Group Counseling at a Distance:

Considerations of Internet Based Counseling

Deborah F. Corkindale

Capella University

Abstract

The internet has always been touted as being a tool to connect people. As the technology that supports personal computers and the internet continues to improve and become more affordable, more and more individuals are taking advantage of what the World Wide Web can offer, and more and more counselors are taking advantage of that medium to offer their services and help to potential clients. The advantages are obvious: availability, ease of use, reduced cost, and attractiveness. The drawbacks are just as obvious and center on privacy concerns and ethical considerations. This study explores the advantages and drawbacks of internet counseling, the different forms it can take, and the stance taken by professional organizations to this form of counseling.

Group Counseling at a Distance:

Considerations of Internet Based Counseling

Since its inception, the internet has been touted as offering the ability to connect people. The notion of a true "global community" is now possible with the ever expanding presence of the World Wide Web. It has brought people together who are separated by thousands of miles as friends, as business partners, as romantic partners, as members of a support network, as people that share an avocation or hobby, and as fellow learners. The phenomenon of the internet has changed people’s lives in a very real way, and we are still in the process of realizing its potential and maximizing its benefits to us. With each passing day we are coming to understand that we have barely scratched the surface of what this form of communication can eventually offer us.

The internet is well-known as a medium through which people are willing to share very private thoughts and feelings and parts of their lives with people they have met only in cyberspace. Deep attachments often result from these cyber relationships. Counseling over the internet, both privately and in groups, is an obvious outgrowth of this phenomenon and one that can be useful and powerful but one that also requires much rigor pertaining to confidentiality, privacy, legal restrictions, logistics, and technological issues.

This paper will present an overview of the forms that web counseling can take, with a special eye to group counseling, considerations for the practitioner, considerations for the client, legal issues, and the positions that professional organizations are taking on this.

There are a number of forms that internet based counseling can take. The National Board for Certified Counselors, Inc. (NBCC) website presents the most detailed information on considerations for this type of counseling, and has provided a very comprehensive list of the forms that it can take. That list is presented here in its entirety, including information on traditional face-to-face forms of counseling, because it is complete and concise, and it is a good starting point for the discussion of different web based counseling formats (NBCC website, 2001):

• Face-To-Face Counseling
• Individual Counseling
• Couple Counseling
• Group Counseling
• Technology-Assisted Distance Counseling
• Telecounseling
• Telephone-Based Individual Counseling
• Telephone-Based Couple Counseling
• Telephone-Based Group Counseling
• Internet Counseling
• E-Mail-Based Individual Counseling
• Chat-Based Individual Counseling
• Chat-Based Couple Counseling
• Chat-Based Group Counseling
• Video-Based Individual Counseling
• Video-Based Couple Counseling

Although telephone counseling is included under the NBCC "technology assisted" heading, it can be considered a much more a traditional method of counseling, and one that quite often might be an adjunct to face-to-face counseling, or might be used in a crisis situation, i.e., crisis hotlines, or might be used as part of an employee assistance program. While there are some discussions about group telephone counseling, there is not abundant information on it, and it appears not to be very wide spread. This technique seems to be used most often for support groups, lending itself as a way for home-bound individuals to connect with one another and with therapists (Multiple Sclerosis Long Island website).

This document will concentrate on internet counseling, and the different mediums that it can take -- written, i.e., email or chat rooms; audio, i.e., internet phone or voice services; and visual, i.e., net meetings, web cams, or other video conferencing tools (Microsoft website, 2003).

These methods can be synchronous or asynchronous. Synchronous communication occurs in real time, or when all participants in the communication are active at the same time. These forms of communication are offered for free by a number of services. Some of these services are AOL (America Online, 2003), Yahoo! (Yahoo!, 2003), and MSN (Microsoft, 2003). One example of this is instant messaging, and another is chat rooms. Once an internet user signs up for an instant messaging service, the user is able to send and receive text messages with people, in real time (HowStuffWorks, 2003). Chat rooms are either public or private messaging functions where more than one person can text message each other. Some internet providers offer internet voice services, including voice chat rooms for groups of people. They allow users to communicate via voice with other chat room members. Web cams are becoming more common also. These are digital video devices that can be attached to a PC and that allow the user to show a visual image to others. Both Yahoo! and Microsoft offer this service, free of charge, to their users.

Asynchronous communication is back and forth written communication, but not in real time. A good example of this might be emails or message boards. Email is electronic mail, or electronic letters (Tech Target, 2003). They are delivered over the internet to an individual’s email service. Message boards allow people to create new discussion topics or add to already started topics (Tech Target, 2003). Asynchronous communication could take the form of audio or video, but it would not be as useful a tool for group counseling. Using internet search engines (Google), there were no instances of audio or visual asynchronous communication being used for group counseling on the internet. Below is a chart of representative examples of the two types of communication and the three different forms that they can take, relative to group counseling.

Synchronous                                       Asynchronous

Written Instant Messaging                 Email

Chat Rooms                                         Message Boards

Audio Internet Phone                         N/A

Voice Messaging

Visual Net Meeting                             N/A

WebCams

There are a number of things that must be taken into account when considering doing internet counseling. First, the therapist must decide on the formats that will be used. Once this is determined, technological aspects must be put into place to ensure confidentiality. Internet counseling certainly adds an extra layer of ethical concerns. Not only must the practitioner adhere to the ethical code of their selected organization, but additional situations particular to web based therapy must also be addressed. The technology of the internet and computers is constantly evolving, and the internet practitioner must be vigilant. There are a number of issues for the internet mental health provider to consider. Some are:

• Verification of identity: The use of unique user names and passwords solves this.

• Privacy: User names and passwords solve this.

• Depending upon the state, minors may need parental consent.

• Informed consent issues must be addressed in the online environment as well, which includes off-hours contact numbers, fees, mandated reporting, etc.

• Security concerns have been an ongoing issue for the internet, and this is also true for counseling via the web. Encryption methods must be used. Encryption is a method of turning data into codes that can only be unscrambled by the receiver using the same encryption device (Computer User.com, 2003).

• The therapist must establish how client files will be maintained, and must then inform the client.

• Group counselors must additionally consider the dynamics of bringing groups together and must provide information to group members about those issues.

It is worthwhile for the internet counselor to anticipate the concerns a potential client might have. Doing so can serve as a double check for the therapist to ensure that as many as possible issues have been addressed.

First and foremost, any person using the internet must be extremely wary of information provided on any given website. Therefore, it is important for the therapist to provide links that substantiate their statements whenever possible. The cautious internet user will expect information that is verifiable, such as certification or licensing credentials. A good example of this is providing a link back to a state website that list the status of your license, if you claim to have one. The client might choose to research legal restrictions to see if any apply. Therefore, it would wise for the internet counselor to provide links to state or local statutes that pertain to the form of counseling they are practicing, if those laws exist. If none apply, providing information on the state office that regulates therapists might be helpful. The therapist might provide links to their selected professional organization that mention the practice of internet counseling. Membership in a professional organization is probably also a prudent choice for the internet based counselor, because it provides potential clients with an additional point of reference.

The important point here is that the internet counselor attempt to look at their practice from the perspective of a potential client. Whatever referral links that can be given will serve to further reassure the potential client, which will ultimately benefit the internet counselor.

Legal Considerations
This can be an important issue, because in many situations, the internet counselor lives in one state and the client lives in another state, or even another country. The internet counselor must ensure that the local, state, and national laws for his location are met when establishing the internet counseling site. Again, the selection of a professional organization also allows the provider to use those ethical guidelines provided by that organization to additionally ensure that all issues are appropriately addressed. Issues of mandated reporting of abuse of children, the elderly, and disabled individuals must also be considered. A counselor located in Connecticut might be counseling an individual who resides in Colorado. The laws and statutes of both states should be considered when the counselor agrees to take on an individual as client because this situation might possibly be considered interstate commerce. However, one website made the statement that there are currently no laws that govern interstate counseling over the internet, and there may be no recourse if you feel that there might have been ethical violations (Ainsworth, 2003). There are a number of pending bills at both the national level and at the state level that relate to electronic delivery of health services, sometimes called "telehealth" or "telemedicine", but the laws seem to mostly center on expanding rather than limiting the scope of delivery of healthcare services (Telemed, 2003).

Professional organizations have addressed the issue of internet counseling to varying degrees.

As mentioned earlier, the National Board of Certified Counselors (NBCC) has presented the most comprehensive information on this growing form of counseling (NBCC, 2001). They are very detailed and clear about how the internet provider should present their offerings and what information should be included. It also gives a very comprehensive list of definitions of internet counseling terms.

The American Psychological Association (APA) provided a general statement related to internet counseling (American Psychological Association, 2003). They refer back to other ethical standards adopted by the APA and really leave it up to each practitioner to develop their own method of presentation, keeping in mind the APA ethical standards that currently exist.

The American Counseling Association (ACA) developed guidelines for internet counseling in 1999 (American Counseling Association, 2003). These guidelines provide a good starting point for its members set up an internet counseling service, and that mirror normal ethical considerations, with the addition of privacy and security concerns associated with the internet, and suggestions on when or when not internet counseling might be appropriate.

It is a safe assumption that more guidelines will be issued from these professional organizations if problems arise from the delivery of internet based counseling. If it continues to remain primarily trouble-free, the current guidelines and informational background will probably suffice.

As described previously, there are a few forms that web based group counseling can take. Although the potential exists for video conferencing in groups, a rather exhaustive search of the internet for sites that offer video based group counseling currently returned no results. Video based internet counseling will probably be one of the up and coming delivery formats, as web cams and digital imaging become more widespread. There are a number of sites that do video based individual counseling, but the group counseling seemed to be confined to email lists or message boards. Appendix A provides an annotated list of some of the more interesting and well documented online counseling websites.

Convenient Counseling (Convenient Counseling website, 2003) provides group counseling using an email discussion group. These groups are structured to last a certain length of time and to concentrate on a particular topic. The group leader oversees the members’ communications and responds on a regular basis to the ongoing discussions.

MM Help (Murray website, no date) provides individualized email counseling and also group chat rooms. The chat rooms allow members to participate as a group in synchronous communication at a particular time, discussing a particular topic. The members participate anonymously.

One particular incident is interesting and important to ponder when considering group counseling. In 1998, one member of a support group for problem drinkers confessed to starting a fire in his home and killing his daughter (Holmes, 1998). Three of the group members reported the confession to police, and the other group members criticized them for doing that. This brings up a few things relative to online group counseling. First, it brings up issues of confidentiality. Group members are not bound by the same ethical considerations that licensed therapists are. Group members are not mandated reporters. But more important is the issue that the anonymity associated with online therapy might prompt participants to reveal more than they might have had the therapy been done face to face.

Online counseling is right now an exploding area of service delivery. The first steps that web based therapy is taking seem to be more towards individual counseling, but the medium lends itself very well to the group counseling mode, and that would be an obvious next step, especially spurred on by advancing technology.

Group counseling always felt to be well described by "the whole is more than the sum of its parts." That is, much work can get done by a therapist and a client working well together, but when more people are added in, a wealth of experiences and perspectives is added also, thus bringing up the entire level of the group to a higher place. We can get support from several individuals at once in a group setting. There is evidence of this in the support groups that have sprung up online as the internet becomes more firmly entrenched in our lives. A recent television advertisement for the American Cancer Society shows several people participating in a "Cancer Survivors Network" online group (ACS, 2003), with the participants showing positive reaction to the emotional help they receive from that support group.

For the individual who is confined to home or lives in a rural setting, internet group counseling can bring people together with shared concerns. This may not be an option available to them unless they use the internet. Here then, is one area of service delivery that can only be performed via the World Wide Web. It is important for the professional counselor to see the benefits that can be gained by offering services on the internet.

There was a need and now there is a viable solution, but vigilance and knowledge are crucial to ensuring this form of counseling is properly used.

Representative Websites Offering Internet Counseling

An Annotated Reference

American Cancer Society (2003). ACS Message Boards. Retrieved March 10, 2003, from http://www.cancer.org/asp/messageBoards/msg_global.asp

• This site offers a free discussion board and support group for cancer patients and their families.

AskTheInternetTherapist, LLC (2003). Discussion Groups. Retrieved March 4, 2003, from http://www.asktheinternettherapist.com/discussiongroups.asp

• Individual, telephone, chat based groups.

Axis-One, Inc. (2002). Group Counseling: How It Works. Retrieved March 4, 2003, from http://www.axis-one.com/group.htm

• Individual, video, discussion boards, groups.

Convenient-Counseling.COM, Inc. (2001). Services. Retrieved March 14, 2003, from http://www.convenient-counseling.com/services.htm

• This counselor provides group counseling in an asynchronous, email based format.

Gerstner, L. (n.d.) Lee Ricciardi Gerstner, MA, NCC, PC, Retrieved March 4, 2003, from

http://www.athealth.com/leericciardi.cfm?list=2196&loc=3580

• Good example of internet counseling informed consent information

Murray, M. (n.d.) MM-Help, Chat Rooms. Retrieved March 15, 2003, from http://www.mm-help.com/chat.php

• A South African counselor’s site with an example and description of chat room services offered.

National Multiple Sclerosis Society, The (2003). National Multiple Sclerosis Society - Long Island. Retrieved March 4, 2003, from http://www.nationalmssociety.org/NYH/home/

• This site offers a telephone group for homebound victims of MS.