Self Injury and Confidentiality.The article review should be written on the article titled Issues of Confidentiality and Potential Disability Discrimination in Behavior I

Online Counseling: A Narrative and Critical Review of the Literature Derek Richards1 and Noemi Viganó2

1University of Dublin, Trinity College 2Alliance Counselling, Dublin, Ireland

Objective: This article aimed to critically review the literature on online counseling. Method: Database and hand-searches were made using search terms and eligibility criteria, yielding a total of 123 studies. Results: The review begins with what characterizes online counseling. Out- come and process research in online counseling is reviewed. Features and cyberbehaviors of online counseling such as anonymity and disinhibition, convenience, time-delay, the loss of social signal- ing, and writing behavior in cyberspace are discussed. Ethical behavior, professional training, client suitability, and clients’ and therapists’ attitudes and experiences of online counseling are reviewed. Conclusion: A growing body of knowledge to date is positive in showing that online counseling can have a similar impact and is capable of replicating the facilitative conditions as face-to-face encounters. A need remains for stronger empirical evidence to establish efficacy and effectiveness and to under- stand better the unique mediating and facilitative variables. C© 2013 Wiley Periodicals, Inc. J. Clin. Psychol. 69:994–1011, 2013.

Keywords: online counseling; outcomes and process research; therapeutic relationship; cyberbehaviors; ethics; attitudes and experiences; suitability and training

The field of cyberpsychology involves the study of human experiences (cognitive, emotional, and behavioral) that are related to or effected by developing technologies, in other words the psychological study of human-technology interaction (Richards & Viganó, 2012). One area of cyberpsychology is online counseling, also referred to as e-therapy, e-counseling, or cyberther- apy. While the very nature and definition of online counseling have been debated, we will use the one employed by Richards and Viganó (2012), defining online counseling as the delivery of ther- apeutic interventions in cyberspace where the communication between a trained professional counselor and client(s) is facilitated using computer-mediated communication (CMC) technolo- gies, provided as a stand-alone service or as an adjunct to other therapeutic interventions.

Alongside technological developments online counseling has grown in the past 15 or so years. Researchers in online counseling have been considering the potential effectiveness of online counseling and whether it is possible to establish a therapeutic relationship in cyberspace. Re- search studies have focused on establishing its potential benefits and challenges, client suitability for online counseling, therapists’ and clients’ attitudes and experiences of online counseling, and professional training for working online with clients. Additionally, its very nature and definition as a therapeutic intervention has been debated. Researchers have been exploring newly observed phenomena that form part of understanding the psychology of online counseling behavior. Ar- eas of interest include the effects of apparent anonymity and distance, disinhibition, identity and impression management, writing and emotional expression in cyberspace, and ethical behavior in cyberspace.

While other reviews of online counseling have been written, notably, the special issue from the Journal of Clinical Psychology, 2004, and the volume from The Counseling Psychologist, 2005, the contribution of the current article is the systematic nature of the work, and we believe the extensiveness and thoroughness of the work will provide the discipline with a comprehensive review of the field and also an evaluation of the present empirical knowledge and suggestions for the future clinical practice and research. The paper reviews, among others, research relat- ing to process and outcome, the therapeutic relationship, the characteristic features of online counseling, and ethical considerations for delivering therapeutic interventions online.

Please address correspondence to: Derek Richards, University of Dublin, Trinity College. Dublin. E-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(9), 994–1011 (2013) C© 2013 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21974

Online Counseling: A Narrative Review 995

Method

Literature Search and Selection of Studies

The aim of the literature search was to find all references related to online counseling. We drew on our research experience and knowledge of the field and we reached agreement regarding the means to carry out the search and the search terms to be used. A search of three leading databases for psychology (EMBASE, PubMed, and PsychINFO including PsychARTICLES) was conducted for studies published in peer-reviewed journals. Based on the literature, eight search terms were employed–online counseling and online counselling, cybercounseling and cybercounselling, web therapy, web counseling and web counselling, e-therapy, e-counseling and e-counselling, cybertherapy, and web consulting–culminating in a total of 24 searches.

Results, which included original research, meta-analysis, and other reviews, were assessed at title, abstract, or by reading the full paper to determine whether they met our eligibility criteria. Studies were included when they met (a) the definition of online counseling employed by Richards and Viganó (2012): involving the delivery of a therapeutic intervention by a trained professional to client(s) using synchronous or asynchronous computer mediated communication (CMC). Included were (b) papers that addressed any aspect of this encounter such as process and outcome studies, ethics, online behaviors associated with the encounter, training, suitability, its definition and nature, attitudes, experiences, (c) and all age groups. Papers were excluded (a) if they did not involve a trained professional counselor and client(s), (b) that did not deliver a therapeutic intervention e.g., careers guidance counseling or medical therapeutics, (c) and that did not use CMC, but instead telephone, or was solely a self-administered program.

We rejected duplicates and we assessed each of the studies for inclusion, any difficulties we discussed and a final decision was made. Further, a hand search was made of papers to identify other relevant studies for inclusion. Reasons for rejecting papers included that they were not a therapeutic intervention, were not in English, did not employ CMC, were an unpublished thesis, or a conference paper (see Figure 1). A comprehensive summary of information extracted from the papers was written, considering the characteristics of online counseling, associated process and outcome research, the therapeutic relationship in cyberspace, potential benefits and challenges, client suitability for online counseling, therapists’ and clients’ attitudes and experiences of online counseling, and professional training for working online with clients. Further, the review considered online behavior as it applies to online counseling: anonymity and distance, disinhibition, identity and impression management, writing and emotional expression, and ethical online behavior.

The subheadings under which the papers were reviewed evolved from the study of the pa- pers and also from our own experience with online counseling. Therefore, some subheadings were initially derived as needing to be represented such as outcome and process research, the therapeutic relationship, benefits, and challenges, while others evolved more naturally from the literature and include attitudes, training, suitability, and unique features of online counseling behavior.

Results and Discussion

Three databases, PubMed (n = 1,163), EMBASE (n = 1,124), and PsychINFO including Psy- chARTICLES (n = 185), were searched. Identified papers (n = 2,319) were screened against the established eligibility criteria, yielding 85 papers. A further 38 papers were identified through hand-search. Figure 1 shows the results of the systematic search.

Characteristics of Online Counseling

Providing a definition for online counseling is somewhat problematic as the exact nature of interventions involving therapists and clients online have been in flux and are a continued source of debate. Recently, Barak, Klein, and Proudfoot (2009) have tried to bring some clarity by providing some guiding definitions, classifications, and descriptions of a range of online

996 Journal of Clinical Psychology, September 2013

Figure 1. Results from the systematic search.

Online Counseling: A Narrative Review 997

therapeutic interventions. However, definitions still remain unspecific regarding any theoretical or technical approach, and professionals’ level of training (Rochlen, Zack, & Speyer, 2004).

Synchronous (chat and video conferencing) and more popularly asynchronous (e-mail) com- munication, as well as combinations of these have been employed to deliver online counseling as a standalone service and as an adjunct to other services. Some web-based, self-administered treatments for a variety of disorders have included online counseling support, usually in the form of asynchronous postsession feedback, which appears to increase adherence and yield enhanced outcomes (Newman, Szkodny, Llera, & Przeworski, 2011; Richards & Richardson, 2012).

Some (Castelnuovo, Gaggioli, Mantovani, & Riva, 2003) consider that online counseling is a transposition of face-to-face (F:F) counseling online, with technologies mediating the therapeu- tic communication and affecting the process with their associated advantages and limitations. However, others (Fenichel et al., 2002; Grohol, 1999, 2001) consider that online counseling should be considered a new type of therapeutic intervention, a distinct way of engaging thera- peutically and therefore needing a different theoretical framework from F:F counseling. From this perspective online counseling is considered a new, versatile, and flexible resource with the potential to complement and support other types of interventions.

A number of issues that have been debated in the literature from the beginning have been raised as criticisms by both professionals and laypeople (Barak, Hen, Boniel-Nissim, & Shapira, 2008): the effect of the loss of cues on the process of therapy and consequently whether counseling can occur in such a context; ethical issues and in some cases their potential legal implications regarding the delivery of online counseling; and practical issues have arisen concerning training for conducting online counseling and concerns about relying on technology. Yet in spite of strong criticisms being put forward, from its beginning the various technology-delivered psychological interventions have flourished. Barak et al. (2009) state that this is likely due to several factors including:

� Increasing acceptability of the Internet as a legitimate social tool � Computer hardware and software developments (especially in relation to ease of use, privacy

protection, and online communication capabilities) � Development of ethical guidelines by various professional organizations � Growing research � Establishment of online training for professionals

Outcomes and Process Research in Online Counseling

The goal of counseling is to alleviate the distress, anxiety, and concerns that clients can present. Counseling attempts to return a client to precrisis functioning and in doing so foster clients’ well-being, build on a client’s strengths, and help improve overall functioning (Mallen, Vogel, Rochlen, & Day, 2005). It is our opinion that online counseling must also adhere to the same objectives, because it seems reasonable to assume that that is what users of counseling (online or F:F) are seeking.

Efficacy and effectiveness of online counseling. Cohen and Kerr’s (1998) analogue study using the State-Trait Anxiety Inventory measured participants’ anxiety before and after being assigned (N = 24 students) to one session of either F:F or online synchronous (chat) counseling. Both groups showed a decrease in anxiety outcomes posttreatment. Although the study was somewhat artificial, as it used students to deliver and receive treatment, it screened out participants with high levels of distress, and the sample was small; nevertheless, it represented a worthwhile beginning.

The series of studies by Glueckauf and colleagues (1999, 2002) attempted to assess outcomes by randomizing teenagers (N = 39) with epilepsy and their parents for six sessions of fam- ily counseling among video, audio, F:F counseling, and a waitlist control. They employed a number of measures such as the Problem Severity and Frequency Scale, Social Skills Rating System Scale, and a modified form of the Working Alliance Inventory, and they also tracked treatment adherence. Twenty-two families completed the treatment and data were collected at

998 Journal of Clinical Psychology, September 2013

week 1 and 6 months posttreatment. They found that the teenagers and parents in each of the treatment groups demonstrated significant reductions in both problem severity and frequency at both posttreatment and 6-month follow-up. At posttreatment, prosocial behaviors increased, as reported by parents, and these were maintained at follow-up. However there didn’t seem to be any changes in problem behaviors over time. The sample size was small and also the population very specific, thereby limiting generalizability of the results.

Day and Schneider (2002) randomized 80 clients and compared process and outcome variables across three treatment groups: F:F, telephone, and video psychotherapy. Participants completed five sessions and measures of working alliance, session outcome, and satisfaction. The results showed no statistically significant differences between the three delivery modes for either working alliance or outcomes. However, they found a statistically significant difference in the level of participation: clients in distance therapy participated more actively than those in F:F therapy. The researchers speculated that the clients in the distance modes perhaps made more of an effort to communicate or took more responsibility for the interaction, or perhaps the distance made those participants feel safer. Although the study is an important contribution to empirically establish online counseling, it is limited by sample size and the broad range of presenting issues included (Day & Schneider, 2002).

Robinson and Serfaty (2001, 2008) employed qualified therapists who corresponded with clients with an official Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; Amer- ican Psychiatric Association, 2000) diagnosis for an eating disorder via e-mail at least twice a week for a period of 3 months. The therapists were supervised by specialists with experience in eating disorders psychiatry, who received each e-mail correspondence, annotated it, and returned it to the therapist. Robinson and Serfaty (2001) reported significant improvements in bulimic symptoms for participants at 3-month follow-up and a significant reduction in the number of participants fulfilling DSM-IV eating disorder criteria at posttreatment (50% of the 19 partici- pants), compared with a waitlist control group. Although the samples were small and the design did not include a comparison with F:F treatment, the results are encouraging for the use of online counseling for eating disorders.

A number of studies employed videoconferencing technology to deliver therapy for the treat- ment of eating disorders. For instance Mitchell et al. (2008) delivered 20 sessions of cognitive- behavioral therapy (CBT) over a 16-week period for the treatment of bulimia nervosa (BN) in a sample of 128 adults meeting the DSM-IV criteria for BN or eating disorder not otherwise specified (EDNOS). Participants were randomly assigned to either F:F CBT or online-delivered CBT. Participants were assessed by interview at posttreatment, and at 3-month and 12-month follow-up. Retention was comparable in both groups, and abstinence rates were higher for the online group compared with the F:F group, but not statistically significant. They concluded that delivering online treatment was acceptable to many patients and roughly equivalent in outcome to F:F therapy.

Simpson and colleagues (Simpson, Bell, Knox, & Mitchell, 2001; Simpson, Deans, & Brebner, 2005) have reported on the use of videoconferencing technology to deliver treatments for BN and eating disorders to remote and geographically distant populations. The first study (2001) assessed participants (N = 10) F:F, and then assigned them to 10 sessions via teleconferencing. Prescores and postscores from the General Health Questionnaire (Goldberg, 1972) and post- session Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM;Barkham et al., 2010) scores revealed that participants showed a decrease in symptamotology and increases in well-being. In a second study (2005) of six participants meeting DSM-IV criteria for BN or EDNOS, Simpson and colleagues reported finding that most participants made clinically important improvements in terms of bulimic symptoms, levels of depression, and borderline symptomatology. Although the studies included official diagnostic assessment of symptoms, they had small samples and lacked follow-up.

Zabinski and colleagues (Zabinski et al., 2001; Zabinski, Wilfley, Calfas, Winzelberg, & Taylor, 2004) examined the use of synchronous Internet-delivered group chat for the prevention of eating disorders in four female students. The program was advertised as an educational intervention for women with elevated weight and shape concerns. It consisted of eight 1-hour weekly sessions. All sessions were moderated by an advanced graduate student in clinical psychology specializing

Online Counseling: A Narrative Review 999

in eating disorders. The study employed a number of standard self-report instruments, such as the Body Shape Questionnaire, Eating Disorders Inventory, and Eating Disorders Examination Questionnaire, and reported improvements ranging from small to medium effect sizes in eating disordered behavior and body image attitudes (Zabinski et al., 2001). A follow-up randomized controlled study demonstrated that intervention participants showed significant improvements over the waitlist control participants on most subscales of eating pathology with robust effect sizes, particularly from baseline to follow-up as measured by the Eating Disorder Examination Questionnaire (Zabinski et al., 2004).

Hopps, Pépin, and Boisvert (2003) employed chat technology to investigate the effect of cognitive-behavioral group therapy on feelings of loneliness among a sample (N = 19) of chron- ically lonely people with physical disabilities. The study, using a waitlist control randomized design, employed a number of outcome assessments including the Loneliness Scale, Emotional Versus Social Loneliness Scale, and personal definitions of loneliness. The results showed signifi- cant improvements for participants on items regarding personal, social, and emotional loneliness and these were maintained at 4-month follow-up. Generalizing results is, however, limited by the sample size and the particular population studied.

Other online counseling interventions have been experimented with where users (adults and teenagers) have presented a broad variety of presenting concerns. At the University of Athens, students who used online asynchronous counseling noted advantages, including ease of use, speed, and anonymity, followed by ambivalence about traditional counseling (Efstathiou, 2009). The traditional social stigma toward seeking help and social factors hindering help-seeking behaviors (e.g., gender and physical appearance) appeared to be reduced (Efstathiou, 2009). Richards (2009), investigating asynchronous online counseling with students, highlighted the benefits for users in having one single session online with a counselor. Apparent anonymity and distance, the therapeutic benefits of writing, the cultivating of a zone of reflection, and the resourcefulness of young adult students were suggested to be important variables mediating the success of single-session online counseling. The single-session model employed also allowed content to become a resource for all users (Efstathiou, 2009). The building of such a database is also supported by the work of Michaud and Colom (2003), where after 4 years of operation, the number of teenage visitors continued to increase but the number of questions dropped to half.

A meta-analysis of Internet-based psychotherapeutic interventions (Barak et al., 2008) re- ported an overall weighted mean pre-post effect size of d = .53. More precisely, the effects achieved for studies (n = 27) that represented work conducted synchronously (d = .49) and asynchronously (d = .44) were not statistically different, although chat and e-mail modes were statistically superior to forum, audio, or webcam. The study provides evidence for the use of on- line interventions, concluding that online interventions are as efficacious or nearly as efficacious as F:F ones. However, the study did not discriminate on the basis of quality, and was based on a wide variety of studies with mixed methods, approaches, and objectives.

Several randomized controlled trials that have included a treatment condition using syn- chronous or asynchronous online counseling have reported significant posttreatment and follow- up effects (Kessler et al., 2009; Vernmark et al., 2010), demonstrating the efficacy of delivering structured, online CBT treatments for depression (Richards & Richardson, 2012). Similarly, a broad range of mental health issues have been addressed through the delivery of various online interventions, for instance, interventions for panic disorder (Carlbring et al., 2006; Carlbring, Ekselius, & Andersson, 2003), insomnia (Ström, Pattersson, & Andersson, 2004), and smoking cessation (Strecher, Shiffman, & West, 2005), to name a few. Interventions included therapist support and counseling delivered through a range of technologies and communication modes, synchronously and asynchronously (Newman, et al., 2011).

Process variables in online counseling. The study by Cohen and Kerr (1998) described earlier reported that while clients rated higher levels of arousal in F:F encounters, there were no differences found regarding ratings of depth, smoothness, or positivity between online and F:F clients. Barak and Bloch (2006) using 140 transcripts investigated the perceived helpfulness of emotional support carried on by professional helpers through Internet chat with distressed individuals. They reported positive outcomes for clients who had used the service. They found

1000 Journal of Clinical Psychology, September 2013

no significant difference in clients’ perceived session helpfulness for online than would be found with F:F services. Barak and Bloch (2006) have also demonstrated that perceived helpfulness correlated highly with impact from both clients’ and therapists’ perspectives. Similar to F:F ther- apy, deep, smooth conversations that yielded positive responses and aroused clients’ emotions were helpful. This is in contrast with the common criticism that online therapeutic conversations might be shallow, superficial, or distant (Barak & Bloch, 2006).

Their findings have also been confirmed by Reynolds, Stiles, and Grohol (2006), who studied session impact and alliance in online counseling with 16 therapists and 17 clients over the course of a total of 178 sessions and reported that session impact and alliance were similar between online and F:F treatments. This has also been a point noted in other studies, and perhaps session impact may be a variable more closely related to outcomes in online counseling than is the therapeutic alliance (King, Bambling, Reid, & Thomas, 2006; Reynolds, Stiles, & Grohol, 2006).

Liebert, Archer, Munson, and York (2006) using the Client Satisfaction Inventory (CSI; McMurtry & Hudson, 2000) investigated satisfaction with online counseling, establishing a mean satisfaction rating of 67.8 (out of 100) for a sample of 81 participants. When benchmarked with F:F studies of satisfaction the authors concluded that clients were reporting satisfaction but less so than in F:F counseling (Liebert et al., 2006). For example, a validation study of the CSI in a F:F counseling sample generated a client satisfaction score of 88.1 (out of 100; McMurtry & Hudson, 2000). The authors found that the more hours respondents spent online, the more likely they were to make use of online counseling. Noted advantages in using such a service included convenience, anonymity, and privacy. It can be speculated that some individuals presenting with specific issues, such as trauma, phobia, or social marginalization, may “need to communicate without fear of the listener’s first reaction” (Liebert et al., 2006, p. 83).

In a more recent study the authors reported no statistically significant difference in satisfaction scores for F:F and online clients (Murphy et al., 2009). It would seem that satisfaction rating for online counseling have been high, yet perhaps not as high as those found in F:F studies, but, again, the studies were limited by small samples and there is only a small number of studies available.

Much valuable work has been achieved to investigate and establish an empirical base for online counseling. Yet the existing empirical literature that supports any in-session effects and the achievement of outcomes from online counseling, while positive, is limited at present. Con- sequently, apart from stating that it seems to work like it does in the F:F context, it is difficult to draw precise conclusions as to the efficacy and effectiveness of online counseling. Robust empir- ical investigations with larger samples and comparisons to F:F clients and/ or control groups of some type would strengthen the empirical base. Additionally, investigating process variables that contribute to in-session events and eventual outcomes need further research, especially to find out whether they are the same predictors of outcomes as exist in F:F counseling.

The Therapeutic Relationship in Online Counseling

At the center of the therapeutic endeavor is the belief that a responsive relationship produces changes in cognition, feelings, and behaviors (Holmes & Lisndley, 1989). In F:F counseling it has been noted that the early absence of the therapeutic alliance or the failure of it to develop is a likely indication that the therapy will be unsuccessful (Gelso & Hayes, 1998). Research has demonstrated the importance of the working alliance to successful outcome in F:F counseling (Horvath & Bedi, 2002; Martin, Garske, & Davis, 2000). A significant challenge for online counseling is establishing the possibility to create equally meaningful relationships through CMC.

The study described earlier by Glueckauf and colleagues (1999, 2002) used the Working Alliance Inventory (WAI) to compare the alliance in videoconferencing, audio phone, and F:F counseling for teenagers. While clients reported higher levels of alliance in the F:F condition, there did not exist any significant differences across the three treatment groups for the alliance. Another early study (Cohen & Kerr, 1998) that compared the effects of computer-mediated online counseling and traditional F:F counseling on levels of anxiety and attitudes toward

Online Counseling: A Narrative Review 1001

counseling reported that participants in both modes of delivery reported similar ratings regarding clients’ perceptions of therapists’ expertness, attractiveness, and trustworthiness.

Cook and Doyle (2002) in their study of 15 clients of online therapy–e-mail and chat-based– compared with a F:F sample (N = 25), found equivalent alliance scores for both groups on the WAI. They reported significantly higher means on the goal subscale and the composite score for the WAI, suggesting that a working alliance as a central ingredient to outcome could also be established in online counseling. However, the study did not include a F:F comparison group and the self-selected sample were small. Qualitatively online clients reported experiencing strong bonds with their therapists and benefiting from the effects of disinhibition. This latter point perhaps supports McKenna and Bargh (2000) findings that individuals who are socially isolated and anxious and who have difficulties forming relationships are more likely to form deep and lasting relationships online than in person.

A review of the literature concluded that studies concerning the therapeutic alliance in online counseling were scarce, yielding mixed results (Mallen, Vogel, Rochlen, & Day, 2005). How- ever, the review (Mallen et al., 2005) considered only three studies regarding the therapeutic relationship in online counseling and, while they found that F:F contact was superior to online communication in establishing a relationship, no significant difference was found for emotional understanding. Since that literature review subsequent research seems to increasingly support the feasibility of developing therapeutic relationships online with modest to high alliance scores being consistently found.

For instance, Prado and Meyer (2004) in a study of the alliance in asynchronous online therapy reported that clients (N = 53) and therapists (N = 20) created solid working alliances as measured by the WAI. The study revealed significant differences in working alliance levels reported, greater for those who completed treatment (n = 29) compared with those who abandoned treatment early (n = 19). However, they concluded that it was possible to conduct therapy asynchronously online and the therapeutic relationship was similar to what is generally found in F:F studies.

Using a convenience sample of 81 participants Leibert, Archer, Munson, and York (2006) examined levels of therapeutic alliance in online counseling and compared them against levels found in F:F counseling. They showed that clients from F:F reported significantly higher ratings than those in online counseling; this was found to be the case on the composite and each of the three subscales of the WAI. Additionally, alliance scores significantly predi

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