Therapy from afar. While the very notion of it makes some queasy, a growing number of people are seeking—and providing—mental-health help through nontraditional means, such as by telephone or videoconferencing or via E-mail or online chat. E-therapy petered out somewhat after the dot-com bubble burst, when several online "clinics" went bankrupt, but there's been a resurgence as technology has advanced, says John Grohol, a psychologist who is an expert in online mental health and founder of Psychcentral.com, a comprehensive website that features informational articles, support groups, professional blogs, self-help quizzes, and other resources for patients and professionals.
Online counseling holds tremendous promise, advocates say, because it bulldozes the barriers that bar people from face-to-face treatment, such as disability, distance, or hectic schedules. The anonymity also is alluring. But even staunch proponents of telemental health say that tapping into online therapy through E-mail and instant messaging requires caution. It may take just a few keystrokes to find a individual practitioner's website or sites that feature a menu of professionals, but there are several things you should consider before clicking "Pay." "It's really buyer beware," warns Patricia Recupero, a clinical professor of psychiatry at Brown University who chairs the American Psychiatric Association's Council on Psychiatry and Law. Here are seven areas to consider:
1. Licensing. Online counseling websites may advertise chat sessions with a "licensed professional." Sounds great, but what does it mean? "Normally, psychologists are required by law to be licensed in the states in which they practice," says Roberta Nutt, director of professional affairs for the Association of State and Provincial Psychology Boards, to which all the psychology licensing boards in the United States and Canada belong. In this context, that means the state where the patient resides, says Marlene Maheu, a California-based clinical psychologist and executive director of the Center for Online Counseling and Therapy, a professional training program for therapists wanting to use technology in their practices. If your therapist is licensed only in California and you live in Delaware, he or she could technically be practicing without a license, which is illegal, notes Maheu. That could leave you with little legal recourse if something goes wrong, she says. She suggests asking yourself: Is this professional licensed in my state of residence so that if I have a problem, I will know which licensing board to send my complaint to? Check other credentials, such as expertise in what the therapist purports to offer, too. A "substantial" number of people offering therapy online don't disclose such information, says Recupero, whose findings after surveying 55 E-therapy sites were published in the Journal of Clinical Psychiatry in 2006.
2. Short cuts. What concerns psychologist and ethics expert Thomas Nagy, an adjunct clinical assistant professor at the Stanford University School of Medicine, is that therapists offering services online might take short cuts. A crucial part of face-to-face therapy is informing patients about confidentiality and privacy up front, which includes addressing the exceptions to confidentiality—such as if a patient divulges that he has abused a child or elder at home. "Those are reportable offenses in most states," says Nagy, "and patients don't know that unless we tell them ahead of time." That discussion, he worries, might be omitted in the interest of time when communicating via E-mail or instant messaging. To make sure it doesn't, Maheu advises asking yourself: Is the therapist telling me everything I need to know regarding confidentiality? For example, isn't he or she supposed to report me if I do something against the law? What are those things? What's going to happen with that information? Who can get it under what circumstances (perhaps with a subpoena)? Will he or she tell me ahead of time in a written agreement? What else should I know ahead of time?
3. Privacy. Similarly, it's important to ensure privacy on the therapist's end by understanding who else has access to his or her computer, where and how records are kept, etc. If the counselor ever stepped away from his or her desk midsession, would a secretary take over? You'll want to insure privacy on your end, too. If you share a computer with your family, for example, it's possible that someone could catch a glimpse of your E-mail divulging details of that regrettable affair. And experts advise never conducting a session on your workplace computer.
4. Technological reliability. Despite rapidly advancing technology, the Internet still has its shortcomings. Though websites can be made "secure," says Maheu, E-mails can be intercepted and chat sessions hijacked unless they are protected by both parties with encryption. Moreover, the connection can be spotty. Imagine if the moment after you divulge your deepest secret during a chat session, service drops. What would you think as your cursor blinks?
5. Lack of nonverbal cues. During face-to-face sessions, therapists have access to an array of nonverbal cues: whether a patient becomes tearful or blushes, say, or fidgets, bristles, or avoids eye contact. "These things make a difference," says Nagy. Even videoconferencing doesn't allow for the same clarity of signals that therapists normally get to help them understand their patients. Ask yourself if you're comfortable with that.
6. Backup. Issues that arise during therapy often are being explored for the first time, and emotions can spill forth unexpectedly. Maheu advises asking: What does the online therapist do if I get emotional during a session? What if we get disconnected at those times? Does he or she call my house or just forget about me? How does the therapist know where to send me in my local community? A therapist is supposed to have some ability to respond to your acute needs.
7. Training. Finally, it's fair to ask if the therapist has had any training in Web therapy, says Grohol. "I would be looking for people who had taken courses and really gone out of their way to try and be an expert—a specialist in this field." The American Psychological Association stipulates in its ethics code that professionals provide services "within the boundaries of their competence or undertake relevant education, training, supervised experience, consultation, or study," says Maheu. Yet, many professionals who offer therapy online can't document that they've undergone such training, she says. "Rather, they are just Dr. Pete or Dr. Sally, who might have had a practice for a while down the street and now decides to open a website and start delivering services to the world."
Though Maheu is an advocate of telemental health, she doesn't believe that therapy delivered over the Internet is quite ready for prime time. "Much better technologies exist than the Internet alone at this point," she says. An example, she says, is the videoconferencing system in use by the military worldwide. But she's training professionals in how to best use technology in practice now—and in the not-so-far-off day when the Internet can be unleashed in full force to counsel patients. Says Maheu: "It's so ready to explode."