Hello. I have been providing, and speaking about Online Counseling and Telephone Counseling for a number of years. I even wrote a book about it, which is for sale on Amazon.com. --To answer your question about seeking help through the internet, and through writing. It can be cathartic, and it helps to write out your thoughts sometimes, but it probably will not be as helpful as a counseling relationship with another person (a professional).
This is probably overkill, but here is an excerpt from an article I wrote that talks about the advantages and challenges of online counseling:
Did you know that only 10% of depressed people who are referred by a physician to seek mental health services ever receive those services? Why is this? Is it because they do not want to get well, or are there other factors? As you might guess, the reasons are many; and include the problem that acquiring counseling is too difficult. Consider this, a man suffering from depression, to receive counseling must:
1) Overcome his apprehension, embarrassment and fear of seeking counseling
2) Come to terms that people in his community might find out he is in therapy
3) Research and locate reputable local counseling services
4) Make contact with a service (usually by phone) to schedule a session
5) Accept, if insurance is to be used, that he will be diagnosed with a psychological disorder that will go in his health record
6) Maintain motivation and courage while waiting for a scheduled session—the wait is often weeks or longer
7) Execute his intentions of arriving at the counseling appointment (which may necessitate taking time off work).
For a person battling even the most common life-issues, this is quite a series of tasks! And what is more, we—as counselors—cannot do much to make it easier. We often have long waiting lists for new clients, business hours that conflict with client work schedules; we allow clients to suffer social stigma, require them to travel to an unfamiliar place, and to arrive promptly and presentably; all while battling depression, anxiety, agoraphobia, grief, psychosis, or perhaps the greatest personal crisis of their life.
And all the while we wonder, “why is the compliance rate only 10%?”
In response to these tasks that reduce compliance so remarkably, several thousand counselors across the country are taking on the challenge of providing eCounseling. They are using distance communication technologies like telephone, email, online text chat, and even videoconference (see “eCounseling” column in 2007 issue of CCT). To these persons, eCounseling is more than a back-up service for clients who just “can’t make it in” for therapy (see table 1). Practitioners and researchers contend that, in numerous ways, eCounseling can be superior to in-person counseling. These proposed advantages include a series of client-related factors presented below.
Proposed Advantages
Safety and Assertiveness
eCounseling may increase clients’ sense of safety, for they are able to receive help from within their home environment. This may help clients express themselves more fully. For example, a study investigating Thai women in a co-ed online discussion found that females who took a passive role in face-to-face (FTF) interactions spoke more assertively and frequently online.
Anonymity
While some counseling ethics codes regard client identification as necessary, eCounseling may still benefit from anonymity. For example, although a client may be required to provide their name and location, the Internet is a phenomenon where persons “communicate without the distractions of race, gender, age, size, or physical deformity or impairment.” One of the first online counseling services, called “Dear Uncle Ezra”, was developed in 1986 by Cornell University. This service allows queries from anonymous students, and a counselor responds via a public internet post. After 21 years this program is still active and users confirm that if it were not for the anonymous format, their problem issues would never have been revealed.
Social Stigma
eCounseling assures clients they will not encounter their counselor in public , nor will they risk meeting persons from the community in the counselor’s waiting room. Therefore, eCounseling may be effective in eliminating the social stigma of receiving therapy. One study investigating the use of phone counseling services by Arab Israeli callers found the stigma-free medium “may be a culturally appropriate modality of providing helping services to people who conventionally underutilize other forms of professional mental health intervention.” With similar ideas, the University of Wisconsin’s counseling center allows therapists to be contacted by email, and George Mason University provides counseling by videoconference.
Selection
eCounseling may provide clients a greater selection of therapists to choose from. This is especially beneficial for persons looking for a counselor with specific experience, or with particular language, religious or ethnic understandings. Similarily, online support groups and forums dedicated to a variety of emotional problems have been present since the 1980’s, and they have allowed persons to reach others dealing similar issues from across the world.
Accessibility
eCounseling is advantageous to individuals residing in areas where counseling services are not available and with clients who are unable to leave home. Also, while in-person counseling may be incompatible with a client’s work schedule, eCounseling possesses potential for 24 hour service availability—this is apparent with some crisis and eCounseling services currently available 24 hours-a-day.
Even if counselors are not online or at a phone at all hours, counseling by email creates the perception of a counselor’s perpetual availability. A client can communicate anytime, instead of waiting for a weekly or bi-weekly session. And since sessions do not have a defined beginning or end, a more intense psychological holding environment may be present between counselor-client exchanges.
Affordability
eCounseling may be more economical than in-person counseling due to lower overhead costs of counselors who do not need to rent commercial space, and the elimination of client and counselor commuting expenses. Concerning the value of time, the hours invested in counseling may be less with eCounseling due to elimination of travel, lack of a waiting room, and the goal-directed dialog that often ensues with distance communication. Regarding the latter, studies show that when communicating through phone and internet, “small talk” is greatly lessened and individuals address important issues faster.
Proposed Disadvantages
In contrast, opponents of eCounseling present these issues of concern—whether eCounseling is ethical and legal, clinically effective, and financially viable.
Ethical and Legal Concerns
Similar to FTF provision, there are numerous ethical and legal issues in eCounseling. Areas of particular concern include confidentiality, dealing with suicidal or dangerous clients, crisis response, and counseling clients across state lines. While the latter is an issue most state boards have no formal position or legal precedent, a number of articles have been published concerning the ethical issues of eCounseling, and they are commonly found to be challenging—but not impossible to resolve (a detailed investigation is outside the scope of this article, but will be tackled in a later article with George Ohlschlager; see endnotes).
Rapport
Traditional views contend online communication (text-based) is an inferior modality for developing rapport, due to the inability to read body language and hear emotional cues. However, other empirical studies have found eCounseling technologies to be effective rapport building mediums. Today, the debate of how well rapport builds through distance communication continues.
Clinical Efficacy
According to ethical standards of the ACA, NBCC, and others, counselors are ethically obligated to provide viable treatment. With eCounseling, while some studies contend efficacy to be inferior to in-person sessions, others have found client improvement with various online and telephone modalities to be equal, and in some cases greater, than in-person services (see endnotes for a list of studies).
Financial Viability
Financial issues include the cost of beginning and maintaining a practice; receiving training, marketing, acquiring clients, and receiving payment. Currently, literature does not show clearly whether eCounseling is advantageous or disadvantageous to counselor financial viability.
Text-based eCounseling: The Plot Thickens
The Clinical Social Work Federation states in reference to text-based counseling, “… psychotherapy services cannot be delivered online [specifically via text] because of the inherent nature of the service and, therefore, the federation is opposed to the practice of Internet-based treatment.” However, others involved in the research and practice of online counseling disagree. Proprietors of text-based counseling identify numerous intrinsic advantages to the modality—in addition to those of eCounseling in general. These proposed advantages are described below.
Attention and Reflection
Text based interactions (especially those with a time delay) allow both client and counselor to pay close attention to their communication exchanges, and reflect on their own thoughts and feelings, while still in dialogue.
Confession and Framing
A client’s need to confess is automatically framed through the process of writing. For example, journaling is sometimes assigned as homework to persons participating in in-person counseling, partly because of its framing and cathartic effects.
Objectivity and Externalization
Writing often invokes one to reread and review what was written, a process that promotes increased objectivity and externalization of a problem on the part of the client.
Associations and Insight
New associations, insights, and the recovery of old memories are common benefits of the process of writing out one’s story. Further, it has been said that while with in-person sessions a client may speak for an hour and not reach the heart of a matter, with email eCounseling a client can communicate more in one sentence written after an hour of reflection.
Accountability
Text-based interactions allow participants to comment on and directly quote pertinent excerpts of previous exchanges. This heightens the accountability of both client and counselor to their statements.
Ownership and Control
Clients might communicate in a less restricted manner by text, for they are less affected by positive or negative leads of a therapist. Clients also possess heightened ownership of the counseling process for they set the pace and tone by controlling both the frequency and content of disclosures.
Maximum Anonymity
While all eCounseling methods increase client anonymity, text-based counseling offers more anonymity that even telephone counseling, for clients need not even share the timbre of their voice with a counselor.
Testament of Treatment Progress
Discussions are easily saved or printed with text counseling, allowing clients to reread therapeutic guidance years after the termination of therapy. This may strengthen old resolutions, and be a testament of the client’s treatment progress.
The Debate Continues
The aim of this article was not to advocate for, or oppose, eCounseling practices; it was simply to introduce the proposed advantages and disadvantages. Though it is difficult for me to hide some of my bias, I will denounce neither the pessimism nor the over-enthusiasm that exists in the field (though I may want to). To do this would make me a politician either for or against—another voice of opinion, not of legitimate conclusion.
In order for authoritative assertions to be made, there are many meaningful studies that remain to be conducted on the various counseling factors, the proposed advantages and disadvantages mentioned. For now the debate continues. However, if good research, honest appraisals, legitimate concerns and open attitudes continue in the manner they have for the last several years, eCounseling may soon stand as an accepted and invaluable tool to bring help and healing to persons with a spectrum of needs, in a variety of settings.
Boston Counseling, Boston Psychotherapy, Boston Online Counseling, www.ThriveBoston.com
