By Shannon D. Smith, Ph.D., DAPA, and Cynthia Reynolds, Ph.D., Licensed Psychologist
Cyber-therapy is a fast growing phenomenon in the field of psychotherapy. Internet sites are being established on a routine basis, most offering some form of therapy on a fee for service basis. Proponents of this method of delivering mental health services hold that the internet is a viable way to provide a range of psychotherapy services. However, opponents of e-therapy hold that too many legal and ethical issues make this particular practice unfathomable. Many of the psychotherapeutic governing bodies have developed ethical guidelines to assist cyber-therapists in the practice of e-therapy. However, there are several problematic issues that confound the practice of cyber-counseling. This article reviews the current state of cyber-psychotherapy and the issues that psychotherapists need to be aware of as this method of delivering services continues to expand. This article reviews the above issues related to cyber-psychotherapy.
Cyber-psychotherapy, Internet counseling, legal issues, ethical issues, use of technology in psychotherapy
The Internet and the world wide web (WWW) have become an intricate part in almost every aspect of our society, including psychotherapy. Internet sites now advertise on-line psychotherapy under such labels as “cyber-therapy,” “cyber-counseling,” “cyber-psychology,” “e-therapy,” and “virtual coach therapy”. Some psychotherapists are fully embracing the use of the Internet and have established web sites, while others are cautiously standing back or denouncing its use entirely. Whether one is opposed to or in support of the use of the Internet as a viable method of delivering psychotherapeutic services, it is imperative that psychotherapists understand the current state of Internet psychotherapy. This article provides a review of both the potential benefits and limitations of “cyber-psychotherapy”.
The use of the Internet as a means to provide psychotherapy is a recent phenomena in the field of psychology and counseling. Since the mid-1990s, many professional therapists have successfully delivered psychotherapeutic services, including on-line psychological assessments, interactive psychotherapy, therapeutic advice (for a select fee), educational counseling, virtual support groups, etc. Individual therapy sessions are commonly held via e-mail, while group services are held using secured chat rooms. Recent advances in technology are now allowing for the transmission of visual images of the client and therapist through video conferencing. Many web sites attempt to ensure confidentiality by using “encryption,” as this technology allows for the secure transmission of information between two or more parties.
There are several well-established cyber-therapy web sites that are accessible simply by typing the word “psychotherapy,” “counseling,” or “therapy” into a WWW search engine. One of the most popular sites to appear on the list of e-therapists is called Metanoia (http://www.metanoia.org). This is a very user-friendly site for those seeking psychotherapeutic services. It discusses the “ABC’s of Internet Therapy” and provides a list of question and answers for potential users seeking e-therapy. It is one of the pioneer web sites in cyber-therapy, and is a pristine site for the up-and-coming cyber-therapists to use as a model when establishing their own “e-therapy” web site.
Advocates of cyber-therapy claim that the Internet is a viable method for the delivery of psychotherapy services. They believe that there are many benefits which ultimately outweigh the limitations of cyber-counseling, and that any ethical issues can be remedied. Therefore, such proponents contend that cyber-therapy should be actively embraced by the mental heath community.
Five of the most prominent benefits cited include the following: 1) the ability to reach clients in remote areas or those who have the inability to access a therapist due to lack of transportation or physical disability (Sampson, Kolodinsky & Greeno 1997), 2) the ability to schedule sessions at times convenient for both the client and therapist that would otherwise be unmanageable, 3) the ability to establish a permanent record of the therapeutic communication, 4) the ability to access psychotherapists with specialized training, and 5) the ability for clients to reveal information more freely then they might otherwise in a psychotherapy session (International Society for Mental Health Online [ISMHO]). Unfortunately, there are no solid empirical research studies comparing the efficacy of e-therapy versus the traditional, orthodox face-to-face therapy.
With the rise in the use of internet psychotherapy, several challenges and concerns have also emerged. Limitations regarding cyber-therapy include the following: 1) issues of confidentiality, 2) risk management, 3) the inability to verify the provider and the provider credentials and competence level, 4) the inability to provide appropriate level of clinical care, 5) the inability to appropriately discern cultural nuances. Additionally, several legal matters arise when the cyber-therapist traverses across state and international lines, including the violation of specific licensing and jurisdiction laws, as well as conducting unethical practices. Other problems involve the use of technology itself, such as lack of compatible technology for communication between the client and therapist, as well as the failure of technological systems.
Confidentiality is a major issue presented by web-therapy. Limitations include the lack of secure communication between e-therapists and their clients, as well as the concealment of the therapeutic communication such as e-mail. Even after the e-therapy has been completed, it is not always possible to guarantee the security of the record of communication, particularly in the home of the client.
Perhaps the most serious matter concerning the use of the cyber-therapy is risk management. Cyber-therapists are limited in their potential to properly assist clients when imminent danger is present. One of the major issues of risk management is suicide. When a client becomes actively suicidal, it is the psychotherapists’ responsibility to assist the client by ensuring his or her safety. However, the ability to provide an avenue of safety is severely limited when the client is not immediately accessible. Although e-therapists provide some measure of security for this particular situation by outlining emergency procedures to follow such as a phone number to call (i.e., the National Suicide Hotline, 1-800-SUICIDE) or going immediately to the nearest hospital emergency room) there is no way to ensure that a client will follow through with such instructions. The situation is complicated by the fact that most people who are in a suicidal state of mind are often less likely to take the proper steps to ensure their own safety. Thus, such procedures are, in effect, useless, especially in the most severe clinical cases.
A closely related risk management issue for e-therapy is the inability of psychotherapists to provide an appropriate level of care to clientele. Due to the lack of direct face-to-face contact with a client, “e-psychotherapists” must base all of their clinical decisions in each situation upon the information obtained via the Internet. Whether such information is transmitted as an e-mail or through video conferencing, the same fact holds true: without direct client contact, it is not possible for cyber-therapists to fully assess a clients’ mental status and determine an appropriate clinical intervention or level of care.
The potential for imposters to falsely represent themselves as professional therapists is another hazard of web-therapy. A client does not have the verifiable methods to ensure that the e-therapist is truly the e-therapist advertised. It is also possible for clients to falsify their identity, leaving cyber-therapists to conduct therapy with an unknown person. Rudimentary steps have been taken to ensure the authenticity of therapists’ credentials. For example, some counseling web sites have verified the credentials of the cyber-therapists listed on their web pages with their respective state and national credentialing bodies. There is also a credentialing check service that verifies the authenticity of on-line providers (http://mentalhelp.net/check).
With the advantage of being able to expand psychotherapy services into remote neighborhoods via the Internet also comes the disadvantage of not being able to appropriately discern cultural nuances. Communication via the written word limits one’s ability to properly interpret and transmit specific cultural and ethnic gestures and idiosyncrasies. This creates the potential for miscommunication and misunderstandings between e-therapists and e-clients, which can ultimately confound clinical issues that clients come seeking help to resolve.
There are several regulatory concerns associated with Internet psychotherapy. Cyber-therapists are faced with the challenge of remaining within the geographical realm of their professional jurisdiction. Crossing state and international lines can very easily cause psychotherapists to violate specific licensing and regulatory laws ordained by their governing body. This fact holds true for many of the helping professionals including psychiatry, psychology, social work, counseling, and marriage and family therapists. E-therapists should check with their governing bodies and other state and international licensing organizations to ensure they are in compliance when treating e-clients.
Several professional organizations have taken steps to develop ethical standards and guidelines for the practice of cyber-therapy. Included in this effort are the following: The American Psychological Association (http://www.apa.org/ethics/stmnt01.html), the American Counseling Association (ACA) (http://www.counseling.org/gc/cybertx.htm), the National Board for Certified Counselors (NBCC) (http://www.nbcc.org/ethics/wcstandards.htm), International Society for Mental Health Online (ISMHO) (http://www.ismho.org/suggestions.html), the Health On the Net Foundation (HON) (http://www.hon.ch/HONcode/Conduct.html), and the Internet Healthcare Coalition (IHC) (http://www.ihealthcoalition.org/ethics/draftcode.html). These organizations are to be applauded for their efforts in taking proactive steps to address the issues of Internet psychotherapy. However, there still remain several problematic concerns yet to be resolved.
Many of the ethical guidelines provided by these organizations are overlapping in content. Some of the guidelines outline unique or specific instruction as it pertains to the characteristics of each organization, and therefore cannot be generalized to all situations or clinical populations. The most critical issue that remains to be adequately resolved is risk management. The gap between the computer monitor and the client and therapist does not allow for immediate intervention in the most critical matters.
There still remain many potential pitfalls and unresolved dilemmas that the above governing bodies, ethical practices and guidelines do not necessarily remedy. Therefore, e-psychotherapists are faced with the challenge to develop the necessary solutions to these unresolved matters. This effort will ensure the safety of clients, the security of each psychotherapist’s professional practice, and the integrity of the psychotherapy profession at large.
About the Authors
Shannon D. Smith, Ph.D., PCC, DAPA, completed his M.A. in Counseling at the University of Ashland, Seminary Division, Ashland, Ohio and his Ph.D. in Counseling from the Oregon State University, Corvallis, Ore. He has worked as a child and family therapist in community mental health and as a school counselor in the public school system (K-12). Currently, he is an Assistant Professor in the Department of Counseling at The University of Akron, Akron, Ohio. His research interests include child and family therapy, school counseling, play therapy, counselor education and the use of technology in counseling. Of particular interest to Dr. Smith, is the diagnosis and treatment of Attention Deficit Hyperactivity Disorder in both children and adults.
Cynthia A. Reynolds, Ph.D., LPCC, NCC, RPTS, Licensed Psychologist and certified School Counselor, completed her B.S., M.Ed. and Ph.D. at Kent State University, located in Kent, Ohio. She has been an elementary school counselor for 16 years in the Kent City public school system. Currently, she is an Assistant Professor and coordinator of the masters in school counseling program in the Department of Counseling at The University of Akron, Akron, Ohio. Her research interests include school counseling, play therapy, Gestalt therapy and the use of technology in counseling.
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