Tag Archives: Technology

Rethinking the accessibility of digital mental health

By Chris Gamble July 11, 2022

If your social media algorithm is anything like mine, you’ve probably seen an increasing number of ads for companies offering teletherapy through an app-based platform. Maybe you’ve seen Olympians Michael Phelps and Simone Biles sharing their own mental health stories in TV commercials for a couple of these companies. Regardless of how you come across your information, one thing is clear: the digital mental health (DMH) era is here. 

A 2020 report by the World Innovation Summit for Health defined DMH as “the use of internet-connected devices and software for the promotion, prevention, assessment, treatment and management of mental health, either as stand-alone tools or integrated with traditional services.” This can include platforms that offer varying combinations of therapy, medication management and coaching and those that don’t provide therapy but instead rely more on self-guided, therapist-created content. There are even artificial intelligence chatbots and virtual reality-based mental health interventions, which are likely to expand with the buzz surrounding the metaverse (a digital world where people can interact with others in a computer-generated environment). Throw in meditation apps, guided journals and mood trackers and the crowded bucket of DMH is surely overflowing. 

Although many of these platforms existed before 2020, the onset of the COVID-19 pandemic contributed to their expansion, as many poised themselves as solutions for filling the access gap made wider by the global health crisis.

I have worked as a licensed professional counselor in Washington, D.C., for six years, mostly with low-income, Black youth and families in schools, community-based agencies and currently a children’s advocacy center. So, the constraints of a fragmented public mental health system, long waitlists and a lack of culturally relevant services have been at the forefront of my mind for quite some time now. I regularly see how inadequate availability of quality mental health services can compound trauma and further complicate the healing process. As a Black counselor, I am protective of the populations I serve and vigilant toward any sweeping claims of answers to long-standing problems. Thus, I keep my clients and other marginalized groups in mind when approaching the larger question of how access can be improved through the medium of digital technology. In this article, my aim is not to endorse or dissuade from any specific DMH company but to examine the field of DMH and its shortcomings in improving access for marginalized populations.

Accessible for whom?

In the public discourse around mental health, access is often limited to definitions of ease and convenience. People often assume that removing the burden of internet searches and transportation needs and increasing privacy protection by being in one’s home are key to making mental health care more accessible. In this sense, app-based therapy seems to be a good fit. At least for some. 

The COVID-19 pandemic and the need for schools to switch to remote learning exposed the digital divide in the United States. I personally witnessed similar issues in my community mental health work at the time. For many low-income, Black households, a parent’s smartphone may be the only internet-accessible device they have, or their internet service may not be adequate to sustain full therapy sessions. Add to that the higher likelihood of multigenerational households within certain racial groups, and suddenly one’s home is not so private. Even more barriers exist for disabled people and those with no or limited English proficiency. Considering the amount of work it takes to develop an app, it is concerning that these issues are so often overlooked. If the innovations spurred by DMH continue to ignore cultural differences and structural disparities, the contradictions with goals of increased access will only become more noticeable.

For apps offering self-guided content and therapist-created videos or live discussions, we have to wonder about the cultural relevance of this material. A quick look at popular media and creative content-based platforms supports the suspicion that certain groups could be catered to over others. This is an inherent vulnerability in the “attention economy.” In the battle for our eyes and ears between social media, podcasts, TV and movie streaming, music streaming, and video games, DMH platforms are poised to join the arena. Adding self-guided and therapist-produced content to attract users may seem antithetical to attending to their mental health needs, but when subscriptions and engagement drive a company’s value, what safeguards keep this from happening? 

Given these market-driven incentives, it is imperative that marginalized communities are able to find content that reflects their lived experiences. And DMH companies will need to demonstrate a responsibility to these communities and not stray from public accountability. Suppose a company signs a contract with a popular therapist with a large social media following to produce informational and educational videos for their app. Over time, perhaps users begin to notice cultural bias in this therapist’s mental health tips, or the therapist becomes the subject of a scandal involving discriminatory behavior or public commentary. Would users again be left to trust a tech company to make moral decisions over monetary ones? And how a company responds to such an issue could illustrate whether the well-being of marginalized groups is a priority. Counselors would be wise to take notice of this intersection between the mental health field and broader societal trends in order to understand the varying effects on different groups.

Impacts on the mental health workforce

DMH is also positioned as a solution to fill the gaps in the mental health workforce shortage by using technology to bring clinicians to underserved areas. Let’s first look at what might draw counselors to working for DMH companies. One potential benefit is that therapy apps could handle the business aspects of independent practice, such as insurance paneling, client referrals, scheduling and billing. Taking these responsibilities off the counselor’s plate can make the increased use of these platforms attractive to the field, especially for those who prefer working from home or other remote locations. 

Before looking at how this affects access, we can’t disregard possible downsides for DMH workers. Because many DMH companies are startups, they tend to rely on contract work to facilitate business growth. There have even been instances of changing salaried, benefit-receiving employees into contractors, leaving therapists in precarious financial positions. Other practices such as being paid per the number of words texted to clients call into question whether a counselor would be incentivized to provide care for clinical reasons or personal financial ones. Everyone’s finances and living conditions are different, but these parallels to the gig economy should draw caution. On a broader scale, accepting pay that doesn’t match the labor, along with following business practices that are possibly out of line with the ACA Code of Ethics, can influence how the counseling profession is perceived.


In the presence of a DMH industry looking for more workers, the previously mentioned problem of the digital divide becomes heightened. As more mental health professionals transition to DMH platforms, fewer are left to work with those who can’t access them. This trend could accelerate even further if we consider the recent progress with establishing the Counseling Compact. I and many others have been eagerly awaiting this development, but I also wonder: Could expanding our reach through the Counseling Compact amid increased DMH options end up siphoning the counseling workforce away from those most in need within our proximity? For instance, if I took advantage of licensure portability in the future and was able to practice in several different states, my caseload would likely be easier to fill and maintain, but marginalized D.C. residents would suddenly find my services to be less available. If licensure portability were implemented on a larger scale, counselors may cast a net so wide that those closest to them end up falling through the holes. 

What to do?

Now that the possible effects of DMH on marginalized groups and the counseling profession have been laid out, the question remains: What can we do about it? Here are some ideas to consider.

1) Get to know the research. With billions of dollars being invested into DMH, the industry does not seem to be going anywhere anytime soon. Counselors need to pay attention to the research and marketing around these products in order to understand what is being prioritized. Determining whether apps are equally or more effective than in-person therapy will be an ongoing project, with outcome-based studies being conducted both internally by DMH companies and by independent parties. It is important for counselors to know what constitutes a quality study design and how companies represent their evidence-based claims. Sample size, outcome measures and the time range of studies are all things to keep in mind. A glaring omission I’ve noticed within much of the DMH research is the lack of racially diverse participants and the fact that sometimes racial demographics are not collected at all. To position DMH as improving access without even looking into possible differential outcomes for people of various identities could actually result in deepening preexisting health inequities. I encourage counselors to take the time to browse the websites of different DMH companies to see if the research studies they reference collect comprehensive demographic data, and then ask themselves what this means in the context of who the app is marketed to.

2) Find the problem-solvers. There are growing pockets of research focused on these problems and their potential solutions. In a 2021 article published in JMIR Mental Health, Elsa Friis-Healy and colleagues developed five recommendations for how the DMH industry can design products that increase utility for racially and ethnically minoritized groups. There are also implementation studies such as Samantha Connolly and colleagues’ 2020 narrative review, published in the Journal of Technology in Behavioral Science, which examined factors for successful implementation of mental health apps, from their design to their uptake and sustained usage. Counselors can use research such as this to understand what elements make for a quality app, thereby empowering us to make informed decisions around their use. Additionally, we can get involved in developing ways to advocate for these solutions or propose our own, whether through national organizations already doing this work or by creating local networks attuned to local needs.

3) Know your clients. Most importantly, counselors who work with marginalized populations need to recognize all the ways their clients can be left behind by an increasingly tech-focused field. By leveraging what we know about the social contexts we work in, we can become better equipped to dismantle barriers to DMH or identify more appropriate solutions to access needs.


The necessary uptake of teletherapy onset by the pandemic lockdowns seemed to open a door to solving the long-recognized problems associated with accessing mental health services. If the heads of DMH companies are the main force behind this change, however, there may end up being more hurdles than expected. This article explores some of the mismatches between DMH’s promises and the needs of communities most affected by the inaccessibility of mental health services. By incorporating the conversation of technology and access into the counseling profession’s efforts to practice with cultural intentionality, we can ensure the best interests of all clients are maintained amid the rapid changes occurring in our society.



Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is committed to showcasing the power within marginalized communities. Contact him at cmgamble92@gmail.com and follow him on Instagram @chris_thecounselor.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the book: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Compiled by Bethany Bray January 11, 2022

The COVID-19 pandemic exponentially increased counselors’ use of distance counseling and moved telebehavioral health from a lesser-used, avant-garde approach to a mainstream practice within the counseling profession, say Daniel G. Williamson and Jennifer Nivin Williamson, co-editors of the ACA-published book Distance Counseling and Supervision: A Guide for Mental Health Clinicians. There are both pros and cons that come with this development, but, most of all it affords an opportunity to refine and implement best practices for distance counseling.

“The COVID-19 pandemic quarantine will serve as a watershed event that ushered in the use of telehealth … It is remarkable how our profession rose to the occasion during this crisis,” say the Williamsons, who are both core faculty with Capella University and co-founders of PAX Consulting and Counseling in Texas. “It is an exciting new frontier for the field. The challenge in the ethical and legal aspect is that the technology and oversight are a moving target, and it is challenging for counselors to keep pace with the changing rules and regulations.”


Q+A: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Responses co-written by book co-authors Daniel G. Williamson, Jennifer Nivin Williamson, Marty Jencius, Susan Belangee, Stephanie Marder, Jeff Parsons, Angela McDonald, Jason Martin and Mykia Griffith.


From your perspective, what are some “pros” and “cons” that have come from counselor’s increased use of telebehavioral health?

Jason Martin: The clearest and greatest “pro” is definitely the increased availability of counseling that telebehavioral health brings. If someone has access to the internet, they can now access counseling services. People who live in more remote areas, have transportation issues, or health issues can now access counseling. Because of the hesitance some clients have about seeing a counselor within the community where they live and work, they now may access counseling services in other communities, thereby providing an additional layer of privacy within their home community. Above all else, these “pros” provide unprecedented access to care, and that impact cannot be overstated.

The “cons” are a bit more complicated. First, while the technology used for telebehavioral health continues to become more user-friendly, there are still many people who may struggle with the technology necessary to make it work. Some may not even have the devices needed to access telebehavioral health. Second, it also may bring insecurity to the counseling environment. No longer may the counselor be able to restrict who may enter the therapeutic setting because the client’s environment may not be secure or even private. Third, some clients and counselors may experience interacting through a computer screen to be less intimate and personal than meeting face-to-face, thereby affecting therapeutic rapport, and increasing possible distractions.


The circumstances of the COVID-19 pandemic have led to some clients never meeting their counselor in person. What are the nuances that counselors should be aware of and mindful of when treating a client 100% virtually?

Marty Jencius and Stephanie Marder: Counselors should be aware that a virtual presence is possible even when meeting with clients using telebehavioral health. Like many tools available for use by counselors, how a client’s outcome is impacted depends on how the counselor wields the tool. Clients can form a solid therapeutic relationship with a counselor online or over the phone. It may not be a counselor’s preferred way of working, but in response to the pandemic, counselors have had to embrace a change leading to a new way to provide client service.

Some insights gained from practicing online throughout the pandemic:

  • Invest in a good microphone and earbuds so your client can hear you clearly and you can hear your client without distraction from outside noise.
  • Consider your space and have good lighting when conducting video sessions. It is just as vital for the client to see you as for you to see the client.
  • Have a plan for when technology is not operating properly.
  • Pay attention to observable cues the client could potentially misinterpret or misread when meeting virtually (e.g., thinking the counselor is tearing up when they are scratching their eye).
  • Create specific guidelines to prevent clients from being distracted or multitasking during appointments (running errands, driving, etc.)
  • Try to wait an additional one or two seconds after you think a client has stopped speaking to avoid talking over one another due to lag.
  • Working with younger children can still be a challenge; however, adolescents can often adapt to telehealth quickly.
  • Do not automatically think older clients would be averse to using technology for distance counseling. Like many of us, they have developed a new comfort with video chat.

We encourage practicing counselors to seek continuing education opportunities as telebehavioral health counseling evolves.


What would you want counselors to know about navigating virtual sessions with a client who is not alone or in a private area (i.e. children are in the background, a spouse or parent is in the next room, or a client is at their workplace on lunch break, etc.)?

Daniel and Jennifer Williamson: Confidentiality is an ongoing concern in any counseling relationship, and one of the largest changes in the shift to telehealth is that the counselor has lost the ability to control many aspects of the clinical space. Educating clients about what constitutes an appropriate clinical space and how to be creative in finding appropriate meeting places is an important and ongoing conversation. We define being in a clinical space as being alone in a room with a door, the door is closed, and a “sound machine” is on. Clients can be creative in finding ways to create their own “clinical spaces.” Many have met in walk-in closets, parked cars, offices, bathrooms, and garages.

It is helpful when counselors remain aware of nonverbal shifts in attentions that indicate someone has entered the clinical space. It is important for the counselor to continue to explore informed consent surrounding the importance of clients protecting their own privacy. The ability to create a clinical space should be considered during the initial evaluation to identify if the client is suitable for this modality.

It might be prudent to establish a “signal” between client and counselor in the case that someone enters the client’s clinical space. A client might touch their nose or ear to indicate that someone has entered the private space and it is no longer safe to talk. Virtual services that constantly monitor for voice commands such as Siri, Alexa, Google, bluetooth connected devices, or gaming programs including Discord should also be considered, and clients should be informed about these potential breaches.


In the book, you mention that distance counseling will not be a best fit for some clients and that counselors must assess clients to determine whether it’s an appropriate medium. What are some “red flags” counselors should listen for that might indicate telebehavioral health is not a good fit for a client?

Daniel and Jennifer Williamson: While each client should be assessed individually, several considerations seem to signal “red flags” for the use of telehealth. Safety is a number one priority, and counselors must assess if the client is connecting from a place that is physically and emotionally safe. Clients in domestic violence situations or who are a harm to self or others might not be a good fit for the telehealth option. Emotional stability, trauma history, impulsivity, level of care, and ability to self-regulate are also considerations when evaluating clients for suitability.

It is equally important to explore the client’s comfort and skill using this type of technology. Many clients report enjoying the convenience and access that telehealth counseling provides while others miss the in-person human contact. Some clients have reported feeling stuck once the session had ended because they can’t leave the place where they explored difficult topics.

Counselors must assess the clients’ access and ability to navigate the hardware and software involved in telebehavioral health systems. Clients may not have stable internet access or updated technology for interfacing with the telehealth platform. Amber Hord-Helme created an assessment for evaluating clients for telehealth that is included in the book.


With vaccines widely available in many areas, some practitioners are opting to offer both virtual and in-person counseling. What would you want practitioners to know about managing this hybrid model?

Susan Belangee and Mykia Griffith: We are both currently doing the hybrid model, returning to the office one or more days a week and working virtually from the home office during the other time. One idea to manage this is to schedule clients who want to come in person on one day and any clients who wish to do sessions virtually can schedule on a different day. This can help to foster a rhythm to work depending on the day.

Is it best to have a client stick to one or the other (virtual or in-person)?
Allowing room for change allows for flexibility as well as opportunity for growth within the therapeutic relationship/alliance. Clients report that they appreciate the flexibility even if they tend to choose one option most of the time. Knowing that they don’t have to miss a session if they are unable to come into the office as planned seems to reduce stress. Life happens for everyone, and having the ability to maintain appointments through telebehavioral health will allow for continued work and continued progress.


During the pandemic, state regulatory boards and insurance companies broadened their acceptance of distance counseling (and telehealth as a whole). Where do things stand now – what would you want counselors to know? And/or where should they be looking for the latest updates and changes regarding insurance coverage and regulation of telebehavioral health?

Jeff Parsons and Angela McDonald: Prior to the pandemic, many state boards and insurance companies were ambivalent towards distance counseling. While some states had clear regulations around the practice of distance counseling, others did not. The pandemic spurred change in several areas. In an immediate sense, it allowed for the provision of distance counseling in most states; including registries that allowed for services across state lines. It also loosened restrictions, allowing for the use of technologies that would not traditionally be acceptable (e.g., phone, non-HIPAA software). In many cases, it opened up billing opportunities for distance counseling in states where this may not have been an option in the past. Finally, it encouraged states to actively engage distance counseling as a legitimate delivery model for counselors.

The long-term impact of COVID-19 on distance counseling will vary by state. Some provisions, such as interstate registries and loosened restrictions around phone/non-HIPAA compliant software, will likely be retracted once the state of emergency is lifted. However, it is likely that many states will (if they haven’t already) enact regulation around the provision of distance counseling, formalizing its place in our profession.

Counselors should continue to closely monitor their state(s) regulations and board activities for updates about distance counseling and supervision. Many states issued temporary changes that impacted healthcare practice during COVID-19 state of emergency declarations. As the emergency declarations expire and are lifted, boards will need to issue updated guidance to the public so that counselors can be certain that they are acting in accordance with the regulations. In some cases, boards may issue new interpretations of regulations that protect the public and attend to the expanded capabilities of safe practice in telehealth, and, in other cases states may pass legislative changes that make more permanent changes such as adopting the interstate compact for counselors or adopting broad telehealth regulations that apply in a state to many different regulated professions, all healthcare professions, or all behavioral health professions.


From your perspective, where does telebehavioral health fit in the future of professional counseling?

Jeff Parsons: Distance counseling is here to stay. It opens opportunities for services to a wider range of clients, including those who may have transportation or health issues. It also holds a convenience factor that may be appealing to counselors looking for flexibility in their schedules. However, its insertion into the everyday lives of counselors and clients has limitations. Confidentiality issues and video conference burnout are common complaints from counselors who have focused their practices around distance counseling during the pandemic. Likewise, distance counseling may not be ideal for all clients.

Long-term I think we are going to see significant growth in the creation of counseling agencies that focus on distance counseling. However, for most agencies, I think it’s more likely that distance counseling will be used as a tool that adds flexibility to the provision of face-to-face services. For example, counselors might use distance counseling with clients that are on vacation or have transportation issues. However, as this future unfolds, I believe states will be in a much better position to support the provision of distance counseling, as they develop much needed regulatory processes.

Angela McDonald: I am really excited to see telebehavioral health expand access to care, support continuity of care for mobile counselors and clients, and for communication skills in the tele-space to be strongly incorporated into standards for counselor education and supervision.

Susan Belangee: I think telebehavioral health is here to stay as a valid and effective treatment delivery option. The pandemic forced the profession to utilize virtual counseling options and this likely changed professionals’ opinions about how effective they could be using this method of treatment delivery. It will necessitate the development and revision of best practice guidelines as technology continues to evolve.

Mykia Griffith: Although telebehavioral health will never be able to replace the experience that comes with in-person treatment/therapy, telebehavioral health is essential for the future of professional counseling. The virtual method was previously just an option that left room for uncertainty. At this point in time, telebehavioral health has had an incredibly quick shift into our everyday reality and may prove to be fundamental moving forward.

Marty Jencius and Stephanie Marder: Telebehavioral health fits into the future of counseling by extending a counselor’s ability to reach clients when certain barriers exist (e.g., health, distance, inclement weather, global pandemic) which may have previously prevented a client from obtaining services. COVID-19 forced the counseling profession to use telebehavioral health tools more widely than ever before.

We may not need to use telebehavioral health tools as profusely as during the pandemic. However, the benefits of these tools have been demonstrated and their usefulness to the profession has promoted a willingness among counselors to explore these tools as viable options for providing counseling services.




Distance Counseling and Supervision: A Guide for Mental Health Clinicians is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/store or by calling 800-298-2276.

Watch ACA President S. Kent Butler’s conversation with Jennifer Nivin Williamson and Daniel G. Williamson in a recent episode of the “Voice of Counseling” video podcast: https://youtu.be/jtIk5jJjv-0


Proceeds from book sales will benefit Uganda Counseling and Support Services, a nongovernmental organization that brings counseling and mental health services, education, clean water, farming and medical services to rural Uganda. The organization was established by one of the Williamson’s former graduate students, Ronald Kaluya.



Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Adapting evidence-based interventions for telehealth

By Nicole M. Arcuri Sanders October 29, 2021

The COVID-19 pandemic expedited the push to move mental health services to distance platforms. With providers ethically and legally bound to ensure their clients are not neglected or abandoned, state boards and federal regulators, such as the Health Insurance Portability and Accountability Act (HIPAA), relaxed their guidelines to support all providers in promptly changing how they were used to, and for many, even trained to provide counseling services. The Office for Civil Rights at the U.S. Department of Health and Human Services offered telehealth discretion during the COVID-19 nationwide public health emergency; penalties for noncompliance with the regulatory requirements under HIPAA would not be imposed against covered health care providers in connection with the good faith provision of telehealth during the pandemic. This enforcement discretion is still active with no known expiration date.

This increase in telehealth services has left many providers asking, “How do I actually implement my training of evidence-based interventions (e.g., empty chair, guided imagery) in an online setting?” Ethical and best practices recommend counselors implement evidence-based practices while being competent using the delivery platform (See Standards C.2. and H.1. of the ACA Code of Ethics).

Understanding how to implement counseling interventions using distance platforms is a necessity for counselors now. The purpose of this article is to support clinician understanding of how evidence-based practices can be creatively implemented with clients using a distance modality for a multitude of theoretical orientations.

I use the video conferencing platform Zoom for the technical instructions because it is a widely known and used platform and it offers HIPAA-compliant features. Zoom is accessible on a range of devices such as desktops, smartphones and tablets. Clinicians can use these techniques with other telehealth platforms (e.g., doxy.me, thera-LINK), but be aware that the terms and exact steps may change depending on the software used.

Before implementing creative approaches within the distance platform, clinicians should become comfortable and confident in the platform to ensure not only an easier implementation on the clinician’s end but also a clear and concise receipt of the counselor’s intention by the client. Furthermore, these guides do not replace the various ethical and legal implications a clinician must be cognizant of with their telehealth work. Some of these considerations include:

  • Being up to date on state board requirements (Standard H.1.b.)
  • Addressing issues related to the use of distance counseling in the informed consent (Standard H.2.)
  • Verifying the clients’ identity (Standard H.3.)
  • Ensuring electronic records follow security protocols (Standard H.5.)

When you feel comfortable with the ethical codes, legal standards, the modality of services and the platform, you are ready to begin to transform your talk therapy sessions.

Audio and video

There are ways to angle and position the camera when using Zoom to support both verbal and nonverbal exploration. I often ask my clients to move back from their screens so I can see their full body and gain a better sense of their nonverbals. Using wireless earbuds, such as AirPods, can also enhance this experience because not only can you hear when you are away from your screen but you can also freely dialogue while still being able to see the person in full screen. Additionally, you can use the closed caption button on the toolbar if either party prefers this accessibility option.

I’ve found this approach useful when implementing role plays with clients. Seeing the entire person on screen allows me to incorporate techniques I typically use in face-to-face sessions. With the empty chair technique, for example, clients can place an actual chair next to them, which gives clients the opportunity to imagine the person they are talking to is sitting beside them. The client could wear Bluetooth-enabled earphones with microphone capabilities (e.g., AirPods) and move their device, such as a laptop or smartphone, to show their whole body while doing this exercise.

If the client wants to have this conversation with the identified person for the empty chair technique via phone, I may ask the client to act out this scenario by taking their phone and sitting in the area where they would make the call. I would remain on screen and guide the client through this exercise. Clients have reported this approach makes them feel supported and empowered enough to take the next step and actually communicate with whom they desire. This exercise highlights some of the benefits associated with the telehealth platforms because I would not be able to have my client do this activity if we were meeting in a face-to-face setting.

Some clients struggle to imagine seeing this person and share that it’s intimidating for them to talk to an empty chair. So, I ask them to find a digital image of this person and share their screen during the video call, which allows them to talk directly to this image during the session. (Later in this article, I provide directions on how to share your screen to incorporate this intervention.) I can even remove myself from the screen, so the client simply sees themselves and the person with whom they are speaking.

Here are the technical instructions on using the audio and video functions on Zoom:

  • Audio: To turn your audio on and off, click on the microphone icon in toolbar located in the lower left side of the screen.
  • Video: To turn your video on and off, click on the video icon in the toolbar located in the lower left side of the screen.
  • Remove video participant from screen view: To hide your own video, you can either turn your video off by clicking the video icon on the toolbar or by clicking the three-dot icon on the right, upper corner of the video thumbnail and selecting “stop video.” To hide the video of other participants, click the three-dot icon on their video thumbnail and select “hide video participants.”

Virtual backgrounds and filters

The virtual background tool in Zoom can support a number of therapeutic interventions such as mindfulness exercises, progressive muscle relaxation and guided imagery. For instance, I have had clients change their background to a color of their choice and then I have mirrored them by doing the same. Clients have reported that this has limited distractions for them; they simply focus on what we are doing in the present moment because they can only see me and themselves on screen without any distractions in the background.

I have had other clients select a background that offers them a sense of security, lightness or relaxation while we practiced progressive muscle relaxation. I either used the same background as the client or hid my screen, so the client could simply focus on themselves in this exercise. Clients have told me the background provides them with a sense of comfort, which helped them focus on the somatic work.

Some clients have told me that they find guided imagery easier to do in person because they can feel the counselor’s presence in the room, but with distance counseling, they find themselves opening their eyes to check if the counselor is still there, which distracts from the experience. To overcome this obstacle, I often have clients select a virtual background that resembles the one they are imagining. Then if they open their eyes during the exercise, the virtual background can help them regain focus and take them back to their imagined experience.

To use a virtual background:

  1. Click the up arrow beside the video icon on the toolbar.
  2. Select “choose virtual background.”
  3. Choose from preselected options or select your own by uploading an image.

Another option is to have clients use a virtual filter, which blurs the background and makes the client the main focus. This works well for clients who may be timid about sharing their background or if the clinician wants to truly focus more on the client’s nonverbals.

I have found the virtual filter to be especially helpful when working with dance and movement techniques because the filter allows the clinician to better explore the client’s shape, which informs the counselor about the client’s limitations and helps with treatment planning. Clients with a broader movement repertoire, for instance, tend to be able to better cope due to their ability to have alternate means to deal with stress, whereas someone with rigid movement is known to have difficulty relating to others. Ultimately, movement elements provide counselors with insight concerning how a client behaves. In a studio, the clutter that often fills our homes and offices is not present to distract from the experience of movement.

To use a virtual filter:

  1. Click the up arrow beside the video icon on the toolbar.
  2. Select “choose virtual filter.”
  3. Choose from preselected options.

The preselection options include color variants, which can be a creative way to have the client either share their personality or perhaps a bit of their emotion/mood in regard to the day, session or topic being explored.

Screen sharing

Clinicians have the option to share their screen during a video call, and they can also give their clients access to share their screen. This tool can help support the client’s progression toward their goals, and as mentioned previously, sharing audio and video can support mindfulness and guided imagery interventions.

To share your screen:

  1. Click the share screen tool, which is an image of a box with an up arrow, located in the center of the toolbar at the bottom of the screen.
  2. Select the boxes “share computer sound” and “optimize screen sharing” (located in the lower left corner) for video clips.
  3. Ensure the file or video is open on your computer and select the application (e.g., YouTube Video, image) you want to share.
  4. Click “share” in the lower right corner.

Clinicians can use this feature to share psychoeducation services and information or to walk through something together with a client. In career counseling, for example, the practitioner could review jobs with clients or explore a client’s resume and help them identify and highlight strengths or gaps. Screen sharing can also support client accountability with homework assignments. Clients can share journals, charts, supplemental materials (e.g., ABC worksheets), drawings, research they completed, videos, pictures and narrative therapy letters. Counselors and clients can even use this tool to review treatment plans together.

This feature also allows clients and clinicians to collaborate through a virtual whiteboard. I often use a whiteboard when providing an individual check-in with scaling questions so clients can help me define the increments in the scale. This makes the scale more personalized and provides clients with a more active and engaged role in session. Clinicians can save the scale and reshare it in future sessions to modify the client’s feelings or progress or to highlight changes or patterns over time.

Counselors can use screen sharing to incorporate creative approaches with clients. This option allows both the clinician and client to explore a virtual sand tray together despite not being in the same room. (See onlinesandtray.com for a free, interactive sand tray you may want to use with your clients). They could also have the client create visual creations such as drawing on a whiteboard. Counselors can save and reuse these drawings or virtual sand trays at later times with clients if needed. These visual representations are also a nice way to document the session progress.

I often use these tools when doing exposure therapy remotely with clients. If a client has a fear of snakes, for example, then the counselor and client could first read about the fear- or anxiety-provoking item or experience. The counselor or client could share information related to snakes on the screen and together they could process the client’s feelings and reaction to the content. Next, the counselor could display pictures of snakes using the screen share tool. The gradual exposure and processing support a desensitization of the fear, and within time, the counselor could also introduce snake-related videos through screen sharing.

The counselor could even arrange for the client to take a virtual trip to the pet store or zoo. Eventually, the client could take a real-world excursion, and with the help of technology, the counselor could join them remotely. The client could take the device they use for telehealth services (e.g., tablet, smartphone) with them, and the counselor (who would remain on screen) would talk the client through the experience and process it with them in real time.


Telehealth can be much more than talk therapy via audio and video. I hope these guides help support my fellow clinicians in embracing the tools technology offers us to provide clients with enduring evidence-based approaches. Telehealth continues to rise in popularity both by counseling providers and with clients, so ensuring we as clinicians feel confident and competent in adapting our counseling interventions to align in a new platform will not only help us be successful in meeting our clients’ needs but also support the advancement of our profession.

Olga Strelnikova/Shutterstock.com


Nicole M. Arcuri Sanders is a board-certified telemental health counselor licensed in numerous states, an approved clinical supervisor, and a counselor educator and supervisor. She supervises students conducting distance counseling, and she has participated in research, presentation, publication, and course development for distance supervision and telemental health best practices. She can be contacted at Nicole.ArcuriSanders@capella.edu.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Internet gaming disorder: A real mental health issue on the rise in adolescents and young adults

By Doyle L. Raymer Jr. September 1, 2021

I grew up playing video games and have followed their technological evolution through the years. As such, video games have been a big part of my life and remain so to this day. These games are a source of entertainment and relaxation, and they can even provide opportunities for social interaction and connection. They can contribute to improving a person’s cognitive skills, creativity, communication and reflexes. Many people use them as a healthy coping mechanism to decompress.

On the flip side, there is growing concern about the potential of negative mental health consequences associated with playing video games. Some of these concerns include gaming addiction, negative coping mechanisms, unhealthy lifestyles, loneliness and isolation, depression and even suicidal ideation.

As someone who still plays video games, I have met an alarming number of individuals who struggle with these concerns. In many cases, these individuals have no support system or don’t know how (or when) to seek professional help. My concern is that many counseling professionals are unaware of the devastating impact that gaming can have on a person’s life — just as any form of addiction can.

The evolution of gaming

As a gamer myself, I have always been fascinated by what draws people to play games and how games can affect and influence individuals, from their thoughts to their worldviews to their social identity. It raises a question: How does playing a game give meaning to one’s life?

Playing a game is not simply playing a game. A lot is going on in the player’s mind as they are playing, which often presents a hidden meaning behind gaming interactions. As the world continues to develop and evolve around technology, video games will also continue to develop and evolve. Video game addiction has grown at alarming rates over the past few years, and this trend will likely continue. For this reason, concern is growing in the mental health community around video game addiction and the gaming population.

Video games have been around for decades, and as time has gone by, their popularity has increased exponentially, as has the size of the gaming community. As of 2020, it was estimated that more than 2 billion people around the world played video games. In the U.S. alone, 160 million Americans engage in online gaming daily, making the gaming industry worth over $90 billion.

Video games have developed into esports and are being more widely recognized as electronic but real sports. Both share many of the same principles of competition, including professional players, recognized teams and huge audiences of fans. Stadiums fill with fans as professional esports teams face off, competing for prizes in excess of $1 million. In 2017, more than 250 million online viewers watched popular online games such as League of Legends and Overwatch, generating $756 million in revenue that year (for more, see Internet Gaming Disorder: Theory, Assessment, Treatment and Prevention by Daniel L. King and Paul H. Delfabbro).

In addition, many video gamers make a living playing games by streaming to online platforms such as Twitch to thousands of viewers. As the video game industry has developed, it has gained popularity and will continue to do so.

Mental health impact

As the popularity of video games has grown and the community of players has expanded, certain negative consequences and mental health impacts have become increasingly evident. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), internet gaming disorder was included in the section recommending conditions for further research. Gaming disorder was defined in the 11th revision of the International Classification of Diseases (ICD-11) as a “pattern of gaming behavior (digital-gaming or video-gaming) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.”

Internet gaming disorder was not classified as a unique mental disorder in the DSM-5 due to a lack of research in the field and debates regarding the recognition of behavioral addiction, but I believe recognition could help millions in need. At the same time, the opposing side argues that inclusion of internet gaming disorder in the DSM-5 would only generate unnecessary concern and lead to a stigma around such behavior.

Meanwhile, gambling disorder is recognized by the DSM-5 as a form of behavioral addiction, and it shares many similar characteristics with gaming disorder. So, I ask, why is this issue being ignored? Countries such as South Korea and China, where gaming addiction numbers are very high, have already recognized this as a serious disorder and developed treatment programs.


Factors that can lead to addiction

Video gaming is a fun activity for many people, in large part because of the positive reinforcement players receive for the split-second decisions they make while playing the games. From clicking a mouse button or controller to moving a character, from slaying the enemy to leveling up, games provide constant and instant feedback to their players.

Games also contain online environments where real-time players can connect with other players or join a guild. This gives players a social identity and can provide feelings of self-worth. Many players experience a sense of meaning in-game because they are constantly presented with objectives to achieve or obstacles to conquer.

In addition, massively multiplayer online role-playing games (MMORPGs) provide players with endless opportunities, scenarios and outcomes from quests, intense guild battles, endless levels and intense competition to be the strongest player on the server. But such games motivate players to spend long hours playing a game that has no ending, potentially leading to poor sleep habits, unhealthy diets, isolation from others and the real world, and addiction.

Perhaps the most important factor leading to video game addiction is the increased dopamine levels experienced during play. This is where the concern originates because it can lead to maladaptive behaviors, unhealthy coping mechanisms and, potentially, addiction. Given the constant feeling of reward for in-game decision-making and the often-endless levels or possible outcomes in a game environment, gaming can become addictive. It can end up serving as an alternate reality and an escape from real life because the game provides the player with a “better” version of it.

According to the DSM-5, the presence of five or more of the following symptoms over the period of 12 months characterizes such behavior as concerning and maladaptive. These nine symptoms include:

1) Preoccupation with internet games

2) Withdrawal symptoms such as irritability, anxiety and sadness

3) Tolerance or the need to increase time in gaming

4) Unsuccessful attempts to stop gaming

5) Loss of interest in other activities

6) Psychosocial problems due to excessive gaming

7) Deceiving family members, therapists or others on the amount of time spent gaming

8) Use of internet gaming to escape or relieve negative moods

9) Jeopardizing or losing a significant relationship, education, job or career opportunity because of online gaming

Three stages

The process of gaming addiction occurs in three stages. In stage one, the game is played actively for fun. In stage two, games are no longer “fun,” but the individual still spends many hours playing to remove negative emotions such as stress, sadness and worry. In stage three, the game is no longer fun and no longer removes negative emotions.

During stage three, biological addiction occurs due to constant and persistently high levels of dopamine release, leading to a state of dopamine exhaustion. When dopamine exhaustion is reached, not only do games lose their potential for fun and pleasure, but so do other areas and activities. At this stage, individuals often find themselves feeling apathetic, directionless and without meaning in life. We can compare this evolution to alcoholism, in which the effects of alcohol decrease over time, requiring more alcohol to achieve the same effect.

Treatments and theoretical approaches

An effective way to reestablish normal functioning, regulate dopamine levels and improve quality of life is simply to take a break from gaming. During this period, which can take three weeks to two months, those who are addicted are encouraged to explore other activities and hobbies of interest as an alternative to gaming while dopamine levels reset.

What separates gaming from other addictions is that the addiction does not require quitting games forever. Instead, recovery focuses on learning to control time spent playing games. Strategies such as creating a schedule that incorporates healthy gaming habits into a routine while prioritizing other aspects of life have proved effective.

Much research is still needed about video game addiction to address the most efficient treatments and theoretical approaches for working with this population. When considering intervention strategies in counseling for gaming addictions, it is important to remember that no one-size-fits-all approach works. What works great for one individual may not work well for another. No single treatment has proved superior or most efficient yet. Cognitive behavior therapy has been the standard approach for many professionals, according to King and Delfabbro.

Professionals have also had positive results treating video gaming addiction with narrative therapy, especially with children and adolescents. As Alice Morgan writes in the book What Is Narrative Therapy? An Easy-to-Read Introduction, such therapy is effective because it “views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments, and abilities that will assist them in reducing the influence of problems in their lives.” Narrative therapy might address strengths involving achievements in a game, such as being among the top players or leading the team to victory. It further explores these strengths and skills by incorporating them into real-life scenarios. It is equally important to assess the level of addiction as mild, moderate or severe by analyzing the severity of symptoms and the negative impact of gaming behavior.

It is important to establish trust and rapport during initial sessions. One effective way of developing rapport and trust with such clients, especially those who are resistant, is to mindfully disclose any experience the counselor has with video games. The counselor and client can find common ground through such shared interests and experiences. In contrast with substance abuse and alcohol addiction, the ultimate goal with gaming addiction is often not to eliminate gaming once and for all but rather to effectively control and reduce time spent playing video games. The goal is to normalize behavior that does not negatively interfere and affect other areas of life and overall physical and mental health.

As we rapidly move into technological and online environments in many aspects of our daily lives, video games will continue developing exponentially, and gaming communities’ growth will follow. Mental health issues are also rising among this growing body of diverse gamers. Using games as a coping strategy for other underlying issues can lead to an addiction, as real life is replaced with a virtual and more favorable one. Research in this area will continue to develop, and so will the emphasis placed on this issue and population by mental health professionals. More awareness of internet gaming disorder and the struggles faced by this population is needed to promote mental health and well-being.



Doyle L. Raymer Jr. is a mental health counseling student at Walden University. As a gamer himself, he has a deep interest in internet gaming addiction. It is his deep desire to advocate and create awareness to help improve the overall mental health of members of the gaming community. Contact him at doyle.raymer@waldenu.edu.


Related reading, from Counseling Today‘s October magazine: “Six steps for addressing behavioral addictions in clinical work


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Crisis counseling via text

By Bethany Bray July 22, 2021

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. The organization has responded to nearly six million chat conversations since the nonprofit was established in 2013. Some people find the text line more accessible and comfortable than in-person talk therapy, notes Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line.

In crisis counseling, clients need a safe and empathic environment to disclose deeply troubling thoughts and emotions. But how can crisis responders create this same environment using text messages, which don’t allow the clinician and client to see or hear each other?

Reyes acknowledges that crisis counseling through text feels much different than in-person counseling and demands a different approach from the responder. Words sent via text must be chosen very carefully, with the intent of validating the texter’s experience and building rapport.

“During in-person [counseling] services, my face responds to someone’s sadness. In text messaging, my words have to be that mirror, have to communicate that empathy,” says Reyes, who does group and individual counseling at a private practice in Denton, Texas.

Reyes is among Crisis Text Line’s staff of licensed mental health practitioners who oversee the organization’s volunteer crisis counselors, who are located across the United States and come from a wide variety of backgrounds. These volunteers undergo more than 30 hours of training, a large portion of which is focused on ways to ensure safety and build rapport through text messaging, Reyes notes.

Responders are encouraged to frequently use “feeling words,” Reyes says, because they reflect the emotions a texter is describing and help them feel heard, understood and validated. “Perhaps a texter describes that they’re feeling frustrated,” she explains. “We would name that [in a text response]: ‘It feels like you seem frustrated because your mom didn’t respond in the way you hoped she would’ or ‘It sounds like you’re feeling stuck, and it’s normal to feel stuck when things aren’t going the way you hoped or planned.’” These types of statements not only validate what the texter is saying but also act as a gentle way to de-escalate the crisis, she points out.

Many of the aspects of Crisis Text Line’s response model mirror the work a crisis counselor would do in a traditional session with a client, either face-to-face or via telebehavioral health. Crisis Text Line responders begin by introducing themselves and sending the texter a confidentiality disclosure, Reyes says. They use a warm tone throughout the conversation and use open-ended questions to fully understand the texter’s situation and allow them to talk through the issue and emotions that prompted them to contact the organization.

The responders also assess for abuse, homicidal and suicidal ideation as well as self-harm or nonsuicidal self-injury. However, they don’t begin to weave risk assessment questions into the conversation until after report and trust is established. Letting the texter know that Crisis Text Line asks everyone these questions also keeps them from feeling singled out, Reyes adds.

“We acknowledge their braveness,” Reyes says, and continue to use warm tones and statements that communicate care and validation when determining risk. For example, a responder may text, “Thank you for telling me about the stress you’re facing. I just want to make sure you’re safe, and to make sure I’d like to ask, Do you have thoughts about ending your life?” If they answer in the affirmative, the responder would follow-up with more assessment questions, including whether the person has a plan, time frame or means to carry out their thoughts of suicide.

Crisis Text Line responders do not know the location, name or phone number of the person with whom they are texting, although some texters do choose to disclose their name, Reyes says. However, a supervisor does have access to a texter’s phone number and can arrange for external intervention if the texter is deemed a danger to themselves or others, she adds.

Supervisors monitor anywhere from three to 20 conversations happening live on their computer screen, and they can step in anytime a crisis responder needs additional support. They also triage the incoming texts to immediately assign those with the greatest need and queue other less urgent conversations to wait for the next available responder.

In addition to risk assessment and validation, Crisis Text Line responders help texters identify goals and next steps that could improve their situation in the short or long term, Reyes says. Responders then work collaboratively with the texter to explore the resources they have in their life, from self-care to community and social supports. If needed, they may also suggest resources to help texters with a limited or inadequate support system. They share links to national organizations that can direct them to support in their local area because they do not know where the texter is located, Reyes explains.

At the end of the conversation, the responder checks in with the texter one final time to assess how they’re feeling and validate the work they’ve done. They also summarize the next steps and resource options they discussed during the chat. Most importantly, the responder honors the courage it took for the texter to reach out and reminds them that the Crisis Text Line is available 24/7 if they need to chat again, Reyes says.

Many of the people who reach out to the organization in distress are younger, simply because younger generations are usually more comfortable with text messaging. Reyes, who recently completed a doctorate in the counseling program at the University of North Texas, notes that common presenting issues include anxiety, stress, depression, and feelings of isolation and uncertainty — many of which have been heightened during the COVID-19 pandemic — as well as bullying or academic or school-related pressures. There is also a subset of texters who struggle with sexual or gender identity issues, such as the decision to come out to family or friends, she says.

The organization hopes to reach more people with its upcoming launch of Spanish-language services, which Reyes is helping to plan.

Crisis Text Line isn’t meant to be a substitution for long-term counseling, Reyes notes, but it can be a big help to people in moments of despair. The organization does see an increase in text volume in the evening hours, which is often when people are experiencing acute moments of despair, she says. It can also be a first step toward connecting with a local counselor for long-term care.

“It’s beautiful to see how our volunteers learn and blossom through training and experience. This work is meaningful, and it is heavy, but there is also this deep knowledge that you’re helping someone who hasn’t otherwise received any support that day,” Reyes says. “The need at the center of that is decreasing the stigma of mental health services and increasing access to services regardless of financial need or language.”

Tero Vesalainen/Shutterstock.com

Crisis texting in 2020

In 2020, the Crisis Text Line engaged in 1.4 million conversations with 843,982 texters.

The organization began receiving a higher-than-usual volume of texts in March 2020, as the COVID-19 pandemic began to affect Americans’ daily life. Perhaps unsurprisingly, the most common struggles these texters identified were stress and anxiety. However, the Crisis Text Line reports that the volume of conversations in which texters disclosed feelings of depression or sadness dropped by 10% between 2019 and 2020.

Additionally, conversations in which texters expressed thoughts of suicide dropped by 20% from 2019. The Crisis Text Line supported 26,629 conversations in 2020 during which the texter was deemed to be “at imminent risk of suicide because they mentioned that they had thought about ending their lives, they had a plan, the means, and wanted to make an attempt within 48 hours.”

The Crisis Text Line has made this data publicly available in a report, “Everybody hurts 2020: What 48 million messages say about the state of mental health in America.” View the report, including data breakdowns by issue, demographics and state-by-state, at crisistextline.org/everybody-hurts.





Related reading

Look for Counseling Today’s August cover story, “Crisis counseling: A blend of safety and compassion.”



Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.