Griffiths, M.D. (2001). Online therapy: A cause for concern? The Psychologist: Bulletin of the British Psychological Society, 14, 244-248. more

Online thera py Online therap y: A cause for concern? A 27-year-old man comes home from a busy day at work feeling highly stressed and anxious. Unable to relax, he logs on to the internet, locates a self-help site for stress and anxiety and fills out a 15-item checklist. Within a few hours he receives an e-mail which suggests he may have an undiagnosed anxiety disorder. He is invited to revisit the site to learn more about his possible disorder, seek further advice from an online counsellor, and join an online self-help group. On the face of it this fictitious scenario seems harmless enough – until a number of questions raise serious concerns (Rabasca, 2000a). For instance, who scored the test? Who will monitor the self-help group? Who will give online counselling advice? Does the counsellor have legitimate qualifications and experience? Who is the website sponsored by? What influence do the sponsors have over content of the site? Do sponsors have access to collected data? These are all questions that may not be raised by a person in crisis seeking help, but are nevertheless questions that require answers. It is clear that psychologists cannot afford to ignore the internet. Online psychological advice, help and treatment are now commonplace, with psychology, counselling and psychotherapy all entering the computer age. Psychological services provided on the internet range from basic information sites about specific disorders, to self-help sites that assess a person’s problem, to full-blown psychotherapy services such as assessment, diagnosis and intervention (Rabasca, 2000a). Predictably, the subject of internet M ARK G RIFFITHS on the advantages and disadvantages of providing psychological services on the internet. counselling is causing wide debate (particularly on the internet itself). This article briefly overviews the main issues in the area and examines the types of online therapy currently available, the advantages and disadvantages, the monitoring of online therapeutic services, and suggestions for future evaluative research. Forms of online therapy The roots of online therapy most probably lie in the many discussion groups that formed on the internet. Mailing lists, newsgroups, bulletin boards and forums have always been popular with those requiring advice, because there is always someone online who has ‘been there, done that’. These public discussion groups have included forums and support groups for survivors of rape and sexual abuse, those suffering from a variety of addictions and those with congenital diseases and disorders. Many therapists have now set up their own internet sites to deliver behavioural services. There are around 200 online counselling sites offering access to about 350 online counsellors (Segall, 2000). Types of services offered vary in type and expense. They can include ‘ask five questions for free’sites, therapists moderating a group chat online, e-mail correspondence, private instant messaging, or video-conferencing. According to the Alberta Alcohol and Drug Abuse Commission (1999), the most popular form of online therapy occurs by e-mail, with messages received and responded to either immediately or stored and responded to at the convenience of the user (Lago, 1996). There appear to be three main types of website at which psychological help may be given: q q q information and advice sites; websites of traditional helping agencies; individual therapists. Inf ormation and advice sites These sites are typically the agony aunt-type sites in which people usually require a one-off piece of advice from someone who may have no psychological training. These services are usually (but not always) free of charge and may be part of an online magazine. Another popular form of online advice appears to be in the form of online sex therapy for couples who are having trouble with their relationship (‘Can the net pep up your love life?’, 1999). These services are usually e-mail only. Websites of traditional helping ag encies These sites are usually set up by traditional helping agencies that have expanded their services to include an online option for clients. This is usually done by e-mail and is usually free of charge. A good example of this is The Samaritans, who set up an e-mail ‘listening post’back in 1996 (www.samaritans.org.uk). This proved very popular – particularly among males under the age of 25. Much of the suffering was sexual. For instance, gay teenagers found it impossible to talk about their feelings to anyone they know, yet on the internet they could communicate with others like them (Brown, 1996). The Samaritans now receive 1500 to 2000 e-mail problems a month (Welford, 1999). Other examples include various ‘12Step’ groups who meet online. Many online therapy services are available for those suffering almost any kind of addiction. In the world of online therapy you can be an addict who is the only person in a room at an Alcoholics WEBLINKS Professional Affairs Board Working Party report: www.bps.org.uk/docdownload/docdownload.cfm American Counselling Association Online Counselling Guidelines: www.counseling.org/gc/cybertx.htm International Society of Mental Health Online: www.ismho.org The Psychologist Vol 14 No 5 May 2001 Online thera py Anonymous meeting, or be visiting an internet counsellor in the US without having left your UK home. There are a number of 12-Step groups that meet regularly in this way and they are often open 24 hours a day. The only situation where there may be some conflict of interest is when internet addicts seek help at an online addiction centre (such as www.netaddiction.com). For many people this may seem like holding an Alcoholics Anonymous meeting in the pub or a Gamblers Anonymous meeting in a casino! Individual thera pists These sites are set up by individual counsellors or psychotherapists as a way of earning extra income; they are becoming more and more abundant. They usually operate in one of two ways – either by written answers to e-mail enquiries or a real-time conversation in an internet ‘chatroom’. For instance, psychologists like Dr Paul Williams, who set up an online therapy service independently from his work with the National Health Service, are beginning to claim that those with neuroses, phobias, complexes or psychological problems are only a computer click away from help (Champkin & Hughes, 1999). So what does such a service entail? Those logging on to this particular site are asked to respond to a series of on-screen questions and instructions by e-mail: Did you have a happy childhood? What have been, so far, the best and worst moments of your life? How do you deal with conflict? Describe your schooling, upbringing, relationships with your family, and so on. Answers to such questions are then analysed by a panel of experts including psychologists, psychotherapists and psychiatrists who will prepare a report to be e-mailed back within 28 days for a fee of £25 (Champkin & Hughes, 1999). What are the advantages of online therapy? There have been many reasons put forward why people might seek online therapy, and why it might be advantageous. Convenient Online therapy is convenient. In the case of counselling by e-mail, correspondence happens at both the convenience of the client and the counsellor. Online therapy avoids the need for scheduling and the setting of appointments, and may also allow practitioners to provide services to more clients because less time is spent travelling to see them. Appointments can also be scheduled over a potential 24-hour period. Online therapy may be more conv enient,cost-effectiv and less stigmatising than conventional therapy e for clients, accessible , global,disinhibiting However, convenience has a downside. It may mean that the client is less likely to draw on their own existing coping strategies and may use the online therapist as a convenient crutch (something which is actively discouraged in face-to-face therapy). Cost-effective Online therapy is cost effective for clients. Compared with traditional face-to-face therapies, online therapy is cheaper and can provide a way to seek instant advice or get quick and discreet information. This is often emphasised by those selling their services online (for instance, some sites advertise their online services as ‘less than the customary cost of a private therapy session’ or ‘help and therapy at a reasonable fee’). This is obviously an advantage to the less well-off. Accessible Online therapy overcomes barriers which may prevent people from seeking a therapist offline. There are many different groups of people who might benefit from online therapy. These include those who are physically disabled, agoraphobic or geographically isolated; those without access to a nearby therapist (such as military personnel or housebound individuals); those with speech and hearing difficulties; and those who are too embarrassed, anxious or nervous to be able to talk about their problems face-to-face with someone. Disinhibiting The internet has a disinhibiting effect on users and reduces social desirability (Joinson, 1998). This may lead to increased levels of honesty and therefore higher validity in the case of selfdisclosure. The Samaritans’ figures show that someone using e-mail to contact them is twice as likely as a telephone caller to express suicidal feelings (Welford, 1999). This may be because they are reaching atrisk groups more effectively, but is more likely to be because it is easier to express deep feelings via the internet. However, some benefit may simply be the outpouring of written emotions, which might equally be achieved by handwriting an unseen missive. But whereas few people dream of writing to confess all to a stranger on the other side of the world, this happens all the time on the internet. One reason for this is that the internet offers perceived anonymity, particularly through anonymised e-mail addresses. It is an environment that is perceived by many users to be non-threatening. Less stigmatising Online therapy provides little in the way of social stigma. The social stigma of seeing a therapist can be off-putting for some people. However, online psychotherapists offer clients a degree of anonymity that reduces the potential stigma. Global Online therapy allows therapists to reach a rapidly growing number of people. Given the truly international crossborder nature of the internet, therapists have a potential global clientele. It would appear that in some situations, online therapy can be helpful – at least to some specific subgroups of society. Furthermore, online therapists will argue May 2001 The Psychologist Vol 14 No 5 Online thera py that there are responsible, competent, ethical mental health professionals forming effective helping relationships via the internet, and that these relationships help and heal. However, online therapy is not appropriate for everyone. As with any new frontier, there are some issues to consider before trying it. What are the disadvantages of online therapy? Various criticisms have been levelled against online therapy. Legal and ethical considerations As internet counselling services grow, attention will have to be focused on the specialist construction of a legal and ethical code. Cyberspace transcends state and international borders, so there are many legal and regulatory concerns. For example, client/doctor confidentiality regulations differ from one jurisdiction to another. Is it legal for a psychologist to provide chatroom services to patients who are in a jurisdiction in which the psychologist is not licensed? Will certain patients be excluded from services because they lack the financial resources to access the internet, and if so, would this be perceived as discriminatory? If no one knows who is treating whom, how do you ensure quality service? If a psychologist does not know where a patient is, how can the practitioner call for help in the case of an emergency, such as suicidal threats? (Foxhall, 2000.) There are also issues surrounding the conduct of practitioners engaged in all telecommunication therapy, including informed consent, electronic medical records and their security, and electronic claims submissions (Foxhall, 2000). Licensing considerations Are the online therapists fully qualified and licensed to practise? The client has little or no assurance about the qualifications and credentials of those doing the online therapy. The counsellor could be anyone from a high-school psychology graduate to doctoral-level practitioners. Effectiveness There have been few evaluation studies on whether online therapy is an effective treatment approach in any way. Confidentiality Online therapy may compromise privacy and confidentiality. No online therapist can promise confidentiality with a client given the limitations of the medium, although there are now sites offering secure messaging systems which offer the same level of protections as (say) banks. To protect confidentiality, care will have to be taken Online therapy may open up a range of pr oblems.Ther e are legal, ethical and licensing considerations, and issues surrounding eff ectiveness,confidentiality , cost-effectiv eness f or therapists,rapport, and identity: ar e the clients and therapists who they say they ar e? to prevent inappropriate and deliberate hacking into counselling sessions on the internet. There will need to be a continuous upgrading of technology to stay ahead of hackers’ ability to breach security. Technological glitches In remote areas transmission may be less than perfect, and there is always the problem of the server going down and other problems that come from use of a networked computer. Complicated payment structures Given the cross-national nature of the internet, there may be complicated pay structures for clients to overcome in selecting a therapist in the first place. Cost-effectiveness to the therapist For the therapists themselves, there is the problem that online therapy may end up as time consuming as face-to-face therapy but paying substantially less. Identity problems Are the clients who they say they are? Counsellors may not always know that clients are who they claim to be. Anyone (e.g. minors) can log on and lie about their situation, age or identity. Severity of client problems What happens if the client’s problems are too severe to be dealt with over the internet? These might include severe antisocial personality disorder, paranoid schizophrenia, and so on. Client referral problems How does the counsellor go about making a referral for someone in a faraway town or another country? Establishing client rapport Lago (1996) has noted that a look through any book about counselling shows that theories of psychotherapy and counselling lay considerable emphasis on the relationship between the practitioner and client as being a significant (if not the most significant) aspect of therapeutic endeavour. Indeed, Tentoni claimed that ‘internet therapy is an oxymoron [because] psychotherapy is based upon both verbal and nonverbal communication’ (quoted in Segall, 2000, p.40). Most online practitioners do appear to be careful to call themselves ‘counsellors’ rather than ‘therapists’, perhaps recognising that however close to ‘the real thing’online communication may be, there is a difficulty in establishing rapport with an unseen client. What do empathic, reflective, instructive and congruent statements look like on screen and how effective will they be? (Lago, 1996.) One of the paradoxes in this situation is that relationships of an intimate nature can (and do) flourish over the internet (Griffiths, 1999a). This would lead to the conclusion that healthy relationships can thrive in a text-based virtual reality (Griffiths, 1999b; 1999c): so is it in fact possible that they could in a therapeutic context? Incomplete information Making a provisional recommendation or diagnosis is fraught with potential problems. For instance, a client may describe problems that are symptomatic of other, more serious, underlying disorders, but some forms of online therapy (e.g. ‘ask a The Psychologist Vol 14 No 5 May 2001 Online thera py question’ e-mails) allow little or no opportunity for follow-up questions. The British Association of Psychotherapists claimed that many of the online therapy services do not amount to full consultations, instead they resemble the initial application form used by most psychotherapy institutions prior to a first face-to-face meeting (Champkin & Hughes, 1999). Many online therapists do point out on their homepages that online counselling is not a substitute for traditional psychotherapy. They advise that if you can visit a therapist in person, you should; but that if you cannot visit a therapist’s office, online counselling can be a helpful and effective alternative. Loss of therapist contact Therapists can just ‘disappear’only to re-emerge weeks later saying that their server failed, perhaps leaving a client mid-therapy with little that the client can do about it. Commercial exploitation Consumers are not always as anonymous as they might think when they visit health sites, because some sites share visitors ’p e rsonal health information with advertisers and business partners without consumers’knowledge or permission (Rabasca, 2000b). Information can be collected during a variety of tasks including the visiting of chatrooms and bulletin boards, searching for information, subscribing to electronic newsletters, e-mailing articles to friends or filling out health-assessment forms. This allows third parties to build detailed, personally identified profiles of individuals’health conditions and patterns of internet use, and then send targeted e-mails about their products and services. The monitoring of online therapeutic services Online therapy is clearly not for everyone, and those participating should at the very least be comfortable in expressing themselves through the written word. It should not be used by those in serious crisis (where nonverbal cues are vital). There is no particular group that monitors the internet, so it is hard for consumers to make an informed choice about which counselling and psychotherapy services are good and which are not so good. However, given the potential downsides of online therapy, there are a few websites that will research the background of anyone claiming to be an online therapist – www.metanoia.org, is recommended by the APA and www.here2listen.com is advised by psychologists from leading American universities such as Stanford and Harvard (Segall, 2000). These sites have taken a consumer action approach to dealing with the uncertainties of internet counselling by providing lists of internet counsellors whose qualifications and credentials have been verified. They also provide a thorough discussion of the issues around internet counselling, as well as a description and evaluation of sites. However, one major downside is that these services do not extend to checking the credentials and qualifications to those outside the US. They do, however, provide help in a number of areas including how to decide whether online counselling is for you, how to protect yourself from unqualified frauds, how to evaluate therapists and choose a good one to help you, how to make sure you’re getting your money’s worth, how to make sure your online counselling is private, and information about issues and challenges in online counselling; for example: Is this therapy? Is it ethical? Is it confidential? What are the legalities involved? Is it effective? Online therapy: Suggestions for future evaluative research It might well be the case that online therapy can only be effective either as a way of communicating information in response to clients’statements and questions, or as a form of ‘pre-therapy’. This latter suggestion is interesting as it has traditionally been assumed that for pre-therapy to occur, the client and practitioner had to be in the same room. There is no doubt there are still issues of concern – even in such a situation. For instance, Lago has highlighted that: q unconditional positive regard and congruence will prove challenging to demonstrate without verbal cues; q by being reduced to a words-only transaction (i.e. a text-based virtual reality), the client’s perception of the counsellor’s messages will be crucial in determining the extent to which they can stay in contact to resolve their difficulties; q there is a possibility for the development of fantasy, and that the client’s expectation of the therapist might become exaggerated and unrealistic; and q the medium of the internet might exacerbate psychotic tendencies that the client may have. All these areas need to be researched in an online medium, and any new developments involving online therapy should be monitored and researched carefully as to their efficacy, sensitivity and therapeutic potential (Lago, 1996). In the evaluation side there is still little agreement about which technologies are best for delivering which types of service, and whether some media might be better or worse for particular subpopulations. For instance, Stamm (2000) (cf. Foxhall, 2000) says that paranoid schizophrenics who believe television can influence their thoughts may not be good candidates for services provided through videoconferencing. However, children with attention deficit hyperactivity disorder appear to respond well to videoconferencing because they are often fascinated by television. There is a paucity of empirical data References Alberta Alcohol and Drug Abuse Commission (1999). Counselling on the internet. Developments (Alberta Alcohol and Drug Abuse Commission), 10, 3. Brown, A.(1996, April 28). Confessing all, true or not, on the net. The Independent on Sunday, p. 3. Can the net pep up your love life? (1999, October 5). Daily Mail, p. 58. Champkin,J., & Hughes, J.(1999, October 17). Online neurotics take problems to the e-shrink. The Independent on Sunday, p. 5. Foxhall,K.(2000).How will the rules on telehealth be written? APA Monitor on Psychology, 31(4),38. Griffiths,M. D. (1999a).All but connected (Online relationships). Psychology Post, 17, 6–7. Griffiths,M. D. (1999b).Internet addiction: Internet fuels other addictions. Student British Medical Journal, 7, 428–429. Griffiths,M. D. (1999c).Does internet and computer ‘addiction’ exist? Some case study evidence. CyberPsychology and Behavior, 2, 479–486. Joinson,A.(1998). Causes and implications of disinhibited behavior on the internet. In J. Gackenback (Ed.), Psychology and the internet: Intrapersonal, interpersonal, and transpersonal implications. (pp. 43–60).New York:Academic Press. Lago, C. (1996).Computer therapeutics. Counselling, 7, 287–289. Rabasca,L.(2000a). Self-help sites: A blessing or a bane? APA Monitor on Psychology, 31(4),28–30. Rabasca,L.(2000b).Confidentiality not guaranteed by most health web sites, report finds. APA Monitor on Psychology, 31(4),13. Segall,R.(2000,May/June).Online shrinks:The inside story. Psychology Today, 38–43. Welford,H.(1999, October 7).Web life: Online agony aunts. The Guardian, p. 9. May 2001 The Psychologist Vol 14 No 5 Online thera py that assesses the efficacy and feasibility of online therapy for clinical applications. Little research exists on the value of textbased online therapy, although some organisations (e.g. the International Society of Mental Health Online) are investigating online therapy’s benefits and limitations. The ISMHO’s mission is to promote the understanding, use and development of online communication and other information technology for the benefit of mental health. To date, the limited studies carried out (mostly with very small sample sizes) have focused on patient and provider satisfaction with the technology rather than the effectiveness of the technology in delivering services (Foxhall, 2000). Information about the cost-effectiveness of online therapy services is also limited. Future research should address the following areas: q q q q q the differential effects of various online therapeutic interventions among clinical populations; the effect online therapy has on therapeutic relationships; whether providers and consumers find online therapy interventions accessible and desirable; how socio-economic status, ethnicity, culture, geographic location, age and gender affect a patient’s access to, and acceptance of, online therapy; and how to effectively educate consumers and providers in the use of online therapy. psychologists shun the new technologies, other less ethically or morally driven practitioners will come in to fill the vacuum created. Online therapy is growing, apparently at exponential rates, and its growth appears to outstrip any efforts to organise, limit and regulate it. This growth can only continue if the provision of online therapy makes it on to graduate psychology programmes and advanced technologies become more common in practitioners’ offices or clients’ households. Hopefully, I have shown that there is without doubt an urgent need for evaluations of the services provided, as there is a lack of an evidence base to govern this growing practice. s Dr Mark Griffiths is in the Psychology Division, Nottingham Trent University, Burton Street, Nottingham, NG1 4BU. E-mail: mark.griffiths@ntu.ac.uk. Conclusions The internet could be viewed as just a further extension of technology being used to transmit and receive communications between the helper and the helped. If Comment from A DRIAN S KINNER , Convenor of the PAB Working Party on the Ethics of Providing Psychological Services on the Internet. R Griffiths’s article is timely in alerting psychologists to the possibilities and problems of the internet as a new way of doing what we do. Given all the media interest (hysteria?) surrounding the use of the internet for purchasing a bag of potatoes, it is unsurprising both that the internet is replete with sites offering a variety of therapies and that many anxieties are expressed by practitioners. It is important (with apologies to Marshall McLuhan) not to confuse the medium with the message.Therapy and counselling have been delivered via indirect means since the invention of writing.Today it is commonplace for these services to be delivered by telephone, and video-conferencing is used with increasing frequency.The internet is merely a rather new means of performing an old activity, but one that poses some unique and interesting problems and possibilities. One major problem is that the internet itself changes faster than authors can write about it. Griffiths quotes the Alberta Alcohol and Drug Commission’s 1999 view that the most popular form of online therapy is e-mail. It is not certain that this is now the case – real-time chatrooms,live voice transmission and video-imaging have been transformed in the last year and offer facilities that resemble the ‘traditional’ therapy format more closely than e-mail exchange ever could.Many of the objections to the use of the internet vanish if realtime sound and vision is possible. The major danger of the internet for obtaining therapy seems to me to be its resemblance to a bazaar, and Griffiths mentions several disadvantages that flow from this characteristic.A person seeking therapy in the non-online world has a series of checks that they perform, or are performed for them, during the process.Their doctor refers them to a psychologist or therapist, and can vouch for the bona fides. People visit an office, where there will be all sorts of clues to D the genuine nature of the transaction – the office may well be in a hospital, the Chartered Psychologist will undoubtedly have their practising certificate displayed prominently, and so on.While the use of these cues does not provide a guarantee, it does help to minimise some of the risks. In the online world many of these cues tend to be absent.Though a number of web-based mental health organisations are starting to vet therapy sites and offer commentary and seals of approval,the principle of caveat emptor applies as much to therapy and counselling as it does to buying electrical goods.Any web search on keywords such as ‘therapy’ provides an enormous number of links to sites offering all sorts of services.Many of these sites go into great detail about their security, professionalism and ethics, but others omit any such details, and of course some are frankly bizarre. The Professional Affairs Board set up a working party last year to provide recommendations about the provision of psychological services online.The report has now been published and is available from the Society and via www.bps.org.uk/docdownload/docdownload.cfm.This report considers, and makes recommendations about, the whole range of psychological services potentially deliverable via the internet, a much wider range than therapy or counselling. As a cybersociety, the BPS is strongly placed to offer internet services to its members and protection to the public.The PAB report recommends that members of the Society offering internet-based services have a link to their web addresses in the electronic Directory of Chartered Psychologist, and set up a link to the Society on their site. Thus a visitor would be able to ascertain that a psychologist was a member of the appropriate professional body and even be directed to a site via the Directory. The Psychologist Vol 14 No 5 May 2001