By David R. Wheeler
March 18, 2015
If there was any question about whether the mental-health profession would be safe from technological disruption, the answer is now clear—and it’s a resounding “no.” BetterHelp, Talkspace, and other online counseling services can now connect clients with licensed professionals in an array of specialties. In the past year, these startups not only have increased in popularity, but also have gained the adulation of mainstream media outlets.
A Wall Street Journal writer who recently used both services called BetterHelp a “positive, professional experience” and said his Talkspace sessions were “identical to what I had experienced in traditional therapy, except I had access to it any time I pulled out my iPhone.”
However, despite the praise heaped on these counseling sites, some professional counselors worry about the privacy and quality of online therapy.
As recent hacking scandals have demonstrated, nothing connected to the Internet is 100 percent safe. Some counselors worry about the possibility that a client’s deepest secrets could be exposed.
“Clients and clinicians both need to be aware that good hackers can access anything online, regardless of industry security standards,” says Christy Leaver, a licensed clinical social worker with a counseling practice in Lexington, Kentucky. Leaver provides limited online-therapy services to established clients who sign a release indicating full knowledge of the risks of sharing personal information electronically.
While Talkspace describes its encryption as “industry standard,” not all counseling practices can provide that level of protection. For example, some private practices, including small local "mom-and-pop" counseling centers, simply use email. In fact, the American Psychological Association has noted a threefold increase of “service delivery” through email between 2000 and 2008.
“It’s hard to imagine that all the mom-and-pop shops really have a clear sense of all the technical and administrative safeguards that are part of the federal health privacy and security rules,” says Frank Pasquale, a University of Maryland law professor who studies health law and privacy.
In addition to having privacy concerns about online therapy, some counselors worry about the quality of care in these digital sessions.
“Some important aspects of counseling are lost when the services are not provided face-to-face,” says Joyce Marter, the president of the Illinois Mental-Health Counselors Association. “Therapy is an interpersonal process, based on a trusting therapeutic rapport, that may not be able to be facilitated in the same way through a virtual medium.”
In an online session, counselors may not be able to pick up on important aspects of non-verbal communication (such as telltale body language or the smell of alcohol) when they are not physically present with the client.
“From a clinical and ethical perspective, my position would be that face-to-face counseling should be the preferred medium for counseling for clients with significant mental health issues such as clinical depression,” says Marter, who will also serve as president of the Illinois Counseling Association beginning in July 2016.
But perhaps the most challenging problem of online counseling is confusion over licenses. Even in the offline world, it is difficult to understand a mental-health professional’s credentials. There are psychiatrists, psychologists, licensed marriage and family therapists, licensed mental-health counselors, licensed clinical social workers, and many more types of accredited counselors. Sessions with any of these mental-health professionals can be covered by insurance.
Determining the qualifications of a potential counselor is not as simple as asking whether he or she accepts health insurance. Some mental-health professionals in private practices, including certain psychiatrists and psychologists with doctoral degrees, deliberately choose to operate outside of a health-insurance network.
This variability, combined with a sprawling list of acronyms and degrees, opens up the possibility for deception and opportunism as counseling sessions move online.
Although BetterHelp is currently receiving positive reviews, its own website illustrates the confusion over what constitutes counseling. The top of its home page says, “Online counseling is effective, affordable, and discreet.” But a disclaimer in the FAQ section says that while the service “may sometimes have similar benefits” to counseling, “in most cases it does not constitute ‘therapy’ or ‘counseling.’ Please note that your provider won’t be able to make any official diagnosis, to fulfill any court order or prescribe medication.”
When one of the most popular online counseling services both embraces and rejects the word “counseling” in the same breath, it’s not hard to imagine less scrupulous startups using slick websites to lure vulnerable people into unethical situations in order to make money.
Although all counselors on BetterHelp and Talkspace are licensed mental-health therapists, other sites simply offer “life coaching,” which has no hard-and-fast licensing rules. Cloverpop, which has been featured on news outlets like NPR and The New Yorker, is not a counseling service, but rather a platform to “help with your biggest decisions.” The site never uses the word “counseling,” but it offers coaches who “help you work out uncertainties.”
Distance counseling, it should be noted, is not a new idea. It has existed in various forms for decades, albeit with clunkier technology. But increased familiarity with texting and video chat is giving distance counseling a new boost.
Counselors who want credentials in distance counseling can become Distance Credentialed Counselors through the National Board for Certified Counselors. The DCC program addresses issues such as encrypting communication, authenticating the client’s identity, and licensing in the client’s home state.
David Kaplan, chief professional officer of the American Counseling Association, believes that technology plays an important and necessary role in the counseling profession. “Online counseling can be especially useful with individuals in rural America, as a great many rural counties do not have a single licensed mental-health professional,” he says. And for clients with conditions like agoraphobia or severe anxiety, online sessions may be the only choice.
But in an era of increasingly aggressive startups taking advantage of the opportunity to tie all kinds of professions in with technology, some counselors and data-privacy experts wonder if online counseling can remain safe, confidential, and effective.
“The line between counseling, social work, pastoral care, and life-coaching is always blurry,” says Pasquale, whose book The Black Box Society, published by Harvard University Press, explores the lack of consumer protection in the digital age. “At the very least, there needs to be centralized complaint reporting, and a clear standard of care.”
“If a patient of a bad psychiatrist suddenly commits suicide, we at least know that there is some possibility of punishment of the errant psychiatrist if he fell below the standard of care,” Pasquale says. “What's the standard of care for a life coach?”