Online Counseling and Therapy: Critical Issues

Course #96732 - $20 • 5 Hours/Credits


Study Points

  1. Review Internet history and usage trends.
  2. Define terms associated with online counseling.
  3. Evaluate different technological applications for online counseling.
  4. List the advantages and limitations of online counseling.
  5. Identify sociocultural issues involved with the use of online counseling.
  6. Discuss ethical and legal issues pertaining to online counseling.
  7. Describe the empirical literature related to the efficacy of online counseling.
  8. Discuss clinical practice considerations within the context of online counseling.

    1 . Regarding the Internet, which of the following statements is FALSE?
    A) The Internet was started in the 1990s in private, commercial for-profit sectors.
    B) The Internet is an interconnection of commercial and noncommercial computer networks.
    C) The Internet can be traced to the government, particularly to the U.S. Department of Defense.
    D) The Internet was spurred on after World War II, when the U.S. government wanted to develop an electronic communication system to send messages in the event a nuclear attack occurred.

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    The Internet's history can be traced to the military and the government [80]. Although the Internet is generally thought of as a recent phenomenon, it actually began during the period after World War II, when the U.S. government began to develop a system to send electronic messages in the event of a nuclear attack [25]. Between 1959 and 1964, engineers at the military think tank Rand began to conceptualize a framework for distributed communication [166]. At that time, it relied on extensive computer systems and was all text-based. It was exclusively used for government purposes, unlike the current mass media the Internet has become [25].

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    2 . What does the term "digital divide" refer to?
    A) It is synonymous with the gender gap found in the math and science fields.
    B) It refers to the social exclusion of some groups from Internet and computer technologies.
    C) It refers to how Internet penetration has risen significantly among all social groups as digital technologies have become more accessible.
    D) None of the above

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    Despite the proliferation and increased use of the Internet, not all social groups have equal access to a home computer and the Internet. The social exclusion and inequality of Internet access, which is influenced by socioeconomic differences among various groups, has been termed the "digital divide" [23]. Wasserman and Richmond-Abbott categorize access into three components: access to the Internet, frequent use of the Internet, and scope of use of the Internet [80]. It is assumed that socioeconomic status plays a role in access, as it is necessary to have the economic resources to purchase a computer and to pay monthly fees to an Internet service provider [80].

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    3 . Which of the following statements regarding Internet usage trends is TRUE?
    A) Socioeconomic status plays a role in access to technology.
    B) Ethnicity is not correlated with cell phone ownership or Internet access via cell phones.
    C) White Americans generally have higher rates of access than other racial groups in the United States.
    D) All of the above

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    Despite the proliferation and increased use of the Internet, not all social groups have equal access to a home computer and the Internet. The social exclusion and inequality of Internet access, which is influenced by socioeconomic differences among various groups, has been termed the "digital divide" [23]. Wasserman and Richmond-Abbott categorize access into three components: access to the Internet, frequent use of the Internet, and scope of use of the Internet [80]. It is assumed that socioeconomic status plays a role in access, as it is necessary to have the economic resources to purchase a computer and to pay monthly fees to an Internet service provider [80].

    Although Internet usage is generally increasing, there are cultural differences. In 2016, 65% of African Americans and 58% of Hispanics had broadband Internet at home, rates that were lower than home access among white individuals (78%) [168]. However, Asian Americans are slightly more like (82.7%) to have home access to the Internet than white Americans [62]. Racial and ethnic minorities such as African Americans and English-speaking Latinos use cell phones and Internet access via their cell phones at a similar rate as their white counterparts. According to the Pew Research Center, 77% of whites, 72% of blacks, and 75% of Hispanics owned a smartphone in 2017 [168]. Racial/ethnic minorities appear to take full advantage of their cell phone features compared with their white counterparts [77].

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    4 . Individuals tend to seek what type of health information online?
    A) Family health
    B) Methods to improve health
    C) Difficult to discuss health topics
    D) All of the above

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    Although consumers report preferring to obtain health information from their physicians, more consumers are taking advantage of Internet technology to seek health-related information [78]. In 1998, 50 million adults in the United States had ever gone online to seek health information; slightly more than a decade later, this number jumped to 154 million [83]. According to a 2010 poll, 81% of Internet users sought health information online, and 49% used the Internet to do more research after having seen their physician [83]. A study of adults 18 years of age and older found that 65% of Internet users searched for medical information [169]. In a separate 2015 study, 40% of adults used the Internet to search for health information and 3.7% used online health chat rooms [170]. A 2008 study with 569 Internet users found that consumers tended to look for four types of health information online: medical treatment, difficult to discuss health topics, family health, and methods to improve health [78]. A 2016 study found that adults typically sought online medical information on specific diseases, medical treatments, and healthy behaviors [171]. Interestingly, there was a decline in online health information seeking between 2002 and 2012, possibly due to concerns about the validity and reliability of health information on the Internet. This trend of online health information seeking is not limited to the United States. In a study that included 7,934 participants from Norway, Denmark, Germany, Greece, Poland, Portugal and Latvia, 71% of Internet users had used the Internet for health-related activities, particularly to access and read health information [63].

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    5 . In a 2012 survey, what percentage of cell phone owners reported having used their cell phone to obtain health information?
    A) 31%
    B) 20%
    C) 19%
    D) 5%

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    The most commonly used social media resources included Wikipedia (21%), online discussion boards (15%), social networking sites (6%), blogs (4%) and synchronous chat rooms (4%). Another study found that 58% of individuals diagnosed with a chronic illness were enthusiastic about sharing medical information and their experiences with others [84]. Using cell phones to access online health information is becoming increasingly popular. A 2012 survey conducted by the Pew Internet Research Project found that 31% of participants had used their phone to look for health information, compared with 17% in 2010 [88]. In this survey, individuals who were African American, Latino, 18 to 49 years of age, or who had a college degree were more likely to obtain health information using their phones [124]. Providers have also begun to use phones to disseminate health information. In a study involving community health advisors (paraprofessionals) in the African American community, providers reported that they like the ability to communicate quickly to people about cancer screenings, raising awareness, and providing concrete information about services [130].

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    6 . Compared with men, women are more likely to search online for what type of health information?
    A) Weight loss
    B) Geriatric topics
    C) Occupational injuries
    D) Mental health and psychiatric topics

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    There are also specific demographic patterns in Internet health seeking. Compared with men, women tend to search online more for health and medical information [85]. They are particularly more likely to search for information on mental health and psychiatric topics, such as depression [89]. Mothers with young children use the Internet to seek pediatric health information regarding specific health conditions and symptoms and parenting [90].

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    7 . Why has online counseling been compared to telephone counseling?
    A) Both forms require a licensed therapist to provide services.
    B) They both are primarily used in private, for-profit mental health settings.
    C) Online and telephone counseling have been critiqued in terms of their ability to handle crisis situations.
    D) Both forms of counseling are advantageous for those who are physically disabled or who may be geographically isolated.

    AN OVERVIEW OF INTERNET TECHNOLOGIES

    Online counseling has been compared to telephone counseling, as they share similar features. Telephone counseling was initially used for crisis intervention. Examples include suicide, rape, and domestic violence crisis hotlines, operated 24 hours a day, 7 days a week, to meet those who are in crisis and require immediate assistance [61]. Telephone counseling is a viable and valuable option for those who are physically disabled, geographically isolated, or constrained for time, and it is certainly amenable to psychologic disorders that limit contact with others, like agoraphobia [61]. Some who are wary about seeking help may be more likely to seek professional help using the phone because it offers a relative degree of anonymity [61]. In many ways, the debate of whether online counseling is effective and the examination of its strengths and limitations parallel the debate that emerged when telephone counseling became an option in the delivery of mental health services. As of 2009, there were more than 500 therapists offering individual online counseling and more than 300 unique sites offering online counseling [136]. This availability has increased exponentially, and a 2017 Google search of the term "online counseling" returns 4.9 million results.

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    8 . Online counseling is also referred to as
    A) e-therapy.
    B) Internet therapy.
    C) cyberspace counseling.
    D) All of the above

    DEFINITION OF TERMS

    It is necessary to define some common terms that have emerged in the literature about online counseling. Online counseling is also referred to as e-therapy, web-based counseling, cyberspace counseling, and Internet counseling or therapy. Simply put, these terms have been defined as the provision of mental health care through the Internet, whereby the services are delivered as stand-alone services or as a supplement to existing interventions [60,138].

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    9 . Asynchronous communications are carried out
    A) simultaneously, with no gap in time between responses.
    B) face-to-face, to allow for interpretation of nonverbal cues.
    C) on a non-real-time basis, spanning different times and locations.
    D) always via a secure server and in a private office, to ensure the privacy of the parties involved.

    DEFINITION OF TERMS

    Asynchronous refers to communications carried out on a non-real-time basis spanning different times and locations. There is usually a gap in time between the responses of the counselor and the client [52]. Synchronous (real-time) refers to communications that are carried out simultaneously, with no gap in time between the responses of the counselor and the client.

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    10 . One issue of concern when the Internet is used as a mechanism for mental health education is the
    A) information may be lacking on some topics.
    B) excessive amount of information provided may be confusing.
    C) financial constraints due to fees associated with subscriptions.
    D) high level of language used may not be user-friendly for non-professionals.

    APPLICATIONS OF ONLINE COUNSELING

    With Web 2.0, mental health information can be obtained by connecting, interacting, and sharing with other individuals. One of the main benefits of Web 2.0 is being able to harness collective intelligence using dynamic Internet applications [94]. Consumers use these applications not only to find mental health information but to develop communities to support one another, share experiences and information, and evaluate physicians' and healthcare providers' performances [16]. Web 2.0 applications like Twitter and social networking sites may be used to disseminate health promotional messages and reminders. The Centers for Disease Control and Prevention has used Twitter to reach the public with education related to influenza [140]. Accessing mental health information online has become much easier and more convenient; however, the excessive amount of information individuals are exposed to can be problematic. Information may be conflicting, and individuals must understand that the quality and accuracy of information will vary [56].

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    11 . Which of the following is NOT a form of synchronous communications?
    A) E-mail
    B) Instant messaging
    C) Voice over IP technologies
    D) Video-based Internet technologies

    APPLICATIONS OF ONLINE COUNSELING

    E-mail is one of the most common uses of the Internet. It allows an individual to send text messages to another person or to a group rapidly, conveniently, and without incurring long-distance charges [25]. E-mail-based counseling consists of asynchronous interaction between a counselor and client using text-based communications sent electronically [52]. E-mail communications allow the client to exchange brief narratives, while the counselor structures the communication for exploration of the described symptoms with a problem-solving focus [56,177].

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    12 . Which of the following is NOT a potential advantage of online counseling?
    A) Counseling services can continue even if a client relocates.
    B) Online counseling has the potential to increase perceived anonymity, which might reduce stigma.
    C) The ability to reread and edit messages is thought to produce reflective and thoughtful responses.
    D) Online counseling is clinically more effective in establishing rapport with all clients with all types of presenting problems.

    EVALUATING MERITS AND LIMITATIONS OF ONLINE COUNSELING

    The perceived anonymity associated with online environments coupled with the ability to reread and edit messages is thought to produce more thoughtful and insightful responses [57,189]. Some experts argue that the psychologic anonymity of online counseling is therapeutically beneficial as "it facilitates what seems incompatible in ordinary life: to make contact with a stranger over very personal topics, with a degree of self-revelation that overcomes inhibitions regarding the portrayal of one's problems much more readily than would be the case for a meeting in person" [116]. In a study exploring online counseling for problem gambling, participants stated they preferred online rather than traditional face-to-face counseling because the anonymity made it "less daunting" and they felt less "exposed." For some, it was the first time, they were able to talk about their problem gambling and the related despair [147]. However, other studies have found a preference for in-person counseling due to the greater potential for relationship building. Parks and Roberts, for example, compared online and face-to-face communications and found that participants were equally comfortable and confident in sharing information [57]. However, participants stated that knowing the identity of the person from whom they were receiving information promoted a greater sense of commitment in maintaining the relationship [57]. Obviously, there are characteristics of traditional face-to-face counseling that are difficult to capture in an online environment.

    Given the geographic mobility and transient quality of society, online counseling can offer continued support and services if a client or counselor relocates [17]. According to the U.S. Census, 37.5 million people in the U.S. have within the past year [117]. While the majority (69.3%) stay within the same county, 16.7% move to a different county in the same state and 11.5% move to a different state. This can make continuity of care difficult to achieve unless Internet technologies such as online counseling are used.

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    13 . Which of the following is a concern with online counseling?
    A) Privacy and security issues
    B) Unsuitability for clients with severe emotional problems
    C) Lack of mechanism to monitor the quality of clinical services and accountability
    D) All of the above

    EVALUATING MERITS AND LIMITATIONS OF ONLINE COUNSELING

    To date, one of the main challenges with the delivery of Internet counseling and mental health services involves the mechanisms for monitoring quality of services and accountability [22]. There is no established monitoring system to track the credibility and legitimacy of counselors' advertisements. There is also no accountability structure to review and monitor the quality and accuracy of information on websites [22]. Some have also wondered about how to monitor the quality of the clinical process. These concerns may be amplified in cases of chat rooms or support groups, which may or may not involve a licensed and trained counselor. The lack of nonverbal cues (e.g., displayed diploma) may also negatively influence clients' perceptions regarding a therapist's credibility [190]. Just as there are concerns the identity and the credential of the counselors, there is also concern about the identity of the client. Some have recommended that code words mutually developed by the counselor and client be used in the beginning of each session to verify both parties' identities; requiring the client to summarize the last session can also be used to verify identity [119].

    Another concern with online counseling is based on security and privacy issues. Computer hackers, for example, can access particular websites and compromise the confidentiality, privacy, and security of clients' disclosures as well as payment information, such as credit cards [22]. As online counseling websites become more sophisticated, there is a move toward using the same message security systems utilized by banking institutions [22]. It is important not to use personal e-mail accounts or insecure platforms (e.g., FaceTime) [191].

    Online counseling may not be conducive and appropriate for clients with severe emotional problems or who have serious psychiatric problems. In an emergency situation in which a client expresses suicidal or homicidal thoughts, counselors may not know where the client is located and be unable to implement emergency plans [22,65]. In addition, they may not be able to warn vulnerable third parties [17]. However, similar challenges exist with telephone counseling or crisis hotlines [65]. Counselors may also have difficulty referring clients to appropriate local resources and services [17]. Even when clients share their locations, counselors may be unfamiliar with the range and quality of services in any given geographic area.

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    14 . Why is there some speculation that use of e-mails might be more suitable for people from low-context cultures?
    A) E-mail provides the biographical information required by low-context cultures.
    B) Individuals from low-context cultures rely on social cues, and e-mail technology provides social contexts.
    C) E-mail communication emphasizes the use of a shared experience, whereby threads of communication can be used.
    D) E-mail technology focuses on communication styles that are linear and focuses on words to convey meaning, which is characteristic of low-context communication patterns.

    ONLINE COMMUNICATIONS AND COUNSELING: A SOCIOCULTURAL CONTEXT

    Individuals from high-context cultures require more social context in order to understand the meanings of the communication [36]. E-mails, for example, are perceived to be a quick, easy way to communicate, with a focus on words to convey both content and meaning, which may be more amenable to individuals from low-context cultures [36]. Those from high-context cultures may be less likely to initiate communication online or offline due to their adherence to authority structures and tend to be more formal in their communication style; in these cases, the practitioner, as the expert, is expected to initiate communication [121,150].

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    15 . Polychronism, which is embraced by some cultures, influences Internet usage in that
    A) the faster quality of high-speed connections is key to efficacy.
    B) individuals may be less concerned with slower technologies that result in some delay.
    C) the layout and colors used on websites may influence its attractiveness to specific groups.
    D) the need to complete one task before moving on to another makes asynchronous communication desirable.

    ONLINE COMMUNICATIONS AND COUNSELING: A SOCIOCULTURAL CONTEXT

    Other cultural values can influence technology usage. Individuals' attitudes about appropriate uses of time vary from culture to culture [26]. Monochronism refers to preference to perform tasks one at a time; polychronism refers to a preference to parallel task, performing more than one task simultaneously [26]. Certain cultures (e.g., Egypt, Peru) tend to be less concerned with slower technologies with some delay because they adhere to more polychronistic attitudes toward time [40]. Persons from monochronic cultures demonstrate are more concerned with promptness and adherence to schedules [150].

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    16 . How do culture, race, and ethnicity influence attitudes toward the use of technology?
    A) All ethnic minority groups view Internet use as positive.
    B) The Internet is viewed as egalitarian, decreasing the digital and cultural divide.
    C) Culturally embedded gender roles affect perceptions regarding the use of computers.
    D) All of the above

    ONLINE COMMUNICATIONS AND COUNSELING: A SOCIOCULTURAL CONTEXT

    Finally, individuals' perceptions of computer technologies may be influenced by cultural and gender role norms, and understanding cultural differences in attitudes toward computers may have implications in online counseling [35]. One would surmise that some ethnic minority groups may have less favorable attitudes toward computer technology in part due to practical barriers, such as cost and access. One ethnographic study revealed that economics is not the only factor; psychosocial barriers can also affect ethnic minority adults' perceptions about computers [74]. Some participants, for example, did not see themselves as the type of person who used computers. Some thought that computers were a luxury item, and their subcultural identity did not include the image of a computer user [74]. Similarly, in Menard-Warwick and Dabach's case studies of two Mexican families, affective factors included fear in using computers and anxiety revolving around a sense of entitlement [50].

    Culturally embedded perceptions about gender roles also color attitudes toward computers. Some Hispanic men stated that computers and typing were considered female subjects in school. In other cases, some participants stated that computers were equated with educational success, but educational achievement was not part of their life tasks and roles [74].

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    17 . All of the following are identified gender differences in the use and pattern/style of online communication, EXCEPT:
    A) Women tend to have more sophisticated web skills.
    B) Women prefer to use the Internet to connect on a personal level, while men tend to use it for entertainment.
    C) Women tend to gravitate toward topics with practical ramifications, while men seek entertainment and leisure.
    D) Men's voices on online forums tend to be more assertive, independent, and impersonal, while women's voices are more supportive and helpful.

    ONLINE COMMUNICATIONS AND COUNSELING: A SOCIOCULTURAL CONTEXT

    In general, there are gender differences in how the Internet is used. Men are more likely to use the Internet to find news, play games, seek information, and connect to audio broadcasts. Men tend to have more sophisticated web skills, as they are more comfortable and proficient in developing their own websites and changing preferences [81]. In one study, Weiser found gender differences in Internet patterns and applications [81]. Men tend to use the Internet for entertainment and leisure such as pornography, games, and pursuing sexual relationships, while women are more likely to use the Internet for interpersonal communications and education [81]. Women's tendency to use the Internet for education and information seeking seems to also apply cross-culturally. In a study of 386 adults in Turkey, women were more likely than men to rate ease of access to online health information as an important factor. Men are also more likely to use the search engines (88%) compared with women (79%), and they use search engines more frequently (40%) than women (27%) [89]. On the other hand, women appear to use Internet-mediated communications (e.g., social network sites, texting, video chats) slightly more often than men [152].

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    18 . Which of the following is NOT one of the five principles related to establishing and maintaining online relationships as identified in the American Counseling Association's code of ethics?
    A) Counselors should only practice within their area(s) of expertise.
    B) Counselors should not provide referrals via online communications.
    C) Intervention plans should be consistent and reflect the client's individual needs.
    D) Counselors should have an intake process in place that helps assess the appropriateness of online counseling.

    ETHICAL AND LEGAL ISSUES

    Five principles related to establishing and maintaining online relationships are identified in the ACA's code of ethics [47]:

    • Appropriateness of online counseling: Counselors should have an intake process in place that helps assess whether online counseling is appropriate given the client's presenting problems. Clients also should be made aware of situations that might not be amenable to online counseling. In order for clients to make an informed decision about whether to proceed using online counseling, they should be informed about the risks, benefits, and limitations of using online counseling.

    • Counseling plans: Intervention plans should be consistent and reflect the client's individual needs. If it is assessed and determined that online counseling is not appropriate, referrals should be made to alternative services.

    • Continuing coverage: Counselors should provide schedules, response times, and contact information to the client. If a counselor is not available for any reason, arrangements must be made with another counselor to do any follow-up, and this must be conveyed to the client.

    • Boundaries of competence: Counselors should only practice within their area(s) of expertise.

    • Minors and incompetent clients: Informed consent must be obtained from the parents or legal guardians of clients who are minors. For those who are not competent, informed consent must be obtained from the individual who is appointed to give consent.

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    19 . Studies evaluating the effectiveness of Internet interventions for individuals with difficulties maintaining healthy weight have
    A) indicated that such interventions are not helpful and may be harmful.
    B) supported the use of such interventions based on definitive positive outcomes.
    C) been contradictory, with some finding positive results and others indicating lack of efficacy.
    D) been extensive and useful to determining which patients will benefit from online counseling.

    EFFICACY STUDIES OF ONLINE COUNSELING

    Obesity is a major public health concern in the United States. There have been some Internet-based interventions working with individuals who have difficulties maintaining a healthy weight. Studies are slowly emerging to evaluate the effectiveness of these Internet interventions; and these studies have indicated contradictory results. One study, conducted in 2002, did not find positive results [28]. Researchers in this study found that an Internet support group did not appear to be as effective as minimal or frequent intensive in-person therapist support for facilitating the long-term maintenance of weight loss.

    Yet, another experimental design indicated that Internet therapy was effective [76]. Researchers in this study recruited and randomly assigned research participants to one of two groups: a basic Internet weight-loss program (the control group) and an Internet weight-loss program plus behavioral e-counseling (the experimental group). The basic Internet program consisted of a tutorial on weight loss. Furthermore, participants were provided with a daily tip about weight loss and a list of Internet weight-loss resources. Each week, participants in this group had to submit their weight by e-mail [76]. Participants in the experimental group e-mailed their weight-loss counselor and reported their calorie and fat intake, exercise energy expenditure, and questions in a web-based diary. Counselors provided feedback on the self-monitoring, offering reinforcements, recommendations, and general support [76]. Participants in both groups were measured at baseline for weight, waist circumference, and fasting blood glucose. Findings show that participants in the Internet weight-loss program with behavioral e-counseling experienced more weight loss and greater reductions in waist circumference at 1 year than the basic program without behavioral e-counseling [76]. The additional feature of e-counseling appeared to be effective in promoting improved eating habits and weight loss.

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    20 . Which of the following is an aspect of assessing clients for suitability of online counseling?
    A) Internet accessibility
    B) Level of reading proficiency
    C) Preferred communication method
    D) All of the above

    SUITABILITY OF ONLINE COUNSELING

    As stressed throughout this course, it is vital to recognize that online counseling and mental health services are not for everyone. Key questions have been formulated to help determine if utilizing the Internet and other forms of communication technologies are amenable to a particular patient/client [75,134]. Counselors can use the following questions to structure assessments with individuals who are exploring the option of using online counseling [156,205]:

    • What type of communication method does the client prefer? Does he or she prefer using e-mails, chatrooms, or video conferencing?

    • How proficient and comfortable is the client using the identified form of communication technology? Does the client demonstrate sufficient knowledge in using computers and the Internet?

    • What type of access does the client have? Is his or her computer system compatible with that of the counselor? What type of Internet connection does the client have? Where is the client accessing the computer and Internet? Are privacy issues involved?

    • How comfortable and knowledgeable is the client regarding online communication and relationships? Does the client enjoy communicating online? Does the client have any experience with online groups? What other activities does the client pursue online? What are his/her attitudes about the Internet?

    • How proficient and comfortable is the client with reading and writing? Can he or she type well? Is there any cognitive impediment that might hinder the client's ability to communicate online? Does the client prefer face-to-face or phone communications? In the counselor's opinion, would there be therapeutic advantages to using e-mails, instant messaging, chatrooms, or other forms of online communications even though the client might state he/she does not prefer a particular method? If using e-mail or text messaging, to what extent can the client express feelings and emotions in written form?

    • Does the client have any experience receiving counseling or any other type of mental health services? (Previous experiences may influence expectations, perceptions, and goals.)

    • Does the client's personality style, presenting problem, and/or diagnosis affect the suitability of utilizing online communications? (It is usually recommended that those with poor reality testing or who present with severe psychiatric problems [e.g., personality disorders, dissociative disorders, paranoia], suicidal ideations, or homicidal tendencies may not be appropriate.)

    • Is the client comfortable with delayed responses from the counselor if e-mails or text messaging is used?

    • To what extent might cultural issues affect the decision to employ online counseling? Obviously, shared language proficiency between the counselor and client is vital. How might the client's cultural beliefs about mental health and counseling affect counseling?

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