The most controversial of Internet innovations is e-therapy, a new modality of psychotherapy that takes places in many different forms and formats. In its most common flavor, e-therapy is done as a stand-alone treatment via regular email. Each “session” is composed of an email from the client to the therapist, and the therapist’s response back to the client. Some therapists set length-limits on the size of the email, while others charge for the emails by the amount of time it takes for them to read and respond to the client’s message. Generally these email exchanges cost less than half of a traditional face-to-face psychotherapy session.
Less commonplace are when real-time chat applications, instant messaging, or video conferencing modalities are used for e-therapy. Video conferencing is generally similar to face-to-face psychotherapy, is covered under telemedicine guidelines and standards, and is most often used in rural environments. Chat applications, such as Internet Relay Chat (IRC) and instant messaging (IM), are also similar to face-to-face as they are real-time and require scheduled appointment times, but still take place in a text-only environment. Because all of these modalities require appointment times and take place in real-time, they tend to lose many of the benefits traditionally associated with e-therapy, including anonymity, lower cost, and greater convenience.
In addition to using e-therapy as a stand-alone treatment modality, many clients are using it as an adjunct to traditional psychotherapy care. Clients who can no longer afford to see their regular therapist every week for treatment might add e-therapy to their treatment regimen as a way to fill in the gaps of their standard care. For instance, it is often impossible to express a reaction to a dream or other immediate crisis event to the person most able to help you cope or interpret it. E-therapy allows the client to record their thoughts and feelings whenever they have them, and have a much more immediate reply than if they had to hold on to the event for a few days or even a week or more before getting some feedback on it. This greater immediacy can often lead to the client obtaining a more intensive treatment, which in turn leads to quicker positive outcomes.
Ferguson6 differentiates these two type of email modalities as Type 1 and Type 2. Type 1 email is when a client emails a doctor with no prior relationship established; Type 2 email is when the client has a pre-existing relationship with the doctor. Traditional physicians are already using email to help supplement ongoing patient care (Type 2), much as a phone call, while other doctors are offering direct advice and information to individuals who ask for it online (Type 1). Both modalities fit well into the concept of e-Therapy and can be useful for different types of individuals seeking care, under varying circumstances.
Therapists who support the e-therapy modality in their own practice often worry that it will lead to a greater workload, answering emails in their spare time and not getting paid for it. While it’s currently true that under most conditions, insurance companies generally do not reimburse for e-therapy care, such issues can be dealt with by directly billing the client for the service, or limiting the type or amount of care given via email. For instance, simply using email instead of the phone to change or cancel an appointment can be more convenient for both parties, because neither is stuck playing an endless game of phone tag.
New Paradigms: Empowered clients, Empowered providers
These Internet innovations are the tools that are empowering a new generation of clients. Some have called them the Y Generation of patients7. No longer limited by a lack of information about disorders or their treatment, this generation of clients is beginning to take more control of their treatment options and demanding more from their treatment providers. They are becoming to expect the professional will be Internet savvy and connected, to be able to reach their provider when its convenient for them, and even to suggest a modality of care that may fit in better with the client’s needs.
A side effect of all of this greater information becoming available online is that professionals have to learn how to properly and positively deal with this information being brought into session. Clients become more educated consumers when the therapist goes over the information found online in this context, learning to distinguish accurate, objective information from inaccurate or biased opinion. Another side effect is that the more people put to rest their old stereotypes of psychotherapy and the people who seek it out, the less stigma that is associated with mental health problems in general.
Instead of the professional acting as the paternalistic expert, clients will increasingly look to the therapist or psychiatrist as a filter, a guide to the widening variety of treatment choices available. For instance, a client brings in information found online discussing a new relaxation technique they’d like to try. Some therapists might be offended by the suggestion, or feel embarrassed by their own unfamiliarity of the technique. The empowered provider will recognize the limits of their own knowledge, however, and work with the client to either learn the technique if they believe it has any value, or refer the client to another adjunctive provider for this one component of the client’s treatment.
The therapist becomes the partner in care with the client, not the hand-holding empathetic expert. How can a professional profess understanding of what it’s like to feel the symptoms associated with schizophrenia if indeed they never have? No longer do they have to when the client can find the genuine empathetic support from an online group of others who truly know and understand the experience they are going through. Instead of trying to be all things to all clients, the therapist can use their skills and experience to help the client choose treatments best suited for them. Perhaps face-to-face therapy once a week is simply not possible given the client’s hectic schedule, babysitting needs, and more. E-therapy becomes a tenable alternative for the Internet-experienced client, after an initial face-to-face intake evaluation establishes the therapeutic relationship’s parameters.
If providers need convincing, they need look no further than a recent Harris poll8. The survey found that patients want more online doctor/patient communication, would pay for it, and it would even influence their choice of providers. Employers are also on board with encouraging employees to more doctor visits by email, according to a recent article in the Wall Street Journal9. They believe, with evidence to support their position, that such visits will increase the quality of health care for their employees. The empowered patient isn’t just a fad or passing phenomenon, it is the future of health care, and by extension, mental health care.