Best Practices of eTherapy
Clarifying the Definition of e-TherapyJohn M. Grohol, Psy.D.
May 2, 2001
What It IsOnline therapy is a new type of psychotherapy, it is simply not psychotherapy transplanted online no more than telephone interventions are simply psychotherapy transplanted to the telephone, crisis intervention is psychotherapy done quickly, or play therapy is psychotherapy done with toys. This is an extremely simplistic point of view which minimizes the richness and differences associated with this new medium, and the unique characteristics that accompany it.
Online therapy uses the richness of language to help bring about change in the client's life. Language, whether it be written or oral, is the core component of communication. While some might suggest that communication is best achieved via spoken dialogue only (and indeed, suggest that psychotherapy can only be conducted via the spoken word), there is little empirical evidence to back up such a supposition. In order for psychotherapy to be effective (no matter what its type), communication needs to occur and a relationship between the client and therapist must be established. Nothing about online therapy makes these two components any more difficult to achieve. Nor does their achievement come at a cost in terms of quality or understanding.
Online therapy reaches out to the majority of people who would never seek professional mental health services. Traditional psychotherapy, as a general means of change available to nearly anybody (as envisioned by the late President Kennedy via his initiation of the community mental health center system), has largely failed. The U.S. Surgeon General's Report on Mental Health in 1999 showed that the majority of people who have diagosable mental disorders do not presently seek out or obtain professional treatment. This despite the huge treatment advances made in the past decade to help cure many mental disorders within a few months. Online therapy offers a valuable new modality to reach out to a larger group of people concerned about issues of confidentiality and privacy.
Online therapy is potentially more secure, confidential, and private than traditional face-to-face therapy. Because of the unique qualities of the e-therapy, therapeutic change can take place in an anonymous or pseudonymous context. This provides a level of security and confidentiality that cannot be matched in the real world. I've worked in clinics where confidentiality was regularly breached because of thin walls, open doors, files sitting on doctor's and therapist's desks while they went on a break or to lunch, entire filing rooms gone unlocked and unmonitored, and the continuing breach of a client's privacy by third parties, such as insurance companies. For online therapy, you don't have to worry about any of these regular breaches of your privacy, especially since online therapy doesn't require personally identifying information in order to work. After all, therapy is about fostering change in people, not demographics.
Online therapy can be a more powerful, quicker change agent than traditional psychotherapy. As others, such as King & Suler, have pointed out, the online modality pulls for greater projection and psychodynamic characteristics which often enhance the power of the therapy. Also, as has been well written about and documented, people in online therapy tend to get to the point more quickly and do not spend sessions wasting time talking about issues of little relevance to the reasons that brought them into therapy. In traditional face-to-face therapy relationships, entire sessions can be spent discussing issues that have no impact on the person's actual diagnosis or disorder. A great deal of a professional's time can also be spent on non-therapy issues, such as payment, rescheduling appointments, tedious record-keeping on paper forms, and "shooting the breeze." While some of this also takes places in online therapy, it does so to a much lesser extent and to a much smaller overall percentage than in face-to-face therapy.
What It Is NotOnline therapy is not illegal, when practiced thoughtfully and with careful consideration of the issues. Some non-lawyers have made outright, outrageous claims about the legality of online therapy, when in fact, there is not a single state within the United States (or, for that matter, a single country within the world) that has specifically addressed the issue of online therapy regulation through law or a court decision. Nor has there been a single court decision in any state or country (to date) addressing the jurisdictional issues of the practice. Professionals who make well-intentioned claims about the illegality of online therapy are misleading professionals and the lay public. Since online therapy is not psychotherapy (no more than occupational therapy is considered psychotherapy), psychotherapy laws do not obviously or automatically apply. This issue may be decided some day, but as of now, e-therapy is a legitimate form of professional help.
Online therapy is not inherently "distance therapy". Since two people involved in e-therapy can be sitting in the same room together, it is a misnomer to try and classify it as "distance therapy." Nothing about online therapy suggests that it needs to be done at a distance, or that it is most effective at a distance.
Online therapy is not without research backing its use. Some professionals are claiming there are little or no studies out there that support online therapy's effectiveness or use. Many studies are indeed single case studies or research presented at professional conferences (not in peer-reviewed journals). This is a fairly typical pattern for new treatments making their way through academia circles, starting with the lowest and easiest studies to conduct, and gradually moving to larger, more complex, and better funded studies. For instance, in a study presented at a professional eating disorder conference in the U.K. last year, investigators showed that using online therapy is more effective than no treatment at all or a support group. But because this study was never published, few are aware of it.
Online therapy is not a cure-all or answer to everyone's problems. Nor has anyone ever suggested it should be. This straw-man argument is sometimes raised in the context of online therapy "stealing" clients away from traditional face-to-face therapy. In fact, e-therapy is much more likely to increase traditional psychotherapy services because of its outreach to the population of people who would never even consider going to see a therapist face-to-face might try one online. Used as an adjunct to ongoing face-to-face therapy, or when therapy is terminated or the client moves away, it can be a very helpful modality to many people in many different ways. It is no more a "one shoe fits all" approach than face-to-face psychotherapy.
For more information about e-therapy, I suggest reading the other essays in the Best Practices in e-Therapy series.