Journal of Technology in Counseling - Greene - Lawson

Advances in computer technology and Internet accessibility demand that the counseling profession adapt in order to serve computer savvy clients. It is time for a paradigm upgrade for counseling and psychology (Gore, Leuwerke, & Krumboltz, 2002). The expansion of the information superhighway has led

to an almost overwhelming amount of information which can, in turn, lead to interesting dilemmas for counselors. Rapid advances in computer technologies represent some of the most profound changes and challenges facing mental health today. Counselors must be prepared to serve clients whose lives are enriched and complicated by information technology. The Internet affords clients opportunities to gain information on a wide variety of topics related to their concerns. However, the Internet is in many ways an open forum, where anyone can post any sort of information. Information on the Internet is not always accurate, and often is not in the best interest of the client. Counselors need to be aware of how clients assess, interpret, and process Web based information.

Individuals’ daily experiences are impacted in complex ways by the growth of technology in our society (Hughes, Ebata & Dollahite, 1999; Hohenshil, 2000; Gore et al, 2002). Emerging technologies change the environment of mental health care, making new tools and options available to psychologists and counselors. Internet resources provide quick access to mental health information (Guterman & Kirk, 1999), and soon clients will expect to use or reference this resource in their therapy. It is imperative that counselors develop and incorporate new technological competencies into research and practice (Jerome & Zaylor, 2000).

According to the Pew Internet and American Life Project (2004) 75% of online computer users reported that the Internet is an important part of people’s daily lives compared to 50% only 3 years ago. The U.S. Department of Labor, Bureau of Labor Statistics (2003) and the Pew Internet and American Life Project (2004) reported increases in computer ownership across demographic areas (i.e. education, age, race, income and region). It appears that the influence of the Internet will continue to grow and affect clients who come in for counseling in new and profound ways.

As the Internet continues to grow as a prominent component of daily life, Internet usage as a means of relating to clients also increases. Clients can find information about mental health concerns because of on-line information and interactions, and counselors have a corresponding need to be informed about how the Internet may relate to a client’s treatment. Authors have cited the impact of the Internet on children (Bremer & Rauch, 1998), on women (Maheu, 1999), on students (Owen & Weikel, 1999; Casey, 1995; D’Andrea, 1995), on families (Hughes, et al., 1999; Smith, 1999), and on many individuals (Rainie & Kobut, 2000). As computers continue to become less expensive and more accessible, more people will be affected by this technology. Daily, millions of people visit the World Wide Web, creating on-line associations (Wysocki, 1998). As new technologies develop and Internet use continues to grow, clients may come to counseling sessions with the expectation of discussing Internet use or material. Counselors providing face to face counseling need to keep up with technological advances and understand both the positive and negative potential of the Internet. The Internet can be used to enhance the counseling experience, and as such a clear understanding of the client’s Internet use is important in understanding the client’s world.

Purpose

The purpose of this study was to evaluate a) counselors’ knowledge of the Internet, b) the extent to which their clients make use of the Internet, and c) the extent to which counselors believe the Internet contributes to their professional practice. As the proliferation of the Internet continues, inevitably the impact will trickle down to clinical practice, affecting the face to face counseling process. For example, a client may come to a counseling session with information accessed via the Internet related to their symptomology, saying, “I’ve been on the Internet and it says I must be bi-polar, can you help me?” It is the counselors’ responsibility to process that information as it relates to the client specifically, to understand what motivated the Internet research, to ascertain the accuracy of the self-diagnosis, and perhaps to balance the client’s clinical presentation with her/his preconceived notion based on the Internet information. Since the client has already demonstrated Internet proficiency, the counselor could recommend specific ways of using the Internet for interventions in the client’s treatment. The counselor’s comfort level in addressing these client concerns may be rooted in her or his own competence in using computer based technologies. As Internet accessibility increases and the volume of information available over the Internet grows, clients will increasingly expect to use this kind of information to help with their concerns.

Although the potential for technology to play a role in counseling has been recognized (Harrison & Stephen, 1996), it is unclear what actual changes are taking place in counseling practice. This article sets out to describe the impact of the Internet on clinical work. Clinicians can use the information from this study as a point of reference regarding the significance of technology for their clientele and practice. A better understanding of how clients relate to technology can lead to better treatment by utilizing untapped resources. The Internet can be an important component and adjunct tool to the counseling profession.

Study participants were recruited from the membership of the American Mental Health Counselors Association through the state divisions. First, an email letter and a sample of the survey instrument were sent to presidents and executive directors of the fifty state divisions of the AMHCA. That letter explained the nature of the study and requested that the division presidents forward an invitation to participate in the study to their members. Seven state organizations chose to participate, including Vermont, Texas, Missouri, North Carolina, Georgia, Connecticut and Virginia and several individuals from other states were included based on their previous memberships with these seven states. A list was compiled of those counselors who had responded to the invitation, and the survey instrument was sent by email to these 534 participants. Of the 534 participants, 246 responded and of these, 215 were used in the final data analysis. Thirty-one participants were excluded due to missing data or because they did not meet the criteria for the study (i.e. counselors see at least five clients per week in a face to face setting (not cyber counseling)). There is no way to know how many counselors were actually recruited by the state divisions, an inherent limitation to the on-line recruitment of participants, but the response rate among counselors who had indicated a willingness to participate was 46%.

The 215 counselors who were included in the data analysis included 154 females and 61 males, 196 Caucasians, 11 African Americans, 2 Asian, 1 Hispanic and 3 who indicate “other” or did not respond to the question. Ages of the participants ranged from 24-70 with a mean age of 44.97, a median of 46.00 and a SD of 10.53. Number of years of counseling experience ranged from 0.5 to 40 with a mean of 11.44, a median of 10.00 and a SD of 8.58. With respect to work setting 18.6% worked in a community setting (not privately), 40% worked in private practice, 10.7% worked as a school counselor, 3.3% were students and 27.4% worked in other settings. Regarding licensure, 74% of respondents were licensed professional counselors, 12.1% were license eligible, but were not currently licensed, 10.2% were nationally certified counselors, but were not licensed as some states do not have licensure and 3.7% were not licensed. In characterizing their workplace setting, 38.6% endorsed an urban setting, 38.1% suburban and 23.3% rural. Differing levels of education were represented with 3 bachelor’s level, 158 master’s level degree, and 54 doctoral level respondents. Finally, 182 were members of a state mental health counseling organization and 33 were not. A demographic comparison from this study to other studies (Holcomb-McCoy and Myers, 1999) and to demographic data of the ACA (American Counseling Association, 2003) suggests that the sample from this study was characteristically similar to larger counselor populations.

An exploratory questionnaire was sent out to 10 mental health counselors within the state of Virginia who provide face to face counseling. This questionnaire was designed to elicit what kind of information should be included to best understand how clients and counselors use the Internet in the counseling process. Participants were encouraged to respond in detail to the following five open ended questions, which were designed to stimulate brainstorming.

1. List short anecdotal situations in which a client has discussed the Internet in the

counseling session.

2. What topics have clients brought up related to the Internet?

3. In what ways do you use the Internet in your clinical practice?

4. In what ways do clients use the Internet related to their counseling treatment?

5. Please add any information you feel may be useful related to this topic.

From the responses to the open ended exploratory questions, several themes emerged that focused the construction of the final instrument. The instrument scales and scale items were divided into sections within the instrument and are presented in Table 1.

The final survey instrument had 45 questions divided into six sections: (a) the counselors’ discussion of the Internet with their clients; (b) the counselors’ perceptions of clients’ use of the Internet; (c) the counselors’ perceptions of the impact of the Internet to the counseling profession as a whole; (d) the counselors’ self reported Internet competence; (e) practice questions targeting client topics of Internet discussion and targeting counselors’ specific uses of the Internet; and (f) demographics. A seven point partially open Likert scale was used for the content areas and demographic information was gathered through simple checkbox endorsements. Some open fields were included to gather qualitative data. The survey took approximately ten minutes to complete, and was administered on-line with simple point and click technology. Counselors were encouraged to participate through an offer to share a list of on-line resources gathered from the project after completing the survey instrument.

Survey instrument scales were developed to answer each research question listed below. Each scale was computed using the responses from individual items on the survey instrument. A score for each scale was computed from a one to seven point Likert scale. The means, standard deviations and reliabilities were summarized in Table 1.

What are the current self-reported technological and Internet competencies of counselors in practice and to what extent do counselors use the Internet in their practice?

To answer this question three scores were computed and these scores placed counselors on a seven point Likert rating- (a) counselors’ responses regarding discussion of the Internet in sessions, (b) counselors’ self-reported Internet competence, and (c) counselors’ overall Internet use in their practice. These scores, seen in Table 1 for each scale, were computed by taking the sums of the items that pertained to each scale and dividing by the number of items for that scale, placing the counselors’ overall score for each scale on the same seven point Likert demarcations as each scale item. Cronbach’s alpha for the three scales were .83, .88, and .81, respectively. A factor analysis confirmed that individual instrument items loaded to the targeted construct, and the component extraction showed that the scales were appropriate, as evidenced by the alpha scores.

These three scale scores demonstrated a disparity between a counselors’ Internet competence and their overall Internet use in practice or discussion of the Internet with clients in sessions. Correlational analysis of the scales demonstrated a linear relationship among the scales. Counselors who are on the upper end of the continuum in terms of Internet competence do use (r=.318) and discuss (r=.437) the Internet in their sessions more frequently than counselors at the lower end of the Internet competence continuum (p<.01). However even counselors who rate their Internet competence as high have relatively low in session discussions and low overall Internet use in practice. Simply put, high Internet competence does not equate with high Internet discussion or high Internet use, despite the statistically significantly positive correlations. Interestingly, the strongest relationship among any of the variables in this study was between counselors use of the Internet and the discussion of Internet in session (r=.911, p<.01). This highlights the fact that, regardless of how counselors rate their competence, those who use the Internet more also discuss it more.

What demographic variables are associated with the utilization of the Internet in clinical practice?

In responding to this question, counselors’ overall scores for Internet use in practice scale, the counselors’ discussion of the Internet in session scale and the counselors’ Internet competence scale were compared to demographic variables through an analysis of variance to determine if any statistical differences exist related to demographic variables and these scales (i.e. Are there gender differences evident in the responses?).

A t-test of gender differences in relation to scales showed no difference between genders in terms of internet competence (p=.962), suggesting that males and females rate themselves similarly in terms of Internet competence. However differences in overall Internet use in practice and overall Internet discussion in sessions were present (p=.072 and p=.084 respectively, significant at p<.1), with males scoring higher on both scales. This suggests that male counselors incorporate the Internet in their practice at higher levels.

In analyzing a correlation matrix with age compared to the scales, there was a statistically significant negative linear relationship for each of the scales (p<.01). Simply put, as age of the counselor goes down, there was a significant increase in self reported Internet competence, in Internet discussion in sessions, and in overall Internet use in practice (r=-.254, r=-.171 and r=-.186, respectively, correlations were significant at the 0.01 level). This suggests that younger counselors are utilizing the Internet in the counseling profession at higher rates.

An ANOVA analysis was run for age groupings that counselors see in their practices versus each of the three scale means for those groups. The age groupings were children and adolescents ages 1-18 (N=53), young adults ages 18-26 (N=22), adults ages 26-64 (N=93) and seniors ages 65+ (N=4). Similarly, as seen in this ANOVA analysis based on clientele age, counselors working with predominantly younger clientele were discussing the Internet at statistically higher rates in their sessions (p=.045, d=.34), suggesting that younger clientele may have higher expectations of discussing the Internet. The scale means also show that counselors working with clientele that are young adults discussed the Internet at the highest levels followed by counselors working with children and adolescents.

No other statistical differences were noted in running analyses on other demographic variables. Statistically significant differences in workplace settings (urban, suburban, and rural), in a counselor’s position or education, in the counselor’s licensure status and in counselors’ ethnic groupings were not noted.

What are counselors’ perceptions of their client’s knowledge and use of the Internet, as it relates to the client’s own mental health and treatment?

This question was answered by creating two scales related to the counselors’ perceptions of their clients. The first scale focused on perceptions of clients’ in session discussions of Internet use and was computed by summing the items listed for that scale in Table 1 and dividing by the total number of items for that scale, giving a score on a seven point Likert demarcation. The Cronbach’s alpha for the items in this scale was .89. The second scale focused on perceptions of overall Internet use by clients and was computed using the items listed in Table 1 under the respective scale. Item 14 failed to load in a factor analysis, and was removed from the item grouping as suggested by the extraction method. The subsequent Cronbach’s alpha for the items in this scale was .81 after dropping item 14. In examining the means for these scales, counselors’ perceptions of their clients’ uses of the Internet in regards to mental health and the discussions of the Internet during sessions is low. It appears that counselors do not see that the Internet is an important topic to their clients.

How might perceptions of a client’s utilization of the Internet be related to that counselor’s own knowledge and use of the Internet?

Counselors self report scores on knowledge and use of the Internet, and perceptions of how clients used the Internet were compared using a correlation matrix demonstrating a linear relationship between the scales. There is a positive correlation between counselors’ scores on in session discussions of the Internet (r=.414) or utilizes the Internet in their practice (r=.368), the higher the perception that their clients are also utilizing the Internet (both significant at p<.01). Assuming clientele across the sample is characteristically similar regardless of the counselor, the above correlation is important in that it suggests that higher levels of use equate with higher perceived importance to clients. Perhaps the Internet is equally important to clients of counselors in the lower use categories, but that importance goes unrecognized.

How do counselors perceive the impact of the Internet on clients in general or to the counseling profession as a whole?

The perceived impact of the Internet on clients scale was computed by summing the scores for this scale listed in Table 1 and dividing by the number of items. A factor analysis determined the items to be appropriate for a scale and the Cronbach’s alpha for the items was .82. In addition a correlation matrix shows the relationship between the scales. The higher the Internet competence score, the more likely a counselor will see that the Internet has an impact on the profession as a whole (r=.175, p<.05). In addition, and even more conclusive is the finding that the higher the counselors’ in session discussion of the Internet (r=.463) and the higher the overall Internet use in their practice (r=.511), the higher the counselor would rate the significance of the Internet to the profession as a whole (p<.01).

As the Internet becomes an increasingly prominent part of daily life, it will be an important component for counselors to investigate in sessions. Despite this reality, and despite reporting high Internet competence themselves, counselors did not discuss the Internet in their sessions at a high rate. The average in session discussion of the Internet was 2.7 (with a standard deviation of 1.41) on a 7 point scale. One would expect that this mean number would be closer to 4 (the center of the Likert scale), especially considering the volunteer sample and the fact that the survey itself was Web based. This clearly shows that there is a disparity between knowledge of the Internet and discussing it with clients in counseling sessions. This is evidence that although the potential for technology to play a role in counseling has been recognized (Harrison & Stephen, 1996), the day to day work of counselors seems to be unchanged (Chandras, 2000).

According to the U.S. Department of Labor, Bureau of Labor Statistics (2003), the age group between 26 and 33 is the most likely to own a computer; children as young as age 5 are learning about computers and the Internet in school, with schools increasingly utilizing computers in the classroom; and there is an overall increase in Internet activity. Younger generations are being raised in a technologically enriched environment with the expectation and even requirement of using the Internet. Not surprisingly, this project demonstrates that younger generations of counselors have higher levels of Internet competence, and these numbers will likely continue to rise. Also, in looking at age of clientele, there are statistically significant differences present between age cohorts. Counselors whose predominant clientele are young adults (ages 18-26) discussed the Internet in sessions more frequently than any other clientele age classification. Interestingly, despite this difference in competence, there were no statistical differences between age groups on use and discussion of the Internet in practice. Despite their higher level of Internet competence, younger counselors did not employ the Internet in the counseling profession in any statistically different way than older counselors.

Counselors will need to have greater knowledge about how to use the Internet as an adjunct to treatment and, more basically how the Internet influences the daily lives of their clients (Gore, et al., 2002). Even if counselors do not use the Internet themselves, it is likely that clients will come to sessions with the Internet as a topic. Counselors reported in open ended questions that they have served clients who have brought up topics in many different areas; over half of the surveyed counselors have explored such topics as email, chat rooms, Internet relationships, research of presenting concerns, and Internet pornography. Over one quarter of the surveyed counselors reported topics such as instant messaging, family time related to computer use, buying and selling items, Internet addictions, Internet infidelity, career development, researching medications on-line, Internet safety, and on-line support groups. The Internet is frequently an important component of clients’ lives.

The more a counselor talks about and uses the Internet as part of practice, the more it is seen as a component of clients’ topics of interest. This is not surprising because counselors are trained to help guide the content of sessions, and counselors who see the Internet as a part of their practice may be more deliberate in addressing this topic.

This study offer some interesting insight for how counselors may chose to include discussions of the Internet in their counseling practice. The Internet is clearly becoming an integral part of daily life and clients, in large numbers that are increasing daily, are coming to counseling sessions with Internet topics in mind. Counselors would be remiss to exclude from their practice the potential impact of the Internet on clients. As technological issues become more central to the counseling profession, as demonstrated in this research data, it becomes important for counselors to take relevant Internet information and actively bring it into sessions. For counselors with low Internet competence, this means increasing their Internet comfort and knowledge base in order to better understand the impact on clients. Often clients’ presenting issues are confounded by topics that are not readily discussed initially, and since clients are using the Internet at higher rates, a part of the underlying thoughts of that client may be influenced by Internet considerations (i.e. Internet infidelity, Internet addiction). Counselors can actively explore this content area as part of their case conceptualizations with clients to rule it out as an issue. Indeed, incorporating technology into the mental health profession is a profound paradigmatic shift facing the counseling profession (Gore, Leuwerke, & Krumboltz, 2002). That shift should be undertaken by both counselors in practice and counselor educators and supervisors who train beginning counselors.

This study shows that the Internet is becoming a component of the counseling process, and we argue that it is important for counselor educators to prepare their students in this regard. In orientation to counseling courses, students could be required to do an assessment of available resources on the Internet that pertain to counseling. In DSM courses, they could compare Internet sites that explain different diagnoses with what is contained in the DSM, evaluating the accuracy of Internet material in the process. In group counseling courses, students could evaluate on-line support groups and share their assessments with their class so support group resources could be discovered. As mentioned previously, in practicum, students could incorporate questions about the Internet into their case conceptualizations with clients. They could subsequently share Internet resources in supervision and discuss the specific components of their counseling processes that were complimented by the Internet. In assessment classes, students could evaluate on-line assessment tools and compare them with traditional assessment tools. The Internet has the potential to be an adjunct to any course that is taught, and if it is incorporated into daily coursework, students who may be timid in relation to Internet technologies may slowly gain comfort. Likewise, Internet savvy students would see how the Internet could be used as an adjunct tool in therapy. This increase in teaching will provide a greater knowledge base and comfort regarding the Internet for future counselors.

Younger generations of clients will likely have higher levels of Internet competence and use, and many of these clients will not even remember a time when computers and the Internet were not present (Greene, 2000). As this generation gets older, the incorporation of Internet faculties into practice will be increasingly important. This study shows high Internet discussions for clientele in the age range of 18-26. If clients increasingly expect to discuss Internet considerations, counselors in turn will need to have the Internet competence to follow them.

The data in this project suggest that counselors who are open to discussing the Internet may lead to clients talking about this as a part of their concerns. This is especially important if a client’s presenting concern is connected to a topic that deals with the Internet. For example, a person may come in reporting that they are having familial or marital difficulties and perhaps these difficulties stem from a spouse who is spending large amounts of time on the Internet. This perspective would bring an important component of treatment into the session. Most likely, this would come up eventually in the counseling process, even for counselors who in terms of this project are low Internet users. But less obvious are clients who are computer and Internet savvy who come in for treatment and may have already researched their presenting concern or may be open to looking to the Internet as a tool to help with their counseling. Counselors in the medium to low range of Internet use and discussion may miss a golden opportunity to help a client, despite the fact they too are computer and Internet savvy. Much like bibliotherapy is an important adjunct for many counselors’ practices, the Internet could be used as a resource tool in much the same way.

If trends highlighted in this study continue, some clients may be more willing to research self-help in the privacy of their own home by using the Internet. If clients are conducting their research with this medium, counselors need to know what is out there to help clients discuss what they learn. The highest single mean for a survey item in this study was “information clients gather from the Internet is more useful when discussed in sessions”. Clearly this is an important issue for the counselors in this study. Counselors with higher Internet competence could help direct clients toward specific Websites which could benefit clients with specific needs. Much like current counselors often have ideas of self help books they use to compliment their practice, ideas of self-help Websites or informational tools may be relevant. Counselors can be prepared to discuss what specific content clients bring to sessions, and now more than ever, counselors have multiple media outlets for outside resources, incorporating the Internet with traditional items such as books, tapes or workbooks.

Counselors in this study reported that the Internet had an impact upon clients in general and upon the profession itself. Despite this, it appears that counselors tend to distance themselves from actual Internet use and discussion in practice. Perhaps counselors distance themselves from the Internet because they do not see how technology that often is seen as limiting human interaction could fit into a field historically built on human interaction. Whatever the reason, the impact of the Internet on clients is undeniable, and counselors can more fully serve these clients by embracing the Internet as a tool.

This study was conducted using an internet survey, which is non-random. The literature suggests that non-randomness is due to the fact that respondents must have access to a computer in order to participate (Swoboda, Meuhlberger, Weitkunat, & Schneeweiss, 1997). By the nature of the study, respondents who had ready access to a computer were more likely to complete the survey. The survey most likely was not completed by non-computer users, who could provide valuable insight into perceptions of their clients’ use of technology. Furthermore, participation in the study was by choice, and it is unclear what factors may have contributed to an individual’s choice to participate or not, and how the findings may have been impacted. In addition, because it is difficult to access clients directly, this survey sought to access information about clients’ use of technology through the clinician’s perceptions. Perceptions are inherently biased by countless respondent variables, and it is unclear whether clinician perceptions accurately reflected client beliefs.

In addition to design limitations, there were two limitations in the survey sample. First, only 7 of the 50 state counseling associations responded to the original invitation to participate. In addition, of those counselors who responded to the invitation to participate, the response rate was 46%, which is acceptable for an internet survey, but marginal for a traditional mail survey. Each of these limitations raises questions about the generalizability of the results; however, because the demographics of the survey respondents were remarkably similar to those of the ACA membership, some of those concerns can be allayed.

The Internet stands to be one of the most significant innovations of our time because it permeates so many different areas of life today. Counselors’ awareness of the impact of the Internet on their clients and their mental health treatment is increasingly important. Incorporating Internet resources into therapy is likely going to reshape the counseling profession in the years to come, and both current and future counselors need to prepare for these changes. The counseling profession should make strides to keep up with a technologically advancing world by using Internet resources to the fullest, while maintaining the integrity of a profession built on human interaction.

Jerome, L. & Zaylor, C. (2000). Cyberspace: Creating a therapeutic environment for telehealth applications. Professional Psychology: Research and Practice, 31, 478-483.

Rainie, L. & Kobut, A. (2000). Tracking online life: How women use the internet to cultivate relationships with family and friends. The Pew Internet & American Life Project. [Online] Available www.pewinternet.org [2000, May 10].

Smith, C.A. (1999). Family life pathfinders on the new electronic frontier. Family Relations, 48, 31-34.

U.S. Department of Labor, Bureau of Labor Statistics (2003). Issues in labor statistics, Summary 103-4.

Wysocki, D.K. (1998). Let your fingers do the talking: Sex on an adult chat-line. Sexualities, 1, 425-452.

Ryan T. Greene, Ph.D. is a crisis counselor with the Roanoke Valley (Virginia) Community Services Board.

Gerard Lawson, Ph.D., LPC is an Assistant Professor of Counselor Education at Virginia Tech;

Correspondence regarding this manuscript should be sent to Gerard Lawson at glawson@vt.edu.

Hildy G. Getz, Ed.D., LPC, LMFT is an Associate Professor of Counselor Education at Virginia Tech and a counselor in private practice.