Internet-Based Therapy

Internet-based therapy is a form of psychotherapy conducted over the Internet rather than in face-to-face sessions. Therapeutic sessions may be conducted using instant messaging, chat rooms, or email messages. Internet-based therapy is also called online therapy or e-therapy.

Internet-based therapy is sometimes classified together with telephone therapy and videoconferencing as remote therapy, as all three forms depend on remote communication technologies. A number of online therapy providers, in fact, offer telephone-based therapy as well as email and online live chat therapy.

The purpose of Internet-based therapy is to provide psychological help to persons who either cannot get to a physical office for reasons of disability, geographical isolation, or reluctance to be seen visiting a therapist, or who simply prefer electronic to face-to-face communication.

Online therapy can take several different forms, depending on whether the client chooses live online chat/telephone, webcam, or email sessions. One common practice of online therapists is to ask potential clients to complete an online form in which the client provides basic personal information and a description of their problem or reason for seeking counseling. With e-mail sessions, the client fills out the online pre-session form and sends it by a special secure email service, and the therapist replies within one or two business days. Live online chat can begin as soon as the client fills out the pre-session form. For telephone counseling, the client provides the remote therapist with a telephone number and time to call, and the therapist will call at the scheduled time.

Clients are expected to pay in advance, usually via credit card or PayPal. Some online therapists stipulate that all prepaid sessions must be used within six months of purchase.

Online therapy is recommended only for nonemergency mental health services; most online therapy websites state that their services are not appropriate for persons who are suicidal, suffering from psychosis, or having an acute psychiatric crisis. In addition, most will not accept patients under age 18.

As the Information Age progresses, more and more services are becoming available over the Internet. We can buy not only books online but also electronics, clothes, and even groceries. In the business world, the requirement and expense of traveling to in-person meetings are often negated by the ability to teleconference. College degrees no longer need to be earned in the classroom but can be acquired in the comfort of one's own home at one's own pace. The wait for a technician on a manufacturer's help line is often replaced by the ability to search the company's database on one's own or to engage in online chat with the same technician to whom one once spoke. Even for medical problems, one can often chat with a physician or nurse practitioner by email rather than going to the office; this service is known as telemedicine.

There are pros and cons to both sides of the issue of online versus face-to-face therapy. First, communicating through email, online chat, or instant messages has the same drawbacks of any written-only communication: Such nonverbal cues as tone of voice, facial expression, and body language are missing, making interpretation of the message more problematic than in a face-to-face situation. On the other hand, the relative anonymity of online interactions make such therapeutic relationships more attractive to those who would hesitate to go into a therapist's office for fear of being found out by others, fear of embarrassment, or unwillingness or inability to get to the office. In addition, online therapy tends to be less expensive than in-office therapy, a consideration for many clients.

There are, of course, some things that cannot be done over the Internet. For example, psychologists and psychiatrists use a variety of tools and techniques to diagnose mental disorders so that they can prescribe the appropriate course of treatment. Some of the tools used in diagnosis include such psychometric instruments as the Minnesota Multiphasic Personality Inventory (MMPI), such projective instruments as the Rorschach test or the Thematic Apperception Test (TAT), and diagnostic interviews. The various tests and instruments used in diagnosis should ethically be given only by a credentialed professional in a controlled situation and cannot be given across the Internet where there is no control over who will see the test; how long the client takes to answer the questions; or even whether it was the client or someone else who took the test. In addition, it would be extremely difficult to diagnose a patient's problem without a face-to-face meeting for a diagnostic interview.

Research into the effectiveness of online therapy is only beginning. However, a number of disorders have been successfully treated electronically. For example, Internet-based therapy has been successful in the treatment of panic disorder, social phobia, child adjustment after traumatic brain injury, and complicated grief, among others. It is also recommended for treatment of agoraphobia, an anxiety disorder in which people are afraid of wide-open spaces, uncontrolled social situations, and crowds; many are unable to leave their homes without suffering a panic attack.

As with any service provided over the Internet, one must be an informed consumer not only before choosing an e-therapist, but even before deciding to use Internet-based therapy itself. Because Internet-based therapy is an emerging field, there are still many issues to be resolved. Obviously, one must check the professional credentials of a therapist to make sure that he or she is licensed and must determine whether one is choosing a therapist for online or in-office therapy. In addition, it is unclear at this time whether it is legal for a therapist licensed in one state to treat a patient in another state. Choosing a therapist in one's own state makes this issue irrelevant but requires research.

Client/therapist confidentiality is important in any therapeutic relationship. When choosing an online provider of psychological services, one must be certain not only that the therapist subscribes to a professional code of ethics but also that any information, including personal data about the client, is kept confidential and not sold to, or shared with, third parties. Similarly, it is important to check that the website used in online therapy is secure and that conversations, instant messages, and email transmissions between client and therapist are not recorded on the site's secured host computer.

A statement of ethical principles for conducting online therapy is available on the website of the International Society for Mental Health Online (ISMHO). These principles were officially adopted in 2000. It is important to remember that anything sent over the Internet may be subject to being unlawfully sought out by others and that there is an inherent risk to such communication even on secured servers.

Preparation for online counseling requires the client to complete an online form with contact information and a description of the reason for seeking counseling. The client is also asked to choose the preferred method of contact with the therapist (telephone, email, online chat, or webcam) and to pay in advance for one or more sessions. Preparation should also include researching the therapist's company and/ or credentials before making contact.

Potential risks include technical difficulties with Internet or telephone communication and breaches of security by hackers.

KEY TERMS

Agoraphobia—
An anxiety disorder characterized by fear of crowds, open spaces, and/or locations or situations that trigger panic attacks.
Remote therapy—
A general term for therapy delivered by electronic communication technologies; it includes Internet-based therapy along with telephone therapy and videoconferencing.

By early 2011 there were 130 clinical trials of Internet-based therapy under way. Some are trials of cognitive-behavioral therapy or other specific approaches; other trials are comparing online therapy with face-to-face therapy for specific problems or disorders, including smoking cessation, depression, social anxiety, panic disorder, and grief disorder. Still other trials are evaluating the effectiveness of Internet-based counseling for patients suffering from chronic physical conditions with an emotional dimension, such as cancer, chronic pain syndromes, brain injury, or congestive heart failure.

Online therapists are expected to meet the same educational and state licensure requirements as officeor clinic-based therapists. They may be psychiatrists, clinical or counseling psychologists, social workers, marriage and family therapists, or psychiatric nurses. Most have doctoral degrees (M.D., Ph.D., or Psy.D.), with the remainder having master's degrees in psychology, social work, or nursing. There is one professional organization specifically for online therapists, the International Society for Mental Health Online (ISMHO), which was formed in 1997.

Resources

BOOKS

Hsiung, Robert C., ed. E-therapy: Case Studies, Guiding Principles, and the Clinical Potential of the Internet. New York: Norton, 2002.

Kraus, Ron, ed. Online Counseling: A Handbook for Mental Health Professionals, 2nd ed. Amsterdam, The Netherlands: Elsevier, 2011.

Rochlen, Aaron B. Applying Counseling Theories: An Online Case-based Approach. Upper Saddle River, NJ: Pearson/ Merrill Prentice Hall, 2007.

PERIODICALS

Bee, P.E., et al. “Psychotherapy Mediated by Remote Communication Technologies: A Meta-analytic Review.” BMC Psychiatry 8 (July 2008):

Bockling, C.L., et al. “Disrupting the Rhythm of Depression Using Mobile Cognitive Therapy for Recurrent Depression: Randomized Controlled Trial Design and Protocol.” BMC Psychiatry 14 (January 2011): 12.

Buhrman, M., et al. “Guided Internet-based Cognitive Behavioural Treatment for Chronic Back Pain Reduces Pain Catastrophizing: A Randomized Controlled Trial.” Journal of Rehabilitation Medicine 43 (May 2011): 500–505.

Carlbring, P., et al. “Individually-tailored, Internet-based Treatment for Anxiety Disorders: A Randomized Controlled Trial.” Behaviour Research and Therapy 49 (January 2011): 18–24.

Gainsbury, S., and A. Blaszczynski. “A Systematic Review of Internet-based Therapy for the Treatment of Addictions.” Clinical Psychology Review 31 (April 2011): 490–498.

Hedman, E., et al. “Internet-Based Cognitive Behavior Therapy vs. Cognitive Behavioral Group Therapy for Social Anxiety Disorder: A Randomized Controlled Non-inferiority Trial.” PLoS One 6 (March 25, 2011): e18001.

Lampe, L.A. “Internet-based Therapy: Too Good to be True?” Australian and New Zealand Journal of Psychiatry 45 (April 2011): 342–343.

Warmerdam, L., et al. “Cost-utility and Cost-effectiveness of Internet-based Treatment for Adults with Depressive Symptoms: Randomized Trial.” Journal of Medical Internet Research 12 (December 19, 2010): e53.

WEBSITES

eTherapistsonline.com. “About Online Counseling.” http://www.etherapistsonline.com/therapy/about.htm (accessed May 11, 2011).

International Society for Mental Health Online (ISMHO). “Suggested Principles for the Online Provision of Mental Health Services.” https://www.ismho.org/suggestions.asp#principles (accessed May 11, 2011).

ORGANIZATIONS

Find a Therapist, Inc, 6942 E Lomita, Mesa, AZ, United States, 85209, (480) 325-8330, Fax: (480) 396-3213, (866) 450-3463, http://www.etherapistsonline.com .

International Society for Mental Health Online (ISMHO), [online contact only], https://www.ismho.org/contact.asp , https://www.ismho.org/home.asp .

MyTherapyNet, 22425 Ventura Blvd., Suite 350, Woodland Hills, CA, United States, 91364, Fax: (800) 931-9956, (800) 931-9956, customerservice@mytherapynet.com, https://www.mytherapynet.com .