Online Mental Health Cousnseling

Mallen et al. / ONLINE-COUNSELING / November THE COUNSELING PSYCHOLOGIST RESEARCH2005 10.
1177/0011000005278624
Online Counseling:
Reviewing the Literature From a Counseling Psychology Framework

Michael J. Mallen David L. Vogel
Iowa State University
Aaron B. Rochlen
University of TexasAustin
Susan X Day
University of Houston
This article reviews the online-counseling literature with an emphasis on current applications and considerations for future research. It focuses on primary themes of counseling psychology including the history of process-outcome research and multiculturalism. It explores current gaps in the literature from a counseling psychology framework, including the fields focus on normal and developmental challenges and tasks, client strength and resilience, education and career development, prevention and wellness, and multiculturalism. In general, current evidence indicates that online counseling may be a viable service option for some clients, especially those who are typically isolated; however, questions remain regarding the effectiveness and appropriateness of online counseling.
Online-counseling services are currently being provided in a variety of formats and are expected to increase in the next 10 years (Norcross, Hedges, & Prochaska, 2002; Stamm, 1998). Clients are using videoconferencing, synchronous chat, and asynchronous e-mail with professional psychologists in place of or in addition to face-to-face (FtF) counseling. Yet the majority of counseling psychologists are not involved in the provision of these services (VandenBos & Williams, 2000), and few have investigated whether the services are a viable means of client treatment. Several considerations arise from these trends. First, other professionals or even quasi-professionals online may provide mental and behavioral health services, and counseling psychologists may be missing opportunities to reach new clients. Second, an increasing number of individuals are exploring the Internet for mental and
Correspondence concerning this article should be addressed to Michael J. Mallen, Department of Behavioral Science, Unit 1330, University of Texas M. D. Anderson Cancer Center, P.O. Box 301439, Houston, TX 77230-1439; e-mail: mjmallen@mdanderson.org.
THE COUNSELING PSYCHOLOGIST, Vol. 33 No. 6, November 2005 819-871 DOI: 10.1177/0011000005278624 2005 by the Society of Counseling Psychology
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behavioral health services and information, and counseling psychologists are not involved in ensuring that this mode of psychoeducation and prevention is accurate and safe. This review of the available literature has shown online counseling to be beneficial for some clients, but the body of knowledge has not yet established online counseling as a truly effective mode of service delivery. Counseling psychologists are in a unique position not only to extend their services to online modes of treatment but also to conduct research in this area to determine whether online-counseling practices are therapeutically beneficial for clients. These new modes of service delivery may offer counseling psychologists an innovative context for furthering the fields process-outcome research. This article begins to outline specific areas of investigation that may allow counseling psychologists to further their knowledge of what is and what is not therapeutic for clients. Subsequently, this articles purpose is to discuss online counseling (i.e., asynchronous e-mail, synchronous chat, and videoconferencing), to outline and evaluate the research in this area, and to provide guidelines and a context for future research from a counseling psychology framework. We offer a brief overview of the telephone-counseling literature to provide a foundation for the subsequent review of the online-counseling literature. The latter begins with research that has examined online support groups and the potential for computer-mediated communication to facilitate emotional responses and a sense of alliance among group members. We discuss studies that have assessed client and clinician satisfaction with new modes of service delivery. Next, we review the process-outcome research that has been conducted on online counseling. Then, we review studies related to multiculturalism and the access to new treatment modalities. Finally, we conclude with a section regarding what is currently known about online counseling and a discussion of important gaps in the literature from a counseling psychology perspective. Specifically, we use counseling psychologys focus on normal and developmental challenges or tasks, client strength and resilience, education and career development, prevention, consultation, psychoeducation, and wellness to frame this review. By linking the available literature to counseling psychologys unifying themes and the scientist-practitioner model, we hope to integrate and synthesize the research while stimulating the reader to consider how counseling psychology can define the future practice of online counseling. We use the term online counseling throughout the article to encompass the growing variety of therapeutic services currently offered. A definition of online counseling can be found in the previous introductory article (Mallen & Vogel, 2005 [this issue]). Importantly, our goal with this article is not to advocate or to oppose online counseling but to organize the relevant research findings into an accessible format for counseling psychologists. Several articles have already sum-
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marized the debate and the various obstacles and challenges associated with online counseling. For example, Rochlen, Zack, and Speyer (2004) listed potential benefits and challenges of online counseling. Benefits included convenience and increased access (Finfgeld, 1999; Jencius & Sager, 2001; Pomerantz, 2002), the therapeutic effects of writing (L. J. Murphy & Mitchell, 1998; Pennebaker, 1997; Wright & Chung, 2001), and the ability to link clients to limitless multimedia resources (Grohol, 2002). Challenges included lack of nonverbal cues (Alleman, 2002), possible minimization of cultural static (Suler, 2001), misreading cues, time delays, technological glitches (Griffiths, 2001), crisis management (Childress & Asamen, 1998), and potential client or therapist deficiency in computer literacy (ManhalBaugus, 2001). The goal of this article is to synthesize and consider online counseling specifically from a counseling psychology framework. We begin with a discussion of the telephone-counseling literature to provide a foundation for this analysis with a more commonly used technology of counseling psychologists (VandenBos & Williams, 2000).
THE TELEPHONE IN COUNSELING Although Internet-based technologies are currently increasing the amount of services provided outside of the traditional FtF setting, the use of distance technology in practice has been discussed in the literature for more than 30 years. The telephone has a strong historical record in serving clients and is a precursor to more sophisticated distance technologies. This discussion, about the usefulness of the telephone for counseling services, has a direct bearing on the issues related to online-counseling services. Today, the telephone, also a distance-communication technology, has become a standard tool for most practitioners for tasks such as scheduling, consultation, payment, crisis management, and even psychotherapy. In a survey of nearly 600 doctoral-level practicing psychologists who were members of the American Psychological Association (APA), 98% reported providing services by telephone (VandenBos & Williams, 2000). The five primary health care services for which practitioners most often reported using the telephone were referrals (91%), emergency care (79%), consultation and education (71%), individual psychotherapy (69%), and clinical supervision (58%). Thus, today, the majority of practicing APA psychologists report using the telephone not only to conduct routine business activities but also for the direct provision of client care (i.e., crisis care and individual psychotherapy). Despite the telephones being a common and relatively uncontroversial method of communicating with clients, earlier writers vigorously discussed the possible applications of the telephone including pitfalls and limitations
(Lamb, 1969; Rosenblum, 1969). Below, we review the literature related to mental health and behavioral services provided by telephone, using the counseling psychology framework and serving to highlight the current issues that counseling psychologists must consider when using distance-communication technologies to deliver these services. Our major topics involve research that relates to effectiveness and beneficiaries, access to counseling and behavioral services, and the ability to foster client strength, resilience, prevention, and wellness. Effectiveness of Telephone CounselingLearning From the Past One of the main debates in the telephone literature is whether telephone counseling can be effective or as effective as FtF treatments. Sangha, Dircks, and Langlois (2003), for example, studied the effectiveness of genetic counseling by telephone with a sample of 24 pregnant women, finding that participants did not significantly differ on measures of their understanding of the information presented and that both groups experienced a similar reduction in reported anxiety on a 10-item questionnaire. The trial, however, was nonrandomized. Because the study allowed patients to choose either telephone or FtF counseling, it may be that patients who selected telephone counseling were somehow different from those who chose FtF counseling; however, demographic variables demonstrated rather homogeneous groups, and no significant differences were found during the posttest evaluation, indicating that the sample was representative of the population. A second study by Reese, Conoley, and Brossart (2002) also compared data from a nonrandom sample of 186 adult clients who received telephone counseling to data from the Consumer Reports (CR) effectiveness study of FtF psychotherapy (Seligman, 1995). The results from the telephone study were significantly lower than the CR study in regard to how helpful the clients thought the intervention was but slightly higher in regard to their satisfaction with the services provided. Yet, as the CR results are not a true comparison group to the individuals involved in the telephone-counseling study, these findings need to be interpreted with caution. As these studies demonstrate, one of the issues facing researchers examining the effectiveness of counseling through distance technologies is the difficulty in directly comparing telephone counseling to the traditional FtF mode of treatment. As such, several studies have investigated the effectiveness of telephone counseling as an adjunct to traditional FtF treatments. For example, Lovell, Fullalove, Garvey, and Brooker (2000) followed four middleaged patients diagnosed with obsessive-compulsive disorder. Patients were delivered a single 45-minute FtF treatment session, eight weekly telephone
therapy sessions, and a final FtF session. Three clients improved with the remaining one making minor improvements. The brief phone calls appear to have facilitated client growth, but the small sample size reduces the power of these findings. Research, however, has also demonstrated that the telephone can be combined with FtF treatments to increase the likelihood of success. For example, telephone counseling used in conjunction with FtF counseling has been successful for clients attempting to quit smoking (Lichtenstein, Glasgow, Lando, Ossip-Klein, & Boles, 1996; Mermelstein, Hedeker, & Wong, 2003; Mguez, Vzquez, & Becoa, 2002; P. M. Smith, Reilly, Miller, DeBusk, & Taylor, 2002). An example of this research comes from 664 individuals that participated in proactive telephone counseling after nicotinereplacement therapy (Zhu et al., 2000). Patients who received multiple telephone counseling sessions as an extension of their physicians efforts demonstrated a significant decrease in level of nicotine use when compared with patients who received only a single telephone counseling session. This has led some researchers to suggest that telephone interventions should not replace FtF contacts with health care professionals but may be used as an adjunct to improve the lives of patients and their families (Friedman & Grant, 2003). Researchers have also tried to examine which types of clients would most benefit from telephone-based mental health services. For example, Hugo, Segwick, Black, and Lacey (1999) reported the results of a telephone counseling program that targeted women with eating disorders. In all, 26 patients completed the program, consisting of 10 weekly telephone sessions, followed by a call 1 month later, and then calls every 3 months for 2 years from a therapist. Out of 26 patients, 18 returned follow-up self-report ratings of bulimia (BITE; Henderson & Freeman, 1987). They reported fewer instances of vomiting, laxative abuse, and binge-eating frequency. The majority of client change was reported between the program enrollment and the end of the 1st week, indicating that patients desire and readiness to seek help, not the mode of treatment, may be the biggest factor in the effectiveness of the treatment. In the study, Hugo et al. present a case that structured telephone counseling for bulimic patients may offer a viable alternative to conventional FtF treatments. Case studies have also demonstrated that telephone counseling could be effective in helping individuals deal with the psychological effects of cancer. Rosenfield and Smillie (1998) directly examined the usefulness of teleconferencing, a telephone conference call, for providing group counseling for women dealing with cancer. In their study, the researchers formed a group of six women with various forms of cancer from different geographical regions. The group was conducted through teleconferencing 1 hour per week
for 4 weeks. The researchers concluded that the telephone group formed a solid working bond, with the group dynamics and development being similar to FtF groups in terms of support given and received. They provide a detailed week-by-week analysis of the group sessions to support these claims but do not provide outcome data. The authors conclude that the telephone could be an excellent tool to bring together isolated individuals for short-term work. Finally, Grant, Elliott, Weaver, Bartolucci, and Giger (2002) investigated the usefulness of telephone interventions to train family caregivers of stroke survivors in problem-solving skills, which are derived from the field of counseling psychology (Heppner, 1978). In the Grant et al. study, 74 stroke survivors and their primary caregivers participated in an initial 3-hour visit from a nurse and in ongoing telephone calls during the following 3 months. The comparison groups were a control group and a sham-intervention group. The sham intervention consisted of the same amount of telephone contacts from a graduate research assistant who was blind to the purpose of the experiment. Instead of supplying treatment through the telephone contacts, only information about health services received by the stroke survivors was logged during the phone calls. Compared with the sham-intervention and control groups, the family caregivers who participated in the telephone intervention had better problem-solving skills, greater preparedness, less depression, and significant differences in vitality, social functioning, and mental health as measured by a variety of instruments, including the Medical Outcomes Study Short Form Health Survey and the 20-item Center for Epidemiological Studies Depression Scale (Radloff, 1977). The researchers stated that telephone interventions designed to teach problem-solving skills may be useful for family caregivers of stroke survivors. In a response to this study, Friedman and Grant (2003) stated that it was the flexibility in scheduling that may have been one of the main reasons for the interventions success. Fostering Client Strength, Resilience, and Wellness Lester (1974) suggested that the unique qualities of telephone therapy, including the clients ability to control the pace of treatment and to remain anonymous, may allow individuals who would not otherwise seek treatment to feel more comfortable. Williams (1971), however, suggested that anonymity could be a disadvantage because the communication may become devoid of personality. In addition, anonymous callers may not be able to benefit from interventions that require the counseling psychologist to know their identity, such as involving local police and crisis intervention services. Lester (2002) countered that personality is not lost and that we know today that one of the main applications of the telephone is, in fact, the crisis hotline. Crisis tele-
phone lines are common and can be found in most phonebooks or directories. Hotlines are a help-seeking service that adheres to the central counseling psychology principles of support, prevention, and wellness (Conyne, 1987; Gelso & Fretz, 2000; Kiselica & Look, 1993; Myers, 1992; Vera & Reese, 2000). As such, counseling psychologists often rely on telephone crisis interventions in their practices and refer clients to 24-hour hotlines that provide services when others are not available. The telephones usefulness in fostering resilience and wellness has also been discussed with regard to whether telephone counseling is useful for only short-term crisis work or whether a meaningful long-term therapeutic relationship is possible. For example, Spiro and Devenis (1991) discussed the possibility of conducting long-term psychodynamic psychotherapy through a telephone. They present a single case illustration of an 18-year-old female. They state that the client experienced greater equality in the sessions because the power differential was diminished, which resulted in increased intimacy and presence during the sessions. In a recent study, Donnelly et al. (2000) presented findings from a pilot study in which 14 cancer patients were provided long-term interpersonal psychotherapy by telephone. The small sample size eliminated the possibility of pretest and posttest analysis, but participants responded to the program with ratings of excellent or good, indicating that they perceived the experience to be beneficial. Prevention, Consultation, and Increased Access to Services The possibility of increased access is another main issue that telephone counseling has raised. Distance-communication counseling may be used to reach individuals who otherwise could not be reached or would not come to an FtF session. As already mentioned, counseling psychologists use crisis phone lines and other hotlines to make services available when they are out of the office. Ranan and Blodgett (1983) also provided two case examples to illustrate the potential of the telephone to deliver long-term therapy. They focused on reaching unreachable clients, such as those who are paranoid, phobic, or borderline. In a related study, Shepard (1987) followed the experience of two women who received telephone therapy for more than 1 year and hypothesized that the telephone may make therapy possible for some clients who are isolated or might not otherwise pursue treatment. Specifically, Shepard suggested several potential benefits of working with clients through the telephone including lower costs, increased convenience, and perhaps a greater sense of control on the clients part. As such, Shepard suggested that the telephone could be a catalyst for individuals to seek treatment if they are unwilling or incapable of attending FtF sessions.
Summary of the Telephone-Counseling Literature It is apparent that researchers have used the telephone for goals such as outreach, prevention, short-term treatment, and relapse prevention, all important enterprises and initiatives in counseling psychology. Thus, it seems promising for future research on new modes of treatment to consider and use the previous research on telephone interventions. Counseling psychologists can build from this work and use these studies to guide their research methods and design. Telephone services are effective for certain populations, including those looking to learn specific skills and those having a strong desire to commit to change. Yet, despite some evidence of telephone counselings usefulness, it is important to emphasize that the services have not replaced (or threatened to replace) traditional FtF meetings with trained professionals. Practitioners and researchers have combined modes of treatment in attempts to offer new or extended forms of therapeutic services. Similarly, it is our perspective that the development and the potential rise in popularity of online counseling do not signal the end of FtF counseling but create opportunities for new forms of communication to supplement mental and behavioral health services. Yet, as is reviewed in this article, the studies analyzing these distance-communication technologies suffer from small sample sizes and an overreliance on case studies, limiting the generalizability of the findings. Therefore, as with any new intervention, it is important to continue to conduct studies to investigate new modes of service delivery. Most important, for this discussion, the line of research and debate regarding the telephones usefulness for counseling services has a striking resemblance to the issues presently being discussed pertaining to online-counseling services. The discussion of the telephone-counseling literature offers a historical context for current efforts to analyze the suitability of online counseling for a wide variety of mental and behavioral health treatments. The onlinecounseling literature is currently progressing through similar questions, although at a very early stage. Counseling psychologists can rely on this background as they research new modes of technology, such as asynchronous e-mail, synchronous chat, and videoconferencing. Counseling psychology can examine whether computer-mediated communication (CMC) services reach new populations that would be unwilling or unable to pursue FtF treatments. This could be approached in several ways. First, counseling psychologists providing mental and behavioral health services online can evaluate whether their clientele consists of individuals who would normally avoid FtF treatments. Second, researchers can determine whether typically underserved populations, such as prison inmates, individuals with physical disabilities, and those residing in rural areas, are
more likely to obtain mental and behavioral health services through CMC. Third, researchers could implement experiments that compare FtF and online counseling for specific populations, such as international students or students of color on college and university campuses. Researchers could then compare FtF and online services to determine if students of color favor one mode of treatment over the other. Counseling psychologists have a clear understanding about populations that are underutilizing mental and behavioral health services and can analyze if online counseling could be beneficial for clients who are not using FtF services. Next, we discuss newer forms of technology and how they have been used to provide mental health and behavioral services.
COMPUTER-MEDIATED COMMUNICATION IN COUNSELING The following review of the online-counseling literature includes all known, relevant, published articles or chapters in professional journals through December 2004. Dissertations and online journals without a peerreview process were not included; however, because the online-counseling field is in its infancy, all other published articles were included. As detailed in the previous article, there have been numerous terms used to describe online counseling, but there has not been a clear set of terms associated with the new modes of service delivery (Mallen & Vogel, 2005). Therefore, we used PsychINFO to search for the following keywords: online, Internet, computermediated communication, counseling, treatment, and therapy. We also found studies by reading articles on online counseling and by searching references to ensure that studies were not overlooked. We used studies that examined mental and behavioral services with some form of communication between a therapist and a client, including those related to online support groups, as they are applicable to counseling psychologists even though they do not always include communication with a therapist. The search results yielded 27 studies, which were both favorable and unfavorable regarding online counselings effectiveness. The appendix lists these articles and summarizes the current findings related to online counseling. Below, we provide a review of the research relevant to online counseling and attempt to connect the literature to a counseling psychology framework. Specifically, we have organized studies into topic areas that concern the field of counseling psychology, and we highlight gaps in the literature. First, we discuss studies that have investigated how individuals use CMC to gain support. We review these studies because they evaluate CMCs potential to facilitate emotional responses and a sense of alliance among group members. Second, we discuss studies that have assessed client and clinician satisfaction
with new modes of service delivery to demonstrate the current research on how readily clients and professionals accept these treatments. Third, we review process research from online-counseling studies to discuss the unique issues of delivering mental and behavioral health services without both parties being together in an FtF environment. Fourth, we review outcome research from online-counseling studies to present what is empirically known about the effectiveness of new modes of treatment. Last, we discuss studies related to multiculturalism and access to new treatment modalities to explore how online mental and behavioral health services may be extended to new populations. These sections are organized to guide the reader through important components of the online-counseling literature and to connect current findings to core themes of counseling psychology. We then evaluate this literature from a counseling psychology perspective and discuss the conclusions and gaps in the literature from this perspective. The innovations of computer technology led to several new forms of communication, all with implications and applicability for the counseling and psychotherapy practices. CMC began to gain momentum in the 1960s and can be defined as any type of communication between two or more individuals facilitated by computer hardware or software, with e-mail being the most common form (Kraut, Mukhopadhyay, Szczypula, Kiesler, & Scherlis, 1999; Walther & DAddario, 2001). Current examples of CMC include sending an e-mail to a family member, posting a message on a professional listserv or bulletin board, having a conversation with a friend in a chat room, or using a videophone and webcam to send pictures and sounds to a friend. The first well-documented example of a computer programs being used for therapeutic purposes was the software program ELIZA, originally designed as a language program (Weizenbaum, 1976). ELIZA was not strictly a form of CMC because it did not link two individuals together. Instead, it was designed to generate certain language patterns as a response to input from an individual. This commonly used language-generation program is noteworthy and closely associated with counseling psychology because it was meant to replicate a Rogerian therapists statements during an initial therapy session. The curious reader can interact with the original ELIZA program on several Web sites (e.g., http://www.manifestation.com/neurotoys/ eliza.php3). Online Support GroupsDemonstrations of Empathy Counseling psychologists work to convey empathy and support to clients so that their strengths and coping abilities can flourish. Consistent with this notion, some researchers have suggested that one of the Internets main benefits is that it is a way for individuals to connect with others and to gain support
and information (e.g., Barak, 1999; Zelvin & Speyer, 2004). The Internet may be a way to receive social support particularly for individuals who feel isolated, leading them to find new ways to handle problems. However, the question is whether online counseling can effectively accommodate the communication of therapeutic empathy and support without both parties being present at the same location. The research has frequently investigated the use of online support groups and has typically found benefits for participants (e.g., Grohol, 2004; Mallen, 2004). Online support groups consist of messages on discussion boards available 24 hours a day, and these groups have been shown to yield benefits. Because these messages are available to anyone with access to the Internet, researchers have lurked on discussion boards to analyze their content. By lurking, the researchers do not participate in the group but are capable of reading each message that is posted. The ethics of such research are not yet clearly defined, as members of online support groups are not typically guaranteed privacy or confidentiality. Researchers interested in collecting data this way should be aware of potential ethical questions related to publishing data without the knowledge of participants. The following article (Mallen, Vogel, & Rochlen, 2005 [this issue]) elaborates on the numerous ethical issues of collecting data through CMC. Despite the controversy involved in lurking on online support groups to collect data for publication, the research exists and the results warrant review. To begin the review of the online-support-group literature, Braithwaite, Waldron, and Finn (1999) analyzed 1,472 social-support postings from 42 unique members of a computer bulletin board for persons with disabilities. Social-support messages were broadly defined and included any posting that offered caring, belonging, esteem, or assistance to the recipient. Messages were coded into five categories classified by Cutrona and Suhr (1992): information support, tangible assistance, esteem support, network support, and emotional support. Two independent coders were used to analyze the data, with interrater reliability of .76 after being corrected for chance agreement. The results found that the most common form of support that members of the bulletin board offered was emotional support (40%), which was often in the form of understanding or empathy, encouragement, or physical affection. An example of this emotional support is a message responding to a members recent discouraging round of physical therapy: I know! I just got my first symptoms on July 22nd and I still have problems when I move in certain ways (Braithwaite, Waldron, & Finn, 1999, p. 137). In another study, Finn (1999) also investigated an online self-help group that focused on disability issues. The researcher analyzed 718 messages from 42 unique users in 33 states and developed 14 categories for the messages, derived from the therapeutic self-help group mechanisms found in the group-
work literature (e.g., Katz & Maida, 1990) and from the social-support categories that Cutrona and Suhr (1992) developed. Two research assistants coded the messages and reported a mean agreement of .82. Messages categorized as providing support and empathy (21.2%), providing information (15.3%), being devoted to problem solving (14.4%), and involving expressions of feelings or catharsis (12.3%) were the most common on the bulletin board. Although the authors coded the messages into categories, it is unknown whether group members themselves perceived the messages as being emotionally supportive; however, messages on the bulletin board would often be posted in sequence, and the recipients response would confirm that he or she felt supported. Future research should not only look to categorize messages posted on these types of computer bulletin boards but also strive to obtain outcome data from the participants to determine how they perceive the conveyed support and whether it is effective. Sharf (1997) analyzed messages posted to a listserv titled the Breast Cancer List. Listservs differ from computer bulletin boards in that an individual needs to subscribe to receive messages. Anyone who finds the Web page hosting the messages can typically access bulletin boards. The exact membership of the group is continuously in flux because individuals can continuously subscribe and unsubscribe to the board. At the time of the study, the author reported that membership exceeded 825 participants, most of whom resided in the United States or Canada. The author became a lurker on the listserv, meaning that she did not actively participate in sending messages but viewed messages sent by others. Similar to other findings on online support groups, she identified three main categories of messages: information, social support, and personal empowerment. Another study investigated an e-mail group of parents with autistic children (Huws, Jones, & Ingledew, 2001). An analysis of more than 6,000 messages over a 3-month period, using the qualitative data-analysis package QSR Nudist (Gahan & Hannibal, 1998), indicated that chat-group participants were able to convey and gain a sense of interpersonal warmth by using the CMC. The core category that emerged from analyzing the messages was making sense of autism, which was composed of messages related to searching for meaning, adjusting to changes, providing support and encouragement, and sharing experiences narratively. Similarly, Winzelberg (1997) focused on an electronic support group for individuals with eating disorders. Two independent raters analyzed the content of 306 messages and coded it into four categories: searching for meaning, adjusting to changes, providing support and encouragement, and sharing experiences narratively. Members of the group were found to use similar helping strategies to those employed in FtF groups. The members provided emotional support, information, and feedback.
Finally, Bresnahan and Murray-Johnson (2002) analyzed more than 2,000 messages from an asynchronous womens health discussion group, which focused on menopausal issues. The authors provide several examples of participants commenting on the social support they received from the discussion group. One woman wrote, I know where you are coming from and I have a lot of empathy for you. It was really hard for my head to adjust to my changing body. I think informing yourself, being active, laughing, being positive and having support groups like this one really helps (Bresnahan & Murray-Johnson, 2002, p. 405). The authors concluded that participating in an online support group could result in feeling supported and developing a sense of community with other group members. One of the problems with these previous studies is that they have not included the guidance or support of a counseling psychologist or another type of trained practitioner. A professional can prevent some of the negative consequences of online support groups, such as proliferation of misinformation, conflict among group members, and possible development of Internet addiction (see Young, 1996; Young & Rogers, 1998). Hsiung (2000), however, studied an online self-help group that was monitored by a mental health professional. In an 8-month period, the Psycho-Babble group (http://www .dr-bob.org/babble) had more than 20,000 messages posted (an average of 94 per day) by more than 1,500 members. Members of the message board indicated that the forum was effective in their efforts to educate themselves about various mental health and behavioral issues, as well as to gain support. An examination of more than 20,000 messages also provided evidence that the group was effective in terms of participants giving and gaining support for their mental health issues. The study analyzed examples of messages and grouped them into categories, such as education, support, and feedback. Summary of the Online-Support-Group Literature Importantly, the studies of online support groups have not tested the effectiveness of online counseling directly; however, they provide some evidence that individuals can receive general support over the Internet. They also demonstrate that consumers are willing to seek help in an online environment, and online support groups may be a first step toward change for many people (Grohol, 2004). Of course, there are several limitations with studies of this type. First, the voyeuristic nature of the group examination does not allow the research to confirm whether the participants of the online support groups intended or interpreted the categories that emerged in the messages in the same way. Second, because the individuals in the message group are not knowingly participating in a research study, it is impossible to obtain outcome or follow-up data other than what is available in the online messages. It
may be that individuals who are comfortable with online communication gravitate to this form of support, and it may be that these groups are not beneficial to the entire population. Online counseling is not unique in this respect because FtF services are not uniformly effective for everyone and one size does not fit all. Initial evidence indicates that members of online support groups can convey empathy through text-based CMC, which has implications for counseling psychologists interested in researching or practicing online counseling. Future research should examine if empathy from a counseling psychologist can be effectively conveyed and perceived through online-counseling environments and if this therapeutic alliance translates to positive outcomes, including reductions in client symptoms and positive behavioral changes. It may also be valuable to assess how empathy and support are experienced when delivered by peers instead of professionals, including differences in the ability to communicate empathy and support across various training levels among professionals. Satisfaction and Acceptance of Services Traditionally, outcome research on a new intervention is conducted by comparing the new treatment to a no-treatment control or to an established intervention. Thus, online counselings effectiveness is established by comparing the relative changes in client symptoms after participation in online counseling with the relative changes in those not treated or treated in FtF counseling. However, it also important to measure clients satisfaction because they are ultimately the ones who do or do not benefit from the services that counseling psychologists provide. Seligmans (1995) CR study, for example, gathered nearly 3,000 participants to respond to 26 questions, which focused on the participants experiences with mental health professionals. These questions were organized into three subscales: specific improvement, satisfaction, and global improvement. Overall, participants reported that treatment from a mental health professional resulted in feeling better. Counseling psychologists attempts to investigate online counseling should include efficacy and satisfaction measures to develop a more complete understanding of online counselings potential effectiveness. Several studies have examined client satisfaction with CMC services. In one of the first studies on distance technologies, videoconferencing was examined as a potential way for professionals to work with psychiatric patients (Dongier, Tempier, Lalinec-Michaud, & Meuneir, 1986). In this study, 50 patients underwent a closed-circuit TV (CCTV) interview and were compared with 35 matched controls who received an FtF interview, which a psychiatrist conducted for the purposes of consultation on diagnosis, treat-
ment planning, and case management. All of the patients were asked to rate various aspects of the interview, such as feeling at ease during the interview, ability to express themselves, quality of interpersonal relationship, and utility of the assessment interview. No significant differences were found in patients satisfaction ratings between the CCTV (videoconference) and the FtF condition; however, the psychiatrists or consultants rated the CCTV condition as significantly inferior in usefulness of the interview. The local staff or consultees also rated the CCTV interview as significantly inferior to the control interview in terms of global assessment and diagnosis. The authors interpreted the results as demonstrating that professionals, such as counseling psychologists, may be more critical of new modes of treatment and service delivery than clients are. Meanwhile, patients responded to the CCTV interviews in a similar fashion to patients in a matched FtF control group, indicating that patients were equally satisfied with the new mode of treatment. Stevens, Doidge, Goldbloom, Voore, and Farewell (1999) analyzed general psychiatric assessments conducted by psychiatrists through either FtF or videoconferencing conditions. First, 40 clients were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) and randomly assigned to an FtF or a videoconferencing condition. Five psychiatrists, blind to the initial diagnosis, performed the assessments. Clients and psychiatrists were asked to complete the California Psychotherapy Alliance Scale (Marmar, Horowitz, Weiss, & Marziali, 1986) and the Interview Satisfaction Scale, a 12-item measure developed by the authors. No significant differences were found between the FtF and the videoconferencing conditions for the client or psychiatrist on the California Psychotherapy Alliance Scale or for the client on the Interview Satisfaction Scale. A significant difference was found on the Interview Satisfaction Scale, with psychiatrists reporting less satisfaction in the videoconferencing group than in the FtF group. Videoconference technology has also been used to conduct neuropsychological assessment interviews. Schopp, Johnstone, and Merrell (2000) randomly assigned 98 participants with a wide range of neuropsychological problems to two modes of evaluation: videoconferencing or FtF interaction. The study used nine interviewers, including four neuropsychologists, three neuropsychology postdoctoral fellows, and two neuropsychology interns. Interviewers and clients rated their satisfaction, how relaxed or stressed they felt, their ease of communication, how caring they perceived the interviewer to be, and whether they would repeat the experience. No significant differences were found between the conditions on measures of client satisfaction, ease of communication, and level of relaxation during the interview. In fact, clients in this study reported a greater willingness to repeat the experience in
the videoconferencing condition than in the FtF condition; however, interviewers expressed significantly lower satisfaction with the videoconferencing condition than with the FtF condition. In another example, correctional psychologists used videoconferencing technology to consult with prison inmates. On a six-item questionnaire developed by the authors (Magaletta, Fagan, & Peyrot, 2000), 75 inmates reported that they were satisfied with various aspects of the online-consultation process and were willing to return for a follow-up to the consultation. Furthermore, inmates with severer pathologies still reported that they were satisfied with the process, although some problems did arise when inmates became angry or frustrated. At times, the early signs of frustration and anger were not readily apparent to the psychiatrist because of the technologys slow transmission speed and low resolution. The authors stressed the importance of audio quality during videoconferencing sessions and suggested that future research and practice should use more advanced technologies. A limitation of this study is that the authors did not evaluate the psychologists attitudes. As previously mentioned, psychologists attitudes and satisfaction with online modes of treatment may not be as forgiving as clients, and this disparity may lead to negative therapeutic outcomes in long-term treatment. Also, the authors acknowledged that the six-item measure they created for the study was too simplistic. Future research should use more rigorous measures to evaluate the overall satisfaction with online modes of treatment. These studies show a similarity between the satisfaction ratings of participants in videoconferencing versus FtF sessions. Videoconferencing, where one can see and hear the other person, is more similar to FtF than are other forms of CMC that rely on synchronous chat. The studies looking at textbased online counseling have yielded mixed results. For example, two studies have examined member satisfaction with online group counseling and found different results. Meier (2000) investigated an online support group for job-related stress. The group members (52 masters-level social workers) reported a high level of satisfaction with the overall experience in the group, the group leaders presence, and the range of topics discussed during the group. These variables were assessed by an 83-item satisfaction survey designed by the author. Members also commented that they enjoyed the convenience and privacy of being able to participate from home. Although group members reported high levels of satisfaction, they did not demonstrate changes in levels of stress, which indicates that client satisfaction may not be associated with a reduction in symptoms. The author noted that most of the sample (95%) reported having good to excellent computer and Internet skills, perhaps contributing to their acceptance of the online group. Sander (1996) examined couples group therapy, which shifted from sessions held in an office to sessions conducted from home through synchro-
nous chat. The shift in the mode of treatment was initiated after several couples could not attend FtF sessions because of child care conflicts. The study participants reported less satisfaction with the chat sessions compared with their previous FtF encounters, suggesting that clients from an established FtF setting could downgrade the quality of the relationships when placed into an online environment. The therapist also expressed his frustration with the textbased mode of treatment, which may have been communicated to the clients, perhaps making them more negative about the process. The author acknowledges that clumsiness and disjointedness characterized his efforts to transport his FtF counseling group to an online environment (Sander, 1996, p. 309). Although the report is mostly negative in terms of the usefulness of online couples group therapy, the author predicted that as technology advances, the practice of online mental and behavioral health services will likely increase and become less cumbersome. In line with the previous study, Rochlen, Beretvas, and Zack (2004) suggested that when presented with a choice, people might prefer FtF treatments. In an instrument-development project of comparable measures of online- and FtF-counseling attitudes, it was found that participants expressed more favorable attitudes toward FtF counseling than online counseling in regard to perceived value and discomfort level. The primary limitation is that it was an attitude-comparison study, and attitudes might be based on familiarity and expectations, particularly because these were general college students and not actual clients or individuals experiencing distress. Yet the research finding suggests that the implementation of online-counseling services may need to pay particular attention to potential client attitudes and comfort levels with computers and distance communication. This study merits mention because it assesses potential clients interest level in online counseling. The research could be considered a preprocess study because it measures attitudes and expectations about treatment. The study also serves as a bridge to begin discussing the literature that has investigated the process of online counseling. Summary of the Satisfaction and Acceptance Literature Thus far, research has demonstrated that according to clientsself-reports, they perceive forms of online counseling as satisfactory and useful. It appears that professionals are less likely to accept new modes of treatment. Professionals may not accept new modes of treatment because they possess knowledge and training in the effectiveness of traditional treatments; however, Day and Schneider (2000) found that over time, therapists comfort level increased with counseling delivered through videoconferencing. Clients, on the other hand, may simply appreciate the services provided and may not scrutinize
outcomes in a similar manner as professionals. Research should investigate the possible disparity between clients desire for and acceptance of online counseling and professionals lack of acceptance of online counseling. Process, Interventions, and Working Alliance While some studies have started to examine the outcomes of online counseling, fewer have attempted to measure process variables. This is an important omission as one of the most significant challenges for online counseling is whether it is possible to meaningfully connect with a client through distance-communication technologies. Without the benefit of contextual and nonverbal cues, the therapeutic alliance might be significantly hampered, and because the client and the counseling psychologist are not in the same location, it might be difficult to really explore the person-environment interactions. This could be problematic as the therapeutic alliance is one of the critical factors related to counselings efficacy (Gaston, Piper, Debbane, Bienvenu, & Garant, 1994; Gelso & Carter, 1994; Hartley & Strupp, 1983; Horvath & Luborsky, 1993; Krupnick et al., 1996; Robbins, 1992; Wampold, 2000), and if a therapeutic alliance cannot be formed through CMC, then online counseling is unlikely to be efficacious for most clients. Yet only three studies have attempted to examine the type of relationship or therapeutic alliance that can be formed during online counseling. They have produced mixed results. In a Hufford, Glueckauf, and Webb (1999) study, in which they compared videoconferencing with FtF counseling for families with epileptic teens, the teens in the videoconference condition reported significantly lower alliance levels than did those in the FtF condition. This is interesting because we may expect that younger individuals more readily accept new technologies. In turn, though, participants in a study by Cohen and Kerr (1998) provided similar ratings between the CMC and the FtF condition regarding the therapists expertness, attractiveness, and trustworthiness as measured by the Counselor Rating Form (Barak & LaCrosse, 1975). These findings are notable given possible concerns that clients in the CMC would rate their counselors lower due to lack of visual or nonverbal cues to use in their judgments. Participants also responded to the Session Evaluation Questionnaire (Stiles & Snow, 1984) to rate the depth, smoothness, positivity, and arousal of the counseling sessions. Participants expressed higher levels of arousal in the FtF condition, and there were no other significant differences between groups. Other research has shown that a working alliance can be adequately established during online counseling (Cook & Doyle, 2002). Cook and Doyle (2002) compared differences in the ratings of the working alliance from 15 online therapy clients with normative data from a comparable FtF-counseling
sample. The participants completed at least three counseling sessions, which were conducted through either asynchronous e-mail or synchronous chat. The findings were that clients participated more in the distance modes and had equivalent working alliances with their counselors as measured by the Working Alliance Inventory (Horvath & Greenberg, 1989). This study is limited because it did not have a strict FtF comparison group and was composed of a small sample. Future studies should include larger participant samples and randomly assign participants to an online, FtF, or control group. Studies of this type will give the counseling psychology field more specific answers on the process and outcome of online counseling. The process of online counseling needs to be further explored in future research. For example, it would be useful to directly examine how the absence of verbal and nonverbal cues, such as speech, clothing, skin color, and appearance, changes the dynamics of the session (Mallen, 2004). Clients might dislike the treatment because therapists miss important social and cultural aspects of the presenting problem and the relationship because only typewritten messages are transmitted during the sessions (Zelvin & Speyer, 2004). Culturally sensitive counseling psychologists may be able to inquire about these issues online in the same way as in FtF therapy; however, the potential for misunderstandings is present. One example of the potential for increased problems is that without the presence of nonverbal cues, the use of common stereotypes may be more likely. Preliminary research has found differences in the way therapists in training approach male and female clients. In a Mallen and Vogel (2002) study, therapists in training conducted an online session through synchronous chat with a client who they thought was genuine; the client was a confederate. Information about the clients background and presenting issues was standardized so that each therapist in training met with the same client. The only difference was that therapists in training were randomly assigned to have a male client or a female client, while the rest of the identifying information was kept constant. The therapists in training reported being significantly more satisfied with the female client and assessed the male client as being significantly more hostile and proud. With the lack of nonverbal cues, counseling psychologists and their clients may fill in the blanks with stereotypes or idealized versions of their online partners. Future research should investigate the likelihood and implications of this process. Future research may also need to further examine the types of messages exchanged in online counseling. One previously mentioned study (Meier, 2000), which investigated the feasibility of an online support group for practicing masters-level social workers to discuss job-related stress, also started to examine specific process variables that occur among members of an online group. Qualitative analysis of 209 comments made by members throughout
the life of the group found that 54% of the comments offered emotional support and validation, 29% expressed encouragement, and 17% offered information advice. Although the listserv could have stunted emotional communication and led to a question-answer cycle, members of the group mainly chose to offer emotional support to other group members. But we know little about what transpired between counselors and clients. One way that counseling psychologists can directly examine the process variables of online counseling would be to analyze online-counseling sessions with the Counselor Response System and Client Behavior System (Hill, 1978; Hill & OBrien, 1999). Investigations into the online-counseling process should use these classification systems to code the interventions used by therapists and the responses offered by clients during online-counseling sessions. Researchers could compare therapist intervention tendencies and styles, along with client responses, across different modes of service delivery to determine if there are differences between forms of online counseling (i.e., asynchronous e-mail, synchronous chat, and videoconference). Such analyses would go a long way in furthering our understanding of what happens during online counseling. Summary of the Process, Interventions, and Working-Alliance Literature The current knowledge base concerning the process of online counseling is not extensive. Only a few studies have examined process variables through online interventions for mental and behavioral health issues, and these have demonstrated mixed results. For example, Cohen and Kerr (1998) and Cook and Doyle (2002) found no significant differences in reported therapeutic alliance between CMC and FtF interventions; however, Hufford et al. (1999) found that teenagers reported less therapeutic alliance in CMC compared with FtF. Given these mixed findings, future research needs to build on these studies and further examine the process variables in online counseling. Online-Counseling Outcome Studies The main goal of counseling is to alleviate the distress, anxiety, or concerns experienced by a client when he or she enters therapy. Counseling psychologists also focus on building on a clients strength to improve overall functioning. As a result, it is important to directly examine whether online counseling is effective. In our review of the literature, we found several studies that have directly examined the effectiveness of CMC technologies such as synchronous chat, asynchronous e-mail, and videoconferencing in deliv-
ering online-counseling and behavioral services. Cohen and Kerr (1998) assigned 24 undergraduate students to either one semistructured session of FtF counseling or one semistructured session of CMC counseling delivered through synchronous chat by a counseling psychology graduate student. Participants showed significant decreases in anxiety in both modes of treatment as measured by the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970), with no difference in the level of change in the two modes. These results provided some initial support for the use of CMC in delivering mental and behavioral health services, but it should be noted that individuals with severer presenting issues, such as major depression or substance abuse, were screened out of the study. It may be that the clients allowed to participate were experiencing very little distress before the study, and thus, CMC counseling may not have been as effective as FtF counseling for severer clients. The low number of clients used may have also limited the ability of the researchers to find significant differences. To address these issues, Day and Schneider (2002) randomly assigned 80 clients, who volunteered to participate through numerous media and referral sources, to three modes of psychotherapy: FtF, videoconference, and twoway audio. They also used a wait-list group as a control condition. The clients presented a variety of issues, including weight issues and personality disorders. The most common problems the clients reported were body image or weight, family relationships, other relationships, and work or school. Before treatment, clients in each condition had similar averages on the Global Assessment of Functioning (GAF), with each groups having a mean GAF of either 69 or 70. The outcome measures included the Brief Symptom Inventory (Derogatis & Coons, 1993), GAF, Target Complaints method (Battle et al., 1966; Mintz & Kiesler, 1982), and modified versions of the Client and the Therapist Satisfaction Scales (Tracey & Dundon, 1988). The authors gave 16 doctoral students in a counseling psychology program training in cognitive-behavioral therapy but also flexibility to reproduce conditions similar to FtF-therapy relationships. A MANOVA comparing the treatment groups to the control groups on outcome measures demonstrated the effectiveness of treatment over the control condition. For example, after completing five sessions, clients in the treatment groups reported less severe target complaints and were assessed as having a higher GAF than those in the control group. The authors explored possible differences between the treatment groups with a MANOVA on this set of outcome measures and found no significant differences among the three modes of therapy. The authors reported that the similarities among the three treatment groupsface-to-face, video teleconference, and audio conferencecame through more strongly than any differences (Day & Schneider, 2002, p. 501).
In a series of studies (Glueckauf et al., 2002; Hufford et al., 1999; Liss, Glueckauf, & Ecklund-Johnson, 2002), Glueckauf and colleagues compared videoconferencing to FtF counseling for families with epileptic children. In one study, the authors randomly assigned 39 teenagers with seizure disorders and their parents from the rural Midwest to the following conditions: homebased family video counseling or audio counseling through speakerphone, traditional office-based family counseling, or wait-list control. The authors provided six sessions with an integrative family-therapy approach to the participants and collected data twice at 1 week and at 6 months after the conclusion of treatment. A total of 22 families completed the counseling program after 17 families dropped out early in the study; dropouts were usually in the office-counseling group, which required long-distance travel for the participants. The outcome measures used in the study were problem-specific scales from the Family and Disability Assessment System (FDAS; Glueckauf et al., 2002; Glueckauf, Whitton, & Nickelson, 2001) and the Social Skills Rating System (Gresham & Elliott, 1990). Process measures included a modified version of the Working Alliance Inventory (Horvath & Greenberg, 1989) and Homework Completion Ratings and Missed Appointments (Glueckauf et al., 2002). Across all treatment types, participants reported significant reductions in both severity and frequency of family problems as measured by the FDAS; mode of transmission did not affect the outcome of the treatment. The overall level of therapeutic alliance was moderately high across the three conditions, although teens perceptions of this alliance were significantly higher in the office condition than in the videoconferencing condition; parents did not report significant differences in the alliance. Also, no significant differences were found between groups on measures of treatment adherence. This study demonstrates videoconferencings usefulness in providing services to clients. These results are limited in their applicability to the most common types of online counseling (i.e., asynchronous e-mail and synchronous chat) in which messages are typed back and forth between the client and the therapist. Text-based modes of counseling do not allow as much information to be transmitted between parties, and future research should examine the differences between these modes of service delivery. Wright and Chung (2001), in a review of literature related to therapeutic writing, suggested that therapeutic writing has been beneficial for those who perceive themselves to be powerless, who are not using their first language in FtF therapy, who are silenced by shame or other inhibiting emotions and feel unable to speak, who need to disclose stressful or traumatic events, and who are at particular stages of life (e.g., adolescents, hospice-care patients) associated with experiencing strong feelings. Because text-based online counseling includes written communication, this review is relevant to the likely
effectiveness of services provided through asynchronous e-mail and synchronous chat. Online counseling may be able to work by using this type of writing component. Directly examining the effects of writing through a computer, Lange, van de Ven, Schrieken, and Emmelkamp (2001) randomly assigned 25 undergraduate students who were experiencing post-traumatic stress to either a computer-based treatment group or a wait-list control condition. The computer-based treatment was composed of biweekly writing sessions over 10 weeks. During the 45-minute writing exercises, one of seven clinical psychology graduate students responded to peoples writings halfway through the sessions to give them feedback about their progress and instructions on how to proceed. These graduate students followed advanced courses in behavioral and cognitive psychotherapy, received special training in applying writing assignments in the treatment of post-traumatic stress and pathological grief, and were closely supervised during each phase of treatment. Results from the study demonstrated that the participants in the computerbased writing treatment showed larger reductions in post-traumatic stress symptoms than did control-group participants The control group was not kept waiting until the treatment group had completed the follow-up but received treatment directly after the experimental group had terminated treatment. These reductions in stress symptoms were measured by the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979); the anxiety, depression somatization, and sleeping problems subscales of the Symptom Checklist 90 (SCL-90; Derogatis, 1977); and the Profile of Mood States (Wald & Mellenbergh, 1990). These results remained stable 6 weeks after the treatments conclusion. Limitations of the study include the fact that the participants were college students who received extra credit for their participation. As a result, the findings may not be generalizable to general or clinical populations. Although there was a follow-up at 6 weeks, future research should evaluate the effects of online counseling over a longer period to determine the long-term effects. Two other studies, generating mixed results, have also examined the effectiveness of online counseling for group work. Meier (2000) investigated the effectiveness of an online support group for practicing masters-level social workers to discuss job-related stress. For the online-intervention group, Meier randomly assigned 52 participants to a discussion listserv or a notreatment control group. Participants completed the standardized Occupational Stress Inventory (Osipow & Spokane, 1987) before and after the intervention. A group leader facilitated the discussions, which included encouraging members to explore their work-related stress in more depth, raising new concerns, and trying to enhance the experience for the members to
increase their satisfaction with the group. While members of the group expressed satisfaction with the experience, they did not show any significant changes in their levels of occupational stress, psychological strain, or coping resources. The authors suggested that the small sample size and weak intervention (Meier, 2000, p. 259) did not allow for the detection of differences. In addition, the participants may have only been experiencing mild levels of stress. In turn, however, Hopps, Pepin, and Boisvert (2003) found evidence for the potential usefulness of goal-oriented, cognitive-behavioral therapy delivered through synchronous chat to 19 individuals with chronic physical disabilities in Canada. Using a pretest-posttest design with a wait-list control group, the authors found that participants reported less loneliness at posttest than the control group. In the study, loneliness was measured by a French translation of the University of California at Los Angeles Loneliness Scale (Russell, Peplau, & Cutrona, 1980), Emotional Versus Social Loneliness questionnaire (Russell, Cutrona, Rose, & Yurko, 1984), and personal definitions of loneliness. The participants maintained the reduction in loneliness at a 4-month follow-up. A main limitation of the study, noted by the authors, is that the sample was relatively homogeneous and may not represent all people with physical disabilities. Specifically, participants were most likely more educated, independent, and less impaired than the general population of individuals with physical disabilities. In addition to this limitation, the sample size was very small: Groups were composed of only 9 or 10 participants. Summary of the Outcome Literature The findings from studies that have evaluated the outcomes of online counseling have been mostly positive, generally reporting significant client improvement (Cohen & Kerr, 1998; Day & Schneider, 2002; Glueckauf et al., 2002; Hopps et al., 2003; Lange et al., 2001). Taken as a whole, these studies provide preliminary evidence that online modes of counseling can be effective in reducing clients presenting problems. As a result, these findings provide the foundation for future research to determine whether online counseling is a useful treatment option for counseling psychologists and their clientele. Multiculturalism and Access to Services Online counseling may be useful for reaching persons of color, who have typically underutilized FtF mental and behavioral health services. For example, research has demonstrated that Asian Americans underutilize counseling
services (Matsuoka, Breaux, & Ryujin, 1997; S. Sue, Fujino, Hu, Takeuchi, & Zane, 1991), are more likely to prematurely terminate psychotherapy (OSullivan, Peterson, Cox, & Kirkeby, 1989), and are less likely to disclose emotional and interpersonal issues (Tracey, Leong, & Glidden, 1986) when compared with European Americans. It is unknown at this point if online counseling would be effective in bringing persons of color to therapy because research has been so sparse in this area, but counseling psychologists can use their expertise to answer this question. A potential problem associated with online counseling is that those who might benefit most from its services may be without access to CMC. One such population is African Americans, who have an elevated rate for several stress-related diseases and must overcome the negative influence of racism (Utsey, Bolden, & Brown, 2001). One reason that African Americans have less access to CMC is their poverty rate, nearly 3 times as high as White Americans (D. W. Sue & Sue, 1999). These statistics demonstrate that African Americans are a population that would potentially benefit from new modes of mental and behavioral health delivery, although they may not have the tools to access these services. Online counseling may be useful for African American clients, who sometimes display a differential response according to the individuals race with whom they are communicating. In text-based online counseling (e.g., asynchronous e-mail and synchronous chat), obvious differences in race, such as skin color and speech, are not visible, and the therapists racial anonymity may allow clients to be more natural during online sessions. It should be emphasized that this is a tentative and speculative assumption that warrants further empirical investigation. Another issue with extending services to African Americans is their traditionally negative view of mental and behavioral health services, which may be a response to their mistrust of American society (Vontress & Epp, 1997). There is currently no research that has investigated if African Americans would feel more comfortable meeting online with a therapist, but counseling psychologists are in a unique position to begin addressing these and other questions. Other populations underserved by traditional FtF mental and behavioral health services are Latinos and Hispanics. They are also overrepresented among the poor and have high unemployment rates. This is witnessed by a discrepancy between the annual income and the poverty rates between Hispanics and White Americans, with Hispanics earning a smaller salary and living in poverty more often (D. W. Sue & Sue, 1999). A challenge facing Hispanics interested in mental and behavioral health services is that few counseling psychologists are bilingual, presenting a hurdle for those who speak English as a second language. A potential of online counseling is that therapists who can speak two or more languages can extend their services through distance-
communication technologies to populations that need their expertise and multilingual abilities. Potential obstacles for online counseling to be effective with Latinos and Hispanics may include limited access to CMC technologies, language proficiency, and uncertainty about or distrust of the new mode of service delivery. D. W. Sue and Sue (1999) recommended that therapists should carefully explain the roles of client and therapist in counseling and discuss the goals for the counseling relationship. The explanation of services, roles, and goals may take on greater importance in online-counseling relationships, as contextual cues are lost when parties are in different locations. One population that has been studied is Asian Americans. Chang, Yeh, and Krumboltz (2001) randomly assigned 32 Asian American male undergraduate students to either an online treatment group or a no-treatment control condition. The online treatment group was composed of 16 participants and was moderated by a clinical psychology doctoral student who was supervised by a licensed psychologist. The results indicate that the online support group was a viable means of providing support to Asian American male students. The participants found the service to be convenient and posted the majority of their messages (75%) in the evening or early morning hours between 5 p.m. and 9 a.m. This finding lends more support to the notion that online services may be an attractive option for individuals who need services outside the normal business hours of 9 a.m. to 5 p.m. The authors state that online support groups moderated by counseling psychologists may be an option for university counseling centers to provide new means of outreach services. Specifically, these services could target persons of color who may underutilize mental health services, and counseling psychologists have been committed to ensuring that they extend their services to individuals from minority cultural groups. Shernoff (2000) detailed his use of the Internet to provide therapeutic services to lesbian, gay, bisexual, and transgendered (LGBT) clients. The article does not present empirical data to support the effectiveness of the services provided but provides anecdotal reports regarding the delivery of counseling services to LGBT clients. The author states that e-mail was incorporated into the FtF treatment for some of the clients who were highly anxious and desired additional contact between weekly sessions. The author also suggested that the Internet was beneficial for LGBT individuals who sought services online when feeling too stigmatized to seek out counseling or who were isolated in remote areas. Although the article does not present empirical data, it is an interesting commentary on how counseling services can be provided to a population that is at risk because of discrimination (DeAngelis, 2002). Finally, Rochlen, Land, and Wong (2004) investigated males attitudes toward cognitive- and emotions-based counseling vignettes from online and
FtF conditions. Overall, participants evaluations of online and FtF counseling were fairly positive and similar. However, there was some evidence suggesting that men with difficulty expressing their emotions responded more favorably to the online-counseling vignette as opposed to FtF counseling, indicating that online counseling may be useful in reaching out to males, who typically underutilize counseling services (see Addis & Mahalik, 2003). One of the primary goals of counseling psychology is to reach out to disenfranchised or underserved individuals (e.g., Brammer et al., 1988; Pearson, 2003). As access to distance-communication technology increases, online counseling may also provide a link to treatment for individuals who might otherwise avoid FtF treatments. For instance, some individuals may not seek assistance from an FtF therapist, out of concerns related to fear, stigma, availability, or convenience. The field of counseling psychology may be missing opportunities with these clients (Alleman, 2002; Barak, 1999; Kraus, Zack, & Stricker, 2004; Suler, 2000), and researchers may want to investigate whether online counseling can reach these populations. One of the shortcomings of the online-counseling literature is that most of the participants have been college aged and predominantly White. There has been little research including individuals from other cultural backgrounds. For instance, a 19-year-old gay teenager living in a rural town is likely to have few outlets for counseling services. The young man may not see the local therapist because of the stigma attached to receiving therapy or perhaps because of the therapists lack of experience with LGBT clients. Online counseling is an avenue for him to pursue services that he otherwise would not. A further discussion of the practical aspects of working with diverse clients can be found in the next article of the Major Contribution (Mallen et al., 2005). One of the most useful aspects of online counseling may be the ability to use new technologies to conduct assessments, evaluations, and therapy in remote locations and for individuals who might not otherwise be able to seek treatment. Reaching disenfranchised clients is one of counseling psychologys key tenets. By working with clients through CMC technologies, counseling psychologists may be able to extend their expertise to new areas that they could not reach without extensive travel. They could accomplish this through direct interventions with underserved clients or through a consultative role by offering advice to local physicians and therapists who may be struggling with a particular case. Clement, Brooks, Dean, and Galaz (2001), for example, described a neuropsychology clinic for Army personnel. For the purposes of conducting a screening interview, discussing the results of neuropsychological evaluation, and participating in ongoing psychotherapy, 32 patients were seen for 87 videoconferencing sessions. The authors
reported that the clinic was able to coordinate care easily with superiors, family members, and soldiers in the study because of the videoconferencing system. Similarly, in a previously discussed study (Winzelberg, 1997), which focused on an electronic support group for individuals with eating disorders, two thirds of the messages were posted between 6 p.m. and 7 a.m., which is a time when members would least be able to obtain support from FtF professionals. As a result, the members were able to receive support and information around the clock. Summary of the Multiculturalism and Access-to-Services Literature Currently, there have been limited efforts to systematically evaluate if online mental and behavioral health services are effective for clients from different cultural backgrounds or if the process and the outcome of these services are different from experiences in traditional FtF therapy. The studies reviewed offer preliminary support for the notion that online counseling may be useful for populations that underutilize clinical services, such as Asian Americans, men, and LGBT community members. Future research also could investigate online counselings ability to accommodate counseling psychologists focus on multiculturalism. Because nonverbal cues are lost in text-based communication, certain characteristics may be overlooked during the course of service delivery, and it will be important for future researchers to incorporate the study of this issue into their online-counseling investigations. Conversely, it may be beneficial for there not to be visual cues to race or ethnicity, equalizing the counseling situation (Day & Schneider, 2000). In fact, some researchers have suggested that distance technologies can lead to the clients experiencing greater equality in the sessions because the power differential is diminished. Yet these assertions need to be directly tested, and counseling psychologists should be actively involved in this process.
COUNSELING PSYCHOLOGY AND ONLINE COUNSELING CONCLUSIONS AND GAPS IN THE LITERATURE As the above literature review suggests, many unanswered questions regarding online counseling remain; however, the review does provide counseling psychologists with a basis of knowledge. For instance, studies of online support groups provide some evidence that individuals can receive and give general support over the Internet, and as demonstrated by client selfreports, research has also demonstrated that new modes of service delivery are perceived as satisfactory and useful; however, it appears that profession-
als are less likely to accept or be satisfied with these new modes of treatment. The literature related to process variables in online counseling is sparse, but the findings of studies evaluating the outcomes of online counseling have been mostly positive, reporting significant client improvement on a variety of outcome measures. These results provide preliminary evidence that online modes of counseling can be effective in reducing clients presenting problems and symptoms. Research has also offered preliminary support to the notion that online counseling may be useful for populations that underutilize clinical services, such as disabled or rural individuals. Furthering the quality and quantity of research in this area should provide critical information on both the positive and the negative aspects of online counseling. Limitations that exist in the literature at this point include the fact that many of the interventions detailed in the literature are limited in terms of time. Although counseling psychologists primarily focus on short-term interventions, the current literature does not allow for any type of long-term analysis of the outcome of mental and behavioral health services delivered by CMC technologies. At this point, research suggests some potential uses of online counseling but more is needed to directly examine differences across various process and outcome variables between FtF and online-counseling conditions. In addition, some potential limitations exist including issues related to the therapeutic alliance, who is most appropriate for online treatment, the ability to intervene during a crisis, and the lack of nonverbal cues. Future research efforts should investigate elements of process and outcome that have already been explored in FtF modes of treatment. Common factors of effective FtF counseling have been identified (Wampold, 2000), and these factors should be examined to see the degree to which they are present during an online-counseling session. Preliminary research has suggested that these important common factors can be achieved in online counseling (Cook & Doyle, 2002; Day & Schneider, 2002), but future research efforts are needed to continue studying the setting of online counseling, such as working with clients without the assistance of nonverbal cues and how it affects the process. For instance, research on the therapeutic alliance, the critical factor related to outcome in counseling (Bachelor, 1991; Eckert, 1993; Henry, Strupp, Schacht, & Gaston, 1994; Horvath & Symonds, 1991) is crucial. If a therapeutic alliance can be formed through CMC, then online counseling may likely be efficacious for certain clients. In an online environment, however, it will require researchers to determine the best way to measure a therapeutic alliance in the absence of traditional FtF cues. Because process and outcome research has a long history in the field of counseling psychology, it seems natural that counseling psychologists would be involved in evaluating new modes of treatment. In addition to measuring process and outcome vari-
ables from the clients perspective, it will also be important to measure therapists evaluation of online mental and behavioral health services. Research has demonstrated that therapists have been less favorable toward online services than have clients, and this dynamic should continue to be evaluated. Future research also needs to build on the existing literature on FtF counseling (see Heppner, Kivlighan, & Wampold [1992] for a discussion of research design in counseling). Analogue studies, for example, could be useful in comparing online counseling to FtF counseling to determine the effectiveness of the new mode of treatment. Before treatment begins, participants could be given pretests (e.g., Beck Depression Inventory; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) to assess baseline functioning. Subsequently, researchers could use process and outcome measures to determine significant differences between FtF and online counseling. For example, it would be useful to gauge clients responsiveness to treatment as well as the therapists attitudes to the new mode of treatment. An instrument used often in counseling research is the Counselor Rating Form (Barak & LaCrosse, 1975), which measures client perceptions of the therapist in terms of attractiveness, expertness, and trustworthiness. This type of study would provide the field with an indication of the benefits, risks, and effectiveness of online counseling in comparison to traditional FtF counseling. The advantages of analogue studies include increased experimental control, degree of specificity of operational definitions, and ability to isolate specific processes in the complex activity of counseling. Disadvantages include generalizability and external validity (Heppner et al., 1992). Analogue research can be beneficial because the increased experimental control can minimize potential ethical dilemmas related to online treatment (see Mallen & Vogel, 2002). Several areas of interest for counseling psychology specialists should be considered in future online-counseling research efforts. Areas of emphasis for counseling psychologists yet to be addressed in the literature are normal and developmental challenges or tasks, client strength and resilience, education and career development, and issues related to prevention, consultation, psychoeducation, and wellness. There are several gaps in the literature regarding these topics, and counseling psychologists can determine how online mental and behavioral health services might help or hinder these core components of the field. Normal and Developmental Challenges or Tasks Counseling psychology has focused on normal or developmental challenges and tasks with short-term interventions. The current literature review reveals numerous holes in the knowledge base regarding which specific pop-
ulations are best suited for specific online mental and behavioral health services. Counseling psychologists interested in delivering online mental and behavioral health services likely desire information about the types of clients that respond best to online treatments. Also, information detailing the most effective forms of online interventions would be helpful for professionals delivering these services. At this time, there is not enough research to make firm and specific conclusions or suggestions regarding which clients and interventions are the most successful. One of the most important questions that pertain to the effectiveness of online counseling is who would most benefit from online-counseling services and who may most likely be harmed. It is believed that online counseling would benefit individuals functioning at a moderately high level (e.g., Stofle, 2001; Suler, 2001). For example, individuals who have more severe issues that require close attention and supervision may be better served through traditional FtF methods. Specific populations that fall under this heading might include clients who express suicidal ideation, reveal a recent psychotic episode, or admit to substance abuse (Suler, 2001; Zelvin & Speyer, 2004). Future research efforts should establish if online treatment yields positive outcomes for clients with a wide range of presenting issues, from developmentally appropriate issues to severer presenting concerns. Client Strength and Resilience Counseling psychologists seek to empower their clients by finding areas that the client can control and successfully manage. From that point, counseling psychologists can build from a clients strengths instead of focusing only on negative affect or behaviors. By allowing an individual to receive treatment without coming directly to a counseling psychologists office, onlinecounseling methods may result in the clients feeling less dependent on his or her therapist. Not only may a client feel more comfortable in his or her normal environment, but in some modes of online counseling, the client may also have more control over self-presentation and can think through what he or she wants to say. However, control over self-presentation may not always lead to a positive outcome if the client were holding back from openly communicating with the therapist or if the therapist were overlooking certain client assets because they may not be evident in an online setting. Looking at online counseling from this vantage point reveals the need to research issues such as how dependent or comfortable clients feel in an online therapy session versus an FtF session, as well as what they are willing to self-present in the different formats. It also reveals the need to understand what counseling psychologists are able to pick up in an online session and what they may miss.
Education and Career Development In addition, counseling psychology has been at the forefront of studying academic decisions and providing career counseling services. Vocational counselors have already infused technology into their services by often directing clients to computer-assisted programs for career exploration. Counseling psychologists can begin to conduct research on the effectiveness of current online career interventions, such as the online version of the Occupational Outlook Handbook (http://www.stats.bls.gov/oco) or O*Net database. O*Net takes the place of the Dictionary of Occupational Titles (DOT) as the nations primary source of occupational information. This database organizes occupations in terms of knowledge, skills, abilities, job family, or job codes from databases such as the DOT (Converse et al., 2004). The interested reader can find more information about the creation and implementation of O*Net in Baughman, Norris, Cooke, Peterson, and Mumford (1999). Counseling psychologists are well trained to assist the development of Internet sites devoted to career guidance, which can be used at times when FtF professionals are less likely to be available. We are thus able to educate the public about various career-related issues and to assess the impact of these education and training efforts. Another important function of counseling psychologists in terms of online career interventions is to eliminate or minimize the vast amount of misinformation available on the Internet. For example, a search for the terms career and counseling on Google.com yielded more than 9.7 million Web sites. Numerous online career inventories can be found on the Internet, but most are questionable at best. The measures are not proven assessment tools and have not been psychometrically validated. Many of these career resources are put together by individuals with no training in counseling psychology, or any other professional psychology training. There are also questionable career consulting services, which offer assessment on their Web sites. Clients who find these services may not seek out FtF career counseling services, and when they do arrive for FtF services, they may bring in the output from these assessments, which rarely have any meaningful value for a counseling psychologist because of the absence of psychometric information. Counseling psychologists have the training to provide accurate information about career services and psychometrically validated career assessments. A problem common to the Internet is that there is some great and useful material available but also a lot of bad information. Counseling psychologists cannot only create online resources for clients but also help their clients to evaluate the millions of career-related Web sites that offer career guidance and assessment.
Prevention, Consultation, Psychoeducation, and Wellness In addition to the availability of career resources on the Internet, counseling psychologists have limitless potential to provide services that encourage prevention and wellness among individuals. This potential benefit comes with elements of danger as well. The power of the Internet allows information to be accessible 24 hours a day, but the vast amount of literature on Web pages is not always accurate. Many Web sites offer self-help information, but it is sometimes of questionable origin and validity. Counseling psychologists are in a position to develop Web sites that provide useful mental and behavioral health information, but a more important function for counseling psychologists may be to eliminate the great amount of misinformation available online. Online self-help services provided and moderated by trained professionals can supplement other self-help materials. For an example of a self-help Web site, visit MySelfHelp.com (http:// www.myselfhelp.com). Counseling psychologists can refer their clients to psychoeducational resources as well as online bulletin boards that provide answers and support for a variety of issues. Clients or users must pay $15 per month to access the Web sites materials. Currently, MySelfHelp.com has not provided any empirical data to indicate the effectiveness of the self-help materials, and it is unclear whether these types of online resources would be more effective than common self-help resources offered during FtF treatment. With more individuals gaining access to the Internet and searching for health information (Harris Interactive, 2002), counseling psychologists can use new modes of communication, especially Web sites, to extend their prevention aims and to encourage wellness in the general population but must also investigate these services to determine their effectiveness. Related to prevention and to the promotion of wellness is counseling psychologys emphasis on consultation. Only one study reviewed detailed the use of distance technologies for consultative purposes. Dongier et al. (1986) found that the individuals receiving consultation through CCTV from a trained professional reported that the process was inferior to FtF consultations in terms of the global assessment and diagnosis. Although counseling psychologists can share their knowledge with other professionals and organizations around the world, the lack of contextual cues may hinder the ability to offer an accurate diagnosis of the client or situation. If, however, future research demonstrates this process to be successful, counseling psychologists may find it easier to share their knowledge and expertise with a wider range of populations instead of being limited to geographical regions. Future research should investigate if counseling psychologists can effectively use CMC technologies for consultation.
ISSUES FOR COUNSELING PSYCHOLOGISTS CONDUCTING ONLINE-COUNSELING RESEARCH As mentioned previously, counseling psychologists have been at the forefront of evaluating the effectiveness of FtF mental and behavioral health services. It will be important for counseling psychologists to use similar skills, measures, and procedures to ensure reliable and valid empirical findings related to online counseling. CMC creates new conundrums that researchers must consider when evaluating online-counseling services. Childress and Asamen (1998) offered guidelines for initial research conducted on the therapeutic use of the Internet. These guidelines included the precautions of locating at least three mental health referrals in proximity to the client, encrypting e-mail or chat communication to protect confidentiality and guard against vandalism or hacking, and recruiting participants from only the state in which the investigator is licensed. These guidelines echo other principles and methodologies prescribed for gathering data from participants through CMC (Reips, 2002; M. A. Smith & Leigh, 1997), conducting sociological studies (Hewson, Laurent, & Vogel, 1996), and improving online surveys (Kaye & Johnson, 1999). Research in this area should not overlook standard methodology, but investigating online counseling presents unique challenges. The following topics deserve careful attention during any online-counseling investigation. Ethical Issues Online counseling presents several ethical hurdles with important obstacles and considerations for researchers including confidentiality issues and possible duty-to-warn dilemmas (see Bloom, 1998; Finfgeld, 1999; Griffiths, 2001; Jencius & Sager, 2001; Kraus, 2004; Manhal-Baugus, 2001; Pomerantz, 2002; Rochlen, Zack, & Speyer, 2004; Suler, 2001). For instance, researchers should familiarize themselves with changing local, state, and federal regulations on delivering mental health services through distance communication. It is still necessary to receive proper informed consent when collecting data over the Internet from participants who are not at the same physical location as the researcher. Technological Failure Even the best computer or program can crash or fail at one time or another. Hence, it is important to account for possible breakdowns with contingency planning ahead of time. Also, one should properly inform participants that
disconnection of an online session is possible and present them with a plan of action if the connection is lost. This issue is not present in FtF studies of counseling; a client or a therapist does not suddenly disappear from the counseling room. The disconnection of a session, especially if the content of the session were at a high emotional level or at a crisis level, could be disorienting to both the client and the therapist. The client could feel abandoned and disillusioned, while the therapist would likely have feelings of panic and frustration. Researchers should have a clear plan to make sure that the therapist and the client not only expect such disconnections but can also deal with them in a timely manner (Mallen, 2004). Logistical Issues There will need to be management of at least two schedules for each online session studied. It is imperative that counseling psychologists and their clients are ready to communicate with each other once the session is scheduled to begin. Scheduling sessions can become confusing when connecting individuals separated by several time zones. Data collected through an online survey, e-mail, or questionnaire can be sent and received by fax or standard mail. Because participants cannot simply complete a pencil-andpaper measure while in the same room as the experiment, data collection can become cumbersome. On the other hand, an instant online survey could be projected and recorded on the spot, with item responses put directly into a data set. Researchers should inform participants about possible delays to reduce confusion and irritation. Differences in Technology There may be differences between telephone, synchronous chat, asynchronous e-mail, and videoconferencing regarding quality of care. Yet, at this point, the research largely neglects these questions. It is possible that counseling by telephone and videoconferencing is superior to synchronous chat and asynchronous e-mail because nonverbal cues are transmitted instead of text. It could be argued that videoconferencing would be most successful in connecting a client with a counseling psychologist because of the technologys video and audio capabilities. However, text-based communication such as synchronous chat and asynchronous e-mail may also be useful in certain situations. For instance, asynchronous e-mail may work best for a client who has a nontraditional schedule and cannot meet with a professional at regularly scheduled times. The ability to send messages to a therapist at any time dur-
ing the day or night still allows the client to receive services that might otherwise be impossible because of scheduling conflicts. Future research should investigate differences in technology regarding the process and outcome of counseling services. Previous Online Experience Any study analyzing the dynamics and process of online relationships should use some measure of online experience. Communicating effectively through asynchronous e-mail, synchronous chat, and videoconferencing takes time and practice. A study by Mallen, Day, and Green (2003) found that as online experience increased, participants reported a greater amount of closeness in synchronous-chat conversational dyads. This study found that familiarity with online communication was related to feeling comfortable with the technology and understanding the nuances in its rate, presentation, style, and idiosyncrasies. Including this variable in studies may help to explain differences in results. Research has attempted to define the construct of computer experience, and several scales are currently available to assess this characteristic (C. Murphy, Coover, & Owen, 1989; Potosky & Bobko, 1998; B. Smith, Caputi, Crittenden, Jayasuriya, & Rawstone, 1999). Digital Divide It is also important to be aware of the potential digital divide, which describes socioeconomic barriers to access. Online counseling may be unavailable to populations that are already underserved by traditional mental health interventions. Digital divide is a term that describes the differential access to the Internet and related technologies because of financial and other socioeconomic issues (Hoffman, Novak, & Schlosser, 2000). While most public libraries provide Internet access that would allow individuals to find helpful psychoeducational material, the library is not an ideal setting for a client to receive online-counseling services. It is imperative for equal access to become an integral part of any new mode of service delivery for it to become a tool of empowerment rather than disenfranchisement (see Lee, 2000). Time Walther (1993) points out a flaw in the existing literature comparing FtF and CMC, stating that many studies do not allow a significant amount of time for online communication to develop. The key difference may be that the rate of relationship building and impression formation is slower in CMC but that
similar levels could be achieved over time (Walther, 1996). However, FtF communication has also been shown to outperform CMC. For instance, a study on group decision-making tasks demonstrated that the FtF group members performed at a higher level, while CMC group members experienced more frustration with the process (Barkhi, Jacob, & Pirkul, 1999). A similar study found that group members in the FtF groups reported higher levels of satisfaction, decision confidence, and ease of use than the CMC groups (Olaniran, 1996). An example of the time issue at work is found in a Mallen and Vogel (2002) study, which analyzed synchronous-chat transcripts from analogue sessions. The authors compared transcripts from the online sessions with similar FtF transcripts from a Day and Schneider (2000) study. An interesting finding from the study was the difference in the amount of discourse that could flow between the therapist in training and the client in an FtF session. The FtF transcripts had a mean of close to 6,000 words, while the synchronouschat transcripts had a mean of only 2,000 words. It should not be concluded that the quantity of words equals the quality of service or care, but it cannot be denied that the sheer amount of discourse in an FtF session far exceeds synchronous-chat sessions of the same length. It would be wise to consider variables such as typing speed and even reading comprehension, as some clients may lack skills in both areas, which would likely limit their ability to communicate effectively online.
THE ROLE OF COUNSELING PSYCHOLOGY IN SHAPING ONLINE COUNSELING At its core, counseling psychology is composed of professionals trained in the art of practice and the science of research. Counseling psychologists are equipped to shape the field of counseling psychology to ensure that its aims are met in these new modes of service delivery. The field can continue to champion the causes of servicing intact populations, focusing on personenvironment interactions and client strengths, providing career services, and delivering brief interventions. In addition, counseling psychologists can work to minimize the negative effects of the digital divide and to ensure that clients are not disenfranchised by the development of new mental and behavioral health services provided through CMC. The review of the available research provides answers to several questions regarding who should be treated, the appropriate types of interventions, and the characteristics of counseling psychologists that might function effectively in an online setting. It may be surprising that preliminary research has shown online counseling
to be beneficial and accepted by clients. However, it also shows the lacunae in our knowledge and the need to investigate further the benefits and limitations of these new modes of treatment. The field of counseling psychology is specifically ready to be mobilized to provide answers to these questions through dedication to the scientist-practitioner model.
APPENDIX Research Focusing on Online Counseling

Technology Asynchronous message board Sample Type of Study; Data; Measures (Constructs) Main Counseling-Related Research Findings
Author and Date
Braithwaite et al. (1999)
Bresnahan & Murray-Johnson (2002)
Asynchronous message board
1,472 support messages from 42 group members with disabilities 2,000 messages from approximately 700 members of a menopause and midlife transition group 32 undergraduate students. Mean age = 20. Race = 32 AA. Sex = 32 M
Chang et al. (2001)
Clement et al. (2001)
Videoconference
32 patients with known or suspected neurological disorder or traumatic brain injuries. Sex = 27 M, 5 F
Observation; coding Majority of messages offered emotional support (40%), followed of messages by two by information (31.3%), esteem support (18.6%), network support coders into 5-category (7.1%), and tangible assistance (2.7%). system Observation; coding of Almost all messages (80%) included action facilitative support. Most messages by two coders; messages were supportive, but some postings were argumentative. anecdotal accounts of The three most common content areas of the messages about process/outcome menopause: participants problem in communicating to physicians, discussion of problems with hormone replacement therapy, and identification and discussion of alternative treatments. Experiment with control On 10-point scale, participants of group reported feeling support from group; process/outcome; the group (M = 7.1), thinking the concerns raised were relevant MEIM, CSES-R, (M = 7.8), and felt connected and comfortable (M = 7.8). Majority of OSGQ, TVRM participants thought the format worked well (95%). All participants preferred the anonymous format of group. No significant differences were found at posttest between support and control groups on MEIM or CSES-R. Participant/observation; Anecdotal report indicates that video interviews/screenings with anecdotal account of patients have been effective for extending services to new settings process that would otherwise be difficult to reach.
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858 APPENDIX (continued)

Technology Synchronous chat 24 undergraduate students self-identified as wanting help dealing with anxiety Sample Type of Study; Data; Measures (Constructs) Main Counseling-Related Research Findings Asynchronous 15 clients. Sex = 14 F, e-mail; 1 M. 66% U.S. citizens, synchronous chat 33% Canadian Videoconference; 80 clients recruited from audio only community. Mean age = 39.35. Race = 66 W, 8 AA, 3 A. Sex = 52 F, 28 M Videoconference 50 patients participated in CCTV and were compared to 35 matched controls in FtF condition. Diagnoses: schizophrenic psychoses (27%), neurotic depression (12%), affective disorders, depressed (12%) Experiment with FtF Participants showed significant decreases in both modes of treatment control group; outcome; (p < .001); however, no significant differences were found between STAI, CRF, SEQ, CUS treatment groups (p = .85). No significant differences were found between client ratings of counselors on expertness, attractiveness, and trustworthiness in CMC and FtF. Clients in the FtF condition rated their session as significantly more arousing than in the CMC condition (p = .017). Process compared with Participants reported comparable levels to the FtF comparison group normative FtF data; of the working alliance in the online sample using the WAI. WAI Experiment with FtF Significant superiority of treatment to no treatment was found, F(12, comparison group; 265) = 1.82, p = .01. No significant differences between video, process/outcome; audio, and FtF treatments, F(12, 144) = .67, p > .15. observer ratings, client/clinician self-reports; VPPS, BSI, GAF, TC, CSS, TSS Experiment with FtF No significant differences were found in clients satisfaction rating comparison group; between the videoconference (CCTV) and FtF conditions; however, client/psychiatrist the psychiatrists rated the CCTV condition as significantly inferior self-report; process, in regard to the global assessment (p < .05) and diagnosis (p < .01). satisfaction.
Author and Date
Cohen & Kerr (1998)
Cook & Doyle (2002)
Day & Schneider (2002)
Dongier et al. (1986)
Finn (1999)
718 messages from 42 members of disability group
Glueckauf et al. (2002)
Videoconference; audio only
Majority of messages were related to socioemotional exchanges (53.3%), with the rest focusing on information. Majority of messages provided support or empathy (21.2%), followed by information (15.3%), and problem solving (14.4%). Most common content areas were health (38.2%) and relationships (28.4%). Teens and parents reported moderately high to high levels of alliance across all conditions (M = 6.15 on 7-point scale). Teens reported significantly lower alliance in the video than in both the audio-only (p = .05) and the FtF group (p = .004). Teens and parents reported significant and equivalent reductions in the severity and frequency of identified family problems from pre- to posttreatment across groups. CHESS group reported quality of life improvement over control group in terms of participation in health care (p < .007). CHESS group reported fewer hospitalizations (p < .02) and shorter hospital stays (p < .009) than control group during intervention; these differences were not significant at the posttest. Participants who received the group therapy through CMC reported significantly lower scores than the control group on UCLA-L (p = .001) and ESL (p = .005); there were no other significant differences on the outcome measures between treatment and control groups. Participants in CMC group showed significant decreases on the UCLA-L (p = .002), ESL (p = .002), and DSLP (p = .022) from pretest to posttest.
Gustafson et al. (1999)
Asynchronous e-mail, synchronous chat, Web site
Hopps et al. (2003)
Synchronous chat
Observation; coding messages by two raters into 14 categories; anecdotal accounts of process/outcome 22 teenagers with epilepsy Experiment with FtF and their parents (n = 36). control group; process/ Mean age = 15.4. Race = outcome; client self100% W. Sex = 14 M, 8 F report, observation; FDAS, SSRS, WAI, completed assignments, missed appointments 204 HIV-positive patients Experiment with no from community sample. treatment control; preMean age = 35. Race = 84% and postintervention W. Sex = 183 M, 21 F client self-reports; quality of life, health behaviors, health service utilization 19 individuals with visible Experiment with wait-list physical disabilities. control group; outcome; Mean age = 34.2. client self-report; Sex = 9 M, 10 F UCLA-L, ESL, PD, ADS, DSLP
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Technology Asynchronous message board Asynchronous e-mail Sample Type of Study; Data; Measures (Constructs) Main Counseling-Related Research Findings 21,230 messages from 1,516 members of mental health group 6,142 messages from 374 members of Parents of Children with Autism group 25 students who had experienced a traumatic event at least 3 months prior. Mean age = 22. Sex = 16 F, 9 M Asynchronous e-mail; Web site Videoconference 75 prison inmates. Sex = 100% M Participant/observer; Categories of messages posted: education, support, feedback, setting anecdotal accounts of limits. Anecdotal evidence is provided to demonstrate effectiveness process/outcome of online support group. Observation; qualitative Main categories that emerged from messages: searching for meaning, data analysis through adjusting to changes, providing support and encouragement, and QSR Nudist; anecdotal sharing experiences narratively. Report indicates that e-mail groups accounts of process/ can offer support and an adjunct to treatment. outcome Experiment with control Significant decrease in post-traumatic stress disorder symptoms was group; outcome; found in CMC group compared to wait-list control (p < .015). client self-report on pre- General psychopathology on SCL-90 significantly decreased test and posttest; IES, (p < .01; d = 1.07). Client mood improved in CMC group (p < .04), SCL-90, POMS, EQ especially less depressive (p < .01; d = .91), and tense (p < .01; d = .89). Client improvements were found to be sustained 6 weeks after treatment, and 95% of the participants reported that the therapy was helpful. Process/outcome; client On a scale from 3 to 3, inmates reported positive ratings of how good self-report; 6-item treatment over the TV felt (M = 2.04), and how they felt about consultation coming back for another session (M = 2.29). Inmates perceptions of questionnaire treatment became more positive over time (r = .36). Most inmates thought treatment was comparable to FtF services (46%), with the rest reporting that FtF was worse (35%) or better (19%) than CMC treatment.
Author and Date
Hsiung (2000)
Huws et al. (2001)
Lange et al. (2001)
Magaletta et al. (2000)
Mallen & Vogel (2002)
Synchronous chat
20 graduate students in counselor training programs
Meier (2000)
Asynchronous e-mail
52 social workers recruited from listservs. Mean age = 43. Race = 95% W, 1 La. Sex = 84% F
Rochlen, Beretvas, & Zack (2004)
Rochlen, Land, & Wong (2004)
Asynchronous 471 undergraduate students e-mail, for factor analysis, 51 synchronous chat students for test-retest reliability, 213 students for construct validity Synchronous chat 198 undergraduate students. Sex = 100% M
Experiment with normative FtF data; process/outcome of therapist; PANAS, IOS, satisfaction Process/outcome; self-report, qualitative analysis; BIQ, OSI, 87-item satisfaction survey Instrument development and preliminary validity and reliability; online and FtF counseling attitudes Analogue; measured attitudes toward online counseling and gender role conflict; CRF
Sander (1996)
Synchronous chat
Significant difference found between the amount of discourse that occurs in CMC sessions (p < .001). Most participants (95%) reported an above-average level of satisfaction on a 6-point scale. Most participants (90%) reported a low or moderate level of closeness with their client as measured by the IOS. 209 supportive comments were identified in group: 54% offered emotional support. The majority of members rated the group as helpful in clarifying their professional values (69%) and as a source of coping (63%). No significant differences were found for stress reduction on the OSI. Overall sample endorsed more favorable attitudes toward FtF counseling as contrasted with online counseling, particularly for female respondents. Good preliminary evidence of reliability and validity established for new and comparable measures of online and FtF counseling attitudes. Similar and positive evaluations observed of both online and FtF counseling sessions. Men with high and low levels of restrictive emotionality did not differ in their perceptions of online counseling but differ in perceptions toward FtF counseling, with men who reported difficulty with emotional expression expressing lessfavorable perceptions. Couples counseling through CMC was noted as slow and fragmented, and the clients and the clinician were not satisfied with the sessions. Clients more likely to report desire to repeat experience in videoconference group than FtF (p < .05). No significant differences were found for satisfaction, ease of communication, degree of relaxation during interview, or participant ratings of psychologist caring. Psychologists gave higher rating satisfaction ratings in FtF group (p < .01). Cost-benefit analysis states that technology can be cost-effective for psychologists.
Schopp et al. (2000)
Videoconference
2 couples transitioned from Case study; anecdotal FtF to CMC counseling. accounts of process/ Mean age = 50. outcome 98 adult outpatients with Experiment with FtF cognitive disabilities. comparison group; Mean age = 33.8. process/outcome; Race = 90 W, 6 AA, client/psychologist 1 A, 1 La. Sex = 57 M, 41 F self-reports, BSI, WAIS-R or WAIS-III, GSI, satisfaction interview
861
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Technology Asynchronous e-mail Asynchronous e-mail; Web site Sample Type of Study; Data; Measures (Constructs) Main Counseling-Related Research Findings Identified three major dimensions of messages: exchange of information, social support, and personal empowerment. Suggested e-mail may be a lifeline for LGBT population, which is often isolated, and clients who travel frequently and cannot attend FtF sessions regularly. Participant/observer; anecdotal account of process/outcome Case commentary; anecdotal account of process Videoconference More than 800 participants in breast cancer support group. Sex = 75% F 20-25 e-mail questions from clients per month; unspecified number of individual LGBT clients in private practice 40 clients recruited from community. Mean age = 43.8. Sex = 18 M, 22 F No significant differences between videoconference and FtF interviews on ISS or CPAS for clients. Psychiatrists rated the videoconference interviews as less satisfying (p < .001), but no difference was found on the alliance measure. Asynchronous message board 302 messages posted by 70 members of a support group for eating disorders. Most participants in early 20s. Sex = 68 F, 2 M Experiment with FtF comparison group; process/outcome; client/psychiatrist self-reports; SCID-P, CPAS, ISS Observation; coding of messages by two raters into 7 categories The majority of participants only posted one or two messages (69%). Personal disclosures (31%) were the most common type of message posted, followed by information provided (23%) and support provided (16%).
Author and Date
Sharf (1997)
Shernoff (2000)
Stevens et al. (1999)
Winzelberg (1997)
Yager (2001)
Asynchronous e-mail
4 clients with anorexia nervosa. Ages = 17, 18, 22, 50. Sex = 4 F
Case study; anecdotal accounts of process/ outcome
Patients comments suggest that e-mail increases frequency of contact with clinician, emotional value of e-mail is great because they can communicate whenever inspired, quasi-daily e-mails allow them to update clinicians about details and focus on more meaningful issues in FtF. Negative consequences may include clinician failure to respond in a timely fashion, recognize urgent messages.
NOTE: Information about race was provided when available. A = Asian; AA = African American; ADS = Acceptance of Disability Scale; BIQ = Background Information Questionnaire; BSI = Brief Symptom Inventory; CCTV = closed-circuit television; CHESS = Comprehensive Health Enhancement Support System; CMC = computer-mediated communication; CPAS = California Psychotherapy Alliance Scale; CRF = Counselor Rating Form; CSES-R = Collective Self-Esteem ScaleRevised; CSS = Client Satisfaction Scale; CUS = Computer Usage Survey; DSLP = Questionnaire on Social Difficulties Related to Physical Disability; EQ = Evaluation Questionnaire; ESL = Emotional Versus Social Loneliness; F = female; FDAS = Family and Disability Assessment System; FtF = face-to-face; GAF = Global Assessment of Functioning Scale; GSI = Global Severity Index; IES = Impact of Events Scale; IOS = Inclusion of Other in the Self Scale; ISS = Interview Satisfaction Scale; La = Latina/Latino; LGBT = lesbian, gay, bisexual, and transgendered; M = male; MEIM = Multigroup Ethnic Identity Measure; OSGQ = On-line Support Group Questionnaire; OSI = Occupational Stress Inventory; PANAS = Positive and Negative Affect Scale; PD = personal definition of loneliness; POMS = Profile of Mood Status; SCID-P = Structured Clinical Interview for the DSM-III-RPatient Version 1.0; SCL-90 = Symptom Checklist90; SEQ = Session Evaluation Questionnaire; SSRS = Social Skills Rating System; STAI = State-Trait Anxiety Inventory; TC = target complaints; TSS = Therapist Satisfaction Scale; TVRM = Taxonomy of Verbal Response Modes; UCLA-L = University of California at Los Angeles Loneliness Scale; VPPS = Vanderbilt Psychotherapy Process Scale; W = White; WAI = Working Alliance Inventory; WAIS-III = Wechsler Adult Intelligence ScaleIII; WAIS-R = Wechsler Adult Intelligence ScaleRevised.
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Mallen et al. / ONLINE-COUNSELING / November THE COUNSELING PSYCHOLOGIST RESEARCH2005 10.

Reviewing the Literature From a Counseling Psychology Framework

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APPENDIX Research Focusing on Online Counseling

Author and Date

Braithwaite et al. (1999)

Bresnahan & Murray-Johnson (2002)

Asynchronous message board

Chang et al. (2001)

Asynchronous message board

Clement et al. (2001)

858 APPENDIX (continued)

Author and Date

Cohen & Kerr (1998)

Cook & Doyle (2002)

Day & Schneider (2002)

Dongier et al. (1986)

Asynchronous message board

718 messages from 42 members of disability group

Glueckauf et al. (2002)

Videoconference; audio only

Gustafson et al. (1999)

Asynchronous e-mail, synchronous chat, Web site

Hopps et al. (2003)

860 APPENDIX (continued)

Author and Date