OUT OF MY MIND!

WHY ONLINE PSYCHOTHERAPY?
Because There is a Need

October 24, 1997


 Online professional discussions about psychotherapy often come around to the same topic -- online therapy (or "e-therapy"). Is it good? Can you really do psychotherapy online?? If so, what are the disadvantages to such a modality? Are there any advantages?

 Something like therapy or counseling is already being conducted online. (What you call these online services is really a minor matter of semantics to me, so I'll use online therapy, e-therapy, online psychotherapy, online services, online counseling interchangeably throughout this article.) See Metanoia's list of Internet Mental Health Services for over 50 such providers. And this index is by no means exhaustive; there may be as many as 100 or more providers of online mental health services today. Some of these providers have been doing this type of counseling for over a year. Where did all of these providers come from? Why are they offering services online?

 I would argue these providers are online because there is a demand for their services. After all, setting up a Web site and setting aside the time to administer this type of service is not something most people can do in a few minutes. This kind of effort takes a fair amount of commitment and understanding of the online world. So most of these providers are not "fly-by-night" operations. On the contrary, most providers are simply therapists who already practice in the real world. They saw the need to offer similar services online and being somewhat familiar with the online world, developed an online service.

 Most professionals I know argue against these types of services for basically one reason -- the idea that psychotherapy and everything it encompasses simply cannot be done in the same manner as it is done in the real world. Let's examine some of the advantages and disadvantages to e-therapy:

Advantages

    Increased Perception of Anonymity
    This is one of the strongest and most influential factors contributing to the popularity of online counseling services. Whether people really are more anonymous online or not is really a moot point (although I believe they are, especially when using anonymous Web browsing such as The Anonymizer, and any of the free Web-based e-mail services such as Hotmail or Rocketmail). What is important is that people believe they are more anonymous and therefore respond and behave differently online. One of these differences is the ability to discuss more important, personal issues in a therapeutic relationship online much more quickly than they could in real life.
     
    For instance, in my thrice-weekly mental health chats online, I get quite a few private messages throughout each chat. I have seen a fair amount of these discuss issues of extreme importance to the individual (childhood abuse, feelings of guilt about a loved one's death, sexual abuse, chronic pain and ways of dealing with it, suicidal ideation, suicidal behaviors, self-mutilating behaviors, etc.) with me in these chats, having never had any previous interaction with the individual. In addition, some of these individuals go on to tell me that they felt more comfortable talking in an online chat room or environment, and hadn't even told their current therapist or clinician about this issue of importance to them! This is a very powerful effect in my opinion, and one which is often not given enough weight. After all, what good is three years of psychotherapy if the client never felt like they could discuss their childhood sexual abuse? (This is a true example.)
     
    Because of this factor, it is my supposition that the therapeutic relationship is equally as strong and effective in online therapy as it is in real-life therapy. This presupposes that both the client and the therapist have certain basic online skills and meet the other usual qualifications for best-outcome psychotherapy (e.g., highly verbal, motivated for change, etc.).

    Ease of Contact
    It is easier, in some cases much more easily, to contact your online mental health provider through e-mail and get a quick response than if you call a therapist or psychiatrist in real-life to ask a general question. This varies, but ideally, an online therapist could respond to an e-mail or chat request immediately if he or she did that full-time. While I don't know of anyone who does online therapy full-time, the potential is there.

    Expert Opinion
    Since the online world knows no geographical boundaries, finding an expert to treat you or to offer a second opinion on a diagnosis is potentially much easier. Know of a specialist in Borderline Personality Disorder in Canada and you live in Texas? Not a problem if the interactions are conducted online. This type of use of online communication is already common within the telemedicine field. There's little reason it can't be extended to the behavioral healthcare field equally as effectively.

    Cost
    E-therapy is usually less expensive than real-life therapy.

Disadvantages
    Lack of Nonverbal Communication
    This is the largest and most important disadvantage to online counseling. However, the existing body of literature on telephone therapy could logically be applied to most aspects of online therapy. Telephone therapy has been shown to be a cost-effective, clinically-useful, ethical intervention modality in the research literature (see, for example, Grumet, 1979; Swingson, Cox and Wickwire, 1995; Haas, Benedict and Kobos, 1996; and Lester, 1996). Stuart Klein, 1997, has hypothesized that the lack of visual cues intensifies the need to listen and the ability to listen. He points out this theory is supported by information processing research. And he notes Lester's (1996) research, which reported the lack of nonverbal cues is nothing new in counseling roles in society. Psychoanalysis, where the analyst sits out of view of the patient, and Catholic confessions are illustrative examples.
     
    We trust some of the most serious mental health problems to phone interventions now (e.g., helping those who are extremely suicidal, a common practice on telephone helplines set up in most communities, as well as by The Samaritans, a U.K.-based charity organization who has been counseling people with suicidal thoughts over the phone for years). This modality lacks nearly all nonverbal cues. The one item phone interventions have over online interventions is voice. Voice can include important cues, admittedly. However, voice over the telephone is usually real-time, immediate. Online therapy is most often conducted via e-mail exchanges, which allow for greater thought and elaboration on one's emotions. It remains to be seen whether this is sufficient to make online interventions comparable to phone interventions.

    Anonymity
    One of online therapy's greatest advantages is also one of its greatest disadvantages for the ethical therapist. Clinicians who take their role seriously also must seriously assess individuals for suicide, if appropriate, and take necessary action to ensure their client stays alive. If that client is largely anonymous through online communication, and reports suicidal ideation and behavior, the therapist may have little recourse for interventions. One way to overcome this problem is to screen for suicide at the onset, but that also means a lot of people who need and could most benefit from immediate help won't find it online.

    Therapist's Credentials
    There are only two ways to ensure a clinician online really has the education, experience and credentials he or she says he or she has. One is to call up the clinician's university to verify education credentials, call the state licensing board in the state the therapist resides and verify licensure, and call past employers of the therapist. This is a time-consuming task most people won't bother to take. I and Martha Ainsworth set up Credential Check to help do this legwork for you, but only about a quarter of therapists offering online services have signed up for this service. This service makes it much easier to ensure the clinician a person is dealing with is legitimate.

    Breaking the Law
    State boundaries in the real world are pretty clearly defined and therapists know not to practice across them, unless they are properly licensed in all states of practice. In the online world, it is just as easy to practice on a person living in India as it is in Indiana. This means that clinicians who "see" people online who live in a different state where the clinician is not licensed may be breaking the law. Although no court cases have yet gone to trial to clearly define this area of the law, it is a gray area of concern. If the therapist's services online are clearly defined and not "psychotherapy" as defined by the law, then there may be no problem. Phone counseling services are available nationwide which seem to operate under similar principles.

    Grievance Process
    The grievance process for addressing complaints against online therapists is just as murky. Who does a client file a complaint with? Their district attorney's office? The D.A.'s office in the clinician's state? Their Better Business Bureau or the clinician's? Their state board of licensure or the clinician's? Again, these questions remain unanswered. Good online therapists will clearly define their policies for grievances, and who to contact if they believe the therapist has acted unethically or wrongfully. This may be an area which needs further thought and an arbitration service.

 This is by no means an exhaustive list of the pros and cons of e-therapy. A lot more could be said in each category, but I believe this covers some of the most pertinent issues.

 Online services in mental health are here to stay. In fact, all trends indicate that these services will continue to grow and proliferate with the enormous growth of the Web in general, and the steady increase in numbers of people who are getting online. Clinicians who do online therapy would benefit from some basic research in this area which back up the effectiveness of this modality and ensure the disadvantages outlined above do not hurt clients more than the advantages help them.

 - John

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References:

Grumet, G. (1979). Telephone therapy: A review and case report. American Journal of Orthopsychiatry, 49, 574-584.

Haas, L.J., Benedict, J.G., & Kobos, J.C. (1996). Psychotherapy by telephone: Risks and benefits for psychologists and consumers. Professional Psychology: Research and Practice, 27, 154-160.

Lester, D. (1995). Counseling by telephone: Advantages and problems. Crisis Intervention, 2, 57-69.

Swingson, R.P., Fergus, K.D., Cox, B.J., & Wickwire, K. (1995). Efficacy of telephone-administered behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, 33, 465-469.


    If you want the whole shi-bang of over 10,000 separate resources that have to do with psychiatry and mental health online, then you might want to visit Psych Central. It's the largest and most comprehensive site of its kind in the world and we're looking to build upon it in the upcoming years, acting as a super guide to mental health online. If you didn't find what you needed here, look there next!

Last reviewed: By John M. Grohol, Psy.D. on 27 Jan 2007
    Published on PsychCentral.com. All rights reserved.

 

 

The willingness to accept responsibility for one's own life is the source from which self-respect springs.
-- Joan Didion