Drawing on an evidence base of over 700,000 words of email-based counselling and therapy, this exploration highlights 9 simple observations about the practice and process of online therapy. This paper is available here as a series of brief web pages, or separately as a single PDF download.
Do Unique Ethical Principles of Online Practice Exist?
Several major organizations offer ethical or ‘best practice’ guidelines on online therapeutic work (ACA, 1999; APA, 1997; ISMHO, 2000; Kane & Sands, 1998; NBCC, 2001), making them freely available to both consumers and professionals via the web. Yet, as far as I can tell, no fundamentally new ethical territory has been created by the advance of technology which enables online counselling to take place. There is, rather, merely new technological territory. These ‘guidelines’ are primarily what ethicists call technology assessment documents, providing introduction and orientation to the technological context and its ramifications for our existing normative principles, such as the principles of non-maleficence or fidelity embodied in BACP’s Ethical Framework (Bond, 2002). Technology assessment documents are subject to debate and disagreement, are virtually never complete, and typically go out of date quickly — unlike the underlying normative principles themselves, which do not change with technology. (Consider the normative principle of non-maleficence, for example: it will not suddenly become right to harm clients merely as a result of someone’s inventing a new way of communicating.)
Moreover, the application of existing normative principles to the online context, in all its complexity, does not lend itself particularly well to codification in the form of technology assessment guidelines. Unfortunately, the preponderance of available guidelines may nonetheless encourage some online practitioners to accept adherence to them as a substitute for the technical competence required to support ethical decision-making and risk assessment in situ.
By way of analogy, consider a f2f counsellor’s duty to evaluate the extent to which a consulting room is sound-proof before using it, a duty which derives from the normative principle of fidelity and respect for client confidentiality. Judgements about the suitability of a particular room are not a matter for prescriptive mandate (e.g., “practitioners should only use rooms with wall thickness exceeding 14mm”); instead, they require well-informed personal experience and awareness. In this example, that awareness presupposes an ability to hear, and a hearing-impaired counsellor would not be able to practise ethically — with vocalizing clients, anyway — without taking steps to evaluate sound-proofness in some alternative way. She cannot guarantee ethical practice merely by adhering to prescriptive guidelines about wall thickness any more than a technologically unskilled online practitioner can work ethically by merely keeping to ‘best practice guidelines’.
An online therapist operating without intimate knowledge of her technological context is akin to a hearing-impaired counsellor who hasn’t checked whether her clients can be overheard outside the consulting room. It is not enough for an online practitioner merely to propose something along the lines of “I’m going to focus on my clinical skills and not worry about the technology” — like an underwater welder saying “I’m going to focus on my welding skills and not worry about the swimming”.
Thanks to Louise Young for feedback and reflections which helped refine many of the ideas offered here.
APA (1997) APA Statement on Services By Telephone, Teleconferencing, and Internet. Washington, DC: American Psychological Association. Retrieved 19 September 2005: http://www.apa.org/ethics/stmnt01.html.
Bond, T. (2002) Ethical Framework for Good Practice in Counselling and Psychotherapy. Rugby: British Association for Counselling and Psychotherapy.
Chechele, P.J. & G. Stoffle (2003) Individual therapy online via email and Internet Relay Chat. In S. Goss & K. Anthony (Eds.), Technology in Counselling and Psychotherapy, 39-58. New York: Palgrave Macmillan.
Christensen, H., K.M. Griffiths & A. Korten (2002) Web-based Cognitive Behavior Therapy: Analysis of Site Usage and Changes in Depression and Anxiety Scores. Journal of Medical Internet Research 4(1), e3. Retrieved 19 September 2005: http://www.jmir.org/2002/1/e3/index.htm.
Day, S.X. & P.L. Schneider (2000) The subjective experiences of therapists in face-to-face, video, and audio sessions. In J.W. Bloom & G.R. Walz (Eds.), Cybercounseling and cyberlearning: strategies and resources for the new millennium, 203-218. Alexandria, Virginia: American Counseling Association.
Day, S.X. & P.L. Schneider (2002) Psychotherapy Using Distance Technology: A Comparison of Face-to-Face, Video and Audio Treatment. Journal of Counseling Psychology, 49, 499-503.
ISMHO (2000) ISMHO Suggested Principles for the Online Provision of Mental Health Services. International Society for Mental Health Online. Retrieved 19 September 2005: http://www.ismho.org/suggestions.html.
Kane, B. & D.Z. Sands (1998) Guidelines for the Clinical Use of Electronic Mail With Patients. Journal of the American Medial Informatics Association, 5(1). Retrieved 19 September 2005: http://www.amia.org/pubs/other/email_guidelines.html.
Kiesler, S., J. Siegel & T.W. McGuire (1984) Social psychological aspects of computer-mediated communication. American Psychologist, 39, 1123-1134.
Lambert, M.J. (Ed.) (2004) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change. New York: John Wiley & Sons.
Lewis, J., D. Coursol & K.H. Wahl (2004) Researching the cybercounseling process: A study of the client and counselor experience. In J.W. Bloom & G.R. Walz (Eds.), Cybercounseling & Cyberlearning: An Encore, 307-325. Alexandria, Virginia: American Counseling Association.
Mitchell, D.L. & L.J. Murphy (2004) E-mail Rules! Organizations and Individuals Creating Ethical Excellence in Telemental-Health. In J.W. Bloom & G.R. Walz (Eds.), Cybercounseling & Cyberlearning: An Encore, 203-217. Alexandria, Virginia: American Counseling Association.
Mulhauser, G.R. (2005a) How Much Online Therapy Really Goes On? Part 1. Retrieved 19 September 2005: http://counsellingresource.com/features/archives/2005/online-mental-health/online-therapy-quantity-1/.
Mulhauser, G.R. (2005b) How Much Online Therapy Really Goes On? Part 2. Retrieved 19 September 2005: http://counsellingresource.com/features/archives/2005/online-mental-health/online-therapy-quantity-2/.
NBCC (2001) The Practice of Internet Counseling. National Board for Certified Counselors and Center for Credentialing and Education. Retrieved 19 September 2005: http://www.nbcc.org/webethics2.
Rowling, J.K. (1997) Harry Potter and the Philosopher’s Stone. London: Bloomsbury.
Samaritans (2005) Samaritans Statistics. Retrieved 19 September 2005: from http://www.samaritans.org/know/samaritans_stats_popup.shtm.
Tallman, K. & A.C. Bohart (1999) The Client as a Common Factor: Clients as Self-Healers. In M.A. Hubble, B.L. Duncan & S.D. Miller (Eds.), The Heart & Soul of Change: What Works in Therapy, 91-131. Washington, D.C.: American Psychological Association.
 Ratios reflect 3-month average ‘reach per million’ as of 19 September 2005 for CounsellingResource.com (10.5), bacp.co.uk (4.4), samaritans.org (3.65), nhsdirect.nhs.uk (74), and apa.org (96.5).
 All clients mentioned have given explicit written consent to be directly quoted for this paper.
 BACP does not feature here: unlike the Ethical Framework, access to the organization’s suggestions in this area is restricted to members only.
 For example, some therapists apparently now believe — erroneously, in my view — that the technological step of using encryption equals the ethical step of safeguarding client confidentiality. Mitchell and Murphy — themselves encryption software vendors — have gone so far as to assert that practitioners are ethically required to use encryption when communicating with clients and that it is unethical for a practitioner even to publish what they call a “regular e-mail address” (Mitchell & Murphy, 2004, p. 208).