By Paula Bradley, InPsych Production Editor

In recognition of the increased use of the internet for the provision of on-line psychological services, an APS Working Group devised a set of ethical guidelines recently to assist psychologists using or planning to use the internet for on-line counselling services. InPsych production editor PAULA BRADLEY spoke to two Working Group members, Karen Sullivan and Robert King, and sourced some comments from UK-based clinical psychologist, Darren Spooner, to get a better idea of this rapidly developing area of exchange between psychologists and their clients.

ON-LINE counselling has various manifestations, including the provision of therapy via chat-based platforms or email (see www.makingchanges.com.au, www.kidshelp.com.au, www.psychologyonline.co.uk), on-line support groups (see www.mentalearth.com for a therapist mediated on-line community) and self-help sites (see www.kpchr.org/feelbetter for a self-help site for depression).

These websites can all be found via search engines, which unfortunately don't filter out the disreputable sites. According to senior lecturer at the School of Psychology and Counselling, Queensland University of Technology, Dr Karen Sullivan, it is important to encourage users of on-line counselling sites to look for the factors they would ordinarily consider when choosing to see a psychologist. "These include such things as evidence the practitioner is registered and a member of the APS, and details about qualifications, speciality, cost and type of service that will be provided. This information should be easily accessible on the site," she says.

Senior Lecturer at the Department of Psychiatry, University of Queensland, Robert King, who uses on-line counselling in his clinical practice and has a research interest in the area, adds that sites should be confidential - they should not have major banners or screen features that reveal it as a psychological service and the mode of communication must be secure. Communication by email is best protected through attached encrypted (password protected) files. "The site should also provide competent counsellors who are adequately trained both in counselling generally and in the specific use of text exchange," he says.

UK-based clinical psychologist, Darren Spooner, whose PhD research compares two forms of on-line CBT for the self-treatment of depression and who uses the internet in his clinical practice, says the better on-line counselling sites have a simple, user-friendly interface, geared towards the lowest common denominator is terms of the user's computer competence and equipment. The site should also have simple graphics and limited downloads in order to compensate for low bandwidth, he says.

On-line counselling: advantages and suitability
The benefits of on-line counselling are yet to be demonstrated empirically, but probably include the potential to improve access to psychological services and greater anonymity, according to Karen. "For example, access to psychological services may be improved for people in remote locations; for people with specific cultural or language needs; for people seeking specific services that are not widely available; for people who, by reason of psychological or other impairment, are housebound; for people who prefer the convenience that communication via this medium provides; and for people for whom high levels of confidentiality or anonymity are important," she says, adding that this argument assumes that these people have access to a computer and the internet, which may not necessarily be the case.

"A further possible advantage of on-line counselling is that it could be used to improve continuity of care, for example, clients who travels overseas could potentially keep in closer contact with their psychologist by the internet than may be possible via other mediums. The internet allows comparatively rapid communication, so clients may be more likely to email their psychologist rather than attempt to keep in contact by phone or mail."

Robert has conducted some online focus groups with young people who use the Kids Help Line online counselling service. "They are mostly very positive about the experience," he says, "There are quite a lot of young people who would not be prepared to phone a counsellor let alone make an appointment, but who feel comfortable using the anonymity of text message exchange to communicate about their problems.

"The only significant problem is that text message exchange is rather slow (because of limitations of keyboard speed of counsellors and clients) and is therefore time consuming. Young people tend to report the counselling session has not gone on for long enough, even though in real time it has often exceeded one hour."

The Queensland-based Kids Help Line has provided counselling for children and young people (ranging from five to 18 years) by email since 1999 and a real-time service since May 2000. During 2002, the service's counsellors responded to almost 8300 on-line counselling sessions including:

  • 5148 emails (1904 more than in 2001), and
  • 3145 via web-counselling sessions (up by 240).

The Kids Help Line says this 25 per cent increase occurred despite no advertising and limited media exposure. Interestingly, females accounted for the greater proportion of on-line clients (87 per cent). Males were less likely to seek help through on-line mediums (13 per cent) than is the case by telephone (28%).

The top-10 concerns were family relationships, mental health, peer relationships, partner relationships, suicide, emotional/behaviour management, child abuse, self image, grief and sexual assault. The Kids Help Line reports that young people were at least three times more likely to seek help for mental health concerns, suicide, eating behaviours and emotional/behaviour management using on-line services compared with telephone counselling. Double the number of young people sought on-line help about self image and sexual assault.

Using these statistics, the service concludes that: "many young people value the anonymity and less intrusive style of communication provided by email and/or web counselling." (See www.kidshelp.com.au/upload/1861.pdf - Acrobat icon - small [51kb] for further information)

The issue of which psychological conditions are better suited to treatment via on-line counselling is a matter of some debate. Robert says some caution is required in making statements about what conditions are suited to the medium, as there is "not much of an evidence base" yet. However, he says it is likely that a wide range of life problems and adjustment disorders that are typically helped by counselling will also be responsive to online counselling.

"There is a reasonable evidence base for efficacy of self help in treatment of depression and good evidence that depression is responsive to a wide range of bona fide psychological and counselling treatments - I would therefore expect that depression would respond to online treatment even though there is not an established evidence base," he says.

"Justin Kenardy and his team at UQ have some preliminary evidence for online self help CBT treatment for anxiety. The key to successful treatment of anxiety is likely to be application of behavioural components of a CBT package. A reasonably well-motivated person can probably learn to apply these procedures through utilisation of an online resource. I am not aware of any public access interactive online treatments for anxiety but I see no reason why these should not work so long as they use the procedures known to be effective."

Robert says on-line therapy is unlikely to be effective as a primary treatment for bipolar disorder or psychosis, but may be helpful as an adjunct to treatment. Karen agrees that the medium may be less suitable for conditions that involve serious mental illness, or where the client is at risk of harming themselves or others, particularly if this is the only form of treatment they are receiving. In such cases, she says, extra precautions may need to be undertaken.

However, the counter argument to the position that high-risk situations are less suitable for on-line counselling is that services like crisis telephone counselling have existed for some time and that such services may be used by high-risk clients, Karen says. "Therefore it would seem to me that it is not so much a matter of whether or not the counselling is delivered face-to-face, over the phone, or on the internet. Rather, the broader issue is one of how that risk is managed irrespective of treatment modality."

Crisis management
The case of a suicidal client (as an example of a crisis situation) identified in an on-line counselling session may raise specific issues for the psychologist, according to Karen, although there will be similarities in how to manage the situation, whether it has been identified on-line, by
telephone or in a face-to-face situation.

"The on-line counsellor, like the therapist seeing someone face-to-face, may attempt to verify if the client has a past history of such behaviour, if they have a plan for taking their life, if they have access to necessary means and so on. The counsellor may also seek assurances from the client as to what the client will undertake to do if they feel they will act on their intention," she says.

"The on-line psychologist would also have explained to the client at the outset of communications what they would do if such information was to come to light during a 'session', as would occur in a face-to-face situation."

 Of course, it may be argued that in the case of on-line counselling, there may be difficulty verifying the client's identity and that this may further complicate crisis interventions. "This may well be so, although this risk probably also applies in telephone counselling situations, as well as in some face-to-face counselling situations, where the client does not reveal their true identity. There may be ways that such risks can be managed, by negotiating with the client to seek face-to-face help if such issues arise, whilst maintaining their internet-counselling relationship," Karen says.

Robert suggests that on-line counsellors develop 'contracts' with higher-risk clients that permit them to contact a local GP or mental health service or other crisis response service, whenever the client is at risk to self or others. He says lower-risk clients can be provided with risk-assessment and risk-minimisation interventions and information about local resources.

Any contact with a mental health worker may well be better than no contact at all during a crisis, Darren says, and as such, the ability for a person  to manage a crisis may well be improved if they can access help on-line. "Service providers should use a 'contract', and clear guidelines and protocols should be made salient to service users in preparation for an emergency. One example is preparing a client for what they should do, and think, if their therapist's dial-up fails or computer hangs."

Some pitfalls
On-line counselling is sometimes thought to be 'less secure' than face-to-face counselling, in the sense that communication over the internet may not be confidential, according to Karen.  For example, emails may be inadvertently sent to the wrong address or files on a computer may be read by parties other than those intended by the author. "Yet these risks seem to me to be no greater than the risks that ordinarily exist with written documentation of the type that may be kept in face-to-face counselling situations," she says.

Depending on how the service is delivered, Karen says, on-line counselling may have some disadvantages such as the loss of information that is typical of internet-based communication, specifically the potential loss of non-verbal information or observational data that might normally be gathered by the psychologist during consultation. "However the potential loss of non-verbal information depends to some extent on whether the service provided includes the use of web cams (real-time video link-ups), for example. But even when this information is lost, it is important to note that this is not specific to on-line modes of service delivery and is also true of telephone counselling," she says.

Keeping professional boundaries in place is another potential problem, adds Karen. "Communication via the internet, such as by email, is usually different from communication face-to-face.  For example, a more abbreviated style of communication may develop in email, or a more familiar, less formal communication style could evolve, possibly as a consequence of the 'distance' this type of communication allows.  This may raise some professional boundary issues for practitioners that service providers need to consider.  In general, I think it is important for users of on-line counselling services (both clients and psychologists) to be familiar with the concepts of 'netiquette'.

New APS guidelines
The new ethical guidelines for providing psychological services and products on the internet will offer encouragement for psychologists who wish to make use of the benefits of on-line communication, according to Robert, and assist them to think through the range of issues that arise when on-line media are used.

In formulating the guidelines, the Working Group considered a variety of sources of information, including recent journal articles and reports from overseas. "The Working Group was aiming to formulate guidelines that retain some flexibility whilst at the same time flagging issues that we felt may need specific consideration by psychologists," Karen says.

"For example, we looked at the issue of confidentiality, and whilst we acknowledge that there will be a great deal of overlap between how this issue is managed in face-to-face situations and internet consultations, we also tried to consider issues that may be specific to the on-line counselling environment.  We were also mindful on the need to come up with guidelines that were as free as possible from specific technological references, in the interests of the longevity of the document.

"I think the guidelines will be useful to the extent that they articulate issues that are specific to on-line counselling, and highlight these for practitioners. Feedback on these guidelines will be welcome."

The new ethical guidelines for providing psychological services and products on the internet will be available to APS members in 2004.

The British Psychological Society also established a working party recently looking at the same issues.