Counselors Perceptions of Distance

Counselors’ Perceptions of Distance
Counseling: A National Survey
Rakesh Kumar Maurya1
Mary Alice Bruce1
Sumedha Therthani21)
Journal of Asia Pacific Counseling
ⓒ 2020 The Korean Counseling Association
2020, Vol.10, No.2, 1-22
Doi : 10.18401/2020.10.2.3
Investigating how counselors perceive technology as a tool for delivering counseling services is crucial to understand
the usage and challenges that may have implications for training programs, policymaking, and allocation of resources.
With the COVID-19 crisis and accompanying shelter-in-place and self-distancing guidelines, telemental health, including
distance counseling, has become a satisfactory primary delivery system and is now expected to be part of routine
counseling care. The present pre-COVID-19 study explored practicing counselors’ perceptions of distance counseling
regarding advantages and challenges. While noting benefits, results indicate continuing barriers to widespread telemental
health use encompassing licensure, training, safety, privacy, evaluation, and regulatory policies. Also, attention is needed
for therapeutic relationships and culturally alert digital interventions. In addition, counselors can take advantage of
rapidly changing technologies to provide numerous innovative counseling services.
Keywords: distance counseling, telemental health, technology, online counseling, Covid-19
Pre-COVID-19, mental illness affected one in five people in the United States annually (National Alliance
on Mental Illness [NAMI], 2018), while around the world, mental health disorders or neurological issues
affected approximately one in four people during their lifetime (World Health Organization, 2017). However,
according to NAMI (2018), of those with mental health issues in the U.S., only 41% were receiving
treatment. The presence of COVID-19 has resulted in an unprecedented number of people who now need
mental health assistance as they experience anxiety and fear in conjunction with numerous pandemic-related
issues (Burkhalter, 2020). The specific psychosocial impacts of COVID-19 include: disrupted lives, anxiety,
depression, economic hardships, and numerous deaths (Rauch et al., 2020), as well as race-related
discrimination (White, 2020).
With powerful technological advances and easy access to tele-communication, new vistas continue to open
University of Wyoming
Mississippi State University
Corresponding Author
Rakesh Kumar Maurya, School of Counseling, Leadership, Advocacy, & Design, University of Wyoming, 1000 E.
University Ave. Laramie, WY 82071
Email: [email protected]
Regular Article
for much-needed counseling services (Vincent et al., 2017). As numerous people protect themselves by
sheltering in place and social distancing, COVID-19 has resulted in a rapid and wide-spread use of various
forms of teletherapy, including distance counseling (DC) (Litam, 2020), which the Center for Credentialing
and Education, an affiliate of the National Board for Certified Counselors (NBCC), defined as:
a counseling approach that takes the best practices of traditional counseling as well as some of its
own unique advantages and adapts them for delivery to clients via electronic means in order to
maximize the use of technology-assisted counseling techniques. (CCE, 2017)
According to Stephan et al. (2016), with the great majority of the U.S. population having an online
presence and using social media, technology has become increasingly familiar and accepted at all
socioeconomic levels and across all ages. In particular, communities have installed or expanded technology
services for those populations which previously may have been underserved; in addition, school districts have
instituted a wide variety of distance services for youth.
Numerous advantages of technology-based services for counseling clients include anonymity, accessibility,
cost, and convenience, resulting in increased use by those in need, especially disadvantaged populations
(Richards & Viganó, 2013). In the past, a few of the reasons that people affected by mental health issues did
not use technology services included feelings of alienation, a sense of stigma, lack of time, and difficulties
related to accessibility (Lewis et al., 2015). Lack of service often then resulted in severe consequences,
including hospitalization (Agency for Healthcare Research and Quality, 2009) and significant loss of earnings
(Insel, 2008).
Pre-COVID-19, empirical evidence revealed the continuing effectiveness and positive impact of DC on
client welfare (e.g., Berger, 2017; McCord et al., 2011; Richards & Vigan,2013;Richardsetal.,2018).Following
the World Health Organization (WHO)’s declaration on January 31, 2020 of the pandemic as an international
health emergency (Federal Emergency Management Agency [FEMA], 2020), mental health professionals in
the U.S. began helping those in need almost entirely by teletherapy (Brown, 2020; Burkhalter, 2020; Taylor
et al., 2020). As a result, expectations continued to build for teletherapy, particularly DC, to become a usual
part of counseling care (Taylor et al., 2020). However, in response to the COVID-19 crisis, many mental
health professionals were thrust into a quick transition to working remotely, had to train themselves, and
initially felt somewhat inadequate (Brown, 2020). In addition, pre-COVID-19 issues such as licensure, safety,
privacy, and evaluation continued to challenge DC (Taylor et al., 2020).
The researchers believed that investigating how counselors perceive technology as a tool for delivering
counseling services was crucial to the scope and content of counseling training programs, policy making,
provision of services, program accountability, ethics, and allocation of resources. Therefore, the purpose of
this pre-COVID-19 survey research was to explore and understand practicing counselors’ perceptions of DC.
The research questions that guided this study were as follows:
1. How prevalent is DC among practicing counselors?
2. How comfortable do counselors feel in offering DC services to clients?
3. What is the perception of counselors regarding possible challenges and benefits in offering DC?
4. Does work-setting, level of experience as a practitioner, theoretical orientation, and
training/workshop in DC influence counselors’ perception of DC?
5. With the rapid evolution of technology, what do counselors envision for the future of DC?
Background of Distance Counseling
Distance Counseling, including variations of teletherapy such as videoconferencing, social media messaging,
emails, websites, and telephone connections (Richards et al., 2018), has been found to produce client
outcomes that are in keeping with face-to-face (F2F) counseling sessions and seems quite promising as digital
evidence-based interventions are used (e.g., Bashshur et al., 2016; Berger, 2017; Garde et al., 2017).
Historically, DC, also known by such terms as online counseling, e-counseling, cybercounseling, and web
counseling, has resulted in a wide variety of reactions ranging from skepticism to eagerness from practicing
counselors (McCord et al., 2011). Concerns and reluctance from counselors revolve around social advocacy
and access, the therapeutic relationship, ethical and legal concerns, finances and profitability, counselor
effectiveness and treatment efficacy, counselor experience, and training.
Social Advocacy and Access
Of great significance is the provision of telemental health services to underserved populations who may
suffer from a variety of mental health concerns, particularly depressive symptoms and addiction that may
affect their lifestyle and ability to find mental health support (Jang et al., 2013; McCord et al., 2011). Such
individuals include those residing in geographically remote areas who historically face issues that encompass
the unavailability of transportation, poverty, cultural barriers, and lack of qualified counselors, as well as
worries regarding confidentiality, stigma, and poor overall health (Baca et al., 2007). Offering mental health
access and resources to underserved populations can help alleviate these disparities and offer ample
opportunities to individuals.
Similarly, many linguistically isolated individuals experience unmet mental health needs that may be only
alleviated by means of DC. As stated by US Census Bureau report (2017), 21.1% of those living in the U.S.
do not identify English as their primary language. Access to translation services and cultural understanding
often may be more easily available via DC, to successfully support those who need mental health assistance,
including children/adolescents in schools, adults, and families (Jang et al., 2013).
At the same time, some individuals in urban settings are unable to travel for mental health services due
to poverty, lack of transportation, and prohibitive health issues. In addition, those with disabilities or anyone
for a variety of reasons who may be more comfortable in their own home or personally selected surroundings
may find DC a long-awaited answer to meet their needs (Gournaris, 2009). The ability to reach out to clients
in such debilitating situations is increasingly a viable alternative to F2F counseling sessions, especially since
the power differential may appear to lessen with distance connections, with each person being in a
self-selected comfortable space within which to build an alliance together (Lewis et al., 2015; Menon &
Rubin, 2011; Suler, 2004).
During the COVID-19 crisis, the ongoing U.S. sociopolitical climate of cultural racism and systemic health
disparities was dramatically illustrated (Litam, 2020). People of color and other marginalized groups in the
United States experienced increased racial discrimination and microaggressions due to misinformation and
blame regarding infectious diseases. Concurrently, the Black Lives Matter movement and sustained protests
advanced the need for equal rights and justice. Telemental health services may provide a way for counselors
to address the recent increase in race-based trauma experienced by racial, ethnic, and marginalized groups.
Therapeutic Relationship
According to Richards et al. (2018), critics have expressed concern regarding the nature of therapeutic
alliance that Berger (2017) claimed has often been identified as the crux of all client change and growth. Eye
contact, as well as visual and auditory clues, especially micro-facial expressions, may not be of the same
quality as in F2F connections and thus stymie meaningful interactions (Deane et al., 2015). Critics also point
out that due to a focus on the head and upper body during videoconferencing, body language may be
obscured, thereby preventing a fuller therapeutic relationship (Deane et al., 2015). In addition, Balick (2018)
mentioned the possible detraction of self-consciousness both for the client and counselor who may initially
focus on themselves and their own image rather than a meaningful connection with each other.
On the other hand, Suler (2004) pointed out that people feel less inhibited and are able to express
themselves more freely due to the Online Disinhibition Effect. Suler added that because clients are secure in
a space of their own choosing, they can avoid any perceived stigma in a waiting room, can bring forward
their worries, and are, in fact, more able to connect quite easily. Jang et al. (2013) found that
socially-isolated clients eagerly looked forward to their DC sessions, appreciated the security, and were
relieved to avoid stigma that they were more than satisfied with their counseling connection and therapeutic
sessions. In their extensive work, Baca et al. (2007) identified a genuine sense of meaningful connections,
especially for those clients utilizing video web conferencing for DC. In his thorough review of
empirically-based studies, Berger (2017) reported that while clients rated alliances with their distance
counselor equivalent to those in F2F studies, counselors’ ratings of their therapeutic alliances were mixed.
Ethical and Legal Concerns
In addition to therapeutic alliances, counselors had indicated worries pre-COVID-19 about clients’
protection related to ethics, privacy, confidentiality, counselor training, professional guidelines and ethics,
licensure, and legalities (Richards et al., 2018). During the pandemic, “State of Emergency” orders issued by
many states gave counselors the right to counsel clients in other states by means of telemental health
(American Counseling Association [ACA], 2020). The American Counseling Association (ACA) cautioned
that services across state lines by all unlicensed, professional counselors had to end when the Order ended,
thus reminding counselors to ensure continuity of care for their clients.
The American Counseling Association Code of Ethics (Section H; ACA, 2014) gives special attention to
ethical considerations and standards of care regarding the use of technology and distance counseling. In
addition, the ACA offers numerous resources, training opportunities, and free ethics consults to support
members wherever located (ACA, 2020). Since 1997, the National Board of Certified Counselors (2016)
continues to stay abreast with evolving issues and offers resources as well, by means of updated and revised
policy statements related to distance services. McAdams and Wyatt (2010) found in their study that with the
lack of licensure portability nationwide, state licensing boards and the counseling profession specifically have
focused on issues that included threats to confidentiality, legal accountability, and crisis management. In
addition, specialized training and standards of practice have emerged as an expected necessity for DC,
especially with risk mitigation as a consideration in light of how litigious the U.S. society is today.
Since the use of DC continues to increase without professional guidelines, practitioners must carefully
monitor their own safeguards and client situations (McAdams & Wyatt, 2010). Specifically, best practices
include ongoing attention to informed consent and special emphasis on practicing within individual state
regulations. According to Gournaris (2009), personal health information as protected by Health Insurance
Portability and Accountability Act (HIPPA, 1996), privacy and confidentiality as emphasized by the HIPAA
Privacy Rule (2003) and HIPPA Security Rule (2003), as well as the Health Information Technology for
Economic and Clinical Health Act (HITECH Act, 2009), which focuses on digital health information, are
obligatory legalities for practitioners. Meanwhile, state licensing boards may further expand their expectations
and standards to protect clients (Carlisle et al., 2017). Overall, practitioners must consider encryption of all
data, compliant software (HIPAA Final Omnibus Rule, 2013), emergency procedures, and liability insurance
when considering best practices.
Finances and Profitability
As discussed, DC has the potential to reach underserved populations in a cost-effective manner. More
advanced technology increasingly is accessible at a lower cost to consumers (Baca et al., 2007), and
government funding for a variety of initiatives has boosted delivery. However, for the 20% of the U.S.
population living in remote communities that may not have the most current access, infrastructure quality for
technological transmission may still delay the best capabilities of DC (McCord et al., 2011).
As for the perspective of private practitioners and community agencies that use DC, many financial
advantages that include reimbursement through third party payers and Medicare are available. Realizing these
opportunities, practitioners may reach new clients and expand their practice by means of DC. On the other
hand, researchers (Gournaris, 2009; Richards et al., 2018) discovered that some practitioners remain hesitant
regarding the use of technology in their own practice, due to lack of training, concern over legalities, and
doubts surrounding the adequacy of the therapeutic relationship.
Counselor Effectiveness and Treatment Efficacy
Overall, DC has been shown to be satisfactory for clients in its effectiveness in providing needed services
(McCord et al., 2011; Richards et al., 2018). In their survey study of practitioners, Menon and Rubin (2011)
reviewed the counseling theoretical frameworks and associated interventions DC services offer. While
Cognitive-Behavioral and Solution Focused were the theoretical orientations practitioners most used, a wide
range of other models were successfully employed, including Psychodynamic, Eye Movement Desensitization
Reprocessing, and Person-Centered Therapy.
As for client issues and concerns treated via DC, Baca et al. (2016) reported that practitioners reliably
diagnose a variety of issues. In addition, distance counselors effectively help clients with problems such as
panic disorder and childhood depression. Menon and Rubin (2011) found that practitioners identified anger
management, PTSD, self-esteem, marital strife, grief, and depression as issues they successfully addressed
with DC. According to Berger (2017), across client issues with long lasting effects and efficacy, interventions
delivered online resulted in similar outcomes as compared with F2F delivery.
Counselor Experience
While supporting their clients, counselors may nevertheless experience hesitation regarding the use of DC
depending on their years of experience and seniority (Richards et al., 2018). For many senior experienced
counselors, their foundational preparation occurred before the Internet age, while other experienced counselors
had some use of adjunct technologies in their F2F practices, including encrypted email/text contacts and a
professional website. Vincent et al. (2017) found that older counselors (61-70 years) were slightly more
hesitant in moving to complex technologies as compared to younger experienced counselors (40-60 years of
According to Menon and Rubin, counselors in their study with years of “practice wisdom” (p. 139) were
more likely to be at ease and willing to move into distance services with technological support. Vincent et
al. (2017) found that the great majority of experienced counselors were more alert than less experienced
counselors in realizing that expectations regarding boundaries and availability of responsive connections
should be thoroughly considered and discussed between counselor and client. More experienced counselors
were also more perceptive in identifying and managing ethical issues. Additionally, more experienced
counselors emphasized the need for ongoing, professional dialogue as the use of technology and digital
mental health interventions exponentially increase.
The present study used a descriptive survey research design to explore counselors’ perceptions of DC. A
descriptive research design is utilized to learn characteristics of people including their beliefs, attitudes,
opinions, and behaviors as they naturally occur (Johnson & Christensen, 2016). To achieve this goal,
descriptive survey research design uses structured questions to measure participants’ responses and analyzes
them using quantitative statistical tools such as descriptive statistics and t-test.
Theoretical Framework
The researchers used the United Theory of Acceptance and Use of Technology Model (UTAUT) to
understand and interpret the results (Venkatesh et al., 2016). This recognized theory offers a cogent
framework to understand users’ intentions and usage behaviors regarding acceptance and use of technology.
The UTAUT Model emphasizes the influence of psychological and social factors related to the use of
technology (Venkatesh et al., 2016). According to the UTAUT model, the factors in organizations that may
impact technology compliance and use include performance expectancy, effort expectancy, social influence,
and facilitating conditions, which in turn are influenced by gender, age, experience, and voluntary use
(Venkatesh et al., 2016) (see table 1).
The degree to which an individual believes that technology will
assist in performing job duties
Effort expectancy The degree to which an individual perceives the technology’s ease
of use
Social influence The degree to which an individual feels social pressure to use
particular technology
Facilitating conditions The degree to which an individual believes that his or her
organization supports change
Moderator Description
Gender Male, Female
Age Continuous
Experience Ordinal—low, medium, high
Voluntariness of use A categorical variable (high, low)
Table 1
Description of key determinants and moderators in the United Theory of Acceptance and Use of Technology
In keeping with this model, an organization must carefully facilitate members to accept and use new
technology by educating those members regarding the benefits of the new technology, the potential ease of
technology’s use, the presumption of technology’s use in the work of the organization, and promised
supportive assistance given to the organization’s members (Venkatesh et al., 2016). At the same time,
administrators must thoughtfully consider how gender, age, experience and openness to change may present
challenges. Thus, for counselors in an organization/institution to successfully change regarding the acceptance
and use of technology, there needs to be strong, visionary leadership with an interest and understanding of
the potential for telemental health, as well as resources by which to move the organization and use of DC
Procedures and Participants
After obtaining approval from the university’s Institutional Review Board (IRB), an email containing the
survey link was sent by NBCC on behalf of the researchers to 6,300 counselors across the United States. The
NBCC selected these participants through stratified random sampling from their total population holding NCC
certification. NBCC chose to distribute the email request for research participation only once in order to
avoid excessive communication with members. Additionally, given that the researchers did not send email
invitations directly, they did not know how many of the 6,300 email addresses were active at the time of
distribution. In some instances, emails may have gone to spam folders of some potential participants.
The researchers used Qualtrics, an online survey tool (, to create the survey and
collect survey responses online. With only one distribution of the survey, which occurred during August
2018, a total 242 responses were received. After removing incomplete responses, 193 responses were
available for data analysis. Thus, 80% of those who began the survey completed it.
Of the 193 participants, 30 (15.54%) were male, 161 (83.42%) were female, and 2 (1.04%) identified
themselves as “other” or gender non-conforming. The participants’ mean age was 46.96 years (SD = 12.84;
range = 23-77). The participants came from various levels of experience as practitioner: 51 (26.56%) with 0-5
years of experience, 50 (26.04%) with 6-10 years of experience, 32 (16.67%) with 11-15 years of experience,
and 59 (30.73%) with more than 15 years of experience. Also, participants came from various work settings:
23 (11.92%) working in schools, 52 (26.94%) in agencies, 74 (38.34%) in private practice, 19 (9.84%) in
hospitals, and 25 (12.95%) in universities/colleges. Regarding educational qualifications of the participants,
168 (87.05%) reported having earned a master’s degree, and 25 (12.95%) reported holding a doctoral degree
in counseling.
Survey Instrument
Since there was no suitable survey instrument in existence for the purpose of investigating counselors’
perceptions of DC, the researchers developed a survey instrument. Another reason for creating a new survey
instrument was that tele-communication technologies are continuously improving. As a result, instruments
developed based on older technologies may have limited relevance today. Nevertheless, we drew upon the
literature of numerous peer-reviewed research studies that addressed potential advantages and disadvantages of
DC, as well as existing questionnaires including the E-therapy Attitude Scale (Finn, 2002), E-therapy Ethics
Scale (Finn, 2002), and the Online Counseling Attitude Scale (OCAS), in addition to the Face-to-Face
Counseling Attitudes Scale (FCAS) (Rochlen, Beretvas, & Zack, 2004). Based on an extensive research
literature review, the researchers identified five constructs to include in the design of the survey instrument
used in this study. These five constructs were: prevalence and comfort in offering DC, perceived effectiveness
of DC, perceived challenges in offering DC, perceived advantages of DC, and future outlook toward DC.
The initial version of the survey questionnaire was reviewed by an independent counselor educator who
holds a PhD degree in Counselor Education and Supervision with more than five years of experience
conducting DC services both in Australia and the United States. Based on the counselor educator’s feedback,
two more items “I fear my professional identity being weakened if I provide distance counseling,” and
“Distance counseling is as profitable as in-person counseling in terms of financial gain for the counselors”
were added to the instrument. Next, the researchers requested five practicing counselors not involved in the
survey development or research to take the survey (data not included in the results of this study), who
offered feedback regarding clarity of language. Based on their feedback, the researchers reworded three
questions for clarification before the NBCC distribution.
The final survey instrument was divided into three sections: (1) informed consent, (2) survey questions,
and (3) respondent demographics. The survey questions included 21 items that comprised five sub scales:
prevalence and comfort in offering DC, perceived effectiveness of DC, perceived challenges in offering DC,
perceived advantages of DC, and future outlook toward DC. The demographic section included 14 questions
related to participant’s gender, age, level of experience as practitioner, highest degree completed, training in
DC, theoretical orientation, work setting, and primary counseling specialty.
Prevalence and comfort in offering DC were measured with 4 items. Example items were: “I feel
comfortable in offering distance counseling if needed,” and “How often do you provide distance counseling
services?” Participants responded to these items using a five-point Likert scale response format that ranged
from “strongly disagree” to “strongly agree” and “never” to “very often.” Internal consistency alpha was .66
suggesting adequate reliability in the present sample. Perceived effectiveness of DC was measured with 4
items such as “In your opinion, how effective is distance counseling when compared to in-person
counseling?” Participants responded to these items using a five-point response format ranging from “not
effective at all” to “extremely effective” and “strongly disagree” to “strongly agree”. Internal consistency
alpha was .62 suggesting adequate reliability in the present sample.
Perceived challenges of DC were measured with 4 items such as “It is very challenging to establish an
effective therapeutic relationship in distance counseling.” Participants responded to these items using a
five-point response format ranging from “strongly disagree” to “strongly agree.” Internal consistency alpha
was .72 suggesting adequate reliability in the present sample.
Perceived advantages of DC was measured with 5 items such as “distance counseling promotes
disinhibition among clients.” Participants responded to these items using a five-point response format that
ranged from “strongly disagree” to “strongly agree.” Internal consistency alpha was .46. Counselors’ future
outlook toward DC was measured with 2 items: one on a five-point Likert scale, while the other was a
multiple-choice question. These two items were highly correlated (r = .7 4, p < .05).
For data analysis, both descriptive and inferential statistics were used. For research questions 1, 2, 3, and
5 that explored prevalence, comfort, and perceived challenges and benefits in offering DC, descriptive
statistics including percentage, were used. For research question 4, t-test and descriptive statistics, including
mean and standard deviation, were used.
According to the research questions, the researchers offer the following results.
Prevalence and Comfort
In general, our survey results indicate that only a minority of practicing counselors offer DC services. Of
the 193 participants, 80.8% (n = 156) reported that they have either never or rarely provided DC services to
their clients, while only 5.2% (n= 10) frequently offer DC services to their clients. Out of 193 participants,
19.2% (n= 37) reported offering DC sometimes, often, or very often. Out of those 37, 62% worked in private
practice; 10.80% worked in schools, 10.80% in agencies, 10.80% in a university/college, and 5.6% worked
in a hospital setting. When asked about the likelihood of providing DC services if the client lives a long
distance away and is unable to visit in person, 57.6% (n= 111) participants responded that they would offer
services through DC, perhaps demonstrating significantly more open-mindedness and risk-taking tendency than
actual practice indicated. Regarding the level of comfort in offering DC services, a majority of participants
(62.7%, n= 121) responded that they were comfortable with offering DC if needed. The respondents also
indicated a high level of comfort with learning a new technology, while 88% (n= 170) participants said they
would feel a medium level of comfort in learning a new technology.
Challenges and Benefits
When considering challenges related to DC, ethical issues and development of a safe and trustworthy
therapeutic relationship emerged as the main concerns of the participants. Specifically, 42.49% (n= 82)
participants marked ethics related to online behavior and ensuring confidentiality as their top concern.
However, participants were equally divided regarding the degree of challenge in establishing an effective
therapeutic relationship through DC; while 40.93 % (n= 79) perceived this aspect of DC as not challenging,
40.41% (n = 78) found it challenging.
On the other hand, accessibility and convenience, as well as the minimization of social stigma attached
with seeking therapy, emerged as the primary benefits of DC. In particular, 77.07% (n= 141) participants
rated accessibility and convenience as the top benefit of DC services. Further, 68.04% (n = 132) participants
thought that DC minimizes the social stigma attached with seeking mental health services. Regarding the
effectiveness of DC as compared to F2F counseling, 45% (n = 87) perceived DC as moderately effective, and
25% (n = 49) perceived it as very effective. However, a great majority (61.14%, n= 118) perceived DC as
effective when used as an adjunct to F2F counseling rather than a distinct or independent means of offering
counseling services.
As for other counselor beliefs, a majority of participants (61.7 %, n= 119) reported that they do not
perceive DC as weakening their professional identity if they choose to offer their services through distance.
However, almost half of the participants (45%, n= 87 ) were uncertain if DC is as profitable as F2F
counseling in terms of financial gain for the counselors themselves. Yet, profitability does not have the same
consideration across all work settings; thus, some participants may have responded from a more
knowledgeable perspective. Meanwhile, a majority of participants (65%, n = 126) also believe that younger
clients are more open to DC as compared to older clients.
Researchers observing online behaviors have discussed the concept of a disinhibiting effect with online
communication, which was initially conceptualized by Suler (2004). As such, in DC, the disinhibiting effect
may encourage clients to be more expressive and open about the issues and problems they face. However,
most participants in this study did not agree with the disinhibition concept. Only a minority of participants
(24.9%, n= 48) perceived DC to facilitate disinhibition among clients, while the rest of the practicing
counselors either disagreed or were unsure about the disinhibiting effect of DC. On the other hand, a majority
of participants (n= 131, 68%) perceived that DC minimized the social stigma attached with seeking mental
health counseling.
Variables Associated with Perceptions of Distance Counseling
The researchers considered other variables that had been explored as possible considerations in the
provision of telehealth work, including counselor work setting, experience, theoretical orientation and training.
Work setting and training. Counselors in private practice were found to be significantly more open to DC
(n= 74, M= 3.61, SD=1.42), as compared to those in non-private practices (n= 118, M= 3.19, SD=1.38), such
as schools, universities/ colleges, hospitals, and agency settings; t (190) = -1.996, p = 0.047 (see table 3).
Trainings or workshops on DC emerged as a key factor in determining the perception of participants toward
DC. Participants who have undertaken any training/workshop related to DC (n=77, M= 3.23, SD= 0.91)
perceived DC to be significantly more effective than those without any training (n=112, M= 2.96, SD= 0.85);
t (187) =2.06, p = 0.041 (see table 4). Additionally, participants with a training/workshop related to DC
(n=78, M= 3.82, SD= 1.20) feel significantly more comfortable in offering DC than those without any
training (n= 114, M= 3.32, SD= 1.35); t (190) = 2.655, p = 0.009 (see table 5). A key point to remember
is that one’s comfort with DC does not necessarily equate with competence in this area.
Type of Practice
95% CI for Mean
Private Practice Non-Private Practice Difference
M SD n M SD n t df
Openness in
Offering DC 3.61 1.42 74 3.19 1.37 118 0.821, 0.005 -1.996* 190
* p < .05.
Table 2
Results of t-test and Descriptive Statistics for Openness to Offer DC by Type of Practice
Have you taken training in DC?
95% CI for Mean
Yes No Difference
M SD n M SD n t df
Effectiveness of
DC 3.23 .91 77 2.96 .85 112 0.012, 0.527 2.063* 187
* p < .05.
Table 3
Results of t-test and Descriptive Statistics for Perception of Effectiveness of DC Based on Counselors’
Training(in DC) Status
Experience. Level of experience as a counselor practitioner surfaced as another factor in determining the
comfort level of counselors in offering DC (see table 4). Counselors having more than 15 years of experience
as a practitioner (M = 3.83, SD = 1.22) were found to be significantly more comfortable in offering DC, as
compared to counselors having 0 to 5 years (M = 3.31, SD = 1.30) of experience as practitioner; t (108) =
-2.146, p = 0.034. Meanwhile, participants’ responses with 6 to 10 years and 11 to 15 years of experience
were not found to be significantly different from participants having more than 15 years of experience in
terms of their level of comfort in offering DC. The rationale for using a class interval of 5 years is based
on both the recommendation of statisticians (Salkind, 2007) and our understanding of how experience is
perceived among counselor practitioners and educators. Generally, we can divide counselors in four categories
based on their years of experience as practitioner: 1) beginners or novice counselors (0-5 years), 2)
counselors having moderate level of experience (6-10 years), 3) counselors with mid-level experience (11-15
years), and 4) counselors with high level of experience (more than 15 years of experience).
Level of Experience as Counselor Educator
95% CI for
0-5 Years Above 15 Years Mean Difference
M SD n M SD n t df
Comfort in
Offering DC 3.31 1.3 51 3.83 1.22 59 0.994, 0.04 -2.146* 108
* p < .05.
Table 4
Results of t-test and Descriptive Statistics for Comfort in Offering DC by Level of Experience as Counselor
Have you taken training in DC?
95% CI for Mean
Yes No Difference
M SD n M SD n t df
Comfort in
Offering DC 3.82 1.20 78 3.32 1.35 114 0.130, 0.880 2.655* 190
* p < .05.
Table 5
Results of t-test and Descriptive Statistics for Comfort in Offering DC Based on Counselors’ Training(in DC)
Theoretical orientation. Also, participants did not differ in terms of their comfort in offering DC based on
their primary theoretical orientation in their counseling work. Participants with their primary theoretical
orientation as Cognitive/Cognitive Behavioral (M= 3.47, SD = 1.36) did not differ significantly from
participants having Rogerian/Person Centered (M= 3.73, SD= 1.20) as their primary theoretical orientation; t
(86) = -.7 9, p = 0.216). Participants also did not differ in terms of their openness to offer DC based on the
counseling program, either counseling psychology (M= 3.30, SD= 1.51) or counselor education (M= 3.42,
SD= 1.35), from which they graduated; t (179) = -0.534, p = 0.594.
Pertaining to the technology itself, practitioners offer DC primarily through two mediums: telephone and
video conferencing. Video conferencing emerged as the most effective medium of DC; 49 % (n= 95)
participants perceived counseling through video conferencing as very effective, while 43% (n= 82)
participants considered it to be moderately effective.
Future Direction of Distance Counseling
When considering the future of DC, counselors expressed a positive outlook about DC, primarily due to
their perception of easy access to constantly improving technologies. Of the study participants, 55.44% (n =
107) reported that more use of telecommunication technologies will occur in the future especially when
reaching out to under-served populations for delivery of counseling services. On the other hand, 35.75% (n
= 69) shared that the use of telecommunication technologies will increase but will always remain a secondary
option of delivering counseling services with F2F preferred.
While the majority of counselors in this pre-COVID-19 study who offer DC work in private practice, the
use of DC seems very limited at the organizational level, such as at an agency, school or institution. A
possible explanation for this variance may come about because a smaller private practice offers more
individual and financial freedom for counselors to experiment, take risks, and attempt DC at this point in
time, while those in larger established organizations must proceed through more formal procedures for
permission or resources to experiment. Perhaps without facing institutional bureaucracy, a counselor in private
practice can act more quickly, choose to investigate DC, and then invest time and finances in a course,
training, and certification.
On the other hand, as practicing counselors look to their professional organizations for guidance,
practitioners can recognize the leadership steps already taken that support the counseling field’s advancements
in telemental health. For example, the American Counseling Association (ACA), the world’s largest
membership organization representing professional counselors, added a separate Section H in its Code of
Ethics (ACA, 2014) that is devoted to DC, technology, standards of care, and social media. The addition of
section H reflects ACA’s seriousness toward helping counselors realize the legal issues and effectively
navigate the ethical challenges associated with DC.
Similarly, NBCC, which first adopted the standards for the ethical practice of DC in 1997, has consistently
revised its guidelines regarding DC in light of the new challenges and improving technologies. In its latest
revision in 2016, NBCC has set clear guidelines that National Certified Counselors (NCCs) must follow when
offering DC services (NBCC, 2016). The Council for Accreditation of Counseling and Related Educational
Programs (CACREP) standards, which serve as the foundation of the counseling profession, also provide
encouragement for the creative use of technology. For example, the curriculum of accredited programs needs
to include up-to-date information regarding “technology’s impact on the profession” (CACREP, 2016, 2.f.1.j.)
and in counseling practice, students must have opportunities “…with a variety of professional activities and
resources, including technological resources, during their practicum and internship” (CACREP, 2016, 3.D.).
However, despite these steps taken by ACA, NBCC and CACREP to support counselors with varying state
regulatory boards’ policies and laws, the practice of DC appears limited at the systemic, organizational level,
such as in a university/college, hospital, agency, and school. These findings may not be so surprising, since,
as the UTAUT model noted, regarding the acceptance and implementation of technology in organizations,
building on the work of professional organizations, the institution itself must support and educate
practitioners. Currently, few master’s and doctoral level counseling programs at universities appear to exceed
minimal exposure, much less provide training that encompasses knowledge, skills and supervised experiences
regarding the practice of DC (Holland, 2016).
Training/workshops related to DC emerged as another factor that influences the perception of counselors
toward DC. According to the UTAUT model, a training/workshop on DC can increase effort expectancy and
performance expectancy (see table 1), which can positively influence the perception of counselors toward DC.
According to Venkatesh et al. (2016), performance expectancy is the most important factor that can boost the
belief that DC is viable. Additionally, the Center for Credentialing and Education (CCE), an affiliate of
NBCC, has recently announced a new credential as a Board Certified-TeleMental Health Provider (BC-TMH)
( This new credential replaces the former credential of
Distance Credentialed Counselor (DCC) and appears to address both ethical/legal and technological concerns,
as well as the distance therapeutic relationship. This CCE series focuses on a variety of issues regarding
telemental health including: orientation and presentation skills, compliance with HIPAA regulations,
procedures for crises, technological considerations, collaborative services across settings, and the best practice
elements of creating distance therapeutic relationships, which can enhance the important factor of performance
expectancy (Venkatesh et al., 2016).
Meanwhile, the therapeutic relationship is consistently found as the single key predictor of successful
counseling outcomes across theoretical orientations (Berger, 2017; Safran, Muran, & Proskurov, 2009). Since
some theories prioritize the therapeutic relationship more than others, the researchers hypothesized that
counselors having a person-centered approach, which depends greatly on the therapeutic relationship as their
primary theoretical orientation, would differ in their perception of DC from counselors having
cognitive/cognitive behavioral approach as their primary theoretical orientation. This formulation was based on
the idea that developing a therapeutic relationship in DC is difficult as compared to traditional F2F
counseling and thus may not appeal as much to counselors who claimed a person-centered model. However,
there was no significant difference in the current study between these two groups in their perception of
effectiveness of DC and comfort level in offering DC.
One possible explanation for this finding may be that despite some similarities with F2F counseling,
according to Cipolletta, Frassoni, and Faccio (2018), the DC modality has specific relational elements, many
of which are unique to DC and not dependent on a counselor’s theoretical orientation. In their study,
Cipolletta et al. (2018) analyzed the transcripts of the first three counseling sessions of five clients that were
conducted via video conferencing. The following particular elements that characterize online interactions
emerged: 1) early conceptualization of the problem by clients, 2) supportive management of technology, 3)
understanding the motivation to use the DC modality, 4) explaining DC therapeutic rules to clients, 5) instant
exchange of files, 6) multimedia repair, 7) reasonable inter-session availability of the counselor, 8) use of
extra-session materials, 9) handling interruption related to loss of communication, 10) utilizing both the
counselor’s and the client’s environment to strengthen the relationship, 11) integrating F2F sessions with DC,
and 12) discussing environmental privacy. The findings of Cipolletta et al. (2018) were quite similar to those
of Mohr et al. (2010) who used behavioral interventions in their work with more than 600 clients and found
that multiple elements other than a counselor’s theoretical framework influence the effectiveness and
satisfaction with a DC therapeutic relationship.
Another key relational feature of DC is the disinhibition effect, which refers to clients’ perceived
anonymity in online mediums that causes clients to be more expressive and open with the counselor (Suler,
2004). However, in the present study, almost half of the participants were not sure if DC promotes
disinhibition, and only 24% thought that DC promotes disinhibition among clients. One possible explanation
may be that in recent years the ACA has set clear guidelines for how clients should be recruited, identified,
and assessed in DC. The ACA guidelines under section H-3 of the Code of Ethics (ACA, 2014) emphasize
that “counselors who engage in the use of Distance Counseling, technology, and/ or social media to interact
with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process”
(p. 18). By establishing the clear identity and location of the client, these guidelines may have affected
counselors’ perceptions of the disinhibition effect in DC, since they know the client’s name and specific
locale. Despite the above-mentioned guidelines, DC still offers relative anonymity to clients which facilitates
self-disclosure and reduces social stigma that some clients experience when seeking mental health services,
since clients in most cases are in the personal space of their choice. Also, the researchers of this study
believe that videoconferencing advancements seem to approximate F2F counseling more than ever, thus
facilitating therapeutic relationships in DC.
When examining other factors that may affect perceptions of DC, the researchers also considered counselor
experience. A number of studies have demonstrated that younger people are more comfortable and open to
using technology in their everyday life compared to older people (Anderson & Perrin, 2017). Hence, it was
expected that young counselors would be more open and comfortable with DC technology, since a
practitioner’s level of experience and age very often go together.
Yet, our study’s findings suggest that participants with more experience were more open and comfortable
conducting DC when compared to young counselors with less experience as practitioners. One possible
explanation of this phenomenon is that while young counselors may be comfortable with using new
technology for delivery of DC services, using finely honed clinical skills to develop a strong therapeutic
alliance requires more clinical experience. Since DC is less about learning to use a new technology and more
about using the clinical skills in a new medium by which to deliver counseling services, experienced
counselors indicated feeling more comfortable and open toward DC than young and less experienced
Meanwhile, the majority (61.14%) of the study participants still perceive DC as a secondary mode of
delivering counseling services and consider DC effective only as an adjunct to face-to-face counseling rather
than the sole means of offering counseling services. In addition, adopting an alternative medium may be
daunting, since there appears to be a perceived fear of being judged negatively by fellow professionals that
may result in weakening of one’s professional identity. The researchers wondered if this fear might further
keep counselors from adopting DC. However, a majority (61%) of participants do not think that DC would
weaken their professional identity. One possible interpretation is that offering DC requires not only the
knowledge and understanding of online relational dynamics but also a solid understanding of core counseling
skills. Therefore, counselors offering DC do not perceive DC as weakening their professional identity, since
they are confident in their abilities.
With the COVID-19 crisis and accompanying shelter-in-place and self-distancing guidelines, counselors are
forced to engage in telemental health delivery rather than traditional F2F sessions with their clients.
According to Taylor et al. (2020), telemental health seems to be considered as part of routine care rather than
a special COVID-19 occurrence. With such societal expectations emerging for mental health services, future
research must investigate a variety of barriers that previously constrained the use of telemental health.
Limitations, Implications, and Future Research
The present study is not without its limitations. A key limitation is small sample size and low response
rate. The reason for low response rate can be attributed to the following factors: 1) while the NBCC
distributed the survey to approx. 10% of their total NCC certificate holders (Approx. 63000), there is no
guarantee that everyone received the email invitation. Response rate in online surveys depends on the quality
of the email list (Monroe & Adams, 2012). Counselors frequently change their email address, and there is no
way to ascertain the exact number of counselors who received the email invitation. 2) The email request was
sent only once by NBCC. Sending a second and third reminder would have certainly increased the response
rate (Monroe & Adams, 2012; Van Mol, 2017). 3) No incentives were offered to the participants, which
might also have influenced the response rate (Cook et al., 2016). 4). Research suggests that in online surveys,
a personalized email invitation increases response rate (Monroe & Adams, 2012). Since the survey was
distributed by NBCC, which did not have the required technology and work force to send a personalized
email invitation, it would have certainly influenced the response rate. 5) The timing of the survey might also
have influenced the response rate. The survey was sent during summer when people generally go on vacation.
Further, when investigating perceptions, a mixed methods research design that includes both quantitative and
qualitative data may offer more insights into how counselors perceive DC.
The findings of the present study have implications for the organizations that offer trainings/workshops/
certifications in DC. As the present study suggested, training programs should primarily address the two key
facets of DC that seem to be most worrisome for practitioners: (1) ethical and legal safeguards that protect
clients and counselors, and (2) factors and best practices for therapeutic interventions that result in positive
client outcomes. Also, a major focus currently relative to DC concerns developing a therapeutic alliance in
an online medium as well as identifying other factors that may lead to positive client change. Thus, counselor
educators should be careful about incorporating DC into their programs especially at the master’s level. That
is, early introduction of DC with counselors-in-training without the development of core counseling skills
required in F2F counseling may end up being a disservice (Anthony, 2015; Menon & Rubin, 2011).
Counselors-in-training who are uncomfortable sitting with clients in person may find DC attractive. Therefore,
while introduction of DC related to the ethical and legal responsibilities can complement considerations
outlined for F2F counseling, practice and skills in DC should be done only after counselors-in-training
develop the solid core counseling skills in F2F counseling and the personal growth necessary for emotional
Another consideration for universities is to locate internship sites that support and carefully supervise DC.
As the present study demonstrates, the practice of DC is very limited on the systemic level, thus finding an
internship site that offers DC experiences to counselors-in-training may be difficult. However, being creative,
counseling programs can consider partnering with their own university counseling center to offer DC to
students enrolled in distance learning courses unable to commute to the main campus for mental health
counseling. Moreover, with the exponentially increasing number of distance students, universities must find
means to provide needed services. This arrangement will not only support students enrolled in distance
learning programs but also offer a learning opportunity for advanced counselors-in-training to gain supervised
experience of DC. Another implication of the present study relates to policy makers and government funding
agencies. DC can be a viable solution to offer counseling services to remote areas, linguistically isolated
communities, and other underserved populations. Therefore, policy makers and funding agencies can play a
role in integrating DC services at institutional levels to reach numerous populations.
Pre-COVID-19 empirical research on DC primarily consists of outcome studies with clients and counselors
whose primary focus is on the success of DC. Now, in light of the increased use of DC during the
COVID-19 pandemic, building an evidence base as to the viability and effectiveness of DC is a critical need
for the profession and the safety of clients. Very few studies have explored relational elements of the DC
therapeutic relationship; thus, future research should focus on the therapeutic process and relational elements
involved in DC. Examining the changing role of the counselor, unique therapeutic interventions for online
work, effective theoretical frameworks, and factors that may support client change are also recommended for
future research endeavors.
Taking an expansive view, future research must support governing bodies and professional organizations
that address challenges involving “supervisory, reimbursement, and regulatory frameworks” (Taylor et al.,
2020, p. 1156). Integrating telemental health into routine care calls for research investigations and changes of
system requirements and policies are fundamental to facilitate uncomplicated worldwide delivery with special
attention to health disparities and barriers that exist for oppressed groups. Most visionary is future research
into practices that take advantage of the exponentially changing technologies that may provide a variety of
innovative new services.
Agency for Healthcare Research and Quality, the Department of Health & Human Services. (2009). HCUP
Facts and Figures: Statistics on Hospital-based Care in the United States, 2009. Retrieved January
16, 2015, from
American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.
American Counseling Association. (2020). Counseling in a time of COVID-19. Retrieved from
Anderson, M., & Perrin, A. (2017). Barriers to adoption and attitudes towards technology. Retrieved from
Pew Research Center.
Anthony, K. (2013). Training therapists to work effectively online and offline within digital culture. British
Journal of Guidance & Counseling, 43(1), 36-42. doi:10.1080/03069885.2014.924617
Baca, C. T., Alverson, D. C., Manuel, J., K., & Blackwell, G., L. (2007). Telecounseling in rural areas for
alcohol problems. Alcoholism Treatment Quarterly, 25(4), 31-45. doi:10.1300/J020v255n04_03
Balick, A. (2018). How to think about psychotherapy in a digital context. In P. Weitz (Ed.), Psychotherapy
2.0: Where psychotherapy and technology meet (pp. 21-28). Routledge.
Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The empirical evidence for
telemedicine interventions in mental disorders. Telemedicine and e-Health, 22(2), 87-114. doi:
Berger, T. (2017). The therapeutic alliance in internet interventions: A narrative review and suggestions for
future research, Psychotherapy Research, 27(5), 511-524, doi:10.1080/10503307.2015.1119908
Brown, S. (2020). How are counselors coping with Covid-19? Therapy Today, 31(4), 16-20.
Burkhalter, E. (2020). We weren’t ready for mental, physical toll of COVID-19, experts say — and it’s not
over yet. Retrieved from
Carlisle, R., M., Hays, D., G., Pribesh, S. L., & Wood, C. T. (2017). Educational technology and distance
supervision in counselor education. Counselor Education & Supervision, 56(1), 33-49. doi:10.1002/
Center for Credentialing and Education (CCE) (2019). Board Certified-TeleMental Health Provider
(BC-TMH). Retrieved from (
Cipolletta, S., Frassoni, E., & Faccio, E. (2018). Construing a therapeutic relationship online: An analysis
of videoconference sessions. Clinical Psychologist, 22(2), 220-229. doi:10.1111/cp.12117
Council for Accreditation of Counseling and Related Educational Programs (CACREP). (2016). 2016
CACREP Standards. Alexandria, VA: Author.
Cook, D. A., Wittich, C. M., Daniels, W. L., West, C. P., Harris, A. M., & Beebe, T. J. (2016). Incentive
and reminder strategies to improve response rate for internet-based physician surveys: A randomized
experiment. Journal of Medical Internet Research, 18(9), e244. doi:10.2196/jmir.6318
Deane, F. P., Gonsalvez, C., Blackman, R., Saffioti, D., & Andresen, R. (2015). Issues in the development
of e‐supervision in professional psychology: A review. Australian Psychologist, 50(3), 241-247.
Federal Emergency Management Agency. (2020). COVID-19 emergency declaration.
Finn, J. (2002). MSW student perceptions of the efficacy and ethics of internet-based therapy. Journal of
Social Work Education, 38(3), 403-420. doi:10.1080/10437797.2002.10779107
Garde, E. L., & Manning, V., & Lubman, D. I. (2017). Characteristics of clients currently accessing a
national online alcohol and drug counselling service. Australasian Psychiatry, 25(3), 250-253.
Gournaris, M. J. (2009). Preparation for the delivery of telemental health services with individuals who are
deaf: Informed consent and provider procedure guidelines. Journal of the American Deafness &
Rehabilitation Association (JADARA), 43(1), 34-51.
Health Information Technology for Economic and Clinical Health Act, Pub. L. No. 111-5 (2009). Retrieved
Health Insurance Portability and Accountability Act, Pub. L. No. 104-191, 110 Stat. 1936 (1996). Retrieved
HIPAA Final Omnibus Rule, 45 C.F.R. §§ 160-164 (2013). Retrieved from http://www.hipaasurvivalguide.
HIPAA Privacy Rule, 45 C.F.R. §§ 160-164 (2003). Retrieved from
HIPAA Security Rule, 45 C.F.R. §§ 160-164 (2003). Retrieved from
Holland, D. C. (2016). Counselors’ Perceived Preparedness for Technology-Mediated Distance Counseling:
A Phenomenological Examination (Doctoral dissertation). Counseling and Human Services, Old
Dominion University. doi:10.25777/9m8h-gn42
Insel, T. R. (2008). Assessing the Economic Costs of Serious Mental Illness. The American Journal of
Psychiatry, 165(6), 663-665. doi:10.1176/appi.ajp.2008.08030366
Jang, Y., Chiriboga, D. A., Molinari, V., Roh, S., Park, Y., Kwon, S., & Cha, H. (2013). Telecounseling
for the linguistically isolated: A pilot study with older Korean immigrants. The Gerontologist, 54(2),
290-296. doi:10.1093/geront/gns196
Johnson, R., Christensen, L. (2016). Educational research: Quantitative, qualitative and mixed approaches.
Sage Publications.
Lewis, J., Coursol, D., Bremer, K. L. & Komarenko, O. (2015). Alienation among college students and
attitudes toward Face-to-Face and online counseling: Implications for student learning. Journal of
Cognitive Education and Psychology, 14, 28-37. doi:10.1891/1945-8959.14.1.28
Litam, S. D. A. (2020). “Take your Kung-Flu back to Wuhan”: Counseling Asians, Asian-Americans, and
Pacific Islanders with race-cased trauma related to COVID-19. The Professional Counselor, 10(2),
144-156. doi:10.15241/sdal.10.2144
McAdams, C. R., III, & Wyatt, K. L. (2010). The regulation of technology-assisted distance counseling and
supervision in the United States: An analysis of current extent, trends and implications. Counselor
Education & Supervision, 49(3), 179-192. doi:10.1002/j.1556-6978.2010.tb00097.x
McCord, C. E., Elliott, T. R., Wendel, M., Brossart, D. F., Cano, M. A., Gonzalez, G. E., & Burdine, J.
(2011). Community capacity and teleconference counseling in rural Texas. Professional Psychology,
Research, and Practice, 42(6), 521-527. doi:10.1037/a0025296
Menon, G. M., & Rubin, M. (2011). A Survey of online practitioners: Implications for education and
practice. Journal of Technology in Human Services, 29(2), 133-141. doi:10.1080/15228835.2011.595262.
Mohr, D. C., Siddique, J., Ho, J., Duffecy, J., Jin, L., & Fokuo, J. K. (2010). Interest in behavioral and
psychological treatments delivered face-to-face, by telephone, and by internet. Annals of Behavioral
Medicine, 40(1), 89-98. doi: 10.1007/s12160-010-9203-7
Monroe, M. C., & Adams, D. C. (2012). Increasing response rates to web-based surveys. Journal of
Extension, 50(6), 1-6.
National Alliance on Mental Illness (NAMI). Mental Health by the Numbers. Available at (last accessed September 18, 2018)
National Board for Certified Counselors (NBCC). (2016). National board for certified counselors (NBCC)
policy regarding the provision for distance professional services. Retrieved from
Rauch, S. A., Simon, N. M., & Rothbaum, B. O. (2020). Rising tide: Responding to the mental health
impact of the COVID-19 pandemic. Depression and Anxiety, 37(6), 505-509. doi:10.1002/da.23058
Richards, D., & Vigan, N. (2013). Online counseling: A narrative and critical review of the literature.
Journal of Clinical Psychology, 69(9), 994-1011. doi:10.1002/jclp.21974
Richards, P., Simpson, S., Bastiampillai, T., Pietrabissa, B., & Castelnuovo, G. (2018). The impact of
technology on therapeutic alliance and engagement in psychotherapy: The therapist’s perspective.
Clinical Psychologist, 22, 171-181. doi:10.1111/cp.12102
Rochlen, A. B., Beretvas, S. N., & Zack, J. S. (2004). The online and face-to-face counseling attitudes
scales: A validation study. Measurement and Evaluation in Counseling and Development, 37(2),
95-111. doi:10.1080/07481756.2004.11909753
Safran, J. D., Muran, J. C., & Proskurov, B. (2009). Alliance, negotiation, and rupture resolution. In R.
Levy & J. Ablon (Eds.), Handbook of evidence-based psychodynamic psychotherapy (pp. 201-225).
Humana Press.
Salkind, N. (2007). Class Interval. In N. J. Salkind (Ed), Encyclopedia of Measurement and Statistics (pp.
140-150). Sage Publication.
Straub, E. T. (2009). Understanding technology adoption: Theory and future directions for informal
learning. Review of educational research, 79(2), 625-649. doi:10.3102/0034654308325896
Stephan, S., Lever, N., Bernstein, L., Edwards, S., & Pruitt, D. (2016). Telemental health in schools.
Journal of Child and Adolescent Psychopharmacology, 26(3), 266-272. doi:10.1089/cap.2015.0019
Suler, J. (2004). The online disinhibition effect. CyberPsychology & Behavior, 7(3), 321-326. doi:10.189/
Taylor, C., Fitzsimmons-Craft, E., & Graham, A. (2020). Digital technology can revolutionize mental health
services delivery: The COVID‐19 crisis as a catalyst for change. International Journal of Eating
Received February 6, 2020
Revision received June 16, 2020
Accepted August 5, 2020
Disorders, 53(7), 1155-1157. doi:10.1002/eat.23300
US Census Bureau (2017). Commuting Times, Median Rents and Language other than English Use in the
Home on the Rise. Available at (last
accessed September 18, 2018)
Van Mol, C. (2017). Improving web survey efficiency: The impact of an extra reminder and reminder
content on web survey response. International Journal of Social Research Methodology, 20(4),
317-327. doi:10.1080/13645579.2016.1185255
Venkatesh, V., Thong, J. Y. L., & Xu, X. (2016). Unified theory of acceptance and use of technology: A
synthesis and the road ahead. Journal of the Association of Information Systems, 17(5), 328-376.
Vincent, C., Barnett, M., Killpack, L., Sehgal, A., & Swinden, P. (2017). Advancing telecommunication
technology and its impact on psychotherapy in private practice: Telecommunication technology and
psychotherapy. British Journal of Psychotherapy. 33(1), 63-76. doi:10.1111/bjp.12267.
White, A. I. R. (2020). The art of medicine: Historical linkages: Economic threat, economic risk, and
xenophobia. The Lancet, 395, 1250-1251.
World Health Organization, World Health Report. (2017). Mental disorders affect one in four people.
Retrieved from Copyright of Journal of Asia Pacific Counseling is the property of Korean Counseling Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.


Get professional assignment help cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason may is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Our essay writers are graduates with diplomas, bachelor, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college diploma. When assigning your order, we match the paper subject with the area of specialization of the writer.

Why choose our academic writing service?

  • Plagiarism free papers
  • Timely delivery
  • Any deadline
  • Skilled, Experienced Native English Writers
  • Subject-relevant academic writer
  • Adherence to paper instructions
  • Ability to tackle bulk assignments
  • Reasonable prices
  • 24/7 Customer Support
  • Get superb grades consistently







Get Professional Assignment Help Cheaply

fast coursework help

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason may is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Our essay writers are graduates with diplomas, bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college diploma. When assigning your order, we match the paper subject with the area of specialization of the writer.

Why Choose Our Academic Writing Service?

  • Plagiarism free papers
  • Timely delivery
  • Any deadline
  • Skilled, Experienced Native English Writers
  • Subject-relevant academic writer
  • Adherence to paper instructions
  • Ability to tackle bulk assignments
  • Reasonable prices
  • 24/7 Customer Support
  • Get superb grades consistently

How It Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.


order custom essay paper
Order a unique copy of this paper
(550 words)

Approximate price: $22

Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

We value our customers and so we ensure that what we do is 100% original..
With us you are guaranteed of quality work done by our qualified experts.Your information and everything that you do with us is kept completely confidential.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

The Product ordered is guaranteed to be original. Orders are checked by the most advanced anti-plagiarism software in the market to assure that the Product is 100% original. The Company has a zero tolerance policy for plagiarism.

Read more

Free-revision policy

The Free Revision policy is a courtesy service that the Company provides to help ensure Customer’s total satisfaction with the completed Order. To receive free revision the Company requires that the Customer provide the request within fourteen (14) days from the first completion date and within a period of thirty (30) days for dissertations.

Read more

Privacy policy

The Company is committed to protect the privacy of the Customer and it will never resell or share any of Customer’s personal information, including credit card data, with any third party. All the online transactions are processed through the secure and reliable online payment systems.

Read more

Fair-cooperation guarantee

By placing an order with us, you agree to the service we provide. We will endear to do all that it takes to deliver a comprehensive paper as per your requirements. We also count on your cooperation to ensure that we deliver on this mandate.

Read more

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
The price is based on these factors:
Academic level
Number of pages
error: Content is protected !!
Open chat
You can contact our live agent via WhatsApp! Via +1 817 953 0426

Feel free to ask questions, clarifications, or discounts available when placing an order.
  +1 (301) 710 0002           + 44 161 818 7126           [email protected]
  + 44 161 818 7126         [email protected]