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Providing Online Counseling

Whether you are a practicing counselor or a client receiving counseling, there is value in understanding online counseling’s importance and ramifications. Before 2020 and the mass adoption of virtual services, online counseling services were an exception to the norm. Mental health professionals preferred and prioritized in-person services over online services. As social distancing became necessary, the option of providing telehealth services became many providers’ primary modalities. The prevailing question that counselors will be required to answer as the need for social distancing decreases is whether they will continue to offer virtual services or make the transition back to a model focused on in-person services.

Whether or not counselors prefer in-person or online counseling – there is no question that online counseling is incredibly exciting. It opens the door to counseling access for populations that have previously been unable to access counseling. That said, it would be irresponsible not to explore the reservations counselors have about online services. Counselors have pointed to the reality that the practice of counseling is reliant on a healthy relationship. They have made the argument that it seems impossible for a virtual connection to have the same quality as a face-to-face relationship (McAdams & Wyatt, 2010). The good news is that research on online counseling has already been done and has found that the therapeutic relationship suffered little due to its digital nature (Backhaus et al., 2012; Hilty et al., 2013). Backhaus et al. (2012) found that the largest obstacle to effectiveness in the provision of online counseling was technological failure, which caused frustration for both counselors and clients. This support for distance counseling’s efficacy seems to show that it is a valuable resource for counselors to explore.

Online counseling offers several benefits to the counseling profession that set it up to become a permanent part of what counselors do. One of the overarching benefits of online counseling is that it expands the reach of counselors. It allows counselors to connect with those who live in rural and geographically remote locations that previously lacked access to counseling services (Barnett & Kolmes, 2016). The ability to quickly and conveniently expand the counseling profession’s reach to provide more people with access to services is an incredible opportunity.

Expanding the literal reach of the counseling profession is only one of the benefits of online counseling. It also enables people who cannot access service due to lack of mobility or inclement weather to connect with a mental health professional (Barnett & Kolmes, 2016). The extended reach leads to greater access for populations like the geriatric community who may not be as mobile and enables greater continuity of care regardless of environmental factors like inclement weather. It also allows people like single parents or busy professionals whose schedules and responsibilities do not allow for a physical trip to an office.

Online counseling can also increase the level of safety clients experience in pursuing counseling (Centore & Milacci, 2008). Seeking mental health services of any kind still comes with a stigma, and that stigma can be enough to keep people from ever pursuing counseling. Online counseling allows people to receive counseling services from the comfort of their own homes, eliminating the exposure of physically showing up at a counseling office (Centore & Milaccim 2008). The common themes found throughout all benefits of online counseling are the increased ease and reach of access. The apparent benefits afforded by online counseling make it easy to overlook the importance of exploring this type of practice’s ethical implications.

Every new approach to counseling brings new ethical issues, and online counseling is no different. While its benefits to the profession seem straightforward, it comes with many legal and ethical issues that require attention to provide the most ethical online professional services possible. In exploring the ethical ramifications of online counseling, there are three types of standards: legal, honest, and best practice (Remely & Herlihy, 2016). The traditional standards set the minimum requirements for the protection of the population.

The next level of standards is the ethical codes; these raise the bar from focusing on avoiding harm to a higher standard to promoting health. Licensed counselors in the United States must adhere to the American Counseling Association (ACA) Code of Ethics (2014). Beyond the mandatory ethical codes exist standards of best practice. These represent a level of functioning that is not required – but recommended. Counselors who adhere to best practices go above and beyond the base requirement to provide the highest quality possible services. All three standards are necessary and play different roles in protecting the population and in the formation and regulation of online professional services.

Ethics in providing online counseling

Taking a closer look, the ACA’s Code of Ethics (2014) section on providing online professional services has two general focuses. The first area of focus requires counselors to develop competency in the use of online professional services. The second is informing clients about the potential risks to their privacy that arise when technology is involved. Both areas emphasize that the necessary steps for providing ethical counseling services through distance professional services require more steps than providing counseling face-to-face. Variables such as knowledge of software encryption specification or client identity verification system require extra attention and effort not typically needed during face-to-face counseling (Turvey et al., 2013; ACA, 2014). To better understand some of the specific ethical issues involved in providing online professional services and propose best practices, one of the first places counselors should look at is section H of the Code of Ethics (ACA, 2014).

One of the most frequently occurring ethical issues within the practice of online counseling is a lack of competency. Counselors fail to acknowledge the need for competency in understanding the software they are utilizing and the additional risks they are shouldering. As a result, they engage in distance counseling ignorantly (Carlisle, Hays, Pribesh, & Wood, 2017). This failure to build competence directly contradicts section H.1.a of the ACA Code of Ethics (2014), which requires counselors who provide distance counseling to maintain knowledge and competence regarding the ethics that pertain to online counseling. This lack of competency presents a risk to the clients’ privacy through improper software usage and potentially to the clients’ well being due to a lack of preparation for emergencies. 

Section H.1.b. of the Code of Ethics (ACA, 2014) requires counselors who practice online counseling to know the specific legal requirements of both the jurisdiction in which they practice counseling and the client’s location. The expectation here goes beyond knowledge about licensure and includes laws regarding hospitalization and mandated reporting (Barnett & Kolmes, 2016). Failure to gather this information before engaging in distance counseling can have severe consequences for all involved parties.

Another theme woven throughout section H is the importance of understanding the implications of online counseling on confidentiality (ACA, 2014). The use of technology brings several factors that the counselor must be aware of to ensure their client’s privacy. The good news is that as telehealth has grown, HIPAA compliant services have become more readily available. This increased availability is vital because any software used to communicate with or about clients must be HIPAA compliant (Barnett & Kolmes, 2016). Clients have a right to privacy, and a breach of confidentiality by using unencrypted software, whether intentional or not, results in the same consequences as any other breach of confidentiality.

Proper documentation maintenance is another ethical area in which counselors may frequently be at risk of ethical issues. Section H.5. of the Code of Ethics (2014) stipulates that counselors maintain documentation of communication, whether written, audio, or visual – and that the client has access to, and is informed about the storage of their records. Maintaining proper documentation is a significant task. Counselors are used to documenting their sessions but are less used to adding every email or text regardless of significance to the client’s file (Turvey et al., 2013). The importance of proper documentation often seems to get overlooked simply because the counselor decides the interaction was insignificant.

Online counseling also creates a different dynamic between the counselor and the client. Communicating through videoconferencing, emailing, and text messaging can often be more comfortable for individuals in a way that causes them to lower their guard. This decreased inhibition makes it easy for the boundary in the relationship between the client and counselor to be blurred, resulting in ethical violations (Sude, 2013). Just as in face-to-face counseling, section H.4.b. outlines that the counselor and client’s professional relationship must still be maintained (ACA, 2014). Regardless of the medium, counselors always have a responsibility to maintain professionality in their relationships with their clients to protect the clients’ interests.

Distance counseling is not right for everyone, and section H.4.c. of the Code of Ethics (ACA, 2014) places the responsibility of deciding fit on the counselor. Counselors are responsible for assessing whether or not an individual would be the right candidate for distance counseling. Instances such as severe depression, suicidality, reality testing, violence, or homicidal tendencies are all issues that are better suited to in-person services (Barnett & Kolmes, 2016). Once potential clients are screened, the counselor is responsible for documenting in the client’s file whether they are an appropriate candidate for Distance professional services and why (Barnett & Kolmes, 2016). If a client is not a suitable candidate for distance counseling, section H.4.d stipulates that the counselor is responsible for assisting the client in finding a more appropriate option (ACA, 2014). As with the standard for face-to-face counseling, the counselor is accountable to the client as soon as they made their first contact.

Another potential ethical issue with online services is whether the informed consent provided to clients includes information about online counseling risks. Using the same informed consent for distance counseling as face-to-face counseling is another potential ethical issue unless the informed consent for the face-to-face practice contains additional information about online counseling. The ACA Code of Ethics (2014) and the Health Insurance Portability and Accountability Act (HIPAA) of the U.S. Department of Health and Human Services (2015) outline the standards required for an informed consent that covers online professional services. Besides all of the typical informed consent requirements, informed consent for online professional services involves explaining all additional confidentiality risks. This explanation includes information about the potential dangers posed to the client’s confidentiality, the software to be used and its encryption, a process for communication in emergencies, a method for communication during technical failure, and information about the location of the counselor (U.S. Department of Health and Human Services [DHHS], 2015; ACA, 2014). Additionally, informed consent must also contain details on the storage of any client information and communication that the counselor will maintain (DHHS, 2015; ACA, 2014). Developing an informed consent that contains such detailed information requires a significant effort from the distance counselor before they begin offering online professional services.

The two primary areas of ethical focus in online counseling of developing competency and providing a thorough informed consent present a large hurdle for any counselor interested in offering distance professional services. Developing the required competency is further complicated for the counselor by the rapidly evolving technology and expanding application in online professional services. There will continuously be new ethical issues that need time and attention. That is where best practices come into play; by following best practices, counselors can stay ahead of the curve and maintain a continuous ethical practice.

Best practices for counselors in online counseling

Establishing best practices for online counseling services starts with the legal and ethical requirements and then raises the bar higher. Maintaining best practices is comparable to going the extra mile – it is not required – but it is suggested (Remely & Herlihy, 2016). Establishing best practices for online counseling services is about working on getting ahead of the competency learning curve and going above and beyond to protect the client’s right to privacy. Doing this starts with establishing a better approach to training counselors to offer their clients online professional services.

Though the ethical codes require competency to offer online professional services, there is no official required training. Part of best practices should involve pursuing standardized training and credential like those provided by the Center for Credentialing & Education (CCE). The CCE partnered with the Telehealth Training Academy and Resource Center to develop training and credentialing for offering online counseling services. The training consists of nine units focused on various components of ethically and effectively providing online professional services and a final examination. Upon completion of the requirements, counselors receive the Board Certified-TeleMental Health Provider (BC-TMH) certification. Because technology is always changing, the training must be redone every five years to stay up to maintain certification. Pursuing this or similar training should be part of best practices for counselors offering distance professional services. 

           Beyond pursuing more standardized training, the counselor can also take additional steps to protect their client’s privacy better. Rather than just using their informed consent to disclose and potentially insecure platforms, the counselor can use only HIPAA compliant platforms for all activities (Turvey et al., 2013). Two examples of HIPAA compliant platforms are Simplepractice, an all-in-one EMR service, and Google Business Suite (with a signed BAA) for email services. While HIPAA compliant platforms for all communication methods are readily available, it is still the counselor’s responsibility to do their homework to ensure the protection of their client’s wellbeing and privacy. Best practices in online counseling involves placing the safety and security of the client as the main priority. 

           Best practices also requires the implementation of a plan for dealing with emergencies. Providing immediate assistance can be difficult when the counselor is geographically distant from the client. Part of the intake process should involve collecting the contact information of someone located in the client’s physical area who could respond quickly if necessary (Turvey et al., 2013). A thorough list of the contact information for the emergency services in the region should be compiled so that the counselor is prepared to respond promptly when necessary (Turvey et al., 2013). Gathering these resources takes time, but in an emergency, they become an invaluable resource.

           The advancement of technology and the development of new ways of connecting with clients and providing counseling services is exciting for the counseling profession. The advent of distance professional services to the counseling profession has the potential to expand the reach of counseling to places and people who have previously been unreachable. Simultaneously, the use of new technology comes with unknown legal and ethical risks. Counselors are responsible for exploring and understanding the implication technology has on the counseling relationship and the clients’ confidentiality. The counseling profession is responsible for providing ethical counseling practice that protects the client’s best interests. Both counselors and clients need to be informed about the requirements and risks of online counseling. While everyone should be aware, it is the responsibility of counselors and the counseling profession to band together and establish a thorough code of ethics and best practices that pertain to the provision of online counseling.

References

American Counseling Association (2014). ACA codes of ethics and standards of practice. Alexandria, VA: Author.

Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., … Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services9(2), 111–131. https://doi.org/10.1037/a0027924

Barnett, J. E., & Kolmes, K. (2016). The practice of tele-mental health: Ethical, legal, and clinical issues for practitioners. Practice Innovations1(1), 53–66.

Carlisle, R. M., Hays, D. G., Pribesh, S. L., & Wood, C. T. (2017). Educational technology and distance supervision in counselor education. Counselor Education and Supervision56(1), 33–49. https://doi.org/10.1002/ceas.12058

Centore, A. J., & Milacci, F. (2008). A study of mental health counselors’ use of and perceptions of distance counseling. Journal of Mental Health Counseling30(3), 267–282.

Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of Telemental health: A 2013 review. Telemedicine and E-Health19(6), 444–454. https://doi.org/10.1089/tmj.2013.0075

McAdams, C. R., III, & Wyatt, K. L. (2010). The regulation of technology-assisted distance counseling and supervision in the United States: An analysis of current extent, trends, and implications. Counselor Education and Supervision49(3), 179–192. https://doi.org/10.1002/j.1556-6978.2010.tb00097.x

National Board for Certified Counselors. (2016). Policy regarding the provision of distance professional services. Greensboro, NC: Author

Remley, T. P, & Herlihy, B. (2016) Ethical, legal, and professional issues in counseling. Boston: Pearson.

Sude, M. E. (2013). Text messaging and private practice: Ethical challenges and guidelines for developing personal best practices. Journal of Mental Health Counseling35(3), 211–227. https://doi.org/10.17744/mehc.35.3.q37l2236up62l713

Turvey, C., Coleman, M., Dennison, O., Drude, K., Goldenson, M., Hirsch, P., … Bernard, J. (2013). ATA practice guidelines for video-based online mental health services. Telemedicine and E-Health19(9), 722–731.

U.S. Department of Health and Human Services. (2015). Health insurance portability and accountability act of 1996. Washington, DC: Autho

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