Potential Risks and Benefits of Online Psychotherapeutic Interventions

by Craig Childress

As a new medium of communication, the Internet (e-mail, chat, and interactive web pages) offers mental health professionals unprecedented opportunities to provide mental health outreach to persons who, while they may benefit from some form of psychological intervention, may not otherwise present to the mental health system. While the Internet offers tremendous potential, we must likewise understand that our current level of experience with this new communication medium of interactive text is limited. As we strive to understand the potential psychological benefits made possible by this new communication medium, we must also strive to understand the limitations inherent to the medium and the challenges which text-based communication presents to efforts to deliver online interventions.

This discussion will attempt to present an overview of our current understanding regarding some of the potential risks as well as the potential benefits of using the Internet to deliver psychological interventions. This is not meant to be an exhaustive list or complete discussion, but is intended merely to highlight some of the more significant challenges and opportunities afforded by the Internet. In addition, different types of Internet media,such as chat versus e-mail, may present differing challenges and opportunities. This discussion will not focus on specific issues related to the individual media of Internet communication but will only raise general issues in order to generate thoughtful consideration of these issues.

Mental health professionals have an ethical obligation to evaluate and disclose to clients the possible risks associated with the therapeutic interventions employed, including those risks associated with the medium of communication. This ethical obligation compels mental health professionals to understand the potential risks associated with the delivery of psychological interventions using the Internet so that the risks assumed by clients engaging in this type of psychological service may be appropriately evaluated and disclosed. By understanding the risks associated with interactive text-based interventions appropriate steps may also be taken to eliminate or minimize the risks assumed by our clients.

While an appropriate regard for, and disclosure of, the potential risks of providing interactive text-based intervention is ethically mandated, these potential risks need to be evaluated within the context of the potential benefits to be derived from online interventions. A presentation of either the potential risks alone or the benefits alone is inherently biased and misleading. Only through a balanced evaluation of the potential risks and thepotential benefits can mental health professionals ethically advise clients regarding an appropriate course of action. In addition, we must guard against projecting onto this new communication medium fears regarding change and the unknown which might cause us to withhold appropriate interventions. The challenge is to neither undervalue nor over inflate either the potential risks or the potential benefits available from interactive text-based therapeutic interventions.

Toward this end, it is hoped that the following discussion will stimulate reflection regarding the potential challenges and opportunities offered by the Internet for the delivery of mental health interventions:

Potential Risks

1. The loss of visual and auditory cues:
   The loss of visual and auditory cues creates several challenges for mental health professionals seeking to use the Internet to deliver psychological interventions.

   1. Theoretical Basis of Interventions:
      Theories of therapeutic change derived from face-to-face (in-person)therapeutic relationships may not be applicable to text-based communication. New models for producing therapeutic change which are appropriate to themedium of the Internet may need to be developed prior to providing online text-based interventions.

   2. Diagnosis:
      Text-based communication restricts the ability of mental health professionalsto make adequate diagnoses. Without the ability to adequately diagnose aclient, the ability to develop an appropriate treatment plan may likewise be restricted.

   3. Identity:
      Text-based communication restricts the mental health professional's ability toverify the client's identity. This difficulty in verifying identity on the Internet becomes a significant issue regarding the treatment of minors without parental consent and in addressing crisis issues such as reported suicidal ideation, homicidal intent, child abuse, spousal abuse, or elder abuse.

   4. Misscommunication:
      The potential for destructive miscommunication may be increased by the loss of visual and auditory cues in text-based communication which normally serve to provide context to the spoken word. In addition, online therapists lose the visual and auditory feedback from their clients which might otherwise cue thetherapist regarding a potential miscommunication.

2. Confidentiality:
   Ensuring confidentiality is more problematic on the Internet than with in-person (face-to-face) relationships. Online risks to confidentiality occur at four locations, transmission, therapist-end, client-end, and legal subpoena.

   Transmission: The Internet relies on electronic copying of information for transmission, creating the possibility of interception at many points. While encryption offers greater security, it should not be assumed that encryption codes cannot be broken by knowledgeable computer hackers.

   Therapist-end: It is probably prudent not to store client communication on a hard drive of a computer which has Internet access since such information can be accessed by computer hackers. In addition, steps should be taken to secure client communication from being read by unauthorized persons at the therapist's office or home (e.g., password protecting files). Files containing client communication should also be regularly and frequently backed-up to protect against the possible loss of clinical records resulting from hardware failures.

   Client-end: The possibility that others at the client's home or office have access to records of client/therapist communication needs to be evaluated. If the client is communicating using an office computer, the employer has a legal right (in the United States) to read such communication. In addition, the possibility of family members of the client having access to the client's online communication conducted from the home also needs to be evaluated. The client also should be made aware that deleting files from the hard disk means that the space previously occupied by the file is made available to be written over but that until such time as this disk space is used the deleted file may still be recovered, possibly compromising confidentiality.

   Legal Subpoena: For several legal reasons, it is currently unclear if communication using the Internet is covered by therapist/client privilege (in the United States). Client communication to the therapist may therefore be subject to the legal process of discovery. This may be especially relevant for clients involved in divorce and child custody matters and clients should be made aware of this possibility. However, legal issues related to the Internet become more complex and obscure when clients and therapists of differing nationalities are involved.

3. Competence:
   The absence of appropriate training in text-based communication may affect the clinical competence of therapists attempting to deliver text-based interventions. The competence of therapists in this new medium may affect both the quality of clinical care provided as well as the therapist's potential liability should ethical or legal proceedings develop from the therapist's online work.

4. Crisis Management:
   Difficulties in responding to crisis situations may arise both as a result of client anonymity and because the therapist may be unfamiliar with the local community resources available in the client's geographic region. In addition,local laws requiring mental health professionals to breech confidentiality and report a client's danger to self or others, or suspected incidents of child, elder, or spousal abuse, vary from one geographic jurisdiction to another. When the client resides in a different legal jurisdiction from the therapist, it is currently unclear which laws, those covering the therapist's geographic region or those covering the client's geographic region, are applicable. This issue becomes more complex when differing nationalities are involved.

5. Legal and Jurisdictional Issues:
   Legal and jurisdictional issues are currently in the early formative stages and are complicated by the trans-boundary nature of the Internet. While legal issues remain unclear, online therapists practicing in the United States need to consider legal issues related to licensure in the client's home state. While the courts have yet to rule on interactions conducted entirely through the Internet, it remains a distinct possibility that the courts (in the U.S.)may determine that a therapist's webpage constitutes advertising (i.e.,conducting business) in a different state from the therapist's state of residence (and licensure) and therefore subjects the therapist to the legal authority, including the licensing laws, related to the practice of therapy in that other state.

   Some online therapists may try to limit legal and ethical constraints on the services they provide by offering a disclaimer in which the services they provide are called "psychoeducational" in nature. Such a disclaimer should not be viewed as offering blanket protection in the United States, however, since courts and state regulators do not use the words of the therapist as a criteria for determining whether a therapeutic relationship has been created, but instead look to the reasonable expectations of the client. It may also be difficult in court to disavow the therapeutic intent or impact of "psychoeducational" interventions, and the subtle distinction between "advice" and "directive psychotherapy" may be difficult to establish.

   There remains, however, considerable controversy regarding the jurisdictional authority of geographically determined governing bodies over the activities occurring in the trans-boundary domain of cyberspace. The geographically determined governing bodies may nevertheless try to assert jurisdictional authority over cyberspace and online therapists may be subject to legal proceedings if they transgress against this asserted authority.

Potential Benefits of Online Therapeutic Interventions

1. Screening:
   An online mental health presence may provide beneficial wide-scale screening for persons with issues amenable to therapeutic intervention. Contact withonline mental health professionals may provide an effective introduction tothe mental health system for persons who may benefit from therapeutic intervention but who may not otherwise present to the mental health system.

2. Treatment of Non-Clinical Problems:
   The Internet may be an appropriate medium for treating persons with non-clinical problems who may nevertheless benefit from psychological consultation. Many persons with "normal-range" issues might benefit from psychological consultation but may never present to the traditional mental heath system due to the social stigma, cost, and inconvenience of seeking professional consultation. The Internet might provide such persons with a convenient and private way to seek psychological consultation related to their issues.

3. Unique Advantages Available to Online Communication:
   The text-based medium of the Internet offers unique advantages unavailable to in-person therapy.

   1. Asynchronous Communication:
      The asynchronous quality of e-mail communication provides both client andtherapist with the opportunity to devote greater thoughtfulness to their communication which may encourage greater clarity in their communication and more precisely targeted interventions.

   2. Convenience:
      The asynchronous quality of e-mail communication is more convenient for both client and therapist than in-person therapy.

   3. Depth of Disclosure:
      People tend to disclose more personal information to a computer than they do with an in-person interviewer. This greater depth of self-disclosure may lead to greater depth in the therapeutic work.

   4. Transference:
      Transference issues on the Internet may be significantly different than in face-to-face relationships and may involve transference to technology and to computers as well as interpersonal transference issues. With the development of appropriate theoretical models, this change in the transference relationship might be usefully exploited in treating clients over the Internet.

4. Support Groups:
   The Internet can facilitate the provision of peer support groups to underserved populations. Peer support is more convenient and accessible through the Internet than through traditional in-person groups and the Internet may be useful in providing support groups for persons with illnesses or disabilities which prevent them from accessing in-person groups. Peer support groups can also be formed to address disorders for which in-person groups may not be applicable because the infrequency of the disorder prohibits the gathering of sufficient members to form an in-person support group.

5. Adjunctive Internet Use:
   The use of the Internet may be useful as an adjunct to ongoing in-person therapy.

   1. Avoids Problems of Internet-Only Interventions:
      Using the Internet to augment an ongoing in-person relationship avoids many ofthe problems associated with Internet-only interventions, such as client anonymity, diagnostic issues, legal licensing issues, and crisis intervention responsiveness.

   2. Experience and Increased Therapist Competence:
      The adjunctive use of the Internet within the framework of an ongoing in-person relationship provides the therapist with valuable experience in using text-based communication to deliver therapeutic interventions, thereby increasing therapist competence in this medium.

   3. Monitoring Homework:
      The adjunctive use of the Internet can be used to monitor therapeutic homework assignments given to the client, such as daily behavioral monitoring or written explorations of the client's relationships to specific incidents or people.

   4. Increased Depth of In-person Sessions:
      By extending the therapeutic hour, the adjunctive use of the Internet can improve the depth of the material covered in face-to-face sessions. The client can continue to explore issues outside of the in-person therapy session and the results of these explorations can be communicated to the therapist using the Internet prior to the beginning of the therapeutic session, allowing the therapist time to reflect upon the client's material and to develop more thoughtfully targeted treatment plans for the session.

   5. Termination:
      The adjunctive use of the Internet can be used to ease client termination by gradually reducing in-person contact while substituting contact through the Internet. The client's reliance on the therapeutic relationship can be shifted gradually to either client self-support or a reliance on the client's natural support systems.

This document is Copyright © 1998 Craig Childress. All rights reserved.