Course content © Copyright 2018 - 2025 by William W. Deardorff, Ph.D, ABPP. All rights reserved.

Course Outline

Introduction and Overview

Learning Objectives

A Brief History of Online Treatment

A Confusing Array of Terms

Prevalence and Scope of Online Treatment

Online Searches

Professional Societies

Ethical Guidelines

Practitioner Guidebooks

Training Programs

Journals

Professional Attitudes toward Online Treatment

Client-Patient Attitudes toward Online Treatment

Defining Terms and Approaches

Web-Based Interventions

Online Counseling and Therapy

Internet Operated Therapeutic Software

Other Online Activities

Effectiveness of Internet Based Interventions

General Advantages and Disadvantages

Ethical Guidelines and Standards of Practice

Compliance with Ethical Standards

State and Legal Guidelines

If You Do It, What Should You Do?

Plan for the Worst Case Scenario

Conclusions

References

Introduction and Overview

The Internet has impacted virtually all aspects of our lives, and the provision of mental health services is no exception.  As will be discussed in this course, Internet-based health and mental health services have become more prevalent over the past two decades.  Counseling provided over the Internet is done in many forms and these will be reviewed in this course.  An overview of Internet based treatment is as follows:

Proponents of Internet-based treatment cite benefits such as cost effectiveness, relative anonymity, immediacy, increased access, easy self-disclosure, and convenience for clients with mobility and transportation issues.  However, opponents of this increasingly prevalent mode of treatment list such issues as a loss of the human factor in psychological treatment, the inability to utilize non-verbal cues as part of treatment, potential threats to confidentiality and privacy, a variety of potential ethical and legal problems, and a lack of research and guidelines to justify its use.  Given these factors, you will find a range of practitioner attitudes towards online counseling from complete opposition to embracing the approach whole-heartedly.  Regardless of one’s position on the matter, it is important to be informed about this type of practice and its impact on mental health (and health) treatment. 

The purpose of this course is to provide an overview of the area of Internet-based mental health interventions.  This will include an overview of its history, attempts to agree on definitions and a taxonomy, estimates regarding its prevalence and scope, a discussion of professional’s attitudes towards this type of intervention, the advantages and disadvantages of this type of approach, available research relative to these interventions, a review of ethical guidelines and standards of practice, and an overview of future issues.  Although the course will include a detailed discussion about definitional and taxonomy issues related to Internet-based interventions for ease of communication, we will generally use the terms e-therapy, online treatment, or Internet based interventions.    

Current Resources

As will be seen, online mental health treatment is changing very rapidly in terms of technology, efficacy of interventions, and regulatory statutes (ethical and legal). This course may refer to following ethical codes:

It is not possible for any course about internet-based mental health treatment to be completely current since the field is changing so rapidly. However, all the issues addressed in this course will always be applicable to online treatment. The following resources will allow the reader to investigate the most up-to-date information about various issues.

Check with your professional organization. If you are considering online treatment, you should first check with your professional organization to get current information for your profession (ethics, etc.). For instance, the American Psychological Association (APA) offers Guidelines for the Practice of Telepsychology, which state that “Psychologists should make reasonable effort to be familiar with and, as appropriate, to address the laws and regulations that govern telepsychology service delivery within the jurisdictions in which they are situated and the jurisdictions where their clients/patients are located.” 

Check with your state licensing board. After that, check with your state licensing board about jurisdiction, legal issues, and state laws. This might also include checking with your states Dept. of Consumer Affairs or similar entity. For example, if you live in New York, the New York State Office of the Professions provides links to relevant “Laws, Rules, & Regulations” for each profession (psychologist, social worker, etc.). Once you have a good understanding of your state’s laws that relate to your specific profession, you’ll still need to do some more research for the states in which your clients reside if you plan to serve people that live outside of your home state. For instance, the California Board of Psychology has a notice to consumers regarding those who choose to seek psychological service over the Internet (click here).  The notice provides warning about the practice, the requirement for written informed consent, and the statement, “Individuals who provide psychotherapy or counseling to persons in California are required to be licensed in California”.  Although there are efforts to change these state statutes, to our knowledge, that has not occurred. Similar statutes likely exist in other states and these should be checked carefully by the E-therapy provider.

Check federal statutes. Finally, research any federal issues relative to online practice (e.g. HIPAA, Medicare billing, etc.). Current information about federal issues can be found in some of the following resources, through your professional organization, or going straight to USA.gov Federal Laws and Regulations.

Check technical and practice requirements. Once you have investigated with the above agencies, there is still the issue of actually "doing it". This involves being sure about the technology you are using, billing and reimbursement issues, malpractice coverage for this type of work, etc. 

Learning Objectives

A Brief History of Online Treatment

The provision of e-therapy includes the concept of “distance therapy” which simply addresses a treatment intervention in which the therapist and patient are in different locations while treatment is being implemented.  The use of distance or non-face-to-face therapy is not new and can be traced at least as far back as Freud in the early 1900’s.  As discussed by Brabant et al. (1994), Freud was well known for his use of the exchange of letters as a cornerstone of his practice. 

The advent of telephone and telephonic services provided another avenue in which distance, non-face-to-face psychological therapy could be delivered.  Psychological services delivered over land-based telephone lines presented such issues as confidentiality (e.g. party lines, as well as the issue of leaving information on early, non-secured phone answering machines).  These confidentiality issues became more relevant with the promulgation of cell phone use and associated technologies (text messaging, IM, etc.).  Each of these new technologies was initially met with resistance relative to use and this seemingly waned as they became more accepted by society.  In addition, various guidelines and recommendations for use (standards of practice) seemed to follow as the technology became more prevalent.  Currently, we are experiencing similar issues with Internet-based treatments.  Also, as is often the case, the technological advances proceed much more rapidly than guidelines for use (e.g. ethical standards, standards of practice, liability and risk management guidelines, etc.). 

Mental health services emerged on the Internet as early as 1982 in the form of online self-help support groups (Kanani & Regehr, 2003).  One of the earliest known services to organize mental health advice online was “Ask Uncle Ezra,” a free service offered to students of Cornell University.  This program has been operating since 1986 (Ainsworth, 2002).  In 1993, Ivan Goldberg, M.D. began answering questions online about the medical treatment of depression (Skinner & Zack, 2004).  Subsequently, John Grohol, Psy.D. developed a free mental health advice website in 1995.  Dr. Grohol was one of the early innovators relative to this type of Internet-based intervention or “advice” and is still active in this area currently.  As discussed by Ainsworth (2002), fee-based mental health services offered to the public began to appear on the Internet in the mid-1990’s.  These systems were fairly rudimentary and generally offered “advice services” in the form of answering one question for a small fee. 

According to Skinner & Zack (2004), the first known fee-based Internet mental health service was established by Sommers in 1995.  The program established by Sommers went beyond answering a single question and sought to establish longer term online therapeutic relationships.  In 1995, Needham became the first practitioner to offer e-therapy via real time chat. 

After these initial innovations in the mid 1990’s, it did not take long for counselors to begin experimenting with online counseling as extensions of their existing private practices.  By the late 1990’s, e-therapy services were emerging and these were often done through the formation of “E-clinics.”  Counselors interested in providing this type of online service could join an E-clinic and, in turn, the company would offer such resources as a secure website, active marketing, and other practice management tools (Skinner & Zack, 2004).  During this time, the International Society for Mental Health Online (ISMHO.org) was founded in approximately 1997.  The organization was founded to promote the understanding, use, and development of online communication, information and technology for the International Mental Health Community.  Over the past ten years, the use of the Internet for the provision of mental health (and health) education, advice, and treatment, has skyrocketed.  The use of the Internet in this manner has taken on many forms, going far beyond the simple process of e-mailing back and forth. 

As discussed by Barak et al. (2009) “although the provision of therapeutic interventions through the Internet has encountered a considerable amount of opposition, especially on the grounds of ethical-related issues, this means of seeking and obtaining health information has flourished. The authors go on to state that this is likely due to several factors including the following: 

Increasing acceptability of the Internet as a legitimate social tool;

Continuous improvement of computer hardware and software (especially in relation to ease of use, privacy protection, and online communication capabilities);

Development of specific ethical guidelines by various professional organizations;

Growing research; and

Establishment of online training opportunities for professionals. 

Clearly, given these factors, the use of the Internet to provide these various services will continue to grow and expand. 

A Confusing Array of Terms

One of the difficulties when discussing Internet-based mental health (and health) interventions is agreeing upon exactly what type of procedure one is discussing.  A number of definitions of online counseling have been proposed including the following: 

The practice of professional counseling that occurs when client and counselor are in separate or remote locations and utilize electronic means to communicate with each other (Bloom, 1998, p. 53)

Ongoing interactive, text-based, electronic communication between a client and a mental health professional aimed at behavioral or mental health improvement (Alleman, 2002, p. 200)

Any delivery of mental health and behavioral health services, including, but not limited to therapy, consultation, and psycho-education by a licensed practitioner to a client in a non-face-to-face setting through distance communication technology such as the telephone, asynchronous E-mail, synchronous chat, and video conferencing (Mallen & Vogel, 2005, p. 764). 

In addition to these various definitions, an overwhelming number of terms have been coined to describe Internet-based mental health treatment and just some of these are listed in Table 1. 

As discussed by Barak et al. (2009), even though the field of Internet interventions has expanded rapidly, it has certainly suffered from a lack of clarity and consistency.  The authors go on to discuss that:

Scientists and professionals have operated mostly independently with little intercommunication or accepted standards, which has brought about the use of numerous rival terms and applications alike-all of this typical of a pioneering area.  Moreover, because of the lack of professional leadership and of accepted governing approaches, terminology, professional standards, and methodologies, the area has been described as being “inconsistent, diffuse, incoherent, and sometimes even perplexing” (p. 5). 

Internet-based mental health treatment can take on many forms including e-mail, chat, IM, videoconferencing, and more structured web-based programs.  Given that each of these different types of interventions may carry with them unique advantages and disadvantages, as well as potential benefits and risks, having an agreed upon set of definable and descriptive terms is important.  We will discuss the status of this issue in more detail subsequently. 

Prevalence and Scope of Online Treatment

It is likely impossible to even come close to accurately estimating the current prevalence of Internet-based mental health treatments.  Without a doubt, as discussed previously, there has been a steady increase in this type of practice over the past 25 years.  Some idea of the rate of expansion of this type of intervention can be gained from looking at the early research and comparing it to current data. Some trends can be seen as of 2011 (Barak and Grohol. (2011). Current and Future Trends in Internet-Supported Mental Health Interventions. J. of Technology and Human Services, 29, 155-196). More current information can be obtained at the Telehealth.org Bibliography which contains over 1,000 references related to the field. 

Online searches.  Sampson et al. (1997) completed an online search in an effort to determine the number of individuals providing online counseling in 1996.  The investigators found at least 275 individuals who were offering online services over the Internet at that time. 

In a similar study, Ainsworth (2002) estimated that in 2001, there were over 300 private practice websites and E-clinics representing more than 500 individual therapists offering online services.  In 2006, one of the largest online therapy companies (www.mytherapynet.com), had more than 1000 registered therapists in its database (Lavallee, 2006).  There are many other “E-clinics” that recruit mental health practitioners and offer such things as professional listing, booking, billing and online sessions, HIPAA Compliance Security, marketing, ecommerce ready websites, encrypted client progress note systems, a private virtual office, among other things.  For interesting examples, some of the larger E-clinics are: Betterhelp.com, www.mytherapynet.com,  and www.asktheInternettherapist.com. According to a spokeman for Betterhelp.com, their membership is doubling year over year as of 2018. In fact, Betterhelp was recently acquired by TeleDoc.com in 2014 for $4.5 million and is expected to exceed $27 million in revenue in 2018. 

If you conduct a simple Google search, you will obtain hundreds of thousands of hits depending on which of the search terms you use as listed in Table 1.  There are other indicators of the increasing prevalence and scope of Internet-based mental health treatment.  These include the following:

Professional societies.  As discussed previously, the International Society For Mental Health Online (ISMHO) was established in 1997 to “promote the understanding, use and development of online communication, information and technology for the International Health Community.  The organization offers a number of resources such as information about starting an online practice, discussion groups and forms, practice guidelines, etc. 

Another organization is the American Distance Counseling Association (ADCA).  According to the website, the ADCA is a professional organization founded to promote safety and confidence and counseling treatment on the Internet, and through phone services.  The website provides information for both practitioners and potential users (“clients”).  According to the website, the group was formed in 2007 and offers membership to State Board Licensed Counselors who provide online counseling services via the Internet.  The ADCA is a professional organization for “American-based licensed counselors who have been approved by virtue of their credentials clearly posted for clients at their counseling websites.” 

Ethical guidelines for E-Therapy. As will be discussed in more detail later, most of the ethics codes that guide the provision of mental health services do not specifically address Internet-based interventions; however, this has changed as discussed previously.  For instance, e-therapy has not been specifically addressed in the most recent version of the APA Ethics Code (2002, 2010, 2016), but there are plans to address this new intervention approach in future versions.  For psychologists, some very general guidance have been incorporated into the 2002 Code.  There is also “a statement from the Ethics Committee of the American Psychological Association” issued on November 5, 1997 (click here to review) which is now considered “inactive.”  However, it has been superceded by the Guidelines for the Practice of Telepsychology (2013). 

Some professional counseling organizations have become more active in developing ethical guidelines for online counseling or e-therapy.  For instance, the National Board of Certified Counselors (NBCC) developed web counseling guidelines in 1998 and updated them in 2001, 2007 and 2016 (Policy Regarding the Provision of Distance Professional Services, NBCC, 2016, NBCC, 2016).  Similarly, the American Counseling Association (ACA) developed E-therapy ethical guidelines in 1999 and included best practices for Internet counseling in the most recent update of their ethical code (ACA, 2014).  Even more current Ethical Guidelines and Position Statements will be reviewed later.  For instance, the National Association of Social Workers and the Association of Social Work Boards published the Standards for Technology and Social Practice in 2005.  And, NASW incorporate treatment and techonology issues in their most current ethics code revision (NASW, 2017). According to some research, counseling licensing boards in the United States, relative to the online treatment issue, are generally using the ACA (2014) and NBCC (2016) standards to evaluate ethical issues and develop regulations. 

Practitioner guidebooks.  Another indicator of the prevalence and scope of practice in this area is the publication of practitioner guidebooks.  Some examples include Online Counseling: A Handbook For Mental Health Professionals (Kraus et. al., 2004); Technology and Counseling and Psychotherapy: A Practitioners’ Guide (Goss & Anthony, 2003); E-Health, TeleHealth and TeleMedicine: A Guide To Start Up and Success (Maheu et. al., (2001); The Mental Health Professional and The New Technologies (Maheu et. al. (2004), Online Counseling: A Handbook for Practitioners (Jones and Stokes, 2009). To find more current examples, simpy complete a Google or Amazon Books search. You will get many, many examples. 

Training programs.  There are now training programs that offer “certification” in online counseling or e-therapy.  Some of these include the following: 

Online training for counselors: This program offers training to the diploma level for therapists who work online and is based in Great Britain. 

Online therapy Institute:  The Online Therapy Institute offers online “therapy and subjects related to mental health and technology.”  Some of their courses include: Introduction to Cyberspace: A Primer for Helping Professionals; The Online Therapeutic Relationship: Theoretical Considerations; Ethical Considerations of Online Therapy; and Introduction to Online Supervision: Text-Based Strategies. The organization is based in the United States.  The Online Therapy Institute offers a six module certificate training for practitioners (30 hours) which is delivered entirely online.  The diploma course (60 hours) encompasses all of the courses along with experiential exercises including training in video counseling. 

Cybercounseling.com:  The therapy online offers a 12 week certification course in cybercounseling in collaboration with Canada’s University of Toronto. 

Telebehavioral Health Institute. The TBHI offers credentialing in "telehealth" and "reimbursement". According to the website, one is for treatment-related issues and the other is to become elegible for reimbursement by third-party payors. TBHI also has a number of other services and resources.  

Journals.  Most articles related to e-therapy are published in journals that have broad content (see the references for this course as an example).  However, there are some journals that are more focused in the area of the technology and psychological treatment (both in the broad sense and related to e-therapy).  Some of these journals include: Computers in Human Behavior Cyberpsychology and Journal of Technology in Human Services. Also, check the bibliography list at TBHI for many more examples.   

Professional Attitudes Toward Online Treatment

Although the following summarized data is from 2007 and 2008, an Internet search demonstrates that not much reserach has been done in this area since that time. Only now have researchers focused on developing a standardized questionnaire to measure professionals' attitudes toward telemedicine in mental health (See Tonn et al., 2017, Development of a questionnaire to measure the attitudes of laypeople, physicians, and psychotherapists toward telemedicine in mental health. JMIR Ment Health). 

Although the use of E-therapy is becoming more and more popular, its use continues to be quite controversial amongst professionals.  However, systematic survey data is lacking in terms of mental health professionals attitudes towards E-therapy.  In one of the first studies of this type, Wangberg et al., (2007) examined the attitudes of psychologists in Norway regarding the use of Internet-based therapies.  The authors discussed that online therapy was becoming a popular psychotherapeutic practice in Norway, especially compared to online therapy use rates in the United States and United Kingdom.  In a sample of psychologists surveyed, the researchers found that the practitioners generally maintained a neutral stance towards online therapy.  They found that psychologists who were psychodynamically oriented were less likely to endorse online therapy when compared to cognitively oriented psychologists. 

Following-up on the Wangberg et al. (2007) study, Mora et al. (2008) attempted to investigate psychologist’s attitudes towards E-therapy in the United States.  The researchers mailed a questionnaire packet to 450 psychologists randomly selected from the membership directory of the New York State Psychological Association.  The final sample for analysis consisted of 138 participants which yielded a response rate of 31%.  The participants received a questionnaire that contained a brief vignette description of a 35-year-old individual who was dissatisfied with his her or her occupation and felt a lack of direction in life.  No presenting symptomatology was reported, but treatment history was systemically varied.  In one condition, the individual in the vignette was described as having been treated several years earlier for a major depressive disorder.  In another condition, the individual in the vignette was described as having been treated for an anxiety disorder.  In a third (control) condition, no statement about past treatment history was included.  The vignettes were identical in all other aspects.  In the study, participants were instructed to rate their treatment recommendations for each of four online therapy modalities as either an adjunct to face-to-face therapy or as an alternative treatment modality.  Treatment recommendations were rated on a five point scale from 1 (very unlikely) to 5 (very likely).  The four online therapy modalities included E-mail therapy, Internet-based individual chat, Internet-based group chat, and Internet-based videoconferencing. 

Additional questions survey participant’s attitudes about possible advantages of online therapy, their willingness to receive training in these techniques, and their willingness to use them in practice.  These items were rated on a five point Likert-type scale from 1 (strongly disagree) to 5 (strongly agree).  Participants also rated their level of concern about the nine aspects of Internet-based therapy from 1 (not at all concerned) to 5 (extremely concerned). 

Table 2 presents descriptive data regarding the psychologist’s attitudes towards online interventions.  As can be seen, the respondents generally felt that online therapy has value in serving people in rural areas and for people with disabilities, who may have difficulty accessing or participating in face-to-face treatment.  Even so, the psychologists generally expressed low levels of interest in using online therapy in their practices, even if they received appropriate training.  They also did not express much interest in receiving training in online therapy if it were made available.  Practitioners generally endorsed the statements that online therapy would grow in popularity. 

Table 3 summarizes the psychologist’s concerns relative to online therapy.  As can be seen, the highest level of concern involved the lack of non-verbal behavior that would be available to the clinician during the course of treatment.  Other concerns included the lack of legal guidelines, and difficulties establishing a strong therapeutic working alliance with the patient.  The researchers concluded that the psychologists in the sample did not express strong levels of endorsement of online therapies as either adjuncts or alternatives to traditional face-to-face therapy.  They also did not express a strong interest in using online interventions or receiving training in this modality.  In terms of participating in any type of Internet-based intervention, the practitioners most highly endorse the possibility of Internet-based therapies as adjunctive treatments rather than alternative treatments.  In addition, the treatment history as provided in the different vignettes was a factor in predicting endorsement of Internet-based therapy.  Practitioners showed lower levels of endorsement of online therapy for a patient with a history of treatment for major depression versus an individual with the same presenting problem, but without any representation of past treatment history.  Not surprisingly, as reported by the researchers, cognitive behavioral practitioners expressed higher levels of endorsement of Internet-based interventions versus those documenting a more psychodynamic orientation. 

The researchers also found that the use of E-mail emerged as the most highly endorsed adjunctive Internet-modality.  They discussed that this finding suggested that E-mail applications would be more readily integrated into contemporary practice than other forms of Internet-based treatment.  This is certainly understandable since other forms of Internet-based treatment (IM, chat, videoconferencing) requires more technical skill, scheduling issues, and possibly costs. 

Although the authors reported that the mean age of the respondents was 54-years-old, they did not report the number of years in practice.  It would certainly be interesting to assess the attitudes of mental health practitioner (various disciplines) reports online therapies based upon such things as number of years in practice (graduated less than 10 years ago versus graduated more than 20 years ago), the practitioners’ level of comfort with technology, the practitioners use of technology in his or her own life, etc.  A large study of this type might give us some indication as to where the field is going relative to online interventions and how fast it is getting there. 

Another study of mental health professionals’ attitudes toward online treatment included practitioners of many disciplines.  As discussed by Wells et al. (2007), recent publications suggest that mental health professionals are hesitant to utilize the Internet in providing treatment to clients.  However, it is generally unknown whether this reluctance is a function of the novelty of the Internet, specific features related to online communication, ethical concerns, risk (malpractice) concerns, or limitations related to online mental health treatment.  The authors point out that very few studies have systematically assessed mental health professionals’ attitudes regarding the provision of online mental health treatment.  It is discussed that there is also a lack of clear directives related to the provision of online treatment.

The goals of the Wells et al. (2007) study was to examine three questions:  (1) To what extent are mental health professionals currently providing online treatment? (2) What are professionals’ primary concerns regarding provision of online treatment? and (3) Do mental health professionals have specific clinical needs related to providing online treatment? 

The research study was conducted using the Survey of Internet Mental Health Issues (SIMHI).  The SIMHI collects data related to a variety of problematic Internet experiences being seen by mental health professionals.  It also collects data related to mental health professionals needs related to Internet and mental health treatment.  Surveys were sent to a random sample representing approximately 17% of the membership of a variety of professional organizations including the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the National Association of School Psychologists, and the American Association for Marriage and Family Therapy, The American Mental Health Counselors Association, among others.  The final sample consisted of 31,271 professionals who received a preliminary screening survey sent in 2003.  There were 7,841 valid respondents to the preliminary one page survey.  A total of 3,398 respondents consented to participate in a follow-up detailed survey.  Of these, 2,170 were completed and returned.  The Wells et al. (2007) study analyzed a limited number of measures from the SIMHI detailed survey instrument including: (1) measures of Internet use for therapeutic purposes, (2) professionals concern regarding online treatment, and (3) professional needs regarding online treatment.  Specifically, professionals were asked the following questions: 

(1) Whether or not they use the Internet “to provide online therapy or counseling”

(2) To rate their top three concerns regarding the use of the Internet as part of mental health practices, and

(3) To check whether they were “not at all interested, somewhat interested, very interested, extremely interested, or already had information” about four types of professional material related to online treatment.  This section of the detailed survey instrument asked professionals about the need for material about clinical guidelines or criteria for “treatment online,” “deciding what approach to online treatment is most beneficial for clients,” “identifying who could most benefit from online treatment approaches,” and “when to stop the use of online treatment.” 

As far as demographics, approximately 60% of the overall sample of professionals were female and over 75% were over the age of 40.  Social workers and psychologists comprised the largest groups of professionals in the sample and over 50% reported at least 15 years of providing direct services to clients.  Fifty percent of the professionals were primarily in independent practice. 

The authors state that “an almost unanimous finding is that the professionals included in this sample did not see themselves as using the Internet to provide online therapy or counseling.”  A little over 2% of the entire professional sample reported using the Internet to provide online therapy.  Across professional groups, use of the Internet for online therapy ranged from 1% amongst mental health counselors to about 5% among marriage and family therapists.  Less than 2% of social workers reported providing online therapy or counseling. 

The mental health professionals were asked to list their primary concerns regarding the use of the Internet in treatment.  These results can be seen in Table 4.  As can be seen, confidentiality of client information, liability, and misinformation being provided by clients were of the greatest concern.  In addition, inadequate training to conduct online therapy was also a significant area of concern. 

Approximately 60% of the mental health professionals were somewhat, very, or extremely interested in having additional information related to providing online treatment, selecting online treatment approaches, criteria regarding who would most benefit from this approach, or when to stop the use of online treatment as areas of interest.  The other 40% of the professionals were not at all interested in this material.  Less than 1% already had information regarding any of these professional topics. 

The authors concluded that “these mental health professionals’ interests and concerns related to online treatment generally reflect the existing literature” (page 457).  The primary list of concerns related to provision of mental health services over the Internet include confidentiality, liability, and misinformation being provided by clients.  The authors concluded that descriptive comments provided by a subgroup of the respondents suggested that the two primary areas of liability concern include client safety and that the use of the Internet may blur boundaries related to professional liability.  The authors also discussed that “a striking finding is that very few (1% or less) of the professionals surveyed already had professional information related to online mental health treatment.  The authors felt that if professionals do not have adequate evidenced-based information on the use of online therapy, they cannot accurately assess whether or not to utilize it as a treatment modality.   They also predicted that mental health professionals will be increasingly presented with opportunities to incorporate Internet technology into their professional practice.  In fact, previous research had already demonstrated that one-third of graduate social work students saw online therapy as “a good adjunct to in-person services” (Finn, 2002). 

Client-Patient Attitudes Toward Online Treatment

Given that the field is not widely accepted by the professional and clinical-scientific communities, there is little well-controlled research in this area.  Robinson and Serfaty (2001, 2008) did studies of email psychotherapy for eating disorders. In the 2001 study, most patients felt they had been helped either to reduce their bulimic episodes or accept the idea of a referral to a clinic for treatment.  In the 2008 study, about 60% of the comments were positive (qualitative evaluation of the process).  Patients liked the anonymity, and the therapy helped them gain control of the eating issues.  On the negative side, some patients did not like the gap between their emails and the therapists’ responses. Robinson et al. (2006) further explored the use of text messaging after traditional outpatient treatment for bulimia.  The low rate of follow through (e.g. responding to the texts) suggests the program was only moderately accepted by the patient; however, a sub-group who did participate consistently felt supported and encouraged.  Many patients found the method “too formal”, “computerized”, and did not like the lack of personal contact (e.g. phone call).

In another study, Liebert et al. (2006), self-selected participants (from online e-groups related to mental health) were asked to comment on their past experience with e-therapy.  The most common reasons for pursuing e-therapy were convenience, anonymity, and privacy.  Although satisfied with treatment, the e-therapy satisfaction ratings were less than that found for face-to-face in other studies.  A greater ease of self-disclosure was noted for the e-therapy versus face-to-face (different studies) especially in the early stages of the therapy.

Young (2005) investigated client attitudes towards online counseling.  The clients were receiving therapy through the Center for Online Addiction.  The Center was established in 1995 to address a variety of Internet addiction issues and offers both face-to-face and online treatment.   The potential research sample was screened for high-risk behaviors (e.g. history of trauma) or Axis II diagnoses.  Data was collected from 48 e-clients who received online counseling at the Center for Online Addiction. Variables such as client perceptions and concerns about using online counseling, clients' reasons for seeking online counseling over in-office treatment, and demographic profiles of e-clients were assessed. Results suggested that Caucasian, middle-aged males, with at least a four-year bachelor’s degree were most likely to use online counseling and anonymity, convenience, and counselor credentials were the most cited reasons they sought online counseling over in-office treatment. The lack of perceived privacy and security during online chat sessions and the fear of being caught while conducting online sessions were the main concerns reported by e-clients.

Although this is by no means an exhaustive review of the literature in this area, it is not very extensive.  The studies located generally investigated a specific type of problem being addressed (e.g. eating disorders, etc.), contained a self-selected sample, and are not controlled.  The research does not offer much guidance in this area.  Rather than simply asking patients’ perceptions about online e-therapy, a more important question is who might benefit from this type of approach, who will not, and who is at risk for being harmed.    This issue will be discussed further.  A recent study by March, et al. (2018: Attitudes toward e-mental health services in a community sample of adults: online survey. J Med Internet Res) found that 86% of respondents preferred face-to-face servcie over e-mental heatlh. However, 40% endorsed an intention to use e-mental health servcie if needed. In another study by Apolinario-Hagen et al. (2018: Public attitudes toward guided internet-based therapies: Web-based survey study, JMIR Ment Heatlh) found that 81% assessed therapist-guided interventions as helpful but not equivalent to face-to-face.      As such, some of the concerns found in 2008 still ring true in 2018. 

Defining Terms AND APPROACHES

As discussed previously, the field of Internet-supported treatment interventions has suffered from a lack of clarity in consistency.  Only recently have authors and professional organizations attempted to operationalize terms and suggest taxonomies for online treatment activities.  For instance, Barak et al. (2009) present a conceptualization of Internet supported treatment interventions using four categories based on prime practice approaches.  This conceptualization will be the basis for the following discussion while including other taxonomies that have also been proposed.

Barak et al. (2009) suggest that their categories may serve as guiding definitions and related terminologies for further research and development in the field.  After a comprehensive review of the literature, four categories were developed including:

web-based interventions

online counseling and therapy

Internet-operated therapeutic software

other online activities (e.g. as supplements to face-to-face therapy)

Web-Based Interventions

Web-based interventions was established as the most inclusive category relative to a number of other terms commonly used in the field.  The authors state that terms such as “therapy” and “treatment” are too restrictive and do not include interventions that focus on prevention, promotion, and education.  A preliminary definition for a web-based intervention is as follows: 

A primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking healthy-and mental health related assistance.  The intervention program itself attempts to create positive change and/or improve/enhance knowledge, awareness, and understanding via the provision of sound health-related material and use of interactive web-based components. 

The author discussed that based on the definition; three broad web-based intervention subtypes can be identified: 

(1) Web-based education intervention

(2) Self-guided web-based therapeutic interventions

(3) Human supported web-based therapeutic interventions

The authors go on to specify various components of each subtype including program content, multi-media use/choices, provision of interactive online activities, and provision of guidance and supportive feedback.  The authors point out that the four web-based components are not mutually exclusive.  The following is a brief overview of each of these components: 

Program content. Program content is the most basic and necessary component of a web-based intervention.  Program content refers to the nature of the information being disseminated within the program and is intended to educate and/or create a therapeutic change. 

Multi-media choices.  The second component is the use of multi-media.  Web-based interventions largely use text to disseminate program content, but other options are available including pictures, graphics, animations, audio, and video.  The authors give examples of The Panic Center which is a highly text-based cognitive behavior therapy web-based program for panic disorder whereas Sleep Healthy Using The Internet (SHUT-I) is based on cognitive-behavioral therapy for insomnia (CBT-I). Users complete daily online sleep diaries in addition to receiving weekly access to six interactive "Cores" of information. As they progress through the program, users receive tailored instructions for how to improve their sleep. SHUT-I provides text, pictorial, animation, and audio formats.  Preliminary studies suggest that including a greater variety of multi-media formats is generally advantageous and makes the web-based intervention more engaging and dynamic. 

Interactive online activities:  A third component relates to whether the web-based intervention offers a patient the opportunity to participate within the program in a more interactive way such as the use of self-assessment and self-monitoring tools.  Examples of interactive web-based programs include weight loss management or web-based CBT for social phobia.  Research suggests that the use of interactive online activities enhances the patient’s understanding of the program content, makes it more personalized, and potentially facilitates a greater sense of connectedness to the intervention. 

Guidance and supportive feedback.  The fourth component in the Barak et al. (2009) definition of web-based interventions relates to a mechanism whereby patients can obtain “external” information about themselves and their progress (Barak et al., p. 7).  This type of feedback can range from none (no guidance or feedback provided) to high (provision of sufficient amounts of tailored feedback).  The guidance and feedback is provided by an automated program based on algorithmic sequences built into the intervention. 

In the following, we will further investigate the various types of Web-based interventions.  For ease of communication, we will use the following abbreviations:

Web-Based Education Intervention (eWBI)

Self-guided web-based therapeutic interventions (sWBTI)

Human supported web-based therapeutic interventions (hWBTI).

Web-based education interventions.  eWBI programs are designed so that consumers can access health and mental health information about a particular problem area.  By nature of its content and design, it is considered to be relatively therapeutically “inactive.”  However, these programs do seek to improve one’s knowledge, awareness, and understanding of the area.  eWBI can provide fairly comprehensive information, but do not form a highly structured treatment or intervention program.  Meta-analytic studies have suggested that eWBI programs do achieve medium to high effect sizes (Barak et al, 2008). 

eWBI’s vary in the use of multi-media and interactive formats that tend to be relatively “static.”  For instance, The Mayo Clinic Health Information Site is static WBI-e in which the user can research thousands of conditions including information and referral links, but without online activities or supportive feedback.  A similar medical-condition specific website is Spine-Health which include an information, videos, and forums.  eWBI’s may include the use of some partial support (either human or automated) including simple self-assessment questionnaires in which patients receive automated feedback.  The user may also be able to access a moderated online form or chat room or the use of “informed supporters.”   

Self-guided web-based therapeutic interventions.  The next category is self-guided wed based therapeutic intervention (sWBTI).  sWBTI’s can be both self-guided and human supported and are designed specifically to create cognitive, behavioral, and emotional change.  The content is comprehensive and presented in a highly structured format.  Most often, the intervention is based on CBT and modeled after face-to-face treatment programs that have been found to be effective through empirical research.  The multi-media and interactive formats can range from fairly basic (text) to highly dynamic (varied multi-media formats and activities).  sWBTI’s generally include some degree of automated feedback support that is often specifically tailored to the individual user.  The sophistication of the automated tailoring also ranges from none, to partial, to high.  With automated feedback, the frequency and quantity is dependent upon predetermined algorithms.  An example is eCouch which is a self-guided online CBT based program for treating depression and anxiety.  Other examples of sWBTI’s include MoodGym and Internet Beating the Blues.  Recent meta-analytic studies have supported the effectiveness of self-guided web-based therapeutic interventions. 

Human supported therapeutic web-based interventions.  Human supported web-based therapeutic interventions (hWBTI) also seek to provide behavior change and vary in their use and number of multi-media formats and interactive online activities.  hWBTI incorporate a human (either peer support or mental health professional) to provide support, guidance, and feedback.  Support provided by a health or mental health professional is considered a more central component of the web-based program and is usually completed on a one-to-one basis (e.g. through E-mail, instant messaging, videoconferencing etc.).  The hWBTI may include components of both automated feedback and human feedback with concomitant adjusting of the intervention.  The nature of the human support can vary significantly including the total time of human support, frequency of feedback, immediacy of response, face-to-face versus online contact, etc.  In the conceptualization developed by Barak et al. (2009), the human feedback is broadly classified as ranging from partial to high.  The authors give an example of a highly dynamic hWBTI as PTSD Online.  PTSD online is a ten module CBT program for people with a DSM-IV diagnosis of post-traumatic stress disorder.  The program contains a variety of multi-media formats and a high level of therapist support.  The PTSD Online program is just one of many offered by CBT Online addressing a variety of conditions.  Recent meta-analytic studies indicate that human support of programs offer larger effect sizes than self-guided programs, but both types have been found to be effective (Barak et al., 2008). 

Online Counseling and Therapy

When practitioners are discussing the pros and cons of Internet-based psychological treatment, they are invariably referring to online counseling (versus the other categories reviewed).  As discussed by Barak et al. (2009, p. 9), interpersonal communication through the Internet includes four basic communication modalities:  Individual or group contact using either synchronous or asynchronous communication mode.  The authors point out that online counseling may be delivered through various modalities (subtypes) including e-mail, chat, IM, texting, or video-based.  E-mail is asynchronous while chat, IM, texting, or video-based counseling is synchronous (real time).  The authors point out that using text or communication solely in online counseling necessitates the use of more words and verbal expressions to clarify messages and have them understood accurately (by both parties).  They discussed that one of the aides available online for this purpose is “emoticons” which enriches the message by caricaturing a missing intonation or gesture.  Given that online counseling is delivered in a unique manner, it is important to determine that the patient is appropriate for this type of intervention in terms of technical and writing skills, lack of extreme pathology, and the nature of the problem area.  The authors go on to point out the various differences between traditional face-to-face intervention and online counseling (non-video format).  These include the following:

(1) There was a lack of non-verbal communication cues including body language and voice qualities.  Therefore, special attention must be paid to maintaining accurate and more complete understanding of the textual message.  These steps might include such things as extended wording, stylistic procedures for emphasizing text, using emoticons, and making sure that each party understands there is a greater potential for misunderstandings. 

(2) The expression of feelings through online communication is not as automatic and autonomous as in face-to-face relationships.  Therefore, special steps must be taken by the therapist to communicate such things as empathy, care, concern, and warmth.  In addition, patients must have an understanding that their feelings will not be as obvious in textual communication as they would be in a face-to-face encounter. 

(3) Due to the nature of online therapy, the therapist must be concerned with making emergency provisions if a dangerous or crisis situation arises (suicidality, severe physical condition, medication or drug issues, homicidality, etc.). 

(4) The authors feel that due to these issues, the practice of online therapy necessitates that counselors receive specialized training that cover all of the unique characteristics of this type of work. 

The National Board for Certified Counselors (NBCC) has developed a taxonomy for Technology-Assisted Counseling which includes face-to-face forms as well.  The categories can be seen in Table 5.

The delivery methods of online counseling is highly varied. If you want to see examples of everything that is out there, simply do a Google search for “online counseling”. Barak et al. (2009) reviewed the treatment outcome literature on online therapy.  They point out that “in terms of process and contrary to common myths, most studies show that close, empathic, warm, and allied therapeutic relationships can be created and maintained online through various types of technologies” (p. 10).  Research has demonstrated that online counseling sessions can have a substantial impact of clients, that the experience for both therapist and client can be similar to what is seen in face-to-face counseling, and that the therapeutic alliance is also similar.  The authors point out that quantitative outcome research on online therapy has been relatively sparse and the literature consists primarily of case studies.  However, they do review studies that demonstrate support for the effectiveness of online therapy in various areas including anxiety, loneliness, and smoking cessation (See Barak et al., 2008, 2009) 

Internet Operated Therapeutic Software    

Barak et al. (2009) conceptualized the third group of Internet inventions as referring to therapeutic software that uses advanced computer capabilities such as artificial intelligence principles for: (a) robotic simulation of therapists providing dialogue-based therapy with patients, (b) rule-based expert systems and (c) gaming and three dimensional virtual environments.  The earliest example of robotic software was “Eliza” which was designed to support a non-directive therapy conversation with a user and was one of the first programs to be developed in which users were unable to tell the difference from talking with a person.  Eliza has been extended and developed to operate through the Internet (for an example click here).  Typical programs include Chatterbot or Chatbot systems that can learn simple vocabulary and conversation rules that are text-based.  Recent developments such as the Artificial Linguistic Computer Entity Program (ALICE) have further extended this technology to include voice recognition and spoken responses rather than text.  Progress is also being made in developing computer applications that can detect, label, and react to the emotional and social needs of the user as well as emulating empathy and create the perception of caring. 

Barak et al. (2009) discusses a second subgroup of Internet operated therapeutic software which includes the rule-based systems for assessment, treatment selection, and progress monitoring. These systems are becoming more common in the area of behavioral health.  One example is the computerized exercise expert system, which creates a tailored exercise plan for older adults after gathering information across a number of domains.  There are other examples assessment, feedback, and decision-making related to a user’s level of readiness for change related to alcohol consumption.   and smoking cessation.

A third subgroup of Internet operated therapeutic software includes gaming programs and 3-D virtual environments.  The authors point out that the popular Second Life system with over 15 million registered “residents” allows users to participate in a number of social networking pursuits.  For individuals with health and mental health issues, Second Life can provide opportunities for such things as gaining information, acquiring skills, and even receiving therapy.  Various therapeutic computer games are being developed and used effectively as health interventions particularly for children and adolescents.  Examples include Personal Investigator, a 3-D computer game based on solution focused therapy for adolescents with anxiety, depression, behavior problems, or social skills difficulty.  Recently, a therapeutic computer game development tool (Playwright) has made it possible to enable clinicians to develop their own therapeutic games utilizing different therapeutic models and targeting a range of disorders and conditions.  Research is also investigating such things as computer games as a treatment tool for helping to prevent PTSD. 

The efficacy of virtual reality clinical occupations has been clearly demonstrated over the last ten years.  Virtual reality clinical applications has been shown to be as successful in the treatment of anxiety disorders, specific phobias, eating disorders, and obesity, male sexual dysfunction, drug use, and pain management.  Virtual reality programs are particularly suitable for exposure therapy.  Recent developments in this software allow the intervention to be delivered via the Internet and therapists can share the online virtual space with their patients.  In this model, the therapist can “accompany” the patient through the threatening situation and modify the interaction as indicated by the clinical need.  A free open source virtual reality platform (NeuroVR) has been designed for non-expert users and allows customization of the virtual environment by choice of stimuli or stressors from a database and the use of the patient’s personal photos or movies to maximize the potential of exposure efficacy.  The therapeutic potential of Internet operated therapeutic software is substantial, but further research is necessary to elucidate its most appropriate use as well as risk. 

Other Online Activities 

The authors’ fourth category of Internet interventions consist of other online activities such as the publication of personal blogs, participation of support groups via chat, audio, or web-cam communication channels, the use of online assessments and accessing health-related information via information sites, wikis, and pod-casts.  They point out that these activities may be used as standalone functions or prescribed by therapists as supplements to a face-to-face intervention or another online intervention. 

Personal Blogs and Twitters offer individuals the opportunity to publish their thoughts and experiences as an online journal and receive responses from others.  Younger online users are especially familiar with this technology and nearly 80% of individuals under 28-years-old regularly visit blogs and 40% create their own.  The authors point out that there is plenty of evidence about the therapeutic benefit of paper and pencil writing about emotional experiences, but little research relative to such things as personal blogs and Twitters. 

A second subtype of online activities is support groups and networks.  These are available in either synchronous or asynchronous formats including web-based discussion forums or bulletin boards, live chat rooms, and E-mail lists.  Online support groups may be moderated or unmoderated and are quite popular with patients, especially with medical conditions.  Social networking tools such as MySpace and Facebook also have a high social acceptance and are beginning to be used within the health arena.  There is essentially no research relative to the benefits or risks of online support groups in terms of health and mental health issues. 

Online activities may also be used by clinicians as adjuncts to standard face-to-face interventions.  A health practitioner may ask a patient to try out behavioral exercises related to some type of online activity or request reports from patients typically delivered by email (between face-to-face sessions).  Homework assignments particularly amenable to an adjunctive online activity might include daily mood charting, journaling negative thoughts, or a condition specific web-based monitoring program. 

Effectiveness of Internet Based Interventions

The effectiveness of Internet based interventions can be difficult to determine since the treatments are often not standardized and outcome variables difficult to define and measure (especially in real world settings).  Most of the research has been on Web Based Treatment Interventions (WBTI) as defined previously.  These are most commonly developed from face-to-face CBT treatment programs that have been found to be successful.  For the most up-to-date information, check the bibliography at TBHI.org, various Cochrane Reviews, etc. I nice overview and review has been provided by Andersson and Titov (2014). Advantages and limitations of Internet-based interventions for common mood disorders (World Psychiatry, 13, 4-11). 

In one of the first literature reviews, Ritterband et al. (2003) investigated the outcomes of 12 controlled studies of WBTI’s addressing such areas as smoking cessation, panic, body image, headaches, physical activity, etc.  The authors concluded that, “Generally these studies provide support for the notion that Internet interventions can be feasible and effective.  These studies also demonstrate that some behaviorally related psychological treatments can be operationalized, transformed, and transported to the user via the Internet. 

Barak et al. (2008) completed a review and meta-analytic study of 92 outcome studies that included clients who were treated for a variety of problems through different Internet-based psychological interventions. The study also looked at possible intervening variables including: type of therapy, type of outcome measure, type of measurement of outcome, type of problem treated, therapeutic approach, and communication modality, among others. The authors differentiated between online interventions that included human involvement (etherapy) and self-help, web based therapy (sWBI).  The results showed a mean weighted effect size of about 0.53 (medium) which is similar to what is seen for traditional, face-to-face therapy. The effect size was found across a number of different interventions types, outcome measures, etc.  The mean effect size of the 27 studies that examined etherapy was 0.46.  In the 14 studies that compared Internet to face-to-face interventions, no differences were found in effectiveness.  However, a number of factors were found to moderate the effects of Internet therapy as follows:

Type of problem. Internet based interventions were better for problems that are more psychological in nature and less suited to those that are primarily physiological or somatic.

Therapeutic approach. CBT was more effective than other types of therapy for the online format.

Type of therapy. Self-help web-based interventions provide as effective therapy as online communication-based etherapy.

Synchronicity of communication.  Of the 27 studies that investigated e-therapy, there was no difference in effect size between synchronous (chat, audio, webcam) and asynchronous (e-mail) communication.

Type of modality.  For e-therapy, results suggest that chat and e-mail may be more effective than forum and webcam.

Age of patients. The age of the clients impacted their ability to gain from the therapy.  The mid-range age group (19-39) was able to obtain more benefit that those younger or older.  (However, the authors discuss that this result may have changed since data collection ended with studies up until 2006).  

The authors discussed that there is very little research on the efficacy of combining face-to-face therapy using Internet-based intervention adjunctively. In addition, several methodological problems have been pointed out (e.g. mixing of intervention types, sampling bias, only publication of studies that demonstrated results, inclusion of poor quality studies).  Even so, the results do provide some initial guidance in this area, especially for the web based treatment interventions.

Cuijpers et al. (2008) completed a systematic review of 12 studies that investigated the use of CBT Internet intervention programs directed at health problems (three on pain, three on headache, and six on other conditions).   In a previous meta-analytic study, the authors had found large effect sizes for Internet based treatment inventions for depression and anxiety (Speck et al., 2007) and similar to results found for the traditional face-to-face format.  Based on the description in the articles, the reviews included a mixture of CBT Internet treatment formats (e.g. educational, email contact, weekly telephone calls) and very few were purely web based only without human contact or monitoring.  Overall, the results were positive but slightly less than what was found for a similar approach to depression and anxiety.

It appears that there is a fair amount of research investigating web based treatment interventions (WBTI) using a CBT format along with some human (therapist involvement) and positive results are seen.  As pointed out by Cuijpers et al. (2008), using Internet resources in this manner can free up a therapist’s time by allowing much of the routine aspects of the intervention to be done in between contact, allowing access in remote areas, increase patient accountability if independent practice is monitored, and possibly improving outcome due to completeness of the material.  For this type of intervention there is support for its use for a variety of conditions (See Cuijpers et al., 2008; Fitzgerald et al., 2010 for reviews).  There is definitely a paucity of research on the effectiveness of online counseling or other formats.   

There is very little research on online counseling using asynchronous email even though this is by far the most common method seen available on the Internet and through e-clinics.  Aside from case studies, there is also little research on email being used adjunctive to traditional face-to-face treatment.  Most studies investigating email in between face-to-face sessions (or some other non face-to-face contact such as chat, IM, text, telephone, etc) has been done within the context of a structured CBT intervention program as reviewed previously.  

Advantages and Disadvantages of Internet-Based Interventions

Internet-based interventions for both mental health and health-related issues have advantages and disadvantages.  These advantages and disadvantages apply in a general sense, as well as to the various subtypes of Internet interventions.  Various subtypes of Internet interventions include such things as highly structured web-based treatment programs that are adjunctive to face-to-face interventions, E-mail, chat, IM, videoconferencing, etc.  These various subtypes of interventions will be discussed subsequently.  The following is an overview of the advantages of these types of interventions. 

Access

Advantages. One of the primary advantages of Internet-based treatment is the potential to increase access to services.  One example is the ability to bring mental health services to individuals in underserved, geographically isolated, or rural areas.  Another example is those individuals who cannot leave their home due to illness, physical disabilities, transportation difficulties, or family obligations.  Another example in which online treatment may provide greater access is for those who are tentative about the face-to-face counseling process or afraid to seek psychological services due to anxiety or stigmatization.  Lastly, the cost of online services tends to be less than the traditional face-to-face intervention, making Internet-based interventions more financially accessible. 

Disadvantages. Although access is one of the primary advantages listed by proponents of E-therapy, it may also be viewed as a limitation.  Of course, Internet-based interventions are only available to those who have access to a computer and the Internet.  Those users must not only have access, but also at least some level of technical skill in order to utilize the Internet-based intervention technology.  It may be that those in underserved areas, or who have physical limitations, are least likely to make use of this type of technology.  In fact, a recent report by the PEW Internet and American Life Project (2010) on Chronic Disease and the Internet (Fox and Purcell, 3/24/2010) supported this conclusion.  These researchers found that “adults living with chronic disease are disproportionately offline in an online world.”  In recent survey data, the researchers found that 81% of adults reporting no chronic disease go online whereas only 62% of adults living with one or more chronic diseases go online.  In addition, people managing multiple diseases are less likely to have Internet access.

Convenience

Advantages.  Internet-based interventions may also be more convenient than the traditional face-to-face format.  This is especially true if asynchronous versus synchronous online treatment is being provided.  As we will discuss in more detail subsequently, asynchronous online modalities include such things as email in which client information and therapist responses are not provided in real time.  Synchronous modalities include such things as chat and videoconferencing.  For asynchronous modalities, clients can send messages whenever they most feel the need or are interested in therapy.  In addition, these messages can be sent from anywhere in the world.  Online interventions can be accessed from the convenience of one’s own home and, for the therapist, it allows for more flexibility in the work schedule.  For asynchronous communications, there is no need to schedule a particular appointment time which requires synchronizing therapist and client availability. 

Disadvantage-Lack of Skills.  Internet-based treatment requires that the patient and therapist both have the skills necessary to utilize the Internet and the chosen method of communication efficiently.  Also, in any of the online methods aside from videoconferencing, the patient (and therapist) must have reasonable reading and writing skills.  Some have suggested that patients who are unable to express themselves fairly readily through writing are not good candidates for this type of intervention. 

Time Delay (Asynchronous Communication) 

Advantages. The time delay in e-synchronous communication (such as E-mail) can be viewed as a disadvantage or an advantage.  Relative to the advantages, it allows the mental health professional and patient time to develop a thought or question that most accurately and precisely reflects the concern or issue.  Both the therapist and the patient can reply whenever he or she is ready.  In many situations, this might allow the mental health professional time to research a particular topic and respond with more appropriate and accurate information. 

Disadvantages.  As discussed previously, the time delay in asynchronous Internet-based treatment interventions can be an advantage for several reasons.  On the other hand, a time delay in communication may also be due to a technical failure.  A time delay relative to a clinician’s response (whether due to a technological failure or not), can lead to frustration on the part of the patient.  Even if the delay is specifically outlined in the informed consent procedures (you will receive a response within 12 hours of your E-mail submission), a patient with a pressing need may find it difficult to “wait for the answer.” 

A Permanent Record

Advantages.  Some proponents argue that another value of online services is that it establishes a permanent and tangible record of the counseling sessions.  From a treatment prospective, this might include many benefits including such things as allowing patients the ability to re-read emails, focusing particularly on the process in approaching a problem, and the mental health professional’s reflections and recommendations.  The permanent record can be used to remind both the patient and the mental health professional about things that have been previously expressed and to allow for more complete reflection on previous issues.  It has also been suggested that the written record can hold both the practitioner and the patient to a higher level of accountability and as a tool for both supervision and consultation. 

Disadvantages.  In face-to-face therapy, the clinician may or may not takes notes during the session, but usually summarize important issues in a progress note.  In text-based online interventions, a permanent record of every detail of the interaction may be permanently stored by the Internet Service Provider (ISP) and exist even if both therapist and patient delete their own copies.  The U.S. Patriot Act permits the FBI to issue subpoenas against communication networks (e.g. ISP’s, telephone companies) and requires the recipients to produce customer records under certain circumstances.  Although I am not an attorney, in legal proceedings other than national security (e.g. wrongful death suit against the therapist), it may be conceivable that text-based communication information might be subpoenaed from the ISP even though all other stored information had been deleted.

The Act of Writing

Advantages. Many practitioners are aware that the simple act of writing is therapeutic and they will often prescribe a diary as adjunctive to the face-to-face intervention.  The act of writing is viewed as something that facilitates self-disclosure and self-awareness.  Clinicians who utilize online interventions suggest that some individuals are more open and honest in writing relative to face-to-face sessions.  It is also suggested that writing enables a patient to say whatever they want, whenever they want.  It has also been suggested that the anonymity of writing using a computer (versus a diary that will be read by the therapist in front of the patient) offers even more potential for self-disclosure. 

Disadvantages. Although one advantage of the online treatment method was the power of the written word, a disadvantage may be the lack of emotional content contained in text responses from the clinician.  The response written by the clinician may have a cold and stark tone even if they are expressed with the utmost empathy.  There can also be a great difference in the interpretation of text messages as compared to verbal exchanges.  This can lead to the potential for misunderstanding.  Depending on the intonation, the simple phrase “are you kidding” may be a rhetorical remark that expresses surprise in an empathic manner; or, it may be an actual question in response to a lighthearted joke, or it may perceived as an aggressive response.  Depending on the patient, there may be a more or less propensity towards misinterpreting the simple text of an e-mail or text communication.  For the highly sensitive patient, even the slightly ambiguous written message may be taken in a negative way.  If the same patient is reluctant to share that type of impact with the online therapist, the treatment relationship might be destroyed permanently through patient termination of treatment. 

Anonymity and Non-Face-to-Face Format

Advantages.  Proponents of online counseling and Internet-based interventions cite anonymity as one of the major advantages.  This suggests that the “invisible” client can reduce or eliminate the stigma that can be associated with seeking mental health services.  When one is anonymous, it is felt that honesty, increased self-disclosure, and decreased defensiveness may occur relative to sitting face-to-face with a practitioner.  It has also been suggested that the anonymity of online counseling may ease the discomfort of revealing potentially embarrassing information that is important to the treatment process.  This issue of revealing important, but potentially embarrassing information is relative to both health and mental health treatment. 

Disadvantages.  There are several disadvantages to anonymity and non-face-to-face treatment.  There are summarized as follows:

Loss of the Human Factor.  As we have discussed previously, one of the greatest concerns amongst practitioners relative to online treatment is the loss of non-verbal cues and possibly the “human factor” relative to treatment.  Some have argued that the lack of face-to-face treatment may hamper any type of therapeutic alliance from developing.  In addition, for some people, the lack of physical presence of the therapist may reduce the sense of intimacy, trust, and commitment to the treatment relationship. 

Lack of Non-Verbal Cues.  Related to the loss of the human factor is the lack of non-verbal cues when engaging in online counseling.  When utilizing online interventions, there is a lack of such things as visual and focal cues including facial expressions, body language, and voice tone.  Practitioners traditionally rely on non-verbal cues in order to accurately interpret what a client may be feeling or thinking, beyond the actual content of the communication.  Any clinician who has been in practice for more than a year or two can recount numerous episodes of a patient tearing up while telling a presumably funny story, pausing for an extended period of time while attempting to finish a thought, or inappropriate laughter while relaying emotionally charged responses.  Depending on the sophistication of the computer user, none of these nuances would be expressed in the simple text of an E-mail, IM, or chat.  The lack of non-verbal cues can result in a greater potential for miscommunication.  Some clinicians have asserted that highly experiential treatment approaches depend heavily on the use of real time non-verbal cues and simply cannot be adapted to any mode other than face-to-face interaction. 

Managing Crises.  One of the biggest problems and disadvantages associated with Internet-based interventions is the management of crisis situations.  This may be due to a number of issues including technological failure, suicidality, homicidality, anonymity, among other things.  These specific issues will be discussed in more detail subsequently.  The overriding issue is that a patient in crisis may not have the ability to contact the clinician or have a sense of “connectedness” such that a “cry for help” will be expected to be answered within a reasonable amount of time.  This is quite different than face-to-face treatment in which most practitioners have a 24 hour voice mail or contact system in which he or she can be paged/alerted.  This feature is not inherent in most online treatment programs and the patient/client is simply instructed to call 911 or go to the local emergency room if he or she feels the need.  Certainly, many of these crises could be averted within the context of a face-to-face therapeutic relationship. 

Advantages and Disadvantages of Specific Types

of Internet Based Treatments

E-mail as an Adjunct to Face-To-Face Counseling. 

Advantages. Many practitioners use e-mail as a therapeutic adjunct to the treatment intervention.  e-mail contact can allow the patient to raise issues that they may have forgotten during the session or were reluctant to raise in person.  E-mail can also be used for self-monitoring of specific behaviors which increases accountability between sessions.  This can also free up treatment session time for other issues.  Proponents of this approach suggest that e-mail provides another opportunity for patients to self-disclose especially when they are reluctant to do so in the face-to-face situation.  E-mail may also be beneficial for patients who become inattentive to the treatment expectations (e.g. homework exercises) to be done in between face-to-face visits.  Murdoch & Connor-Greene (2000) highlight some of the advantages of using E-mail as a therapeutic adjunct to cognitive behavior therapy including the following: 

Integrates the patient’s attention to therapeutic goals, strategies, and progress into the everyday routines. 

Provides opportunities for practice and strengthening of skills for patients who have persistent negative cognitions.

E-mail prompts may overcome negative thoughts regarding the usefulness of homework or the patient’s perceived competency. 

Disadvantages.  E-mail as an adjunct to face-to-face counseling also has many disadvantages, many of which have been hotly debated amongst practitioners.  The disadvantages as discussed by practitioners fall into two types:  Technologically-related and treatment-related.  The disadvantages of e-mail contact from a technological perspective involve issues primarily related to confidentiality and privacy.  Unless both the patient and clinician have taken special steps, routine e-mail communication is not encrypted and should not be considered secure.  Clearly, unless encryption and certification procedures are in place, e-mail communications between the clinician and patient should not be considered confidential.  Although this may be obvious on a moment’s reflection and recorded in the clinician’s informed consent procedures, patients will often simply forget that this is the case due to the frequency and routine use of this mode of communication. 

Beyond the problem of encrypting e-mail communications, there is the potential for a violation of confidentiality on either the patient or clinician’s end of the e-mail correspondence.  Unless the patient’s e-mail account is password protected, anyone living in the household can easily access the communication.  This also applies to the office of the clinician.  These issues have been overcome by requiring encryption and certification procedures if e-mail communication is to be used.  Another option is to use a service that specializes in secure e-mail such as Hushmail and Safe-Mail.  These types of services require that both the clinician and the patient use the encryption service. 

The other disadvantage related to e-mail is treatment related.  Many practitioners simply want to limit their services to the “50 minute hour.”  Establishing e-mail as adjunctive to one’s treatment intervention does require more time.  This includes the process of retrieving, reading, and (in some cases), responding to e-mails.  Depending on the style and issues of an individual patient (and the total number of patients involved in this type of adjunctive treatment), the “out of office” treatment activity could become somewhat overwhelming.  This can also present boundary issues since there will often be the perception by the patient that the clinician is available “24-7”. 

Instant Messaging and Chatting

Advantages.  Suler (2000) has listed the benefits of synchronous communication such as chat and instant messaging as follows:  The ability to schedule sessions defined by a specific, limited period of time. 

A feel of presence created by being with the person in real time. 

Interactions may be more spontaneous, which may result in more uncensored disclosures by the patient. 

Making the effort to be with the patient for a specific appointment may show commitment and dedication. 

Pauses in the conversation, coming late to a session, and no-shows are not lost as psychologically significant cues. 

Chat and Instant Messaging (IM) enable more direct and immediate communication and there is more continuous and immediate feedback in both directions.  Some authors have suggested that instant messaging and chat may be an appropriate method for discussion and practice of particular skills such as cognitive restructuring. 

Disadvantages.  Even with advances in technology, chat rooms and instant messaging are more difficult to utilize than E-mail communication.  Unlike asynchronous methods, chatting and using IM require that the clinician and patient schedule a time to “meet.”  This can often be challenging, particularly if the individuals are in different time zones.  Lastly, with real time chat and IM, the skills of the users can significantly impact the efficiency of the method.  Anyone who is not a particularly adept typist knows the frustration that can come from attempting to text, chat, and IM in real time. 

Videoconferencing

Advantages. Videoconferencing is the closest technological method to face-to-face interventions.  Certainly, videoconferencing can increase the access of mental health and health services to rural populations, individuals with disabilities, and those individuals who are otherwise isolated.  Videoconferencing provides multiple cues that are not available with the other methods of distance treatment including visual appearance, body language, and vocal expression.  Suler (2000) lists other advantages of videoconferencing including the feeling of the therapist’s presence may be powerful when multiple sensory cues are available, which can enhance the impact of the therapist’s interventions, the sense of intimacy, and commitment to therapy. 

It may be less ambiguous that typed text, which can lead to less misunderstandings. 

It may be a benefit to those that express themselves better through speaking than writing. 

Speaking is faster than typing and may therefore convey information more quickly. 

Disadvantages.  Suler (2000) also outlined some of the disadvantages associated with the use of videoconferencing including the following:  Videoconferencing requires the use of extra equipment, more technological knowledge, and a fast Internet connection to work efficiently. 

Some clients may be less expressive when face-to-face with the therapist or may be more uncomfortable with too many visual and auditory cues. 

Saving a record of audiovisual files consumes a great deal of storage space. 

Although there have been great technological advances over the past five years, videoconferencing still does not provide a real life experience unless one is utilizing very expensive equipment (we have all seen the Cisco Telepresence Advertisements).  Although some hospitals have set up videoconferencing systems for remote evaluation and treatment of health conditions, this has not generally occurred in the mental health fields.  Using inexpensive and lower tech systems such as Skype comes with its own security and confidentiality issues.  Although the Internet is replete with videoconferencing software and systems using “your webcam,” security is often unknown and the patient must also have the equipment and technical skills to operate these systems. 

Ethical Guidelines and Standards of Practice

As discussed previously, Internet technology related to all types of web-based interventions is developing and expanding much faster than ethical guidelines and standards of practice to guide this type of practice.  Therefore, clinicians do not have a lot of guidance relative to this type of intervention.  The following will review some of the ethical codes that are available currently. 

American Psychological Association. 

Most of the ethic codes that guide mental health practitioners do not specifically address E-therapy although that is changing as discussed previously.  For instance, E-therapy has not been specifically addressed in 2002 (with 2010 and 2016 Amendments) APA Ethics Code, but there are plans to address this new intervention approach in future versions.  The only guidelines at this time are the Practice of Telepsychology Guides discussed prevously. In the 2002 APA Code of Ethics (with 2010 and 2016 Amendments), the same guidelines still apply.  As discussed by Smith (2003), the 2002 Ethical Code does not specifically address e-therapy, but language throughout the code addresses Internet and electronic transmission.  Smith (2003) specifically mentioned Standard 4 (Privacy and Confidentiality, especially 4.02c) which stipulates that psychologists who offer services, products or information via electronic transmission, inform their clients/patients of the risks to privacy, and limits of confidentiality.   

The Social Work Organizations

The National Association of Social Workers and the Association of Social Work Boards published the Standards for Technology and Social Practice in 2005.  This lengthy document specifically addresses, “The standards that apply to the use of technology as an adjunct to practice, as well as practice that is exclusively conducted with technology.”  The document goes on to state that, The NASW Code of Ethics and the ASWB Model Social Work Practice Act served as foundation documents in developing these standards, along with a variety of other sources.” This document has recently been updated. The social work organizations (NASW, ASWB, CSWE, CSWA) recently released Technology in Social Work Practice (2017) which can be found here or here. In addition, the newest updated to the NASW Code of Ethics (2017) addresses technology. 

The National Board of Certified Counselors

The National Board of Certified Counselors (NBCC) has specifically addressed the practice of Internet counseling.  In the introduction, the document acknowledge that there are many technology-assisted distance counseling methods, of which Internet counseling is one example.  The Policy Regarding the Provision of Distance Professional Services (NBCC) is specific only to Internet counseling and includes the following sections:

A Taxonomy of Defining Face-To-Face and Technology-Assisted Distance Counseling

Nature of Counseling

Forms of Counseling

A Taxonomy of Forms of Counseling Practice

Definitions

Standards for the Ethical Practice of Internet Counseling

Internet Counseling Relationship

Confidentiality and Internet Counseling

Legal Considerations, Licensure, and Certification

The American Mental Health Counselors Association

The American Mental Health Counselors Association (AMHCO) represents mental health counselors that are bound by the AMHCO Code of Ethics (2010).  Section 6 of the Code (Technology-Assisted Counseling) specifically addresses the issues related to any type of technology assisted counseling.  This section can be found in Table 7.

American Counseling Association

The American Counseling Association (ACA) has a Code of Ethics (2014) that has incorporated issues related to Technology Applications.  The Technology Applications (A.12) can be found in Table 8.  

Commission on Rehabilitation Counselor Certification

According to their web site, the Commission on Rehabilitation Counselor Certification (CRCC) is an independent, not-for-profit organization that sets the standard for quality rehabilitation counseling services through its internationally recognized certification program.  Technology ethics was incorporated into the CRCC Code of Ethics in 2002 as an independent section.  In this form, it was done in a fashion similar to other professional organizations.  The CRCC revised the Code of Professional Ethics in 2017 in 2017 and completed a significant update of the Technology Section (See Table 9).  As discussed by Barros-Bailey and Saunders (2010), referring to a previous version, “the Code provides for the first standards within the counseling and human service fields assisting practitioners and academics with behavioral guidance in the use of technology in these areas.”  Given that this Code provides the most extensive guidance related to technology of any of the professional organizations, it is worth review by anyone involved in the use of Internet based interventions of any type. 

International Society for Mental Health Online

Aside from professional organizations who are incorporating Internet-based treatment guides into their ethics codes, there are organizations that have been established specifically for individuals who do only this type of work.  The International Society for Mental Health Online (ISMHO) was the first of these organizations.  As far as we can tell, it does not have an “Ethic Code” but rather “Suggested Principles for the Online Provision of Mental Health Services”.  This document can be found in Table 10.

Compliance to Ethical Standards

Several studies on compliance have utilized the traditional method of surveying online practitioners and patients (however, not many of these types of studies have been recently).  Even though the following studes are not particularly current, they offer guidance in the kind of issues that should be scrutinized for any e-therapy site or company.

For instance, Maheu and Gordon (2000) completed a compliance study of 56 online practitioners.  The researchers found that 78% offered behavioral E-health services to individuals in states other than the ones in which they were licensed to practice.  In addition, despite the acknowledgement of 76% of therapists on the importance of ethical concerns, only 50% of the respondents either used consent forms or had arrangements to deal with emergencies. 

Aside from survey research, a more recent trend is to evaluate the actual e-therapy website to investigate their compliance to ethical standards.  Two studies found a low level of compliance with the APA, the ISMHO, and the NBCC’s Ethical Standards regarding e-therapists’ compliance to confidentiality, services to minors, and response to emergencies (Heinlen et al., 2003a, 2003b).  Only 14% of the 44 E-therapy web-sites by psychologists specified that their licenses to practice online are limited by State Law.  Almost 50% of the sites explained the procedure to get informed consent from their clients and a third of the E-therapy sites used identification numbers and passwords to protect privacy as well as encryption for protection of confidentiality.  36% of these sites provided procedures such as contacting 911 and similar modes to respond to emergency situations.  Specifically relative to the ISMHO and APA Ethical Standards, 73% of the psychologists did not provide a description of the potential risks and only 34% had a policy on service to minors.  In a study of 136 professional counselor websites, Heinlen et al. (2003 b) used the compliance of counselors to the NBCC standards.  Only 22% of the sites followed a method of encryption using the secure socket layer (SSL) and only 26% of the websites referred to issues related to the treatment of minors.  Approximately 57% of the sites discussed the confidentiality of client disclosures and 40% of the sites provided information related to the duty to warn and protect.  Heinlen et al. also compared professional web counselors and web counselors with no credentials in their ethical compliance.  Professional web counselors showed higher levels of compliance than web counselors with no credentials.  In a study completed by Shaw & Shaw (2006), the ethical compliance of 88 online counseling websites was investigated (23 of which were licensed social workers).  79% of the websites identified their state of practice and over 30% of the sites required that clients sign a waiver explaining limits of confidentiality over the Internet.  Less than 50% of the online counselors followed a minimum of eight of 16 areas of professional ethics identified by the ACA Ethic Online Ethics Guidelines. 

More recently, Santhiveeran (2009) investigated compliance of social work e-therapy websites to the NASW Code Of Ethics.  Special attention was given to specific areas of ethical conduct including 1) the duty to inform, 2) the duty to maintain professional boundaries, 3) the duty to maintain confidentiality and 4) procedures to be used in an emergency.  In the study, 66 E-therapy websites with social workers were investigated.  The study utilized a mixed method of both qualitative and quantitative approaches.  An e-therapy site compliance evaluation form (ESCEF) was created specifically for the study and focused on the four areas of ethical conduct listed previously.  Investigation of each website included only written information available to the public.  Results are as follows: 

The duty to inform.  The duty to inform was categorized into sub-themes including:  The nature of e-therapy, benefits, potential risks, safeguards, and alternative treatments.  Approximately 68% of the sites informed users about the nature and extent of the e-therapy process.  This was generally summarized as “a secure and affordable way to consult with online professionals at anytime from anywhere.”  The aim of e-therapy is stated as “a process to enable clients to learn how to meet life’s challenges” (p.7).  The benefits of e-therapy were also outlined as part of the nature of e-therapy and included such things as convenience, anonymity, privacy, immediate professional guidance, access, etc.  Approximately 62% of the e-therapy sites informed the user of potential risks and these fell under three general categories including: technical difficulties, third party damages, and shortcomings of the modality.  Third party damages included such things as problems with PayPal services and web hosting services that could affect quality of service.  Short comings of online counseling were generally concerned with the fact that it is “experimental” and “cannot replace face-to-face therapy.”  About 44% of the websites informed the user of the safeguards to be taken while using computers and therapy, and 59% of the websites informed the users about treatment alternatives. 

The duty to maintain professional boundaries.  About 85% of the websites listed their social work therapists’ primary state of practice, but only 33% stated that the social worker would serve clients from other states in which they had a license to practice.  All social work e-therapists listed their areas of specialty.  The most popular areas of specialty included depression, post-traumatic stress disorder, anxiety disorder, anger management, addiction, pre-marital and marital counseling, family therapy, grief and loss, dissociative disorder, relationship issues, mental health counseling, and adjustment disorders. 

Duty to maintain confidentiality.  The duty to maintain confidentiality was categorized into three sub-themes: privacy and confidentiality, limits to confidentiality, and the maintenance of treatment records.  Only 49% of the websites presented information on the duty to maintain confidentiality.  These websites used encrypted e-mail, secure chat, or SSL to prevent hacking.  A few sites discussed limits to confidentiality and some sites stated that they would reveal the contents of a discussion if required to do so by a court of law.  Only 12% of the sites discussed how treatment records were maintained. 

Procedures to be used in an emergency.  The issue of procedures to be used in an emergency is divided into sub-themes:  Procedures to deal with emergencies and providing information on local back-up services.  59% of the sites had procedures in place to deal with emergency situations.  The most common method was directing clients to use either an emergency telephone number such as 911 or a toll-free suicide hotline.  Only 32% of the websites included local emergency back-ups such as hospital, medical, treatment, physician, or close friend information that was taken at the time of intake to handle emergencies. 

Overall, the author concluded that a high level of compliance was found with the duty to inform and a low level of compliance was found in the area of duty to maintain professional boundaries.  The duty to maintain confidentiality and procedures to be used in an emergency “yielded mixed results, raising some concerns.”  The author felt that there was a “dire need” to revisit and revise the NASW Code of Ethics to address changes in technology that have occurred over recent years. 

State and Legal Guidelines

Aside from Ethical Guidelines, several state licensing boards have adopted laws and guidelines for professional practice in online counseling and “tele-psychology.”  For instance, there may be problems if a psychologist licensed in one particular state provides e-therapy service to a patient in another state.  This is due to the fact that each state has their own set of professional licensing and practice laws in order to protect their citizens. To assess this issue, Koocher and Morray (2000) conducted a survey of the 50 state attorney generals and asked several questions related to telepsychology.   The researchers asked questions about laws regarding telepsychology practice, whether any charges had ever been brought related to this practice, and how the state handles those telepsychology services provided from another state. At that time, 24 states claimed regulatory authority over practitioners residing in other states that provided e-therapy services in their state.  Seven states acknowledged receiving complaints about e-therapy services and charges had been brought in E-therapy cases in at least two states.  Given the exceptional advancement and use of the Internet in the ten years since that publication, things have likely changed.  For instance, the California Board of Psychology has a notice to consumers regarding those who choose to seek psychological service over the Internet (See Table 11 or click here). Similar statutes likely exist in other states and these should be checked carefully by the e-therapy provider.  

More recently, McAdam and Wyatt (2010) investigated the regulation of technology assisted distance counseling and supervision by counseling licensing boards in the United States.  The authors state that in response to the proliferation of online counseling, some states have independently enacted regulation specific to the governance of technology assisted distance practice (TADP).  The purpose of this study was to identify the states in which TADP was formally being regulated, the specific aspects of TADP that were being regulated, and the degree to which existing TADP regulations were distinct from regulations for traditional counseling practices.  The study also sought to assess current trends in thinking among policymakers related to TADP that might influence regulation in the future.  The researchers contacted all of the State Boards of Counseling in the United States inquiring about existing and proposed regulations pertaining to TADP.  The researchers found that less than a third of the states have existing regulations in place for technology assisted distance counseling (TADC), and only 13% have regulations in place for technology assisted distance supervision (TADS).  A number of states reported that regulations were under discussion or development.  Interestingly, 22% of the states prohibited TADC and 41% prohibited TADS. 

The researchers also attempted to get a sense of trends that were developing as far as regulation of online counseling.  The issue of legal accountability for the conduct of TADP was reported to be a major concern for all boards.  Concerns centered on the difficulty in determining and enforcing legal accountability for TADP involving constituents from multiple legal jurisdictions.  For some of the Boards, the complexity of this issue was the primary reason for their decision to simply prohibit TADP altogether.  In states where TADP was permitted, current and proposed regulations ranged from a broad requirement to meet legal requirements of any jurisdiction in which electronic presence is maintained (40%) to more specific standards requiring licensure in each state where TADC is practiced (60).  Few Boards have formally addressed the issue of “specialized training” as a prerequisite for TADP.  There was general agreement that obtaining a consumer’s informed consent specific and prior to the delivery of TADB services is a necessity.  Every Board that had authorized TADP discussed counselor adherence to available ethical standards including the current ACA (2005) and NBCC (2005) Ethical Guidelines specific to online counseling.  It should be noted the findings of this study reflected the standing of TADP regulation in the United States as reported in mid to late 2008. 

If You Do It, What Should You Do?

The following is based upon literature reviews and recommendations by Shiller (2009), Robinson (2009), Abbott et al. (2008) and the references included. It is also based on the varoius more current resources listed prevously (new ethics codes, technology practice guides, bibliographies, etc.)

Confidentiality and Informed Consent

With respect to confidentiality, there are threats at multiple levels including the clinician, the patient, the Internet Service Provider (ISP), and in transmission (hackers).  All of these potential issues must be addressed and proper informed consent procedures completed (See Fitzgerald et al., 2010 for a review).

Practitioners should inform clients of the standard limits to confidentiality (e.g. child abuse, duty to warn, and other reporting mandates) and the threats to confidentiality that are unique to electronic transmission of information (Fisher & Fried, 2003).   

Practitioners should take steps to mitigate the risk of potential security breaches; for example, secure web sites and e-mail encryption should be used (Manhal­-Baugus, 2001).

Practitioners should advise clients of the specific procedures being used to protect confidentiality (Fisher & Fried, 2003).

Clients should be informed of their own confidentiality burden (Kanani & Regehr, 2003). They should be advised to participate in online therapy in a private room in which family members or others are not likely to intrude (Ragusea & VandeCreek, 2003). They should password protect any email used for treatment purposes.

Clients should also be informed of the risk of keeping records of online sessions (Mallen, Vogel & Rochlen, 2005).

Practitioners should inform clients of the methods in which and the time period for which records of online sessions are being retained (Kanani & Regehr, 2003). They should also be informed that a permanent record may always exist with the Internet Service Provider and this may be accessible by legal institutions under exceptional circumstances.

Informing patients about the various threats to confidentiality can be a challenging task, especially with changing technology and laws.  For instance, the Supreme Court just issued a decision (June, 2010) about the privacy (or lack thereof) of text messages sent to and from a public employer-provided device.  The Court ruled that the text messages on devices provided by a public agency (police department). The ruling has not been tested relative to private employers.  For a review of the decision, click here and search for City of Ontario v. Quon (No. 08-1332).     

Informed Consent (other areas)

Practitioners should provide clients with a means of verifying their credentials (Fitzgerald et al., 2010).

Practitioners should confirm the age and legal status of the client through an initial interview (Fisher & Fried, 2003) or through another screening or intake procedure (Shaw & Shaw, 2006). This might include photo identification, birth certificate or initial meeting with a local therapist (Fitzgerald et al., 2010; Midkiff & Wyatt, 2008).

The practitioner must ascertain that the client has competence to give consent (Fitzgerald et al., 2010).

Jurisdiction

Online practitioners should be familiar with the licensure restrictions and exemptions in their jurisdiction and the jurisdictions in which their clients are located (Zack, 2008)

Therapists should only deliver mental health services in jurisdictions in which they are licensed (Mallen et al., 2005 and various state regulatory agencies).

Practitioners should contact their licensing body to ensure that they are able to practice e-therapy (Kanani & Regehr, 2003).

Practitioners should contact their insurer to ensure that their policy covers online counseling (Murphy, MacFadden & Mitchell, 2008).

Online therapists should provide links to websites of all relevant certification and licensing boards Oencius & Sager, 2001).

Suitability for Treatment Approach

Anyone providing online treatment (primary or adjunctive) should complete some type of suitability of the patient for this type of approach.  Although guidelines are still not clear, at least the following issue should be considered.

Practitioners should only conduct online therapy in conjunction with face-to-face therapy or with a prerequisite meeting in person, so that identity can be verified via conventional means (Ragusea & VandeCreek, 2003).

Practitioners should acquire identity information from the client (Ragusea & VandeCreek, 2003).

Practitioners must assess the client's suitability for online therapy, looking at such factors as knowledge of computer systems and Internet technology; motivation and capability of experimenting with new communication environments and techniques; and, physical or cognitive problems that may limit the client's typing ability and/ or ability to read and write (Suler, 2001).

Online counseling websites should disclose topics that are not appropriate for online counseling, such as sexual abuse and violent relationships (Maheu, 2001).

E-mail should not be used with clients suffering from severe boundary problems (Bailey, Yager, & Jenson, 2002).

Practitioners should not take on clients for online counseling who are (See Abbott et al., 2008; Carlbring & Andersson, 2006; Maheu, 2001; Mallen, Vogel & Roch1en, 2005):

suffering from psychiatric disorders needing immediate attention

who are significantly depressed

who pose a danger to themselves or others

those with serious substance abuse issues

clients presenting psychotic or actively suicidal concerns

psychological disorders characterized by distortion of reality

patients who are highly reactive and potentially dangerous

patients with certain personality disorders such as those with borderline personality disorder, paranoia or dissociative disorders

General Clinical Issues

The following issues are general in nature and do not address the unique aspects of being competent at doing effective online treatment (e.g. the writing style, checking for understanding of information, etc.)

Practitioners can attempt to maintain boundaries with respect to expectations for immediate responses by establishing a time frame for responses (Kanani & Regehr, 2003).

Practitioners must work with clients to establish rules with regard to appropriate use of e-mail communication (Tate & Zabinski, 2004).

Practitioners should fully describe the online services to be provided as well as any factors that might discourage clients from wanting to participate in online counseling (Shapiro & Shulman, 1996).

Practitioners need to make clients aware of additional risks due to the online medium (e.g. confidentiality, possibility of technical difficulties, possibility of misunderstandings due to limitations inherent in text-based communication and difficulties intervening in the case of an emergency) (Zack, 2008).

In obtaining informed consent, practitioners must disclose the fact that, although empirical evidence on the benefits of certain types of online counseling is growing (e.g. cognitive behavioral therapy for mood disorders, etc.), there is still limited support for other areas (Fitzgerald et al., 2010; Kanani & Regehr, 2003).

Crisis Management

Practitioners should have back up resources to avail themselves of in the event of an emergency. Maheu (2003) recommends that backup resources include the emergency department of a local hospital, a trusted colleague, the client's primary care provider, his or her specialty provider or a family member.

Practitioners should have an alternative method of contacting the patient or mobilizing resources other than the Internet communication mode.

Practitioners should be part of a network of e-therapists so as to be able to obtain assistance or effect referrals to someone in a client's local jurisdiction as required (Kanani & Regehr, 2003).

Practitioners should provide clients with clear written guidelines regarding planned emergency practices (Fitzgerald et al., 2010; Koocher & Morray, 2000).

Online counseling websites should have a notice for suicidal individuals with information about hotlines, crisis centers and emergency departments of hospitals (Manhal-Baugus, 2001).

Crisis situations requiring quick response should not be addressed online and clients who are experiencing such situations should be encouraged to seek face-­to-face counseling (Murphy, MacFadden & Mitchell, 2008).

Competence/Lack of Skills

Performing Internet based (or assisted) interventions clearly requires a special set of skills.  Practitioners should seek out training necessary to acquire competence in this area (Fitzgerald et al., 2010; Goss and Anthony, 2009; Zack, 2008).

Online counseling training should cover technology, theory, applications and ethics (Fenichel et al., 2002) as well as licensing laws (Maheu, 2003). It should also include skills in text-based communication (Murphy, MacFadden & Mitchell, 2008) and protecting client information online (Wells, Mitchell, Finkelhor, Becker-Blease, 2007).

With respect to technological competence, practitioners should only use software that is congruent with their capabilities or if new software is used to expand competencies (Sampson Jr., Kolodinsky, & Greeno, 1997).

Practitioners should stay aware of emerging developments in research as to the efficacy of online counseling, including research as to which clients can benefit from online counseling and which modes of online care are most beneficial (Oravec, 2000).

Informed consent should be an ongoing process that is re­evaluated periodically as new information about online counseling becomes available (Recupero & Rainey, 2005)

A template agreement should not be used in place of an informed consent discussion (and documentation) as clients must be able to demonstrate understanding of the material (Recupero & Rainey, 2005).

Time Delay/Technological Failure

Back-up procedures to be implemented in case of technological failure (such as telephone contact by the counselor) should be provided to the client in advance of commencing online therapy (Oencius & Sager, 2001).

The client should be given emergency procedures to utilize in the event of technology failure (Fitzgerald et al., 2010).

Loss of the Human Factor/Lack of Non-Verbal Cues/Impact of the Written Word

To prevent misunderstandings, the counselor should check with the client often to make sure the client understands what the counselor is saying and that the counselor understands what the client is saying (Stofle, 1997).

Practitioners should actively check in with clients with follow-up questions to comments that may cause concern (Zabinski, Celio, Jacobs, Manwaring & Wilfley, 2003)

Monitor clients for potential barriers to continuing with online counseling (Abbott, Klein, & Ciechomski, 2008).

Clients should be empowered along with practitioners to suspend online treatment if they feel uncomfortable (Oravec, 2000).

Practitioners should not use e-mail with patients with borderline personality disorder as the risk of hypersensitive distortions of e-mail communications may be substantial (Yager, 2003).

Online counseling should perhaps not be used for experiential, insight-oriented or psychodynamic psychotherapy (Bouchard et. al, 2000).

Online therapy should only be used as an adjunct to face-to-face counseling (Maheu, 2003). With respect to using e-mail as a therapeutic adjunct, Peterson and Beck (2003) suggest that the adjunctive model of e-mail application presumes the following:

An already established therapeutic alliance;

Therapist preparedness for the implications of e-mail dialogue:

A clearly negotiated e-mail contract to include boundaries and mutual expectations;

A "promises kept" understanding in which the patient can rely on the therapist to respond, even if not instantaneously; and

A "bailout" safeguard, wherein the therapist calls for face-to-face sessions when e-mail use is regarded as counter-therapeutic.

The use of videoconferencing allows for multiple sensory cues, such as visual appearance, body language and vocal expression (Suler, 2000).

Plan for the Worst Case Scenario

All of the previous recommendations must be considered carefully.  Planning for the worst case scenario always helps a practitioner be prepared.  The following case example addresses crisis management specifically. Assume you have been in traditional practice for awhile and you decide to supplement your practice with some online counseling services.  Then, assume the following case example occurs as part of your online counseling practice.  This type of situation has likely occurred to any practitioner who has been working in the field (face-to-face treatment) for any length of time. As is by far the most common online treatment method, you use asynchronous email.  You have been fairly careful to get your patient/client to fill out the usual forms you use in your office practice that have been adapted to online counseling (demographics, etc.).  The client is in the same state but lives 200 miles away in a small town.  You get the following e-mail at 11 AM (when you check your email) and note that it was written five hours earlier.  You have just checked your e-mail in between sessions at your office.  

In this situation, you first attempt to e-mail back right away and request a response.  There is none, but you can tell she is online from the IM status (or at least her computer is online).  You then attempt an IM with no response.  You attempt to call her home but the answering machine picks up.  You have one emergency contact phone number on your “intake” sheet (from five months ago) but it is disconnected.  You call her work number and find out she did not shown up for work today (four hours ago).  You have the first name of her boyfriend and know that he works at some restaurant you have never heard of in a town “nearby”.  You are not familiar with the area in which she lives or the surrounding communities.  You start calling the local police but, again, get the wrong jurisdiction and are re-directed.  You ask about a Psychiatric Emergency Team, which is common in metropolitan areas, but there is no such service where Lori lives.  You finally talk with the local police department and they agree to go by her apartment (she’s not there).  You talk with the police further and they ask for description of Lori so they might look out for her.  You don’t have a description aside from her age. You don’t have any information about the boyfriend or his place of employment.  You only have his first name. 

In this situation, many issues are present.  The case underscores the need to proceed cautiously when doing online therapy.  Issues include at the very least (1) careful pre-screening for appropriateness of this type of approach, (2) ongoing informed consent such as what the patient is to do in crises, and that the patient understands exactly how to proceed in crisis situations (e.g. it is OK to call if necessary, call a local therapist that will provide emergency backup, etc.), (3) keeping information up-to-date such as emergency contacts, (4) getting detailed information during treatment that you would normally get during a face-to-face intervention (e.g. information about the boyfriend, the town, the place of work), and (5) gaining knowledge about local resources if you are another jurisdiction.

Summary

Regardless of whether you are a proponent, opponent or an “undecided” relative to Internet-based or Internet-supported treatment interventions, they are clearly here to stay and they are rapidly expanding.  As with many scientific developments, the technology is greatly outpacing our understanding of how to best to utilize it, not only from a treatment perspective but also in an ethical manner.  Although empirical evidence is mounting relative to the type of problem (and person) that is most suited to these approaches, at this time the clinician is generally left to decide without all the facts “being in”.  There are advances in some ethical guidelines, but these are in varying stages of development.  Lastly, many of the legal and regulatory issues are either unclear or have not been tested in the courts.  A practitioner who desires to add any element of online communication/treatment to his or her practice should be very familiar with the current literature, seek out the ongoing counsel of other colleagues, and proceed with due diligence.   

REFERENCES

Abbott, J.M., Klein, B., & Ciechomski, L. (2008). Best practices in online therapy. Journal of Technology in Human Services, 26, 360-375.

Ainsworth, M. (2002). E-therapy: History and Survey.

Alleman, J.R (2002). Online counseling: The Internet and mental health treatment.  Psychotherapy: Theory, Research, Practice, Training, 39, 199-209.

Andersson, G., Bergstrom, et al. (2008). Development of a new approach to guided self-help via the Internet: The Swedish experience. Journal of Technology in Human Services, 26, 161-181.

Bailey, R, Yager, J., & Jenson, J. (2002). The psychiatrist as clinical computerologist in the treatment of adolescents: Old barks in new bytes. American Journal of Psychiatry, 159, 1298-1304.

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