E-Therapy: History and Survey
Development of E-Therapy from 1972-2002
Almost as soon as the Internet was invented, its potential for psychotherapeutic communication was apparent. One of the first demonstrations of the Internet was a simulated psychotherapy session between computers at Stanford and UCLA during the International Conference on Computer Communication in October 1972.
On-line self-help support groups were the precursor to e-therapy; the enduring success of these groups has firmly established the potential of computer-mediated communication to enable discussion of sensitive personal issues. Local computer bulletin board systems began to develop not long after the introduction of the first personal computers in 1976; it is not unreasonable to assume that small, informal support groups gathered on some of them. When the first national on-line services (The Source and Compuserve) allowed nationwide on-line communication for personal computer users, beginning in 1979, it was not long until formally organized on-line support groups became popular. I personally organized such groups as early as 1982.
It is not possible to know precisely when mental health professionals began interacting with patients on line. As long as psychotherapists have participated in on-line activities and have been known to be psychotherapists, they have probably received requests for help, and some have probably responded. Thus, the earliest history of e-therapy is lost in confidential obscurity.
The earliest known organized service to provide mental health advice on line was "Ask Uncle Ezra," a free service offered to students of Cornell University in Ithaca, NY. (http://cuinfo.cornell.edu/Dialogs/EZRA/) "Ask Uncle Ezra" (named for Ezra Cornell, the University's founder) was founded by Jerry Feist, at that time Director of Psychological Services, and Steve Worona, and has been in continuous operation since September, 1986.
Ivan Goldberg, M.D. began fielding questions online about medical treatment of depression at least as early as 1993. He did not solicit questions on his own popular website, "Depression Central" (http://www.psycom.net/depression.central.html) but generously served as unofficial advisor to the online depression support group "Walkers in Darkness," responding to inquiries about medications in an "educational" capacity.
John Grohol, Psy.D. has offered free mental health advice in a popular weekly public chat since 1995 (http://psychcentral.com/chats.htm).
Fee-based mental health services offered to the public began to appear on the Internet in mid-1995. Most were of the "mental health advice" type, offering to answer one question for a small fee. The earliest was Leonard Holmes, Ph.D. who offered "Shareware Psychological Consultation" (http://www.leonardholmes.com) answering questions on a "pay if it helps" basis. Holmes reports that as soon as he set up a website advertising his practice, he began to receive e-mail from people asking for help; it was apparent that people were ready to reach out to psychotherapists via the Internet.
"Help Net" and "Shrink Link" were two other fee-based mental health advice websites available in the fall of 1995 (neither is still online).
David Sommers, Ph.D. can be considered the primary pioneer of "e-therapy." He was the first to establish a fee-based Internet service in which, more than answering a single question, he sought to establish longer-term, ongoing helping relationships, communicating only via the Internet. From 1995 through 1998, Sommers worked with over 300 persons in his online practice, spanning the globe from the Arctic Circle to Kuwait. Sommers employed several consumer-level Internet technologies for e-therapy, primarily e-mail with encryption but also real-time chat and videoconferencing.
Ed Needham, M.S. established his "Cyberpsych" IRC chat service (http://www.win.net/cyberpsych) in August 1995, and was the first to focus exclusively on e-therapy interaction via real-time chat. He worked with 44 persons from 1995 to 1998. Other early explorers of ongoing e-therapy included the Pink Practice in London (http://www.pinkpractice.co.uk).
The development of hospital- and clinic-based telemedicine-the use of sophisticated videoconferencing hookups to allow physicians to work with patients in remote locations-has been well-documented elsewhere.
Although they are not professional psychotherapists, no survey of Internet helping relationships would be complete without mention of the Samaritans (http://www.samaritans.org.uk). These trained volunteer crisis counselors have answered e-mail from despairing and suicidal persons daily since 1994, anonymously and without charge. Their life-saving work has been of immeasurable value. In 2001 alone, Samaritan volunteers responded to e-mail from 64,000 persons. Originally handled by one Samaritan branch in Gloucester, U.K., e-mail services are now available at 68 branches, including Hong Kong and Perth.
In the fall of 1995, when I first began to track this field, I found twelve e-therapists practicing on the Internet. My database has now grown to include over 300 private-practice Web sites where e-therapists offer services and "e-clinics" which represent, collectively, more than 500 more e-therapists.
The advent of commercial "e-clinics" marked a significant development in e-therapy. These business ventures seek to offer an improved environment for e-therapy by offering resources most independent e-therapists cannot afford: the most robust online security possible, credit card billing services and other practice management tools, thorough screening of clinicians, and active marketing. Therapists may join these e-clinics for a modest monthly fee and are offered a generic template web page, through which they may conduct their own e-therapy practice. Consumers who visit the sites are offered a long list of e-therapists from which to choose, all of whom have been carefully screened to ensure they are qualified professionals. Other features include the ability to select a therapist according to various criteria, access to self help information, and support groups for members. Other features include the ability to select a therapist according to various criteria, access to self help information, and support groups for members. HelpHorizons.com (http://www.helphorizons.com) and MyTherapyNet.com (http://www.mytherapynet.com) are examples of e-clinics.
The formation of the International Society for Mental Health Online (or ISMHO, http://www.ismho.org) was a milestone in the development of e-therapy. ISMHO is a nonprofit society formed in 1997 to promote the understanding, use and development of online communication, information and technology for the international mental health community. It has become the unofficial professional organization for e-therapists, providing peer support and insightful discussion as mental health professionals seek responsible ways to use the Internet to provide mental health help. ISMHO provides a public discussion forum (accessible from the website) in addition to a members-only area. Perhaps most important, it sponsors a clinical case study group that provides valuable insights to new clinical issues and intervention formats developing on the Internet.
E-Therapy Today: A Survey
At the beginning of the 21st century, interaction between mental health professionals and consumers on the Internet may be divided into four types. Two types of interaction take place entirely via the Internet, while the others combine Internet communication with in-person treatment.
- E-therapy (a term coined by John Grohol, Psy.D.) - psychotherapists form ongoing helping relationships that take place solely via Internet communication.
- Mental health advice - psychotherapists respond to one question in depth, again with communication taking place solely via Internet.
- Adjunct services - psychotherapists use Internet communication to supplement traditional, in-person treatment.
- Behavioral telehealth and telepsychiatry - mental health professionals (typically psychiatrists) use sophisticated videoconferencing systems to work with patients in remote locations, as an extension of traditional clinic or hospital care.
These four types of interaction, though each uses telecommunication in some way, are very different. A separate volume could be written about each. Although all have great promise, my primary focus has been on the field of "e-therapy." I believe that e-therapy has the most potential to reach the people who particularly concern me: troubled and despairing people for whom traditional mental health treatment is inaccessible.
It is worth noting that "adjunct services," though not often publicized, are used increasingly by many psychotherapists, in the same way as telephone conversations, to communicate with patients between sessions, or to keep in touch when a patient has moved or is traveling. As mental health professionals become more accustomed to using the Internet, and discover the disinhibiting quality of online communication, they are beginning to take advantage of it and incorporate it into their relationships with patients.
E-therapists are exploring all modes of Internet communication for their work with e-patients. Services are currently available using e-mail (regular or encrypted), real-time chat, secure web-based messaging, videoconferencing, and voice-over-IP (Internet phone). Many e-therapists offer more than one of these modes, giving the e-patient a choice based on preference and available technology. As broadband Internet connections become available to more consumers, videoconferencing and voice-over-IP are increasingly available. Even so, many consumers continue to prefer the non-visual, non-voice, low-tech environment of e-mail and chat, finding it easier to communicate about sensitive issues without visual or voice connection.
Providing support for consumers, Metanoia.org addresses the issues that are important for prospective e-patients to consider. I educate consumers about the opportunities presented by working with a therapist online, and the risks, including ethics and privacy issues and the lack of legal protection.
Over the course of four years, I have offered on my site a consumer satisfaction survey, which has yielded some interesting information. In May 1999, out of 619 total responses, 452 respondents (73%) had tried e-therapy. Of those, 416 (92%) said that it had helped them, and 307 (68%) said that they had never been in therapy before contacting a therapist via the Internet.
The data seem to suggest that many of those who are drawn to contact a therapist on the Internet do so because, for them, traditional psychotherapy is not accessible. The most common reason for inaccessibility is stigma; many people are too embarrassed to make in-person contact with a psychotherapist. Mental Health: A Report of the Surgeon General (Department of Health and Human Services, 1999) revealed that nearly two-thirds of people who need mental health care never get it and cited stigma as a primary reason.
It is not news that traditional mental health care serves only a fraction of the population who need it. To many people, the Internet feels more private, and this perceived privacy helps them get past the barrier of stigma to seek help through e-therapy. Interestingly, in my survey, of the 307 persons for whom e-therapy was their first contact with a therapist, 197 (64%) eventually moved on to consult a therapist in person.
It would appear that, as I had hoped, the Internet is providing a bridge across one of the barriers that keeps people from getting the help they need. As psychotherapists have ventured into this cyberspace sanctuary, where people find it easier to speak their innermost thoughts, more and more people who would not otherwise have been helped are finding a path to healing.