1. Kathleen Bazile M.a. NCC, LPC Mercer University
Moving Towards Standardization in Online Counseling: New Ethical Considerations
Kathleen Bazile M.a. NCC, LPC
Mercer University

2. Online counseling, Telemental health, Cyberpsychology, e-counseling, web counseling
Within the past 15yrs, online counseling has grown along side the growth technology and internet.
Online counseling: Delivery of therapeutic interventions in cyberspace where communication between a trained professional counselor and client(s) is facilitated using computer-mediated communication(CMC)technologies, provided as a stand-alone service or as an adjunct to other therapeutic interventions (Richards & Viganó, 2012).
Internet is a ubiquitous medium of communication

3. Computer Mediated Communication (CMC)
Online Counseling
Delivery methods
Computer Mediated Communication (CMC)
Instant messaging
Chat rooms
Videoconferencing
Computer voice message system.
Synchronous: Interacting in real time. Instantaneous messaging, chatting in real time.
Asynchronous: Time-lapse between interaction. communication.
2 distinctions in how online counseling is delivered: Synchronous/asynchronous. Carries special ethical issues.
Mallen, M.J., & Vogel, D.L. (2005). Counseling psychology and online counseling. The Counseling psychologist, 33,

4. Ethical and Legal implications

5. Considerations and concerns
Competence
Technological Skills
Proficient typing skills, speed, and accuracy
Data security and clinical record confidentiality
Internet-based language (ex. LOL) and use of emoticons (ex ), other common internet related forms of expressions.
Helping Skills-version online
Communicate empathy, warmth, openness, genuineness
Non-verbals of client
Multicultural Competence
Increased exposure to various cultures
Relatively new phenomenon. One has never conducted video-based psychotherapy using the internet before. Being familiar with various computer and internet technologies. Ensure sensitivity to clients’ beliefs and practices, so these are not misinterpreted or violated.

6. Considerations and Concerns
Jurisdiction
Standard face to face (F2F) therapy requires clinicians to practice in the state they are licensed.
Online counseling blurs this line
Online counseling provides access to potential clients w/o geographical boundaries.
Which state is the clinician practicing in? Theirs or the clients, or both?
Malpractice insurance
Only covers services that are within the clinicians scope of license which is usually bound by state regulations
Are they practicing where they are being virtually received? Currently, there is minimal state laws provisions.

7. Considerations and Concerns
Limits to Confidentiality
Online counselor cannot completely guarantee confidentiality to clients over internet
Provisions include password protection, data encryption, use of secure socket layer encryption, and firewall.
Cannot protect against accidental interception, snooping, unauthorized access and other forms of counseling applications.

8. Considerations and Concerns
Informed Consent
Mandated reporting
Clinician obligated to be aware of laws and duties in clients’ residential state as well as clinicians’ state.
What if laws conflict?
Imminent danger
What online behaviors indicate risk of self-harm
Abrupt termination of chat session, allusions to suicide, direct threat
How will clinician respond?
Clients responsibility
Educating client on how to protect sensitive information online

9. Considerations and Concerns
Ethical and legal implications that have and continue to arise concerning online counseling lead us to question: Should there be formal training for appropriately conducting online counseling and facilitating an effective online therapeutic relationship?

10. Current Standards & Rules

11. NBCC National Board of Certified Counselors
Standards for the Ethical Practice of WebCounseling 1997
The Practice of Internet Counseling
Distance Professional Services
Use of electronic or other means (e.g., telephone or computers)
20 Set Standards
NBCC Policy Regarding the Provision of Distance Professional Services: Approved February 6, 2016

12. ACA American Counseling Association 2014 ACA Code of Ethics Section H
Distance Counseling, Technology, and Social Media
Protocols for:
H.1 Knowledge and Legal Considerations
H.2 Informed Consent and Security
H.3 Client Verification
H.4 Distance Counseling Relationship
H.5 Records and Web Maintenance
H.6 Social Media
American Counseling Association (2014).

13. ISMHO International Society for Mental Health Online
Nonprofit formed 1997 “to promote understanding, use and development of online communication, information and technology for the international mental health community.”
International Society for Mental Health Online. (2016, March). Retrieved from

14. Georgia GA State Board Rules: CH. 135.11 Telemental Health Provisions
Implemented October 2015
Includes but not limited to telephone, video, internet, smartphone, tablet, desktop computer, or any other electronic means.
Provisions
Informed Consent
Client Assessment
Code of Ethics
Scope of Practice
Out of state Clients
‘Advised to check w/ the state board in which client resides for information about telemental health regulations outside of GA’

15. Georgia 6 Continuing education hours that include:
Internet use dependency and psychological problems
Research in Telemental Health
Intake & Assessment
Delivery Methods
Theory Integration
Termination
Risk Management
Business of Telemental Health
Ga Comp.R. Regs. R

16. Louisiana Louisiana Professional Counselors Board of Examiners
Louisiana's Position Statement on Internet Counseling
“Mental health services delivered over the internet are rendered where the patient is situated.”
“This position is based on assertions that all counselors serving Louisiana residents will be licensed in Louisiana and will otherwise adhere to all applicable state laws relative to the practice of mental health counseling”
LA LPC board of Examiners 2012

17. Therapy? There’s an App for that

18. Therapy Apps: TalkSpace and Betterhelp
Talkspace. Groop Internet Platform inc. [Mobile application software] Retrieved from
Betterhelp. Compile, inc. [Mobile application software] Retrieved from

19. Why Standardization is needed

20. Need for standardization
Several studies conducting surveys of online counseling website (2006)
Practitioners’ credentials varied widely
32% of practitioners requested clients sign informed consent
42% of practitioners did not use any encryption to protect confidentiality
Very low compliance with established ethical standards for online counseling were found.
High number of practitioners provided information about the limitations of online counseling
As cited in Richards, D. & Vigano, N. (2013). Online counseling: a narrative and critical review of the literature. Journal of Clinical Psychology, 69(9),

21. Need for standardization
Increasing number of apps for mental health offering ‘trained’ and ‘expert’ help

22. Standardization
Development of ethical frameworks has been significant in contributing to regulate and standardize the practice of online counseling
As online counseling becomes more incorporated and accepted as a legitimate form of delivery of therapeutic interventions, it will be looked at not as an insurgent but as a trustworthy and viable option that would benefit from regulation and standardization.
In conclusion, online counseling continues to grow and is becoming a more acceptable delivery method of counseling. Great that NBCC and ACA have set an ethical framework regarding this new and ever growing popular method; however it will be imperative for ethical guidelines to be developed at the state level, training to be provided, and ideally a nationwide standard to accommodate the uniqueness of this form of delivery.

23. References American Counseling Association. (2014). American
Counseling Association code of ethics. Retrieved
from
Barnett, J.E., & Kolmes, K. (2016). The practice of tele-mental health: ethical, legal, and clinical issues for practitioners. Practice innovations, 1(1),
Betterhelp. Compile, inc. [Mobile application software] Retrieved from
Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists. (2015, October). Rules and regulations of the state of Georgia, March 2016 (Rule Telemental Health). Retrieved from

24. References
Haberstroh, S., Barney, L., Foster, N., & Duffey, T. (2014). The ethical and legal practice of online counseling and psychotherapy: a review of mental health professions. Journal of technology and Human Services, doi: / International Society for Mental Health Online. (2016, March). Retrieved from Louisiana Licensed Professional Counselors Board of Examiners. (2012, September). Louisiana’s position on internet counseling. March Retrieved from Mallen, M.J., & Vogel, D.L. (2005). Counseling psychology and online counseling. The Counseling psychologist, 33,

25. References
National Board for Certified Counselors.(2016) National Board for Certified Counselors policy regarding the provision of distance professional services. Retrieved from Richards, D., & Viganó, N. (2012). Online Counseling. In Y. Zheng (Ed.), Encyclopedia of cyber behavior (Vol.1, pp ). New York, NY:IGI Global Richards, D., & Vigano, N. (2013). Online counseling: a narrative and critical review of the literature. Journal of Clinical Psychology, 69(9), Rummell, C.M., & Joyce, N.R. (2010). “So what do you want to wrk on 2day?”: the ethical implications of online counseling. Ethics & Behavior, 20(6), Talkspace. Groop Internet Platform inc. [Mobile application software] Retrieved from

26. Discussion/Questions