By far the most frequent media request to come to the Practice Directorate in the last six months concerns "online therapy." The steady stream of press calls has not decreased even in the face of the dot-com industry's recent reversal of fortune. Almost always the starting point of any interview is, "What is APA's position on online therapy?" The implication of this question is usually that online therapy is a singular procedure that we could evaluate and take a position "for" or "against."
The reality is that online therapy is not a singular entity and there is no single position appropriate to this complex and broad-ranging area. In fact, the Board of Professional Affairs Work Group on Professional Practice Issues in Telehealth has carefully articulated numerous issues relevant to applying technology to the delivery of health-care information and services. Many of the issues pertain to questions about online therapy. The more appropriate questions are: under what conditions, for what problems and with which interventions does the application of Internet technology facilitate the delivery of health-care services?
A tool for consumers
With some caveats, the Internet continues to be extremely useful for disseminating health and mental health information. Estimates range anywhere from 35 million to 98 million people going online to find health-care information. And a 1999 Harris Poll found that seven of the top 10 most frequently searched topics were either mental health disorders or health conditions with significant psychological components. The most popular health-care information search was about depression.
The degree to which the Internet is useful in disseminating mental health information, however, is conditioned upon the privacy, objectivity and credibility of the information. More than other information on the Net, people seeking mental health information need to be sure they are able to preserve their privacy. An e-health site without a good privacy statement that is conscientiously followed by the site should be avoided. So, too, should sites whose objectivity is questionable by virtue of connected product sponsors and proprietary interests. Also, it is a must that those individuals providing the information have adequate professional credentials. (For more information about evaluating e-health sites, go to www.dotcomsense.com.)
Interestingly, a number of e-health sites on the Web that represent themselves as providing online therapy actually appear to be providing psychoeducational information. In other words, while attempting to provide a consumer with a "therapeutic" response to a presenting complaint, the response is more a customization of existing mental health information than it is a "psychotherapy intervention." Admittedly, there is a fine line between these two types of responses, and the latter raises some additional and complex issues addressed below. To the extent that an e-health site is providing psychoeducational information specifically tailored to individuals, the Internet can no doubt be a very valuable tool.
It's for the profession to decide
The use of the Internet to provide what is recognized as more traditional psychotherapy is a much more complicated issue. The degree to which the application of new technologies, including the Internet, is useful for delivering effective psychotherapy services remains an unanswered question. The accumulation of data and experience over time ultimately will answer the necessary questions--to repeat, under what conditions, for what problems and with which interventions does the application of Internet technology help to deliver quality services? A number of related research projects are already under way around the country.
In the meantime, as with any emerging area, both consumers and health-care professionals must rely on common sense and good judgment. Strengths and weaknesses of any new technology must be kept in mind when determining possible uses. We know, for example, one of the Internet's strengths is connectivity--that is, its ability to connect people, groups or organizations that might not otherwise get connected. In this context, using the Internet to help people unable or unwilling to access mental health professionals may be a very good use of the Internet. Bear in mind, though, that using it for this purpose does not automatically mean that therapy, from start to finish, can or should be provided online. It may be that initial online connections can best be used as a precursor to face-to-face psychotherapy. Or it may be that only certain types of interventions can be effectively made through electronic communication.
Whatever the use, current professional ethics remain in force. Confidentiality, informed consent and scope of competence limits, for example, are all relevant to any effort to provide psychological services via the Internet. In the end, the profession must determine when the Internet is useful and when it is not.
Until then, it is neither appropriate to conclude that this new technology can be universally applied nor that it has no use in the provision of psychological services.