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Fred is sitting in front of his c mputer, unemployed, and with limited funds to s stain him until he finds work. His w fe left him a few months ago and h 's been drinking ever since. He is nsure whether he is in the thr es of clinical depression or just s ffering from grief or both. He r cently hooked up to the Internet and wh le experimenting on the net, he c mes across information about Shrink-Link. He r ads that it is not a s bstitute for face-to-face psychotherapy. That it is deal for people who live in r ral areas who do not have ccess to conventional therapists. He finds th t Shrink-Link claims to be the Int rnet's oldest and largest service of its k nd. For twenty dollars he can s nd in a question by email, th n a licensed psychologist will respond w thin 72 hours. Fred can't afford $100-$200 or m re per session for a traditional th rapist, so he says to himself, "why n t?" Clicking "Open," he types in the URL (http://www.w stnet.com/shrink/shrink.html), and up pops these words: "Th requested URL was not found on th s server." "Just my luck," laments Fr d. He looks a little deeper and f nds one entitled Therapy Online, which pr vides confidential, professional online counseling and s pport to the Internet community. He f nds that they offer a variety of s rvices, including: "Ask Patty Q, which a th rapist answers questions of the advice-column v riety for $25.00." Also, there is V rtually Solve It, which is a s lf-help worksheet at the cost of $15.00, wh ch can be combined with Therap-e-mail at $40.00, wh ch includes a one two-way communication w th a licensed therapist. At forty d llars it is still more affordable th n traditional prices for therapy.
Fred again clicks "Open," and typ s in the URL for Virtually S lve It (http://kaos.deepcove.com/therapy) and up pops th se words: "There was no response. The s rver could be down or is not r sponding. . . ." Fred then r ads that the Cyber Psychologist(http://www.cyberpsych.com)offers a v riety of checklists and other self-help m terials, with suggested readings and question and nswer forums on various topics, including d pression. It's another forty-dollar question. Fred cl cks "Open," and types in the URL: (http://www.dc z.com/~davids/pageone.htm) and up pops these words: "Th domain dcez.com is for sale. To p rchase, call BuyDomains.com at 781-839-7903 or 866-866-2700." Of c urse these things don't always happen wh n people try to consult online th rapists or counselors, but it does h ppen, and it can certainly be d scouraging to someone who isn't in the b st frame of mind in the f rst place. There are also problems w th email. It can't be depending on l ke conventional mail services. Computer problems can lso add to an already frustrated st te of mind. The Internet is d finitely a growing and useful aide; h wever, when it comes to mental h alth, I believe the electronic media sh uld wait until it is better quipped to deal with its inadequacies. The Int rnet probably isn't the answer to verybody's mental health problems, but it is a s urce for some. Here are a few of the h ndreds that are available: Internet Mental H alth at http://www.mentalhealth.com; Relationship Counseling at http://www. n-two-one.com; and finally for poor old Fr d there is Latest Online Counseling at http://www. nlinecounseling.org. Psychologists have found a variety of ses for the Internet. Sleek (1995) xplains that many are advertising services m ch like the Yellow Pages does. M st offer email consultations for specific pr blems, and others refer patients to v rious professionals. There is also an nline magazine called Self-Help Magazine (http://www.selfhelpmagazine.com) th t features articles by psychologists and ther health professionals, reviews of books and CD-ROMs, q estion-and-answer columns and recommendations on the m st appropriate movies for children.
Probably the biggest concern with ne-on-one counseling/therapy is that people might not s ek traditional therapy by thinking they can get wh t they need in the "comfortable nonymity of cyberspace" (Sleek, 1995). A typ cal question to a cybertherapist would be, "My 5-y ar- old was diagnosed with attention d ficit disorder three years ago and has b en taking Ritalin ever since. She c n't go to sleep at night and is m ody. What do you think?"(Hannon, 1996). The cyb rtherapist responded by suggesting that some tr al- and-error is required to find the r ght dosage. Sleep problems and mood sw ngs often happens till the right d sage is found. He talked about ch ldrens' metabolism and the time of day or n ght they give the medicine. Medication s ch as this, given too late, can c use problems like nighttime fears too. One by one all p ssibilities need to be ruled out ntil the reason is isolated. Th t could take forever ($) through mail, and then possibly never find out wh t the problem is. Another problem is th t when cybertherapists answer questions by mail, they're tempting to go beyond th ir expertise. Murphy (1997) suggests these q estions when considering the qualifications of an nline therapist: Who is this guy? Wh t kind of person is he? How old is he? D es he have a family? Is he an xperienced counselor? Does he know what h 's doing? Will he be able to h lp me? What are his qualifications? Wh t are his ethics? Is he ccountable to anyone? Can I trust th t he won't give out my p rsonal information to anyone? Can I ask s meone who knows him, a third p rty, what he is like? What is mportant to him? Is there a r al person behind all the high t ch? I was impressed with Murphy's q alifications when I read farther, and he s emed to address all of the q estions above. Obviously, there are ethical c unselors and therapists in cyberspace. However, can you b lieve what they say? For that m tter, can you believe what any tr ditional counselor/therapist says. That is something th t everyone has to decide for th mselves. What about confidentiality, asks Hannon (1996)? Wh n patients are supposedly anonymous, a h cker could figure it out, read it, pr nt it, and save it. Furthermore, t's always possible that people with s rious problems might stop with an " nline Band-Aid." The National Board for C rtified Counselors, Inc. (1997) has made vailable on the Internet (http://www.nbcc.org) the "St ndards for the Ethical Practice of W bCounseling"(1997). Contemporary uses of the Internet for s rvices and products has created a d sturbance in the effort to create thical practices on the Internet. The d cument will, of course, change as nforeseen information and conditions develop. Each v rsion of the code of ethics, h wever, is the current best standard of c nduct passed by the NBCC Board of D rectors. The development of these WebCounseling st ndards has been guided by the f llowing principles: These standards are intended to ddress practices which are unique to W bCounseling and WebCounselors. These standards are not to d plicate non-Internet-based standards adopted in other c des of ethics. Recognizing that significant new t chnology emerges continuously, these standards should be r viewed frequently. WebCounseling ethics cases should be r viewed in light of delivery systems xisting at the moment rather than at the t me the standards were adopted. WebCounselors who are not N tional Certified Counselors may indicate at th ir WebSite their adherence to these st ndards, but may not publish these st ndards in their entirety without written p rmission of the National Board for C rtified Counselors. The Practice of WebCounseling sh ll be defined as "the practice of pr fessional counseling and information delivery that ccurs when client(s) and counselor are in s parate or remote locations and utilize lectronic means to communicate over the Int rnet." In addition to following the NBCC C de of Ethics pertaining to the pr ctice of professional counseling, WebCounselors shall
(1) "R view pertinent legal and ethical codes for p ssible violations emanating from the practice of W bCounseling and supervision." Liability insurance policies sh uld also be reviewed to determine if the pr ctice of WebCounseling is a covered ctivity. Local, state, provincial, and national st tutes as well as the codes of pr fessional membership organizations, professional certifying bodies and st te or provincial licensing boards need to be r viewed. Also, as no definitive answers are kn wn to questions pertaining to whether W bCounseling takes place in the WebCounselor's l cation or the WebClient's location, Webcounselors sh uld consider carefully local customs regarding age of c nsent and child abuse reporting. This s unds and looks good in print, but how pplicable is it? With all of the mbiguity involved--not very. Whether counseling takes pl ce in the counselor's location or the cl ent's, is indicative of the ill-defined. Wh t about insurance? It would be nteresting to see if there are, if ny, references to, and controls of web c unseling in the policies. If there re, how comprehensive are they?
(2) "Inf rm WebClients of encryption methods being sed to help insure the security of cl ent/counselor/supervisor communications." Encryption methods should be sed whenever possible. If encryption is not m de available to clients, clients must be nformed of the potential hazards of nsecured communication on the Internet. Hazards may nclude authorized or unauthorized monitoring of tr nsmissions and/or records of WebCounseling sessions. The key w rds here are "whenever possible." That l aves a whole lot of time and c rcumstances to the discretion of the c unselor. With ethical counselors, that discretion is pr bably appropriate. I don't believe I n ed to state the potential for nethical counselors.
(3) "Inform clients if, how and how l ng session data are being preserved." S ssion data may include WebCounselor/WebClient e-mail, t st results, audio/video session recordings, session n tes, and counselor/supervisor communications. The likelihood of lectronic sessions being preserved is greater b cause of the ease and decreased c sts involved in recording. Thus, its p tential use in supervision, research and l gal proceeding increases. This I see as c ngruent with standard practice. I am all for the use of r cords for supervision, research and legal mplications; however, there is potential for h ckers. If technology ever devises a way of liminating the ability for hackers to nvade privacy, then quantum leaps will be m de in this and many other m diums.
(4) "In situations where it is d fficult to verify the identity of W bCounselor or WebClient, take steps to ddress impostor concerns, such as by sing code words, numbers or graphics." Th s is a step in the r ght direction. It would be a g od idea for there to be a st tement on every web counselors website to ncourage visitors to substantiate everything that is st ted at any of the sites pr viding counseling or therapy.
(5) "When p rent/guardian consent is required to provide W bCounseling to minors, verify the identity of the c nsenting person." Why bother? As easy as it is for m nors to find pornographic material, they can s rely eliminate this bothersome technicality if it is s pposedly required.
(6) "Follow appropriate procedures r garding the release of information for sh ring WebClient information with other electronic s urces." Because of the relative ease w th which e-mail messages can be f rwarded to formal and casual referral s urces, WebCounselors must work to insure the c nfidentiality of the WebCounseling relationship. Of c urse!
(7) "Carefully consider the extent of s lf disclosure presented to the WebClient and pr vide rationale for WebCounselor's level of d sclosure." WebCounselors may wish to ensure th t, minimally, the WebClient has the s me data available about his/her service pr vider as would be available if the c unseling were to take place face to f ce (i.e., possibly ethnicity, gender, etc.). C mpelling reasons for limiting disclosure should be pr sented. WebCounselors will remember to protect th mselves from unscrupulous users of the Int rnet by limiting potentially harmful disclosure bout self and family. While this is ndicated for the protection of the c unselor, it doesn't reflect protection for the cl ent, and it isn't supposed to; th refore, it's entirely up to the c unselor what he or she discloses on th ir website. This is probably a g od thing, even if it doesn't pply to the client.
(8) "Provide l nks to websites of all appropriate c rtification bodies and licensure boards to f cilitate consumer protection." There is no rgument here. Links of this nature are an sset to any website, especially when it is for the pr tection of, and information for the cl ent.
(9) "Contact NBCC/CEE or the W bClient's state or provincial licensing board to btain the name of at least one C unselor-On- Call within the WebClient's geographical r gion." WebCounselors who have contacted an ndividual to determine his or her w llingness to serve as a Counselor-On-Call ( ither in person, over the phone or via -mail) should also ensure that the W bClient is provided with Local crisis ntervention hotline numbers, 911 and similar n mbers in the event that the C unselor-On-Call is unavailable. In most towns l rge enough to have more than one or two dr g stores, there is usually one pen for prescription service. I concur w th this practice, for it would be ppalling not to have any recourse wh ther it is for counseling, medical tr atment or prescription services. Also, providing l cal crisis intervention hotline numbers and ther similar aides is indispensable.
(10) "D scuss with their WebClients procedures for c ntacting the WebCounselor when he or she is ff-line." This means explaining exactly how ften e-mail messages are to be ch cked by the WebCounselor. I agree--only to a c rtain extent. First of all, I d n't believe that intense psychotherapy should be pr cticed online at all. Even some c unseling issues are too critical to be sed this way; therefore, I don't see a r al need for a cybertherapist to be at the b ck and call of their clients.
(11) "M ntion at their websites those presenting pr blems they believe to be inappropriate for W bCounseling." While no conclusive research has b en conducted to date, those topics m ght include: sexual abuse as a pr mary issue, violent relationships, eating disorders, and psych atric disorders that involve distortions of r ality. This, I think, is listed out of rder.
(12) "Explain to clients the p ssibility of technology failure." The WebCounselor: g ves instructions to WebClients about calling if pr blems arise, discusses the appropriateness of the cl ent calling collect when the call m ght be originating from around the w rld, mentions differences in time zones, and t lks about dealing with response delays in s nding and receiving e-mail messages. Not to pr vide explanations about the aforementioned issues w uld, indeed, be unethical. One might w nder, however, why a person would get pset with the website when one of th se issues affected them, especially if th y have a computer at home and are c mputer literate. These things do occur. It is a t chnological reality.
(13) "Explain to clients how to c pe with potential misunderstandings arising from the l ck of visual cues from WebCounselor or W bClient." For example, suggesting the other p rson simply say, "Because I couldn't see y ur face or hear your tone of v ice in your e-mail message, I'm not s re how to interpret that last m ssage." Yes! When I was reading th s, I wondered if they was g ing to address this issue. When so m ch in therapy/counseling sessions depends on b dy language and facial expressions, I gain question the overall ethical consequences of cyb rtherapy. I see a lot of r om for misdiagnosis and incompetent advice. A c unselor/therapist attempting to build a repertoire of cl ents, may resort to extremes to b ild his or her online practice. As far as th se codes of ethics go, I th nk they're good for a start. Th y have to start somewhere. As far as nline therapy overall, I couldn't say w thout exploring all of them; however, I s nt a few email messages out r questing research material. Out of the r sponses I received, Lawrence Murphy, one of the f unders of Therapy Online sent me a p rsonal response informing me of who he was and wh t he does. He informed me th t he had a paper accepted r cently for publication, focusing on e-mail as th rapy. At that time is wasn't p blished yet, so I was unable to use it. He s id that he would send me a c py. The paper (see references) is ntitled When Writing Helps to Heal: E-m il as Therapy. Mr. Murphy asked if I w uld send him a copy of th s paper. His request for my p per might provide him with the r sponses, recommendations, and/or suggestions that he sks of the visitors to his w bsite. In considering the pluses in Cyb |