ABCs of Internet Mental Health Services

What is e-therapy?


THE ISSUES: What you need to know about e-therapy



Copyright 1996-1999 Martha Ainsworth. All rights reserved.

Psychotherapy has gone online ---and critics say that's depressing

Kirk Kicklighter, STAFF
The Atlanta Journal and Constitution

In the ether of the Internet, you can find friends, have sex or day-trade, all from the comfort of your home via computer. Now you can talk to somebody online about your problems, too.

Online counselors and therapists increasingly are providing help to clients over the Internet, trading face-to-face voices and gestures for words on the World Wide Web. Known as Internet therapy, "e-therapy" or "e-counseling," the practice seems to capture the essence of online communication --- anonymity, convenience and uninhibitedness --- in a therapeutic bottle.

David Stone, a clinical psychologist in San Antonio, swears by it. He cites the case of a religious man from Indiana who wanted to save himself for marriage but instead contracted genital warts while having sex.

"He was embarrassed and ashamed, and convinced God was punishing him for his sin," says Stone. "He didn't know anyone he could turn to for help." Severely depressed, the man logged onto a Web site,, typed in his credit card number and, within no time, was chatting privately with Stone.

"We met four times online," says Stone, a licensed therapist for 10 years, who eventually helped the man find traditional therapy. "It didn't matter where he was from or where I was from. What mattered was that he needed support and privacy."

Critics say "Internet therapy" is an oxymoron. They define therapy as the physical act of two or more people gathering in its name and argue that e-therapy poses too many ethical and legal problems to be legitimate.

"I'm really torn about it," says Linda Buchanan, clinical director of the Atlanta Center for Eating Disorders. "We definitely wouldn't do it now, because it's so unproven. I'm uneasy about the lack of physical contact, but I can envision scenarios where it might work. We'll have to wait and see."

Such questions are why David Nickelson, director of technology policy and projects for the American Psychological Association, advises people to first seek face-to-face therapy. "We still need research," Nickelson says. "And it may find that there are just some things therapists and their patients can't do over the Internet."

Proponents say that 500 to 1,000 Internet "therapists" are chatting with up to 10,000 clients a week worldwide. estimates that 160 Web sites, from Chicago to Hong Kong, offer e- counseling. These would-be e-shrinks range from psychiatrists and social workers to licensed professional counselors and quacks, which is why would-be clients are advised to first check therapists' credentials with state licensing offices.

Says Linda Campbell, a psychologist and University of Georgia associate professor who teaches mental health ethics: "It's so new that we haven't come up with any way to regulate it or judge its efficacy yet. And there are definitely so-called professionals on the Web who are walking a fine line. They say they aren't technically doing therapy, but I'll bet it seems that way to the client."

Proponents say e-therapy erases barriers that keep people from physically visiting a therapist. About 30 percent of people who make a first appointment for traditional counseling never show up or never return after one visit, says the APA. Others may live in isolated areas, be disabled, travel often or fear the stigma of seeking therapy. The distance of cyberspace also creates a sense of safety that can lead to a kind of intimacy, advocates say.

Martha Ainsworth, a New York-based Internet communications specialist, says she contacted an online therapist for depression in 1995. They exchanged e-mails for two years, an experience she calls "profound."

"It was a little bit like writing in a journal, except that I got feedback every day," she says. "Because we were working online, I felt like he was nearer to me than if we had met in an office. (It) really helped me to focus on what I was working through."

Ainsworth later started an Internet therapy advocacy site,, which reviews issues surrounding the practice and lists therapists who have passed a background check of licensing and training conducted by Williamson and other volunteers.

Critics denounce the idea of sending private thoughts into cyberspace to someone who may not be qualified and who can't see the doubt or tears in a patient's eyes.

"I've been asked to do Internet therapy by companies, and I've refused," says Patti Beaudoin, a psychologist who practices in Roswell. "It would be ineffective . . . especially when you consider that 80 percent of all communication is nonverbal."

Beaudoin says that little signals such as a patient's voice tone, foot jiggling and posture can provide vital information to therapists. She uses her own voice and body as well, softening her tone or emphasizing a point while leaning forward. "How would I do all that on the Internet?"

Also, e-therapists usually don't have access to patient histories or medical files.

And then there's payment for such services. Online services vary in format and price, from $25 for a question to $50-$90 for an hour of chat to $150-$300 for a month of unlimited e-mails. Most clients pay by credit card. Stone says he makes $45 every half-hour from an upfront credit card payment, without worrying about insurance company approval. He chats online with 10 clients a week, in addition to his office practice. By comparison, an hour of face-to-face psychotherapy in Atlanta can cost $150 or more.

But health insurers don't cover online counseling. "We're hearing about it and getting a few queries," says Daniel Jolivet, a vice president of clinical services for Magellan Behavioral Health of Georgia. "If the interest is there, we'd begin a process called 'new technology assessment.' You're probably looking at a few years at least."

Legal jurisdiction also could be an issue, because those who are licensed typically have credentials in only one state. Where is licensed therapy taking place, for example, if a social worker in Georgia is working with a client in Michigan via a chat room originating on a server in California?

"The professional at a desktop computer in Atlanta might say they are practicing in Georgia," says Linda Campbell, who recently chaired the Georgia Psychological Association's Ethics Committee, "but what recourse does the out-of-state client have under Georgia laws if something goes wrong? And what does the professional do about having backup emergency services in the client's location in case of crisis?"

The Georgia licensing board neither sanctions nor forbids Internet therapy. The Georgia Psychological Association says the state should establish a policy once national task forces on the Internet draft their own standards.

Even its staunchest advocates don't claim that the Internet is always the most appropriate place for therapy. Stone and Williamson agree that online counseling may work best as a short-term introduction to conventional therapy or as a continuing relationship between parties who have met face to face for a while.

Ultimately, technology may settle many questions about e- therapy's viability. Sophisticated Internet video conferencing, which would allow therapist and client to hear and see each other, is an estimated three years away.


Graphic Sigmund Freud sitting in a chair with a laptop. / VERNON CARNE / Staff Photo Roswell psychologist Patti Beaudoin, who says "80 percent of all communication is nonverbal," criticizes Web therapy for leaving out body language and visual cues. / PHIL SKINNER / Staff Graphic


ASK-A-QUESTION: A client writes a counselor with a detailed question or problem and receives a customized solution. Plus: If you have well-defined problems that can be explained in a few paragraphs or less. Minus: If the problem is complex, overwhelming, persisting.

ONGOING PRIVATE CHAT: The counselor and the client chat privately through instant messaging, usually for an hour. Plus: If you're struggling with nontraumatic issues (job or relationship stress). Minus: If you suffer from severe depression, trauma or addiction, when facial cues and body language are vital.

E- MAIL: The counselor and client correspond via e-mail. Plus: If you want to be able to unload at any time. Also, e- mail counseling can complement a traditional therapeutic relationship. Minus: If you feel uncomfortable writing about issues at length.

SUPPORT GROUPS WITH A COUNSELOR: Participants chat in an online group facilitated by professionals at mental health-related Web sites. Plus: If you're struggling with something severe and feel alone; if you could benefit from immediate feedback from fellow sufferers but are too embarrassed or unable to meet face to face. Minus: Poses some contentious legal and ethical issues, because minors --- or anyone else --- can easily sign on to the sites and lie about their age or situation.

VIDEO CONFERENCING: Sometimes called "tele-health" or "tele-therapy." The counselor and client meet for an hour and can actually see and hear each other through cameras (available for $50 to $300) or a phone-line video hookup. Plus: If you want the counselor to better evaluate you. Minus: Visuals are still relatively poor, and usually only one party can speak at a time. --- Source: Psychology Today

IF CONSIDERING ONLINE THERAPY Decide whether the Internet is the right setting. If you're in a crisis or considering suicide, call a mental health hotline immediately. People who seem to benefit the most from Internet sessions are those comfortable and effective at expressing themselves in writing and who may feel inhibited by face- to-face meetings. Always perform a check on any therapist found online. Be sure the therapist provides you with his or her name, address, telephone number and credentials. Depending on whether the therapist claims to be a licensed psychiatrist, psychologist, social worker or counselor, check the state licensing organization or professional group for proof (for psychologists, the Georgia Psychological Association: Your Web browser should inform you when you are about to enter a secure or insecure area. If not, ensure that the counselor informs you of any limits in the security of correspondence and whether the information is secured by encryption. Remember, your e-mail at work can be legally read by an employer. Try to find a therapist licensed in your state and whose liability insurance covers the services provided over the Internet. This protects both parties. Prices and methods vary. Know what you're paying and what you'll get for your money. Most payments are made by credit card. Make sure the site is labeled secure before you provide a card number.

USEFUL WEB SITES Metanoia, which means "change of mind," is a private, nonprofit advocacy site that lists dozens of online therapists and provides guidance on how to pick one and what to expect. The International Society for Mental Health Online is a nonprofit professional and consumer group founded in 1997. It offers membership to anyone and is generally an advocate of Internet therapy. The society recently released guidelines dealing with such issues as privacy, disclosure of a therapist's credentials and the promptness of e-mail responses. The group also created an ongoing online conference devoted to case studies of Internet therapy. Developed by Internet mental health pioneer John Grohol, Psy.D., this is one of the most comprehensive guides to mental health online. Based in San Antonio, another network of online therapists with various specialties. (Currently being redesigned.)

--- Compiled by Kirk Kicklighter