The Problem with “Online Counseling” & “Online Therapy” (Part I)

Do we need a new category of mental health service to properly identify the new services being offered online?

Telehealth and Telemedicine Precedents

Online CounselingWhen offering telehealth service in the health care world, the patient is seen by someone “in the system” initially for an in-person consult. An administrative assistant will open the file, check the insurance card and/or driver’s license to verify identity, and ask the patient to complete lots of paperwork, then double check it to make sure it is properly completed. A patient file is then opened. Often a nurse will take vital signs, ask the patient to describe symptoms and notes are taken in the new chart. Then a patient will be referred to a mental health specialist of some type.  That’s the standard of care for telehealth.

When a client or patient enters a psychotherapy practice without a referral from a healthcare office in the “real world,” the therapist usually has the client complete an intake form, sign HIPAA documents; give more identifying information during the intake such:  as names and dates of contact with other treating medical or mental health professionals in the community; previous arrests; a medical history. The therapist opens a client file for record-keeping, gets proper relases and an informed consent document signed.

Online, these steps are not being followed by many counselors and therapists. In fact, some therapists don’t do any of those steps, and simply get a credit card swipe along with a problem description. Are these therapists engaging in counseling or therapy when they deliver their service online? Should they be calling their service “online counseling” or “online therapy”?

A remarkable number of mental health professionals have decided that most of the precautions and conventions we’ve developed for decades aren’t necessary. They want to use the credibility of their licensures and the ability to say they deliver counseling or therapy when they are online, without meeting the requirements imposed by the same statements about their services when they are delivered in the real world.

Is This Really Happening?

If you conduct a Google search on the words “online counseling” or “online counselling” (British spelling), “online therapy” or even “online “psychotherapy,” you will see many thousands of practitioners have hung their shingles online. If you look further, you will see that a significant portion of those are treating people exclusively online. That is, while they may be operating in the real world under traditional rules of practice, as set forth by their legal and ethical groups, they are operating quite differently online.

Licensed Clinicians are Seeing Consumers Exclusively Online

I see several issues that raise questions about this alteration our traditional standard of care in ways that might not only be detrimental to us as professionals, but more importantly, to consumers.

Intake Procedures

First, let’s address this new trend of offering “online counseling” or “online therapy,” without an in-person assessment or referral by a trained professional. My assumption is that most of these professionals are intent on delivering good, quality care. However, they seem unaware that in many cases, they are violating the legal and ethical mandates of their licensing or ethical codes, and in far too many cases, placing their malpractice coverage in jeopardy. It’s noteworthy to see large groups of licensed counselors, social workers and psychologists charging anywhere from $2.50 to $4.99 a MINUTE for their professional, licensed, online services. (Psychiatrists can also be found engaging in such anonymous practice, but they are on different websites.) 

The problem of course, is that these practitioners are operating as if their services are part of the new movement toward telehealth and telemedicine, without the hassles.

“But We’re Helping People!”

From self-help articles to interactive smartphone apps to direct care — all these services are indeed possible now. We can offer a wide range of services to over 2 billion consumers worldwide. That’s a monumental step forward. But simply because we can do something only as professionals, should we? Should we consider all direct care delivered online to be either “counseling” or “therapy”?


Anonymity is another serious issue when offering mental health services online. Many online counseling and therapy practitioners, and the companies who serve them, are offering professional help without knowing the name or location of the client. This raises questions about our mandated reporting capabilities for abuse, suicidality, homicidality, and other responsibilities for maintaining patient records. See my other blog post detailing concerns about anonymity.

What about Emergencies?

Just to be clear, the services in question are not related to community emergencies, where a pregnant woman might be stuck in an automobile under a collapsed bridge, and is using her cell phone to communicate with a professional offering emergency services with the Red Cross.

I’m referencing professionals in developed countries availing themselves of the power of technology without regard to established telehealth practice models that have evolved for over 50 years; without having been formally trained in the potential limitations of distant care; who are relying on others who deliver similar services and a rapidly growing online ethos that it is “OK” to do whatever we want online.

Self-Assessment, Self-Diagnosis or Self-Screening

Other problems also complicate the issue. For instance, many online therapists also publish disclaimers on their websites that ask clients and patients to self-assess, self-diagnose or otherwise self-select and go elsewhere if they have a “serious” problem. Self-assessment is acceptable for self-help, but is it appropriate for counseling or therapy by professionals?

I recently mentioned this new technology-based trend toward self-assessment and self-diagnosis to a journalist, who promptly offered that indeed, she was once convinced she had ovarian cancer before she was assessed by a physician, who readily informed her that she had a simple hernia. In mental health, the fact is that the potentially abusive, violent and lethal populations we sometimes treat are not the best self-diagnosticians or decision-makers regarding the seriousness of their symptoms.

Certainly some people are quite capable of self-assessment, but are we doing our jobs if we hang our shingles and assume everyone who approaches us online understands our disclaimers? Is that a safe assumption for us to make, given the variety of people from different countries, languages, cultures and religions who have access to us via the Internet?

Do We Need a New Category of Mental Health Service?

Consumers deserve useful care, regardless of what we call it. But perhaps is it time we develop a new name for this category of service? Is it perhaps “support” or coaching, or maybe simple “advice-giving”?

Training is also needed to help us think through these important, underlying issues. Most of us are honest, reasonable and well-intentioned. We would never think of ourselves as engaging in questionable practices. The problem is, the Internet’s capacities have outstripped the ability of our professional associations and regulatory bodies to keep us educated and aware of all the important issues related to online practice.

Training options have been limited. They aren’t limited anymore. It’s time we take responsibility for our work, wherever we deliver it. When that delivery is online, we need to have undergone a thorough training program that helps us think through the issues to make sure we “do no harm.”

That’s my opinion, What’s yours?

Want to know where to get good training? We have a range of TeleMental Health courses specifically designed to help you understand these issues, and a whole lot more. 

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