A study of mental health counselors' use of and perspectives on distance counseling.

Using a survey measuring 21 factors proposed in recent literature to be advantages or disadvantages of distance counseling, with a sample of 854 mental health professionals, we investigated perceptions and use of counseling by telephone, e-mail, text chat, and videoconference. Most participants reported using distance counseling in some form, but they perceived more disadvantages than advantages. Recommendations are provided for professionals considering the practice of distance counseling.

**********

Counseling relationships have historically developed through a series of in-person communications between counselor and client. However, today telephone and online modalities offer an alternative for forming those relationships. This change has a plethora of both advantages and disadvantages that mental health professionals might perceive. Though several studies have addressed the perceptions of clients (Young, 2005; Reese, Conoley, & Brossart, 2006; Leibert, Archer, Munson, & York, 2006) and students (Finn, 2002; Rochlen, Beretvas, & Zack, 2004) about distance counseling (the provision of counseling services by telephone or Internet modalities), there is a dearth of studies of how mental health professionals view and use it.

TELEPHONE COUNSELING

Telephone counseling is a professional relationship between a counselor and a client carried out entirely by telephone; it has existed in some form since the Samaritans started a suicide prevention hotline in London in 1953. Today telephone counseling services fill many roles, among them health assessment, education, crisis intervention, consultation, client referral, and counselor supervision (Cruz, SanMartin, Guitierrez, Farias, & Mora, 2001; Boucher, Pronk, & Gahling, 2003). Services range from treating disorders one-on-one to group counseling to the related fields of psycho-education and life coaching.

In a recent survey of American Psychological Association (APA) members, 98% affirmed that they have provided counseling services over the phone, and 69% that they provide psychotherapy by phone at least on occasion (VandenBos & Williams, 2000). Similarly, a survey of psychiatrists found 45% use the telephone as an adjunct to in-person sessions and 19% as their primary medium for providing treatment (Lester, 2002).

ONLINE COUNSELING

Online counseling is recognized by many names, such as "webcounseling," "etherapy," "ecounseling," and "cybercounseling." Nearly 1,000 professionals offer counseling services online, and even more have Internet dimensions to their practices that include advertising, information, and the ability to e-mail the clinician (Manhal-Baugus, 2001; Heinlen, Reynolds, Richmond, & Rak, 2003).

RECOGNITION BY PROFESSIONAL ORGANIZATIONS

In response to the expanding use of technology in counseling, ethical statements or codes have been written by the APA (1997), the American Counseling Association (1999), the National Board for Certified Counselors (2001), and the American Mental Health Counselors Association (2000). The AMHCA code states:

   Mental health counselors engaged in delivery of services that
   involve the telephone, teleconferencing and the Internet ... take
   responsible steps to ensure the competence of their work and
   protect patients, clients, students, research participants, and
   others from harm (Principle 14).

The sentiment of nearly every organization that has addressed the issue is the same: one can practice online counseling if it can be provided with competence and if counselors can fulfill their ethical duties.

FACTORS IN DISTANCE COUNSELING

Distance counseling may have several advantages over in-person counseling. Among them might be, for clients, increased safety and anonymity, reduced social stigma, greater counselor selection and accessibility, and service affordability. In contrast, providers see factors that raise concerns, such as whether distance counseling is ethical and legal, clinically effective, and financially viable. These factors are discussed below.

Safety

Distance counseling may increase the sense of safety, because clients are able to receive help from within their home environment. This may make it easier for them to express themselves more fully. For example, a study investigating Thai women in a coed online discussion found that those who were passive in face-to-face interactions spoke more assertively and frequently online (Panyametheekul & Herring, 2003).

Anonymity

With distance counseling clients can communicate without concern for the bias of race, gender, age, size, or physical appearance (Worona, 2003). One of the first online counseling services was that of Cornell University, begun in 1986 (see http://ezra.cornell.edu). This service allows queries from anonymous students, and a counselor responds in a public Internet post. After 21 years this program is still active; users confirm that if it were not for the anonymous format, they would never have revealed their problems.

Social Stigma

Because it is unlikely for distance counseling clients to encounter the counselor in public or be seen by others near a counseling center, distance counseling may be effective in eliminating social stigma. One study investigating the use of phone counseling services by Arab Israeli callers found the medium may be a culturally appropriate method of providing services to people who underutilize other forms of professional mental health services (Al-Krenawi, Graham, & Fakher-Aldin, 2003).

Selection

Distance counseling may offer clients a greater selection of therapists to choose from. This is beneficial for persons looking for a counselor with specific experience or with a particular language, religious, or ethnic understanding. Similarly, since the 1980s online support groups and forums dedicated to a variety of emotional problems have allowed persons to reach others dealing with similar issues across the world (Grohol, 2004; Anthony, 2003).

Accessibility

Distance counseling is advantageous to individuals residing in areas where counseling services are not available and to those who are unable to leave home. Also, while in-person counseling may be incompatible with a client's work schedule, some distance counseling services are available 24 hours a day. Even if counselors are not available at all hours, e-mail gives the perception that they are. A client can communicate any time, and since sessions do not have a defined beginning or end, there may be a more supportive psychological holding environment (Childress, 2000).

Affordability

Distance may be more economical than in-person counseling because counselors who do not need to rent commercial space have lower overhead costs, and neither client nor counselor has commuting expenses. Moreover, clients may be able to invest fewer hours in distance counseling because the dialog that ensues is often more goal-directed. In communications through telephone and Internet, small talk is greatly lessened and individuals address important issues faster (Boucher, Pronk, & Gahling, 2000; Tidwell & Walther, 2002).

Ethical Legal and Practice Concerns

As in in-person provision, numerous ethical and legal issues arise in distance counseling. Areas of particular concern are confidentiality, dealing with suicidal or dangerous clients, crisis response, and counseling clients across state lines (Kraus, 2004). While the last is an issue on which most state boards have no formal position or legal precedent (Slavich, 2003; Kraus, 2004), a number of articles have been published about other ethical issues in distance counseling, which have usually been found to be challenging but not impossible to resolve (Zack, 2002). With regard to rapport, the traditional view is that text-based communication is substandard for building rapport, but other studies have found distance counseling technologies to be effective (Lea & Spears, 1995; Walther, 1996; Manning, Goetz, & Street, 2000).

According to the standards of the AMHCA (2000), counselors are ethically obligated to provide viable treatment. While some studies contend distance counseling is less efficacious than in-person sessions (Champion, 1988; Parks & Floyd, 1996; Michailidis & Rada, 1997; Hian, Chuan, Trever, & Detenber, 2004), others have found client improvement with online and telephone modalities to be equal to, or in some cases greater than, with in-person services (see Lynch, Tamburrino, & Nagel, 1997; Celio et al., 2000; Lange, Van de Ven, Schrieken, Bredeweg, & Emmelkamp, 2000; Winzelberg et al., 2000; Klein & Richards, 2001; Robinson & Serfaty, 2001; Tate, Wing, & Winett, 2001; Zabinski et al., 2001; Reese, Conoley, & Brossart, 2002).

Last come financial viability issues, including the cost of beginning and maintaining a practice: being trained, marketing, acquiring clients, and receiving payment. Currently, the literature does not demonstrate clearly that distance counseling is either advantageous or disadvantageous for counselor financial viability.

FACTORS RELATED TO TEXT-BASED DISTANCE COUNSELING

The Clinical Social Work Federation (CSWF) states in reference to text-based counseling that "psychotherapy services cannot be delivered online [specifically via text] because of the inherent nature of the service and, therefore, the federation is opposed to the practice of Internet-based treatment" (Lonner, Trimm, Phillips, Amey, & Jean Synar, 2001). However, those who offer text-based counseling identify numerous advantages to the modality, in addition to those of distance counseling in general:

1. Text-based interactions (especially those with a time delay) allow both client and counselor to pay close attention to their communications, and reflect on their own thoughts and feelings, while still in dialogue (Suler, 2000, 2004; Speyer & Zack, 2003). Also, writing often invokes the writer to reread and review what was written, a process that promotes client objectivity about a problem (Childress, 2000).

2. New associations and insights and the recovery of old memories are common benefits of the process of writing out one's story. Also, while with in-person sessions a client may speak for an hour and not reach the heart of a matter, with email counseling a client may be able to communicate more in a single sentence that is written after an hour of reflection than in an entire in-person session.

3. Text-based interactions allow participants to comment on and directly quote pertinent excerpts of previous exchanges. This heightens the accountability to their statements of both client and counselor. Clients may also communicate in a less restricted manner by text because they are less affected by the positive or negative leads of a therapist (Suler, 2004).

4. While all distance counseling modalities increase client anonymity, text-based counseling offers the most--clients need not even share the timbre of their voice. Though they are more anonymous, clients also have heightened ownership of the counseling process, for they set the pace and tone by controlling both the content and frequency of disclosures.

5. Discussions are easily saved or printed, allowing clients to reread therapeutic guidance years after therapy ends. This may strengthen old resolutions and testify to the client's progress (Speyer & Zack, 2003).

SUMMARY

Clearly, researchers have raised the possibility of both advantages and disadvantages to distance counseling. However, a further question is how clinicians in general perceive distance counseling and its potential, both positive and negative.

PURPOSE OF THE STUDY

Using a survey that measured 21 factors proposed in recent literature to be advantages or disadvantages of distance counseling, this study undertook to investigate counselor perceptions and use of four distance counseling modalities (telephone, email, text chat, videoconference). Congruent with recent studies, we predicted that participants would perceive some advantages to distance counseling but would perceive disadvantages to items related to rapport, clinical efficacy, and ethical duties.

METHOD

Participants

Two requests for participation were sent to persons on an email list for a national counseling organization that claims 50,000 members (American Association of Christian Counselors). The first went to 10,117 addresses and was opened by 42.6% (n=4,306) of recipients. The second, sent to the same list, went to 10,162 addresses and was opened by 38.0% (n=3,856). Potential participants (volunteers) were given the option to take the survey online or request a paper survey: 2,429 persons completed an online survey, and 7 paper surveys were mailed in response to requests. No completed paper surveys were returned. Surveys that were incomplete or completed by persons who did not self-identify as a mental health professional were excluded from the study. The final sample consisted of 854 mental health professionals. As compensation for participation subjects were enrolled in a drawing to win one of 12 items (books and DVDs).

Participants self-reported their professional status: 8.5% (n=73) were clinical psychologists, 15.2% (n=130) clinical social workers, 58.5% (n=500) licensed professional counselors (LPC, LMHC, etc.), and 27.9% (n=238) marriage and family therapists (cumulative 110.2% due to colicensed participants). Only 2.6% (n=22) had been providing counseling for less than a year; 24.5% (n=209) had been providers for 1-5 years, 23.5% (n=201) for 6-10 years, 22.7% (n=194) for 11-16 years, and 26.0% (n=222) for 17 or more years.

Only 0.8% (n=7) were 25 or younger; 13.2% (n=l13) were 26-35, 17.8% (n=152) 36-45, 37.0% (n=316) 46-55, and 29.4% (n=251) 56 or older. Only 1.7% (n=15) did not disclose their age. The sample was about 37.1% (n=317) male, and 61.8% (n=518) female, with 1.1% (n=9) not disclosing sex.

Instrumentation

Survey questions were designed to reflect peer-reviewed articles that addressed potential advantages and disadvantages of distance counseling and were influenced by four surveys used in previous studies of student perceptions of online counseling (see Finn, 2002; Rochlen, Beretvas, & Zack, 2004). The final survey was a 148-item inventory designed to access counselor use of distance counseling and perceptions of 21 distance counseling factors.

RESULTS

Participant-Reported Use

Participants were asked to report their use of the four distance counseling modalities, which were defined as follows: "'email counseling' is the provision of counseling by means of email exchanges between client and counselor"; "'online text chat counseling' is the provision of counseling by online text exchanges in 'real time'"; "'telephone counseling' is the provision of counseling by telephone"; and "'videoconference counseling' is the provision of counseling by video where both client and counselor can see each other and verbally communicate back and forth in real time." To assess use, participants confirmed or denied the statement, "I provide or have provided [variable]."

Telephone counseling was most widely reported; 73.8% (n=630) of participants stated they had used the medium for counseling. Email counseling was second, confirmed by 28.1% (n=240). Text chat was third with 5.6% (n=48). Videoconference was least utilized at 1.2% (n=10).

Participant-Reported Attitude

For each of the four mediums, participants were asked: "Please rate your attitude toward the following [variable modality]." Responses were given on a five-point Likert scale ranging from "very positive" to "very negative" (the middle value was "neutral").

Responses were more negative than positive. While 24.7% (n=221) did state they had a "very positive" or "positive" attitude toward email counseling, 43.5% (n=459) said they had a "negative" or "very negative attitude." Videoconference counseling was similar: 28.7% (n=245) stated they felt positively and 34.9% (n=298) negatively. Attitudes toward text-chat counseling were the most negative: only 14.0% (n=120) reported positive attitudes against 65.5% (n=559) negative. In contrast, 49.2% (n=420) of participants reported positive attitudes toward telephone counseling, and only 19.3% (n=165) reported negative attitudes. However, high percentages stated they felt "neutral" toward all the mediums: 20.1% (n=172) reported a neutral attitude for email, 34.5% (n=295) for videoconference, 18.6% (n=159) for text chat, and 30.1% (n=257) for telephone (1.4% of participants did not answer for email and telephone modalities, and 1.9% did not answer for text-chat and videoconference modalities).

PERCEPTIONS OF DISTANCE COUNSELING FACTORS

Perceptions of Counseling by Email

To elicit perceptions of email counseling factors, participants were asked two questions, one on client and the other on counselor factors. The client item read: "In comparison to face-to-face counseling, email counseling provides clients [variable]." The counselor item read: "Compared to face to face counseling, counselors using email counseling [variable]." The variables are listed in Table 1. Using a 5-point Likert scale, participants rated their perceptions from increased to decreased. Responses showed a range of opinions on each issue (see Table 1).

Perceptions of Counseling by Text Chat

To assess perceptions of text-chat counseling factors, participants were presented with the same questions and variables used for accessing email counseling, but with "online text chat counseling" substituted for "email counseling" in the item. Responses again showed a range of opinions on each issue Table 2).

Perceptions of Counseling by Telephone

To elicit perceptions of telephone counseling, participants were presented the same questions and variables used for accessing email counseling, with "telephone counseling" substituted for "email counseling." Responses again showed a range of opinions on each issue (Table 3).

Perceptions of Videoconference Counseling

To assess perceptions of videoconference counseling, participants were presented the same questions and variables used for accessing email counseling, with "videoconference counseling" substituted for "email counseling." Responses again showed a range of opinions on each issue (Table 4).

Summary

While reported perceptions varied between modalities, some trends were consistent. For all four modalities, participants reportedly perceived one item, "client social stigma," to be decreased (an advantage), but also reported decreases in a counselor's ability to "build rapport," "fulfill ethical duties," and "treat mental disorders" (disadvantages).

DISCUSSION

Participants in this study reported less use of distance counseling modalities than those in previous studies. For instance, while a survey of APA member psychologists found that 98% had used telephone counseling (VandenBos & Williams, 2000), only 74% of participants in this study reported its use. The question is whether mental health professionals have decreased their use of distance counseling or whether differences in the samples account for the discrepancy.

It is not yet known what increases use of, or improves a professional's attitude toward, distance counseling. While in general participant perceptions of client and counselor factors for a modality, positive or negative, seemed to be similar to their attitude to and use of that modality, there were exceptions. For example, participants reported positive perceptions of individual factors of videoconference counseling (two-thirds of factors for videoconference counseling were considered equal or better than in-person counseling), but few used it. Similarly, though counselors perceived ethical and clinical items negatively for all distance counseling mediums, they still reported a positive attitude toward telephone counseling. One explanation is that even if distance counseling modalities are perceived to be inferior in some areas to in-person practice, counselors may still perceive them as sufficient in those areas, and advantageous in others, such as convenience.

Ethical and Efficacy Issues

For every distance counseling modality, the participants perceived their "ability to fulfill ethical duties" to be decreased. It is not yet known whether counselors are at a disadvantage in fulfilling ethical duties with distance counseling, or whether they merely lack confidence in their abilities. In either case, counselor training that addresses emerging ethical issues in distance counseling could be useful in improving counselors' perceived abilities.

Likewise, while recent studies have suggested that distance counseling is successful in providing both rapport and efficacy with a variety of clients and settings (Lynch, Tamburrino, & Nagel, 1997; Hian, Chuan, Trevor, & Detenber, 2004), participants gave very negative responses to clinical items. Perhaps this discrepancy exists because, though the research is optimistic, there is not enough supporting research at this time to convince practitioners.

Financial Viability

Financial issues specific to distance counseling provision were assessed. Upon analyzing responses, the majority of participants reported "cost of providing services" and "overall financial earnings" to be neither increased nor decreased compared to in-person counseling. Since financial reward is a powerful motivator, this result may help to explain why online mental health services have grown slowly compared to other online industries, such as shopping, networking, and banking.

Influences on Negative Perceptions

Though responses were not universally negative, many participants expressed negative attitudes toward the various modes of distance counseling. There may be several reasons for this. First, because the earliest studies of distance counseling were profoundly negative (Parks & Floyd, 1996; Michailidis & Rada, 1997), some counselors who express a negative perception of distance counseling may recall those early writings. Other counselors might never have been shown, or are not convinced of, the potential advantages of distance counseling. Studying student perceptions of online counseling, Finn (2002) found his participants to be unfamiliar with the modality; he said, "few students had ever even seen an etherapy website" (p. 412).

Limitations of Study

This study is not without limitations:

1. Though response rates were high--as many as 62.99% of the 3,856 persons who opened the official request for participation completed the survey--there may still be a relevant difference between those who did and those who did not complete it.

2. Participants were solicited from an email list of the American Association of Christian Counselors. While we could not identify a plausible reason that religion would significantly affect perception of distance counseling, a sample is never fully representative of a population.

3. Solicitations for participation were sent by email. Though participants had a choice of completing the inventory online or by hard copy, email solicitation leads to a potential sampling bias, since all potential participants must have at least minimal technological proficiency.

Usefulness of Findings

The findings of this study are useful in several ways:

1. It adds to the current knowledge base of the topic.

2. Because professionals' perceptions of distance counseling may directly affect whether they will or will not use it, understanding such perceptions will help mental health associations like the AMHCA to assess needs as they endeavor to support and equip clinicians.

3. For advocates of distance counseling, the data from this study provide considerable insight into disadvantages that mental health counselors perceive. Improving these perceptions may be an effective way to improve attitudes toward distance counseling and promote its adoption.

Recommendations for Mental Health Counselors

For mental health counselors considering distance counseling, important preliminary steps in due diligence are to become familiar with current modalities for distance counseling (telephone, email, text chat, and video conference) and gain a foundational knowledge of ethical regulations and allowances for distance counseling (see, e.g., AMHCA, 2000).

After these foundations are in place, formal training is advisable. Several sources are currently offering training, and professional conferences now often include workshops on distance counseling. Also, a number of books and clinical guides have recently been published on the topic (see Centore, 2007).

It would also be advisable to approach the practice of distance counseling slowly, as competence and comfort level permit. The practice might start with creating a Web site that contains biographical and practice information and allows visitors to the site to contact the provider by telephone or email. Counselors can also practice using distance counseling modalities in a nonprofessional context by joining online groups that utilize them. Engaging with groups of this sort makes it possible to test skills at building rapport and providing empathetic support to others.

Whether mental health counselors choose to adopt distance counseling methods or not, it is possible that client demand for such services will increase. In future more and more clients may reach out for help by telephone, email, text chat, and even videoconference. It will take a skilled and flexible generation of clinicians to listen, and respond.

REFERENCES

Al-Krenawi, A., Graham, J. R., & Fakher-Aldin, M. (2003). Telephone counseling: A comparison of Arab and Jewish Israeli usage. International Social Work, 46, 495.

American Counseling Association Governing Council. (1999). American Counseling Association code of ethics. Alexandria, VA: Author.

American Mental Health Counselors Association (2000). Code of ethics of the American Mental Health Counselors Association. Principle 14. Retrieved October 1, 2005, from http://www.amhca.org/code

American Psychological Association. (1997). APA statement on services by telephone, teleconference. and internet: A statement by the ethics committee of the American Psychological Association. Retrieved February 20, 2005 from http://www.apa.org/ethics/stmnt01.html.

Anthony, K. (2003). The use and role of technology in counselling and psychotherapy. In S. Goss, & K. Anthony (Eds.), Technology in counseling and psychotherapy: A practitioner's guide. Great Britain: Palgrave Macmillan.

Boucher, J., Pronk, N., & Gahling, E. (2003, Fall). Telephone based lifestyle counseling. Diabetes Spectrum, 13, 190.

Celio, A. A., Winzelberg, A. J., Wilfley, D. E., Eppstein-Herald, D., Springer, E. A., Dev, P., et al. (2000). Reducing risk factors for eating disorders: Comparison of an Internet and a classroom-delivered psychoeducational program. Journal of Consulting & Clinical Psychology, 68, 650-657.

Centore, A. J. (2007). The therapist's clinical guide to online counseling and telephone counseling: The definitive training guide for clinical practice. Cambridge, MA: Author.

Champion, P. S. (1988). A comparison of telephone and face-to-face intervention within an employee assistance program. Dissertation Abstracts International, 49, 2847.

Childress C. A. (2000). Ethical issues in providing online psychotherapeutic interventions. Journal of Medical Internet Research. 2(1): e5. Retrieved February 20, 2005, from http://www.jmir.org/2000/1/e5/.

Cruz, B. R., SanMartin, A. H., Guitierrez, B. L. N., Farias, M. V., & Mora, I. S. (2001). Identifying young people's guidance needs through telephone counseling. Adolescence, 36(141), Retrieved April 1, 2006, from http://findarticles.com/p/articles/mi_m2248/is_141_36/ai_76498115.

Finn, J. (2002). MSW student perceptions of the efficacy and ethics of Internet-based therapy. Journal of Social Work Education, 38, 403-432.

Grohol, J. (2004). A historical perspective. In R. Kraus, J. Zack, & G. Strickler (Eds.), Online counseling: A handbook for mental health professionals, New York: Elsevier Academic Press.

Heinlen, K. T., Reynolds, W. E., Richmond, E. N., & Rak, C. F. (2003). The scope of web counseling: A survey of services and compliance with NBCC standards for ethical practice of web counseling. Journal of Counseling and Development, 81, 61-69.

Hian, L. B., Chuan, S. L., Trevor, T. M. K., & Detenber, B. H. (2004). Getting to know you: Exploring the development of relational intimacy in computer-mediated communication. Journal of Computer Mediated Communication, 9, 1-24.

Klein, B., & Richards, J. C. (2001). A brief Internet-based treatment for panic disorder. Behavioural & Cognitive Psychotherapy 29, 113-117.

Kraus, R. (2004). Ethical and legal considerations for providers of mental health services online. In R. Kraus, J. Zack, & G. Strickler (Eds.), Online counseling: A handbook for mental health professionals. New York: Elsevier Academic Press.

Lange, A., Van de Ven, J-P. Q. R., Schrieken, B. A. L., Bredeweg, B., & Emmelkamp, P. M. G. (2000). Internet-mediated, protocol-driven treatment of psychological dysfunction. Journal of Telemedicine and Telecare, 6. 15-21.

Lea, M., & Spears, R. (1995). Love at first byte? Building personal relationships over computer networks. In J. T. Wood, & S. Duck (Eds.), Under-studied relationships: Off the beaten track (pp. 197-233). Thousand Oaks, CA: Sage.

Leibert, T., Archer, J., Munson, J., & York. (2006). An exploratory study of client perceptions of Internet counseling and the therapeutic alliance. Journal of Mental Health Counseling, 28, 69-83.

Lester, D. (ed.) (2002). Crisis intervention and counseling by telephone, Springfield, IL: Charles C. Thomas.

Lonner, R. B., Trimm, S., Phillips, D. G., Amey, B., & Jean Synar, B. (2001). CSWF position paper on Interact text-based therapy. Clinical Social Work Federation. Retrieved February 22, 2005, from http://www.cswf.org/www/therapy.html.

Lynch, D. J., Tamburrino, M., & Nagel, R. (1997). Telephone counseling for patients with minor depression: Preliminary findings in a family practice setting. Journal of Family Practice, 44, 293-299.

Manning, T., Goetz, E., & Street, R. (2000). Signal delay effects on rapport in telepsychiatry. Cyber Psychology and Behavior, 3. 119-127.

Manhal-Baugus, M. (2001). E-therapy: Practical, ethical, and legal issues. CyberPsychology & Behavior, 4, 551-563.

Michailidis A., & Rada, R., (1997). Activities and communication modes. International Journal of Human-Computer Studies, 46, 469-483.

National Board for Certified Counselors. (2001). Standards for the ethical practice of web counseling. Retrieved February 20, 2000, from http://www.nbcc.org/ethics/wcstandards.htm

Panyametheekul, S., & Herring, S. (2003). Gender and turn allocation in a Thai chat room. Journal of Computer Mediated Communication, 9(1).

Parks, M. R., & Floyd, K. (1996). Making friends in cyberspace. Journal of Communication, 46, 80-97.

Reese, R., Conoley, C., & Brossart, D. (2002). Effectiveness of telephone counseling: A field-based investigation. Journal of Counseling Psychology, 49, 233-242.

Reese, R., Conoley, C., & Brossart, D. (2006). The attractiveness of telephone counseling: An empirical investigation of client perceptions. Journal of Counseling & Development, 84, 54-60.

Robinson, P. H., & Serfaty, M. A. (2001). The use of e-mail in the identification of bulimia nervosa and its treatment. European Eating Disorders Review, 9, 182-193.

Rochlen, A. B., Beretvas, S. N., & Zack, J. S. (2004, July). The online and face-to-face counseling attitudes scales: A validation study. Measurement of Evaluation in Counseling and Development, 37, 95-111.

Slavich, S. (2003). The status of online mental health services. Unpublished doctoral dissertation, Wichita State University, Kansas.

Speyer, S. & Zack, J. (2003). Online counseling: Beyond the pros and cons. Psychologica, 23(2), 11-14.

Suler, J. (2000). Psychotherapy in cyberspace: A 5-dimensional model of online and computer-mediated psychotherapy. CyberPsychology and Behavior, 3, 151-160.

Suler, J. (2004). The psychology of text relationships, In R. Kraus, J. Zack, & G. Strickler (Eds.), Online counseling." A handbook for mental health professionals, New York: Elsevier Academic Press.

Tate, D. F., Wing, R. R., & Winett, R. A. (2001). Using Internet-based technology to deliver a behavioral weight loss program. Journal of the American Medical Association, 285, 1172-1177.

Tidwell, L. C., & Walther, J. B. (2002). Computer-mediated communication effects on disclosure, impressions, and interpersonal evaluations: Getting to know one another a bit at a time. Human Communication Research, 28, 317-348.

VandenBos, G. R., & Williams, S. (2000). The Internet versus the telephone: What is telehealth, anyway? Professional Psychology: Research and Practice, 31, 490-492.

Walther, J. B. (1996). Computer-mediated communication: Impersonal, interpersonal, and hyper-personal interaction. Communication Research, 23, 3-43.

Winzelberg, A. J., Eppstein, D., Eldredge, K. L., Wilfley, D., Dasmahapatra, R., Dev. P., et al. (2000). Effectiveness of an Internet-based program for reducing risk factors for eating disorders. Journal of Consulting & Clinical Psychology. 68, 346-350.

Worona, S. (2003). Privacy, security, and anonymity: An evolving balance. Educause Review 38, 62-63

Young, K. S. (2005). An empirical examination of client attitudes towards online counseling. CyberPsychology & Behavior, 7, 171-177.

Zabinski, M. F., Pung, M. A., Wilfley, D. E., Eppstein, D. L., Winzellberg, A. J., Celio, A., et al. (2001). Reducing risk factors for eating disorders: Targeting at-risk women with computerized psychoeducational program. International Journal of Eating Disorders, 29, 401-408.

Zack, J. (2002, September/October). Online counseling: The future for practicing psychologists? National Psychologist, 11(5), 6B-8B.

Anthony J. Centore is in private practice in Cambridge, MA, Fred Milacci is affiliated with Liberty University. Correspondence concerning this article should be addressed to Anthony J. Centore, Thrive Boston Counseling, 875 Massachusetts Ave, Suite 83, Cambridge, MA. E-mail: [e-mail].

Table 1. Reported Perceptions of Factors for Email Counseling
(Percentages)

Variables                  Increased   Somewhat    Equal   Somewhat
                                       Increased           Decreased
Client Factors
Sense of safety               7.1        26.5      18.6      30.4
Sense of anonymity           38.9        41.7       8.7       5.4
Social stigma                 4.4         7.6      22.5      39.8
Access to counselor          15.3        36.1      21.2      16.6
Selection of counselors      14.9        22.8      30.6      18.6
Cost/price for counseling     4.6        13.3      47.8      23.3
Feeling understood            2.2         4.7      22.1      44.7
Feeling cared for             2.8         6.8      18.9      44.5
Feeling connected             3.6         9.4      13.6      38.1

Counselor Factors
Fulfill ethical duties        1.9         2.8      30.0      42.7
Build rapport                 1.2         3.4      10.7      56.6
Assess issues                 1.2         5.0      20.1      50.8
Administer mental
status exam                   0.8         4.4      17.4      36.8
Treat life issues             0.7         3.0      25.6      49.2
Treat spiritual issues        1.1         3.2      25.1      49.3
Treat mental disorders        0.4         0.8       4.9      35.6
Deal with crisis              0.8         3.0       7.4      32.8
Overhead                      2.0        15.5      32.2      31.5
Client base                   4.0        26.7      34.4      21.7
Can charge low fee            4.8        39.0      35.6      11.8
Earnings                      2.9        19.7      42.4      22.2

Variables                  Decreased   No
                                       Answer
Client Factors
Sense of safety              14.9         2.5
Sense of anonymity            3.3         2.1
Social stigma                22.6         3.0
Access to counselor           7.6         3.2
Selection of counselors      10.1         3.0
Cost/price for counseling     6.2         4.8
Feeling understood           23.2         3.0
Feeling cared for            24.2         2.8
Feeling connected            32.6         2.8

Counselor Factors
Fulfill ethical duties       20.5         2.1
Build rapport                26.3         1.9
Assess issues                21.1         1.8
Administer mental
status exam                  38.4         2.1
Treat life issues            19.6         1.9
Treat spiritual issues       19.2         2.2
Treat mental disorders       56.1         2.2
Deal with crisis             54.1         1.9
Overhead                     15.3         3.5
Client base                   8.2         5.0
Can charge low fee            4.7         4.1
Earnings                      7.7         5.0

Table 2. Perceptions of Counseling Factors for Online Text-chat
Counseling

Variables                   Increased   Somewhat    Equal   Somewhat
                                        Increased           Decreased

Client Factors
Sense of safety                5.4        25.8      22.0      29.7
Sense of anonymity            23.8        45.0      13.1       8.0
Social stigma                  2.9         7.3      25.4      42.6
Access to counselor            6.9        27.4      35.2      18.4
Selection of counselors        7.5        21.1      30.9      22.7
Cost/price for counseling      3.2        12.3      45.8      25.2
Feeling understood             1.8         6.4      26.7      43.1
Feeling cared for              2.2         7.4      22.8      43.2
Feeling connected              2.1         9.0      18.7      39.1

Counselor Factors
Fulfill ethical duties         1.1         2.1      27.4      38.4
Build rapport                  1.2         2.7      13.8      52.0
Assess issues                  1.3         3.3      17.2      50.4
Administer mental
status exam                    0.6         3.2      15.2      37.2
Treat life issues              0.9         2.7      21.8      48.7
Treat spiritual issues         1.1         3.2      21.7      47.5
Treat mental disorders         0.4         0.9       4.8      36.1
Deal with crisis               0.8         2.2       8.7      36.7
Overhead                       1.8        12.9      33.7      34.0
Client base                    3.5        22.6      35.6      23.2
Can charge low fee             4.7        32.8      36.7      13.6
Earnings                       2.8        19.1      41.0      21.3

Variables                   Decreased   No
                                        Answer

Client Factors
Sense of safety               11.6         5.5
Sense of anonymity             4.3         5.9
Social stigma                 15.8         6.0
Access to counselor            6.1         6.0
Selection of counselors       11.9         5.9
Cost/price for counseling      6.2         7.4
Feeling understood            15.0         7.0
Feeling cared for             18.3         6.1
Feeling connected             24.5         6.6

Counselor Factors
Fulfill ethical duties        25.8         5.3
Build rapport                 25.1         5.3
Assess issues                 22.4         5.5
Administer mental
status exam                   38.2         5.6
Treat life issues             20.3         5.6
Treat spiritual issues        20.5         6.1
Treat mental disorders        52.1         5.7
Deal with crisis              45.7         6.0
Overhead                      10.5         7.1
Client base                    8.0         7.1
Can charge low fee             4.7         7.6
Earnings                       7.4         8.4

Table 3. Perceptions of Telephone Counseling (Percentages)

Variables                    Increased   Somewhat    Equal   Somewhat
                                         Increased           Decreased

Client Factors
Sense of safety                 7.5        31.3      36.1      21.3
Sense of anonymity             10.2        45.4      31.0       9.7
Social stigma                   2.8         8.4      32.3      45.3
Access to counselor             7.7        33.7      39.3      14.2
Selection of counselors         7.0        16.7      44.5      23.0
Cost/price for counseling       3.3        10.7      56.4      21.4
Feeling understood              4.3        12.1      36.9      38.8
Feeling cared for               5.3        12.6      33.8      38.6
Feeling connected               5.7        14.4      24.8      41.1

Counselor Factors
Fulfill ethical duties          2.0         4.0      40.6      38.2
Build rapport                   2.5         5.0      26.6      53.6
Assess issues                   2.1         4.7      26.2      52.8
Administer mental
status exam                     1.1         2.3      17.4      46.3
Treat life issues               1.9         3.5      30.6      48.6
Treat spiritual issues          1.6         4.7      32.3      45.6
Treat mental disorders          0.6         1.2       8.3      44.5
Deal with crisis                2.8         6.1      27.5      40.6
Overhead                        2.3        12.9      38.1      33.3
Client base                     3.6        21.5      41.3      23.2
Can charge low fee              4.0        32.3      39.8      14.3
Earnings                        3.2        19.4      45.3      18.9

Variables                    Decreased    No
                                          Answer

Client Factors
Sense of safety                 2.5         1.4
Sense of anonymity              1.9         1.8
Social stigma                   8.7         2.5
Access to counselor             2.5         2.6
Selection of counselors         6.4         2.3
Cost/price for counseling       4.2         4.0
Feeling understood              5.4         2.6
Feeling cared for               6.6         3.0
Feeling connected              11.4         2.6

Counselor Factors
Fulfill ethical duties         12.2         3.0
Build rapport                   9.6         2.7
Assess issues                  11.2         2.9
Administer mental
status exam                    30.1         2.8
Treat life issues              12.6         2.8
Treat spiritual issues         12.3         3.5
Treat mental disorders         42.7         2.7
Deal with crisis               20.4         2.6
Overhead                        8.7         4.8
Client base                     6.1         4.2
Can charge low fee              4.4         5.2
Earnings                        6.6         6.7

Table 4. Perceptions of Videoconference Counseling (Percentages)

Variables                   Increased   Somewhat    Equal   Somewhat
                                        Increased           Decreased

Client Factors
Sense o safety                 0.6        23.3      41.0      23.4
Sense of anonymity             1.6        13.7      53.2      19.1
Social stigma                  1.4         5.9      47.4      32.9
Access to counselor            2.9        14.1      46.4      24.6
Selection of counselors        3.3        11.4      32.3      30.4
Cost/price for counseling      2.3        12.4      58.9      16.0
Feeling understood             2.8         8.8      50.0      26.8
Feeling cared for              2.8         8.4      41.2      34.7
Feeling connected              3.0         9.4      32.2      39.8

Counselor Factors
Fulfill ethical duties         1.4         3.0      40.9      36.3
Build rapport                  1.8         4.4      33.3      44.7
Assess issues                  1.4         4.9      41.7      37.0
Administer mental
status exam                    1.1         4.6      39.3      33.8
Treat life issues              1.3         4.0      42.7      35.9
Treat spiritual issues         1.6         3.4      41.3      36.9
Treat mental disorders         0.8         2.3      19.8      42.7
Deal with crisis               1.1         3.2      24.5      42.9
Overhead                       5.7        21.0      35.7      24.5
Client base                    3.0        15.7      41.9      23.8
Can charge low fee             2.2        22.4      41.3      19.4
Earnings                       2.3        15.6      47.4      19.1

Variables                   Decreased    No
                                         Answer

Client Factors
Sense o safety                 3.4         6.0
Sense of anonymity             6.1         6.3
Social stigma                  6.0         6.4
Access to counselor            5.6         6.4
Selection of counselors       16.3         6.3
Cost/price for counseling      2.8         7.5
Feeling understood             5.0         6.6
Feeling cared for              5.6         7.3
Feeling connected              8.5         7.0

Counselor Factors
Fulfill ethical duties        11.4         7.0
Build rapport                  8.7         7.1
Assess issues                  8.3         6.7
Administer mental
status exam                   14.2         7.0
Treat life issues              8.5         7.5
Treat spiritual issues         9.6         7.1
Treat mental disorders        26.8         7.5
Deal with crisis              21.1         7.4
Overhead                       2.6         8.5
Client base                    6.8         8.8
Can charge low fee             5.5         9.1
Earnings                       5.7         9.8