Interview Concerning the Ethics of Internet Counseling by Professional Caregivers Including a Brief History of Online Therapy
By Celeste Greenlee, Dallas Baptist University
September 20, 2006
In October of 1972 computers at Stanford and UCLA were used during the International Conference on Computer Communication to simulate a psychotherapy session (Ainsworth, 2002). "Ask Uncle Ezra," formerly located at http://cuinfo.cornell.edu/Dialogs/EZRA (now offline), is the earliest known organized service to provide mental health advice. It has been in continuous operation since 1986 and provides free services to students of Cornell University (Ainsworth). Since then, many different forms of online counseling, also known as "e-therapy", have come and gone. In 1997, the International Society for Mental Health Online was formed as a non–profit corporation to promote the understanding, use, and development of online communication, information, and technology for the international mental health community" (ISMHO, 2003). On January 9. 2000, a joint committee of the ISMHO and the Psychiatric Society for Informatics posted on their website the "Suggested Principles for the Online Provision of Mental Health Services" (ISMHO). These suggested principles provide some clarification of ethical issues as they relate to internet counseling and were first presented in a preliminary form as part of "Clinical Use of the Internet: Some Suggestions" at the 1999 American Psychiatric Association annual meeting (ISMHO).
Martha Ainsworth, co-chair of this committee and also the 2002 President of the ISMHO maintains several Websites dedicated to Internet Therapy (Ainsworth, 2002). The website for her private internet consulting practice, http://www.metanoia.org, provides a plethora of useful information to help consumers locate practitioners of Internet therapy (Ainsworth). It was through this website I was able to contact two therapists who very generously took the time to answer my interview questions concerning the ethical principles of internet counseling.
Gary S. Stofle, LISW, CCDCIIIE, CSWR, is licensed in Ohio and New York. He is currently the Team Leader of the Dual Diagnosis Treatment Team at North Central Mental Health Services in Columbus, Ohio. Mr. Stofle has written a book and several articles during his career and has presented at many noteworthy events. Since 1996, Mr. Stofle has been providing online counseling. He has become a national advocate for online therapy and is the former secretary/treasurer for the ISMHO (Stofle, 2003).
Judith L. Allen, Ph.D., LPC, LMFT is licensed in Texas. Dr. Allen teaches a six week Distance Learning Certification in Medical/Analytical Hypnosis, approved by the Texas State Board of LPC for Continuing Education for Licensed professionals. She is certified in Trauma Resolution, and was previously a Registered Sex Offender Treatment Provider. Dr. Allen has a thriving Internet Therapy practice and has been "seeing" clients via e-mail and instant messaging services since 1997. Dr. Allen is also on the Board of Directors of ISMHO – International Society for Mental Health Online, and is the 1992 Founder of APMHA.
What follows are various highlights from my Internet Interview with both therapists.
- What is your theory of change? How and why do people change and what is necessary before they change?
Mr. Stofle: I subscribe to Prochaska/DiClemente's Stages of Change Theory. It states basically that change is a process that people go through and ambivalence/resistance are normal parts of that change process. One first has to identify that something needs changing. Then they sometimes need help in knowing how to change and then people sometimes need support in maintaining a change in their lives (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: People generally seek to make changes when something is not working in their life and they feel a change could make it better. There is usually some emotional pain they are experiencing. People change by setting a clear goal, and breaking down the steps they need to take in order to reach their own goal. Sometimes during this process, the goals may be somewhat amended through new information they gain. Before anyone can change, there has to be the motivation and it is best when the motivation comes from within. Sometimes people make changes for their partners or others but they still have to see the advantage for themselves in doing so (J. Allen, personal communication, March 16, 2003).
- What are the most stressful types of clients for you to work with online as a therapist?
Mr. Stofle: Currently suicidal clients. I've had that happen twice, and I just did not know if the person would follow through with the recommendations for in-person follow-up. In both cases, the client did follow-up (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: Clients who refuse to take any responsibility for their lives. This is not only online but in all therapeutic settings. People who always blame others for the problems they have can be difficult for the therapist who is seen as the person to ‘fix' the problems for them (J. Allen, personal communication, March 16, 2003).
- What are some of the goals you have for clients in online counseling?
Mr. Stofle: My goals in online counseling are the same as the client's goals. I mostly work with people who have been brought up in dysfunctional homes and who most often have problems dealing with feelings and intimacy (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: My goals always come from the client. They bring their unique set of circumstances. They bring their problem and I help guide them to the decision that they want to make. It doesn't matter what I want. I have no preconceived goals, other than to help the client resolve their conflict, feel better about themselves, and feel more equipped to handle future issues on their own (J. Allen, personal communication, March 16, 2003).
- Describe your multi cultural experience, training, beliefs, etc.
Mr. Stofle: I think each of us brings a unique set of issues to all relationships we have. I th ink a good therapist tries to get in the shoes of the client they are working with in order to have a sense of the world from the clients' perspective. I am aware of the main issues in therapy with the main cultures in the US: white, black, Asian, Hispanic (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: My belief is ‘people are people'. You may have to take into account their cultural background to help resolve their inner conflict, but we all have the same basic needs. This belief has been further enhanced by working online with clients from France, China, Puerto Rico, Australia, Taiwan, Brazil, England, and other countries over the past six years. Listening to what the client brings from their culture can quickly help the therapist to put goals within the limitation and structures of any given culture. There are rules written and unwritten in every culture and through communication, these can e understood and taken into account. It would be fruitless, for example, to try to impose liberal Western views on a wife in Pakistan who is trying to be happy within her cultural boundaries (J. Allen, personal communication, March 16, 2003).
- How do you determine when you will refer a client for face-to-face counseling either with yourself or another therapist?
Dr. Allen: I have referred (clients) for medication management and I then begin working with the doctor, with the permission of the client, so that we can all be aiming in the same direction.. . . I might also encourage face to face therapy if the client is too isolated and depends on the computer for all their social interaction (J. Allen, personal communication, March 16, 2003).
- Are you aware of the most recent Supreme Court ruling about the "Duty to Warn" concept in the state of Texas and how does this apply specifically to online counseling?
Mr. Stofle: Ohio has a ‘Duty to Warn' bill as well (HB 71). If I have knowledge that an online client is threatening to harm an identifiable person or institution, I need to notify that person or institution, and/or the police, and work with the client to be able to either seek the appropriate type and level of treatment, including involuntary hospitalization if needed (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: Yes I am aware. It is no different online that face-to-face. I'm originally from California, and although Texas had no Duty to Warn in force, I frequently used my own judgement in matters involving potential harm. Online, I have information on my clients to know who and where they are. I would not hesitate (and have done so on one occasion) to notify local authorities of an impending danger of which I was made aware, through the counseling (J. Allen, personal communication, March 16, 2003).
- Do you have any specific techniques that you use for online clients that help you stay centered and not react to the client to attempt to meet your needs through them?
Mr. Stofle: No techniques that are any different than the usual self-care skills I use with face-to- face clients. A therapist needs to be centered and stable to last in this business without driving themselves or people in their lives crazy. A good book to read for therapists is ‘The Tao of Leadership' by John Heider (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: There are boundary issues on and off-line that can keep the work professional, warm, and effective. The need to stay centered - to which you refer- may be an issue more with new therapists who absorb too much of the issue through personalization. If a therapist is meeting their own needs through the client (counter transference) the therapist has not been trained adequately and/or has not had enough personal experience with their own therapy to be able to identify this. The experience of supervision is extremely important for new therapists to help avoid these pitfalls (J. Allen, personal communication, March 16, 2003).
- What were the factors that influenced you to enter the counseling field in general and specifically, what motivated you to start doing online therapy?
Mr. Stofle: I've always liked helping people. I became a social worker because I thought that it is a good way to help others. I started working online after being approached by a person who needed treatment and had met an online ‘therapist' who turned out to be a sexual predator. I felt obliged to help that person so she would not be further damaged by another online person who wasn't ethical. I've been working online since 1997 and have written on the subject of Chat Room Therapy as well as supervision online with a master's level student (G. Stofle, personal communication, March 13, 2003).
Dr. Allen: I was actually pushed into the counseling field. I was working as the administrator of a community mental health clinic in Los Angeles and I was also Assistant Administrator for California State Psychological Association. Many doctoral level friends encouraged me to get into the counseling field, telling me that I would be great at it. I found a profession I absolutely love. My online work began when I moved to Nevada for a few years and my Texas clients asked if I would talk to them through e-mail. I've learned a lot in the past six years and there is an enormous amount to learn; lots of research now about the issue and many online resources for therapists to better understand how to make the communication transition to a different medium; much like when sessions began to be conducted by telephone. Lots of resistance and fear (concerns) are constantly addressed in groups such as ISMHO (International Society of Mental Health Online) of which I am a current board member (J. Allen, personal communication, March 16, 2003).
Ainsworth, M. (2002). ABC's of "Internet Therapy". Retrieved March 16, 2003, from http://www.metanoia.org
Allen, J., & Robinson, M. (2003). The Problem Solvers at TherapyAve. Retrieved March 16, 2003, from http://TherapyAve.com
Allen, J. (2003) Net Counselors Online Counseling Retrieved March 16, 2003, from http://NetCounselors.com
ISMHO (2003). International Society for Mental Health Online. Retrieved March 16, 2003, from http://ismho.org
Stofle, G. (2003). Gary S. Stofle, LISW. Retrieved March 16, 2003, from http://members.aol.com/stofle/index.htm