13.3 Emerging Issues in Online Counseling
While technology is an excellent way of overcoming barriers to access to mental health care, there are still some issues that need to be addressed.
Group Counseling
Online group counseling offers solutions to significant barriers, such as transportation challenges; however, counselors have raised concerns regarding its efficacy compared to in-person modalities. Havlik et al. (2023) explored counselors’ experiences facilitating online groups, highlighting critical challenges warranting attention.
First, counselors reported difficulties fostering client engagement, noting frustrations about the inability to assess body language or maintain eye contact. Participants frequently relied on chat functions to communicate, which hindered free-flowing conversation and disrupted the development of key therapeutic factors essential for group counseling effectiveness (Havlik et al., 2023). Second, the online format intensified challenges related to multicultural broaching and exploration. Limited visual cues, verbal sharing, client-counselor differences, and contextual issues of oppression diminished group cohesion. This lack of cohesion negatively impacted facilitators’ comfort and ability to address important group topics effectively (Havlik et al., 2023). Lastly, counselors identified unique challenges in engaging adolescents in online group settings. While adult populations appeared to benefit more readily from therapeutic factors in virtual formats, adolescents required more creative and tailored approaches to maintain engagement. This finding underscores the importance of diversity considerations and adaptive strategies to meet the needs of different populations (Havlik et al., 2023).
Although research suggests a positive correlation between therapeutic alliance and outcomes in online group therapy, there remains a pressing need for further investigation into group cohesion, the therapist’s reduced control over the therapeutic environment, and the implications of limited nonverbal communication—especially when clients opt to keep their cameras off (Weinberg et al., 2021).
Case Example: Group Telehealth Challenges
Hayley, a clinical counselor, facilitates weekly online aftercare groups for ten clients. Hayley sends out a Zoom link to be kept from other clients or people not participating in the group. Hayley included this in her informed consent during her first group session, emphasizing confidentiality and requesting clients to use a private room where no one could see the participants of the meeting nor listen to the conversations. However, during one of the meetings, Hayley noticed that one of the clients had a nonparticipating member lingering behind her in the room. As all clients must keep their cameras on, the nonparticipating member can see clients participating in the meeting.
Moreover, their conversations are heard as the client is seen not using headphones. The client was also seen pointing at the screen and conversing with the nonparticipant present in the room. Hayley understands this is a breach of confidentiality but is unaware of how to address the situation. She also realizes that the clients share their personal information during the conversation and is considering how to protect client privacy.
The case is a good example of how group sessions can go wrong. While dealing with multiple people, such as during group sessions, tracking client movements and privacy is challenging. This case also shows how it may not be possible for people to find a private space to attend a counseling session. Moreover, other clients’ confidentiality is breached. Hayley, in this case, can consider removing the particular client from the group and having a private conversation with the client, reminding them of confidentiality rights. This also shows the importance of navigating the online platform to perform seamless tasks of removing clients from group meetings, muting clients when they are interrupting, or taking other necessary steps to ensure a smooth session.
Risk Management During Telehealth
Counselors, as mandated reporters, are required to address suicidal and homicidal ideations disclosed by clients. However, crisis intervention becomes more complex in telehealth settings, mainly when clients are not in or near a treatment center. In supervised environments, such as treatment centers, clinical staff can intervene immediately, provide mental health support, coordinate with emergency services, and even accompany clients to emergency departments. In telehealth, these opportunities are limited when clients join sessions from unsupervised locations using phones or computers (Luxton et al., 2014).
Case Example: Risk Management
Sumitra, a counselor at a treatment center who also interns in the evaluation department, collecting treatment outcome data from clients for grant purposes. Using her work phone, she contacts treatment graduates to gather information on substance use, mental health, and their treatment experiences. During one such call, a client disclosed experiencing suicidal ideations with intent but no specific plan. Sumitra attempted to explore the client’s support systems and access to resources, but the client denied having any and refused assistance, stating they would manage on their own. The client subsequently ended the call. This left Sumitra in a difficult position. The client was no longer in treatment, her release of information authorization for involving nearby hospitals was invalid, and she was not responding to follow-up calls. Sumitra grappled with how to provide crisis intervention, which was compounded by uncertainty about confidentiality boundaries. Her dual role as a counselor and data collector further complicated this dilemma, raising questions about her responsibilities and ethical obligations. While Sumitra worked in two different roles, as a licensed counselor, her duty to report precedes her role as an intern in the evaluation team.
The NAADAC (2021) Code of Ethics states:
“Addiction professionals shall only reveal client identity or confidential information without client consent when a client presents a clear and imminent danger to themselves or to another person, and only to emergency personnel who are directly involved in reducing the danger or threat. Counselors shall obtain supervision or consultation when unsure about the validity of an exception, and shall document the recommendations” (Standard II-8).
The ACA (2014) Code of Ethics also provides guideline around breach of confidentiality:
“The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues” (B.2.a.).
While counselors are authorized to breach confidentiality in cases of imminent risk, assessing the severity of a situation becomes challenging when clients are not visible, such as during phone calls or when they join virtual sessions with their cameras turned off. This difficulty is compounded when clients abruptly leave a session or end a call, limiting the counselor’s ability to conduct further assessments. To address these challenges, treatment centers, and private practices can develop protocols tailored to such scenarios while adhering to ethical guidelines. However, the complexity increases when minors are involved, as notifying parents or guardians introduces additional considerations. There is a need for further exploration to establish best practices for addressing at-risk youth, particularly within school-based telehealth models (Holland et al., 2021).
Missing Cues
Maintaining eye contact on a virtual platform and assessing verbal or non-verbal cues leading to potential misunderstanding is challenging.
The NAADAC (2021) Code of Ethics refers to this and provides guidelines for informing clients about potential misunderstandings:
“Addiction professionals shall acknowledge the differences between non-verbal and verbal cues in face-to-face and electronic communication, and how these could influence the counseling/supervision process. Providers shall discuss with their client/supervisee how to prevent and address potential misunderstandings arising from the lack of visual cues and voice inflections when communicating electronically” (Standard VI-15).
The ACA (2014) Code of Ethics provides similar guidance:
“Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically” (Standard H.4.f.).
Supervision Through a Virtual Platform
Clinical supervision has evolved from a face-to-face experience to being facilitated using various technological platforms (Khanna & Kendall, 2015). The use of technology in clinical supervision has benefits and challenges (Carlisle et al., 2017). Benefits include flexibility with scheduling and providing easier access to education platforms, particularly for students who live outside of metropolitan areas. Challenges include a limited ability to engage in non-verbal communication and confidentiality and privacy conundrums (Carlisle et al., 2017).
As we explore the ethics of virtual supervision, it is also important that we differentiate between virtual supervision and telehealth services. Virtual supervision is designed to support the professional development of counselors-in-training or practicing clinicians. Its primary focus is enhancing counseling skills, discussing case conceptualization, and ensuring ethical practice. Conversely, Telehealth aims to deliver clinical services directly to clients, address mental health issues, and work toward therapeutic goals. While both rely on secure, HIPAA-compliant platforms, the content and objectives of the interactions differ significantly. Supervision focuses on the supervisee’s growth and ability to serve clients effectively, whereas telehealth centers on the therapeutic relationship and outcomes for the client.
Both modalities share common advantages, such as increased accessibility for those in remote or underserved areas and greater scheduling flexibility. They also require competence with technology on the part of the counselor or supervisor and an understanding of the ethical issues involved in virtual interactions. These include ensuring confidentiality, using secure platforms, and having contingency plans for technical failures. However, the ethical challenges differ slightly between the two. In telehealth, client confidentiality and safety are paramount, with added concerns about assessing clients’ suitability for remote care, managing crises, and ensuring the effectiveness of virtual interventions. In virtual supervision, ethical concerns often involve protecting client information during case discussions, maintaining supervisee privacy, and ensuring supervision meets professional standards.
Virtual supervision became commonplace during the COVID-19 pandemic. Many states have changed in-person versus virtual requirements regulations, allowing virtual supervision sessions to be counted as face-to-face or in-person supervision. Despite the benefits of the practice, concerns persist about the quality of virtual supervision. Moretti and Simmons (2023) conducted a study exploring psychology doctoral students’ satisfaction with virtual supervision. In this study, the authors compared the efficacy of in-person supervision with virtual supervision, as reported on and rated by the doctoral student. While students highlighted that in-person and virtual supervision were beneficial overall, most students shared that they were more satisfied with in-person supervision than virtual supervision.
As technology reshapes the counseling profession, supervisors must approach virtual supervision intentionally and ethically. By addressing the challenges of technology use and adhering to established best practices, supervisors can provide high-quality guidance and support to supervisees. Ethical and competent use of virtual platforms enhances the supervision process. It contributes to clients’ overall quality of care, ensuring that supervisees are well-prepared to meet the demands of an increasingly digital world.
Key Takeaways
- Online group counseling provides accessibility solutions but presents challenges in fostering client engagement, group cohesion, and addressing multicultural dynamics effectively.
- Counselors must establish clear protocols to protect confidentiality in online group settings, including addressing breaches when nonparticipants are present.
- Crisis intervention during telehealth requires tailored strategies to assess risk and provide support in unsupervised environments, emphasizing the importance of ethical and legal guidelines.
- Virtual counseling and supervision platforms demand clear communication about potential misunderstandings due to limited nonverbal cues and voice inflections.
- Supervisors must navigate ethical considerations unique to virtual supervision, ensuring the process maintains high-quality support and meets professional standards.
- While virtual supervision offers flexibility and accessibility, research suggests that in-person supervision is generally rated as more satisfying, highlighting the importance of intentional, ethical approaches in digital supervision settings.