E-Therapy: Case Studies, Guiding Principles, and the Clinical Potential of the Internet

Robert C Hsiung, Editor

Overview – Excerpt – Table of Contents

Chapter 1: Introduction

The Clinical Potential of the Internet

Robert C Hsiung, MD

Five curious blind men visited the palace of the Rajah to learn the truth about e-therapy. They were taken to his study, where he kept his computer (the Rajah’s computer had screen reader and voice recognition software installed, so it was usable by the blind men).

The first blind man reached out to the keyboard and used a search engine to look up the side effects of Prozac. "E-therapy is comprehensive like an encyclopedia!" he declared.

The second blind man used the computer to send an expert psychiatrist a question. "E-therapy is personal like Dear Abby," he announced when he received an answer.

The third blind man e-mailed his therapist to tell her he had had another dream about elephants. "I was right," he decided. "This is having access to my therapist whenever I want."

The fourth blind man talked with a psychiatrist in far-off Arizona. "What we have here," he said, "is a telephone."

The fifth blind man went into a chat room and had a session with a therapist who did not know he was blind. "I believe e-therapy is like a magic carpet that takes me to a place without stigma," he said. (adapted from Blubaugh)

It seems preposterous that e-therapy could be all these things. But different parts of it have evolved to specialize in different functions, sometimes with incongruous results. This book reflects its subject and may itself be a little ungainly, but at least does not weigh a ton.

Information On Line

Robert Kennedy, in "The Information Exploration in Mental Health," provides an overview of the initial use of the Internet in mental health: to exchange information. He reviews the development of the Internet from a U.S. military project to a mass medium and addresses both its technical and sociological aspects. He discusses the two sides of information exchange: what consumers are looking for and what e-publishers like Medscape (www.medscape.com) are providing. He explains how to search effectively for information and how to assess the accuracy of the results. He concludes by looking into the future of on-line information, where he sees distance learning, digital health records, XML, personalization, and the lessening of information overload.

The Web is disorganized. It is an example of what could be called the Second Law of Infodynamics: information tends toward a state of randomness (Klyce, 2001). Organization and structure require the input of energy. Kennedy refers to this as Phase II of the evolution of information transfer. Writers have to work to organize their thoughts; "webmasters" have to work to organize their Web pages; and someone has to work to organize Web sites. Most users achieve some organization with their "bookmarks." Many also rely on what Kennedy calls the "catalog" type of search engine, essentially the bookmarks of third parties. Many use a combination of these approaches. The more extensive—and organized—their bookmarks and the catalogs they use, and the more skilled they are at using what Kennedy calls the "index" type of search engine, the more helpful users will find the Web. Another aspect of the filtering process involves not relevance, but quality. Quality can also be assessed by users themselves or by third parties. Third parties may be biased, however, so the more information-literate users are, the better. As Terry (chapter 9) puts it, utility is based on a series of factors: breadth of information, search efficiency, and quality of information.

Case Study: Ask the Expert

In "The Internet ‘Expert’: Promise and Perils," Ronald Pies presents his Ask the Expert Web site (www.mhsource.com/expert), at which he responds publicly to questions submitted by consumers and professionals. His individualized information service is a hybrid between general information like that discussed by Kennedy (Chapter 2) and individual treatment like that provided by Stofle (Chapter 6). The key is to provide information but not advice, education but not treatment, and thereby to avoid creating a doctor-patient relationship (see Chapter 9). At most, Pies provides "heuristic," as opposed to "prescriptive" or "proscriptive," advice. The distinction is between suggesting a way to solve a problem and suggesting a solution to the problem—the classic difference between teaching someone how to fish and giving them a fish. There are exceptions to every rule, however, and Pies does give prescriptive and proscriptive advice in certain circumstances, for example, when it is common sense, in cases of clear malpractice by a treating professional, and in life-threatening situations.

The site says it is "intended . . . not as a substitute for . . . urgent medical evaluation, treatment or consultation," but falls short of saying it should not be used, period, in crisis situations. That sort of use could be considered non-compliance, but Yellowlees (Chapter 7) tells us that the patient is becoming more autonomous and the provider-consumer relationship more egalitarian and that professionals need, in turn, to become more flexible, and Pies demonstrates how he still does try to help in those situations.

Pies gives us six actual examples of questions and answers. They are mini-case studies in which he shows us not only what he does, but why he does it. He concludes by touching on the personal satisfaction he derives from this work. It is a change of pace from his usual office practice, many visitors are grateful for his help, and those efforts, as do other forms of "media psychiatry" (American Psychological Association, 2001), go much further than they would in person.

Although what Pies is providing at his site is not therapy, he nevertheless uses his therapy skills. He attends not only to the questions that are submitted, but to those that are unspoken; he approaches each interaction with specific goals; he keeps in mind the real-world lives of his visitors; and he anticipates both how they might feel and what they might do in response to his responses. He is aware of both the promise and the perils of this psychoeducational form of e-therapy. He is an expert in terms of not only what he knows, but also how he deals with people.

Case Study: Adjunctive E-Mail

In "Using E-Mail to Support the Outpatient Treatment of Anorexia Nervosa," Joel Yager describes how his use of e-mail has evolved from scheduling appointments to being an integral part of the treatment he provides. As more and more of his patients started to use e-mail, and especially after he moved from Southern California to New Mexico, he realized that e-mail could augment the treatment and consultation he provided. He presents cases, with e-mail transcripts, to illustrate seven ways in which e-mail may be incorporated into treatment directly and, through consultation with other professionals, indirectly. It may be used to enhance weekly sessions, to monitor treatment from a distance, to monitor behavior daily, to smooth a transition between care providers, to communicate with family members, to co-manage a patient, or to intervene in a crisis. The e-mail transcripts provide concrete examples of both how patients use e-mail and how therapists can be responsive, supportive, and therapeutic using just text. This is another case of the flexibility that Yellowlees advocates.

Yager then discusses the potential positive and negative consequences of the adjunctive use of e-mail and the possible directions future work might take. Incorporating e-mail into treatment may increase the frequency of therapist-patient contact and therefore the "object constancy" (Mahler, Pine, & Bergman, 1975) of the therapist. The patient may feel the therapist is more "present" (see Chapter 6) and provides more of a "holding environment" (Winnicott, 1953). The patient may more easily initiate contact and may therefore feel both more cared about and more empowered. Because the communication is on line, the patient may feel safer and therefore less inhibited (Stofle, Chapter 6; Ainsworth, Chapter 10); because it is "asynchronous" (not in "real time"), the patient may worry less about possibly intruding. The patient may engage "while the iron is hot" and may share more meaningful material earlier in the process.

The only actual drawback Yager found was resentment at being expected to "report in." A potential drawback was getting less information via e-mail than in person, but in these cases, e-mail was an adjunct to and not a substitute for contact in person. The potential for a breach of confidentiality was the greatest with his patient A because at one point she shared a home computer, but Yager was aware of the situation and protected her privacy by taking pains to be discreet—as he would have had he met with the patient and a family member in person. Yager finds his adjunctive use of e-mail accepted by his patients and his colleagues and not too demanding of his time. He does not charge for e-mail services. Therapists could, however, bill for adjunctive on-line contact directly, as a distinct procedure like a telephone call (Current Procedural Terminology (AMA, 2001) code 99371, 99372, or 99373), or indirectly, by "bundling" it, like an office expense, into other charges.

Yager notes that patients with eating disorders tend to be compliant, but shy, so they may be especially likely to make use of and to benefit from this type of e-therapy. For any patient with a behavioral problem, frequent self-reports by e-mail would help them to confront those behaviors more consistently. In general, which patients are likely to benefit from which e-therapy techniques needs more study. One size does not fit all any more on line than it does in the office; even Yager was not able to engage his patients E and F by e-mail.

Case Study: Community Telepsychiatry

In "A Model Community Telepsychiatry Program in Rural Arizona," Sara Gibson, Susan Morley, and Catherine Romeo-Wolff share their experiences with NARBHA Net, the Northern Arizona Regional Behavioral Health Authority (www.rbha.net) videoconferencing system that connects—via a central hub—11 rural mental health care agencies in a 62,000-square mile area, Arizona State Hospital, the University of Arizona, the state Department of Health Services, and two other regional networks. Gibson provides all outpatient psychiatric services to one 11,000-square mile county from the hub, over 150 miles away. She never meets those patients in person, yet diagnoses their problems and prescribes their medications. She cannot assess some patients adequately that way, but she refers them to local resources, and they are no worse off than before.

One of the advantages of rural areas is that people have room to spread out. As Yager (Chapter 4) also found when he moved to Albuquerque, one of the disadvantages is that resources are more difficult to access in person. NARBHA staff sometimes used to take an entire day to attend a 30-minute meeting. Electronic communication can bridge those distances. NARBHA Net is an electronic network, but it forms the basis for human networks (see also Chapter 2) that include outpatient clinicians, inpatient clinicians, subspecialist consultants, school personnel, patient advocates, families, and, of course, patients themselves. Gibson, Morley, and Romeo-Wolff estimate that in 1998-99, 6500 hours of staff travel time and $100,000 in expenses were saved. And of course there are no automobile accidents in "cyberspace." Private insurers pay for the services provided by the telepsychiatrist at the same rate as services provided in person (but do not cover the services simultaneously provided in person by other professionals at the rural clinics). Gibson, Morley, and Romeo-Wolff found no significant differences in medication costs or hospitalization rates between the telepsychiatry patients and NARBHA patients overall.

In 1999, NARBHA Net was used for 2200 videoconferences, 90% of which were for clinical purposes. To maximize video quality and confidentiality, they transmit at 512 kilobits per second (kbps) over private lines. A network is a many splendored thing, and NARBHA Net is also used for voice and data applications and provides educational and administrative benefits.

Feedback from both patients and staff in the rural clinics has been overwhelmingly positive. No patients have refused telepsychiatry services. In fact, the patients have tended to like telepsychiatry more than the staff has, and the price of success has been heavy demand. Gibson, Morley, and Romeo-Wolff share some tips on how to help patients "forget the machine," to make the interaction as much like interacting in person as possible and to maximize their feeling of "presence" (see Chapter 6). They also include their consent form for others to use as a model.

Videoconferencing at 512 kbps is the next best thing to being there. Taking into account the cost of travel, it may be even better than being there. The question is, how much bandwidth is close enough to being there? NARBHA insisted on 512 kbps in order to administer the Abnormal Involuntary Movement Scale. If not assessing for movement disorders, however, that much bandwidth might not be necessary; one does not need the Concorde to go to the grocery store. NARBHA plans to experiment with portable telemedicine units that connect at 56 kbps, i.e., over Plain Old Telephone Service (POTS) lines. That will be like taking the bus, but that may be good enough. POTS is already widely, if not universally, available in patients’ homes, so patients will not even be tied to their local clinics. The Concorde, like the VTEL TC2000, is of more limited application not only because it is itself expensive, but also because it requires an expensive infrastructure. A bus does not need an airport. Sometimes less is more.

Case Study: Chat Room Therapy

In "Chat Room Therapy," Gary Stofle reviews the use of chat rooms for individual e-therapy. He believes that to be competent at e-therapy, it is necessary, but not sufficient, to be competent at therapy in person, since "the methods of intervention must be adapted to fit the methods of communication." He discusses how both knowing who patients "really" are and protecting their confidentiality are in some ways more difficult on line than in person. He also rightly points out that e-therapy should not be held to a higher standard than therapy in person. How many therapists ask the patients they see in person for identification or have ironclad office security?

Stofle mentions three practical ways in which chat room therapy is different from therapy in person: it is not obvious to third parties when the therapist is with the patient, so the therapist is more easily interrupted; the patient is not watching the therapist, so the therapist is more easily distracted; and the delay, even if slight, caused by having to type and to wait for transmission may lead to the therapist and the patient getting "out of synch" (as can happen on the telephone when connecting via satellite; even in person, it may take time to absorb what someone says or to formulate a response).

The heart of the chapter is transcripts from three types of cases: single-session, short-term, and long-term. Stofle proves to us that psychotherapy can be done on line by doing it. He explores, empowers, supports, gives hope, assesses suicidality, makes cognitive and behavioral interventions, elucidates psychodynamics, and interprets. We see that he can do what therapists do in person and that it has therapeutic effects. His chat room patients share meaningful feelings, face previously unfaced issues, and demonstrate insight.

Stofle draws a parallel between nonverbal communication in person and "nontextual" communication on line. Tone of voice provides information in person, but is absent in a chat room. "Interaction tempo" provides information in a chat room, but is absent in e-mail. Word choice, however, provides information even in e-mail. It is all a matter of degree, of the degree of experiential "richness" (or technical bandwidth) of the medium. Expressive patients are easier to get to know—whatever the modality. On line, they are more "present," and therapists will have a greater sense of "presence" with them. Other patients feel safer with more distance and take longer to get to know—again, whatever the modality. Some patients may also be more expressive in one medium than another, e.g., Ainsworth (Chapter 10) says, "I write better than I talk." There is also an intersubjective factor (Stern, 1985): the better the fit is between the therapist and the patient, the more smoothly the process will proceed. Therapist selection is an issue just as patient selection is.

A nice example of "presence" is how Stofle refers to his typing back and forth with his patients as "talking." At least to some extent, he experienced it as being with them in person, and, even reading now, so do we.

Guiding Principles: Clinical

Peter Yellowlees, in "Clinical Principles to Guide the Practice of E-Therapy," says first that the Internet should be integrated into real-world practice. Therapists should, for example, welcome e-mail from patients (though not unconditionally). Yager sets a good example of this. Yellowlees then puts forward four basic clinical principles to guide e-therapy. E-therapists must be flexible and able to integrate a wide variety of information and to work in a "24/7," global mode. E-therapists must be respectful of patients and allow them to have a greater voice in shaping their treatments and to join with them in more egalitarian therapeutic relationships. E-therapists must be competent and possess both people and computer skills, be aware of their own limitations, continue to educate themselves, contribute to the field’s evidence base. E-therapists must be responsible and, for example, accept, even encourage, requests for second opinions and the keeping of transcripts of interactions. There are also potential problems on line, including Internet addiction, "cyberchondria," and deception by and questionable advice from others, to which e-therapists should alert their patients.

Yellowlees uses as an example of good e-therapy practice the system at Doctor Global (www.doctorglobal.com). Automatic screening enables immediate responses to serious problems, and quality "audits" (reviews) maintain a high level of care. He sees the accountability of e-therapists as essential and the further transition toward self-care as inevitable. Emphasis will continue to shift from professionals to self-help networks and friends and family, and from the therapist as authority to the therapist as advisor and collaborator.

The goal of quality audits would, of course, be quality improvement, but there are two sides to every coin, and the other side of this one may be resentment by the audited therapists. We have seen this in the U.S. with managed care. One hopes that lessons learned from auditing costs will be applied to auditing quality.

Guiding Principles: Ethical

In "Suggested Principles of Professional Ethics for E-Therapy," I discuss some of the opportunities and dangers of e-therapy. Guidelines may help both therapists and patients to chart ethical courses of treatment. I review the development of various e-therapy ethics guidelines and present a set of suggested principles produced by a joint committee of the International Society for Mental Health Online (ISMHO) and the Psychiatric Society for Informatics (PSI). The members of the committee came from different countries and different professional backgrounds; one of the co-chairs was a patient and not a therapist. The suggested principles were intended to be broad enough to be applied internationally and to the entire continuum of e-therapy services. The development process was conducted completely on line. Like NARBHA (Gibson, Morley, & Romeo-Wolff, chapter 5), using electronic communication to bridge the distances separating them enabled more members to participate and the work to be more continuous, since members did not have to travel to collaborate in person.

There are three sets of suggested principles. The first has to do with informed consent: the patient should be informed about the process, the therapist, the potential risks and benefits, the safeguards that the therapist takes and that the patient could take, and the alternatives. The second set concerns "standard operating procedure": e-therapy should be provided within the same standard framework as therapy in person. The therapist should be competent, legally allowed to practice (see Chapter 9), reach an agreement with the patient on the frequency and cost of services, adequately evaluate the patient, be mindful of other treatment providers, protect the confidentiality of the patient, and maintain records of the treatment. The third set deals with emergencies: the procedures to follow in an emergency should be discussed, and if the therapist and the patient are geographically separated, the therapist should identify a local backup such as the patient’s primary care physician. These principles should help guide e-therapists as they develop their practices and e-patients as they select among them. I have established a message board, Tele-Psycho-Babble (www.dr-bob.org/babble/tele), to facilitate further discussion of "distance" mental health.

Guiding Principles: Legal

Nicolas Terry, in "The Legal Implications of E-Therapy," reviews an area that is rapidly changing and often mystifying, yet essential to understand. He defines e-health and e-therapy, respectively, as the use of technology to deliver health care services and the clinical (as opposed to the "backend," or administrative) uses in mental health. The "business-to-business" side of e-therapy, consulting with other clinicians, is what he considers telepsychiatry; its "business-to-consumer" counterpart is direct patient care.

He starts with a discussion of the impact of e-health on the overall structure of the health care system. Rather than entering the health care system at a single point, patients will now enter at multiple points. The primary care physician gatekeeper will be rendered obsolete, and regulation will also become "multipoint." For example, a state may require not only therapists in that state, but also therapists in other states who treat patients in that state, to be licensed in that state. Or, to stay within its borders, a state may require pharmacies in that state not just to require prescriptions, but prescriptions issued on the basis of "valid" doctor-patient relationships. What constitutes "valid" relationships (or the "accepted medical practices" on which such relationships might be based) is, of course, open to interpretation. Obtaining a history is cited as an example of an accepted medical practice. But what about obtaining a history over the Internet?

Terry breaks down the relevant legal issues into four groups: those having to do with regulation, the therapist-client relationship, quality, and security and privacy. Regulatory issues include licensure, malpractice coverage, and the prescribing and dispensing of medication. Licensure is complicated because federal, state, and intrastate jurisdictions overlap, but in interstate B2B e-therapy, licensure may be covered by specific telemedicine clauses. In interstate B2C e-therapy, telemedicine statutes do not (currently) apply. The key concept in licensure is the practice of a regulated profession. States have the power to define those professions and may include B2C e-therapy involving their residents. States also have the power to regulate those practices, for example, by requiring licenses, certificates, etc. E-therapists may of course hope that distant states do not expend the resources to enforce their regulations, or they may press for some form of national licensure (or at least increased reciprocity between states). Though the law may (and perhaps should) lag behind technology, it does eventually adapt. Today, statutes are starting to address telemedicine; soon, they will also deal with e-medicine.

Regarding the therapist-patient relationship, one legal issue is when a therapist-patient relationship is created. Malpractice hinges on such a relationship; in its absence, a therapist is not liable for negligence. Terry states that one does not have to practice medicine to create a doctor-patient relationship, but also cites Miller v. Sullivan, in which the court stated, "the relationship is created when professional services are rendered and accepted for the purposes of . . . treatment." A separate legal issue, once a therapist-patient relationship has been established, is informed consent, particularly regarding risks to confidentiality.

Technology will raise the quality of care even in traditional practice. We will see a decrease medical error and, at least in theory, "administrative simplification." In e-health, quality of information is one issue. Simply linking to other Web sites may be problematic. It is more efficient than quoting or paraphrasing, but also increases the possibility of conflicts of interest and liability for the linked-to information (which, among other problems, may change without notice). Malpractice-like actions may be difficult, but fraud and dangerous products will continue to be targeted. The quality of care issue Terry focuses on is the therapist’s Tarasoff duty (to protect third parties) when patients are potentially violent. "Forum selection" clauses may deter some litigation, but cultivating realistic patient expectations is, in his view, more likely to be effective.

Finally, Terry discusses security and privacy. Security is keeping third parties from "breaking in" and helping themselves to information; privacy is not sharing information with third parties without authorization. The Health Information Portability and Accountability Act will have a major impact in both areas, at least in the U.S. Of note are the rights of patients to correct and to know who has accessed their records. Disclosure to public health and law enforcement officials will be more relaxed, but there will be increased responsibility for disclosures by business associates such as billing or practice management companies.

It could be argued that that the multipoint access to health care services that e-health will bring will have advantages and disadvantages analogous to the multipoint access to health information that the Web has already brought (see Chapter 2). The references in this chapter are links to the e-health and legal literature, and many also include links to the Web. Although only "plain" text here, the chapter is hypertext in spirit. (Readers unfamiliar with legal citations may take advantage of the parallel information explosion in the law and consult on-line guides such as that provided by the Boston College Law Library, 1999.)

A Patient’s Perspective

Martha Ainsworth, in "My Life as an E-Patient," starts with a review of the history of e-therapy, which she considers, more narrowly than Terry, to include only ongoing dyadic relationships in which all interactions are on line. She considers both the advent of the dot-com e-clinics and the formation of ISMHO to be milestones in the evolution of e-therapy. Both were in fact developmental or evolutionary steps in that they involved the coming together of individuals to form organizations.

She then tells us about her own e-therapy. In some ways, her story is like that of a traditional therapy patient. She was in pain, and she was alone. She shopped around for a therapist. She wondered whom she could trust. She chose someone and luckily, they clicked. She was not instantly cured, but she was no longer alone and now had hope.

Her e-therapist established a therapeutic frame (Bleger, 1967). She held back, i.e., resisted. He sensed her moods, i.e., was empathic. Their relationship deepened. He made comments; he interpreted. There was transference, and there was healing. In other ways, it was very different from therapy in person. Connecting from the safety of her home (or at least her hotel room) and free from his physical presence, she felt more secure, was less inhibited, and got more quickly to the heart of the matter. The process was more user-friendly; she "talked" to him when she wanted, she "listened" to him when she wanted, and she didn’t have to do both at the same time. Granted, more user-friendly is not necessarily more therapeutic, but it is at least an example of the flexibility that Yellowlees advocates.

Ainsworth went on to establish Metanoia.org to share what she had learned with others, i.e., to use the Internet to provide information. First, she created a directory of e-therapists. She also conducted a survey and presents some of that data here. Her sample was self-selected. Of 619 responses over four years, 73% had already tried e-therapy. Of those, 68% had never been in any kind of therapy before, 92% thought their e-therapy had helped, and 64% went on to try therapy in person. That 68% tried e-therapy before therapy in person shows that it appealed to some individuals. That 92% considered it helpful, but 64% went on to therapy in person, is interesting. Without more complete data, it is hard to know whether the e-therapy glass was more empty (64% did not stay with e-therapy) or more full (64% were willing, after the more user-friendly e-therapy experience, to try therapy in person).

Ainsworth became alarmed by some of the responses she received and by some of the e-therapy practices she found and decided not just to direct patients toward e-therapy, but also to guide both them and e-therapists down the trail she and her e-therapist had blazed. She discusses the appropriateness of e-therapy, the competence (see Chapters 6 and 7) and accessibility of the e-therapist, the cost of the e-therapy, and the privacy of the e-patient.

Finally, Ainsworth reflects on the evolution of e-therapy and notes that the question has shifted from whether e-therapy should be provided to how. Which e-therapists, for example, should treat which e-patients? She does not claim that "true" psychotherapy can take place on line and merely states that whatever it is called, it can be tremendously helpful and will continue to be demanded. Her pragmatic wish is that therapists who are qualified will provide it. She appeals to other patients to speak out and to mental health professionals to listen. The voices of patients may be softer on line, coming from behind the "anonymity shield" and across the gulf of cyberspace, so therapists not only need to, but to listen closely.

Discussion

"E-therapy is like an encyclopedia," said the first blind man. "Surely we can agree on that."

"An encyclopedia? E-therapy is Dear Abby!" answered the second blind man.

"It's an extra session, I tell you," insisted the third blind man.

"I'm certain it's a telephone," said the fourth blind man.

"Magic carpet. There's no doubt," said the fifth blind man.

Their argument continued and their shouts grew louder and louder.

"Encyclopedia!" "Dear Abby!" "Having a session whenever I want!" "Telephone!" "Carpet!"

"STOP SHOUTING!" called a very angry voice.

Licensure (and regulation in general) can be a contentious issue. Stofle urges us "not to recreate barriers to treatment that the Internet has eliminated." Terry explains how licensure affects e-therapy, but takes it as a given and does not attempt to justify it. The current crazy quilt of state requirements is of course inconvenient for e-therapists who would like to be able to treat patients from coast to coast. Licensure, like a guardrail, does, however, serve a purpose. Over-regulation would of course be undesirable, like just closing the highway. But if the guardrail is removed while the highway is being upgraded to a superhighway, it should be replaced—as soon as it can be decided where exactly to locate it, since traffic patterns might change. It may be paternalistic, but sometimes "pater" does know best.

Gibson, Morley, and Romeo-Wolff found that the patients liked telepsychiatry more than the staff. Terry observed that more e-therapy Web sites were run by masters-level therapists and clinical psychologists than by psychiatrists. We might speculate that in terms of the number of "early adopters" (Rogers, 1995) of e-therapy, there might be more patients than masters-level therapists, more masters-level therapists than clinical psychologists, and more clinical psychologists than psychiatrists. Perhaps psychiatrists as a group are the most conservative. Or perhaps they benefit the most from the current system and so have the least incentive to change.

A number of us comment on the tradeoffs of e-therapy. Ainsworth (Chapter 10) felt more comfortable communicating by e-mail: "I could reveal to him only as much as I felt comfortable revealing"; "the anonymity shield of cyberspace made me feel free." Anonymity is powerful partly because of the shame and stigma that is still—although thankfully not to the same extent as before—associated with mental illness and mental health treatment. Her therapist may not, however, have felt so comfortable; in his very first e-mail, he started asking to talk to her on the telephone. Even after they had established a solid connection and had not only talked on the telephone but also met in person, she still felt more comfortable on line. Not only is less information about the patient available to the therapist, but also less information about the therapist is available to the patient, and as Terry points out, the therapist may seem less warm or, in Stofle’s terms, less "present." Because meeting in person almost always means the patient goes to the therapist, meeting on line, in more neutral territory, is an example of the more egalitarian therapist-patient relationship that Yellowlees refers to. Terry warns that if patients have more autonomy, they may behave in more manipulative ways. Being flexible, as recommended by Yellowlees, however, the therapist might simply use that as grist for the therapeutic mill—as he or she might if treating the patient in person.

Ainsworth was not truly anonymous; her therapist knew who she was. The on-line "anonymity shield" does, however, raise concerns. One of the suggested ethical principles I discuss is that therapists should not be anonymous. But what about patients? I refer to it as an unresolved issue. If people are allowed to remain truly anonymous, they feel even safer and more willing to open up. This phenomenon is apparent in on-line communities like Psycho-Babble (www.dr-bob.org/babble). What difference does it make if the therapist does not know the patient’s name? It is not an issue of contacting the patient, since the therapist would have the patient’s e-mail address (it might change, but so might the patient’s telephone number). One issue is that the patient, by remaining anonymous, shifts the balance of power in the therapist-patient relationship; now the patient knows who the therapist is, but the therapist does not know who the patient is. This may be appealing to the patient, given the underlying power differential in other respects.

This shift in power also has significant consequences in Tarasoff situations. If the therapist does not know who the patient is, the patient is also "safe" from involuntary hospitalization. Stofle’s stance is that e-therapists need to accept that they are powerless in the face of determinedly suicidal patients. Presumably, the courts should also see e-therapists as powerless, i.e., impose no Tarasoff duty on them. Therapists were only held liable for the death of Tatiana Tarasoff because she was "readily identifiable" as the potential victim (Tarasoff v. Regents, 1976). If a patient tells a therapist that he or she intends to go to a random park and shoot a random person, the therapist may be responsible for hospitalizing the patient or notifying the police, but not for warning the victim. Stofle is clear that the e-therapist should recommend appropriate treatment and decline to participate in inappropriate treatment. Perhaps the e-therapist should not be held responsible for protecting the patient from self-harm if the patient is not readily identifiable. The parallel would be with an anonymous patient who calls a hotline or an emergency room. It may be possible to identify the e-patient with the cooperation of their Internet service provider, but if efforts like that may be made, the patient should be informed in advance.

A more restrictive approach would be along the lines of the ISMHO/PSI Suggested Principles: the e-therapist might know the patient only by a pseudonym, but a local backup who knows who the patient is should be involved and could try to hospitalize the patient involuntarily if necessary.

Alternatively, it could simply be considered unacceptable for e-therapists to treat anonymous patients. That, however, would not demonstrate the flexibility that Yellowlees encourages.

Practically speaking, the patient identity problem will be solved on line to a large extent as it is in person: as a byproduct of having to pay for services. To pay, the patient will need, at least in the near term, a credit card and, unless it is stolen, the credit card will identify the patient. Stofle takes checks and uses PayPal (www.paypal.com), so a checking account can be the source of funds, but a checking account also identifies the patient, and PayPal divulges the name of the payor to the payee. Online, one member of a household could pose as another, since access to a credit card or a checking account might be shared, and such a deception might be impossible in person, but at least the household would be identified.

Security may be worse on line in some ways, but may be better in others. Communicating using a Web-based Secure Sockets Layer (SSL) system is both secure and, since most Web browsers have SSL built in and no extra software needs to be installed, user-friendly. Encrypting transmissions from one person to another is a challenge because the "key" must also be transmitted (and therefore itself vulnerable to interception). When one encrypts information for one’s own use, however, neither the information nor the key needs to be transmitted, so the process is much more straightforward. And encrypted patient files may be more secure than paper files locked in a desk.

As Yellowlees advises, e-therapy must pick up where traditional therapy leaves off. It may, however, offer even more potential than he envisions. The issue of anonymous patients has been addressed above. What about answering questions "in a booth at a fair"? That smacks of reading tealeaves more than modern evidence-based best practices. Yet, as Kennedy discusses, access to information on line has clearly been a boon to patients. Patient may now Ask Jeeves (www.askjeeves.com), and Pies is an expert in a sort of virtual booth. Pies does not, however, respond in "real time." If someone like him did, would that not also be a valuable service? AmericasDoctor (www.americasdoctor.com) used to make practitioners available in chat rooms. What about an AmericasExpert? What matters is not the setting (hospital, fair, or Internet), but the quality of the service.

It was the Rajah, awakened from his nap by the noisy argument.

"How can each of you be so certain you are right?" asked the ruler.

The five blind men considered the question. And then, knowing the Rajah to be a very wise man, they said nothing at all.

"E-therapy is very large," said the Rajah kindly, as he sat down at the computer. "Each man touched only one part. Perhaps if you put the parts together, you will see the truth. Now, let me surf in peace."

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About the Author

Robert C Hsiung, M.D., is Deputy Medical Director of the Student Counseling and Resource Service at the University of Chicago and an Assistant Professor of Psychiatry. As 'Dr. Bob,' he runs a Web site out of the University of Chicago that provides a wide range of mental health information.

ISBN: 0-393-70370-3
October, 2002
Paperback, 250 pages