AbstractThis article reviews the nature of the Internet. The utility of this phenomenon in the field of mental health/behavioral health counseling is explored. The purposes of this article are to explore the Internet and its exponential growth, examine the psychosocial aspects of cyberspace and its implications for counseling, and discuss the possibilities of the variety of uses of the Internet at this temporal juncture. Detailed specifics of resource sites are provided.
The phenomenal growth
of the Internet has made it an integral part of many persons’ lives; this
does not exclude counseling, behavioral health, and human sciences information
and services (Young, 1995). Internet
behavioral health services have been labeled cybercounseling, cyber-consultations
(Charkalis, 1998), virtual couch
therapy (Cohen, 1997), cyberpsychology,
and cybertherapy (Rice, 1997).
Grohol
(1998) describes an ever-growing area of the Internet that includes, but
is not limited to free live chat shows, question-and-answer contact between
user and professional, question-and-answer sites via e-mail, on-line mental
health magazines, and mental health resources.
Sampson,
Kolodinsky, and Greeno (1997) discuss the benefits of the Internet
for counseling. The impact of this phenomenon on the field of counseling
may be presented in five areas: A new form of communication, a new source
of information and consultation, a new area of behavior to be studied,
a new form of counseling and education, and a new area presenting ethical
issues and challenges.
The Internet: A New Form of Communication
Prior to the Internet, most communication occurred face-to-face, via telephone, or by postal mail. Today it is possible to communicate via written text on a computer monitor with someone half a world away. Although not totally different from other forms of communication, cybercommunication presents unique parameters not previously encountered. Suler (1997a) discusses the personal impact of communication on the Internet. He distinguishes between in-person relations (IPR) and cyberspace relations (CSR). Some authorities, such as Chenault (1998), would refer to CSR as computer-mediated communication (CMC). Suler (1997a) states that CSR offers the potential for time stretching (e-mail need not be answered immediately), distance shortening (can relate to persons in another continent as easily as someone located in the same city), and fantasy-driven (may change one’s identity, gender, etc.). However, Suler (1997a) states, “As much as I respect and enjoy cyberspace relationships, I would be very unhappy if I could only relate to my family and closest friends via the Internet ... Most people who develop close friendships and romances in cyberspace eventually want and need to meet their friend or lover in-person” (p. 12).
Cybercommunications, or interpersonal relations occurring via the Internet, have both positive and negative aspects. Positive aspects include affording persons in isolated rural areas and/or persons with communications and other physical disabilities to communicate and establish a cyber-support network, or for professionals to consult colleagues on-line about unique and problematic issues. Negative aspects include insulting others, simulated rape (Chenault, 1998) and behaviors that are destructive to one’s lifestyle, as detailed by Young (1998b). Chenault (1998) reviews extensively the multidimensional aspects of personal communication in cyberspace. She begins by stating some premises held by communication scholars concerning computer-mediated communication (CMC):
“Many scholars (and others) assume the following about CMC-initiated and conducted relationships: They are casual, temporary, false, and lack deep (or any) emotion” (p. 2).
Rheingold
(1993), the founder of a “cybercommunity” called WELL, makes a case for
more depth in cyberspace by stating that persons in the community ...
“... exchange pleasantries and argue, engage in intellectual discourse, conduct commerce, exchange knowledge, share emotional support, make plans, brainstorm, gossip, feud, fall in love, find friends and lose them, play games, flirt, create a little high art and a lot of idle talk” (p. 3).
Chenault
(1998)
concludes her examination by stating:
“In the end, the argument should not be whether or not -- if -- CMC can properly foster interpersonal relationships. Instead, scholarship can move into ‘how’ and ‘why’ and beyond the mere ‘if.’
“The popular press has given CMC-fostered personal relationships much more attention than have scholars in speech communications, sociology, psychology, and other related fields. Perhaps scholars do not deem the area worthy of scholarly inquiry. I disagree with that assessment, and find it a shame that some of the best details about CMC relationships are found in glossy magazines instead of being studied and written about in prestigious, peer-reviewed, respected journals” (p. 61).
The widespread use of
cybercommunication by many laymen requires counselors to be aware of the
positive and negative aspects of CSR. Clients will come to counselors with
problems stemming from CSR. They may have been flamed, stalked, seduced,
or rejected in cyberspace. Counselors should realize that this is no longer
unique or a minor problem. Cyberspace is real for many clients and they
will present with particular treatment issues.
One aspect of cybercommunication not mentioned by Suler (1997a) or Chenault (1998) is the requirement of users to be fluent in written communication. This fact would render cyberspace a somewhat skewed sample of the general population . Written text, being the most advanced level of communication when compared to receptive or spoken language, limits cybercommunications to those most adept at language as well as those who are “computer literate.” Therefore, those individuals who are not facile in language and/or are not computer savvy will not be found on the Internet. This fact will, for a long time to come, limit the population found on the Internet as far as being a random sample of the general population.
Network etiquette is commonly called “netiquette.” In relation to cybercounseling, when responding to a post or e-mail, it is courteous to type “==LONG==” if the response is lengthy (more than 100 characters). “==LONG==” is inserted beside the subject description to alert the receiver that some time may be needed to read and respond. When entering information to be sent, hitting the “enter” key (character return key) with every line helps the scroll flow more smoothly, or reader-friendly for the recipient.
Chat communities in cybersocieties refer to on-line nicknames as “avators” (Suler, 1997b). Avators can be used by anyone, including unregistered guests. The two major types of chat rooms are text-only and multi-media chat environments. For multi-media chat communities (known as GMUKS -- Graphical Multi-User Konversations), people may choose an actual character to go along with their name; this allows a visual dimension that creates the illusion of physicality and movement. Common groups of avators include animals, cartoon characters, celebrities, evil beings, seductive beings, and power beings (Suler, 1997b).
Cyberusers can also use “emoticons” to express themselves emotionally. By definition, an emoticon is an ASCII glyph used to indicate an emotional state in e-mail or news; if misinterpreted, they may result in arguments and flame wars (Jargon File, 1994). Hanson (1998) adds that emoticons are symbols composed of a few text characters, and are used as a form of emotional shorthand to add meaning to messages. The top three (or three most-often used), according to Hanson (1998) and The Jargon File (1994) are the smiley face :-) ; the frowney face :-( ; and the winking, or half-smiley face ;-). The other five most commonly denoted in text, per Hanson (1998) are as follows:
:-p tongue stuck out at readerHanson (1998) offers a dictionary of hundreds of emoticons, which can be found by downloading EXOTICON.TXT from his website (at www.utopiasw.demon.co.uk) (*note: references to any sites do not indicate endorsement by the authors or publishers).
8-) wide-eyed look; glasses worn by smiling writer
>:-) devil with a grin: devilish remarks
o:-) haloed angel with a grin; innocent remarks
<:-) dunce capped writer; stupid questions
The interactive text experience of the cyberworld can be contrasted with the non-interactive experience. The user may opt to change his or her identity or become totally anonymous. The user may choose to be the self wholly, share only part of the self-identity, use a false identity, or use a code name. Many environments on the Internet do allow the user to choose any name for identification. The status of users begin as equals (as race, income, gender, age, etc., are not an issue), yet one’s influence is determined by written communication skills, persistence, and computer skills. Users can communicate with persons in other countries, at any time, broadening spatial boundaries. The Internet also allows users to contact a variety of individuals, which is not as easy in the physical world. Finally, most on-line interactions may be recorded, saved, and stored on computer files, which can make a permanent record of all that is said (Suler, 1996a; Suler, 1996b; Suler, 1997a).
When in a chat room or in
an open dialogue or discussion, it is proper to use two character returns
to let the others on-line know you are through talking. Communication may
be slow or fast, depending on the size of the server and the speed with
which the message can travel. As such, when signing off, it is courteous
to wait for conversation partner(s) to sign off as well, to be sure (s)he/they
received the sign-off message.
The Internet: A New Source of Information
The Internet has become a vast source of information for professionals, students, and laypersons. Using various search engines an individual can locate information and data on nearly any subject. Unfortunately, the mass media has given most of its coverage of the Internet to its more sensational aspects, i.e., pornography, chat rooms, etc. A large portion of the Internet is an electronic library of materials on an array of topics. Therefore a student researching a paper about “cocaine addiction,” for example, can enter in his or her subject on a search engine and get plenty of resources to compose a lengthy manuscript. A cautionary note, however, is that out of twenty pages of sources on “cocaine addiction” there will be a great variability in the quality of the resources. For example, a search of the search engine Alta Vista produced nearly 18 pages of links, but the majority were course syllabi from various institutions or advertisements from publishers of texts on the subject.
Through e-mail, listservs
(mailing lists), etc., the Internet also affords the opportunity for consultation.
A quick search of a list of listservs (http://www.liszt.com)
yielded 41 lists dealing with a variety of aspects of counseling. CESNET-L
is a listserv for counselor educators with a discussion of counselor education
and supervision issues. The second author is on a psychopharmacology listserv
where psychiatrists, psychologist, and counselors have the opportunity
to share information about medications and mental disorders. One member
of this list is the only psychiatrist in the Yukon Territory. This list
enables him the opportunity to consult with colleagues he may never have
met without this medium.
The Internet: A New Area of Behavior to be Studied
Almost any phrase related to the Internet begins with the prefix, “cyber.” Moore (1995) states this prefix originated in William Gibson’s science fiction novel Neuromancer, and has been adopted by persons on the Internet to refer to the place where computer-mediated communications take place. What has not been realized by many in the counseling field is the implications of whole “new” areas of human behavior, such as “cyberculture,” “cyberspace,” “cybercommunities,” “cybersex,” and “Internet addiction.”
The cyberworld is unique from the “real” world, and the uniqueness is what shapes the psychological experience of the social realm of the virtual world (Suler, 1996b). The five major features that make the virtual world different from the physical (face-to-face) world, as defined by Suler (1996b) are limited sensory experience, identity flexibility and anonymity, equalization of status, stretching of spatial boundaries, accessibility to numerous relationships, and permanent records.
Limited sensory experience is a fundamental difference in that communication in cyberspace is through the written word (Suler, 1996b; Suler, 1997a). Rheingold (1993) and Horn (1998) report on the psychosocial aspects of on-line communities. Rheingold started the WELL on the West Coast, and Horn started ECHO in New York City. Some objections of “serious” communications scholars included the fact that computer mediated communication lacked the nonverbal dimension, so important in other forms of human communication. Rheingold counters by stating that persons in cyber communication “Exchange pleasantries and argue, engage in intellectual discourse, conduct commerce, exchange knowledge, share emotional support, make plans, brainstorm, gossip, feud, fall in love, find friends and lose them, play games, flirt, create a little high art and a lot of idle talk” (Rheingold, 1993, p. 3). The interactive text experience of the cyberworld can be contrasted with the non-interactive experience. The user may also opt to change his or her identity or become totally anonymous. Or the user may choose to be the self wholly, share only part of the self-identity, use a fraudulent or exploitative identity, or use a code name (Miller, 1995; Stone, 1991). Many environments on the Internet do allow the user to choose any name for identification. The status of users begin as equals (as race, income, gender, age, etc. are not an issue), yet one’s influence is determined by written communication skills, persistence, and computer skills. Users can communicate with persons in other countries, at any time, broadening the spatial boundaries. The Internet also allows users to contact a variety of individuals, which is not as easy in the physical world. Finally, most online interactions may be recorded, saved, and stored on computer files, which can make a permanent record of all that is said (Suler, 1996a; Suler, 1996b; Suler, 1997a).
There are negative as well as deceptive behaviors that appear to come out of nearly all cyberworld users. The first of four to be described is the “flame”. A term coined by Barry (1991), flaming is the action of users that typewrite their rage at perceived errors on the part of other writers. In other words, flaming refers to “going off” or “cussing out” someone, and is typically meant to be personally derogatory (Barry, 1991; Chenault, 1998; Mabry, 1997; Seabrook, 1994). The second is referred to “gender-bender” behavior, which is the concealing of a user’s gender, or the perpetration of actual sexual harassment from one speaker to another (Bruckman, 1998; Chapman, 1995; Chenault, 1998; Danet, Ruedenberg-Wright, & Rosenbaum-Tamari, 1997; Dery, 1994; Dibbell, 1994; Sougstadt, 1994; Span, 1994). Another common behavior is generosity, in the sense that someone may spend hours collecting and sending information to a total stranger via the Internet, or may even mail information and items to the home address (Golden, 1994; Robin, 1994; Wright, 1993).
A fourth behavior is online addiction. Online addiction has been accused of destroying marriages and relationships, and wrecking peoples’ health and careers. More to the point, Shotton (1989) states the online addict has a narcissistic relationship with the computer, and that the computer is a true friend and is ever-faithful. Dr. Kimberly S. Young, founder and director of the Center for On-Line Addiction, states, “Internet addicts tend to form an emotional attachment to the on-line friends and activities they create inside their computer screens. They enjoy those aspects of the Internet which allowed them to meet, socialize, and exchange ideas with new people through the highly interactive Internet applications” (Young, 1998a, p.1). The computer is nonjudgmental and it totally anonymous. Schiebe and Erwin (1980) report that addicts name their computers, much like people name their vehicles, boats, or guns.
The physical symptoms of the online addict include insomnia, poor dietary habits, and poor exercise. Online addiction stems from the users who are in search for something they believe is missing, be it entertainment, connectivity, friendship, love, sex, control, etc. But for those individuals that are happy with themselves and their lives, and are not in search of filling a void, then online addiction is more than likely not a risk. Online addiction is a powerful breeding ground for codependent relationships. Those most vulnerable to Internet addiction are those persons who already have issues related to depression, mood lability, anxiety, low self-esteem, and other forms of addiction (i.e., substances, sex, etc.) (Young, 1998a, p. 1).
Another psychological issue is the concept of transference and computers. As stated by Suler (1998a), “Computers can be a prime target for transference because they may be perceived as human-like” (paragraph 6). Computers “think” and are interactive. They can be tailored to reflect a user’s expectations in a companion by sutomizing the visual and auditory operating systems and software applications. As such, they are programmable to be whatever the user wants them to be (Suler, 1998a).
Four types of transference Suler (1998a) discusses are:
1. You as You, Computer as Parent -- The user takes a passive role and the computer is directive.
2. You as Parent, Computer as You -- The user is active and the computer is passive.
3. You as You, Computer as Wished-For Parent -- The user may perceive the computer as having
the desired characteristics the user may have longed for in his or her parents.
4. You as Wished-For Parent, Computer as You -- The user has the wished-for parental
characteristics and qualities, and the computer becomes like the child.
More detailed information
on computer transference can be found in Suler’s hypertext book at http://www1.rider.edu/~suler/psycyber/psycyber.html
by looking under chapter 2 (“The Psychology of Individual in Cyberspace”)
and clicking on section 1 (“Transference to one’s computer and cyberspace”).
There are dangers in the virtual world that counselors are to be aware. Due to the ability to disguise oneself, “predator types” of personalities are drawn to the virtual world. Such persons may have many characteristics of the antisocial personality, as outlined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1994). Such traits include the failure to conform to social norms by repeating acts that are grounds for arrest; deceitfulness (i.e., lying, aliases, cons); impulsivity or failure to plan ahead; repeated physical altercations; careless disregard for safety of self of others; consistent irresponsibility; and lack of remorse (DSM-IV, 1994).
Others to be leery of in the virtual world are pedofiles (sexual gratification through sexual activity with children), sexual masochists (sexual gratification from fantasies, sexual urges, or real behaviors that involve humiliation and suffering of a victim), sexual sadists (intense sexual arousal from fantasies, sexual urges, or real behaviors in which the humiliation and physical suffering of the victim is sexually exciting; and paraphiles (i.e., necrophiliacs, partialists, and scatologists) (DSM-IV, 1994). Sex addicts’ sole purpose for utilizing the Internet, per Young (1998a) is to engage in cybersex or seek out cyberporn.
Counselors should also be aware of pathological personality types that may come across in cyberspace. McWilliams (1994) and Suler (1998b) describe in their research various personality types that may be drawn into the world of cyberspace. Suler (1998b) reports that “ ... Compulsive people may be drawn to ... cyberspace out of a need to control and manipulate their environment. Schizoid people may enjoy the lack of intimacy. Narcissistic people may use the access to a numerous relationships as a means to gain an admiring audience. Dissociatives may experience the anonymity and identity flexibility of cyberspace as a vehicle for expressing/avoiding the various facets of their personality” (p. 1).
The widespread use of cybercommunication
by many laymen requires counselors to be aware of positive and negative
aspects of CSR. Clients will come to counselors with issues stemming from
CSR. They may have been flamed, stalked, seduced, or rejected in cyberspace.
Counselors should realize that this is no longer unique or a minor problem.
Cyberspace is real for many clients and they will present with particular
treatment issues.
A New Form of Counseling and Education
Individuals seeking continuing education resources via the Internet are able to find such services. For those in search of earning diplomas, certifications, credentials, college credit and degrees may also find help through the Internet. There are several (65 accredited by the Distance, Education and Training Council as of August, 1998) very legitimate home-study programs available in cyberspace that are accredited, yet there are also hundreds that are sketchy at best, and have been labeled “degree mills” (Koepell, 1998). Red flags to unaccredited home-study programs include, but are not limited to facility brochures that list faculty members that do not teach and there is minimal to no contact with faculty; tuition and fees are not charged by semester or course, but are set on a per-degree basis; ability to earn degrees quite rapidly versus the typical four years for undergraduate degrees and two years for graduate and doctoral degrees; ability to earn course credit in exchange for life-experiences instead of actual academic work or assessing the experience in terms of college-level learning; and no accreditation by legitimate educational institutions. To obtain an updated list of agencies that are approved to accredit schools, contact the Department of Education Accreditation and Eligibility Determination Division at (202) 708-7417.
Available online are a multitude
of mental health websites that provide education and counseling services.
Following are descriptions of 10 top sites and services.
Specific Mental Health WebsitesPlanetRx: http://www.depression.com
Depression.com is a comprehensive site sponsored by PlanetRx. It covers the many facets of clinical depression and how clinical depression impacts the whole individual and family members. The site is updated daily with news briefs and daily highlights (PlanetRx, 1999).The DRM WebWatcher Index: http://www.geocities.com
The DRM WebWatcher Index provides a guide on disability resources on the Internet. The complete index can be found at www.geocities.com/~drm//DRMwwwINDEX.html Among the listing of disabilities are mental health and psychiatric disabilities. By clicking on a specific topic, a wealth of information can be found (DRM, 1999).Cyber-Psych: http://www.cyber-psych.com/
Cyber-Psych, another mental health resource on the Internet, states its mission is “Committed to bringing high quality, professional psychological resources and information to the on-line community. We believe that the Internet provides a non-threatening, interactive medium through which mental health care can be provided to the rapidly increasing population of people on-line”. Cyber-Psych’s index provides a multitude of mental health topics and resources.Infoseek: http://www.infoseek.com/
Infoseek is a web site health channel that provides 105 cyberpsychology pages. By entering “Mental Health” in the “Search” block, the user is provided over 30 major web sites addressing mental health. The most-utilized sites are listed in sequence and are as follows: Center for Mental Health InfoSource, Mental Health Net, National Institute of Mental Health, National Institute of Mental Health, Internet Mental Health, National Mental Health Association, PSYC Site, Psych Web, Specific Mental Disorders, their diagnosis and treatment, and Substance Abuse and Mental Health Services Administration. Of particular interest to those seeking counseling services on-line include:1. Internet Mental Health (http://www.mentalhealth.com/) -- a comprehensive encyclopedia
of mental health information, tips, diagnosis, and treatments.
2. Mental Health InfoSource (http://www.mhsource.com/) -- provides news, resources,
links and chat rooms for mental health.
3. Mental Health Net (http://www.cmhc.com/) -- largest guide to mental health on-line,
including over 6,000 individual resources.
4. Online Dictionary of Mental Health
(http://www.shef.ac.uk/~psysc/psychotherapy/index.html) Extensive resource and
research tool that covers all disciplines within the mental health field on a global level
that links to sites that discuss many mental health issues. (Infoseek, 1998).
On-Line Magazines
Self-help and mental health magazines are another form of reference for the on-line consumer. There are least 25 magazines on the Internet that focus on mental health and self-improvement. By going to http://www.selfgrowth.com/mags.html the user will find the list of over 25 magazines, and then may click on any of the 25 to reach the site. Self-Help and Psychology is a popular on-line magazine and is the most utilized on the Internet. As such, there are a variety of ways for the user to access it. The authors found the magazine through the following paths:
http://www.selfgrowth.com/mags.html
http://www.well.com/user/selfhelp/
http://www.cybertowers.com/selfhelp/index.htmlMental Health Infosource: http://www.mhsource.com/
Mental Health Infosource is an interactive mental health website that allows the user to interact with other on-line users as well as professionals. The various offerings the site provides include chat forums, mailing lists, and direct question-and-answer communication with psychiatrist Ron Pies, M.D. (By clicking on “Ask the Expert”). It also has a section that assists users with locating mental health professionals in their local areas, and educational materials covering an array of psychiatric disorders (Mental Health Infosource, 1999b). By clicking on “Healthier You,” the user will find a list of over 600 links (under “The Directory” section) related to psychology and mental health. The Directory contains an index of 43 topics, which are then broken down into a list of links connected to each topic (Mental Health Infosource, 1999a). For example, the topic “Computers and Mental Health” lists four links: Computer Programs in Mental Health, Discover Technology, GlobalPsych Software Repository, and Psychiatric Times computer articles.Mental Health Page: http://www.grohol.com/mail.htm
John Grohol, Ph.D. has devised a very comprehensive Mental Health Page, which provides psychology and support mailing lists. Although this Mental Health Page is quite extensive, another mailing list can be found at http://www.liszt.com The Liszt Database is universal, including information from sources throughout the globe (Grohol, 1998b).Metanoia: http://www.metanoia.org/imhs
Metanoia “is a comprehensive, independent consumer guide to the psychotherapists and counselors who provide services over the Internet, and is compiled by consumers for consumers” (Ainsworth, 1999). The site is designed to be more than an information resource for consumers, but a site designed to allow interaction between the consumers and the professionals. Providers for the site are selected for membership by consumer referrals, self-referral, or review of the professional’s website. No provider pays to be included as a provider for Metanoia. It is suggested by Metanoia that each Internet user review a chosen provider’s website for specifics regarding credentials, fees, payment options for services, the types of services offered, and other facts that may be relevant to the chosen professional (Ainsworth, 1999).1-800-Therapist Network: http://www.1-800-therapist.com/
This website assists consumers with locating a therapist in their area that can address their clinical needs. The website provides the referrals through their telephone system, which connects the consumer with the therapist’s office via telephone. As described on the home page, this program offers “the opportunity to speak confidentially with a trained professional who can help you evaluate your situation and assist you in finding a therapist with special sensitivity and experience in your area” (“1-800,” 1999). The site has been voted “Business of the Year” for innovative design by Entrepreneur magazine, and the services are free (“1-800,” 1999). To utilize, the consumer must call the toll free number at 1-800-843-7274. The caller’s needs are assessed by a referral source counselor, and then the caller is provided the name and telephone number to at least one practitioner in the local area who can clinically assist. The counselor can also connect them directly if requested.Virtual-Addiction.Com: http://www.virtual-addiction.com/
Virtual-Addiction.Com is sponsored by the Center for Internet Studies. It offers a self-appraisal test, and a variety of articles and briefs covering Internet addiction. Psychologist Dr. David Greenfield maintains the site and updates is regularly (Virtual-Addiction, 1999).
The Internet: Ethical
Issues and Challenges for Cybercounseling
Along with professional psychiatry, psychology, social work, and counseling, there are always ethical issues that arise in working with behavioral health clients. Cybertherapy is not unique to ethical concerns. Such concerns for clients include verifying provider credentials, understanding fees for services and methods of payment up-front, and the limits of confidentiality through the use of the Internet (Charkalis, 1998; Kirk, 1996; Schwadron, 1997).
Another ethical dilemma is the inability to have face-to-face contact, which is a disadvantage not to have nonverbal communications (Key, 1997; Kirk, 1996). Such a limitation (therapy through only the written word) impedes the therapeutic interaction (Childress, 1998; Kirk, 1996). There are also issues related to the superficialness and limitations to cybertherapy, or the inability to properly address deep, clinical issues, otherwise known as “therapeutic consultations” or “Ann Landers therapy” (Key, 1997; Rice, 1997; Schwadron, 1997). Such limited progression of treatment poses potential risks for both the writer and the therapist (Childress, 1998, Cutter, 1996). Also at issue are possible cultural issues, in that the counselor and writer may be from far-away locales and the counselor may not have specific training in the multicultural context needed (Kirk, 1996).
Another con to Internet consultation are the limits of confidentiality through the use of e-mail communication (Cutter, 1996). Anonymity of the writer seeking online consultation has both pros and cons. The main asset is that clients who normally would not seek therapy (due to embarrassment, etc.), may opt to go online due to the limitations of identification (Suler, 1996a). Limitations include imposters representing themselves as licensed mental health professionals, or clients who falsify themselves as well (Kirk, 1996). There is also the issue of lack of clinical supervision for clinical service providers (Cutter, 1996; Kirk, 1996).
Even with the ethical dilemmas and pratfalls, cybertherapy and therapeutic consultations have their assets. For those individuals living in remote areas or have the inability to travel to a clinician for services, the Internet can assist (Suler, 1996a). Internet addicts have voiced difficulty finding local treatment programs, support groups, and trained individual therapist that specialize with Internet misuse; consultation via the Internet can aid in filling this void (Young and Suler, 1998). Cybertherapy also aids those consumers who choose not to haggle through the managed health care environment (PhotoDisc, 1996). Many managed health care networks have slashed benefits over the years, and have required preauthorization requests in writing by a consumer’s primary care physician, with still using a disclaimer that does not guarantee payment, and each claim submitted will be reviewed for medical necessity.
For a clinician to market on the Internet, one needs only $49 for six months of service through PsychScapes (1997). The clinician is permitted to write his or her own narrative and discuss areas of expertise. PsychScapes (1997) can provide such services by going to http://www.mental-health.com/PsychScapes/tin_add.htm Another organization on the Internet that utilizes providers as the main resource is Metanoia (Ainsworth, 1999). For a professional who is interested in being added to Metanoia’s Internet provider list, a request for information can be e-mailed to imhs@metanoia.org However, Rice (1997) reports that cybercounseling thus far has not been financially worthwhile to most cyberclinicians. For clinicians who are seeking employment opportunities, residencies, fellowships, or products, Mental Health Infosource provides practice opportunities listed by state (go to http://www.mhsource.com/ and click on “Classifieds”) (Mental Health Infosource, 1999a).
Psychotic disorders and schizotypal personality traits bring about ethical challenges in trying to treat through only the written word. Examples of such disorders include the five sub-types of schizophrenia (paranoid, disorganized, catatonic, undifferentiated, and residual types); schizoaffective disorder; depressive delusional disorder (erotomania, grandiose, and jealous, persecutory, somatic, mixed, and unspecified types); and substance-induced psychotic disorder. Bipolar disorder during a manic or psychotic episode may also prove to be a challenge to treat via the Internet due to ideas of reference, bizarre perceptions, odd beliefs, magical thinking, racing thoughts, and loose associations (DSM-IV, 1994). Such individuals should immediately be referred to a licensed psychiatrist in their immediate area or nearest community that has such professional services for psychiatric evaluation, diagnosis, and medication services.
Pending legal, ethical, and
professional issues are addressed in Self-Help & Psychology.
The American Counseling Association (ACA) is working to develop professional
standards and ethical safeguards for cybertherapy (Cohen,
1997; Key, 1997; Rice,
1997; Schwadron, 1997).
The National Board for Certified Counselors (NBCC) has adopted standards
and are to used in conjunction with the NBCC Code of Ethics and the NBCC
WebCounseling Standards (the standards are available through the NBCC Internet
home page at http://www.nbcc.org) (Guilbert
& Clawson, 1998). The NBCC’s coalition to coordinate Internet-related
activities among mental health professionals began collecting data, information,
and feedback from professional counselors who provide Internet-based services,
with the goal of assessing the way professionals are services on the Internet
(Espina, 1998). Information regarding
the coalitions of cybercounseling , professionals are encouraged to contact
the ACA Center for Effective Counseling Practice at (800) 347-6647, ext.
271 or cecp@counseling.org
Conclusion
The Internet is comprised
of seven basic services, with those being email, mailing lists, the World
Wide Web (WWW), File Transfer Protocol (FTP), Internet Relay Chat (IRC),
Gopher, and Telnet (Stauffer, 1995).
Among these services, behavioral health counseling is offered in a variety
of forms. This allows individuals in rural areas and those who would otherwise
not seek counseling help the ability to obtain services and related educational
information. There are many ethical concerns regarding counseling and the
Internet that need to be addressed until set standards and guidelines are
established by the American Psychological Association and the American
Counseling Association. Only then will professionals have a clearer understanding
of the needed boundaries, limitations, and expectations that will protect
both them and the clients receiving clinical services via the Internet.
Appendix A
Useful Resources Discussed in This Article
Cyber-Psych http://www.cyber-psych.com/ D.A.R.N. http://www.darnweb.com Depression.Com http://www.depression.com The DRM WebWatcher http://www.geocities.com Infoseek http://www.infoseek.com/ Internet Mental Health http://www.mental health.com/ Lizst Mailing Lists http://www.liszt.com/ Mental Health Infosource http://www.mhsource.com/ Mental Health Net http://www.cmhc.com/ Mental Health Page http://www.grohol.com/mail.htm Metanoia http://www.metanoia.org/imhs 1-800-Therapist Network http://www.1-800-therapist.com/ Online Dictionary of Mental Health http://www.shef.ac.uk/~psysc/psychotherapy/index.html Pendulum Resources http://www.pendulum.org/ Self-Help Magazines http://www.selfgrowth.com/mags.html Self-Improvement On-Line http://www.selfgrowth.com/ Virtual-Addiction.Com http://www.virtual-addiction.com (*note: references to any sites in this manuscript do not reflect endosement by the authors or the publishers)
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Ann E. Hackerman is a Licensed Professional Counselor, National Certified Counselor, Certified Cognitive-Behavioral Therapist, and Certified Rehabilitation Counselor. She is presently working with blind and visually impaired individuals at the Clovernook Center for the Blind, Memphis, Tennessee, where she provides individual, family, and group therapies to clients and their families. She can be contacted by email at ahackerman@clovernook.org
Bobby G. Greer is a professor
and Licensed Professional Counselor, a Licensed Psychological Examiner,
and Certified Rehabilitation Counselor in the Department of Counseling,
Educational Psychology, and Research at the University of Memphis, Memphis,
Tennessee. Dr. Greer’s areas of interest include substance abuse
and vocational rehabilitation of the severely disabled, as well as mental
health and anger management. He has been published numerously in these
areas and can be contacted by email at greer.bobby@coe.memphis.edu