All eCounselors provide some crisis counseling.

Crisis situations are a common concern for eCounselors - and rightly so. To be ethical, counselors of all philosophies and practice settings need to handle these situations carefully. If you haven’t been concerned, consider that failures to make efforts to prevent client suicide account for 42% of the dollars paid in malpractice settlements.1 Thankfully, one can make prevention efforts and handle crisis situations successfully with eCounseling.

Emphasis on Crisis

In contrast to in-person clients who visit a counseling center (which is a safe and neutral environment separate from their life-issues), eCounseling clients receive help from within the settings where their problems take place. Hence, when a client says, “I hate my apartment, it reminds me of my ex-husband,” she is saying this from inside that apartment. This can increase the intensity of the counseling process.

In addition to the uncontrolled setting, eCounseling clients seek help during a problem, not after it. They may seek help at odd hours of the night or morning when they feel the worst. eCounselors can be contacted by clients who just experienced violence, clients in fear of violence, or clients feeling guilty over committing violence. And, perhaps most unsettling, eCounselors are sometimes contacted by persons seriously considering suicide.

I’m not saying eCounselors are overwhelmed with emergency calls - that is a common misperception. In fact, emergency calls (such as the suicidal caller) are quite rare. One crisis hotline recently reported that out of more than 500 calls a month, only 10% of callers reported being suicidal. The majority of callers were not in an emergency, but simply felt they were having a personal crisis. The fact is, a client can be in “crisis” whether she is a stressed-out teen or a panic-stricken elderly woman calling because she can’t make her mortgage payment.2

Helping Suicidal Clients

eCounseling is obviously not the gold standard treatment for clients in a life-threatening crisis. However, it is certainly better than no treatment at all, and could be a lifesaver for persons who refuse, or are unable to receive, help in another manner. This idea is not new. The Samaritans, a group in England, “provide emotional support to any person who is suicidal or despairing” through telephone and online care.3 Similarly, 1-800-SUICIDE is just one of several U.S.-based hotlines that has been providing crisis care for decades.

Responding to an Emergency

An important issue when dealing with suicidal, or homicidal/violent, clients is whether a counselor is able to respond effectively to an emergency situation. With some preparation, eCounselors can be sufficiently equipped to respond.

eCounselors, like in-person counselors, should have an official intake process where clients provide their address/location, multiple contact methods, and an emergency contact person. Electronic filing makes this information easy to retrieve, and electronic payment (i.e., credit card; a common eCounseling payment method) provides a verified client address. Hence, in a situation where there is a threat to a client’s self or others, eCounselors can be well equipped to contact relevant local agencies, and even warn parties in potential danger.

Preparing for the Unexpected

Here are some more specific preparation tips:

Before you begin taking clients…

* Have a reliable suicide assessment tool on hand

* Make public (by posting online) a policy explaining if or how you provide care to suicidal/violent clients

* Recommend (by posting online) alternative treatments for persons battling suicide (in-person care, hospitalization, etc.)

* Prepare a thorough informed consent processes that includes confidentiality limits

Before an Emergency occurs…

* Establish contact with a counselor local to the client in case in-person care is needed

* Obtain accurate client information including name, location, and permanent address

* Obtain back-up contact methods, including the contact information of several people the client knows and trusts

* Obtain the contact information of emergency services that are local to the client

* Create an agreed-upon emergency plan with at-risk clients

Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is an Adjunct Graduate Professor for the Center for Counseling and Family Studies at Liberty University. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony is author of The Clinical Training Guide for Online Counseling and Telephone Counseling. Anthony is Director of www.eCounseling.com and practices counseling in Boston and Cambridge, Massachusetts. See www.ThriveBoston.com

Let me rephrase that. No one likes to talk about sexual betrayal when it happens to him or her. Not long ago, Debra Laaser experienced a wife’s worst nightmare. And today, she is ready to tell her story.

And a well-told story it is, written with clarity and eloquence surprising for a first time solo-author*. But this work is neither a biography, nor a collection of Deb Laaser’s memoirs; it is a survivor’s guide for the sexually betrayed.

With exercises throughout, the book over-delivers. There are illustrations, charts, figures, and interactive forms. There are lists of useful web pages, and descriptions of relevant support groups. There is a depression self-assessment tool, and a “thinking it over” section at the end of each chapter lists 4-5 reflective questions for the reader.

For readers seeking “how-to” knowledge, Debra answers a plethora of questions including:

How quickly should I forgive?

In whom should I confide?

What do I tell the kids?

Should I be sexual with my spouse?

It is as if Debra walks side-by-side with the reader, showing her how to understand, feel, respond, grieve, trust, not trust, accept help, gain control, heal, forgive, and rebuild. Even with a short glance, the reader can’t help but take away something useful.

I have already recommended this book to a client.

—– —– —–

*Debora previously co-authored Open Hearts with her husband, Mark Laaser.

* * *
Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is Director of www.ecounseling.com. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony practices counseling in Boston and Cambridge, Massachusetts. See www.ThriveBoston.com

The Best Christian Counseling Content

Today eCounseling.com contains nearly 1000 Christian counseling articles (many taken from the award-winning Christian Counseling Today magazine), with over 100 easily searchable topics. Add to the article database a growing collection of several hundred Christian counseling videos, and eCounseling.com is nothing short of a revolution for the field of Christian counseling.

Telephone and Online Counseling

If great content was all eCounseling.com offered, we would be very pleased. But information is just the beginning. In addition to providing the best Christian counseling content on the web, eCounseling.com is the most state-of-the art website on the Internet for providing counseling by telephone, email, and text-chat.

Since November, our growing network of online counselors have set their counseling rates, scheduled sessions with clients, provided counseling, and received immediate payment for their services. We could not be happier with our early results. User feedback shows that the website is completely functional, and user-friendly.

FREE Counselor Profiles

And there’s more. eCounseling.com has recently begun to offer a FREE profile for counselors who want to advertise their in-person counseling practice. This free profile includes: counselor name, credentials, a biographical statement, a greeting to clients, phone number, email address, office address and map, and the option to post a photo. And, COMING SOON: a FREE profile will also soon be offered for support and recovery groups who want to advertise their meetings and services.

eCounselor Training

Last month, the Director of eCounseling.com, Dr. Anthony Centore, recorded a 6-hour DVD training course on Telephone and Online Counseling. This will be offered by the AACC in the near future, and is a must-have training program for anyone wanting to begin providing telephone or online services (professional counseling, life-coaching, or even lay counseling).

Also, Dr. Centore’s recently released clinical training guide, “The Therapists Clinical Guide To Online Counseling and Telephone Counseling” is a content-rich resource that is getting great reviews.

Groups Coming Soon

This is just the beginning for eCounseling.com. We are improving the website every day, always making it a more functional and enjoyable experience for our many visitors.

Your Feedback Matters

Here at AACC we think the eCounseling.com project is going well. But we still want your thoughts and feedback on how we can make the website even better.

Visit eCounseling.com, create your FREE profile (who doesn’t benefit from free marketing?). Let us know what you like, and if there is anything you would change. eCounseling.com was developed for counselors like you (and your clients), so let us know your thoughts!

* * *

Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is an Adjunct Graduate Professor for the Center for Counseling and Family Studies at Liberty University. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony is author of The Clinical Training Guide for Online Counseling and Telephone Counseling. Anthony practices counseling in Boston and Cambridge, Massachusetts. See www.ThriveBoston.com

* pastoral care pre-dated counseling, certainly in the form that we know at the present time
* pastoral care could prevent much that now arrives on the desk of a counselor from ever getting that far.

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So it is with doctoring the soul. What does the soul need? What nutrients?

We nourish the hunger of the soul by living coram Deo sola scriptura: face-to-face with God by Scripture alone. Deo is Latin for God; coram is Latin for in the presence of, face-to-face, with. Martin Luther used coram Deo to depict that we live with reference to God every second in every situation. Luther taught that all existence found its final meaning and ultimate object in God and that all emotions, actions, volitions, cognitions, and relations had God as their circumference. He perceived that all of life was a story of personal encounter with God and that the deepest questions in the human soul were God questions. Luther used the term sola scriptura to emphasize his conviction that we do not live by bread alone, but by every word that comes from the mouth of God.

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Sickness is so self-absorbing. I was always scanning my illness, hyperconscious of the ongoing flares of my pains and discomforts. I was in constant internal complaint about my inability to escape pain and suffering. I worried incessantly about my diseased heart, imagining that it was going to quit on me. I engaged in a stubborn self-pity because when I get sick on top of my chronic heart disease, I think I should receive special succor—I am due special care.

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What is eCounseling? If you ask five counselors this question, you might get five answers (and one would be, “e-What are you talking about?”). In my doctoral dissertation, I defined eCounseling by saying:

eCounseling is an abbreviation for “electronic counseling” and refers to a variety of counseling-related services provided via telephone or internet that range from (1) mental health information, to (2) spiritual guidance and life coaching services, to (3) professional mental health therapy.

Today there are four basic mediums for eCounseling: telephone, email, text chat, and videoconference.

Telephone Counseling

Telephone counseling was first made popular by the Samaritans who started a suicide prevention hotline in London, in 1953. Since then, it has filled important roles in mental health services. In a recent survey of American Psychological Association (APA) member psychologists, 98% affirmed that they have provided telephone counseling. Similarly, a survey of psychiatrists found 45% use the telephone as an adjunct to in-person sessions, and 19% use it as their primary medium for providing treatment. In my own survey of 1863 Christian counselors, 73% reported they are likely or somewhat likely to provide telephone counseling, if they do not already.

Email Counseling

With email counseling, counselor and client communicate exclusively by written email exchanges. Since counseling sessions need not occur at a specified place or time, a client is not limited as to when he will write to his/her counselor. A client can seek help while in milieu of a problem, even if the counselor is busy (or fast asleep). This way, the counselor is always perceived as available, and help seems only ‘an email away.’

Text Chat Counseling

Also known as “internet relay chat” or “instant messaging”, since text chat communication takes place in ‘real time’ the give and take, pace, and tone of a conversation closely emulates in-person dialogue that we know to be effective in counseling. At the same time, clients benefit from a sense of increased safety, anonymity, and reduced social-stigma—when compared to in-person counseling.

Videoconference Counseling

In some ways, videoconference counseling is the crème de la crème of eCounseling methods. Videoconference closely resembles an in-person encounter; counselor and client are able to view each other and communicate audibly in real time. Though videoconference has obvious strengths, some advantages of eCounseling are forfeited. For instance, research suggests a client’s sense of safety, comfort, and anonymity might decrease with videoconference counseling—when compared to eCounseling without video.

Recognition by Professional Organizations

In response to recent trends in eCounseling practice, statements or ethical codes have been written by the APA, American Counseling Association (ACA), National Board of Certified Counselors (NBCC), American Mental Health Counselors Association, International Society for Mental Health Online, and others.

Specifically, NBCC states:

…telephone counseling has been available and widely used for some time. The rapid development and use of the Internet to deliver information and foster communication has resulted in the creation of new forms of counseling.

APA writes, “The Ethics Code…has no rules prohibiting such services.” And ACA writes:
Professional counselors ensure that clients are intellectually, emotionally, and physically capable of using the on-line counseling services, and of understanding the potential risks and/or limitations of such services.

The sentiment of nearly every organization who has addressed the issue is the same—one can practice eCounseling if it can be provided with competence, and if counselors can fulfill their ethical duties.

I am already over my allowed word count! Next issue’s column will review the clinical advantages of eCounseling. Until then, be well. -AJC

Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is an Adjunct Graduate Professor for the Center for Counseling and Family Studies at Liberty University. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony is author of The Clinical Training Guide for Online Counseling and Telephone Counseling. Anthony practices counseling in Boston and Cambridge, Massachusetts. See www.ThriveBoston.com

References

Rosenfield, M. (2003). Telephone counselling and psychotherapy in practice. In S. Goss, K. Anthony (Eds.), Technology in counseling and psychotherapy: A practitioner’s guide (pp. 93-108), Great Britain: Palgrave Macmillan; Slavich, S. (2003). The status of online mental health services. Unpublished doctoral dissertation, Wichita State University. Wichita.
Hornblow, A. R., & Sloane, H. R. (1980). Evaluating the effectiveness of a telephone counselling service. British Journal of Psychiatry, 137, 377-378; VandenBos, G.R., & Williams, S. (2000, October). The internet versus the telephone: what is telehealth, anyway?. Professional Psychology: Research and Practice, 31, 490-492.
Ibid.
Lester, D. (ed.) (2002). Crisis intervention and counseling by telephone, Springfield, IL: Charles C. Thomas.
Manning, T., Goetz, E., & Street, R. (2000, November). Signal delay effects on rapport in telepsychiatry. Cyber Psychology and Behavior, 3, 119-127.
National Board for Certified Counselors. (2001). Standards for the ethical practice of web counseling. Retrieved February 20, 2000, from http://www.nbcc.org/ethics/wcstandards.htm
American Psychological Association. (1997, November). APA statement on services by telephone, teleconference, and Internet: A statement by the ethics committee of the American Psychological Association. Retrieved February 20, 2005 from http://www.apa.org/ethics/stmnt01.html
American Counseling Association Governing Council. (1999, October). American
Counseling Association code of ethics. Author, A.3.a., A.3.b.

Theorists Debate

Early theorists held that online text communication (OTC) was insufficient for rapport development due to its lack of non-verbal cues and its impersonal “lexical” aspects. This was called the “cues filtered-out” theory.

In contrast, competing theorists have proposed OTC is sufficient for building rapport because (more important than non-verbal cues) persons build rapport by considering themselves socially “in-group” with others, something OTC does well. Others suggest OTC allows for a greater experience of rapport than in-person communication because (1) online text communicators often designate positive characteristics to the persons they dialogue with, using idealized attributions to supplement missing information, and (2) persons can provide ideal self-presentation by optimally editing their disclosures.

So what do the studies show?

Rapport Research: Online Text

One study found that in-person communication and OTC are equal in regards to the quality of dialogue, and only different in regards to dialogue speed. Hence, while online text chat users have less rapport than in-person groups after a first 30-minute meeting, by a third meeting rapport is equivalent. A repeat study found greater relational intimacy with text chat after the first meeting! And a third study found that those using text chat possessed significantly higher rapport than an in-person group, consistent in male-male, male-female, and female-female pairs.

Rapport Research: Videoconference and Telephone

In another study, videoconference counseling sessions were conducted with delays varying from none to severe—the hypothesis being that as delay worsened rapport would decrease (in-person counseling subjects were a control). The findings: While no significant difference in rapport existed between the no delay, severe delay, and in-person sessions with males, with female participants rapport was highest when using no delay, and second highest with some delay. In-person sessions produced the lowest rapport. Regarding telephone counseling, decades of studies have found that persons who receive counseling by telephone rate rapport the same as in-person control groups.

Counselor Techniques for Building Rapport

Again, the absence of non-verbal communication has been the leading critique of why eCounselors cannot build rapport with clients. However, when looking at what facilitates rapport in counseling, of significance are verbal behaviors. Greater amounts of silence (4% to 20%) are found in relationships perceived by clients as having high rapport. Rapport is found to correlate with therapist clinical experience. Rapport is highest when therapists use few encouraging statements (e.g., “uh huh,” “hmm,” etc.) and many empathetic responses. Rapport is associated with counselor verbosity and with counselors who verbally engage clients. Restating the client’s words, with attention to feelings, increases rapport. And highest rapport exists when minimal talk is about the counselors’ own interpretations. All this, of course, is possible with eCounseling.

What would Freud Say?

Sigmund Freud took measures against the face-to-face nature of counseling by placing the therapist behind the client, out of the client’s view (and providing the therapist only a partial view of the client). Freud was also a proponent of text communication; he wrote letters to his patients for therapeutic purposes.

Anthony J. Centore, Ph.D. serves as the Special Assistant to the President for the 50,000-member American Association of Christian Counselors, and is an Adjunct Graduate Professor for the Center for Counseling and Family Studies at Liberty University. He has authored numerous book chapters, articles, and is a columnist for Christian Counseling Today magazine. Anthony is author of The Clinical Training Guide for Online Counseling and Telephone Counseling. Anthony practices counseling in Boston and Cambridge, Massachusetts. See www.ThriveBoston.com

References

Ancis, J. R. (1998). Cultural competency training at a distance: Challenges and strategies.
Journal of Counseling and Development, 76, 134-142.
Hain, L. N., Chuan, S. L., Trevor, T. M. & Detenber, B. H. (2004). Getting to know you: exploring the development of relational intimacy in computer-mediated. Journal of Computer-Mediated Communication. 9(3); Short, J., Williams, E., & Christie, B. (1976). The social psychology of telecommunication. London: John Wiley; Michailidis A., & Rada, R., (1997). Activities and communication modes. International
Journal of Human-Computer Studies, 46, 469-483; Parks, M. R., & Floyd, K. (1996). Making friends in cyberspace. Journal of Communication, 46, 80-97
Lea, M., & Spears, R. (1995). Love at first byte? Building personal relationships over computer networks. In J. T. Wood & S. Duck (Eds.), Under-studied relationships: Off the beaten track (pp. 197-233). Thousand Oaks, CA: Sage.
Walther, J. B. (1996). Computer-mediated communication: Impersonal, interpersonal, and hyperpersonal interaction. Communication Research, 23(1), 3-43.
Walther, J. B., & Burgoon, J. K. (1992). Relational communication in computer-mediated interaction. Human Communication Research, 19, 50-88; Walther, J. B. (1993). Impression development in computer-mediated interaction. Western Journal of Communication, 57, 381-398; Walther, J. B. (1995). Relational aspects of computer-mediated communication: Experimental observations over time. Organization Science, 6(2), 186-203.
Hain, Chuan, Trevor, & Detenber, 2004.
Manning, T., Goetz, E., & Street, R. (2000, November). Signal delay effects on rapport in telepsychiatry. Cyber Psychology and Behavior, 3, 119-127.
Reese, R. J. (2000). Client perceptions of the effectiveness and appeal of telephone counseling. Dissertation Abstracts International, 61(07B), 3857; Brown, L. (1985). Antecedents of compliance in employee assistance programs: Telephone vs. face-to-face communications. Dissertation Abstracts International, 46(09b), 3250.
Sharpley, C. (1997, September). The influence of silence upon client-perceived rapport. Counselling Psychology Quarterly, 10(3), 237-247; Sharpley, C., & McNally, J. (1997, December). Effects of level of academic training on client perceived rapport and use of verbal response modes in counselling dyads. Counselling Psychology Quarterly, 10, 449-461; Sharpley, C., & Guidara, D. (1993). Counsellor verbal response mode usage and client perceived rapport. Counselling Psychology Quarterly, 6(2), 131-143; Sharpley, C., Fairneis, E., Tabary-Collins, E., Bates, R., & Lee, P. (2000, November). The use of counsellor verbal response modes and client-perceived rapport. Counselling psychology quarterly, 13(1), 99-116.
Lester, D. (ed.) (2002). Crisis intervention and counseling by telephone, Springfield, IL: Charles C. Thomas; Stybel, L. (2003). Crisis intervention and counselling by telephone (book). American Journal of psychotherapy, 57, 282-285.