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Correspondence concerning this article can be addressed to Lota A. Teh, Department of Psychology, Ateneo de Manila University, Loyola Heights, Quezon City, Philippines. Telefax + 63(2)4265905. Email: [email protected]

Attitudes of Psychology Graduate Students Toward

Face-to-Face and Online Counseling

Lota A. Teh Avegale C. Acosta

Ma. Regina M. Hechanova Melissa R. Garabiles

Arsenio S. Alianan, Jr. Ateneo de Manila University

This study investigated the attitudes of 80 graduate students of Counseling and Clinical Psychology toward face-to-face and online counseling based on eight distance counseling factors: providing empathy, providing emotional support, providing connection, providing a sense of safety and confidentiality, accessibility, availability of counselor/therapist, eliminating social stigma, and anonymity, (Centore & Millaci, 2003). Respondents were Internet savvy and used the Internet an average of 26 hours each week. Results showed that compared to e-mail counseling and chat counseling, face-to-face counseling was rated higher on four of the eight factors: providing empathy, providing emotional support, providing connection, and providing a sense of safety and confidentiality. No differences were found in the ratings for accessibility and availability. Online counseling was rated higher in terms of addressing issues about social stigma and providing anonymity. Their attitude towards online counseling (vis- à-vis face-to-face counseling) was generally positive. Majority of the respondents also indicated openness to conducting online counseling, although they still consider face-to-face counseling more effective than online counseling. Implications for the potential of the practice of online counseling in combination with face-to-face counseling are discussed.

Keywords: online counseling, face-to-face counseling, attitude, psychology students, counseling modality

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Counseling and help-seeking in the Philippines can take on various forms. According to Tuason, Galang-Fernandez, Catipon, and Carandang (2012), present-day counseling still shows the vestiges of time-honored modalities that involve superstition and reliance on elders and traditional healers when addressing what the West would consider psychological difficulties. As academics and professional counselors and psychologists returned to the Philippines after obtaining degrees and training abroad, mostly in the United States, the western mode of counseling gained wider acceptance, particularly among the more educated middle class (Salazar-Clemeña,2002). With the recent developments in the country, like the licensing of guidance counselors (Republic Act No. 9258) and psychologists (Republic Act No. 10029), demand for counseling and psychotherapy services continues to grow (Melgar, 2013; Tuason et al., 2012).

In discussing the state of counseling in the Philippines, Melgar (2013) described the different predominant counseling models, such as Rogerian, cognitive-behavioral, and spiritual. These approaches use the traditional face-to-face counseling modality which involves the presence of both counselor and client who are together physically, each one in full view of the other as they explore and work out the issues of the client.

Family orientation is integral in the Filipino identity and, thus, Filipinos seek professional counseling upon the referral, and often based on a personal experience of benefit of a family member (Tuason et al., 2012). Whereas this type of referrals may be available to families living together in more urbanized areas and among those who have the financial resources, a good number of Filipinos may not be able to access these services due to employment migration and physical separation from their families. This reality may call for more accessible modalities of counseling.

The advent of the Internet in the early 1970s brought with it possibilities of providing mental and behavioral health services using Internet-related modalities. Online counseling describes the practice of professional counseling and information delivery that occurs between a client and a counselor who may be in separate locations but are still able to communicate with each other through the Internet (National Board of Certified Counselors, 2007). It has been referred

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to as e-mail therapy, therap-e-mail,cybertherapy, e-therapy, Internet counseling, cybercounseling, and webcounseling (Manhal-Baugus, 2001; Maples & Han, 2008; Murphy & Mitchell, 1998; Pollock, 2006; Shapiro & Schulman, 1996; Suler, 2000).

Online counseling can use various modalities, such as the e-mail, real-time text exchange or chat, secure web-based message systems, videoconferencing, and Voice over Internet Protocol (VOIP). These may be classified under one of two types of communication: asynchronous and synchronous. Asynchronous communication, like the e-mail, does not operate on real time and usually pertains to more prolonged exchanges between two individuals. Synchronous communication, which includes Internet messaging (IM) or chat, videoconferencing, and VOIP, allows for instantaneous and real-time communication (Manhal-Baugus, 2001).

With the growing popularity of online counseling as one way of delivering mental health services, this research investigated and compared the attitudes of graduate students in counseling and clinical psychology toward the traditional face-to-face counseling and two modalities of online counseling, namely, e-mail counseling (asynchronous method) and chat counseling (synchronous method). More specifically, this study looked into the attitudes of graduate students in reference to eight factors that are considered advantages and disadvantages of face-to-face and online counseling. Factors favoring online counseling are accessibility, availability of counselor, sense of safety and confidentiality, elimination of social stigma, and anonymity. Factors favoring face-to-face counseling are provision of empathy, emotional support, and connection. The significance of studying a sample of counseling and clinical graduate students lies in the fact that these future psychologists will give us an idea about the trajectory of the practice of counseling and clinical psychology in the Philippines in the years to come.

REVIEW OF LITERATURE

This section presents related studies on the perceived advantages and disadvantages of online counseling vis-à-vis face-to-face counseling, and researches about the attitudes of mental health

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practitioners and other samples toward online counseling.

Advantages of Online Counseling

An extensive review of the literature presents these perceived advantages of online counseling that are investigated in this study: accessibility, convenience and availability, sense of safety, anonymity, and elimination of social stigma.

Online counseling is credited for being accessible to anyone who can log on to the Internet. This is true even among those who reside in remote areas or are geographically isolated (Cook & Doyle, 2002; Haberstroh, Parr, Bradley, Morgan-Fleming, & Gee, 2008), and those who have physical limitations and may not be able to leave the house (Cook & Doyle 2002; Maples & Han, 2008), have social phobia (Fenichel et al., 2002), and have tentative feelings about going through face-to-face counseling (Barnett, 2005). Thus, having internet access alone can enable a person to undergo online counseling.

Online counseling is seen as convenient and readily available because clients can access counseling services at any time of the day, when they feel most in need of it, and even in the comforts of their home (Haberstroh, Duffey, Evans, Gee, & Trepal, 2007; Peterson & Beck, 2003; Richards, 2009). E-mail counseling, in particular, gives the perception that the counselor is available 24/7 due to its asynchronous nature (Manhal-Baugus, 2001). In turn, this allows counselees to receive instant advice or information from counselors (Griffiths & Cooper, 2003) even beyond normal office hours (Menon & Rubin, 2011; Young, 2005).

Online counseling may increase the sense of safety because clients are able to receive help from the counselor within their home environment (Centore & Milacci, 2008). This may make it easier for them to disclose their personal issue and express themselves more fully.

Anonymity creates a safe distance between the clients and therapists, thereby allowing clients to feel less defensive, less pressured, and less uncomfortable in disclosing embarrassing and very personal thoughts and behaviors (Bambling, King, Reid, & Wegner, 2008; Manhal-Baugus, 2001; Suler, 2000). Leibert, Archer,

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Munson, and York (2006) found that loss of nonverbal information, which is often cited as the main disadvantage of online counseling, is offset by the advantage of anonymity. Because the client does not have to be physically present in the clinic or office of the counselor, online counseling may be effective in reducing, if not eliminating, social stigma (Menon & Rubin, 2011).

Not included in this study but are also considered advantages of online counseling are as follows: time delay, presence of a permanent record, writing as form of therapy, client autonomy and empowerment, and novelty.

The time delay inherent in the asynchronous method of online counseling gives counselors and clients the opportunity to read, reread, and reflect on their thoughts, insights, questions, or stories. Moreover, clients may reply when they feel ready or when they have reflected on their experiences instead of being pressured to think quickly or being interrupted by the counselor (Centorre & Milacci, 2008; Haberstroh et al., 2008; Tuliao, Torres, & Hechanova, 2010).

The electronic nature of online counseling provides counselors and counselees a permanent record of their conversations. Counseling transcripts are also easy to save and to access, which allows for monitoring of client’s progress, identification of counselor’s counseling style, or use for other future references (Pollock, 2006). Compared with face-to-face counseling, transcripts reduce the need to memorize and recall information. Rereading the transcripts could enable counselors determine which issues need to be discussed further in succeeding sessions (Tuliao et al., 2010).

The act of writing gives the client control of the content, the pace, and depth of the written material, which can foster a sense of psychological safety (Wright & Chung, 2001, as cited in Richards & Vigano, 2013). Some counselees perceive writing or typing as therapeutic (Wright, 2002) as it can facilitate self-disclosure and ventilation that can promote self-awareness (Suler, 2000).

Online counseling enhances patient’s autonomy in the therapeutic relationship and decreases the power differential between client and therapist. This is particularly evident in e-mail counseling where clients are allowed to transmit their ideas without interruption (Finfgeld, 1999; Yager, 2001).

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Because online counseling is a new method in counseling, it may be particularly effective in gaining the trust of adolescents who desire novelty and creativity (Mehta & Chalhoub, 2006).

In addition to the above, other researchers found that online counseling is viewed as cost effective (Cook & Doyle, 2002). Griffiths and Cooper (2003) found that online counseling is advantageous in that professional fees of online counselors are often cheaper than those of face-to-face counselors. While there is the added expense in terms of internet access, this is far less than the cost of travelling to see a counselor. Additionally, a study by Richards (2009) showed that online counseling can serve as a gateway to traditional counseling services (i.e., it can be seen as the first point of contact that could impel clients to seek further counseling in other forms). Lastly, Menon and Rubin (2011) found that online counseling enables counselors to answer clients’ questions about diverse topics such as relationships, diagnoses, and health issues.

Disadvantages of Online Counseling

The very nature of online counseling inevitably leads to a number of disadvantages, which include the loss of the human factor and the lack of non-verbal cues. These are actually the strongest argument in favor of face-to-face counseling and are the factors looked into in this study.

A major problem with regard to online counseling is the loss of the human factor brought about by the distance between the counselor and the client (Bambling et al., 2008). This may reduce rapport, sense of intimacy, and trust (Griffiths & Cooper, 2003; Menon & Rubin, 2011; Suler, 2000). In a study by Lewis, Coursol, and Wahl (2003), both clients and counselors acknowledge the lack of emotional bond in online counseling such that as clients experience a depth of emotional experiences, their relationships with their counselors appear to remain in the cognitive level.

Related to the loss of human factor is the lack of nonverbal cues as the counselor and the client do not see each other (Bambling et al., 2008; Menon & Rubin, 2011; Tuliao et al., 2010). This could lead to problems in communicating oneself and in assessing client concerns

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(Haberstroh et al., 2008). The above weaknesses of online counseling are the inherent

advantages of face-to-face counseling. Because of the personal connection between the therapist and client, it is easier to establish rapport, provide empathy and emotional support, and build a therapeutic relationship with the client.

Other disadvantages of online counseling, although not focused on in this study, include the following: limited accessibility, time delay, technological failure, lack of skills of counselors and clients, negative impact of the written word, and possibility of misinformation being provided by clients.

Limited accessibility, time delay, and technological failure revolve around technology. For instance, not everyone has access to the Internet. Thus, this digital divide indicates that not everyone can undergo online counseling, particularly those with meager resources (Chope, 2009; Griffiths & Cooper, 2003). Furthermore, an online counseling session tends to have a slow speed of text exchange, which reduces the length and depth of interaction (Bambling et al., 2008; Haberstroh et al., 2008; Tuliao et al., 2010). Technological failure can occur in the form of getting lagged, disconnected, or hacked. In times when the Internet gets lagged or disconnected, the flow in communication is consequently impeded (Menon & Rubin, 2011; Tuliao et al., 2010). This is especially problematic when the presenting problem is severe or is in need of immediate response from the counselor (Haberstroh et al., 2008). Therefore, an alternative means to communicate may be needed to continue the conversation should any of these happen (Haberstroh, Duffey, Evans, Gee, & Trepal, 2007). The possibility of getting hacked raises the question on the confidentiality of the session and privacy of the clients, since transcripts of conversations and electronic records may be accessed by other people, whether authorized or unauthorized (Griffiths & Cooper, 2003; Young, 2005; Rochlen et al., 2004).

Because of the relative novelty of online counseling, counselors and clients alike may lack the technological skills and internet knowhow to engage in counseling online (Alleman, 2002). Thus, only those who are comfortable with technology may benefit from this mode of therapy (Haberstroh et al., 2007).

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Lastly, specific to text-based communication like the email, typed text may come across as cold, formal, and lacking in supportive and empathic tone (Stofle, 1997; Suler, 2000). Written messages may also be misinterpreted, especially by hypersensitive clients (Yager, 2003; Ybarra & Eaton, 2005). Clients may also tend to edit themselves and overanalyze what was said, thereby hindering the session to proceed spontaneously and candidly (Tuliao et al., 2010).

Very much related to the above disadvantages of online counseling are some ethical concerns and considerations that need to be addressed, such as client’s suitability for online counseling, the need for informed consent including the nature of the services, and the measures to be undertaken in case of disruptions in the session due to technology (Maheu & Gordon, 2000). The American Counseling Association (2014) tried to address these by devoting an entire section on the use of the Internet in the practice of counseling in their Code of Ethics. Even so, much still needs to be done to regulate the practice of online counseling to protect both the client and the counselor.

Attitudes Toward Online Counseling and Face-to-Face Counseling of Mental Health Professionals

A number of studies about attitudes toward various counseling modalities have been conducted among mental health professionals. On one hand, majority of the studies report low endorsement of online counseling. Finn (2006) surveyed the email use, attitudes, and difficulties of 384 Central Pennsylvania social workers. Although almost one-third of the sample has used email with clients, majority of the respondents believe that email for therapeutic purposes is both unethical and ineffective. A small minority of social workers has experienced difficulties that include violating a client’s confidentiality through email and sending an email to the wrong person. The non- endorsement of online counseling may also be because of the relatively low adoption rate. In a survey by Wells, Mitchell, Finkelhor, and Becker-Blease (2007) of 2,098 social workers, psychologists, and other professionals about the provision of mental health services over the Internet, only a little over 2% reported using the Internet for online counseling. This reluctance in using technology is due to concerns

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about the limitations of online counseling with regard to the ability to provide proper assessment (Finn, 2002), lack of accessibility to client’s nonverbal behaviors and difficulties in establishing therapeutic alliances (Finn, 2002; Mora, Nevid, & Chaplin, 2008), and because of concerns about confidentiality, liability, and misinformation being provided by clients (Finn, 2002; Wells et al., 2007).

On the other hand, a few studies found support for online counseling. Chester and Glass (2006) examined the attitudes of 67 online counselors and found that 57% of the respondents believed that online counseling was as effective as face-to-face counseling against the 42% who believed it was less effective. Finn and Barak’s (2010) survey of e-counselors likewise reported that majority of the respondents were satisfied with their experience of providing service through online counseling. Others recognize the advantages that online therapy offers, including providing clients who have difficulty with face-to-face therapy access to a therapist (Mora et al., 2008).

Then again, there are those who believe that online counseling can be valuable only as a supplement to face-to-face counseling. Although most of the respondents surveyed by Finn (2002) would not refer a client to an e-therapist, more than one third of the sample considered e-therapy as a good adjunct to in-person services. Wangberg, Gammon, and Spitznogle’s (2007) study of Norwegian psychologists showed that majority (64%) felt that e-media would only work as a supplement to face-to-face interaction.

Further, attitudes toward online counseling appear to be dependent on the nature of technology. A study by Centore and Milacci (2008) found that the attitude of their sample of mental health professionals was most positive toward telephone counseling and most negative toward text-chat counseling. Wangberg and colleagues (2007) also reported that only 40% of their sample of psychologists said that they would consider using text messaging in counseling.

Attitudes Toward Online Counseling and Face-to-Face Counseling of Clients or Potential Clients

The attitudes of clients or potential clients toward online versus face-to-face counseling are likewise mixed. A study by Rochlen,

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Beretvas, and Zach (2004) reported that undergraduate students expressed more favorable attitudes towards face-to-face than online counseling services. However, a more recent study of college students reveal that 64.4% endorse online counseling as a good alternative for their mental health needs (Brown, 2012).

Similar to the attitudes of providers, the attitudes of clients appear to be a function of experience. Skinner and Latchford (2006) found that clients involved in internet support groups had significantly more positive attitudes towards using computers to communicate with therapists as opposed to clients of face-to-face therapy.

Attitudes toward online counseling also vary depending on individual characteristics. Young (2005) reported that online counseling clients tend to be Caucasian, middle-aged males with at least a bachelor’s degree who cited anonymity and convenience as reasons for seeking online versus face-to-face counseling.

Online Counseling in the Philippines

The literature on online versus face-to-face counseling have mostly emanated from developed countries and there is a dearth of literature on online counseling in the Philippines. This might be attributed to the fact that Internet adoption in the Philippines is still relatively low and 65% of Filipinos are neither exposed nor have access to the Internet (Comscore, 2013).

A profile of an online counseling site for overseas Filipino workers (OFWs) reveals that similar to the study of Young (2006), majority of clients were male and educated, and that most of its site users were located in the Middle East (Hechanova, Tuliao, & Ang, 2011). The study reported that anonymity, accessibility, and the opportunity to vent were the most common positive feedback of site users. Slightly more than half (57%) of OFW non-users of the site said they would consider online counseling if they felt they needed advice, solutions, or comfort. Among the non-users of the site, there is reluctance to seek help or share their problems with others and embarrassment at burdening other people with their problems (Hechanova et al., 2011). These findings resonate with literature that Asians are less likely to seek help from mental health professionals (Matsuoka, Breaux, &

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Ryujin, 1997; Zhang, Snowden, & Sue, 1998), are concerned by the stigma and negative relational consequences of seeking help from others, and believe they should solve their problems by themselves (Kim, Sherman, & Taylor, 2008). A follow-up study of overseas Filipino workers (OFWs) and their intent to seek online counseling revealed that problem severity and technology adoption predict intent to use online counseling. OFWs were more inclined to use online counseling when faced with severe problems they feel they cannot handle by themselves. Among the three factors of technology adoption, perceived ease in the use of technology and the presence of both organization and technological infrastructure to support use predicted intent to use online counseling. The results suggest OFWs are more likely to adopt online counseling if they have access to it and if the technology is easy to use (Hechanova, Tuliao, Teh, Alianan, & Acosta, 2013).

More closely linked to this research is the study of teachers enrolled in a graduate program in guidance and counseling which found that guidance counselors mostly use Information Technology and Communication (ICT) as a means to storing, encoding and preparing of materials/documents related to school counseling, retrieving, distributing and utilizing data/information related to school counseling, and for other uses such as entertainment, leisure, and recreational activities. However, they acknowledged the potential and advanced use of ICT in the form of computer-assisted guidance systems and online counseling (Masagca & Londerio, 2008).

There has been no study of the attitudes towards online counseling from the perspective of Filipino psychology students. Thus, this study focuses on this particular sector of the population. From a theoretical perspective, the study seeks to validate the findings of literature from developing countries given the nuances in the state of technology adoption in the country.

Statement of the Problem

This research aimed to answer the following questions: 1. What are the attitudes of counseling and clinical psychology

graduate students toward face-to-face counseling, e-mail counseling, chat counseling, and toward online counseling vis-

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à-vis face-to-face counseling? 2. Are there significant differences in the attitudes of psychology

graduate students toward these three counseling modalities: face-to-face counseling, e-mail counseling, and chat counseling?

3. What is their level of openness to conducting online counseling?

Hypothesis

Based on the cited advantages and disadvantages of face-to-face and online counseling, it is hypothesized that there will be differences in the attitudes of the psychology graduate students toward face- to-face counseling and the two modes of online counseling on the following eight distance counseling factors: providing empathy, providing emotional support, providing connection, providing a sense of safety and confidentiality, accessibility, availability, eliminating social stigma, and anonymity.

No hypothesis is formulated for the comparison between the two modes of online counseling, namely e-mail and chat counseling, in view of the lack of related studies that could support a hypothesis of difference between them on the eight distance counseling factors.

METHOD

Sample

Data were gathered using online and paper-based surveys. The definition of online counseling/therapy as “the practice of professional counseling and information delivery that occurs when client(s) and counselor(s) are in separate or remote physical locations and utilize the Internet to communicate via e-mail or chat” (National Board of Certified Counselors, 2007) was stated as part of the instructions to the respondents. A link to the online survey was sent to the Clinical and Counseling Specialty Divisions of the Psychological Association of the Philippines (PAP). In addition, three private universities in the Philippines that offer programs in Counseling and Clinical Psychology were provided with both the online and paper-based surveys.

A total of 80 MA Counseling or Clinical psychology graduate

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students who have taken at least one graduate level course in counseling or psychotherapy answered the survey. Participants were mostly female (n = 67; 83.8%) with ages ranging from 20 to 51 years old (M = 27.56; SD = 6.17). Fifty-four percent (n = 43) of the respondents have experience in conducting face-to-face counseling/therapy with 21 of them having less than 1-year experience. Ninety-six percent (n = 77) spend several hours using the Internet every week (M = 25.96; SD = 19.80) and 25% (n = 20) have conducted online counseling.

Measures

Attitude toward face-to-face and online counseling (e-mail and chat) was operationalized by using instruments that measure their perception of eight distance counseling factors through the Perceptions of Distance Counseling Factors Scale (Centore & Milacci, 2008) and their attitude toward online counseling vis-à-vis face-to- face counseling through the E-therapy Attitude Scale (Finn, 2002). Questions about openness to conducting online counseling were also asked.

Attitude towards the different counseling modalities. Eight of the nine items of the Perceptions of Distance Counseling Factors used by Centore and Milacci (2008) were revised and used in the survey (the term distance counseling as used by the authors is synonymous with online counseling). Items such as those that pertain to cost of online counseling/therapy was dropped since charging professional fees for online counseling in the Philippines is not yet being practiced. Minor revisions in the phrasing of the items were also made. Using a 5-point Likert scale (1-strongly disagree, 5-strongly agree), participants were asked to what extent these factors in therapy are provided by face-to-face, e-mail, and chat counseling/therapy. The eight factors are: providing empathy, providing emotional support, providing connection, providing a sense of safety and confidentiality, accessibility, availability of counselor/therapist, eliminating social stigma, and anonymity. These are actually some of the factors that are related to the perceived advantages and disadvantages of face-to- face and online counseling. The answers to the eight items for each factor were added up–the highest possible score is 40 while the lowest

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possible score is 8. This study yielded coefficient alphas of .62 for face- to-face counseling/therapy, .72 for e-mail counseling/therapy, and .81 for chat counseling/therapy.

Attitude toward online counseling (vis-à-vis face-to-face counseling). The E-therapy Attitude Scale (EAS; Finn, 2002) was revised to measure attitude toward online counseling (vis-à-vis face- to-face counseling). EAS has an alpha of .87. Items such as “Mental Health Centers and family service agencies should offer e-therapy options” and “Insurance providers should pay for e-therapy sessions” were excluded because the delivery of online counseling in the Philippines is not yet a paid service and thus far has been supported mainly by funding agencies. Other minor revisions were also made, specifically changing the words “e-therapy” to “online counseling/ therapy,” “e-therapist” to “online counselor/therapist,” and “in-person psychotherapy” to “face-to-face counseling/therapy.” Twelve items were retained such as “When properly conducted, online counseling/ therapy can be as effective as face-to-face counseling.” Participants were asked to rate their degree of agreement to the statements using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The ratings for the 12 items were summated such that the highest possible score is 60 while the lowest possible score is 12. For this study, coefficient alpha for attitude towards online counseling was .84.

Openness to conducting online counseling/therapy. This was measured by the participant’s response to the item, “How would you rate your openness to conducting online counseling/therapy?” They were asked to select their answers from these options that were treated as a 4-point scale: (4) “very open,” (3) “open, but with minor reservations,” (2) “open, but with major reservations,” and (1) “I think online counseling/therapy is not for me.” In addition, this open-ended question was asked: “If you have not engaged in online counseling/ therapy, are you willing to give it a try? Why or why not?”

The above measures were put together in one questionnaire.

RESULTS

Results of the descriptive and inferential statistical analysis are

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presented in this section.

Attitude Toward Counseling Modalities

In general, the respondents had positive ratings for the three counseling modalities, as indicated by the scores on the Perceptions of Distance Counseling Factors Scale. As seen in Table 1, face-to-face counseling has the highest overall mean rating (M = 4.00, SD = 0.43) across the eight factors, followed by chat counseling (M = 3.57, SD = 0.64), and e-mail counseling (M = 3.48, SD = 0.56).

The top three factors that the respondents had the strongest agreement with in regard to face-to-face counseling are provides empathy, provides emotional support, and provides connection. The two factors that they rated the lowest are eliminates stigma and anonymity. Conversely, the top two factors for e-mail and chat counseling are eliminates stigma and anonymity, and their lowest are the top three of face-to-face counseling (i.e., provides empathy, provides emotional support, and provides connection). Clearly, what the respondents considered the advantages of face-to-face counseling are perceived as the weaknesses of online counseling and vice- versa; the perceived advantages of online counseling are deemed the disadvantages of face-to-face counseling.

Attitude scores toward the three counseling modalities by the 80 respondents were compared using one-way analysis of variance for repeated measures. The comparison was done on each of the eight distance factors. Post-hoc analysis for the significant results was carried out using the Bonferroni test. Mauchley’s test showed that the sphericity assumption was violated, χ2(2) = 67.51, p < .001. Hence, the Greenhouse-Geisser estimates of sphericity (ε = .63) was used to correct for the degrees of freedom.

To control for the possibility of an inflated Type I error due to the number of comparisons and repeated measures examined, a stringent level of significance was set at .001.

ANOVA results indicated that there were significant differences on the ratings of the three counseling modalities, F(1.26, 100.05) = 30.44, p < .001. Specifically, face-to-face counseling was rated more positively than both chat counseling (p < .001) and email counseling

Attitudes towArd online Counseling80

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Teh, AcosTA, hechAnovA, GArAbiles, & AliAnAn 81

(p < .001). The first three factors refer to the therapeutic relationship in

counseling. All these factors were rated significantly different across the three modalities: provides empathy, F(1.48, 116.75) = 201.77, p < .001; provides opportunities for emotional support, F(1.63, 128.38) = 142.67, p < .001; and provides opportunities for the counselor/ therapist to feel connected with each other, F(1.71, 135.75) = 168.10, p <.001. Post-hoc analysis using the Bonferroni test yielded the same pattern of results for all three factors: significant results were obtained for all three pairwise comparisons (i.e., between face-to-face and e-mail counseling, face-to-face and chat counseling, and between chat and e-mail counseling) (p < .001). Face-to-face counseling was rated the highest in all three factors, followed by chat counseling, with e-mail counseling as the lowest.

A significant result was also obtained for the factor safety and confidentiality F(1.25, 99.04) = 16.64, p < .001. Face-to-face counseling was rated as the highest when it comes to providing safety and confidentiality, followed by e-mail counseling, and chat counseling. Post-hoc analysis indicated that the significant difference was between face-to-face counseling and the two modes of online counseling (p < .001), but not between e-mail and chat counseling (p = .63).

Comparison on accessibility did not yield a significant difference, with F(1.35, 106.62) = 4.44, p < .05. The result for availability of the counselor/therapist was likewise not significant, with F(1.60, 126.22) = 3.14, p = .06. The respondents did not consider accessibility and availability as distinct advantages of any mode of counseling.

Ratings across the three modalities were significantly different when it comes to eliminating social stigma, F(1.14, 89.66) = 42.07, p < .001. Face-to-face counseling was rated the lowest in this factor which was significantly different compared to the two modes of online counseling (p < .001). No significant difference was found between the ratings for e-mail and chat counseling (p = .33).

In terms of its ability to provide anonymity, significant differences were also noted, with F(1.18, 93.12) = 37.71, p < .001. E-mail counseling was rated the highest in terms of its ability to maintain client anonymity followed by chat counseling. Both modes of online counseling were significantly different compared to face-to-face counseling (p < .001),

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but there was no difference between e-mail and chat counseling (p = .44).

Attitude Toward Online Counseling

The respondents had a generally positive attitude toward online counseling (vis-à-vis face-to-face counseling) as measured by the E-therapy Attitude Scale (M = 42.88, SD = 6.28) confirming the results of the generally positive ratings from the Perceptions of Distance Counseling Factors Scale.

Openness to Conducting Online Counseling

When asked about their openness to conducting online counseling using a 4-point scale, results showed that the respondents were open to it with minor reservations (M = 2.84, SD = .92). Frequency count indicated that 21 (26%) were very open to online counseling, 32 (40%) were open but had minor reservations, 20 (25%) were open but had major reservations, and 7 (9%) answered that online counseling was not for them. The answer to the open-ended question as to whether they would be willing to give online counseling a try if they have not engaged in it yielded these results: out of the 60 graduate students who have not tried it, 47 responded to the question. Among the 47 respondents, 39 (83%) were willing to try online counseling, 7 (15%) said no, and 1 (2%) was unsure. Cited reasons for saying yes are: (a) to try a novel method of providing counseling; (b) opportunities for learning; (c) opportunities to help because online counseling is accessible and provides anonymity; and (d) as an adjunct to face-to- face counseling. Reasons for saying no are: (a) face-to-face is still more effective than online; (b) they are not comfortable with online; and (c) not practical for developing countries since it takes a lot of work to set it up.

DISCUSSION

One of the main findings of the study is the clear preference for the traditional face-to-face counseling compared to online counseling,

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whether it is chat or e-mail counseling. This finding is consistent with what other researchers have found (e.g., Centore & Milacci, 2008; Finn, 2006; Rochlen et al., 2004). However, in spite of the strong endorsement of face-to-face counseling, it is evident that the sample of psychology graduate students also had a generally positive attitude and openness toward online counseling. This is in contrast to studies with critical perceptions about online counseling (e.g., Centore & Milacci, 2008; Mora et al., 2008) but corroborate the findings of studies such as those of Brown (2012) and Finn (2002) which considered online counseling as a good alternative or adjunct to in-person service.

Comparison of Face-to-Face, E-mail, and Chat Counseling

The results of the analysis of variance for repeated measures confirmed the hypothesis that the psychology graduate students would rate the three counseling modalities differently on the eight distance counseling factors. Specifically, the respondents gave the highest ratings to face-to-face counseling on the three factors that are central to building a therapeutic relationship in counseling. They consider face- to-face counseling the best modality when it comes to establishing the connection between the counselor and client and in making the client feel that the therapist can provide empathy and emotional support. This finding corroborates the results of many studies about the advantages of face-to-face counseling (e.g., Bambling et al., 2008; Griffiths & Cooper, 2003), specifically that the physical presence of the counselor makes it easier to establish a therapeutic relationship. This is one of the strongest arguments against online counseling, that there is the loss of the human factor which may reduce rapport, sense of intimacy, and trust (Bambling et al., 2008, Griffiths & Cooper, 2003; Menon & Rubin, 2011; Suler, 2000). The lack of nonverbal cues is also a problem as the counselor and the client do not see each other (Bambling et al., 2008; Menon & Rubin, 2011; Tuliao et al., 2010) and this could lead to problems in communicating oneself and in assessing client’s concerns (Haberstroh et al., 2008). In addition, the respondents also believe that face-to-face counseling can give the client a greater sense of safety and that the confidentiality of what is being shared is more assured. This appears to be related to the concern about electronic glitches that may

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give rise to the possibility that transcripts of conversations and e-mail exchanges may be accessed by other people (Griffiths & Cooper, 2003; Young, 2005). The clear preference for face-to-face counseling does not come as a surprise in view of the fact that the respondents are more familiar with this traditional mode, with 54% of them having had some experience with it. They are also being trained to do counseling in the traditional face-to-face context as required in the current prescribed curriculum of the Philippine Commission on Higher Education for a Master’s degree in a Counseling or Clinical psychology program.

The more positive attitudes of the respondents toward online counseling are reflected in two of the eight distance counseling factors, namely, the ability of online counseling to provide client anonymity and eliminate social stigma, which are the top advantages of both chat and e-mail counseling. This is consistent with the finding of Leibert et al. (2006) about anonymity which was cited as one of the top two reasons for selecting online counseling. Although measured separately in this study, these are actually related because it is the anonymous nature of online counseling that reduces or even eliminates social stigma (Bambling et al., 2008; Centore & Milacci, 2008; Menon & Rubin, 2011). The physical distance between the client and therapist and the anonymity make it easier for the client to open up and disclose very personal thoughts, feelings, and behaviors. Suler (2004) noted that anonymity can create a disinhibition effect that can increase self- disclosure and a zone of reflection for both counselor and client. The concern about social stigma attached to counseling especially among Asians (Kim et al., 2008), Filipinos in particular (Melgar, 2013), is addressed effectively by the anonymity of online counseling. The client does not have to worry about being seen in the counselor’s office and being judged for seeking professional help. It also provides help for clients who are embarrassed to seek help for embarrassing or stigmatizing issues (Callahan & Inckle, 2012). In general, the above findings are consistent with what the related literature indicates as the advantages and disadvantages of face-to-face and online counseling. It is interesting to note, however, that three factors which should have been considered advantages of online counseling did not turn out as such.

Face-to-face counseling still obtained the highest mean ratings in

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providing a sense of safety and confidentiality when this should be an advantage of online counseling (Cook & Doyle, 2002; Peterson & Beck, 2003). Perhaps, the respondents equate the physical presence of the counselor with making the client feel safe especially among Filipinos who value highly interpersonal relationship.

The result for accessibility was not significant. This can probably be explained by the trend these days that those who practice face- to-face counseling also post their profile online, thus, making the accessibility of the profile of the counselor for face-to-face and online more or less the same. The other possible explanation is the way the item was presented in the questionnaire: the item reads “gives access to profile of counselors or therapists.” Accessibility as an advantage of online counseling refers to the fact that anyone who has the technology can easily log on to the Internet to receive counseling, not just access the profile of counselors. The result would have been different if the item was phrased instead as “gives access to counselors or therapists” (i.e., deleting the word profile).

Because the client can log on practically at any time, the client might get the impression that the counselor is more available than when an appointment with a therapist has to be set and the meeting has to take place in the counselor’s clinic or office. E-mail counseling, in particular, may give the perception that the counselor is available 24/7 due to its asynchronous nature (Manhal-Baugus, 2001). The nonsignificant result for availability indicates that, perhaps, the respondents are not fully convinced that the counselor can be available anytime the client logs on because they are aware that a counselor needs to set limits no matter the counseling modality. In many instances, the counselor decides with regard to when to chat with an online client, or when to reply to a client’s e-mail. Then again, this factor may also be because there is still a lack of online counseling sites in the Philippines or because internet access in the Philippines is still fairly low (Ignatius & Hechanova, 2014).

These results that run counter to what the related studies (Cook & Doyle, 2002; Griffiths & Cooper, 2003; Haberstroh et al., 2008; Peterson & Beck, 2003; Richards, 2009) found may reflect the strong orientation of the respondents in favor of what they are more familiar with, which is face-to-face counseling.

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Comparison of E-mail and Chat Counseling

Although it was not the main objective of this study to hypothesize differences between the two modes of online counseling on the eight distance counseling factors, the inferential statistical analysis yielded interesting findings. The pattern of results for e-mail and chat counseling on the five factors of safety and confidentiality, accessibility, availability, anonymity, and eliminates social stigma are the same: there was no significant difference between them. This can be easily explained by the fact that both are modes of online counseling and, thus, would share the same strengths and weaknesses. However, for the three factors that describe face-to-face counseling in terms of its ability to provide empathy, emotional support, and connection, chat counseling was perceived to be better than e-mail counseling.

It will be recalled that e-mail uses the asynchronous mode, whereas chat is synchronous. The significant difference between the two modes implies that the client may feel more the therapist’s empathy, emotional support, and connection when the communication is done in real time. Suler (2000) noted that one benefit of synchronous communication is that a feeling of presence is created by being with the client in real time. Counseling through chat allows for more direct, continuous, and immediate communication in both directions (Fenichel et al., 2002; Sussman, 2004). This advantage of a synchronous mode of online counseling confirms one of the findings of Mora et al. (2008) that videoconferencing, which is synchronous like chat, received the highest endorsement rating as an alternative to face-to-face intervention.

Although the e-mail method has its own advantages, such as giving the client more time to reflect on what will be communicated to the therapist and keeping permanent records of the e-mail exchanges (Centorre & Milacci, 2008; Pollock, 2006), these were apparently not considered by the respondents as benefits in relation to the therapeutic relationship variables. Based on this finding, the counselor who uses the e-mail method may have to work harder on building a therapeutic bond with the client. This finding, however, does not necessarily negate the advantages of e-mail counseling which some studies (e.g., Krant et al., as cited in Mallen, Vogel, Rochlen, & Day, 2005; Mora et al., 2008) have rated as the most highly endorsed adjunctive internet modality.

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In the end, it may really boil down to the advantages and features of the online modality that the therapist is more comfortable with and finds more appropriate.

Openness to Conducting Online Counseling

The generally positive attitude that the respondents have toward online counseling, as measured by the E-therapy Attitude Scale and Perceptions of Distance Counseling Factors Scale is supported by the result about their openness to conducting online counseling. A look into the profile of the respondents may explain this openness. The sample is a relatively young group (with a mean age of 27.56) that is very comfortable with the new technology (96% spend an average of 26 hours a week using the Internet). This finding is consistent with the results of some studies that attitudes toward online counseling appear to be related to the level of comfort with the use of internet technology (Leibert et al., 2006; Wangbert et al., 2007).

At the time of the study, the respondents were students of Master’s degrees in Counseling or Clinical Psychology and thereby had limited experience and exposure in counseling. This, in addition to their demographic profile, also contributes to their willingness to try a novel method of counseling. A number of the respondents also realize that online counseling may provide opportunities to practice their counseling skills and to help clients who could benefit more through the online modality, such as those who are uncomfortable with a face- to-face encounter with a therapist.

The main reason cited for the reservations in engaging in online counseling can also be explained by their current status as graduate students who are still undergoing training in counseling in the face- to-face tradition. The 15% who are not willing to try online counseling believe that face-to-face counseling is still better than online counseling. This minority is different from the majority who prefer face-to-face counseling, but are open to adding it to their arsenal of counseling interventions. One doubt mentioned by the respondents is with regard to the practicality of setting up the practice of online counseling in a developing country like the Philippines. Limited accessibility has been cited as one of the disadvantages of online counseling. Not everyone

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can undergo online counseling, especially those with meager resources (Chope, 2009; Griffiths & Cooper, 2003).

Implications of the Findings

The results suggest both advantages and disadvantages associated with the various counseling modalities. Respondents do have a positive attitude toward online counseling and openness to try it although not necessarily the intent to replace face-to-face counseling. One implication for practice would be to blend modalities and use online in combination with or as an adjunct to face-to-face counseling. This combination can take various forms. One possibility is to see the client first in a face-to-face context and then supplement or alternate the face-to-face with online interventions. Some respondents qualified their response about their openness as willingness to try online counseling only with clients whom they have previously encountered face-to-face. Another possible combination is for clients to have initial sessions online if they feel uncomfortable about meeting the counselor face-to-face, and then have face-to-face counseling when they already feel more at ease with meeting the counselor. Lastly, online counseling can be resorted to if the client or counselor is unable to meet in person.

However, the issue of blending modalities raises the question of the readiness of graduate students to conduct online counseling. Courses that will help train future counselors and therapists can be added to the existing courses that teach them the traditional way of doing counseling. This also requires an articulation of the various competence and ethical issues related to the practice of online counseling. Examples of questions that need to be addressed are as follows: What kind of training and skills are needed to establish a therapeutic relationship from a distance in the absence of nonverbal cues from a client? When does the therapist say that online counseling is not appropriate for a certain problem or disorder and what is the protocol for online clients who pose a danger to themselves? How does an online counselor handle ethical issues like confidentiality of records, informed consent, and validity of data provided by the online client?

Guidelines for assessment, selection, and intervention for

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online clients need to be formulated. These include protocols that can be followed during crisis situations, or when client’s concerns can no longer be handled online. Given the possibility of electronic glitches, like getting disconnected during a session, an alternative means of communicating with the client may be established, such as the use of a mobile phone. Ethical guidelines have to be formulated and provided to ensure the level of integrity and the qualifications of online counselors, given that some competencies expected from online counselors are different from those required of traditional counselors. For instance, online counselors need to be internet-savvy and proficient in writing, which are not essential when doing face-to- face counseling. Hence, additional qualifications in terms of their skill in using the Internet and in the written language are imperative. These may apply to counselors/psychologists currently in training or those who have been practicing and would like to add online counseling as a potential medium for intervention.

Limitations and Suggestions for Further Research

One limitation of the study is the homogeneity of the sample in terms of gender (84% female) and level of comfort with the Internet (96% spend around 26 hours using the Internet per week). Follow-up studies could aim for more comparable sample sizes of male and female respondents, and for groups of respondents who differ on frequency and competence with regard to the use of the Internet to find out if there is a difference in their attitudes toward the different counseling modalities. Other comparative studies can also be conducted to look into the differences in attitude between younger and older participants, and between those who have the experience and those who have no experience in online counseling.

Although the sample size of 80 allowed for the use of an inferential mode of data analysis, it is recommended that a larger sample size be used in subsequent similar studies to increase the external validity of the findings.

A question that used a 4-point scale and an open-ended question were used to measure openness conducting online counseling. Future studies can test the reliability and validity of this measure.

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In view of the finding about the differences between e-mail and chat counseling on the therapeutic relationship-related variables, a study comparing attitudes toward the different online modalities is highly recommended. The distinction between the synchronous and asynchronous computer mediated communication can be used as basis for choosing the modalities that will be compared.

To complement this study, attitudes on help seeking of the Filipino population and their preference among the different modalities of counseling (i.e., face-to-face, telephone, various forms of online counseling, etc.) may also be undertaken. This will clarify the relevance and appropriateness of the services mental health professionals are willing to provide vis-à-vis the needs and intentions of potential clients.

In relation to the finding about the openness of the respondents to try online counseling and given that current curricula of counseling and clinical psychology do not incorporate training in online counseling, it is recommended that research on how psychology graduate students and practicing professionals can be trained in online counseling be carried out.

Conclusion

This study contributes to the growing number of researches on attitudes toward face-to-face-counseling in comparison with online counseling. It seeks to fill a gap in the literature by providing the perspective of future counseling and clinical psychologists as well as the developing country perspective.

One of the main findings of this study is that although there is still a strong preference for traditional face-to-face counseling, respondents have a generally positive attitude toward the online modalities and are willing to try online counseling in combination with face-to-face counseling. Such openness to online counseling is very encouraging because given advancements in technology and the relatively young population of the Philippines, technology-mediated counseling may become a reality in the future. Thus, perhaps a key to being of greater help to potential clients in the future might be the ability of counselors to harness the use of technology and expanding the modalities used in counseling.

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Beyond technological competencies, however, future online counselors need to understand the cultural barriers and drivers of online counseling. In particular, issues of access, ease of use, technological capability, and the stigma attached to seeing professional mental health professionals are important considerations for how online counseling should be presented and made available to Filipinos.

At the end of the day, the adoption of online counseling will depend on the readiness of both users and providers. A study by Ignatius and Hechanova (2014) showed significant generational differences in internet use among Filipinos. They describe two generations of Internet users – the digital natives (early 20s and below) and digital immigrants (mid-40s and above). They explain that unlike digital immigrants who have more conservative views of privacy, digital natives appear to be more comfortable in sharing their views and personal information in social media. It is thus likely that the use of online counseling whether by itself or in combination with other methods would appeal to the younger generation. Thus, given the relatively young population of the Philippines as well as rapid advancements in technology, the openness to online counseling of providers is encouraging because using technology in counseling may in the near future become a very viable option for those who for one reason or another choose not to avail of face-to-face counseling.

AUTHORS’ NOTE

This study was supported by the Ateneo de Manila University Research Council grant.

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