Bill C. Greenwalt
Technology is advancing at a rapid pace, and people are jumping on the fast-moving train quickly, lest they be left behind in an ever-changing world. Communication is easier now than it has ever been. One can log onto the internet and "talk" with other people all over the world. Instant communications with very little expense means people can escape remote areas and gain access to services available only in well developed areas. Therapists are hopping onto the train, offering cybercounseling over the Internet in private practices and in groups. Some groups actively are recruiting therapists all over the country. Some therapists, interested in the new medium and looking for ways to expand their market, are intrigued with the possibilities. While the Association of Marital and Family Regulatory Boards (2000) reports jurisdiction as the primary issue in doing cybercounseling, the American Association of State Counseling Boards concluded in January 1999 that counseling could not occur without being face-to-face (f2f) with the client (Hughes, 2000). The American Association of Marriage and Family Therapy (1999) wrote that cybercounseling raised several ethical issues.
Supervisors also have explored the ever expanding possibilities of doing supervision over the Internet. Oregon State University, which has a CACREP (Council for the Accreditation of Counseling and Related Educational Programs) accredited program, offered an Internet-based Counseling Internship course (Christie, 2000). Interestingly, one of the four students had to drop out of the course because the Internship Site would not allow her to have her supervision online. She was informed that she would have to get f2f supervision or find another site. This Internship Site’s and the American Association of State Counseling Boards’ conclusions point to some of the problems with using the technology that is available within our profession. The Association of Marital and Family Therapy Regulatory Boards (2000) indicated that some f2f contact needs to occur in supervision.
This article will discuss some of the ethical issues of doing supervision over the Internet. It will not discuss whether supervision could be done using that medium, but whether it is ethical to do so. Just because something can be done does not necessarily mean it should be done. As with many ethical issues, cybersupervision has arguments on both sides. Issues related to the principles of autonomy, fidelity, beneficence, and nonmaleficence are discussed, but the brevity of the article prohibits a full treatment of even those ethical issues. Unfortunately, very little was found in the counseling or therapy literature on the ethics of doing cybersupervison.
The principle of autonomy is the right of individuals to make their own decisions and act upon those decisions without interference from anyone else (Gladding, Remley, Huber, 2001). Informed consent statements are developed to allow individuals the information necessary to decide whether they want to enter into therapy with a particular therapist and how much information they want to reveal. A client may choose not to disclose that they abuse their children when the therapist informs them of the requirement to report such information to the child protective services. While this potentially limits some of the effectiveness of the therapy, it is the client’s right to divulge or not to divulge any information. Explaining to clients the limits of confidentiality is important to allowing clients as much autonomy as possible during the therapy process. Therapists are required by ethical and legal standards to maintain client confidentiality. Records are to be maintained and handled with great care to protect the client.
Some have indicated that confidentiality over the Internet is not possible. While this is true for routine Internet usage such as e-mail and chat rooms, secure transmissions can take place in other contexts. If a person were to use a strong 128kb encryption program (used for passing financial information over the Internet), the information may go over the Internet more securely than through the mail system. The one aspect that cannot be hidden would be the individual computer addresses, since they are not encrypted. In other words, someone could determine that two computers are in communication with each other. Since the information being passed between the computers was strongly encrypted, no one would know therapy was occurring. In some ways, it is similar to someone being able to observe that an individual enters into the therapist’s office at specific times without being able to find out the purpose of the visits.
Since cybersupervision is the focus of this article, one may be wondering how the principle of client autonomy enters the discussion. Clients have the right to know how their confidential information is going to be handled. A good informed consent statement will inform the client about supervision and the manner in which that supervision is conducted. Clients seen f2f have the right to know of the dangers of information being passed over the Internet (cyberclients probably would not be very concerned about this since they are already putting their information on the Internet). Some people will not place personal information on secure sites, because they do not trust the technology. Therapists should not press this issue, but allow the client the right of autonomy in deciding how the therapist handles the information. If a client objects to cybersupervision, then the supervisee is in the position of either not having supervision for this client or seeking f2f supervision. Since a supervisor is responsible for supervising the entire caseload unless it is a specific case consultation, any single client can frustrate or impede an online supervisory process. The ethical question then is whether a supervisory relationship can be a combined experience of cybersupervision and f2f supervision. This has possibilities, assuming it involves a case that cannot be discussed on the Internet. Certainly, this problem is handled routinely in supervision when a case needs supervision before a regularly scheduled supervisory session.
Autonomy and confidentiality are not the major ethical hurdles for cybersupervision. Fidelity is the principle of being trustworthy and trusting. The supervisor will uphold all commitments and communicate in an honest and open manner, maintaining a loyalty to the supervisee and the clients (Gladding, Remley, & Huber, 2001). Two questions will be discussed: 1) Is cybersupervision really supervision? 2) Is cybersupervision acceptable to the professional and state governing bodies?
First, is cybersupervision really supervision? Since the American Association of State Counseling Boards decided that cybercounseling was not really counseling, then one could reasonably conclude that they might say the same thing about cybersupervision. The primary objection concerns the manner in which the task is performed. At present, most cybercounseling is conducted in a textual manner while counseling is contextual. Since cybercounseling uses words only (and sometimes a limited number of words), all nonverbal communication is lost. The receiver has no idea what the body language or affect was behind the words. Consequently, the depth of the communication is very limited, and the counselor is unable to fully discern all aspects of the communication. While these are objections levied at cybercounseling, the same can be said about cybersupervision.
One could do videoconferencing in a secure mode, though the encryption of the video would slow it down, making the video more jerky than it already is. While a smooth video transmission is technically possible, very few people have the capability of doing this. Even then, one could question whether a video picture would supply the receiver with enough of the nonverbal communications to justify the process being labeled therapy or supervision. One would still miss many of the subtleties of the communication process. Is the supervisor being honest in proclaiming that supervision is taking place when other professionals would say that it is not? Granted, some supervision is done with the supervisee bringing a video and discussing a session with a supervisor while watching the video. However, in these cases the therapist was there during the session and can clarify some of the nonverbal communications when they are not clear.
Clearly, one of the fidelity issues would be whether cybersupervision will be acceptable to the State Licensing Boards. The statement of the Association of Marital and Family Therapy Regulatory Boards (2000) came from the report of a focus group meeting at the annual meeting of delegates and does not represent a position of the Board. Until some definitive decision is made on whether it is acceptable and will count toward the supervisory hours required for licensure, the supervisor has an obligation to inform the supervisee that those hours may be rejected. That allows supervisees the opportunity to maintain their own autonomy and decide for themselves if they want to take a chance on those hours counting. Hopefully, the Association of Marital and Family Therapy Regulatory Boards and the American Association of State Counseling Boards will discuss this issue in their respective boards and come to some consensus. The worst thing that could happen would be for some states to accept cybersupervision and others not. With a very mobile society, this would create problems for individuals who had cybersupervision and did not plan on moving when they later relocated to a state that did not accept those hours. Universities wanting to establish online educational programs also should address the fact that some classes may be rejected by State Counseling Boards, especially with courses involving supervision.
Beneficence is promoting that which is good and looking out for the well-being of the client (Gladding, Remley, Huber, 2001). One can argue that offering cybersupervision allows supervisees in remote areas to get the professional training they need in order to provide the best care possible for clients. Cybersupervision certainly can save time and money since the supervisee would not have to travel great distances. However, if they are getting an inferior product (and no one can say whether it is inferior at this time), then potentially it could do more harm than good. Research needs to be conducted on this topic in order to determine its true worth.
Nonmaleficence demands that the therapist/supervisee and supervisor do no harm (Gladding, Remley, Huber, 2001). If confidentiality is broken in any way, the client may be harmed. One can safely handle sensitive information over the Internet if strict protocols are followed. The danger of compromise is always there, even in f2f therapy and supervision. Working on the Internet requires the supervisor to become more knowledgeable about technology and very aware of ways information can be compromised.
Harm may be done to the supervisee if cybersupervision is not effective or is not allowed by the State Licensing Boards. Valuable time and money would be wasted, causing frustration and anger for the supervisee, who might have been under the impression that cybersupervision would be accepted in the same manner as f2f supervision.
Supervisors considering doing cybersupervision are faced with many ethical issues. This article has discussed the principles of autonomy, fidelity, beneficence and nonmaleficence as it relates to cybersupervision. While many ethical problems can be overcome with available technology, whether State Licensing Boards will accept cybersupervision toward licensure may limit its use. Supervisees need to be informed about the potential of the supervision not counting toward licensure and make their own decision. Before people rush into cybersupervision, the principles of beneficence and nonmaleficence require research into its effectiveness. Cybersupervision may be the wave of the future or a road bump in the developmental path of the profession. Hopefully, this article has stimulated the reader’s thinking. An open dialogue is needed on the use of technology in our future. The world is changing and our profession must change with it in a very responsible and reasoned manner.