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Professional development for counselor educators

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Professional development for counselor educators

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The Center for Credentialing & Education (CCE) Approved Clinical Supervisor (ACS) credential program speaks to a mental health professional's commitment to providing quality supervision and to their qualifications to do just that. ACS credential holders have met national professional supervision standards and must meet continuing education requirements to maintain their credential. The ACS promotes the clinical supervisor's professional identity, visibility, and accountability and encourages professional growth.

Supervision is not only a requirement for licensure; it is a powerful tool for improvement throughout a counselor's career. Many counselors seek out supervision to enhance their professional abilities. For a counselor supervisor, the ACS shows supervisees that you take pride in your supervision. If you are looking for a supervisor, the ACS can help identify a committed supervisor.

"It is important to demonstrate clinical supervision credentials to your clients and supervisees," says Callie Marino, NBCC's Vice President of Credentialing and Quality Assurance. "By showing training, experience, and qualifications in supervision, the ACS helps counselors to further market themselves and grow their business."

The ACS is a voluntary credential for clinical supervisors who wish to demonstrate their qualifications and dedication. However, 15 states currently suggest the ACS in their counseling regulations. As well as experience and education requirements, ACS applicants must document 45 hours of clinical supervision training, which can come from approved continuing education programs or graduate coursework. There is no examination requirement for the ACS, but applicants must include a professional disclosure statement intended for supervisees.

Many graduates of CACREP-accredited doctoral programs may have completed the educational requirements for eligibility, and a portion of the experiential requirements as part of their doctoral internship. The ACS presented a wonderful and easily accessible opportunity to be recognized for the important training completed by professional counselor supervisors.

The ACS was introduced in 1998 by NBCC as a credential for professional counselor supervisors. The program later moved to CCE to open it up to other mental health professions. There are currently 2,600 active ACS credential holders throughout the United States.

Learn more about the CCE Approved Clinical Supervisor (ACS) Program.

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CCE Approved Clinical Supervisor (ACS) Program

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The Center for Credentialing & Education (CCE) Approved Clinical Supervisor (ACS) credential program speaks to a mental health professional's commitment to providing quality supervision and to their qualifications to do just that. ACS credential holders have met national professional supervision standards and must meet continuing education requirements to maintain their credential.

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Access resources and online training on cultural competency from SAMHSA and other agencies and organizations.

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Abstract

Background

The provision of psychotherapy over distance using technology is a growing market reaching many patients and therefore the risks and benefits need to be known by all psychotherapists whether they themselves practice online or not. This comprehensive review of the main ethical arguments for and against different forms of online psychotherapy aims to enhance discussion of ethical issues in this growing area.

Methods

A search of three databases (PubMed, PsycINFO, Web of Science) was conducted in August 2019 using a specific search protocol yielding 249 publications.

Results

Of 24 ethical arguments in favor of online psychotherapy and 32 against, the top five ethical arguments in favor of online psychotherapy were (1) increased access to psychotherapy and service availability and flexibility; (2) therapy benefits and enhanced communication; (3) advantages related to specific client characteristics (e.g. remote location); (4) convenience, satisfaction, acceptance, and increased demand; and (5) economic advantages. The top five ethical arguments against engagement in online psychotherapy were (1) privacy, confidentiality, and security issues; (2) therapist competence and need for special training; (3) communication issues specific to technology; (4) research gaps; and (5) emergency issues.

Conclusions

The findings may be of help to practitioners in deciding whether to engage in online psychotherapy, and in informing patients about risks and benefits, improving ethical guidelines, and stimulating further ethical discussion. The findings are argumentative and qualitative in nature, and further quantitative research is needed.

Keywords: online psychotherapy, telepsychology, telepsychiatry, ethics, technology

Introduction

Technological innovation has led to rapid change in many professions, bringing both benefits and challenges. Since the late 1990s, a growing body of research has addressed issues related to online psychotherapy. To begin, that research focused mainly on the usefulness of online psychotherapy before shifting in emphasis to situations in which online psychotherapy might be used, with a view to evaluating the strengths and shortcomings of this approach ( 1).

The Joint Task Force for the Development of Telepsychology Guidelines for Psychologists ( 2) define telepsychology as "[...] the provision of psychological services using telecommunication technologies [...]" (p. 792), which may be synchronous (real-time) or asynchronous, including "[...] telephone, mobile devices, interactive videoconferencing, e-mail, chat, text, and Internet [...]" (p. 792). The service can be standalone or an adjunct to traditional psychotherapy. The various terms used to describe such services generally refer to psychotherapy delivered remotely using some form of communication technology. In this review, the term online psychotherapy encompasses all such terminological variants, including telepsychology [see ( 2)], telepsychiatry [see ( 1)], online counseling [see ( 3)], behavioral telehealth, telemental health [see ( 4)], internet therapy [see ( 5)], internet counseling, online practice, online therapy, e-therapy, cyber-counseling, cyberpsychology, e-social work [see ( 6)], and e-mental health [see ( 7)]. These terms may differ slightly according to professional context or technological modality.

The practice of online psychotherapy reflects the rapid evolution of technology and may include the use of "virtual reality, augmented reality, intelligent wearable devices, and artificial intelligence applications" [( 8), p. 125]. As these technologies are still in the early stages of development, they are not included in this review. The present review includes online psychotherapy conducted by psychiatrists, psychologist, and social workers. Nurses are not included because of differences in their education and legal restrictions on the scope of their work.

As a growing number of patients seek online psychotherapy, therapists must consider the related ethical issues ( 3) and should be able to participate in this ethical discussion ( 9). For example, one important feature of a thorough process of informed consent is knowledge of risks and benefits in making a fully informed decision ( 10). One of the main barriers to further implementation of online psychotherapy is the uncertainty around ethical and legal issues ( 1), which are increasingly addressed in ethical codes of conduct ( 11).

The aim of this review is to summarize the main ethical arguments for and against the provision of online psychotherapy to further ethical discussion within the relevant professions, and to facilitate the development of comprehensive ethical guidelines to underpin the practice of online psychotherapy. This in turn will help practitioners in deciding to offer this form of psychotherapy and in helping their patients to make a truly informed decision about engaging in online psychotherapy. The present review is not about the quantity or volume of publications in which specific ethical arguments are discussed; rather, our concern was to identify the main ethical arguments to date as a sound basis for future discussion.

Methods

Publications were collected in August 2019 from three databases: PubMed, PsycINFO, and Web of Science. These were selected on the basis that the topic relates to medical, psychological, and ethical issues.

To construct the search protocol, the research question was structured in terms of three topics: ethics, psychotherapy, and online. Synonyms and main terms for these three fields were selected, and a search code was constructed for each database (including MeSH terms for PubMed and Thesaurus of Psychological Index Terms for PsycINFO); for details, see Full Search Code in Supplemental Material). The search code was validated by an expert librarian at the University of Zurich.

Publication titles and abstracts were screened according to defined selection criteria (for details, see Publication Selection Criteria in Supplemental Material).

The main ethical arguments were extracted from the selected publications by JS, clustering text passages according to main topics. JM read the selected publications independently and clustered the publications under these main categories ( Table 1). Disagreements were discussed and resolved.

Table 1

Ethical arguments in favor of online psychotherapy

Enhancing accountability

42, 51, 52, 55, 150, 184- 186, 204, 207

Protection of the therapist

23, 31, 53, 97, 143, 196, 207, 217

Social media

7, 26, 40, 54, 103, 155

Diminishing intimacy

12, 55, 67, 217

Informed consent

56, 57, 72, 117

Prohibition against free market

58

Ethical arguments against online psychotherapy

Dependence and loss of control by the patient

48, 58, 88, 107, 177, 206, 207, 216, 219

Autonomy issues

28, 45, 48, 60, 81, 132, 134

Dehumanization

15, 28, 68, 89, 90, 178

Stigmatization

29, 91, 113, 138

Results

The collection of publications in August 2019 in the three databases PubMed, PsycINFO, and Web of Science and selection according to the selection criteria resulted in a final sample of 249 publications.

The final sample (n = 249) included 179 articles, 6 books, 55 book chapters, 2 doctoral theses, 5 book reviews, 1 brief communication, and 1 item of correspondence. Among these, there were 32 literature reviews, 2 systematic reviews (regarding the socioeconomic impact of telehealth and guidelines in videoconferencing), 6 editorials or introductions, 5 book reviews, and 6 books (including 4 practice guides). Additionally, there was one case study, one correspondence, one research digest, one discussion, and one paper on ethical reasoning. In total, 30 of the selected publications were empirical studies, including 14 surveys and 6 website analyses. Six related to specific mental illnesses, one was a comparison of in-person and online psychotherapy, two included practitioner interviews, one was a study protocol for a meta-analysis, and one related to a practitioner discussion forum. Among other notable features of the final sample, 18 included guidelines, and 25 focused on specific countries.

The selected publications ranged across disciplines that included psychology (70), psychiatry (33), psychology and psychiatry (2), social work (12), and telemedicine (6). The remaining publications (125) related to psychotherapy in general, with no specific disciplinary focus. In terms of technological modality, these included email (13), telephone (5), videoconferencing (28), text-based methods including email and chat (14), email and text messages via cellphone (3), mobile phones (3), text messages (1), email and social media (2), and videoconferencing and mobile phones (6). The remaining 173 related to communication technologies in general rather than any specific technology or mode of communication.

Table 1 summarizes the main ethical arguments (24 pro and 32 contra) extracted from the final 249 publications, organized by number of mentions. The next section describes the various categories. For clarity, the summary does not include all discussion points, and reference is made to only one publication for each ethical argument. For further information about the arguments, readers are referred to the source ( Table 1).

Ethical Arguments in Favor of Online Psychotherapy

Therapy Benefits and Enhancements in Communication

According to a growing number of favorable research findings, online psychotherapy can be as efficient, effective, and efficacious as traditional therapy (or more so) [see ( 1)]. Multiple therapeutic orientations and modalities are translated into online communication, but cognitive behavioral approaches seem to be most appropriate or the easiest to transfer [see ( 15)]. For example, during an in vivo exposure, the therapist could be virtually present [see ( 16)]. However, also other psychotherapeutic orientations such as psychoanalysis assess and discuss ethical issues of practicing online [see ( 17)]. Online psychotherapy offers a viable alternative to in-person treatment but can also be used as a supplement or adjunct [see ( 18)]. This affords new opportunities for creative approaches involving different models of therapy and technological modalities, and additional online material (websites, videos, etc.) are easily integrated into therapy [see ( 19)]. Data recording and documentation of the online therapeutic process is also easier, allowing treatment, treatment stages, and therapeutic techniques used by therapist and patient to be revisited [see ( 20)].

Economic Advantages

Online psychotherapy is reported to be more cost-efficient [see ( 30)], with the potential to reduce healthcare costs for patients, therapists, and society as a whole [see ( 31)]. As a single therapist can reach more patients, especially in underserved populations [see ( 32)], long waiting lists for face-to-face treatment can be reduced [see ( 33)], offering a possible solution to the workforce shortage in mental health provision [see ( 34)]. Online psychotherapy might pose a solution to an undersupply in mental health care in various regions of the world, especially in low- and middle income or developing countries, for example, in India [see ( 34)].

Ethical Arguments Against Online Psychotherapy

Discussion

Online psychotherapy offers many advantages like benefits for the therapeutic process and the therapeutic communication itself, also by being more convenient than traditional settings of psychotherapy. Both many patients and therapists seem to be satisfied with the use of online psychotherapy. Not surprisingly, this kind of psychotherapy is increasingly being used. Online psychotherapy promises to solve economic pressures by being more cost-effective, offering a solution for workforce shortage problems and increasing access to necessary psychotherapy for many different populations suffering from mental health problems who might be difficult to reach such as patients living in rural areas. Reducing barriers to engaging in psychotherapy by reducing stigma, being able to attend online sessions anonymously thus enhancing a sense of privacy, reaching patients worldwide and across borders are other advantages of online psychotherapy. Conducting psychotherapy online gives the possibility to adapt services to specific patients offering more personalized care, enhancing patient control, and empowering the patient resulting in more adherence to and compliance with the treatment itself. The specific setting of online psychotherapy gives the therapist more freedom and offers physical protection, but might also protect the patient from breaches of intimacy boundaries and enhance the accountability of both patient and therapist. Additionally, online psychotherapy offers new opportunities for research, teaching, and supervision, enhancing the informed consent process, offering new opportunities through the use of social media and might give good assistance in emergency situations. Online psychotherapy might even improve and extend the therapeutic relationship.

One of the biggest and most discussed disadvantages of using psychotherapy is the risks with regard to privacy, confidentiality, and data security. Online psychotherapy creates new challenges to therapist competences which brings about the need for new forms of training and education, especially technological competences regarding many technical issues that might occur. Technological competence is not only needed by the therapist, but also by the patient. New communication skills are needed and particular attention must be paid to the development of the therapeutic relationship regarding the many boundary issues that might occur. Difficulties herein are put up by new access and availability issues and the loss of therapeutic control. Broader research, new guidelines, and a consideration of legal issues in general are needed especially regarding the practice across borders of nations, new payment and insurance issues, challenges to the informed consent process, dealing with emergency situations, enhancing the identification process of the therapist and the patient, and selecting patients that are suitable for online psychotherapy. The comparability to in-person treatment might be questioned and some fear danger to the image of psychotherapy. Therapists might fear increased liability and litigation. Online, new forms of misuse are possible and charlatans might utilize this kind of psychotherapy to achieve financial gains. Other feared disadvantages of online psychotherapy are the dehumanization and stigmatization of patients, patient dependence, and loss of patients' autonomy. New adherence issues might occur regarding the ease of ending an online session. Online supervision and teaching and the use of social media raise further ethical questions. Extensive costs might be faced by patient and therapists, when using online psychotherapy, for example, to set up the new technologies. Last but not least, the negative influence of technology itself might endanger its users.

This review has a number of limitations. First, only articles in English and German were included. However, only fourteen of the articles that were found to meet the search criteria were in a different language and therefore excluded. Among the emerging research topics not included in this review are online training and supervision, social media, avatar, second life, robots and bots, artificial intelligence, computer-mediated (self-help) therapy, psychology-related smartphone apps, internet-based group therapy and telecare, online forums, open chat, therapy for older adults, therapy for children and adolescents, and marriage and family therapy.

It is beyond the scope of the present review to offer exhaustive recommendations for clinical practice or how these ethical risks might be resolved in practice, and further systematic research should more fully address this topic. For some recommendations directly deducted from the results of this review, see Table 2.

Table 2

Thorough protection of privacy of the patient, ensuring confidentiality, and security

Engaging in special training and establishing special competence needed when conducting online psychotherapy, such as technological competences

Being aware of communication challenges of the respective medium used, such as missing of non-verbal cues when using email

Preparing for emergencies, for example, by establishing emergency plans, and being prepared to contact a local professional being able to intervene if necessary

Being aware and reassure the true identity, age, and location of the patient

Giving the patient the opportunity to reassure the true identity of the therapist and his/her certifications

Set up an exhaustive informed consent form and thoroughly discuss all the risks and benefits with the patient in order to enable her/him to make a truly informed decision about engaging in online psychotherapy

Clarifying fee and insurance issues

Being aware of boundary issues with regard to the establishment and maintenance of a professional therapeutic relationship online

Offering adequate anonymity and privacy to help eliminating barriers in engaging in psychotherapy

Adapt services to the particular needs of the patient, thus offering personalized care whenever possible

Be open toward further research on online psychotherapy, especially in cross-border online psychotherapy

Support and welcome the establishment of new guidelines for conducting ethical online psychotherapy

Counting the frequency of arguments does not clarify their relative importance; to evaluate their true weight, a more quantitative survey of experts' ratings is needed. Without that deeper understanding, the risks and benefits reviewed here remain anecdotal and qualitative, with only limited validity ( 92).

In future systematic research on efficacy, effectiveness, and efficiency of online psychotherapy is needed and practice guidelines, legal and ethical frameworks need to be developed. Further research in the fast growing field of online psychotherapy seems vital. Some important topics requiring further investigation are summarized in Table 3.

Table 3

Systematic research on the efficacy, effectiveness, efficiency, and comparability of online psychotherapy to in-person psychotherapy regarding different technologies, different mental disorders, and severity of symptoms

Translatability of different therapeutic orientations in online psychotherapy by assessing efficacy, effectiveness, efficiency, and comparability to the in-person setting, alterations needed, and suitability of different technologies for the respective therapeutic orientation

Possibility and applicability of certain clinical practices like online prescription, diagnosis, assessment of suicidality or homicidality, assessing decision-making capacity for informed consent regarding the usage of different technologies

Assessing which client characteristics are suitable for online psychotherapy and which are contraindicated, also regarding different technology use like video-conferencing or e-mail, as standalone or adjunct to in-person sessions, particular handling of homicidal or suicidal patients

Research regarding cross-border, worldwide, and cross-cultural practice by assessing legal issues, influence of cultural factors, language and communication difficulties, patient-therapist fit, malpractice, payment and insurance issues, acquirement of special competences

Assessing the changes in the therapeutic relationship due to different communication technologies used in online psychotherapy and the new forms of abuse that might appear or be possible in online psychotherapy compared to in-person psychotherapy

Research on additional skills needed by psychotherapists in the online setting compared to the in-person setting, assessing the questions who might be suitable to become an online psychotherapist, who might train them, and what kind of education programs might be suitable in which form

Data security issues assessing secure ways of communication using different technologies, also regarding secure data storage and secure online payment

Conclusion

If trained psychotherapists choose not to participate in the new and emerging field of online psychotherapy, it seems likely that charlatans will emerge to meet the ever-growing demand, perhaps driving professional psychotherapists out of the market ( 37). For that reason, psychotherapists from all professional backgrounds must be properly informed about the risks and benefits of online psychotherapy if they are to make well-informed decisions and act in the best interests of their patients. Even if they decide not to offer such services themselves, they should be equipped to provide information about online psychotherapy that enables patients to make a well-considered decision about using such services.

Author Contributions

JS and MT designed the review and developed the search strategy. JS and JM were involved in search, exclusion, and argument extraction processes. JS and MT wrote and edited the final article, which was reviewed and approved by JM.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

Special thanks to Sabine Klein, expert librarian at the University of Zurich, who reviewed the final search code and provided many useful inputs, and to Jörg Zemp, librarian at the Institute of Biomedical Ethics and History of Medicine, University of Zurich, who assisted us in locating the full-text publications that were not directly available.

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Ethical Issues in Online Psychotherapy: A Narrative Review

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The provision of psychotherapy over distance using technology is a growing market reaching many patients and therefore the risks and benefits need to be known by all psychotherapists whether they themselves practice online or not. This comprehensive review of the main ethical arguments for and against different forms of online psychotherapy aims to enhance discussion of ethical issues in this growing area.

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Clinical Supervision-How to be Effective