You can't do Psychotherapy on the Net (yet)
Leonard G. Holmes, Ph.D.

Mental health professionals find themselves divided on the issue of whether it is possible to use the Internet for the delivery of services.  A few have already begun to offer such services, including psychological assessment, advice for free or for a fee, and even education and counseling by chat or email. Most have taken a "wait and see" attitude, either treating the net as a "read only" medium, or posting information about themselves or a page advertising their practice.   Many others have never even "surfed the net."

A Brief History of Online Services

Psychology has had a presence on the net from the very beginning.   In the mid 1980s the BITNET Psychology Newsletter (originally called PsychNet) brought together psychologists who worked at various colleges and universities. (The APA now has the trademark for PsychNET and it can be found at http://www.apa.org.)  The Newsletter also included a mailing list which was similar to today’s listserv lists.   Many listservs are still housed on BITNET, which is now a part of the internet and connects colleges and universities. 

During that period I sometimes used e-mail as a tool to allow clients to stay in touch between sessions.  For several years an interactive computer bulletin board at William & Mary was sometimes used for the discussion of mental health issues.  When a student committed suicide on campus, I joined the discussion with some ideas about coping with the loss and with how to help friends. 

Dear Uncle Ezra is an "electronic counseling and information service" at Cornell University which has operated since 1986 (which can be reached at http://www.cornell.edu/Dialogs/EZRA.html).  Students (and others?) are encouraged to ask "any reasonable question."  Uncle Ezra was originally housed on a gopher server - a text-based internet protocol.  The current website states that Uncle Ezra "offers personal counseling, advice for problems of all sorts, and general information."  Email inquiries are responded to individually, and answers which are of general interest are posted for all to see.

The World Wide Web was gradually developed beginning in 1990.   It was conceived of as a worldwide network of computers which would be linked by a hypertext language.   The first graphical World Wide Web browser, Mosaic, was developed in 1993 by Marc Andreessen (Cailliau, 1995).  This development changed the face of the internet.  It allowed people using Xwindows and Unix to point and click their way through hypertext documents which included graphics. 

Andreessen went on to found Netscape Corporation, which developed the popular Netscape Navigator web browser based on his earlier Mosaic design.

The internet is a complex network.  Coverage of all facets of the internet is beyond the scope of this paper.  Usenet Newsgroups include support groups for various disorders, and these are generally unmoderated.  Professionals participate as equals.  Electronic mail (email) is the most popular aspect of the net.  Email allows users to communicate asynchronously.  They can send a message without the recipient being online to receive it.  Most mental health services on the net are delivered through the web and through email.  Here are some examples of what's out there now

Mental Health Net (http://www.mentalhelp.net) is a huge mental health site with original content, reviews of mental health content elsewhere on the net, and content reprinted from other sites.  It includes an entire hypertext self-help book.   No services are delivered to individuals from this site.  Mental Health Net is also the home of the Credential Check Service (http://www.mentalhelp.net/check) which independently verifies the credentials of online counselors who do deliver services to individuals.

Self-Help & Psychology Magazine (http://www.shpm.com) is a similar site which has a huge amount of original content.  The editors of different sections are mental health professionals who write from their experience as clinicians.  There is a section which explores the delivery of services to individuals, but the site itself does not attempt such a service.

Dr. Bob’s Psychopharmacology Tips (http://www.dr-bob.org/tips) is an excellent resource on psychiatric medications for clinicians and the public. Most of these tips were originally contributed to a psychopharmacology mailing list. No individual services are offered.

Psych Web  (http://www.psychwww.com) is one of the best general psychology resources on the net. Russell Dewey, Ph.D. created this site at Georgia Southern University before many of the bigger commercial sites. It includes excellent original academic psychology resources (such as web versions of The Interpretation of Dreams by Sigmund Freud and Varieties of Religious Experience by William James) as well as comprehensive links to other resources.

The Albert Ellis Institute (http://www.iret.org/) has a website which features "Ask Dr. Albert Ellis."  Dr. Ellis answers one question each month free-of-charge.  This is a technique used on a number of sites.  No confidentiality is offered, but names are not included.   This is a form of media psychology, similar to a radio talk show.

Mental Health Resources at About.com (http://mentalhealth.about.com) is a site of mine which focuses on helping people find mental health resources on the net.  I sift through all of the junk on the internet to find the gems.

Shareware Psychological Consultation (http://netpsych.com/share) is my attempt to deliver services directly to people over the internet.  Before viewing my site there is a statement requiring you to acknowledge that the consultations are educational and are not treatment for any disorder.  This is an important distinction that we will continue to discuss, as we discuss the fact that you can’t do psychotherapy on the net (yet).

The Mental Health Cyber-Clinic (http://www.dcez.com/~davids/) is a site developed by David Sommers, Ph.D.  He emphasizes ongoing interactions which approach "psychotherapy" in their complexity, but states that he is not entering into a "traditionally defined therapy relationship" with clients.   He offers CU-SeeMe video counseling, but reports that few clients have taken advantage of it, and that video quality is poor.

Wired Senses (http://www.revisions.com/enter.html) also offers both email and CU-SeeMe video counseling. They request information on the nature of your problem, presumedly to send your email to the approproiate "counselor."   Catagories include "depression and other mood disorders, addiction related, and abuse-related."  A potential client might see this as a claim that the site treats depression by email.  This should probably be avoided.

Concerned Counseling Incorporated (http://www.concernedcounseling.com) claims a staff of 200 licensed professional counselors.  Information is available for some of these people, and psychologists are included.  The site pays a percentage of their income to other sites as a "promotional fee."  This fee is based solely on referring a client to the site, a procedure which appears to be unethical for psychologists.  [They have changed this policy and no longer engage in fee splitting]

With the explosive growth of the Internet new possibilities have emerged for the delivery of mental health services. For the client, online services offer the convenience of professional contact from their own home.  Along with these new possibilities come new hazards, as well as new responsibilities.  What are some of the issues involved in the delivery of such services?  They fall into at least three categories ethical issues (including a mental health professional's responsibility to keep communications confidential and to protect the client), bandwidth issues, and regulatory and licensing issues.  This paper will begin to address some of these issues in these three areas of concern.

Ethical Issues

The American Psychological Association has released a statement addressing internet, teleconferencing, and telephone services (APA Ethics Committee, 1995).  In this statement they address the applicable APA ethical standards and express some concerns regarding the confidentiality of email and the absence of   non-verbal cues.  The current paper addresses these concerns; as well as broader issues which may also apply to other mental health disciplines.

While the Internet can be a relatively anonymous environment, it is not always a completely confidential environment. While email traveling over the net in the United States is legally protected in a manner similar to U.S. Mail, the same is not true for email messages stored on a company's computer. A company or system simply needs to inform you that you have no expectation of confidentiality (which it can do in fine print when you are hired or via a login screen).  The company can then read any message on its system.

Programs are available which allow encryption of email sent over the net.  These are slowly becoming more user-friendly (although the U.S. government is still pushing for restrictions on encryption technology to give law enforcement access to encrypted messages).  Pretty Good Privacy (PGP) is the pioneering encryption program for the masses.  Programs are encrypted with a user's "public key" which is made widely available.  They can only be decrypted with the user's "private key" which is not made available.   PGP encrypted messages can be considered confidential because it would take so much time, effort and computer power to decrypt them that few people would bother.

Netscape Navigator and Microsoft Internet Explorer include some email privacy features because of their capability to send email as binary files.   This capability does not yet exist in some packages, however.

Mental health professionals have an obligation to inform potential Internet clients/patients/customers (the word "client" will be used in the future) of the incomplete confidentiality offered by un-encrypted email.  This is simply a matter of informed consent.  An even better solution is to provide a form of encryption for those who wish to use it.  Email correspondence is possible without revealing your identity.  This can provide a measure of privacy for some clients.   

Professional interactions over the Internet between a mental health professional and a person seeking to interact with the professional (based on their expertise) are subject to the same ethical guidelines as any other professional contact. This is true whether any money changes hands or not. The absence of face-to-face contact causes several potential problems.  (One of the most obvious problems--the absence of any non-verbal cues on the net--will be discussed in the "bandwidth" section).

What does a "therapist" do when confronted with a suicidal client over the net?  Psychologists have a responsibility to protect their clients from themselves and a responsibility to protect other individuals who may be in danger from their client.  Obviously suicidal and/or homicidal persons are not the ideal population for any kind of therapeutic contact over the net.  It may not be possible to "screen them out", however, and this raises some interesting issues.   What do you do when you get a suicide threat in your inbox? Obviously you make an effort to contact the person, but that is not always as easy as it should be over the net.   What further responsibility do you have?

The Samaritans (http://www.samaritans.org.uk/) are a group of trained volunteer counselors in England who specialize in just this sort of counseling over the net. Their approach is to treat the net as a crisis hotline. Crisis hotlines have many years of experience dealing with just these issues.  If a suicide call comes into a crisis hotline and the caller hangs up an attempt is usually made to trace the call and emergency services (911) are notified if the call sounded at all like a serious threat.  If the person stays on the line and is willing to make verbal contracts not to harm themselves the contract is generally respected and nobody is notified.

What do the Samaritans do when someone threatens suicide and will not contract for their own safety?  They do nothing. They have an agreement of absolute confidentiality which they will "carry to the grave."

A psychologist continues to have the duty to protect a client.    A clinician who is concerned about imminent danger over the net has a responsibility to do what they can to keep the person safe.  In some cases there will be nothing that they can do because they have no identifying information about their client.  Does this mean that trained mental health professionals should stay off the net and leave this work to volunteers?

An attempt must be made to notify someone who might be in a position to prevent a person from taking their own life. This is  possible to the extent that identifying information has been supplied.  Any extended professional contact over the net should probably include the same type of intake information which is obtained in the real world.  Brief interventions which consist of single questions and answers probably do not require that level of detail, and the relative anonymity of the net is one attraction which it has for some people.

Homicidal threats are a less frequent occurrence in any setting.   Several courts have ruled that mental health professionals have a duty to protect someone who has been threatened by warning them of the threat.  Other states have held differently, and it is essential to understand the laws in your state.  Until licensing issues are fully resolved, it is best to clearly state the location of any Internet interaction.  By announcing that the interaction occurs in your home state or province you are also announcing that you will abide by the laws and regulations of the state in which you are licensed.

Bandwidth Issues

Is it ethical to make a diagnosis over the net?  The current bandwidth means that we only have verbal self report to go on.  We generally can't observe the client's speech patterns, affect, nonverbal indicators of anxiety and depression, etc. Internet telephone software gives us a bit more data, but the audio quality is not even equal to that of a real telephone in most cases.  Internet video gives us a jerky image the size of a postage stamp.  We have a very restricted information base.  We might be able to give opinions about possible diagnoses, make suggestions of what information they should give to a health professional, etc., but I do not believe that we should attempt to make a diagnosis over the net.

The same holds for psychotherapy.  Stedman's Medical Dictionary defines psychotherapy as "treatment of emotional, behavioral, personality, and psychiatric disorders based primarily upon verbal or nonverbal communication with the patient, in contrast to treatments utilizing chemical and physical measures."   Counseling, on the other hand,  is defined as "A professional relationship and activity in which one person endeavors to help another to understand and to solve his or her adjustment problems; the giving of advice, opinion, and instruction to direct the judgment or conduct of another" (Stedman's Electronic Medical Dictionary, 1994) Notice the difference in emphasis.  Psychotherapy is generally viewed as the treatment of a disorder.  Verbal and nonverbal communication are both mentioned in the definition, and both are often essential.  Counseling is defined quite differently.  Working from these definitions, some amount of counseling is already occurring on the net.  No diagnosis is needed in order to help a person understand and solve a problem.  There is a long tradition in our culture of "advice giving" through print media.  The Internet is simply a logical extension of this tradition.

Therapists are also beginning to use email as an adjunct to face-to-face psychotherapy.  Clients can write brief questions and not interrupt the day or evening.  Telephone crisis calls can decrease when email contact is allowed. Limits may need to be set, of course, and some communication will still need to be by other means.

The U.S. Department of Veterans Affairs (VA) is faced with many different issues as they attempt to modernize their healthcare system and "do more with less."  Computer networks are being used within this agency to create an "electronic medical record" which will replace the paper medical record. Some rural hospitals are facing staffing problems.  VA is using video conferencing to allow a psychiatrist at the Salem VA Medical Center in Virginia to treat patients at the Beckley VA Medical Center in West Virginia. A psychiatrist had traveled through the mountains to Beckley one day each week in the past.  The psychiatrist is now able to sit in his office in Salem and treat patients in Beckley.

The PictureTel technology used in this VA project uses triple ISDN connections over dial-up phone lines to connect the Centers. Full screen full motion video and high quality audio allows the interpretation of body language, facial expression, voice tone and volume, and other aspects of nonverbal communication.  While a sense of smell is occasionally helpful in therapy (to screen for alcohol use and to check on personal hygiene), this set of non-verbal behavior will not be available online. Telehealth projects are beginning to use telehealth technology to link urban health care facilities with rural providers and patients.  Mental health is an important component of several of these projects.

When the "information super highway" is built, this same audio and video capability will be widely available.  This will allow psychotherapy, psychological assessment (aided by a technician at the remote site) and medication management to truly be possible online.

Regulatory and Licensing Issues

If a client wants to see a health care provider they make an appointment, travel to the provider's office, see the provider, and pay the bill.   Unless they live near a state line they generally go to a provider in their own state or province and trust that the state has licensed that provider. The provider and the client are both bound by the laws and regulations of that state.  I happen to live in southeastern Virginia, and I occasionally see clients who are residents of North Carolina.  By visiting me in Virginia they accept that I am licensed in Virginia and that Virginia laws will cover our interactions.  What about services delivered over the net?  Where do they occur and who has responsibility for regulating them?

I currently provide consultations over the Internet on a "shareware" basis. The client pays for the consultation only if it is helpful.   I address the jurisdiction issue by stating that all consultations take place in Virginia.  The client is "virtually" driving on the "information highway" to my office and seeing me in Virginia.  They then have the same protections as clients who drive on the real highway from North Carolina.

An alternative would be to define the interaction as occurring in the client's state or province (and country) of residence.  This might require a therapist to be licensed in any state (and country) which they wished to received consultations from, and to be bound by many different sets of regulations and continuing education requirements. This is clearly not a practical approach.  If adopted, it would effectively shut down legitimate psychological services on the Internet.  It would do nothing to stop the untrained unlicensed "counselors" who are also providing "services" on the net.

The Credential Check Service (http://www.mentalhelp.net/check) verifies that online providers are licensed and that their published credentials are authentic.   This is an important step toward solving the licensure issues, and it could become a model for a more official effort by a regulatory body.

Conclusions and Suggestions for the Future of Net Psychology

It really isn't possible to do psychotherapy on the net, yet Increased bandwidth will allow online psychotherapy at some point in the future.  As with any new frontier, there are unanswered questions.  A few mental health professionals are already exploring this frontier, and the rest of us can learn from their mistakes and their successes.

Regulatory bodies will need to adapt to the evolving technology.   A mental health professional can best be regulated in their home state or province.   Standards for online work will need to take into account the peculiarities of the medium.  A set of standards for responding to an online suicide threat would be helpful. Such standards might become a part of APA's ethical principles, for example.   They would not necessarily apply to a trained volunteer group like the Samaritans, who have their own set of standards. Encryption should be made mandatory for email communication when it becomes universally available.

The online world is evolving rapidly.  Many of tomorrow's innovations cannot be anticipated today.  The future will offer us opportunities and pitfalls.  If we take proper care, we can offer some online services as an adjunct to traditional mental health practice.