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.



By Connie Lauerman, Tribune Staff Writer.
Published: Thursday, November 2, 2000
Section: Tempo
Page: 1

While going through the rigors of a romantic breakup a few months ago, Karen Pereyra wanted some psychological counseling. So she logged on to her computer to get it.

"I was getting distracted at work because I was thinking about the issues I was having. I wanted to get a resolution as quickly as I could and that's what I got," said Pereyra, 32, a marketing manager in northern California.

Psychotherapy, it seems, is in major league transition.

Couches are often merely icons on a computer screen now that what used to be called "talk therapy" is just a click away, if you wish, with typing taking over for talk.

Pereyra found her therapist through, a Web site that launched a 24-hour cyber office last spring linking those who want psychological counseling to therapists via secure private chat rooms.

"Usually, I would prefer face-to-face interaction, but doing it over the Internet removes all the anxiety of the meeting," said Pereyra.

"It's easier to launch into whatever issue you're having and not have to deal with getting to know [the therapist] in person. After a minute or two we kind of had a rapport. We approached it as 'What's the problem?' and then worked back from there. She helped me identify why I was having the issues I was having. She also recommended some reading, which I did.

"It works well and it's nice because it's immediate. You get help when you're at the peak of wanting it. You don't have to drive anywhere or take time off from work. And it's very private."

Such experiments with so-called e-therapy are popping up all over. There are Web sites offered by individual therapists who do e-mail consultations, sites like that provide private, real-time chat rooms, sites that simply list therapists who do virtual counseling, sites that provide discussion groups, sometimes with a psychologist as moderator, and even group therapy.

The psychotherapeutic establishment is regarding the development -- some sources say there are as many as 200 Web sites offering access to about 350 online counselors -- with care. But it has not written the idea off.

"The bottom line in any emerging area is that we need to be cautious that we're gathering sufficient information and evaluating the application of the new technologies," said Russ Newman, executive director for professional practice of the American Psychological Association.

Proponents, however, hail the technology's ability to bring treatment to those who might otherwise not get it.

"We believe there's a huge population out there that needs help but finds it really difficult to reach for it," said Gunny Cho, chief executive officer and co-founder of

"Either they live in remote locations or they are not mobile or they feel greater shame than others."

Cho, a former international corporate lawyer, said his company's surveys have shown that the "great majority" of people prefer not to see their therapist or be seen. "Why? Because they're talking about things that are fairly embarrassing." offers the services of hundreds of mental health professionals whose credentials, it said, are checked carefully. It also has a blue-ribbon advisory board that includes such prominent names as psychiatrist Peter D. Kramer ("Listening to Prozac") of Brown University and psychologist Philip G. Zimbardo of Stanford University.

Nevertheless, the burgeoning virtual treatment revolution is controversial.

It makes many mainstream psychologists uneasy. They're concerned that unwitting patients may fall into the thrall of quacks and that there are no studies proving that the online method is as effective as face-to-face intervention.

Some said that e-therapy is a misnomer, because psychotherapy, by definition, is the treatment of emotional, behavioral and psychiatric disorders primarily based on verbal or non-verbal communication with the patient.

Indeed many online practitioners refer to themselves as counselors rather than therapists.

When Leonard Holmes, a Virginia clinical psychologist, began offering his services online, he called them "consultations."

"I tried to keep it focused on problems and solutions to problems and to try not to get into anything at all that resembled diagnosis and treatment," he said.

Dr. Robert Hsiung, associate professor of clinical psychiatry at the University of Chicago, said that while he is open to the prospect of online therapy, he does not believe online counseling ever will replace face-to-face therapy.

"Maybe it will be a first step, an entree that will make some people feel more comfortable about actually meeting with a therapist in their office," he said.

One of the frequent criticisms is that online interactions are devoid of the telling visual and verbal cues that therapists pick up in person.

"Sometimes you get a lot [from non-verbal signals]; other times maybe not so much," Hsiung said. "If somebody starts crying in front of you, you get a lot. But if you were chatting with someone [online] they might tell you [they were crying] too.

"You can be helped by information like that but you can also be distracted by it. It potentially can get in the way. If somebody is really good looking or is not so good looking that can make difference in how you react. Or if they do a certain thing that rubs you the wrong way or they're seductive in some way."

Storm King, a clinical psychology intern completing doctorate work in Massachusetts and past president of the International Society for Mental Health Online, cautioned that "when the visual and auditory clues are missing, the mind tends to fill in with its own projections. Both the client and the therapist have to have some understanding of this process or they're likely to have a lot of misunderstanding or miscommunications."

Licensing is one of the thorniest issues involved in a medium that is beyond political control.

Most therapists are licensed to practice in one state. Are they practicing without a license when they counsel someone from a different state via the Internet? What recourse does a client have if something goes wrong?

There is no system in place for guaranteeing that a therapist is legitimate, licensed and otherwise qualified, although several online sources provide credential checks and some Web providers verify credentials and experience.

"There are lots of ethical issues that come into play," said Steve Ilardi, assistant professor of psychology at the University of Kansas. "If I'm treating somebody in another city that becomes suicidal, I'm not nearly as capable of caring for them in a crisis. If worse come to worse [with a local patient] I can say, `Look you can come into my office. I'll meet you there in 10 minutes.' You can't do that online."

Online counseling is not for everyone. Both practitioners and clients must be comfortable with written communication. So far, only one institution, the Pacific Graduate School of Psychology, has begun training psychologists in how to provide mental health guidance online.

John Grohol, a research psychologist and director of, a therapy site, insists that e-therapy is an entirely new field.

"It combines some techniques of regular therapy with some unique attributes," he said. "On the Internet people communicate in a different way.

"Because there's no face-to-face interaction, it's less inhibiting. People feel more comfortable getting right into their issues quickly."

Said counselor Terry McNichols, who offers her services through and on her own site:

"People come online and say, `My baby is brand new and my husband is talking about leaving me and I don't know what to do.' A lot of them aren't counseling savvy. It's not like they've been to three or four therapists and they're trying you out. They may say, `I'm really feeling down,' and I'll start asking depression questions and find that it never occurred to them that maybe they're depressed and can get help for it. They just think life is ending and there's nothing good out there.

"That's the most fulfilling part to me. I'm getting people who might never have gone to counseling out in the world."

If some say written communication is impersonal, Martha Ainsworth begs to differ.

She sought out an online therapist in 1995 when she was dealing with several losses in her life, because it suited her work situation, which involved a lot of travel.

A dropout from face-to-face therapy, she found a therapist through his Web site, checked out his credentials and exchanged e-mail with him for two years.

"He really provided me with a lot of emotional support when I needed it," said Ainsworth, an Internet consultant and producer for, a pluralistic religious site.

"He was caring. He was able to sense the kinds of moods I was in just from my writing. I felt we had a deep connection. It was a wonderful experience. He encouraged me to find a face-to-face therapist and I eventually did.

"I really love my current therapist and he and I have tried exchanging e-mails, but he's not good at it. It's a skill."

In the process, Ainsworth became an advocate of online therapy and started a non-profit, independent Web site,, to provide information and referrals.

She said feedback from consumers indicates that 95 percent of those responding were satisfied with their online counseling experiences and that more than 60 percent of those who talked to a therapist online later sought one out for face-to-face therapy.

The prices for online counseling vary widely. For example, counselors registered with Here2listen charge from $20 to $80 per half hour of chat room time. Some therapists charge a fee per e-mail message or a flat fee for a month of unlimited e-mail responses. Most clients pay with credit cards.

Health insurers don't cover online counseling and probably won't until there is research verifying its efficacy.

The American Psychological Association is closely monitoring that research, said Newman.

"Currently we know of over 35 studies that are just starting to look at the question of what services under what conditions for what kinds of people," he said.

"The concern we have is that the application of new and potentially good technologies don't outstrip their capability, that it not be treated as a panacea."


Information about mental health and online counseling abounds on the Internet. Here are a few Web sites for starters:

- This American Psychological Association site provides help in assessing mental health information on the Internet and tips for protecting your privacy.

- A private, non-profit site developed by advocate Martha Ainsworth provides guidance to consumers on how to choose an online therapist and what to expect.

- A therapy site based in San Mateo, Calif., backed by some Ivy League psychology professors, offers a variety of counseling services from hundreds of online practitioners of various kinds.

- A therapy site developed by research psychologist John Grohol that connects mental health professionals and consumers with information and each other. It offers a free trial e-mail response to a mental-health question.

- This Phoenix-based site developed by therapist Judy Gifford offers a directory of therapists organized by state --plus general mental-health information and options for online and telephone counseling.

- The International Society for Mental Health Online is a non-profit professional and consumer group founded in 1997. A helpful site that includes suggested guidelines dealing with informed consent, privacy and disclosure of a therapist's credentials.