(2/29/2016 Author's note: This article is being maintained for historical purposes. The original links have been disabled because since the time this article was written, many of the links no longer exist or point to web sites unintended by the author. The author is not responsible for the content of other web sites. If you are planning on providing psychotherapy over the Internet, please check with your profession's state licensing agency for current regulations.)
Thoughts about Online Psychotherapy:
Ethical and Practical Considerations
Gary S. Stofle, ACSW, CSWR, CASAC
Written in 1997
This article explores multiple issues surrounding the practice of psychotherapy online, with a specific focus on psychotherapy conducted in chat rooms on America On Line (AOL). The author has conducted online therapy with a client on a weekly basis since December, 1996. Although the specifics of the case will not be discussed in this article, the experience of conducting regular weekly online sessions has led to the formation of many of the ideas in this article.
State of the Art Currently
With the explosion of the Internet over the last several years, psychologists, psychiatrist and social workers are exploring the possibilities of providing helping services to clients online. Most therapists who provide services currently do so using email to provide answers to questions people present to them. Some therapists are very firm in their belief that psychotherapy simply cannot occur online because you can't see the client. Other workers are conducting ongoing individual and/or group therapy sessions with seemingly good results. Below listed are web sites of interest in this topic.
Online Psychotherapy Web Sites
These two web sites are excellent sources of information concerning what is happening online:
http://www.metanoia.org/imhs/intro.htm Metanoia is a website that reviews and publishes on their web page the web pages of online practioniers. It reviews submitted web sites for several factors including the presence of credentials of the provider of services; type of online therapy; security of website for transmission of information and payment information for services. Web sites are divided by single session and ongoing sessions; each web site is given a star rating. This is an excellent place for finding out what is available online. Martha Ainsworth has done a wonderful job on this site.
http://netpsych.com/ NetPsychology is a wonderful and attractive repository for all kinds of therapy happening in cyberspace. A lot of good information on this one.
Here are several examples of web sites by providers of online services:
http://www.counseline.com/ This site has advertises access to encrypted chat rooms for ongoing counseling. It contains a well written disclaimer about not being able to handle clients with "severe issues" or those who need "extensive counseling or psychiatric care".
http://members.aol.com/drjudith77/index.htm Dr. Judith is Dr. Judith Schwambach, who has a Ph.D. in counseling from LaSalle University. She offers email, chatroom, telephone and face to face counseling. Her site is quite attractive and she seems to have worked out all the details regarding billing and so on. She provides ways to verify her credentials including a copy of her yellow pages advertisement.
http://www.couselorscorner.com/page1.html Susan Taber, an MSW and licensed professional counselor, went online in May, 1997. She has established a very well designed site and has been working with clients on a per question basis, where the client will email a question or concern and Susan will respond. She also meets with clients in chatrooms to discuss their concerns, but doesn't do ongoing work with clients.
http://www.nicom.com/~davids/ The Mental Health Cyber Clinic is a wonderfully designed site that is fun to explore. It is amazing the energy, effort and thought Dr. David Somers put into this site.
http://www.netpsych.com/share/index.htm Shareware Psychological Consultation, a web site by Dr. Leonard Holmes, a licensed clinicial psychologist, is quite well constructed. Dr. Holmes is very clear in that he doesn’t think psychotherapy can occur without actually seeing the client, and so limits his online practice to consultation. He asks for payment for his response only if you find value in it (thus the idea of shareware – buy if you like).
Competency in the provision of online psychotherapy needs to be viewed in two levels: 1) experience, training and expertise in providing traditional psychotherapy and 2) skills and abilities in online communication. The therapist needs to be grounded in a system of therapy that works to help clients develop insight, make changes and grow. This grounding comes through formal education, training and actual experience in working with clients in an area of expertise. We feel competent, and our clients perceive us as competent, when we know "how things work". Although each client is unique, when a therapist is experienced he or she can see themes emerging as a new client begins to discuss their issues. With this understanding of themes, we can make predictions about a client’s issues – sometimes even before the client gives voice to the issue. We are able to "fill in the blanks". This ability is indispensable to the provision of online psychotherapy. We need to be able to fill in the blanks at times. Knowing how things work, being able to discern the client’s themes and being able to predict or have a sense of the client’s unspoken issues all help the client feel safe and listened to in the online session. At the same time, the experience of the therapist helps the client trust the therapist over time, particularly if the therapist is grounded in a system of ethics that involve the protection of client rights and respect for the client. However, being a competent therapist by itself is not enough to make one a competent online therapist.
We need to take into account and adjust for the differences that exist in the provision of text based psychotherapy as opposed to face to face psychotherapy. Even the most noted therapist could not conduct online therapy sessions without skills in typing, spelling, grammar and navigating online. These issues will be further explored in the Practical Considerations section.
The therapist needs to focus intently on the session while the potential for distraction is quite great. Online therapy can be done from the comfort of a home office and family members can react differently to an online session as opposed to a client physically being in the home office.
There is much debate and concern about therapists’ providing services to clients in other states or nations. Many people view the provision of services as actually being done in the client’s state rather than the therapist’s state. There is concern about how the client can take legal action against the therapist if the therapist acts inappropriately. Another concern is the question, how does the client know whether or not the therapist is actually licensed and if so, what does that mean? States are considering legislation to limit the provision of online services to the therapist’s state (e.g. California law now states only therapists that are licensed in California can provide online services to residents of California).
A simple and practical solution exists to this problem. The answer is found in the metaphor of the "information superhighway". As the internet became more popular many talked about this "highway". People were encouraged to "cruise the highway". In our travels on the internet, many have gone to foreign countries. Here’s the point: when a person travels the internet, they leave where they are and go somewhere else. If a person drives on Interstate 95 to Connecticut from New York and goes to the Emergency Room in a hospital there, treatment would be provided by an MD licensed in Connecticut. Should the MD be licensed in New York? Of course not. Could you imagine the administrative and logistical nightmares involved in obtaining licensure for every state of every client you have worked with? It would be impossible. Here are some recommendations:
For Social Workers, it may be as simple as adding an additional piece to one of the existing national certifications approved by NASW.
America On Line (AOL) has a wonderful system of oversight to protect the online community members from mistreatment. This system is called the Guidepager. If a person is being harassed in a chat room, all they need to do is summon a Guidepager while cutting and pasting the offensive material and placing it in an email to AOL. The workers in the Terms of Service department will review the material and decide on a consequence. The consequence can be as simple as a warning, or as drastic as termination of the offender's AOL account and notification of the police. (This has been done particularly in cases of child pornography). What a wonderful safeguard for a client in therapy! If a therapist makes inappropriate sexual remarks to a client, it is there for the world to see, and the therapist can face the appropriate consequences. There is no system, and no potential for a system, like this in face to face therapy.
Both the technical support workers and the administrative workers at AOL state clearly no one can be in a chat room without their name being listed on the People in Room textbox. The chat room provides a secure and safe environment for conducting online therapy. Using a Buddy list, it is quite easy to create a private chat room and send an invitation only to your client. The chat can be logged verbatim which keeps a specific record of what occurred during the session. These logs can be password protected like other files using Word for Windows (and probably other word processors as well). The other way a client's privacy can be broken is by someone looking at either the worker's or the client's monitor. Recently, an ongoing client left the chat room precipitously while talking about sensitive issues with her husband when her husband walked into the room. Scheduling of sessions and other arrangements can be made to minimize the risk of someone looking at the monitor during a session.
There are many practical considerations to providing therapy services online. The issues identified are obvious and are included in just about every article regarding the provision of services online:
Lack of nonverbal cues. Text based psychotherapy involves seeing only the written word. Is it possible to express emotion online with only words and characters? Absolutely! Humans will communicate effectively no matter what the medium. A client can greet you in various ways, each of which can tip you off to how they are feeling. Look at these two sentences at the start of a session. The client can start out by saying "I’ve been looking forward to seeing you this week – I’m so excited! You won’t believe what has happened this week…" or she can start out by saying "hi :o(". If you can get a sense of the feeling tone in the sentence as you are starting the session, imagine how much more information you can get in a chat room with a person over a 45 minute period. The therapist needs to be comfortable using smilies (e.g. :o) or :o( ) and abbreviations (e.g. LOL; ROFL), but not to the point where is distracts from the work. The use of smilies goes a long way to reducing the harshness and starkness of the written word and to communicate feelings.
Starkness and potential coldness of text based interaction. To engage a client online, to develop and maintain an online therapeutic relationship, the therapist has to have a good sense of humor. One should not being doing comedy online, but a little humor now and again helps the client regroup. The therapist who genuinely cares for the client can communicate that to the client using words, and the words facilitate the healing. Although the words can be stark at times, communication in phrases and words can be quite dramatic and potent.
Potential for misunderstanding How do you prevent misunderstanding between therapist and client online? This is prevented in the same way it is prevented in face to face therapy – good communication skills. Online, the therapist needs to check with the client often to make sure the client understands what you are saying and that you understand what the client is saying. The experience of the therapist in working with others and his or her superior communication skills are essential in preventing misunderstanding.
Lack of control We are well aware of the potential limitations of online work. Not being able to have the client sitting across from you – where you can have a great deal of influence over the client, particularly concerning their safety – is causing quite a lot of discomfort in most of us. All ethical therapists are concerned about the lack of control we have providing online therapy sessions. There are clients who are clearly inappropriate for online services, e.g. psychotic clients; clients in need of medication; clients that need monitoring for urines; clients with concurrent medical conditions that need immediate treatment and so on. All programs face the issue of people who seek treatment at their facility but are inappropriate. Each program has its admission criteria and is equipped to treat a certain type or range of types of clients. An outpatient substance abuse agency can’t treat a chronic schizophrenic with no substance abuse history. The limitations of online psychotherapy programs are not unlike limitations of other programs - we can't treat all people. Most online providers state quite clearly the limitations in the provision of therapy online.
Can you establish a relationship online? Some say you can’t. Dr. Holmes, an online psychologist who answers psychological questions by email states simply " …please do not write me expecting psychotherapy over the internet. There is no such thing." That has not been the experience of at least several therapists who have conducted ongoing psychotherapy online. We can establish therapeutic relationships online.
Is the client who they say they are? An easy way to verify client’s identity is to obtain real name, address and telephone number. Some workers may not want to ask for that information and that can be ok as well if this lack of information is congruent with the type of therapy being done. All involved need to be aware of the risks when the therapist doesn’t know the client’s identity, address and phone number.
Therapist’s ability to communicate online We must keep in mind the nuts and bolts of providing online psychotherapy – the therapist must be able to type; to spell; to use appropriate grammar; to be able to get around online. As mentioned above, even the most renowned and respected therapist won’t get too far in this process if they can’t type, spell or at a more basic level navigate on the computer.
We can provide ongoing psychotherapy online. Human beings are wonderfully adaptable. We have found many wonderful and unusual ways of communicating with one another. For centuries we have used the written word to express thoughts, feelings and opinions with one another. We have used the written word to titillate; to persuade; to con, manipulate and harm others. And we have also used the written word to heal. Online psychotherapy is a way ethical therapists can use the written word to heal through establishing a therapeutic relationship.
And we do establish relationships online. We do that quite easily. Anyone who is a member of an email discussion group can attest to the fact that one can grow close to another professional as a result of the written word. You can also grow to immensely dislike another professional. I have met people online who I have grown to trust and whose opinions I value.
The characteristics of a competent psychotherapist, e.g. warmth, non judgemental attitude; empathy; centeredness; honesty; genuineness and so on are expressed online just as they are in person. We use words, symbols and actions to express these characteristics online, while in face to face therapy we use nonverbals and actions to express these characteristics.
The words we use reflect our genuine interest in the client and their issues. This can’t be faked online because the therapist needs to be right in there with the client. If you are not paying attention, it can be obvious to the client even though it may not be obvious to you. The therapist needs to utilize superior communication and concentration skills to insure the client’s point is understood and the therapist is making him or herself understood as well.
Trust is built up over time through the therapist’s words and actions, just like it is in face to face therapy. When the therapist says "I’ll meet you online Thursday at 8pm" then he or she needs to do so. If you do, and you do so over time, the client begins to trust you will do what you say you will do. Trust also builds when you and the client have similar goals and values. Clients benefit most when both the therapist and the client value the client’s welfare and place that first.
If we proceed too cautiously in this journey because of the ethical issues, or decide not to provide online therapy services because of the unknown, who will be available to treat the clients who won't, for whatever reasons, seek face to face therapy?
If the ethical therapist is not online, who is?
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Sleek, S. "Online Therapy services raise ethical questions." APA Monitor, November, 1995. (http://www.cmhc.com/articles/apa1.htm)
Suler, J. "Online Psychotherapy and Counseling" (http://www1.rider.edu/~suler/psycyber/therapy.htm)
Metanoia Guide to Internet Mental Health Services, 1997, http://www.metanoia.org/imhs/intro.htm
Counseline, 1997, http://counseline.com/
Ask Dr. Judith, 1997, http://members.aol.com/drjudith77/index.htm
Shareware Psychological Consultation, 1996, http://www.netpsych.com/share/index.htm
Counselor's Corner, 1997, http://www.counselorcorner.com/
The Mental Health Cyber Clinic, 1997, http://www.nicom.com/~davids/