Hi, thanks for your question. Here is an overview of the online
psychotherapy and counseling market and web literature. Based on this
infromation, it seems that there is a large market for this type of
service and there is definitely some "money" in this "business".
However, there are also concerns with the effectiveness of the therapy
and the ethics involved.
Size and Quality of the online psychotherapy market:
Providing Psychotherapy Over the Internet
by James R. Alleman
Psychiatric Times July 2003 Vol. XX Issue 7
<<One researcher's database of online "e-therapy" resources has
already grown to 300 private practice Web sites, as well as a number
of online clinics through which another 500 professional therapists
can be contacted (Ainsworth, 2002). When surveyed, online patients
seemed happy with the treatment they receive (Ainsworth, 2002) and,
judging by the rapidly growing professional membership of the
International Society for Mental Health Online (ISMHO), there are also
respected therapists convinced they can do good work over the Internet
(ISMHO, 2002). Since the World Wide Web cannot be unspun, there is
every reason to believe that people, especially the young and
computer-literate, will continue using it to seek mental health
Technical Difficulties, Formulations and Processes
Michael Fenichel, Ph.D.
<<Clearly, many practitioners who are well-trained and
well-experienced in providing "psychotherapy" or counseling of one
type or another, are enthusiastically embracing the opportunity which
Internet-facilitated communication affords. 1
It is also clear that a large number of people with Internet access
continue to utilize the World Wide Web (WWW) in order to seek
information about mental health topics, while to a lesser extent (and
arguably much more vague in terms of numbers) it appears as if there
is a growing "market" for direct online mental health services. With
increasing access to an increasingly borderless online community, and
fueled by the availability of several for-profit websites which are
heavily promoting their own version of "e-therapy" (and for
practitioners, easy office management), it seems inevitable that both
qualified and wishful mental health professionals will continue to
embrace the "easy" way to "do therapy", and a growing number of
clients will partake of these services as they increase in
accessibility and acceptability. This of course has major implications
for both consumers and practitioners of "mental health online".>>
Who benefits from Online Psychology?
So is Online therapy and assessment right for you? This is a very
personal question. Most agree that traditional therapy is still
better. They also agree, however, that something is better than
nothing, and if online therapy will motivate you to seek needed help,
then it is a positive innovation in the practice of psychology.
Respond to the following items with either true or false to see if
online therapy is right for you:
1. My schedule is so hectic that keeping the same appointment on a
weekly basis would be impossible.
2. I would just like to get some professional advice every now and
then and am not seeking any weekly commitment.
3. The thought of calling a therapist, making an appointment, and/or
going to his or her office terrifies me.
4. I have thought about therapy on several occasions but have not made
the effort to seek help even though I know it would be to my
Strengths of online counseling:
You can have therapy or assessment right from your home during a time
that is convenient for you. There's no commute, no parking problems
Online therapy is often less expensive than traditional therapy.
Although there is a negative side to privacy, there are no concerns
about being seen walking into a therapist's office, or bumping into a
friend as you leave. You can also interact with your therapist
without having to take time off of work or make up excuses as to where
you are going.>>
Not everyone can write fluently or effectively communicate their ideas
through typed or written text
<<There is evidence to suggest that the literacy skills of many
typical adults leave much to be desired. (Some say that the mean level
of ability for reading and writing skills in the U.S. is approximately
8th grade.) World-wide, as well as in the U.S., illiteracy is still
widespread, which functionally removes the appeal and practicality of
text-based communication. While clearly there is beauty to behold in
narrative forms of expression--and the use of computers can facilitate
both bibliotherapy and text-based relationships of many varieties--it
may be unrealistic to expect that reading text on a screen or
responding via a keyboard will be a meaningful or practical method for
the great many people who, even while motivated by lack of access to
other mental health services, are also lacking in written language
skills, reading ability, or typing skill.>>
Some people process phonemically but not via the written word.
<<This is not speculation, but neurological fact. The portions of the
brain used to process speech include entirely different sections of
the brain than those used to read from written text. It is similarly a
different process to speak, spontaneously, than to write. It can be
argued, of course, that having the time to compose and edit messages
(which is notoriously not very common in responding via e-mail) can
result in more thoughtful, focused communication. By the same token,
it may reduce the spontaneity or "free association" which is the basis
for many of the "non-specific" factors of psychotherapy. What exactly
can be made, in such approaches, of the "here and now", or (for the
psychoanalytically inclined) of "slips of the mouse"? How might it be
a different process of establishing trust via the written word rather
than the spoken word?>>
Thoughts about Online Psychotherapy:Ethical and Practical Considerations
Gary S. Stofle, ACSW, CSWR, CASAC
Lack of non-verbal cues
<<Text based psychotherapy involves seeing only the written word. Is
it possible to express emotion online with only words and characters?
Absolutely! Humans will communicate effectively no matter what the
medium. A client can greet you in various ways, each of which can tip
you off to how they are feeling. Look at these two sentences at the
start of a session. The client can start out by saying "I?ve been
looking forward to seeing you this week ? I?m so excited! You won?t
believe what has happened this week?" or she can start out by saying
"hi :o(". If you can get a sense of the feeling tone in the sentence
as you are starting the session, imagine how much more information you
can get in a chat room with a person over a 45 minute period. The
therapist needs to be comfortable using smilies (e.g. :o) or :o( ) and
abbreviations (e.g. LOL; ROFL), but not to the point where is
distracts from the work. The use of smilies goes a long way to
reducing the harshness and starkness of the written word and to
Starkness and potential coldness of text based interaction.
<<To engage a client online, to develop and maintain an online
therapeutic relationship, the therapist has to have a good sense of
humor. One should not being doing comedy online, but a little humor
now and again helps the client regroup. The therapist who genuinely
cares for the client can communicate that to the client using words,
and the words facilitate the healing. Although the words can be stark
at times, communication in phrases and words can be quite dramatic and
Potential for misunderstanding
<<How do you prevent misunderstanding between therapist and client
online? This is prevented in the same way it is prevented in face to
face therapy ? good communication skills. Online, the therapist needs
to check with the client often to make sure the client understands
what you are saying and that you understand what the client is saying.
The experience of the therapist in working with others and his or her
superior communication skills are essential in preventing
Lack of control
<<We are well aware of the potential limitations of online work. Not
being able to have the client sitting across from you ? where you can
have a great deal of influence over the client, particularly
concerning their safety ? is causing quite a lot of discomfort in most
of us. All ethical therapists are concerned about the lack of control
we have providing online therapy sessions. There are clients who are
clearly inappropriate for online services, e.g. psychotic clients;
clients in need of medication; clients that need monitoring for
urines; clients with concurrent medical conditions that need immediate
treatment and so on. All programs face the issue of people who seek
treatment at their facility but are inappropriate. Each program has
its admission criteria and is equipped to treat a certain type or
range of types of clients. An outpatient substance abuse agency can?t
treat a chronic schizophrenic with no substance abuse history. The
limitations of online psychotherapy programs are not unlike
limitations of other programs - we can't treat all people. Most online
providers state quite clearly the limitations in the provision of
Can you establish a relationship online?
<<Some say you can?t. Dr. Holmes, an online psychologist who answers
psychological questions by email states simply " ?please do not write
me expecting psychotherapy over the internet. There is no such thing."
That has not been the experience of at least several therapists who
have conducted ongoing psychotherapy online. We can establish
therapeutic relationships online.>>
Is the client who they say they are?
<<An easy way to verify client?s identity is to obtain real name,
address and telephone number. Some workers may not want to ask for
that information and that can be ok as well if this lack of
information is congruent with the type of therapy being done. All
involved need to be aware of the risks when the therapist doesn?t know
the client?s identity, address and phone number.
Therapist?s ability to communicate online We must keep in mind the
nuts and bolts of providing online psychotherapy ? the therapist must
be able to type; to spell; to use appropriate grammar; to be able to
get around online. As mentioned above, even the most renowned and
respected therapist won?t get too far in this process if they can?t
type, spell or at a more basic level navigate on the computer.>>
Quality of online therapy:
<<This is the million dollar question. There have been no published
studies that address the efficacy of online therapy so much of what we
know about how well it works comes from providers and clients. In
both of these groups you will find those who believe it is very
effective and those who believe it can even be harmful. Most agree,
however, that if performed ethically and with a full disclosure of the
strengths and weaknesses involved, online therapy can be an effective
alternative to traditional psychotherapy. As with any treatment for
mental health concerns, however, there are never any guarantees.>>
<<Competency in the provision of online psychotherapy needs to be
viewed in two levels: 1) experience, training and expertise in
providing traditional psychotherapy and 2) skills and abilities in
online communication. The therapist needs to be grounded in a system
of therapy that works to help clients develop insight, make changes
and grow. This grounding comes through formal education, training and
actual experience in working with clients in an area of expertise. We
feel competent, and our clients perceive us as competent, when we know
"how things work". Although each client is unique, when a therapist is
experienced he or she can see themes emerging as a new client begins
to discuss their issues. With this understanding of themes, we can
make predictions about a client?s issues ? sometimes even before the
client gives voice to the issue. We are able to "fill in the blanks".
This ability is indispensable to the provision of online
psychotherapy. We need to be able to fill in the blanks at times.
Knowing how things work, being able to discern the client?s themes and
being able to predict or have a sense of the client?s unspoken issues
all help the client feel safe and listened to in the online session.
At the same time, the experience of the therapist helps the client
trust the therapist over time, particularly if the therapist is
grounded in a system of ethics that involve the protection of client
rights and respect for the client. However, being a competent
therapist by itself is not enough to make one a competent online
Psychotherapy in Cyberspace
A 5-Dimension Model of Online and
The ethics and law of online therapy
By John Soderlund
"Ethical concerns have long been a focus of mental health
professionals due to the intimate relationship that exists between a
client and his or her provider. Online therapy is a new arena and
with it comes a lot of debate about ethical concerns such as the
performance of therapy across state lines, what to do in case of an
emergency, and how to protect confidentiality of client records.
Several Organizations are addressing these concerns and some states
have already looked into laws regarding online psychology or online
Metanoia is a website that reviews and publishes on their web page the
web pages of online practioniers. It reviews submitted web sites for
several factors including the presence of credentials of the provider
of services; type of online therapy; security of website for
transmission of information and payment information for services. Web
sites are divided by single session and ongoing sessions; each web
site is given a star rating. This is an excellent place for finding
out what is available online.
NetPsychology is a wonderful and attractive repository for all kinds
of therapy happening in cyberspace. A lot of good information on this
Examples of online psychotherapy/ counseling websites:
Dr. Judith is Dr. Judith Schwambach, who has a Ph.D. in counseling
from LaSalle University. She offers email, chatroom, telephone and
face to face counseling. Her site is quite attractive and she seems to
have worked out all the details regarding billing and so on. She
provides ways to verify her credentials including a copy of her yellow
Shareware Psychological Consultation, a web site by Dr. Leonard
Holmes, a licensed clinicial psychologist, is quite well constructed.
Dr. Holmes is very clear in that he doesn?t think psychotherapy can
occur without actually seeing the client, and so limits his online
practice to consultation. He asks for payment for his response only if
you find value in it (thus the idea of shareware ? buy if you like).
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AMHCA (2000), Code of ethics of the American Mental Health Counselors
Association 2000 revision [Principle 14]. Available at:
www.amhca.org/ethics.html. Accessed Oct. 17, 2002.
ISMHO (2000), ISMHO/PSI suggested principles for the online provision
of mental health services. Available at:
www.ismho.org/suggestions.html. Accessed Oct. 17, 2002.
ISMHO (2002), Myths and realities of online clinical work.
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Accessed Oct. 17.
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