Cover Story

A 25-year-old woman wakes up in the middle of the night feeling anxious. Unable to sleep, she logs on to her computer and stumbles upon a self-help site that asks her to fill out a 10-question survey about her troubles. In the morning she receives an e-mail suggesting she might have an anxiety disorder and is invited back to the site to learn more about the disorder, join an online self-help group or seek advice from a counselor through e-mail.

But who's scoring her test, monitoring the self-help group and giving her advice? Is the "counselor" a licensed clinical psychologist qualified to treat anxiety disorders? Is the Web site sponsored by a pharmaceutical or managed-care company?

The problem, psychologists say, is there's usually no way to know. Counselors can range from high school graduates to doctoral-level practitioners, and while most Web sites disclose their sponsors, consumers don't always know how much influence advertisers have over the site's content.

And, that's not the only problem: Psychologists say there's no definitive proof that mental health services provided via e-mail or chat rooms work.

While the Internet likely will be used to provide a range of information and services such as mental health and psychoeducational information, there's not much known about whether "self-help" or other kinds of psychotherapeutic services are effective, "over the wire," says David Nickelson, PsyD, JD, director of technology policy and projects, and special assistant to the executive director in APA's Practice Directorate.

"For example," he says, "there's no good evidence that you can provide interpersonal or dynamic psychotherapy services over the Internet and know they're as effective as face-to-face services."

Yet despite these concerns, the growth of the Internet is leading more consumers to search for mental health services online and managed-care companies are gearing up to respond. Advocates claim that consumers who in the past have shied away from face-to-face therapy are willing to give psychotherapy online a chance. And anticipating these opportunities, scores of psychologists are launching their own Web sites.

Virtual replacing reality

Managed-care firms see the Internet as a means to improve their bottom line. Money once invested in managed-care companies is being pumped into Internet health-care sites. Meanwhile, health-maintenance organizations are partnering with Internet companies or starting their own Web sites.

"The investment money, venture capital and stock investments are drying up in managed care," says Russ Newman, PhD, JD, APA's executive director for practice. "But these are big for-profit companies and they aren't going to go away just because there's not enough money available. Instead, they're going to transform themselves to be financially successful, and they're looking to do that through the Internet."

Kaiser Permanente, for instance, recently launched a $2 billion project to move its administrative operations to the Internet to improve the quality of care and save tens of millions of dollars a year, the company reports. Plans call for Kaiser to create digital medical records that will electronically link its hospitals, clinics and providers, and develop customized Web sites for major clients and administrative purchasing. Industry analysts predict that other health plans will follow Kaiser's lead as market pressures intensify and consumers demand more services and information.

Economists further predict that as more people receive services online, fewer brick-and-mortar stores and offices will be built. Last year, 17 million U.S. households shopped online, according to Forrester Research, an independent research firm. Forrester estimates that the health-care industry will reach $370 billion in online transactions by 2004.

That's not surprising, given that 22 million people looked for health information on the Web in 1998 and mental health tied with dermatology as the topic consumers most frequently searched for online, says Leigh W. Jerome, PhD, a clinical psychologist and behavioral telehealth research scientist in Kailua, Hawaii. Psychological services provided on the Internet range from basic information about specific disorders, to self-health sites that assess a consumer's problem, to full-blown psychotherapy services such as assessment, diagnosis and intervention delivered online through e-mail or videoconferencing.

Poised and ready

Not surprisingly, psychologists are already trying to stake out a corner of this exploding market. Many psychologists have formed partnerships to develop counseling and mental health Web sites.

One such Web enterprise is Epotec, which contracts with employee-assistance programs and managed-care companies--including CIGNA and United Behavioral Health--to offer online behavioral services. Currently, 2 million clients have access to the site, where they can learn about goal setting, loss and grief, stress, coping with change, depression, worry and anger management.

"Our programs really focus on behavior change and use cognitive-behavioral therapy skills and training," says Richard D. Flanagan, PhD, co-founder and chief clinical officer of Epotec. "The programs are all based on proven approaches to behavioral change."

For instance, a client with stress-management problems can read basic information about stress on the site, or sign onto a self-assessment program that appraises a person's stress level and develops a personal plan to help him or her deal with it.

Another psychologist-run Web venture is Here2Listen, a Web site that connects practitioners and clients to psychological services provided by e-mail and videoconferencing. The site registers providers, checks credentials and connects licensed practitioners with clients online, according to Gunny Cho, Here2Listen's CEO.

"We are working closely with licensed counselors to assist them in bringing part of their practice online so that our community of counselors will be available to address people's needs," says Cho.

But what about quality?

Most experts agree that what's currently being offered online is not traditional psychotherapy. However, some say it fills a niche for consumers who are reluctant to seek treatment.

Many consumers aren't getting help because they don't want to deal with insurance plans, the inconvenience of scheduling appointments and the cost or social stigma associated with psychotherapy, says John M. Grohol, PsyD, vice president of an Internet start-up in Texas that plans to offer online therapy services. Online therapy offers clients a degree of anonymity and the convenience of 24-hour services, he says.

But, APA officials caution that in most instances, it's still not known if services provided over the Internet are as effective as face-to-face interventions.

"One of the primary questions in evaluating this type of activity is whether services that are delivered in this way are at least as good as in-person services that would otherwise be available," says Geoffrey Reed, PhD, APA's assistant executive director of professional practice.

For instance, he says, for American Indians on isolated reservations, military personnel in remote locations, prison inmates and homebound individuals, services delivered from a distance might be the best available. But services provided by e-mail shouldn't be seen as a substitute for face-to-face services.

Further, says APA's Nickelson, clients who receive Internet-based services might not have the same outcomes as clients receiving face-to-face therapy and may not seek additional help if their online therapy fails.

"If that's the case," he says, "they're still not getting the services they need."

Concern about the quality of health-related Web sites is why the Practice Directorate is developing materials to help consumers evaluate mental health information provided on the Web, says Russ Newman. An initial brochure--still under development--will give consumers five questions to ask themselves as they look at a Web site to determine the quality of information, confidentiality and whether commercial interests are influencing the content and the degree to which a site purports to be informational but is actually offering services.

For instance, says Nickelson, if a drug for treating depression is advertised on a Web site that offers information about depression, is the site trying to sell the drug or educate the consumer about depression?

Similarly, many people use the Internet because they think they're getting information anonymously but many Web sites put a "cookie" or a piece of information on the visitor's computer to track use and see what other sites the consumer visits.

If a consumer, for instance, researches schizophrenia and bipolar depression and then does research on getting a mortgage, will the mortgage company be able to track the sites this consumer visited? What will it do with the information? The consumer also might start receiving e-mail from pharmaceutical companies about drugs to treat bipolar depression, says Nickelson.

Psychologists need to be there

Despite these concerns, psychologists can't afford to ignore the Internet, says Jerome of Hawaii. Inevitably, she says, telehealth will be used to provide routine psychological services, and "if we shun the technology then someone else will fill the vacuum and they may not have the same ethics as us," she says.

Psychologist Marlene Maheu, PhD, agrees that practitioners could get shut out of the market, especially if managed-care companies are the only ones offering psychological services on the Internet.

"The Internet is going to be an even more powerful tool for managed-care companies to ratchet-down our fees or sidestep us altogether," says Maheu, director of telehealth for the California School of Professional Psychology and publisher of two health-related Web sites. She predicts managed-care companies will hire unlicensed or master's-level providers at a less expensive rate than psychologists to be "lifestyle managers" and interact with patients online in a way that won't be regulated by state licensing boards.

But perhaps the most important reason for psychologists to increase their involvement on the Internet is that consumers are continuing to demand access to more and more Internet services.

"Not everyone is going to like this kind of interaction," says Grohol of Texas, "but it will take its place among the psychotherapy offered today, like group therapy versus one-on-one therapy. Some will choose this over face-to-face therapy."