Providing Psychotherapy Over the Internet

July 1, 2003

Although the prospect of online mental health care raises obvious questions, it also offers an opportunity to make cost effective services available to many who may not otherwise have access. By understanding issues such as confidentiality, emergencies and lack of face-to-face contact, psychiatrists can determine if this area of treatment is right for them.

People who are troubled are beginning to turn to the Internet when they decide to seek psychotherapy. Avoiding the embarrassment and inconvenience of a face-to-face appointment, patients can now easily find a therapist and receive professional counseling through a computer in the privacy of their own home. One researcher's database of online "e-therapy" resources has already grown to 300 private practice Web sites, as well as a number of online clinics through which another 500 professional therapists can be contacted (Ainsworth, 2002). When surveyed, online patients seemed happy with the treatment they receive (Ainsworth, 2002) and, judging by the rapidly growing professional membership of the International Society for Mental Health Online (ISMHO), there are also respected therapists convinced they can do good work over the Internet (ISMHO, 2002). Since the World Wide Web cannot be unspun, there is every reason to believe that people, especially the young and computer-literate, will continue using it to seek mental health services.

Herein lies the nub of this discussion. There will continue to be patients looking for therapy online and, because we live in a market economy, they will almost certainly find someone online willing to take their money. While there are important ethical issues that I will discuss, the moral bottom line is that if professional organizations, licensing boards, legislatures or courts make it too onerous or too risky for qualified, ethical professionals to practice online, we will wind up with only the unqualified and unethical lurking at the other end of the patient's Internet search. It is difficult to justify setting that kind of trap for vulnerable people who are doing nothing more than making use of the technology available to seek therapy.

Is it Psychotherapy?

There might be some who argue that, since an online therapist lacks access to the nonverbal cues of a face-to-face encounter, exclusively text-based work cannot even be considered psychotherapy. In this view, psychotherapy has been developed over many years as an exclusively face-to-face experience. While many methodologies explicitly acknowledge nonverbal cues as important, few make it an essential component. More often, theories of change are rooted in the relationship between the patient and therapist and on the way in which the patient is influenced to think, feel or act. The critical variable to many practitioners, therefore, will not be whether they can see and hear a patient but whether they can form a meaningful therapeutic alliance. Indeed, researchers have noted that people appear to be much less inhibited about verbally expressing feelings over the Internet, that the sense of anonymity makes them feel safer, and that they are consistently willing to divulge more personal information sooner than when they are face-to-face (Suler, 2001; Walther, 1996; Young, 2000). People meet and fall in love online and have done so through ordinary love letters for as long as there has been written language. My conclusion is that a mental health care professional working with a client to effect change is doing psychotherapy--even if it is over the Internet.

One can speculate that in the absence of self-consciousness about one's appearance and without reactions to the visual person of the therapist, a patient may create a mental image of an ideal helping relationship that could contribute to, rather than detract from, expectations of success. When the patient's imagination becomes an increased variable in therapy, however, it raises counterbalancing concerns in attempting to treat certain kinds of mental problems. In a book written to help patients find and choose an online therapist, Stofle (2001) advised against exclusive online treatment for those who exhibit psychotic, borderline or suicidal symptoms. Research in this area is certainly needed.

What About Emergencies?

If patients become a risk to themselves or others during treatment, therapists need to be able to contact emergency services in the patient's community. Clinical diagnoses are always made based on the information available at the time and under the circumstances. Even with a face-to-face intake, all possible information is never available and even if an initial assessment is accurately benign, a patient's emotional state can be notoriously unpredictable between sessions. Clinicians deciding to work online must routinely prepare for the unexpected. The American Counseling Association (ACA, 1999), the American Mental Health Counselors Association (AMHCA, 2000), the National Board for Certified Counselors (NBCC, 2001) and the ISMHO (2000) have all issued specific guidelines for online counseling. These guidelines require practitioners to give patients an alternative way to initiate contact in the event of technology failure and require the therapist to ascertain patient identity and to establish alternative ways to reach the patient or send help. In the event of an emergency, the NBCC and ISMHO guidelines recommend identifying a professional at the patient's location (e.g., primary care physician) as a local backup. Internet therapists should also be skilled in online search techniques to locate local clinics or police departments or to determine local mandatory reporting requirements. A truly wary practitioner might even make arrangements to have prospective online patients visit a nearby clinic in person where they can receive an initial assessment, complete intake forms and sign a hard copy of the therapist's informed consent.

What About Confidentiality?

Because there is so little research and experience available, patients must be advised that computer-mediated therapy is still experimental. Informed consent is particularly relevant as it pertains to choosing among alternative modes of treatment and confidentiality. The requirements of the Health Insurance Portability and Accountability Act of 1996 do not provide special interpretations for therapy conducted in cyberspace, so we must assume that the intent of these requirements applies to online work. The competent online practitioner will practice aggressive due diligence and will see that patients understand and acknowledge the unknowns and potential risks of working over the Internet. Love (2000) also suggested having a written agreement by the patient that the treatment shall take place under the laws of the state which the therapist is licensed.

To help protect the confidentiality of messages, encryption should be used. With encryption software, messages are scrambled and can only be decoded by the intended receiver. Some patients may not want to go to this extra effort, preferring only a disguised screen name and password. Here, as with the original decision to seek therapy online, autonomous patient choice and related waivers should be supplemented with full information about the risks.

Patients need to be educated not only about the risk of intercepted or accidentally misdirected transmissions, but also about the importance of keeping their own computers and stored messages secure. Patients should be advised to never use an employer or school computer for counseling, and therapists should disclose the precautions they take to maintain the security of their own computers. One advantage of working online often cited by patients is the ability to save, reread and reflect on the therapist's messages. Every session can produce its own written transcript. Permanent copies of everything in the patient's hands, however, present a risk to both the patient's and the therapist's confidentiality. A record of discussion of these issues should be retained in the practioner's possession.

How Is Competency Evaluated?

Technological savvy is not the only incremental area of competence an online therapist needs to develop. When I interviewed a sample of online practitioners, they told me that most of the clinical skills they used were the same as those applied in their face-to-face practices, but the clinical competence undergoing the most changes was verbal communication. In a face-to-face environment, both the therapist and patient have multiple ways to surround their words with meaning--voice tone, facial expression, body posture and eye contact. We generally use these nonverbal tools without thought, but in an online setting it quickly becomes apparent that the same words can be interpreted in a variety of unintended ways. According to the online practitioners, misunderstandings are, indeed, frequent, but working through them can be highly therapeutic. With experience, online therapists say they learn new contextual indicators that can be found between the lines of patient messages. A skilled online practitioner reads each message, their own as well as the patient's, for possible alternative meanings and becomes deft at modeling requests for clarity. Perhaps, like people who are deaf or blind, clinicians learn to use their abilities with greater skill, developing a broad repertoire of word intensities, variation and vocabulary. Capitalization, type size, word repetition, spacing, fonts and emoticons (e.g., smiley faces) become supplemental tools to compensate for the loss of visual and auditory cues--as does the technique of simply typing out, "I'm smiling right now" or "My eyes are filled with tears because of what you wrote."

What About Licensure?

Professional mental health care providers in the United States face an online dilemma because each state determines who can practice psychotherapy within its geographical borders. The Internet, of course, transcends geographical boundaries, yet patients and clinicians are physical beings located in physical places. Does an online therapy session take place under the jurisdiction of the patient's location or under the jurisdiction of the therapist's location? Different states have come to different conclusions (Koocher and Morray, 2000). If it is the therapist's location, does the patient have adequate protection? If it is the patient's location, may only therapists licensed in the patient's home state respond to the patient's request for treatment? Can a state legitimately tell its citizens they may only seek help locally when they are on the Internet? Can one state realistically tell practitioners in another state (or in another country) they are not allowed to treat its citizens? If so, how do these governments enforce these edicts?

The Internet is a formidable social change agent. When confronted by hundreds of municipal governments wanting to impose local sales taxes on Internet sales, the U.S. Congress suspended all such taxes just to head off potential chaos. To be completely safe, some online practitioners have chosen to accept only in-state patients. Others have decided differently. Love (2000) examined possible legal defenses for online practitioners and holds up Washington and Colorado as models for state regulation. At present, legal ambiguity and personal interpretations, as well as one's tolerance for risk, will have to guide decision making until policy-makers prepare a nationwide solution. At minimum, the Web site of every online practitioner should clearly show the therapist's name, location, licensing and other credentials. It should also provide a way to verify current standing, preferably through a link to the practitioner's licensing authorities.

In conclusion, while the prospect of online mental health care treatment raises questions, it also offers an opportunity to make cost-effective services available to thousands who might otherwise not have access. Shut-ins; those living in rural or remote areas; the elderly; and those who are too shy, embarrassed or private to travel to a face-to-face therapist may represent groups that psychotherapy has never before been able to reach. Making sure online therapy is safe and effective will be challenging. Succeeding is an exciting idea.

References:

References


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