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Marriage and Family Counselors’ Perceived Ethical Issues Related to Online Therapy

Katherine M. Hertlein1, Markie L. C. Blumer2, and Jennifer H. Mihaloliakos3

Abstract Technology use in the practice of couple and family therapy has many advantages. The use of online and technology-based modes of communication for therapy, however, presents several valid ethical concerns. In a survey of 226 licensed Marriage and Family Counselors, students, and supervisors, participants were asked to identify ethical concerns and drawbacks of online therapy. Five themes related to this topic emerged: (a) confidentiality, (b) impact to the therapeutic relationship, (c) licensing and liability issues, (d) issues related to crises and risky clinical situations, and (e) training and education. Implications for practice, training, and research are discussed.

Keywords technology, online therapy, ethics, Internet, cyber

Telehealth is an emerging practice among both medical and

mental health disciplines. A proportion of the recent growth

in telehealth may be due to the increased availability of tech-

nology, pressure on health care to become more efficient and

affordable, and a mandate to provide equal access to health care

(Baker & Bufka, 2011; Perle, Langsam, & Nierenberg, 2011).

Online therapy is one common form of telehealth, which is

defined as ‘‘the use of telecommunications and information

technology to provide access to health assessment, interven-

tion, consultation, supervision, education, and information

across distance’’ (Nickelson, 1998, p. 527). It is defined by

Dielman et al. (2010) as the ‘‘transmission of images, voice and

data between two or more health units via telecommunication

channels, to provide clinical advice, consultation, education

and training services’’ (p. 12). The National Board for Certified

Counselors, Inc. (NBCC, 2008) classifies telephone, Internet,

video, e-mail, and chat-based counseling underneath a broad

definition of ‘‘technology-assisted distance counseling’’

(n.p.). All modes of this type of mental health treatment share

a commonality in that they use either the phone or computer to

help therapists and clients communicate. The definition of

online therapy, however, may be broadened to include not only

synchronous forms of communication (i.e., Skype or Internet

chatting) but also to include asynchronous modes such as text-

ing and e-mailing (Hertlein, Blumer, & Smith, 2014).

The use of online practices in psychotherapy, referred to

henceforth as online therapy, has several advantages. Barak,

Hen, Boniel-Nissim, and Shapira (2008) found online therapy

is nearly as or as effective as traditional face-to-face therapy.

In particular, online therapy has been found to be effective in

treating depression (Mohr, Vella, Hart, Heckman, & Simon,

2008), particularly when access to other providers is limited or

to prevent relapse (Garcia-Lizana & Munoz-Mayorga, 2010;

Moreno, Chong, Dumbauld, Humke, & Byreddy, 2012), panic

disorder (Carlbring et al., 2006), and a host of other presenting

problems (see, e.g., Andersson, Estling, Jakobsson, Cuijpers, &

Carlbring, 2011; Blankers, Koeter, & Schippers, 2011; Wooton,

Titov, Dear, Spence, & Kemp, 2011). Online therapy may also

be advantageous in rural areas where access to counseling cen-

ters is limited, as well as circumstances where clients are

homebound due to physical or psychological illness (Hertlein

et al., 2013). Couple and family counselors, as well as other

mental health professionals, may find online therapeutic prac-

tices more convenient because it often allows for accommoda-

tion of hectic or inflexible schedules, as well as a tool for

scheduling and appointment reminders.

Despite the effectiveness and convenience, the use of online

modes of communication for psychotherapy presents some

equally valid ethical concerns. One ethical concern is the assur-

ance of confidentiality (Derrig-Palumbo & Eversole, 2011;

1 Marriage and Family Therapy Program, University of Nevada, Las Vegas,

NV, USA 2 Department of Human Development and Family Studies, University of

Wisconsin-Stout, Menomonie, WI, USA 3 Private Practice, Las Vegas, NV, USA

Corresponding Author:

Katherine M. Hertlein, Marriage and Family Therapy Program, University of

Nevada, Las Vegas, Box 453045, 4505 Maryland Parkway, Las Vegas, NV

89154, USA.

Email: katherine.hertlein@unlv.edu

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Nelson, 2010), characterized by both visual and auditory

confidentiality concerns (Nelson, 2010). Auditory concerns are

related to cell phone use; as one can carry on conversations

with clients at virtually any time, there may be a breach in

confidentiality when others nearby can overhear the conversa-

tion. Visual concerns emerge when counselors do not protect

their computer or tablet screen, provide passwords to others,

or use a shared computer. Counselors who conduct services

online must weigh potential treatment benefits and ethical risks

of saving chat transcripts or e-mail chains, which may contain

protected client information. In addition, clients must be made

aware of the benefits and risks of electronic communication

and therapy via informed consent (Nelson, 2010).

A second issue discussed in the literature is boundary man-

agement (Hertlein et al., 2014). With the growing presence of

social networking such as Facebook, MySpace, and chat

rooms, all participating parties may enter unintentionally into

dual relationships or make unintended personal disclosures

(Nicholson, 2011). Similarly, if a counselor and client were

to become ‘‘friends’’ on a social networking site and subse-

quently see a photo or post that contradicts information the cli-

ent reported during a session, counselors have to make

decisions about what to do with the information. Further, other

friends on a counselor or client’s friend list may become cur-

ious as to the relationship between the counselor and client,

potentially breaching confidentiality.

A third issue is the management of crises. Counselors must

discern which of their clients are appropriate for online therapy.

This includes assessing a prospective client’s ability to recog-

nize and respect boundaries, severity of client problems, diag-

nostic information, and whether the client is suicidal or

homicidal (Chester & Glass, 2006; Perle et al., 2013). Further,

counselors must consider how and to whom they will report if a

client plans to harm themselves or others, and be able to refer

clients to emergency services in their zip code. Mandatory

reporting may become a tricky issue when conducting online

therapy in a different state than the client, as the question arises

as to which state the counselor reports and whether it is ethical

to be conducting online therapy outside of the state of licensure

(Derrig-Palumbo & Eversole, 2011).

Previous Literature on Managing Ethical Issues

Maheu and Gordon (2000) conducted one of the earliest studies

on the counselor’s use of technology with clients. They found

78% of their counselor participants (93% of which were licensed to provide counseling services) reported providing ser-

vices via online mechanisms to a client in another state.

Although 60% indicated they checked the state law where the client was located, nearly three quarters of them (74%) were wrong or uncertain about the state regulations. Further, 48% of the participants indicated they used a consent form prior to

the initiation of treatment.

A similar study was recently conducted of psychologists’

usage of online treatments. A sample of 409 licensed psychol-

ogists and 308 doctoral-level students responded to items

regarding their perceptions of online therapy (Perle et al.,

2013). The researchers focused on identifying whether vari-

ables such as theoretical orientation, age of the psychologist,

and extent to which online practices are involved in treatment

(i.e., adjunct to treatment vs. sole treatment modality) affected

a psychologist’s utilization of online therapy. Findings indi-

cated psychologists who operated from a cognitive–behavioral

stance or systems orientations were more likely to adopt online

therapy practices as compared to those who practiced from an

existential or dynamic perspective. There were no significant

differences between students and licensed professionals with

regard to adoption of online therapy practices.

Given the vast nature of providing online services in lieu of

information regarding how best to do so (Maheu & Gordon,

2000), and in consideration of Perle et al.’s (2013) contention

that many of the ethical issues related to telehealth have been

resolved over time and with research, the purpose of this study

was to evaluate Marriage and Family Counselors’ (MFTs) per-

ceptions related to the ethics of conducting online therapy,

including a valuation of the specific benefits and drawbacks

related to ethical concerns.

Method

This study was an exploratory mixed-methods approach

(Gambrel & Butler, 2013). Survey data (both open and

close-ended questions) were collected from a sample of part- and

full-time counselors, and students in MFT programs. Participants

were recruited in three main ways: (a) Internet postings (through

social media such as Facebook, organizational posting, etc.),

(b) advertisements at the American Association for Marriage and

Family Therapy (AAMFT) divisional level, and (c) couple and

family therapy–themed conferences. We also e-mailed program

directors of Commission on Accreditation for Marriage and

Family Therapy Education (COAMFTE)-accredited programs

and asked them to distribute the survey link to their faculty and

students.

We estimated this recruitment procedure may have put us in

contact with nearly 2,000 potential participants, resulting in

226 participants for this study. Participants were invited to pri-

marily complete the inventory online (Questionpro.com 1

).

There were two groups, however, who had the option of com-

pleting a paper version to be entered into the online tool by an

assistant: those who received the request at conferences and

those at the divisional level to whom the survey was mailed.

This research was approved by a university Institutional

Review Board and funded by the Alaska Association for Mar-

riage and Family Therapy.

Instrument

The survey tool was composed of Likert-type, multiple choice,

and open-ended items, consistent with an explanatory type of

mixed-methods research approach (Gambrel & Butler, 2013).

The survey contained 51 items and covered a series of topics

including information about the participant’s practice, use of

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cybertechnology in clinical practice, and the use of technology

in supervision, education, and training as well as assessing the

perception of ethical concerns. In addition to the information

related to ethics, participants were asked about the frequency

by which they use various technological services, social net-

working sites with their clients and colleagues, e-mailing to cli-

ents and colleagues, and other ways they might use technology

with these groups. For a more detailed description of the survey

items, see Hertlein et al. (2014). The findings presented here

represent a subset of the complete survey tool and focus on

counselor perceptions of the potential ethical issues when par-

ticipating in online therapy practices, and the extent to which

guidelines from other organizations, and opportunities for fur-

ther training would be desired.

Because the findings in the Perle et al. (2013) study contra-

dicted the findings of the Mora, Nevid, and Chaplin (2008)

with regard to differences in student versus professional per-

ceptions and practices, data regarding the importance of using

other ethical codes to make decisions were analyzed through a

t-test to determine whether there was a difference between stu-

dents and professionals. The analysis with regard to the open-

ended items involved noting common phrases within the

answer to each prompt following an open and thematic coding

process (Merriam, 2002). Each author reviewed the data and

identified themes and then compared the themes with one

another in order to determine a final list of themes. Specifi-

cally, we employed a bracketing procedure (Patton, 2002) for

theme identification and then used the analytic inductive-

constant comparative method (Glaser & Strauss, 1967) to ana-

lyze themes. This was accomplished through reading and

rereading the data to compare the themes with what was being

presented in the data upon our read throughs, and making sug-

gestions to modifying the themes if necessary. Any disagree-

ments about the themes were settled through conversation

and agreement of what the common theme would be. Final

categories were the result of this modification process and a last

reading of the data to determine if the data still fit with the soli-

dified themes.

Results

Participants who completed the survey included 226 licensed

counselors, Marriage and Family Counselors (LMFTs), and

AAMFT clinical, students, and approved supervisor members.

The sample was predominantly female (n ¼ 176, 79.64%), Caucasian (n ¼ 185, 84%), and AAMFT clinical members (n ¼ 128, 57.92%) who worked in a private practice setting (n ¼ 92, 38%). Approximately 5% (n ¼ 13) of the sample iden- tified as Hispanic/Latin American, 3% (n ¼ 7) as African American/Black, and the remaining identified as American

Indian, Alaskan Native, or of Asian descent (n ¼ 15, 6.6%). Just under half of the participants indicated they work in rural

areas (n ¼ 110, 48.5%), 39.2% in suburban areas, and 12.3% in rural areas. A full quarter (n ¼ 67, 27.46%) worked in a grad- uate program, with 39 of these (58.2%) being students. Another 21.23% (n ¼ 48) worked in nonprofit, state, or community

agencies. The remaining participants worked in for-profit agen-

cies, medical facilities, and employee assistance programs, and

other (n ¼ 37, 16.37%). Just over half of the participants worked part-time in a private practice setting; 44% worked full-time, and eight reported ‘‘other’’ as their employment

status.

Perceived Ethical Issues and Drawbacks in Web-Based Treatment

Five themes emerged with regard to the ethical issues and

drawbacks that emerge in online therapy: (a) confidentiality,

(b) impact to the therapeutic relationship, (c) licensing and lia-

bility issues, (d) issues related to crises and risky clinical situa-

tions, and (e) training and education. The most frequently cited

ethical issue noted by participants was the issue of confidenti-

ality, mentioned by well over half of the participants. Confi-

dentiality included concerns about privacy, concerns about

who could view the video or feedback, and authenticity of the

user. Participants believed online therapy introduced questions

around authenticity of the user, such as ‘‘who has access to the

computer’’ and ‘‘the [chance] of loss of control of who has the

device at the other end,’’ particularly when that computer is a

home computer. One participant asked, ‘‘How can the therapist

or client be sure no one else is in the vicinity of the computer—

that is, how can you assure confidentiality?’’ In addition to the

issue of other persons physically present in the computer room,

there is the risk that someone can gain access to another’s

account. According to another participant, ‘‘confidentiality is

a very big consideration given the number of ways to access

personal cyberspace accounts.’’ Others participants raised the

concern that counselors may not be providing treatment to the

person with whom they think. Confidentiality was also related

to the issue of security for some participants. According to one

participant, ‘‘security online is not guaranteed.’’ Several parti-

cipants noted the potential for hackers and described their

belief that the less secure the connection, the potential for a

breach of confidentiality.

The second theme was impact to the therapeutic relation-

ship. Several participants noted that messages sent may be mis-

interpreted or misunderstood, thus compromising client care

and the therapeutic process. Another issue was the potential for

diffuse boundaries between client and counselor. One partici-

pant exemplified this by writing there may be ‘‘missed infor-

mation, lost feelings/understanding, lack of intimacy and

disclosure.’’ Another example is provided by another partici-

pant who stated that another issue may be ‘‘missing key factors

of the human experience—social relationships and nonverbal

communication.’’ According to another participant, online

therapy ‘‘lacks the opportunity for physical human interaction,

such as offering a crying client a tissue or engaging in therapeu-

tic touch, which could possibly act as a barrier to joining effec-

tively with clients.’’

Participants also characterized the impact to the relationship

as one where nonverbal cues and body language would not be

as easily read and that subtle cues would be missed. Online

Hertlein et al. 7

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therapy was also characterized as one of reduced quality

(resulting in ‘‘dilute[d] treatment’’) due to the lack of face-to-

face interactions and ‘‘personal connection.’’ One participant

exemplified their concerns in this way: ‘‘I am concerned that

MFT never becomes an assembly line service through the use

of cyber-technologies.’’ Web-based therapies were also per-

ceived as contributing to greater degrees of difficult in properly

assessing clients. In addition to the potential impairment to the

relationship in general, the lack of physical presence might

impair one’s ability to intervene. As exemplified by one parti-

cipant: ‘‘ . . . it is more difficult to use body language and posi- tioning to create change and build rapport.’’ As summed up by

one participant, the ‘‘quality of service via Skype/e-mail/chat-

rooms does not equate to therapy [the] client would receive

face-to-face.’’

Boundary-related concerns also emerged within the theme

of impact to the therapeutic relationship. One participant noted:

‘‘client-therapist boundaries may be blurred if client has access

to therapist e-mail . . . ’’ Participants also cited the potential for dual relationships in that clients might be able to contact their

counselors via social media. Also related to boundaries was the

decision around ‘‘how much to show or share.’’ Finally, parti-

cipants reported that the boundary issue might be tied to ‘‘over

use’’ of the computer, thus making the counselor more avail-

able and risk being perceived as available any time.

A third theme was the potential for having sessions with

individuals who are at risk, such as those who are suicidal or

experiencing other potential crises. Some of the issues identi-

fied within this theme include difficulty in ‘‘monitoring self-

injurious behavior,’’ ‘‘safety of the client,’’ and a compromised

ability for the counselor to intervene immediately. One partici-

pant noted: ‘‘if you don’t have the location of the client you are

speaking with and they admit to wanting to commit suicide,

how do you send help their way?’’ In addition, participants

indicated those participating in online therapy might have dif-

ficult properly assessing for risk factors, suicidal or otherwise

unsafe clients, and may ‘‘[miss] imminent harm.’’

The fourth theme was of a professional nature—specifically,

liability and licensing concerns. Participants noted concerns

related to the 1996 Health Insurance Portability and Account-

ability Act, record keeping, informed consent, distributing

forms and handouts to clients, mandated reporting, and invol-

vement of third-party payers. This may result in issues of, as

one participant summed, ‘‘credentialing and quality control.’’

Another issue was the process of conducting interstate treat-

ment as counselors may not be licensed to practice with clients

living in another state. One participant exemplified this by stat-

ing: ‘‘where is the therapy occurring if a complaint is [made?

Which] state does it go to?’’ This theme was also related to the

third theme of conducting treatment with individuals at risk.

For example, one participant wrote: ‘‘if a client has an

emergency and you are not accessible, could you be held

responsible?’’

A fifth theme that emerged was that of the necessity of hav-

ing proper training and education to deliver and conduct thera-

pies online. Participants cited the mechanics of the computer

and that problems may occur with regard to its usage, with

some of these tying back to confidentiality. One participant

wrote it was important to ‘‘[make] sure your cyber connection

is secure to maintain confidentiality.’’ Participants noted the

responsibility of the counselor to be knowledgeable about how

to conduct sessions over the Internet, including ‘‘educating

clinicians about using privacy practices, proper use of both per-

sonal and professional pages on social media sites.’’ One exam-

ple of this is a participant who stated that it was important to

assure ‘‘all who are required to use the technology are fully

trained and can use if effectively.’’

Perceived Potential Issues Related to Informed Consent

In addition to responses to the open-ended items, participants

were asked the extent to which they discuss potential issues

related to web-based practices within their informed consent.

Approximately one third (33.62%, n ¼ 76) indicated that these issues were not presented at all in their informed consent.

Another 10% (n ¼ 23) stated they discussed it to some degree. Nearly another third (29.65%, n ¼ 67) indicated it was included to a high degree in their informed consent (see Table 1).

The Importance of Other Codes When Making Ethical Decisions

With regard to the total sample (see Table 2), 22% (n ¼ 50) of the sample stated that codes from other disciplines were helpful

to understanding how to navigate operating their practice

Table 1. Potential Ethical Issues Related to Cyber-Based Treatment in Informed Consent.

Student Professional Total

N % N % N %

Not at all 18 31.6 58 34.3 76 33.62 A little 6 10.5 17 10.1 23 10.17 Some 4 7.0 8 4.7 12 5.31 A lot 6 10.5 11 6.5 17 7.52 Most 3 5.3 28 16.6 31 13.72 High degree 20 35.1 47 27.8 67 29.65 Total 57 100.0 169 100.0 226 100.0

Table 2. Ethical Guidelines From Other Fields Helpful.

Student Professional Total

N % N % N %

Not at all 4 7.0 24 14.2 28 11.5 A little 6 10.5 19 11.2 25 11.06 Some 17 29.8 33 19.5 50 22.13 A lot 13 22.8 33 19.5 46 20.35 Most 7 12.3 25 14.8 32 14.16 High degree 10 17.5 35 20.7 45 19.91 Total 57 100.0 169 100.0 226 100.0

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where Internet technologies are concerned. Another 20% (n ¼ 46) found the guidelines helped them a lot, and 34% (n ¼ 77) helped them most of the time and to a high degree.

Based on previous literature citing how younger counselors

are less likely to provide telemental health services (Simms,

Gibson, & O’Donnell, 2011) and information from the Perle

et al. (2013) study comparing student and professional percep-

tions of online therapy, we hypothesized the student percep-

tions may differ from those of practicing counselors and

performed t-tests to determine whether there were signifi-

cant differences on this. Further, since there was a rather

large difference between students and professionals (n ¼ 57 and n ¼ 169, respectively), we made comparisons using a ran- dom sample of the professional sample to reduce the risk of

making a Type I error. The final analysis to determine differ-

ences in the sample included 57 students and 57 professionals.

The results indicated that students differed from professionals

on certain variables. Specifically, students were more likely

than professionals to agree that ethical guidelines from

other fields (i.e., American Counseling Association [ACA],

American Psychological Association [APA]) are helpful when

making ethical decisions regarding the use of web technologies

in practice (Mstudent ¼ 3.63; Mprofessional ¼ 2.96; t ¼ 2.128, p ¼ .036, df ¼ 112). Students also differed from professionals in their interest in becoming certified to specialized in cyber-

based practices if that option were to exist (Mstudent ¼ 4.04; Mprofessional ¼ 3.26; t ¼ 2.128, p ¼ .032, df ¼ 112). Students were also more likely to agree with the statement that graduate

programs should be teaching more about the use of technology

in supervision (Mstudent ¼ 4.32; Mprofessional ¼ 3.51; t ¼ 2.485, p ¼ .015, df ¼ 112) and would be more interested in learning about technology in supervision (Mstudent ¼ 4.32; Mprofessional ¼ 3.40; t ¼ 2.658, p ¼ .009, df ¼ 112). There were no statis- tically significant differences with regard to how the students

and professionals viewed whether cyber-based therapies should

be used in rural areas (t ¼ �1.090, p ¼ .278, df ¼ 112), whether cyber-based therapies should be used in urban areas

(t ¼ 1.776, p ¼ .078, df ¼ 112), whether cyber-based thera- pies should be used in suburban areas (t ¼ 1.754, p ¼ .082, df ¼ 112), and whether there are potential ethical issues related to cyber-treatment that are addressed in one’s informed

consent (t ¼ .304, p ¼ .761, df ¼ 112).

Discussion

Perceived Disadvantages

One of the clear disadvantages expressed by the participants

was the issue of confidentiality and the need to maintain a ther-

apeutic relationship. This is consistent with Maheu, Pulier,

McMenamin, and Posen’s (2012) work, which emphasized one

of the challenges in using telehealth as the impact on the rela-

tionship between physician and patient, as well as issues with

regard to confidentiality. Key strategies for managing client

privacy, include limiting information on handheld devices,

encryption (Mallen, Vogel, & Rochlen, 2005), password

protection, and firewalls or a secure Internet connection

(Maheu, Pulier, McMenamin, & Posen, 2012).

Another disadvantage and ethical concern mentioned by

participants was the issue of who was on the other end of the

computer or electronic device. Literature in psychology

emphasizes the need to establish a process by which the treat-

ing professional identifies that the client is who they purport to

be and are able to legally give consent for treatment (Fisher &

Fried, 2003). MFTs, like any other mental health professional,

need to establish a procedure by which they are able to confirm

someone’s age, legal status, and identification prior to engage-

ment in an online therapeutic relationship. This might include

passwords for the client, meeting someone face-to-face for the

initial session, and using video conferencing as opposed to e-

mail (Fisher & Fried, 2003).

Another issue mentioned by participants in the study was

liability. This theme emerged related to working with risky cli-

ents and potential complaints with concern placed on the coun-

selor’s portion of liability in such situations. One question

central to this issue may be establishing whether a therapeutic

relationship exists (Barnett & Scheetz, 2003). Barnett and

Scheetz (2003) noted two factors that determine whether a ther-

apeutic relationship exists, which are (1) exchange of money

and (2) number/frequency of communications. Kluge (2011),

however, noted that there might be more to consider in terms

of liability; for instance, there can be a question of ownership

in the problem liability. Missed cues because of a reliance on

online communication may open op both client and counselor

to liability. Potential remedies can include the development of

an informed consent that includes information of concern with

regard to liabilities, and the engagement in online practices that

include predominantly structured interventions and/or have

been tested and found to be evidence based (Kluge, 2011).

Implications for Training

As mentioned earlier, most of the participants indicated they

rarely or never use video calling software or websites with their

clients. This finding contradicts the earlier research by Maheu

and Gordon (2000), which cited a majority of counselors prac-

tice online with out-of-state clients. When combined with the

open-ended items in the current study, it seems clear that MFTs

believe that training needs to accompany the use of such tech-

nologies in practice. One of the issues that emerged from the

open-ended items is recognition that MFTs providing this treat-

ment be trained to do so. A similar stance is outlined by the

APA in their ethical standards:

Standard 2.01c requires psychologists who wish to expand the

scope of their practice to techniques or technologies that are

new to them to undertake relevant education, study, consulta-

tion, or experiences to obtain the qualifications necessary as

established by the field. (Fisher & Fried, 2003, p. 104)

Finally, the American Counseling Association ethical codes

(ACA, 2014) also identify this by stating:

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Counselors who engage in the use of distance counseling, tech-

nology, and social media develop knowledge and skills regard-

ing related technical, ethical, and legal considerations (e.g.,

special certifications, additional coursework; p. 17).

Yet in the case of MFTs, we acknowledge that we are seeing

more of these cases (Goldberg, Peterson, Rosen, & Sara,

2008), yet the training opportunities are lagging behind. In the

case of psychologists, over 70% of them were interested in learning more about web technologies in their practice (Perle

et al., 2013). This finding was fairly consistent with our MFT

sample, where 85.3% (n ¼ 153) indicated they were somewhat interested in learning about web practices. With regard to the

AAMFT Code of Ethics (2012), section 1.14 electronic therapy

provides general guidelines as to how one may proceed with

online therapy. Specific details, however, are lacking to inform

the MFT on the ethical considerations involved with this mode

of treatment. With the use of video calling, websites, and other

forms of electronic communication for therapeutic purposes

becoming more prevalent, it leaves one to wonder why the

AAMFT 2012 Code of Ethics still lacks precision in how coun-

selors should incorporate technology into practice.

With regard to the therapeutic relationship, participants in our

study, as well as in the Nelson (2010) study, described (a) the

importance of face-to-face contact with clients and (b) their per-

ception that online therapy detracts from the quality of the ther-

apeutic process. This perception, however, has not borne out in

the data (Wade, Wolfe, & Pestia, 2004). In only one study, face-

to-face treatment has been preferred over online therapy

(Rogers, Griffin, Wykle, & Fitzpatrick, 2009). This topic is spe-

cifically addressed within the ACA (2014) ethical codes, where

counselors are advised to consider how differences between

face-to-face and online counseling might affect the therapeutic

process. Counselors should gain more education, and training

aimed at bolstering their therapeutic skills and methods by which

to provide effective online therapy in combination with reducing

fears around online practices as a way to minimize any negative

impact to the therapeutic relationship (ACA, 2014).

Implications for Clinical Practice

The most recent iteration of the ACA’s Code of Ethics

(2014) highlights specific practice with regard to Internet-

based counseling. These include practical guidelines such

as how to communication with clients about confidentiality

and its limitations in a virtual practice, the importance of

verification of the identity of the individual receiving ser-

vices, and how to ensure that the services provided are

effective. In addition, the ACA ethical code identifies the

importance of communicating with a client about the pres-

ence of social media and the limits and boundaries accom-

panying use of such technologies.

Currently, there are some ethical guidelines in the most

recent AAMFT Code of Ethics (2012) which attend to the role

of Internet in practice. One is subprinciple 1.13, dedicated to

electronic therapy. It states:

Prior to commencing therapy services through electronic means

(including but not limited to phone and Internet), Marriage and

Family Counselors ensure that they are compliant with all

relevant laws for the delivery of such services. Additionally,

Marriage and Family Counselors must: (a) determine that elec-

tronic therapy is appropriate for clients, taking into account the

clients’ intellectual, emotional, and physical needs; (b) inform

clients of the potential risks and benefits associated with elec-

tronic therapy; (c) ensure the security of their communication

medium; and (d) only commence electronic therapy after

appropriate education, training, or supervised experience using

the relevant technology. (AAMFT, 2012)

Yet even within this definition, there is ambiguity as to the

manner in which the counselor defines whether electronic

treatment would be appropriate for the client. The other way

in which electronic communication is addressed in the

AAMFT Code of Ethics (2012) is through subprinciple

2.7, which includes how to protect electronic information

and advises counselors to maintain records consistent with

‘‘applicable’’ law. Counselors are advised to take ‘‘reason-

able precautions’’ with regard to record keeping and protect-

ing their client’s confidentiality (Fisher & Friend, 2003,

p. 107). ACA’s codes, however, outlines items to be

included in records and, specifically, what should be cov-

ered in the informed consent, such as credentials of the

counselor in distance counseling, risks and benefits of

engagement in distance counseling, anticipated response

times, cultural issues, and the potential for denial of benefits

based on the insurance company’s policies on distance

counseling. Pollock (2006) discussed the use of technology

in an MFT’s practice. The discussion in Pollock’s (2006)

article, however, fell short of suggesting how therapy could

be used with multiple people in the room and instead high-

lighted the advantages of being able to meet with couples

and families with different schedules but each having a

computer or electronic device through which to participate

in the sessions. This study suggests that the ethics of provid-

ing online therapy to couples and families should be a rea-

sonable goal, given the issues raised by the participants

focused on risk management, confidentiality, and training

issues. It is interesting to note that participants in our study did

not mention the ethical implications, if any, to providing treat-

ment to couples or families simultaneously. This might be

explained by assuming that MFTs do not see meeting with

multiple as an ethical issue, other than the noted concern to the

therapeutic relationship. Yet as Derrig-Palumbo (2013) pointed

out, adolescents are often the people who get behind the tech-

nology the most and actually enjoy that part of the therapeutic

process. Given that information as well as the advantage of

having everyone together in one room (Pollock, 2006), fami-

lies would likely benefit from online therapy. One of the ways

in which counselors can use this with children is to try and

guess what others might type before they type it and have chil-

dren practice reading text in cases where there is also a text

line in addition to video feed.

10 The Family Journal: Counseling and Therapy for Couples and Families 23(1)

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Implications for Research

The sample in this study represented a group of MFTs who, by

in large, refrained from using technology or web-based

devices in their practices. This finding contradicts the find-

ings of Maheu and Gordon (2000) which found that three

quarters of practitioners were engaging in some form of

web-based practice, primarily without regard to accurate

information about state laws regarding online therapy prac-

tice. From this lens, their perceptions about the ethical

challenges related to the practice of online therapy and web-

based communication with clients is limited to those who

do not necessarily practice this work. Future research might

seek to incorporate the voices of those who are currently aug-

menting or operating their practice solely through online

methods. In addition, because so many of the concerns were

related to issues of confidentiality, further research may want

to seek efficient and accurate ways to assess a given online

system as a way to assist counselors in identifying the most

secure channel through which to interact with their clients.

Limitations

This study presents the responses of those who have little prac-

tical knowledge about the subject, and therefore provides little

new information for the field of MFT. Unfortunately, however,

there were not enough MFTs in the study who exclusively used

web-based practice as their primary treatment modality. There-

fore, we listed our findings as ‘‘perceptions’’ of advantages and

disadvantages as a way to demonstrate a higher degree of trans-

ferability. In addition, if few of the participants used online

therapy, the concerns raised might reflect fantasized draw-

backs instead of actual drawbacks, thus inhibiting them from

using online therapies as a successful adjunct to treatment. On

the other hand, there were several practitioners who indicated

that they do not participate in online therapy, yet were clearly

using technology in some way with their clients (i.e., texting,

e-mail, etc.).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for

the research, authorship and/or publication of this article: This project

was funded by the Alaska Association for Marriage and Family Ther-

apy and parts of it were previously presented at the 2011 Alaska Asso-

ciation for Marriage and Family Therapy Annual Conference in

Anchorage, Alaska.

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