We are living in a world where most people live two lives, one in reality and the other online. The Internet has allowed activities like shopping, educating, socializing, dating, banking, and various other activities over the World Wide Web to take place over this new medium. As our technology advances, new industries are slowly integrated into the Internet, counseling psychology is no exception. The growing demand for online counseling has started to raise certain issues involving the laws and ethics of counseling someone. Currently the industry of counseling psychology is so new that we are still learning so much about the effects it will have on the therapeutic relationship between the client and the therapist. As the demand for online counseling grows, more questions arise, questions like “what type of client would be appropriate for online counseling,” and many other questions that will be discussed.
Counseling over the Internet is slowly developing due to the demand it is beginning to present. UK research psychologists have found that the origins and demand of online therapy began with self-help support through chat rooms and news groups. Although, this was not the first documented evidence that therapy took place from a distance, Sigmund Freud had the practice of treating patients by letter. Two major types of online services being requested for mental health are for assessments and counseling (Skinner & Latchford, 2006).
Distance Therapy Procedural Practice
“Researchers have found that various psychotherapeutic approaches can be used online, such as dynamic, narrative, cognitive, cognitive-behavioral, behavioristic, and client-centered” (Finn & Barak, 2010, p.268). These approaches have demonstrated that a therapeutic relationship is possible and can be successful online.
In “duty to warn and protect” situations it is wise to have prepared the necessary steps to take immediate action if required. Clients who are a threat to themselves or others will need the attention of the proper authorities in their jurisdiction and it is the counselor’s responsibility to know this information prior to having an emergency take place (Shaw & Shaw, 2006).
Attitudes Towards e-Therapy
Basic economics tell us if there is a demand, supply will increase. In the case of online therapy, the demand for services of e-therapy will cause an increase in therapy to take place online. According to an interview by Audrey Jung, the president of the International Society for Mental Health Online (ISMHO), clients typically will lead the way to their own healing and in the case of the Internet research has found that it was possible to have a therapeutic relationship with notable advantages (Anthony et al., 2010).
In her interview, Audrey Jung stated that: “clients sometimes revealed information avoided in face-to-face sessions and, with care, their difficulties could be addressed more directly, while retaining a secure therapeutic frame and one that allowed far greater opportunity to reflect” (Anthony et al., 2010, p.1).
The studies that have taken place for online counseling have informed researchers and the psychotherapeutic community that clients will self-disclose more via the Web, though because there are so few studies, researchers are still unsure if it is because of the channel of communication or the personality type that is using the channel of communication (Skinner & Latchford, 2006). This same research has discovered that the online environment allows individuals to feel invisible even when we know their true identity. In being invisible clients feel their status on the Web can be masked because they are not judged by their clothing, age and environment.
Clients who have been most responsive to distance therapy are those individuals that have difficulties getting to a therapist due to “transportation, handicap, need for anonymity, shyness or fear of face-to-face disclosure or interaction, having no free time for counseling during regular work hours and those living in rural places” (Young, 2005, p.174).
Dr. Kimberly Young’s research has concluded that out of 48 online clients, the demographics of the e-client is typically Caucasian, middle-aged, male, and has a four-year degree (2005). In my opinion, because technology has evolved and access to the Internet has allowed other demographics to have use of the Web, new research would have to validate these findings.
Most of the research that has taken place for distance therapy warns therapists using this method to consider the disadvantages associated with the lack of security, confidentiality, non-verbal cues and not being able to provide an empathic, warm, emotionally rich experience to the client. The majority of these issues are of an ethical nature. The primary legal concerns have to do with jurisdiction and qualifications of the counselor (Anthony et al., 2010).
Some topics that come up in therapy are best handled in person, according to Audrey Jung. It would be more comforting to the client if dealing with suicidal ideation or issues of an intense psychotic nature. A face-to-face client would allows the therapist to do more by physically intervening, calling local support like the police, hospital or proper authorities (Anthony et al., 2010).
Distance Therapy Laws and Ethics
The biggest challenges with providing mental health services via distance therapy have to do with legal and ethical issues that can occur in therapy like jurisdiction, regulation, unethical practices that would normally occur in face-to-face therapy and licensing (Baker & Ray, 2011). Issues that can occur are typically honest mistakes like checking email in a different state, providing video conferencing while traveling internationally, and being disconnected from a client and not being able to communicate causing client abandonment. Because online therapy is still relatively new, we are just now starting to see policy makers, professional organizations and other governing parties provide guidelines.
Various works of research have directed much of the ethical guidance to the American Counseling Association (ACA) because they have detailed specific guidelines for therapy taking place online. The 2005 ACA code of ethics goes into rich detail to help therapists and policy makers avoid issues that may occur while practicing therapy via the Internet.
ACA Technology Code of Ethics
The American Counseling Association (2005) has established the following guidelines:
“When establishing informed consent, counselors should do the following:
Social media raises another layer of complexity for therapists that wish to do work at a distance because unethical practices are likely to occur. Clients may find therapists on social media outlets like Facebook, Twitter, and MySpace, with a request to become connected through the social media outlet. The problem the therapist would have in this case is a dual relationship would take place. By allowing the client to enter the therapist’s personal life online, the client would have access to information that would give a great amount of disclosing information that would tarnish the therapeutic relationship (Anthony et al., 2010).
Another concern with social media is allowing clients to see personal information that may put the client’s family and friends in danger if the client were to become hostile or threatening. I personally would not approve of mixing social media with clients. It would be best to create a business page with relevant information for clients and the general public. The key point here is that an innocent request to become friends or connected online will have a negative effect to the client’s view of the therapist because boundaries would be crossed (Anthony et al., 2010).
Training and Supervision
Finn and Barak (2010) have reported that counselors doing online therapy learned proper online therapy skills through various formats. 92% of e-therapists personally read about the subject, 80% had an informal consultation with colleagues, 20% attended an online therapy workshop, and 16% attended an e-counseling training program. The majority did not have supervision in the area of distance therapy.
The education of online counselors varied in the study by Finn and Barak (2010), 27% of online therapists had a masters degree in counseling, 14% a masters in psychology, 10% had a PhD or PsyD in psychology, and the remaining percentage had varying degrees such as social work, education, humanities, medical degree and other graduate work. Although most practicing online therapy have formal education, it is currently not regulated and anyone is able to provide online therapy without formal education. This is a concern and is currently under review with policy makers (Finn & Barak, 2010).
Privacy and Confidentiality
Because privacy and confidentiality is not guaranteed, the e-counselor should attempt to prove they are doing their best to keep privacy and confidentiality by interacting in a secure and private environment. Public hotspots and Internet café’s should be avoided. Clients should also be advised to be in an area where it is private and secure to receive online counseling (Haberstroh, 2009).
Professor Haberstroh of San Antonio (2009) advises that creating a security passcode to confirm identity is recommended, other tips would include copies of official identification from the client. Because hacking is possibility, the e-therapist must be confident with the technology being used. The technology the e-therapist uses should be properly secured with the most advanced security features such as antivirus software, spyware, firewalls and high encryption.
Professor Shane Haberstroh from The University of Texas in San Antonio (2010) has found through research that online therapy has a potential of treating patients with symptoms of anxiety, depression, panic disorders, posttraumatic stress disorder, and eating disorders. Through Haberstroh’s research, he found that men had a higher positive response to online treatment than women (2010). Men were more receptive to having online therapy versus face-to-face counseling.
Further studies have provided further support to the list of appropriate clients that are able to receive help via the Internet; populations that include smoking cessation, sex therapy, loneliness, gambling problems, geographically isolated areas, physically handicapped individuals, those who would not normally seek face-to-face therapy, adolescents and elderly (Finn & Barak, 2010).
One group of the population that is expected to increase the use of online therapy is adolescents. According to research by Shaw and Shaw (2006), “out of 73% of teens between the ages of 12 and 17 using the net, it is likely that most teens will use some form of online counseling services (p.43).” Within 73% of these teens that use the net, they use technology to discuss subjects that would not be discussed with anyone else in person. “Teens that use the Internet the most are most likely to be depressed and to be socially isolated. Many teenagers may therefore be seeking treatment for serious mental health issues such as depression and anxiety and may also have suicidal ideation (Shaw & Shaw, 2006, p.43).”
It is important to note that counseling services require the written consent from a legal guardian if under the legal age of 18 (Shaw & Shaw, 2006).
Disadvantages to Distance Therapy
Although there are many positives aspects to online psychotherapy, there are also setbacks that hinder the therapeutic process. In assessing a client, therapists may find it difficult to correctly diagnose or assess a client compared to a face-to-face assessment (Finn & Barak, 2010).
Research by Finn and Barak (2010) has shown that certain areas of online therapy are at risk: “participants concealing their true identity, possibly impersonating the actual client, which would breach confidentiality and privacy. Other areas of concern have to do with emergency assistance, ability to fulfill mandatory reporting requirements, relying on fragile technology, difficulty in communicating accurately both verbally and non-verbally, cross-cultural misunderstandings, difficulties with billing and fee collection, and legal problems related to jurisdiction and licensing laws as discussed previously” (p.269).
Although there may be disadvantages to distance therapy, a population of clients are requesting therapy through an electronic medium like the Internet. As professional organizations continue to work on the legal and ethical concerns, many counseling professionals can begin to properly work with individuals without being at risk. Education and supervision is expected to grow and evolve as more research uncovers methods that will improve the practice and use of online therapy.
Authored and Researched by:
Orlando Zuniga, LMFT 98936
Licensed Marriage & Family Therapist
Selective Serotonin Reuptake Inhibitors (SSRI’s), also known as antidepressants, are used by prescribing medical professionals to aid in emotional disturbances. The majority of patients getting prescriptions come from non-specialist prescribing medical professionals like their primary care physicians (PCP). A consultation with a PCP typically includes a review of medical ailments and if any reference is made to mood, depression, anxiety or mental related concerns a PCP will prescribe psychotherapy, a psychotropic medication, or both. Once a prescription has been given PCPs are recommended to continue treatment in all patients for at least six months after resolution of symptoms, and for at least two years in patients with high risk of recurrent depression (Middleton, Cameron & Reid, 2011).
Out of all the antidepressants available, two independent studies found that Zoloft and Lexapro are the most effective antidepressants with the least amount of side effects (White et al., 2010). In a similar study, psychiatrists and medical professionals were asked what antidepressant they would choose if they were clinically depressed. The answer was Zoloft as their number one choice, followed by Lexapro. The reasons for their choice were indicated by the importance of the efficacy and safety of the antidepressant (Chaudry et al., 2011).
Over the past several years, the use of SSRI medication has grown so much that it is now the third most prescribed medication in the United States. In fact, most prescribing medical professionals are PCPs without a psychiatric diagnoses. “Because of the growing demand in psychotropic medication like SSRI medication many scientists are hoping to gain a better understanding of the factors driving this national trend and to develop effective policy responses (Pies, p.37, 2012).”
Research has shown that PCPs are prescribing antidepressants to patients with poorly defined mental health conditions, though that is not the concern. The concern here is that there are patients that go untreated by their PCPs because these patients are undetected or misdiagnosed (Pies, 2012).
In speaking to two different physicians about the use of psychotropic drugs in their medical practice, I found two very different answers that indicated pro medication and pro therapy. One physician, Dr. Lynn, indicated that the best practice for her patients is to recommend psychotherapy first and if that fails to produce results or desired improvements, than psychotropic medication would be the last resort. Another physician, Dr. Gonzalez, preferred the psychotropic method for immediate relief of symptoms. In asking other medical professionals, there were many professionals that agreed with Dr. Lynn’s view and others who agreed with Dr. Gonzalez’s view of psychotropic method of prescribing. One physician said he believed that patients did not require psychotherapy because they can discuss any concerns with him while in consultation; I personally disagree with this physician because he only gives patients 15 minute consultations, if this physician had proper psychotherapy training and gave patients more than 45 minutes of face-to-face time on a weekly schedule, I would agree with him.
When a personal friend wanted to terminate medication she didn’t think it would be any different than stopping an antibiotic prescription. The symptoms have been controlled and it was time to get off the medication. Her reason for stopping was an issue of dependence; she did not want to become dependent on any medication for the rest of her life, so she just stopped taking Celexa. Three days later she described the following symptoms, “I first started to get headaches, then I felt electric shocks in my head, it was the worst feeling I have ever felt! I was crying uncontrollably for no reason and I was very confused. I was overly emotional all day and especially at night. I was irritable, and I didn’t feel like myself for 7 days. I figured it was the lack of the medication and so I called my doctor and I was instructed to begin my 10mg dosage immediately after having been off for 7 days. I currently take my medication every other day and I feel fine. I wish my doctor would have explained the side effects of stopping cold turkey before I did that (personal communication, 2014).”
The example my friend provided is one example of antidepressant withdrawal and also a reason why most taking SSRIs fear getting off the medication. Researchers from Amsterdam interviewed patients taking SSRIs and found that there were typically two main reasons for wanting to stop taking medication. The first reason for wanting to stop medication was that symptoms were no longer present and the second reason was the fear of becoming addicted to the medication, even though it is not addicting. According to patients in this research the biggest concern in stopping medication is losing the balance in life that they have achieved with SSRI medication (Verbeek-Heida & Mathot, 2006). What Verbeek-Heida and Mathot (2006) found was that patients were fearful of the unknown when stopping medication and that the best solution would be education and guidance by a medical professional like a primary care physician or someone with prescribing rights in conjunction with psychotherapy.
My Personal Thoughts
I personally feel that most people are overmedicated unnecessarily when they can alleviate health concerns through lifestyle and natural choices like exercise, nutrition and psychotherapy, to name just a few. Once patients have exhausted all lifestyle and natural methods, I can support an integrative approach with medication. This is my personal view of course.
Chaudhry, I. B., Rahman, R., Minhas , H. M., Chaudhry, N., Taylor, D., Ansari, M., & Husain, N. (2011). Which antidepressant would psychiatrists and nurses from a developing country choose for themselves?. International Journal of Psychiatry in Clinical Practice, 15, 74-78. doi: 10.3109/1351501.2010.530668
Howland, R. H. (2009). Prescribing psychotropic medications for elderly patients. Journal of Psychosocial Nursing, 47(11), 17-20. doi: 10.3928/02793695-20090930-06
Knorr, U., & Kessing, L. V. (2010). The effect of selective serotonin reuptake inhibitors in healthy subjects. a systematic review. Nordic Journal of Psychiatry, 64(3), 153-161. doi: 10.3109/08039480903511381
Middleton, D. J., Cameron, I. M., & Reid, I. C. (2001). Continuity and monitoring of antidepressant therapy in a primary care setting. Quality in Primary Care, 19, 109-113.
Pies, R. (2012). Are antidepressants effective in the acute and long-term treatment of depression? sic et non. Innovations in Clinical Neuroscience, 9(5-6), 31-40.
Sansone, R. A., & Sansone, L. A. (2010). Ssri-induced indifference . Psychiatry (Edgmont), 7(10), 14-18.
Verbeek-Heida, P. M., & Mathot, E. F. (2006). Better safe than sorry-why patients prefer to stop using ssri antidepressants but are afraid to do so: results of a qualitative study. Chronic Illness, 2, 133-142. doi: 10.1179/174592006x111003
White, C., Wigle, P., Eichel, E., Albert, L. G., & Udom, L. (2010). Answers to your questions about ssris. The Journal of Family Practice, 59(1), 19-24. Retrieved from http://www.jfponline.com
You call me a loner, and a free-spirit, as if there were some danger behind such a way of living. I understand being free requires one to leave everything behind. It requires one to leave comforts like a steady income, a warm house, secure relationships. Being free requires one to challenge their fears. It doesn’t mean I am running away from the things that try to ground me, it means I trust that I will have another meal without knowing where it will come from, I will sleep in a warm home without knowing the address, I will meet new relationships that will love me.
The only danger is in believing the fears others put onto me. “I hear it’s dangerous to travel there, please don’t go.” That is when I will stop being free, when you convince me that your fears should become my own. Fear is easily spread, and what does fear do? It limits us from moving forward. We retreat from our original intent because we do not feel safe. We begin to doubt. Here is what fear sounds like:
Fear controls us in a way that does more harm than good. At one point in time fear was used to signal danger. Fear signaling to take action from a saber-toothed tiger was healthy. Our modern day saber-toothed tigers are the illusion of terrors, insecurities, criticism, judgments, and other unkind acts. Our fears communicate to us that we will fall and we will have difficulty getting back up. Even so, I encourage you to be free!
I invite you to fall without knowing where you will land. Perhaps while falling you discover that you had wings all along and you could fly so high that you reach the stars where the angels live. Only when you allow yourself to be uninhibited will you understand how truly free you are. Sure you can fall and your fear convinces you that you don’t have wings and so you do nothing because you have been told there is nothing you can do; I encourage you to ignore everything you have ever been told and flap your wings anyway! I challenge you to fly!
My approach to counseling derives from my values, morals, education, observations, professional and personal experiences. The summation of my experiences have led me to whole-heartedly believe that life is an intricate web of systems affecting each other. Much like the physical body performs best when in homeostasis from its systems (cardiovascular, nervous, skeletal systems, etc.), my theory of a high-performing psychology asks us to look at all systems and identify and heal any dysfunction. These systems or layers include: Spirit, Personality, Cognition (mental process), Culture, Environment, Behavior, and of course the Physical.
My theory helps structure the assessment process, which helps identify layers or systems that are in chaos, and ultimately we work together to improve the areas identified as chaotic. My view remains the same for groups and couples as it does for individuals.
In working with client goals, I bring in my own goals of helping individuals, couples, and groups attain high-performing and self-actualized consciousness.
Orlando Zuniga, LMFT is a Licensed Psychotherapist practicing in Los Angeles and most of California. With expertise in mental health counseling, behavioral medicine, relationship counseling, executive coaching, sales training, client relationship management, and organizational-corporate development.