November, 2002
THERAPY OVER THE INTERNET
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Online therapy or “cybertherapy,” defined as the provision of mental health services over the Internet, is a growing field that has created equal amounts of interest and controversy. Prior to engaging in cybertherapy, clinicians should be aware that there are many risk management issues involved with providing therapy over the Net.
As the world becomes more comfortable conducting business and personal transactions over the Internet, more people are searching the web for mental health services and treatment. Some researchers estimate that over 25 million people go online to search for mental health services. There are over 500 individual therapists who provide cybertherapy and more than 200 websites devoted to cybertherapy.
Experts question whether there is definite proof that mental health services provided over the Internet work or are as effective as traditional psychotherapy. Are chat rooms, e-mails and IM’s (instant messages) as effective as face-to-face therapy? Can clinicians provide dynamic psychological services over the Internet? Can therapists treat, evaluate and diagnose patients without ever seeing them?
Advocates and critics of cybertherapy have raised important treatment and ethical questions. From a risk management perspective, clinicians need to consider the virtual minefield that surrounds this treatment modality.
BENEFITS
Availability and Access
Advocates assert that those with mental illness, who have in the past hesitated to seek treatment due to stigmatism, shyness and fear, find online consultation less intimidating and are willing to give cybertherapy a chance. Anonymity provides a certain sense of relief to some patients. Furthermore, geographically isolated patients and military personnel in remote locations can access previously unattainable mental health services via the Internet. Homebound individuals or the hearing disabled can seek therapy in cyberspace. Business travelers can obtain the therapy they need from the comfort of their out-of-town hotel room. Even those patients too depressed to leave their bed and travel to their therapist’s office can walk downstairs and reach out for help by going on-line.
Many cybertherapists believe that the mere conveyance of feelings through text messages provides a therapeutic “journaling” exercise that is both grounding and affirming. Patients can review past messages to and from their therapists to reinforce treatment goals. Also, patients who devote greater thoughtfulness to their written communication provide greater clarity for treatment issues. Some therapists feel that patients disclose more detailed and deeper personal information to a computer than they do with traditional in-person interviews. Unlike traditional psychotherapy, cybertherapy provides an automatic record of every communication between the patient and therapist for future reference.
Convenience and Asynchronous Communications
Sending e-mails to the therapist at any time of the day or night can be cathartic to some patients. Patients don’t have to wait for their weekly or monthly meetings to communicate with their therapist, they can do so 24/7. The mere sending of the e-mail can provide relief to one in need.
Communication by e-mail eliminates the intermediaries, such as an answering service and secretaries. It also removes patients playing telephone tag with their therapist.
Supporters of cybertherapy like to point out that even Sigmund Freud treated some patients through written text. He would correspond by letter to patients he never met.
Cost Savings
Advocates assert that cybertherapy would lead to cost savings compared to traditional office visits.
Confidentiality and Privacy
Even with encryption software and passwords, communications sent over the Internet are not considered “safe” by the Illinois Department of Professional Regulation. Hackers can easily break into and obtain information saved in both the therapist’s and patient’s computer. Moreover, if the patient is e-mailing the therapist from work, his employer may be able to view the e-mail. If the messages are sent from home, the patient’s family could have access to the cybercommunications. If communications over the Internet are not considered “privileged,” they would be subject to general court subpoenas and not protected by the Illinois Mental Health and Developmental Disabilities Confidentiality Act.
Many web sites put a “cookie” or piece of information on a visitor’s computer to track use and see what other sites the consumer visits. Does the patient who visits a mental health website want that information unknowingly furnished to others? Will pharmaceutical companies deluge cyberpatients with advertisements for their psychotropic medication?
Cybertherapy can lead to problems in verifying the client’s identity. How can the therapist be sure the patient is actually the 35 year old male he reports to be and not a 14 year old female.
Many therapists believe face-to-face discussions are essential to practicing good therapy. Can a clinician diagnose someone without observing the patient’s visual cues, body language and appearance? How does a clinician determine the patient’s affect over the Internet? The tonal quality of the patient’s comments and the issue of pressured speech are lost in cyberspace. Often a therapist needs to see the patient’s response to therapeutic suggestions in order to judge the appropriateness of the response.
Crisis Management and Suicide Prevention
Can therapists effectively evaluate a patient’s risk of suicide without a face-to-face discussion? Furthermore, if there is an imminent suicidal risk, how can the therapist call for help if he does not know where the patient is located? Clinical anonymity and geographic uncertainty can interfere with crisis management.
Computer Addiction
Many therapists are overwhelmed by phone calls from patients at all hours of the day. Will those same needy patients send hundreds of e-mails to the clinician? What happens when the patient’s computer crashes or he cannot connect to his on-line server. What if the therapist’s computer crashes?
Boundary Violations
While traditional therapy settings present certain boundary issues, cybertherapy presents its own unique boundary problems. If the patient sends dozens of e-mails in one day, do they all need to be answered? Will the same borderline patient, who repeatedly pages a therapist and waits by the phone, sit by the computer until he receives a response to his e-mail? How soon does an e-mail have to be answered? Does the patient expect his urgent e-mail sent at 3:00 a.m. on Sunday morning to be returned immediately? Do patients assume the therapist is available 24 hours a day? What happens if the message is not received and lost in cyberspace or e-mails are sent to the wrong address?
Obviously, there is a risk that the individual providing cybertherapy is not a licensed therapist. Anybody with a computer can hold himself out to be an experienced therapist. Even if the cybertherapist is licensed, he may not be competent to treat the wide variety of patients surfing the web. Supervision of the cyberclinician is another potential problem.
At this time, it is unclear whether a therapist licensed in one state can legally treat a client in another state over the Internet. Must the therapist be licensed in the state where the patient lives? If a malpractice issue should arise, which state would have jurisdiction over the case? To date, there is no National Telemedicine Law or national licensing system. Each state has its own statutes regarding the practice of therapy over the Internet. The licensing board in Illinois would assert that an out of state therapist cannot provide cybertherapy to Illinois residents if that therapist in not licensed in this state. Moreover, if an Illinois clinician were to provide e-mail consultation to someone outside the state, that therapist could potentially be violating the laws of the patient’s state. Today, the location of the therapist and patient may determine legal guidelines for both medical licensure and legal jurisdiction.
If a therapist needs to report child or elder abuse, which state’s law governs and which family agency should be contacted? If an Illinois therapist is providing cybertherapy to a patient in Kansas, does that therapist subject himself to the legal authority, licensing laws and reporting requirements of that other state?
Cybertherapy has no diagnostic code. Public and private insurers have not yet embraced cybertherapy as a reliable, cost-effective therapeutic modality. As such, therapy provided over the Internet will likely not receive reimbursement.
As this field develops in the future, laws will be enacted to protect the public and ensure the confidentiality of cybertherapy. Until then, therapists need to give careful consideration and think twice before providing any Internet therapy to patients.
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