Maximizing the Benefits of Online Therapy

During the past decade, we have seen explosive growth in modes of communication using computers and the Internet. The reality of online treatment services is unfolding as the behavioral health field, whether willingly or reluctantly, approaches using technology to address addiction and mental health issues.

H. Westley Clark, MD, MPH, director of the federal Center for Substance Abuse Treatment, believes technology can assist in the federal government's larger behavioral health-related goal of ensuring “a life in the community for everyone.” He does not see online ser-vices as supplanting traditional treatment: “The goal is to leverage the impact of people-based services.”

Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), stated in the January/February 2005 issue of SAMHSA News, “At the most fundamental level, electronic access can benefit both the consumer and the provider of services. Consumers can access their own healthcare records and use them to help shape their own treatment. Providers can gain a more complete picture of their patients' overall health as well as have better access to the latest research-based information.”

Online counseling comes in a variety of shapes, sizes, and names, from cyber-counseling to e-therapy, telehealth, and telepsychiatry. It differs from traditional face-to-face counseling by offering services through delivery systems such as e-mail, chat rooms, text messaging, video conferencing, voice-over-the-Internet phones, and interactive Web sites.

A variety of benefits

The strengths of cyber-counseling include the following:

• It offers the clinician a rich tool in assessing the impact of counseling services. Typically, the weakest link in most treatment systems is aftercare. The Internet now offers the counselor an array of options to leverage the treatment gains realized in inpatient or outpatient care.

• It provides a means of reaching clients who otherwise might not get help, such as those with physical disabilities, the deaf, people with agoraphobia, ambivalent clients, low-income people without means of transportation, or those for whom distance impedes regular clinical contact.

• It is cost-effective (with costs expected to continue to decrease while communication speed increases) and, for many clients, it offers much-desired anonymity. For clients uncomfortable with face-to-face therapy, online counseling can offer unique privacy and confidentiality protections.

• It can offer the client and the clinician a permanent record of sessions, progress notes, self-paced activities, and a personal home page.

• For youths, who are far more proficient at technology than most older adults are, it opens up a vast new vista for services.

• In many locations, qualified clinicians are scarce. More than 80% of MSWs and 90% of psychologists and psy-chiatrists practice in urban areas. Meanwhile, more than 60% of rural Americans reside in federally designated shortage areas for behavioral health services. The Internet offers an inexpensive means of providing qualified clinicians right where the client is.

• The array of tools now available to the counselor through the Internet is mind-boggling, from multimedia presentations to video vignettes, Flash and static slides, interactive slides, group and private text messaging, and personal home pages to assess issues such as self-esteem, anxiety, and sobriety progress.

Barriers to progress

However, with the opportunities afforded by cyber-counseling come a variety of questions that the behavioral health field needs to answer:

• What are the qualifications of a cyber-counselor? What specialized training is needed for this developing discipline? In the future, cyber-counselors will need to acquire many of the skills possessed by hearing- and sight-impaired counselors: reading and understanding nonverbal cues, in this case when the technologic screen of the Internet shields the client. Furthermore, standards for credentialing of cyber-counselors will be required, in the manner of specialty certification for treating gambling problems, eating disorders, etc.

• How much time and experience online do most counselors have, given the relative newness of the technology? Along with the needed skills mentioned above, time online will be required to become familiar with the techniques of working on the Internet. I am a “techno-peasant,” as are most individuals in my generation. We will need training and experience online as well as time to learn a new vocabulary.

• What are the appropriate types of interactions for certain clients? How should the frequency of online “visits” and the cost and payment procedures be assessed? And will payers reimburse for such “visits”?

• Most importantly, what federal and state laws apply to govern these ser-vices? Under whose jurisdiction and insurance requirements does the online counselor fall? The client might reside in Connecticut while the counselor works in California (in the future, the counselor might be in India). These issues were addressed after the advent of hot lines and after-hours EAP answering services, under which the laws to be followed pertain to the state in which the client resides. Working in this online environment will require the counselor to be familiar with varying state laws in areas such as duty to warn, child abuse, etc. The American Counseling Association has issued ethical standards for cyber-counseling, while the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and CARF are developing standards for the accreditation of cyber-counseling programs.

• If a therapeutic alliance is so important in counseling, how does a counselor establish rapport when there is reduced interpersonal contact, when there is an absence of physical closeness? How can the clinician ensure the true identity of the client? How can the clinician avoid avatars? I would be presenting myself as an avatar to a chat room if I described myself as a 20-year-old with a full head of hair.

• How does the counselor deal with clinical emergencies if therapy is offered across state lines? Hot lines and EAPs have developed nationwide resource lists to respond in clinical emergencies. Cyber-counseling programs need to tap into these networks.

• How does one avoid misuse of a Web site or online system, such as pornographic communication, cyber-infidelity (cyber-affairs), or Internet addiction? This is a much larger question that the Federal Communications Commission and other regulatory bodies surely will address.

• How can the counselor protect against a hacker getting into the system? Who has access to the information obtained online? While this is the concern I hear raised the most about online services, technology has answers: Through improved broadband capabilities, firewalls, and improved encryption methodologies, providers can ensure confidentiality. “Voiceprinting” and other emerging tools can ensure that the person online is in fact the client. People will always express concerns about technology and confidentiality, even as I did 20 years ago with fax machines and answering ser-vices. A facetious answer I give when the question of confidentiality is raised is, “What makes you think anything you do, even paper-and-pencil forms and charts, is confidential when 17 sets of eyes and hands encounter every claim form you send through for third-party reimbursement? How often have you gone around in a clinic and found charts lying around on desks?” Questions about confidentiality have always been relevant and should be raised, but this should be the case regardless of whether the counseling is performed face-to-face or online.

• Is there an inherent issue of classism, in which the poor might not have access to treatment? Are there cultural and language issues unique to the Internet? For example, are you familiar with Internet lingo such as pnp (party and play), brb (be right back), and lol (laughing out loud)?

• How can online systems be tailored to the particular issues of the substance abuse field? For example, how does a cyber-counselor deal with an online client obviously intoxicated when “in” group counseling? How does a counselor even assess if the client is intoxicated?

Core competencies

Behavioral health professionals working in an online environment will need to acquire not only a new vocabulary but also core skills, such as:

• how to establish rapport with clients over the Internet. Hot line and EAP counselors have been able to do so over the phone, often in high-risk situations.

• how to maintain a professional “tone” when there is no verbal communication. Again, this is not a new issue, as hearing-impaired and blind counselors have been able to “hear and see” clients in different ways.

• when the counselor is visible on-screen, issues such as the counselor's makeup, nuances of facial expressions, body language, voice inflection, etc. Although these issues are obviously relevant in face-to-face communication as well, technology can make them more visible and important to client/counselor communication.

• online group etiquette, which needs to be taught to counselors and clients.

Early results of Internet counseling point to higher percentages of people completing treatment, higher abstinence rates for alcohol and drug abusers, and a vast majority of cyber-clients stating that the experience was beneficial. It seems from early research that people are more comfortable talking online than face-to-face (hence, the use of the term “virtual intimacy”). There is something reassuring and safe about the technologic shield under which we can communicate online. Online treatment appears to generate more personal attention for clients and greater client involvement overall.

Those professionals interested in cyber-counseling should first contact the reputable firms that have pioneered use of the Internet in counseling, such as eGetgoing, WebMD, and others. Second, they should contact their appropriate trade association concerning any available training programs and the ethical standards that apply. Finally, they should contact CARF and JCAHO concerning accredited programs, in order to see the standards being used and which programs are viewed positively.

For additional resources concerning the Internet, I suggest visiting:

• www.virtual-addiction.com

• www.netaddiction.com

• www.mentalhelp.net

The Internet is a reality in our lives. By getting into the game early, the alcohol and drug abuse professional can play an important role in defining the standards for e-therapy.