Pastoral Psychol (2013) 62:211–218

DOI 10.1007/s11089-012-0434-3

E-Therapy: Ethical Considerations of a Changing

Healthcare Communication Environment

Eva Prabhakar

Published online: 17 February 2012

# Springer Science+Business Media, LLC 2012

Abstract This paper outlines the current ethical guidelines for electronic therapy services,
and the sufficiency and implications of these guidelines in a culturally diverse population as
found in the United States. The paper limits the discussion of ethical deliberations to: what is
considered adequate competency to practice mental health therapy electronically; the dis-
closure and identity verification requirements; confidentiality issues when different social
norms exist; the social responsibility of public institutions or individuals; and issues that
relate to miscommunication due to different cultural or educational backgrounds. It con-
cludes that since E-Therapy helps to reach underserved populations and significantly
reduces costs associated with mental health services, compliance with ethical guidelines
must be enforced to benefit from the latest communication technologies. This paper is
relevant for various professions related to psychology and psychotherapy, including pastors
and pastoral counselors, because various forms of E-therapy are emerging in the 21st century
and can serve as resources for “E-pastoral counseling.”

Keywords Guidelines . Culture . E-Therapy . Confidentiality . Consent . Disclosure .

Underserved . E-Pastor

Introduction: What is “E-Therapy”?

Essentially any communication that uses an electronic medium such as the computer (e-mail,
instant messaging, chat rooms, discussion boards, etc.), telephone, mobile devices, and
video-conferencing devices is grouped under the term “E-Therapy.” With regards to the
World Wide Web, the National Board for Certified Counselors (NBCC) formally defines
“Web Counseling” as the practice of professional counseling and information delivery that
occurs when client(s) and counselor are in separate or remote locations and utilize electronic
means to communicate over the Internet (Manhal-Baugus 2001). Oravec further classifies

E. Prabhakar (*)
School of Public Health, The University of Texas Health Science Center, 1200 Herman Pressler,
Houston, TX 77030, USA
e-mail: eva.prabhakar@uth.tmc.edu
212 Pastoral Psychol (2013) 62:211–218

web or online therapy into three kinds: (1) electronic provision of individual counseling, (2)
computer use in group and family therapy, and (3) professionally facilitated online support
groups (Wells et al. 2007).
According to Brabant et al., such “distance therapy” can be traced as far back as Freud in
the early 1900s for his practice of exchanging of letters. According to Kanani and Regehr,
mental health services emerged on the Internet as early as 1982 in the form of online self-help
support groups, and in 1995, Needham became the first practitioner to offer e-therapy via real
time chat (Deardorff 2010).
Currently, the range of ways to access E-Therapy has increased exponentially from the
computer to mobile devices and from the “real-time” interaction to delayed response
methodologies such as e-mail. Patients may also elect to seek services from another country,
in another language, and as individuals or groups from various cities participating in one
counseling session. The average cost of E-Therapy can be as low as $25 for a 30 min e-mail
exchange and as high as $120 for 60 min of video-chatting. Provider costs for simply hosting
a website for E-Therapy can range from $250 to $3,600 annually (Allen 2009).

Current Usage and Ethical Guidelines

A survey conducted in 2007 found that the counseling professionals did not see themselves
as using the Internet “to provide online therapy or counseling,” with approximately 2% of
the entire professional sample using the Internet to provide online therapy. However,
approximately 60% of mental health professionals were interested in additional information
related to providing online treatment, criteria regarding who would most benefit from this
approach, and when to stop use of online treatment (Wells et al. 2007). However, these
findings may be limited with regards to sample size and national representation of counseling
professionals in light of over 250 websites and 400 therapists who offered online counseling as
far back as 1996. “E-Therapy” is increasingly being sought and offered today as is evident from
Lavallee’s findings in 2006 that some of the largest online therapy companies had a database of
more than 1,000 registered therapists, Recupero and Rainey’s findings in 2004 that 23% of
Internet users searched for information on mental health issues, and the establishment of
organizations such as the International Society for Mental Health Online (ISMHO).
Due to the growing population that accesses the internet for mental health needs, the
National Board for Certified Counselors (NBCC) addresses some major issues concerning
online counseling. It urges “web counselors” to review legal and ethical codes for online
practice, provide security and confidentiality information to their clients, identify electronic
storage resources and concerns regarding each session information, list web resources such as
licensing boards and certification bodies to protect the client, and help the client cope with using
electronic communication technologies to prevent miscommunication (Manhal-Baugus 2001).
Another set of guidelines have been developed by the International Society for Mental
Health Online. It addresses some basic issues including determining a client’s suitability for
online psychotherapy. The criteria include the client’s skills in communicating within a
preferred communication modality, and the potentially therapeutic aspects of that modality
for the person (ISMHO 2010).
In 2003, only 22% of sites indicated a method of encryption of communications to
clients, and less than 8% of the sites had links to NBCC, ACA, or other professional
organizations and state licensing boards. None of the websites included procedures to help
clients know that they were actually receiving services by the intended counselor, and 64%
gave no information beyond name and credentials (Heinlen et al. 2003).
Pastoral Psychol (2013) 62:211–218 213

Even though compliance with these guidelines is variable, some studies have been
conducted into best-practices involving E-Therapy. The Swinburne University of Technology
E-therapy Unit has been recognized internationally for the Panic Online program, which has
been rigorously tested through five randomized controlled trials. Panic Online has been found
to be efficacious in helping clinically diagnosed people with panic disorder (Abbott et al. 2008).
Further, in 2002, Allenman reported that an informal survey conducted by Metanoia, a
nonprofit clearinghouse for mental health websites, found that 90% of online clients felt that
E-therapy helped them, and many participants felt that they would not have initially sought
face-to-face therapy (Substance Abuse and Mental Health Services Administration 2009).
Also, in Oregon’s RodeoNet telepsychiatry program, direct costs associated with E-therapy
consultations have been found to be approximately 50% less than face-to-face consultations,
and reduced travel and increased levels of assistance have led to the decrease in costs of
providing care. Additionally, E-Therapy allows for continuity of care when clients or therapists
relocate (Substance Abuse and Mental Health Services Administration 2009), and helps to
serve groups that are otherwise difficult to reach with in-person sessions such as women,
highly-educated people, employed people, and elderly people (Postel et al. 2005).
The National Conference of State Legislatures reported the passing of the California
Telemedicine Act as the only state legislation that focuses on E-Therapy exclusively.
However, 18 other states also have some form of legislation for E-Therapy, with Montana
and Puerto Rico requiring a license to practise E-Therapy. Further, as of 2001, online video-
conferencing can be billed to Medicare, but similar coverage from other healthcare insurance
providers is variable. A majority of clients simply pay for E-Therapy out-of-pocket (Substance
Abuse and Mental Health Services Administration 2009).

Challenges with E-Therapy

E-Therapy has proven to be beneficial for clients in underserved areas, and for those who
may be deterred by the effort to physically exert themselves for a counseling session. It also
accounts for clients who travel frequently, and the convenience of accessing therapy services
according to one’s own schedule. Further, it has been found that clients are more honest and
cooperative in online sessions than face-to-face therapy, and tend to explore deeper concerns
in a shorter time period than face-to-face. However, E-Therapy brings with it multi-faceted
concerns on the part of the providers, patients, and the industry itself.

Provider Challenges

The potential for misdiagnosis and miscommunication increases with text-only therapy ses-
sions. This is because some non-verbal cues may be compromised, social norms may be
understood out of context, and time lapses may not account for events requiring immediate
intervention. Further, the provider may not be equipped with the knowledge of legal, political,
or cultural subtleties of the client’s environment in addition to being sufficiently trained in the
use of various communication technologies and etiquettes associated with them.

Industry Challenges

The healthcare industry faces immense pressure to constantly adapt its rules and regulations
to accommodate the changing communication environment. Extending current legislation to
include web-based counseling services, reimbursement concerns, security and encryption of
214 Pastoral Psychol (2013) 62:211–218

patient health records, maintaining confidentiality over an increasingly unregulated medium

such as the Internet, verifying provider and patient identities, and defining jurisdiction, are
just some of the major concerns for the provision of safe E-Therapy.

Patient Challenges

People belonging to different social and cultural groups may perceive health information in a
way not intended by the online counseling professional. Linguistic and economic barriers
may prevent patients who require mental health services from accessing continued E-Therapy
sessions. Further, the potential for misinterpretation of an e-mail or text-only session is much
higher than when the patient can immediately verify the presented information in-person with
the therapist. Also, E-Therapy may not be appropriate for certain groups of people depending
on their health status or communication capabilities.

Ethical Concerns

Based on these challenges, a number of ethical concerns present themselves in the provision
of E-Therapy. The American Psychological Association (APA) has developed a Code of
Ethics to guide mental health counselors with their practice, which may be extended to E-
Therapy even though the language does not specifically address web-based therapy services.
The APA’s Ethical Principles of Psychologists and Code of Conduct states that:
Psychologists have a primary obligation and take reasonable precautions to protect
confidential information obtained through or stored in any medium. Also, before
recording the voices or images of individuals to whom they provide services, psychol-
ogists obtain permission from all such persons or their legal representatives. (Standard 4:
Privacy and Confidentiality)
Further, Standard 10: Therapy addresses the importance of informed consent and confi-
dentiality by stating that:
When obtaining informed consent to therapy, psychologists inform clients/patients as
early as is feasible in the therapeutic relationship about the nature and anticipated
course of therapy, fees, involvement of third parties, and limits of confidentiality and
provide sufficient opportunity for the client/patient to ask questions and receive
answers. Also, when psychologists provide services to several persons in a group
setting, they describe at the outset the roles and responsibilities of all parties and the
limits of confidentiality. (APA 2010)

Adequate Competency

Consequently, ethical deliberations need to arise from a position of adequate competency. It

is fairly easy to misrepresent oneself professional qualifications over the Internet to a client
unfamiliar with the industry standards and associated jargon. On the other hand, clients may
also misrepresent themselves to protect their identities or to “save face.” As such, even
though the burden of competency falls majorly on the provider, the patient also needs to be
competent to communicate and gain the most out of a virtual environment.
The web-based counselor should be subject to the same competency standards required
by face-to-face therapists, and present credentialing information before the initiation of any
Pastoral Psychol (2013) 62:211–218 215

therapy session that can easily be verified by the patient. Further, the provider needs to be
subject to continuing education tailored specifically to the provision of E-Therapy so that the
potential for miscommunication and misdiagnosis can be reduced.

Disclosure and Identity

Due to the potential for remaining anonymous online, a sense of safety and the potential for
illegal and unethical behaviors exist on both ends of the equation. Electronic signatures are
increasingly being used to verify identities; however, this needs to be coupled with full
information of the client and provider names, addresses, and picture proof of identity.
There is also the possibility of inclusion of online records in legal considerations and
ongoing cases. Currently, it is unclear if the standards for recognition of legal protection of
privileged communication apply from one jurisdiction to another. Online psychotherapists
should consider their policy regarding the disclosure of records in response to legal subpoena,
and clients need to be informed about this possible breach of confidentiality (Childress 2000).

Confidentiality

E-Therapy is subject to a highly unregulated environment with jurisdiction concerns and

breach of security measures, especially when the client and provider communicate from
different geographic regions. Also, what may be considered private information in one
society may be readily available public information in another. An additional concern with
patient information is the location and length of storage of information from online counseling
sessions.

Social Responsibility

Belonging to a certain race or ethnicity doesn’t automatically mean that the health behaviors
of groups classified as such are homogenous. The same is true of gender, education, and
income. In the case of culture, however, health behaviors are rooted in what the group
values. These can range from food and alcohol consumption to sexual behavior to seeking
healthcare services. Further, cultural groups may be defined by a common language and
generally understood social roles.
Two people belonging to different cultural groups and suffering from frequent headaches
may seek help at varying time periods because of the severity attributed to such an affliction
in their culture. One of them may downplay the pain to conform to his or her societal role
whereas the other may immediately seek advice without feeling any sense of weakness of
character. These subtle underpinnings are often overlooked, and health-seeking behavior is
frequently attributed to socioeconomic circumstances.
“The meaning individuals give to symptoms and their emotional response may be shaped
by their cultural background” (Kleinman et al. 1978). Further, physicians and healthcare
providers are also subject to their cultural upbringing, and may interact with patients based
on their perceptions of space, time, and authority.
The way that psychiatric conditions such as depression are perceived and explained to the
healthcare provider by a cultural group such as Asian Indians is extremely distinct from the
general American population. “There is not a word for depression in any of India’s
languages. People in India who have depression most often present with somatic symptoms
initially. These individuals identify the most troubling aspects of their disorder to be aches
and pains” (Eastern Illinois University 2003). “Psychological symptoms and problems are
216 Pastoral Psychol (2013) 62:211–218

less salient than physical symptoms in the Asian Indian culture because they signify weak
character and personal deficit” (Karasz et al. 2007) (Prabhakar, Term Paper: Culture as a
Determinant of Health, 2011).
As such, cultural communication subtleties need to be an added skill of web-based
counselors because of the lack of visual representation of emotions. Some people are adept
at writing with the intent of disclosing intimacies previously unexpressed, and there is also
the potential for clients to devalue communications appearing on their computer screen.
Further, some people may interpret certain messages as being far more representative of the
writer’s firmly held thoughts and feelings than is warranted (King and Poulos 1999).
Video-conferencing devices and cultural sensitivity training help to alleviate some of the social
nuances that may be judged from a different moral vantage point than intended.

Withdrawing from E-Therapy

E-Therapy has been criticized as unhelpful and misleading due to the many challenges that
still need to be resolved for patient protection. However, withdrawing from E-Therapy as a
practice brings with it ethical ramifications because it can potentially lead to a lack of
regulation and standardization if left to develop on its own.
With this comes the idea of ethical relativism, where people are generally tolerant and
accepting of a differing sense of morality. Thus, there is no concept of an absolute truth.
Relativism appeals to many people because it allows for leading life with the principles that are
true of their situation instead of an outside, and often alien, sense of what is right or wrong.
However, one must consider the passive nature of this approach; firstly, because it negates the
need for ethical deliberations when it may most matter such as when taken to the extreme of each
person behaving out of their own sense of morality that may prove harmful towards another
person or persons, and secondly, because the ethics of another culture may not be fair towards
those who have no voice, thus, perpetrating the unethical behavior of those who have the power to
determine what is considered right (Prabhakar,Term Paper: Seven threats to ethics, 2011).
Therefore, withdrawing from E-Therapy does not seem to be a viable option because it
leaves room for self-claimed, unregulated, and misrepresented web-based therapists. E-
Therapy is worth pursuing especially if it alleviates mental health needs of an underserved
population in a cost-effective manner.

The Role of Religion in E-Therapy

Many people find solace in the code of instructions that religion provides, and seek its
guidance when making decisions that seem fair and reasonable. For these people, ethical
decisions are those that are supported by their respective religious beliefs, and thus, ethics is
inseparable from religion (Blackburn 2001).
As such, understanding this duality of ethics and religious beliefs as parallel influences on
people’s health-seeking behavior is an important aspect of E-Therapy. Not only does it help
to appeal to a client’s sensibilities for more effective communication if they wish to disclose
their affiliations, it also helps to locate further sources of aid in their own communities that
complement their online sessions.
On the other hand, there is an abundance of websites maintained by pastors, including
their own blogs, resource articles published as online columns that are part of a religious
group, discussion forums, videos, and even directories of pastor profiles with testimonies.
As part of the American Association of Christian Counselors, one such resource is
Pastoral Psychol (2013) 62:211–218 217

eCounseling.com that, in addition to maintaining counseling articles and videos, also provides
training services to pastors that would like to avail of electronic mediums of conseling (Centore
2008). Such websites are effectively paving the way towards a form of “E-pastoral counseling,”
with predetermined rates for individual online sessions with a selected counselor.
Therefore, today clients can avail mental health services as well as have access to an
online pastoral counselor without leaving their homes. However, the same ethical challenges
outlined in this paper translate into the provision of pastoral counseling online, including
proper disclosure and identity concerns.

Conclusion

The Office for the Advancement of Telehealth (OAT) promotes the use of telehealth
technologies for health care delivery, education, and health information services, and is part
of the Office of Rural Health Policy at the U.S. Department of Health and Human Services.
The 2010 OAT budget is $11.6 million (U.S. Department of Health and Human Services
2011). This shows promotion of E-Therapy as a means to alleviate mental health needs of
underserved populations.
However, care must be exercised in correctly identifying such opportunities to reach these
populations because of people’s fear of using advancing technologies and the “digital
divide,” where “young, affluent, educated, and highly functioning whites have the greatest
access to the technology required” for E-Therapy (Substance Abuse and Mental Health
Services Administration 2009).
In conclusion, starting with the implementation of good communication practices such as
establishing the response period for online communication, the content of the messages,
culturally sensitive interactions, and meticulous confidentiality procedures (Kane and Sands
1998), E-Therapy can be practised in an environment where the participants feel safe-thus,
leading the way to better compliance with ethical guidelines for care in a cost-effective
manner.

References

Abbott, J.-A. M., Klein, B., & Ciechomski, L. (2008). Best practices in online therapy. Journal of Technology
in Human Services, 26, 360–375.
Allen, J. L. (2009). The costs of E-Therapy. Retrieved April 30, 2011, from National Directory of Online
Counselors: http://www.etherapyweb.com/costs.html.
APA. (2010). Ethical principles of psychologists and code of conduct: 2010 amendments. Retrieved April 30,
2011, from American Psychological Association: http://www.apa.org/ethics/code/index.aspx.
Blackburn, S. (2001). Being good: A short introduction to ethics. Oxford: Oxford University Press.
Centore, A. J. (2008). E-counseling.com update. Retrieved December 12, 2011, from American Association
of Christian Counselors: http://www.aacc.net/2008/05/08/ecounselingcom-update-first-quarter-2008/.
Childress, C. A. (2000). Ethical issues in providing online psychotherapeutic interventions. Journal of
Medical Internet Research, 2(1), e5.
Deardorff, W. W. (2010). Internet-based treatment: A comprehensive review and ethical issues. Retrieved
April 30, 2011, from Behavioral Health CE: http://www.behavioralhealthce.com/index.php/component/
courses/?task0view&cid069.
Eastern Illinois University. (2003). Counseling for depression in the Indian culture. Retrieved April 30, 2011,
from EIU: http://www.eiu.edu/csd/files/leitschuh/DSM_sample_paper.pdf.
Heinlen, K. T., Welfel, E. R., Richmond, E. N., & Rak, C. F. (2003). The scope of web counseling: a survey of
services and compliance with NBCC standards for the ethical practice of web counseling. Journal of
Counseling and Development, 81, 61–69.
218 Pastoral Psychol (2013) 62:211–218

ISMHO. (2010). Assessing a person’s suitability for online therapy. Retrieved April 30, 2011, from The
International Society for Mental Health Online (ISMHO): https://www.ismho.org/therapy_suitability_
assessment.asp.
Kane, B., & Sands, D. Z. (1998). Guidelines for the clinical use of electronic mail with patients. Journal of the
American Medical Informatics Association, 5(1), 104–111.
Karasz, A., Dempsey, K., & Fallek, R. (2007). Cultural differences in the experience of everyday symptoms: a
comparative study of South Asian and European American women. Culture, Medicine and Psychiatry. 31
(4):473–97.
King, S. A., & Poulos, S. T. (1999). Ethical guidelines for on-line therapy. In J. Fink (Ed.), How to use
computers and cyberspace in the clinical practice of psychotherapy (pp. 123–132). Northvale: Jason
Aronson, Inc.
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care. Annals of Internal Medicine, 88
(2), 251–258.
Manhal-Baugus, M. (2001). E-therapy: practical, ethical, and legal issues. Cyberpsychology & Behavior, 4(5),
551–563.
Postel, M. G., Jong, C. A., & Haan, H. A. (2005). Does E-Therapy for problem drinking reach hidden
populations? The American Journal of Psychiatry, 162(12), 2393–2393.
Prabhakar, E. (2011). Culture as a determinant of health. Houston: The University of Texas School of Public
Health. Unpublished Term Paper.
Prabhakar, E. (2011b). Seven threats to ethics. Houston: The University of Texas School of Public Health.
Unpublished Term Paper.
Substance Abuse and Mental Health Services Administration. (2009). Considerations for the provision of E-
Therapy. Rockville: U.S. Department of Health and Human Services.
U.S. Department of Health and Human Services. (2011). Telehealth. Retrieved April 30, 2011, from Health
Resources and Services Administration: http://www.hrsa.gov/ruralhealth/about/telehealth/.
Wells, M., Mitchell, K. J., Finkelhor, D., & Becker-Blease, K. A. (2007). Online mental health treatment:
concerns and considerations. Cyberpsychology & Behavior, 10(3), 453–459.