This chapter focuses on how the provider’s changing role, combined with psychoeducational Web sites, online support groups, and emerging modalities like e-therapy, can open the door to providing clients with a higher-quality level of care, reduce cost, and improve access to services. The Internet allows professionals to reach out and offer a wider range of affordable services to more consumers than ever before. The therapist is not only a direct provider of services in this new paradigm of the empowered client, but also the coach and consultant to the patient. This new role allows the professional to help the client be a more educated consumer of the growing set of resources available to them online.
How it Was
Historically, psychotherapists and psychiatrists have acted as the gatekeepers to mental health services. While this role changes marginally from decade to decade, most therapists act as the expert to change in guiding the client to a successful resolution to their problems. No matter the specific psychological orientation of the therapist, whether she be a Freudian or a cognitive-behavioral therapist, the professional nearly always takes the lead in guiding therapy, dispensing information about the specific disorder, and acting as a conduit for additional support services in the community.
Therapist as Expert
These roles are defined by specific boundaries, which are often explicitly elucidated early on in the therapeutic relationship. “Here is how I work. These are my expectations of you as the client, and these are the expectations you can have of me as your therapist. Here is what you do in case of an emergency.” The therapist makes it clear that while she is not a friend or advice-giver to the client, she is acting in the role as an expert in human behavior and experience. This role often translates simplistically to the client, “Doctor knows best.” If the professional says that a psychiatric consultation is necessary in order to evaluate the client for medications, the client goes along with it. If the professional says that he works using cognitive-behavioral techniques in order to help effect change in the client’s life, the client goes along with it. If the therapist suggests that couples counseling is in order, the client goes along with it. Very rarely do clients verbalize disagreement with choices made about their treatment, and for the clients that do, they are sometimes labeled as “resistant” or using some similar psychotherapeutic mumbo-jumbo.
At this point, many professionals will object to this characterization of the traditional psychotherapeutic relationship, claiming, “Oh no, I don’t act like that. I’m a partner with the client in helping them change.” While that may be philosophically many therapists’ orientation, their practice is often reduced to making specific recommendations for behavioral or thought changes in order to effect emotional change. Clients who do not follow the recommendations often spend a great deal of time in therapy, and the therapist is left scratching her head as to why.
Dissemination of Information
Nearly all the information the client wanted to know about their disorder or diagnosis was delivered to them by their mental health professional. “What is depression?” would be answered in session by the “expert” therapist or doctor. Ten years ago, this was the client’s primary, and often only, source of such information. Many therapists refused (and still refuse) to share even the client’s own diagnosis with them, often with the claim, “Well, they wouldn’t understand what that means.” The thought of explaining the assorted complexities of the diagnosis, and the entire diagnostic system used within mental health, was un-thought of.
If the client was prescribed a psychotropic medication by a psychiatrist or their primary care doctor, the client was often left with very little information about the possible side effects or even the insert accompanying the medication. “What should I expect while taking this medication,” was often met with a short reply, and no place for the client to get additional information. For those few clients who felt brave enough to actually ask the question. Most clients are often intimidated by their doctors and defer questions altogether, preferring to take a “wait and see” attitude – “If it doesn’t hurt me, I won’t bother the doctor with all of these silly questions.”
Stages of Care
The average client comes into treatment only after having lived with their problem for a period of time. It may have been a few weeks, a few months, or a few years. They often have tried resolving the problem on their own, talked to family members or friends about it, and maybe even went to a bookstore or library to see if there are any books on subject.
Once in the mental health system, whether they see a psychiatrist or therapist first, the professional does an intake and makes a diagnosis. Then a course of treatment is defined, often with a specific treatment plan written out on a form. Sometimes the client is a part of defining their treatment, sometimes not. Even if the client does collaborate with the therapist on their treatment plan, how they actually obtain the goals defined therein is left to the therapist’s training, experience, and knowledge.
Treatment ends when the client’s self-report of symptoms have decreased enough to the therapist’s or client’s satisfaction, when the client’s insurance coverage is exhausted, or the client is frustrated with the lack of progress in therapy. More recently, the onset of managed care in many health care systems around the world means trying to better define outcomes and measure progress in therapy. This can be done with a variety of measures, including treatment plans, symptom checklists, or other measures of the client’s well-being.
The Internet’s Potential
The Internet is turning the traditional psychotherapeutic relationship on end. No longer are clients content to sit back and be told how to change. Instead, they are taking a more proactive role. Clients are learning more about their disorder and diagnoses ahead of time. Many quality Web sites provide comprehensive lists of diagnostic symptoms for various disorders, as well as the usual and standard treatments prescribed.
Some clients are even helping to narrow down possible differential diagnoses by taking interactive, self-help quizzes online. Clients are finding others online with a similar diagnosis and joining self-help support groups that make living with the disorder easier and more understandable. For some people, the convenience and lower cost of the emerging e-therapy modality makes sense to try.
Since 1995, a wide variety of Web sites are providing a virtual encyclopedia of knowledge about mental health disorders that before that time, was simply not readily available to the lay public. These sites were first begun by a handful of professionals who understood the Internet as an inexpensive transmission medium for disseminating information. By learning a simple language called HyperText Markup Language (HTML), anyone could publish a Web site on any topic they chose.
Given the paucity of consumer-focused information on mental health issues, these Web sites quickly gained a hungry following of mental health consumers. Government-funded institutes, such as the National Institute of Mental Health, worked hard to bring their sites online and provide the wealth of consumer information they had developed over the years in paper brochure format. Before the Internet, even getting a simple list of what constitutes a diagnosis of “major depression,” for instance, was extremely difficult if a person didn’t know a cooperative mental health professional. These Web sites provided valuable resources on mental disorder symptoms, diagnoses, and treatment to a much larger audience than ever before1.
This reluctance on the profession’s behalf to share this knowledge is less surprising when considered in context of the evolution of our modern mental disorder diagnostic system. This system, codified within the Diagnostic and Statistical Manual of Mental Disorders (2), really only gained widespread acceptance a decade earlier, and was still making slow inroads in many established therapeutic practices. Before this more-scientific model of diagnosis was adopted, most professionals handed out diagnoses in a very personalized, experience-based manner that had little empirical support or reliability between professionals. Given the diagnostic system’s overall young age, the lack of information supplied about diagnoses derived from it (and subsequent empirical diagnostic systems) is perhaps more understandable.
In addition to basic information about how mental disorder diagnoses are made, Web sites offered increasingly detailed information about theoretical orientations practiced in psychotherapy and the techniques that accompany them. Not surprisingly, many consumers’ impressions of psychotherapy are still rooted in the traditional Psychology 101 teachings of Jung and Freud, of clients lying on couches discussing their dreams with a distant, unattached therapist. The Web put to rest many of these inaccurate characterizations and brought full light to bear on the wide range of orientations practiced in psychotherapy today. Clients learned that therapy doesn’t have to last for years and cost a significant amount of money. Instead, therapy can be short-term, goal-oriented, and valuable from time to time as life gives a person something unexpected to handle.
As managed care has swept through many health care systems in the 1990’s, it has led to an emphasis on outcome research and improving client outcomes with definable, clear treatment goals. This emphasis has led to shorter treatment periods and often, more paperwork. It also means that professionals providing mental health services often have less time to discuss everything they’d like to in session. In addition to researching symptoms or treatment modalities online, clients can also turn to the Web for access to medication databases. If the client forgot something told to them, or the psychiatrist failed to mention a specific side effect, the client can easily go online, look up the medication, and read in great detail all about it. This simply wasn’t readily available to do before the Web came along, and can help answer a lot of common questions about a medication’s specific side effects and expectations of what to expect from a medication.
Databases made available through the Web also help professionals too. A psychiatrist can go online and check drug interactions quickly and more easily than looking them up in some large tome that may or may not be updated with the most recent information. When the National Library of Medicine of the National Institutes of Health brought the venerable MEDLINE medical research database online, a great deal of free research information was made available. Now a research citation can quickly be looked up online, rather than trudging off to a local university or medical school library. Professionals can quickly stay up to date on the latest advances, and as more and more journals offer the full-text of their articles online, professionals have the potential to stay more current than ever before.
Other databases of information are also made more readily available through a Web interface. The American Self-Help Clearinghouse’s Sourcebook3 of self-help support organizations across the country and around the world makes it much easier to find a real-life support group in one’s community, or learn how to start one if none exists. Similar databases of encyclopedia health information, glossaries, and medical dictionaries are also available online. Many of these types of resources weren’t even available or accessible before the Internet at your local public library.
Interactive Quizzes & Support Groups
Interactive online quizzes have made it possible for someone who suspects they have a problem in a specific area to get immediate feedback on their symptoms. This immediate feedback provides clients with a valuable resource, even if the results of the quiz are not always as empirical or as accurate as an in-depth intake evaluation by a trained mental health professional or a standard paper-and-pencil measure. The fear of the unknown, of suspecting a problem without knowing whether you have one or not, is often as debilitating as the disorder itself can be. While some of these quizzes are not as accurate as their paper-and-pencil brethren, others are empirically based and validated. They also open the door to potential treatment, encouraging the client to seek out professional assistance if the questions answered suggest a possible diagnosis. Since the U.S. Surgeon General’s Mental Health Report (4) in 1999 showed that most people who qualify for a mental health diagnosis never seek out professional treatment, any method that may increase the number of people who are encouraged to seek treatment must be examined. Interactive quizzes are one such method.
These quizzes can also be used in another manner. Some measures are available online that allow an individual to monitor and track their scores on the quiz over time (see PsychTests.com for examples). Such measures allow clients, whether they are in treatment or not, to track the progress of their moods and symptoms to see whether they are noticing improvement. These measures offer immediate feedback, psychometrically validated, and are available to the client for the taking at any time.
Online support groups offer the Internet-savvy client the chance to talk to others who suffer from a similar disorder as their own. The positive, therapeutic effect of peer-run, self-help support groups is well-documented5. As available online, they offer a greater range of variety from which to choose, as well as the convenience of participating in them as one’s schedule allows. Often a person will turn to an online support group before seeking out professional treatment. The group can advise the client on different treatment modalities available, what to expect from a competent and caring therapist, and what possible medications (and their side effects) are available. Offered in a more opinionated and personalized manner than the objective information found on a Web site, the social nature of the support group often makes the information more digestable and easier to understand. The members of the group are speaking in a language that every other member understands (often very unlike when professionals speak to clients). In addition, every member knows that most other members have been there themselves, making it feel like they “are all in this together.” That group effect usually has a positive, beneficial impact for each of its members.
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.
We can see the effects of this new paradigm already as a whole new field of professional coaching has gained exposure. These professionals view themselves as paid cheerleaders for the client, helping emphasize the positive aspects and resources in the individual’s life, and working with them on ways to improve social skills and resources. Therapists can adopt some of these positive components for their own practices, looking more to help guide their clients in an active role of discovery, insight, and change. Rather than being, as is often the case nowadays, the sole change agent in the client’s life, empowered providers will help clients make use of many different possible resources that are available to help them change. In this role, therapists will actually have less work to do because the client is taking on more of the work themselves, or the work is being spread out amongst a wider array of helping resources (such as online support groups, adjunctive e-therapy, and the client’s own online reading and journaling).
Professional’s paternalistic attitude toward their clients is often characterized by the argument, “My clients are too sick to know what’s best for them.” Indeed, when disorders such as major depression or schizophrenia are diagnosed, the client may often be in a state of mind where decisions about their own care do not come easily. Therapists don’t have to give up all rights to helping guide a client to the choices they believe will offer the best outcomes for their clients. By adopting a more open, flexible attitude toward treatment that incorporates many of the components discussed above, the therapist can help the client discover resources and give them a sense of wonder and empowerment from the experience. All too often, clients feel overwhelmed by their disorder, and feel very alone and misunderstood with their feelings. A simple suggestion for joining an online support group, for instance, could make a significant and noticeable difference in the client’s life.
Luckily, professionals are not alone in walking down this road to using email or other online resources to act as an empowered guide to their clients. MDNetGuide has an article10 on this topic and Daniel Sands, M.D. 11 has compiled an excellent Web site and written some excellent guidelines about doctor/patient email that should be read. Professionals who adopt their practices to this new generation of Internet-savvy patients will find their work often easier and perhaps more gratifying. The key to addressing the empowered client’s needs is not to cater unquestioningly to them, but to understand and help guide them through the multitude of choices.
1 Grohol, J.M. The insider’s guide to mental health resources online. New York: Guilford Publications, 2002.
2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author, 1994.
3 White, B.J. & Madara, E.J. (eds.) The Self-Help Sourcebook. Denville, NJ: American Self-Help Clearinghouse, 1998.
4 U.S. Department of Health and Human Services. Mental health: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
5 Kyrouz, E.M. & Humphreys, K. Research on self-help/mutual aid groups.
6 Ferguson, T. From doc-providers to coach-consultants: Type 1 versus Type 2 provider-patient relationships. The Ferguson Report: http:// fergusonreport.com/articles/tfr07-01.htm
7 Cascardo, D.C. Getting ready for the new generation of savvy patients. Medscape Money and Medicine 3(1), 2002: http:// www.medscape.com/viewarticle/436315
8 Unattributed. Patient/physician online communication: Many patients want it, would pay for it, and it would influence their choice of doctors and health plans. Harris Interactive Health Care News, 2(8), April 10, 2002.
9 Carrns, A. In effort to boost health-care quality, employers urge doctor visits by e-mail. Wall Street Journal, March 23, 2001: http:// online.wsj.com/article/0,,SB985304694351531170,00.htm
10 Unattributed. How to make online patient communication work for you. MD Net Guide Magazine, Primary Care Edition, 4(3), March, 2002: http:// www.mdnetguide.com/v4n3/pc_march/CoverStory_pc.shtml
11 Sands, D. Electronic Patient Centered Communication Resource Center: http:// www.e-pcc.org/