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SAMHSA News - Volume XI, Number 1, Winter 2003

"E-Therapy" Raises Questions, Possibilities

Therapy in cyberspace? It sounds like something out of Aldous Huxley's futuristic novel, Brave New World. Yet both service providers and recipients are already using the Internet as a tool in the delivery of treatment services for mental and addictive disorders.

How does "e-therapy" work? What are its limitations? And is it useful?

SAMHSA's Center for Substance Abuse Treatment (CSAT) sponsored a meeting last year to explore some of these questions and to launch a dialogue on this recent innovation.

In his opening remarks, CSAT Director H. Westley Clark, M.D., J.D., M.P.H., identified the most fundamental issue: What is e-therapy? He noted, "We currently have no solid definition for this new mode of treatment."

David Nickelson, Psy.D., J.D., Director of the Office of Technology Policy and Projects for the American Psychological Association, suggested that in order to define e-therapy, several questions would need to be answered: Is it traditional psychotherapy using a new medium? Or is it actually a new type of therapy? Should it be considered something other than therapy, such as counseling?

He identified some questions pertaining to health service as well, such as:

  • How do ethical and legal guidelines apply to e-therapy?

  • Should e-therapy be regulated?

  • Can e-therapy sessions be kept private and confidential?

  • Is it clinically appropriate to use the Internet in this way?

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Gary Walz, Executive Director of the ERIC Counseling and Student Services Clearinghouse at the University of North Carolina-Greensboro, said that people who are in the midst of a serious crisis are not good candidates for e-therapy. This includes people who are suicidal or are experiencing a serious drug addiction.

Mr. Walz further noted that some clients might feel uncomfortable discussing important subjects online, and that the lack of immediacy and nonverbal cues could be a disadvantage. He also observed that no state licensor codes deal with e-therapy, no legislation guides its use, and many professional liability insurance policies will not cover it.

Dr. Nickelson added that some pathologies might present problems to treatment online. For example, when individuals are online, they can alter their identities and claim to be a different age or gender. This could be particularly problematic in the treatment of people with certain personality disorders, he said.

Several participants expressed concern about establishing rapport between client and therapist-often considered vital to successful therapy-over the Internet.

But participants also discussed the potential advantages that e-therapy offers. Mr. Walz noted that therapy online could help reach underserved populations, including those in remote geographical regions. Also, counselors could continue to treat clients who relocate to other areas. Clients with time constraints or difficult schedules might find e-therapy more convenient, he said. All of these factors could enable many more people to receive treatment then receive it currently.

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Guidelines and Standards

Professional organizations are developing professional guidelines and standards for addressing practices that are unique to Internet counseling. Doug Gilbert, Ph.D., NCC, ethics officer for the National Board of Certified Counselors, discussed his organization's process for developing standards. These standards address such issues as verifying the identity of the Internet client, determining if a client is a minor and therefore in need of parental or guardian consent, and explaining to clients the procedures for contacting an Internet counselor offline.

Donna Ford, NCC, LPC, Past President of the American Counseling Association, recommended that counselors provide individual online counseling only through a secure Web site or e-mail application that uses appropriate security measures including encryption. Even so, she said, clients should be informed that some information transmitted may not be secure. Client waivers should acknowledge the understanding of the limitations in ensuring confidentiality of information. She added that counselors should identify potential situations to clients in which confidentiality would have to be breached.

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"E-therapy is at a critical juncture and will remain a valid enterprise or fade away...."

–H. Westley Clark, CSAT Director            

E-Therapy in Action

Judi Kosterman, Ed.D., Vice President of business relations for eGetgoing, an e-therapy program founded in 1999 for alcohol and drug abuse treatment, gave a demonstration of the site's operation. EGetgoing, an affiliate of CRC Health Corporation (a traditional provider of substance abuse treatment), is the only such program so far accredited by the Joint Commission on Accreditation of Healthcare Organizations and the Rehabilitation Accreditation Commission.

All counselors are fully credentialed. And, all therapy sessions are archived for clinical supervision and so that clients are able to view online, support-group chat sessions that they may have missed.

Dr. Kosterman said that clients do better when they can see the counselor through a visual aid provided by streaming video. When the counselor's picture is absent, she said, client participation in the group therapy sessions drops and the atmosphere resembles that of a conference call rather than that of a therapy session.

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Future Directions

Participants agreed that there was a need for client outcome data and for evaluation of treatment efficacy. Since the CSAT-sponsored meeting, Dr. Kosterman has been collecting baseline and subsequent data from eGetgoing's sessions and plans to use this data to address the research void.

Participants also are calling for unified efforts to define terms and to define clearly requirements for licensing and practicing across state lines.

Dr. Clark wants to maintain momentum on the issue of e-therapy. CSAT plans to invite e-therapy recipients to make presentations and discuss their experiences and also plans a followup to the initial meeting later this year.

"E-therapy is a high-tech enterprise that may become increasingly cost-effective over time," said Dr. Clark, using the analogy of the cost difference between laser eye surgery 10 years ago and today. He added, "E-therapy is at a critical juncture and will remain a valid enterprise or fade away like many other trends. It is important to learn how this treatment works, what its limitations are, and whether it is useful."

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