometrically validated career assess-
ments. A problem common to the Internet is that there is some great and
useful material available but also a lot of bad information. Counseling psy-
chologists cannot only create online resources for clients but also help their
clients to evaluate the millions of career-related Web sites that offer career
guidance and assessment.
Prevention, Consultation, Psychoeducation, and Wellness
In addition to the availability of career resources on the Internet, counsel-

ing psychologists have limitless potential to provide services that encourage
prevention and wellness among individuals. This potential benefit comes
with elements of danger as well. The power of the Internet allows informa-
tion to be accessible 24 hours a day, but the vast amount of literature on Web
pages is not always accurate. Many Web sites offer self-help information, but
it is sometimes of questionable origin and validity. Counseling psychologists
are in a position to develop Web sites that provide useful mental and behav-
ioral health information, but a more important function for counseling psy-
chologists may be to eliminate the great amount of misinformation available
online. Online self-help services provided and moderated by trained
professionals can supplement other self-help materials.
For an example of a self-help Web site, visit MySelfHelp.com (http://
www.myselfhelp.com). Counseling psychologists can refer their clients to
psychoeducational resources as well as online bulletin boards that provide
answers and support for a variety of issues. Clients or users must pay $15 per
month to access the Web site’s materials. Currently, MySelfHelp.com has not
provided any empirical data to indicate the effectiveness of the self-help
materials, and it is unclear whether these types of online resources would be
more effective than common self-help resources offered during FtF treat-
ment. With more individuals gaining access to the Internet and searching for
health information (Harris Interactive, 2002), counseling psychologists can
use new modes of communication, especially Web sites, to extend their pre-
vention aims and to encourage wellness in the general population but must
also investigate these services to determine their effectiveness.
Related to prevention and to the promotion of wellness is counseling psy-
chology’s emphasis on consultation. Only one study reviewed detailed the
use of distance technologies for consultative purposes. Dongier et al. (1986)
found that the individuals receiving consultation through CCTV from a
trained professional reported that the process was inferior to FtF consulta-
tions in terms of the global assessment and diagnosis. Although counseling
psychologists can share their knowledge with other professionals and organi-
zations around the world, the lack of contextual cues may hinder the ability to
offer an accurate diagnosis of the client or situation. If, however, future
research demonstrates this process to be successful, counseling psycholo-
gists may find it easier to share their knowledge and expertise with a wider
range of populations instead of being limited to geographical regions. Future
research should investigate if counseling psychologists can effectively use
CMC technologies for consultation.
ISSUES FOR COUNSELING PSYCHOLOGISTS CONDUCTING

ONLINE-COUNSELING RESEARCH
As mentioned previously, counseling psychologists have been at the fore-

front of evaluating the effectiveness of FtF mental and behavioral health ser-
vices. It will be important for counseling psychologists to use similar skills,
measures, and procedures to ensure reliable and valid empirical findings
related to online counseling. CMC creates new conundrums that researchers
must consider when evaluating online-counseling services. Childress and
Asamen (1998) offered guidelines for initial research conducted on the thera-
peutic use of the Internet. These guidelines included the precautions of locat-
ing at least three mental health referrals in proximity to the client, encrypting
e-mail or chat communication to protect confidentiality and guard against
vandalism or hacking, and recruiting participants from only the state in
which the investigator is licensed. These guidelines echo other principles and
methodologies prescribed for gathering data from participants through CMC
(Reips, 2002; M. A. Smith & Leigh, 1997), conducting sociological studies
(Hewson, Laurent, & Vogel, 1996), and improving online surveys (Kaye &
Johnson, 1999). Research in this area should not overlook standard method-
ology, but investigating online counseling presents unique challenges. The
following topics deserve careful attention during any online-counseling
investigation.
Ethical Issues
Online counseling presents several ethical hurdles with important obsta-
cles and considerations for researchers including confidentiality issues and
possible duty-to-warn dilemmas (see Bloom, 1998; Finfgeld, 1999; Griffiths,
2001; Jencius & Sager, 2001; Kraus, 2004; Manhal-Baugus, 2001;
Pomerantz, 2002; Rochlen, Zack, & Speyer, 2004; Suler, 2001). For instance,
researchers should familiarize themselves with changing local, state, and
federal regulations on delivering mental health services through distance
communication. It is still necessary to receive proper informed consent when
collecting data over the Internet from participants who are not at the same
physical location as the researcher.
Technological Failure
Even the best computer or program can crash or fail at one time or another.
Hence, it is important to account for possible breakdowns with contingency
planning ahead of time. Also, one should properly inform participants that
disconnection of an online session is possible and present them with a plan of

action if the connection is lost. This issue is not present in FtF studies of coun-
seling; a client or a therapist does not suddenly disappear from the counseling
room. The disconnection of a session, especially if the content of the session
were at a high emotional level or at a crisis level, could be disorienting to both
the client and the therapist. The client could feel abandoned and disillu-
sioned, while the therapist would likely have feelings of panic and frustra-
tion. Researchers should have a clear plan to make sure that the therapist and
the client not only expect such disconnections but can also deal with them in a
timely manner (Mallen, 2004).
Logistical Issues
There will need to be management of at least two schedules for each
online session studied. It is imperative that counseling psychologists and
their clients are ready to communicate with each other once the session is
scheduled to begin. Scheduling sessions can become confusing when con-
necting individuals separated by several time zones. Data collected through
an online survey, e-mail, or questionnaire can be sent and received by fax or
standard mail. Because participants cannot simply complete a pencil-and-
paper measure while in the same room as the experiment, data collection can
become cumbersome. On the other hand, an instant online survey could be
projected and recorded on the spot, with item responses put directly into a
data set. Researchers should inform participants about possible delays to
reduce confusion and irritation.
Differences in Technology
There may be differences between telephone, synchronous chat, asyn-

chronous e-mail, and videoconferencing regarding quality of care. Yet, at
this point, the research largely neglects these questions. It is possible that
counseling by telephone and videoconferencing is superior to synchronous
chat and asynchronous e-mail because nonverbal cues are transmitted instead
of text. It could be argued that videoconferencing would be most successful
in connecting a client with a counseling psychologist because of the technol-
ogy’s video and audio capabilities. However, text-based communication
such as synchronous chat and asynchronous e-mail may also be useful in
certain situations.
For instance, asynchronous e-mail may work best for a client who has a
nontraditional schedule and cannot meet with a professional at regularly
scheduled times. The ability to send messages to a therapist at any time dur-
ing the day or night still allows the client to receive services that might other-
wise be impossible because of scheduling conflicts. Future research should
investigate differences in technology regarding the process and outcome of
counseling services.
Previous Online Experience

Any study analyzing the dynamics and process of online relationships
should use some measure of online experience. Communicating effectively
through asynchronous e-mail, synchronous chat, and videoconferencing
takes time and practice. A study by Mallen, Day, and Green (2003) found that
as online experience increased, participants reported a greater amount of
closeness in synchronous-chat conversational dyads. This study found that
familiarity with online communication was related to feeling comfortable
with the technology and understanding the nuances in its rate, presentation,
style, and idiosyncrasies. Including this variable in studies may help to
explain differences in results. Research has attempted to define the construct
of computer experience, and several scales are currently available to assess
this characteristic (C. Murphy, Coover, & Owen, 1989; Potosky & Bobko,
1998; B. Smith, Caputi, Crittenden, Jayasuriya, & Rawstone, 1999).
Digital Divide
It is also important to be aware of the potential digital divide, which
describes socioeconomic barriers to access. Online counseling may be
unavailable to populations that are already underserved by traditional mental
health interventions. Digital divide is a term that describes the differential
access to the Internet and related technologies because of financial and other
socioeconomic issues (Hoffman, Novak, & Schlosser, 2000). While most
public libraries provide Internet access that would allow individuals to find
helpful psychoeducational material, the library is not an ideal setting for a cli-
ent to receive online-counseling services. It is imperative for equal access to
become an integral part of any new mode of service delivery for it to become
a tool of empowerment rather than disenfranchisement (see Lee, 2000).
Time
Walther (1993) points out a flaw in the existing literature comparing FtF
and CMC, stating that many studies do not allow a significant amount of time
for online communication to develop. The key difference may be that the rate
of relationship building and impression formation is slower in CMC but that
similar levels could be achieved over time (Walther, 1996). However, FtF
communication has also been shown to outperform CMC. For instance, a
study on group decision-making tasks demonstrated that the FtF group mem-
bers performed at a higher level, while CMC group members experienced
more frustration with the process (Barkhi, Jacob, & Pirkul, 1999). A similar
study found that group members in the FtF groups reported higher levels of
satisfaction, decision confidence, and ease of use than the CMC groups
(Olaniran, 1996).
An example of the time issue at work is found in a Mallen and Vogel
(2002) study, which analyzed synchronous-chat transcripts from analogue
sessions. The authors compared transcripts from the online sessions with
similar FtF transcripts from a Day and Schneider (2000) study. An interest-
ing finding from the study was the difference in the amount of discourse that
could flow between the therapist in training and the client in an FtF session.
The FtF transcripts had a mean of close to 6,000 words, while the synchronous-
chat transcripts had a mean of only 2,000 words. It should not be concluded
that the quantity of words equals the quality of service or care, but it cannot be
denied that the sheer amount of discourse in an FtF session far exceeds
synchronous-chat sessions of the same length. It would be wise to consider
variables such as typing speed and even reading comprehension, as some cli-
ents may lack skills in both areas, which would likely limit their ability to
communicate effectively online.
THE ROLE OF COUNSELING PSYCHOLOGY

IN SHAPING ONLINE COUNSELING
At its core, counseling psychology is composed of professionals trained

in the art of practice and the science of research. Counseling psychologists
are equipped to shape the field of counseling psychology to ensure that its
aims are met in these new modes of service delivery. The field can continue to
champion the causes of servicing intact populations, focusing on person-
environment interactions and client strengths, providing career services, and
delivering brief interventions. In addition, counseling psychologists can
work to minimize the negative effects of the digital divide and to ensure that
clients are not disenfranchised by the development of new mental and behav-
ioral health services provided through CMC. The review of the available
research provides answers to several questions regarding who should be
treated, the appropriate types of interventions, and the characteristics of
counseling psychologists that might function effectively in an online setting.
It may be surprising that preliminary research has shown online counseling
to be beneficial and accepted by clients. However, it also shows the lacunae in

our knowledge and the need to investigate further the benefits and limitations
of these new modes of treatment. The field of counseling psychology is spe-
cifically ready to be mobilized to provide answers to these questions through
dedication to the scientist-practitioner model.
APPENDIX
Research Focusing on Online Counseling
Type of Study; Data; Main Counseling-Related

Author and Date Technology Sample Measures (Constructs) Research Findings
Braithwaite et al. (1999) Asynchronous 1,472 support messages Observation; coding Majority of messages offered emotional support (40%), followed
message board from 42 group of messages by two by information (31.3%), esteem support (18.6%), network support
members with coders into 5-category (7.1%), and tangible assistance (2.7%).
disabilities system
Bresnahan & Asynchronous 2,000 messages from Observation; coding of Almost all messages (80%) included action facilitative support. Most
Murray-Johnson message board approximately 700 messages by two coders; messages were supportive, but some postings were argumentative.
(2002) members of a menopause anecdotal accounts of The three most common content areas of the messages about
and midlife transition process/outcome menopause: participants’ problem in communicating to physicians,
group discussion of problems with hormone replacement therapy, and
identification and discussion of alternative treatments.
Chang et al. (2001) Asynchronous 32 undergraduate students. Experiment with control On 10-point scale, participants of group reported feeling support from
message board Mean age = 20. Race = 32 group; process/outcome; the group (M = 7.1), thinking the concerns raised were relevant
AA. Sex = 32 M MEIM, CSES-R, (M = 7.8), and felt connected and comfortable (M = 7.8). Majority of
OSGQ, TVRM participants thought the format worked well (95%). All participants
preferred the anonymous format of group. No significant differences
were found at posttest between support and control groups on
MEIM or CSES-R.
Clement et al. (2001) Videoconference 32 patients with known or Participant/observation; Anecdotal report indicates that video interviews/screenings with
suspected neurological anecdotal account of patients have been effective for extending services to new settings
disorder or traumatic process that would otherwise be difficult to reach.
brain injuries.
Sex = 27 M, 5 F
(continued)
857
858
APPENDIX (continued)

Cohen & Kerr (1998) Synchronous chat 24 undergraduate students Experiment with FtF Participants showed significant decreases in both modes of treatment
self-identified as wanting control group; outcome; (p < .001); however, no significant differences were found between
help dealing with anxiety STAI, CRF, SEQ, CUS treatment groups (p = .85). No significant differences were found
between client ratings of counselors on expertness, attractiveness,
and trustworthiness in CMC and FtF. Clients in the FtF condition
rated their session as significantly more arousing than in the CMC
condition (p = .017).
Cook & Doyle Asynchronous 15 clients. Sex = 14 F, Process compared with Participants reported comparable levels to the FtF comparison group
(2002) e-mail; 1 M. 66% U.S. citizens, normative FtF data; of the working alliance in the online sample using the WAI.
synchronous chat 33% Canadian WAI
Day & Schneider (2002) Videoconference; 80 clients recruited from Experiment with FtF Significant superiority of treatment to no treatment was found, F(12,
audio only community. Mean age = comparison group; 265) = 1.82, p = .01. No significant differences between video,
39.35. Race = 66 W, 8 AA, process/outcome; audio, and FtF treatments, F(12, 144) = .67, p > .15.
3 A. Sex = 52 F, 28 M observer ratings,
client/clinician
self-reports; VPPS,
BSI, GAF, TC, CSS,
TSS
Dongier et al. (1986) Videoconference 50 patients participated in Experiment with FtF No significant differences were found in clients’ satisfaction rating
CCTV and were compared comparison group; between the videoconference (CCTV) and FtF conditions; however,
to 35 matched controls in client/psychiatrist the psychiatrists rated the CCTV condition as significantly inferior
FtF condition. Diagnoses: self-report; process, in regard to the global assessment (p < .05) and diagnosis (p < .01).
schizophrenic psychoses satisfaction.
(27%), neurotic depression
(12%), affective disorders,
depressed (12%)
Finn (1999) Asynchronous 718 messages from 42 Observation; coding Majority of messages were related to socioemotional exchanges
message board members of disability messages by two raters (53.3%), with the rest focusing on information. Majority of
group into 14 categories; messages provided support or empathy (21.2%), followed by
anecdotal accounts information (15.3%), and problem solving (14.4%). Most common
of process/outcome content areas were health (38.2%) and relationships (28.4%).
Glueckauf et al. (2002) Videoconference; 22 teenagers with epilepsy Experiment with FtF Teens and parents reported moderately high to high levels of alliance
audio only and their parents (n = 36). control group; process/ across all conditions (M = 6.15 on 7-point scale). Teens reported
Mean age = 15.4. Race = outcome; client self- significantly lower alliance in the video than in both the audio-only
100% W. Sex = 14 M, 8 F report, observation; (p = .05) and the FtF group (p = .004). Teens and parents reported
FDAS, SSRS, WAI, significant and equivalent reductions in the severity and frequency
completed assignments, of identified family problems from pre- to posttreatment across
missed appointments groups.
Gustafson et al. Asynchronous 204 HIV-positive patients Experiment with no
(1999) e-mail, from community sample. treatment control; pre- CHESS group reported quality of life improvement over control group
synchronous Mean age = 35. Race = 84% and postintervention in terms of participation in health care (p < .007). CHESS group
chat, Web site W. Sex = 183 M, 21 F client self-reports; reported fewer hospitalizations (p < .02) and shorter hospital stays
quality of life, health (p < .009) than control group during intervention; these differences
behaviors, health service were not significant at the posttest.
utilization
Hopps et al. (2003) Synchronous chat 19 individuals with visible Experiment with wait-list Participants who received the group therapy through CMC reported
physical disabilities. control group; outcome; significantly lower scores than the control group on UCLA-L
Mean age = 34.2. client self-report; (p = .001) and ESL (p = .005); there were no other significant
Sex = 9 M, 10 F UCLA-L, ESL, PD, differences on the outcome measures between treatment and control
ADS, DSLP groups. Participants in CMC group showed significant decreases on
the UCLA-L (p = .002), ESL (p = .002), and DSLP (p = .022) from
pretest to posttest.
(continued)
859
860

Hsiung (2000) Asynchronous 21,230 messages from 1,516 Participant/observer; Categories of messages posted: education, support, feedback, setting
message board members of mental health anecdotal accounts of limits. Anecdotal evidence is provided to demonstrate effectiveness
group process/outcome of online support group.
Huws et al. (2001) Asynchronous 6,142 messages from 374 Observation; qualitative Main categories that emerged from messages: searching for meaning,
e-mail members of Parents of data analysis through adjusting to changes, providing support and encouragement, and
Children with Autism QSR Nud•ist; anecdotal sharing experiences narratively. Report indicates that e-mail groups
group accounts of process/ can offer support and an adjunct to treatment.
outcome
Lange et al. (2001) Asynchronous 25 students who had Experiment with control Significant decrease in post-traumatic stress disorder symptoms was
e-mail; Web site experienced a traumatic group; outcome; found in CMC group compared to wait-list control (p < .015).
event at least 3 months client self-report on pre- General psychopathology on SCL-90 significantly decreased
prior. Mean age = 22. test and posttest; IES, (p < .01; d = 1.07). Client mood improved in CMC group (p < .04),
Sex = 16 F, 9 M SCL-90, POMS, EQ especially less depressive (p < .01; d = .91), and tense (p < .01;
d = .89). Client improvements were found to be sustained 6 weeks
after treatment, and 95% of the participants reported that the therapy
was helpful.
Magaletta et al. (2000) Videoconference 75 prison inmates. Process/outcome; client On a scale from –3 to 3, inmates reported positive ratings of how good
Sex = 100% M self-report; 6-item treatment over the TV felt (M = 2.04), and how they felt about
consultation coming back for another session (M = 2.29). Inmates’ perceptions of
questionnaire treatment became more positive over time (r = .36). Most inmates
thought treatment was comparable to FtF services (46%), with the
rest reporting that FtF was worse (35%) or better (19%) than CMC
treatment.
Mallen & Vogel (2002) Synchronous chat 20 graduate students in Experiment with Significant difference found between the amount of discourse that
counselor training normative FtF data; occurs in CMC sessions (p < .001). Most participants (95%)
programs process/outcome of reported an above-average level of satisfaction on a 6-point scale.
therapist; PANAS, Most participants (90%) reported a low or moderate level of
IOS, satisfaction closeness with their client as measured by the IOS.
Meier (2000) Asynchronous 52 social workers recruited Process/outcome; 209 supportive comments were identified in group: 54% offered
e-mail from listservs. Mean self-report, qualitative emotional support. The majority of members rated the group as
age = 43. Race = 95% analysis; BIQ, OSI, helpful in clarifying their professional values (69%) and as a source
W, 1 La. Sex = 84% F 87-item satisfaction of coping (63%). No significant differences were found for stress
survey reduction on the OSI.
Rochlen, Beretvas, Asynchronous 471 undergraduate students Instrument development Overall sample endorsed more favorable attitudes toward FtF
& Zack (2004) e-mail, for factor analysis, 51 and preliminary validity counseling as contrasted with online counseling, particularly
synchronous chat students for test-retest and reliability; online for female respondents. Good preliminary evidence of reliability
reliability, 213 students and FtF counseling and validity established for new and comparable measures of online
for construct validity attitudes and FtF counseling attitudes.
Rochlen, Land, & Synchronous chat 198 undergraduate students. Analogue; measured Similar and positive evaluations observed of both online and FtF
Wong (2004) Sex = 100% M attitudes toward online counseling sessions. Men with high and low levels of restrictive
counseling and gender emotionality did not differ in their perceptions of online counseling
role conflict; CRF but differ in perceptions toward FtF counseling, with men who
reported difficulty with emotional expression expressing less-
favorable perceptions.
Sander (1996) Synchronous chat 2 couples transitioned from Case study; anecdotal Couples counseling through CMC was noted as slow and fragmented,
FtF to CMC counseling. accounts of process/ and the clients and the clinician were not satisfied with the sessions.
Mean age = 50. outcome
Schopp et al. (2000) Videoconference 98 adult outpatients with Experiment with FtF Clients more likely to report desire to repeat experience in
cognitive disabilities. comparison group; videoconference group than FtF (p < .05). No significant differences
Mean age = 33.8. process/outcome; were found for satisfaction, ease of communication, degree of
Race = 90 W, 6 AA, client/psychologist relaxation during interview, or participant ratings of psychologist
1 A, 1 La. Sex = 57 M, 41 F self-reports, BSI, caring. Psychologists gave higher rating satisfaction ratings in FtF
WAIS-R or WAIS-III, group (p < .01). Cost-benefit analysis states that technology can be
GSI, satisfaction cost-effective for psychologists.
interview
861
(continued)
862

Sharf (1997) Asynchronous More than 800 participants Participant/observer; Identified three major dimensions of messages: exchange of inform-
e-mail in breast cancer support anecdotal account of ation, social support, and personal empowerment.
group. Sex = 75% F process/outcome
Shernoff (2000) Asynchronous 20-25 e-mail questions from Case commentary; Suggested e-mail may be a lifeline for LGBT population, which is
e-mail; Web site clients per month; anecdotal account of often isolated, and clients who travel frequently and cannot attend
unspecified number of process FtF sessions regularly.
individual LGBT clients
in private practice
Stevens et al. (1999) Videoconference 40 clients recruited from Experiment with FtF No significant differences between videoconference and FtF
community. Mean comparison group; interviews on ISS or CPAS for clients. Psychiatrists rated the
age = 43.8. process/outcome; videoconference interviews as less satisfying (p < .001), but no
Sex = 18 M, 22 F client/psychiatrist difference was found on the alliance measure.
self-reports; SCID-P,
CPAS, ISS
Winzelberg (1997) Asynchronous 302 messages posted by Observation; coding of The majority of participants only posted one or two messages (69%).
message board 70 members of a support messages by two raters Personal disclosures (31%) were the most common type of message
group for eating disorders. into 7 categories posted, followed by information provided (23%) and support
Most participants in early provided (16%).
20s. Sex = 68 F, 2 M
Yager (2001) Asynchronous 4 clients with anorexia Case study; anecdotal Patients’ comments suggest that e-mail increases frequency of contact
e-mail nervosa. Ages = 17, 18, accounts of process/ with clinician, emotional value of e-mail is great because they can
22, 50. Sex = 4 F outcome communicate whenever inspired, quasi-daily e-mails allow them to
update clinicians about details and focus on more meaningful issues
in FtF. Negative consequences may include clinician failure to
respond in a timely fashion, recognize urgent messages.
NOTE: Information about race was provided when available. A = Asian; AA = African American; ADS = Acceptance of Disability Scale; BIQ = Background
Information Questionnaire; BSI = Brief Symptom Inventory; CCTV = closed-circuit television; CHESS = Comprehensive Health Enhancement Support System;
CMC = computer-mediated communication; CPAS = California Psychotherapy Alliance Scale; CRF = Counselor Rating Form; CSES-R = Collective Self-Esteem
Scale–Revised; CSS = Client Satisfaction Scale; CUS = Computer Usage Survey; DSLP = Questionnaire on Social Difficulties Related to Physical Disability;
EQ = Evaluation Questionnaire; ESL = Emotional Versus Social Loneliness; F = female; FDAS = Family and Disability Assessment System; FtF = face-to-face;
GAF = Global Assessment of Functioning Scale; GSI = Global Severity Index; IES = Impact of Events Scale; IOS = Inclusion of Other in the Self Scale; ISS =
Interview Satisfaction Scale; La = Latina/Latino; LGBT = lesbian, gay, bisexual, and transgendered; M = male; MEIM = Multigroup Ethnic Identity Measure;
OSGQ = On-line Support Group Questionnaire; OSI = Occupational Stress Inventory; PANAS = Positive and Negative Affect Scale; PD = personal definition of
loneliness; POMS = Profile of Mood Status; SCID-P = Structured Clinical Interview for the DSM-III-R–Patient Version 1.0; SCL-90 = Symptom Checklist–90;
SEQ = Session Evaluation Questionnaire; SSRS = Social Skills Rating System; STAI = State-Trait Anxiety Inventory; TC = target complaints; TSS = Therapist
Satisfaction Scale; TVRM = Taxonomy of Verbal Response Modes; UCLA-L = University of California at Los Angeles Loneliness Scale; VPPS = Vanderbilt Psy-
chotherapy Process Scale; W = White; WAI = Working Alliance Inventory; WAIS-III = Wechsler Adult Intelligence Scale–III; WAIS-R = Wechsler Adult Intelli-
gence Scale–Revised.
863
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THE COUNSELING

Online-counseling services are currently being provided in a variety of

Correspondence concerning this article should be addressed to Michael J. Mallen, Department of

behavioral health services and information, and counseling psychologists are

THE TELEPHONE IN COUNSELING

Although Internet-based technologies are currently increasing the

(Lamb, 1969; Rosenblum, 1969). Below, we review the literature related to

Effectiveness of Telephone Counseling—Learning From the Past

One of the main debates in the telephone literature is whether telephone

Fostering Client Strength, Resilience, and Wellness

Prevention, Consultation, and Increased Access to Services

Summary of the Telephone-Counseling Literature

COMPUTER-MEDIATED COMMUNICATION IN COUNSELING

The following review of the online-counseling literature includes all

with new modes of service delivery to demonstrate the current research on

Online Support Groups—Demonstrations of Empathy

Counseling psychologists work to convey empathy and support to clients

Finally, Bresnahan and Murray-Johnson (2002) analyzed more than

Summary of the Online-Support-Group Literature

may be that individuals who are comfortable with online communication

Satisfaction and Acceptance of Services

the videoconferencing condition than in the FtF condition; however, inter-

Summary of the Satisfaction and Acceptance Literature

Thus far, research has demonstrated that according to clients’self-reports,

outcomes in a similar manner as professionals. Research should investigate

Process, Interventions, and Working Alliance

sample. The participants completed at least three counseling sessions, which

Summary of the Process, Interventions,

Online-Counseling Outcome Studies

ering online-counseling and behavioral services. Cohen and Kerr (1998)

In a series of studies (Glueckauf et al., 2002; Hufford et al., 1999; Liss,

effectiveness of services provided through asynchronous e-mail and syn-

Summary of the Outcome Literature

Multiculturalism and Access to Services

communication technologies to populations that need their expertise and

FtF conditions. Overall, participants’ evaluations of online and FtF counsel-

Summary of the Multiculturalism and Access-to-Services Literature

Currently, there have been limited efforts to systematically evaluate if

COUNSELING PSYCHOLOGY AND ONLINE COUNSELING—

As the above literature review suggests, many unanswered questions

Normal and Developmental Challenges or Tasks

Counseling psychology has focused on normal or developmental chal-

Client Strength and Resilience

Education and Career Development

In addition, counseling psychology has been at the forefront of studying

Prevention, Consultation, Psychoeducation, and Wellness

In addition to the availability of career resources on the Internet, counsel-

ISSUES FOR COUNSELING PSYCHOLOGISTS CONDUCTING

As mentioned previously, counseling psychologists have been at the fore-

disconnection of an online session is possible and present them with a plan of

There may be differences between telephone, synchronous chat, asyn-

Previous Online Experience

THE ROLE OF COUNSELING PSYCHOLOGY

At its core, counseling psychology is composed of professionals trained

to be beneficial and accepted by clients. However, it also shows the lacunae in

Type of Study; Data; Main Counseling-Related

Type of Study; Data; Main Counseling-Related

Type of Study; Data; Main Counseling-Related

Type of Study; Data; Main Counseling-Related

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