E-therapy is hardly a bargain

We’ve got e-commerce, e-banking, e-pharmacy and of course, e-mail. So why not e-therapy?

Actually, there are lots of reasons why not. But that’s not stopping the latest trend in electronic medicine – virtual therapists, some 150 to 200 of them, who offer assessments, generic advice and even ongoing individual psychotherapy online.

The mere idea of sending private thoughts into cyberspace to someone who may or may not be a qualified therapist, who probably isn’t licensed in the state where you live and who can’t see the tears in your eyes when you talk about your mother is enough to send mainstream therapists around the bend.

And the whole notion might indeed be silly except for two things. One: Some people actually prefer confiding in a computer. And two: There’s a huge unmet need for mental health services in America, and Net-based services might help meet it.

Consider depression. Roughly 18 million Americans suffer from it and only two thirds get treatment. Indeed, a recent Harris poll showed that among 60 million Americans who used the Net last year to search for health information, what they most wanted to know about was depression.

There are several ways computer technology can help, and the least controversial is by offering diagnosis and assessment. At www.mediconsult.com, for instance, you can take a 10-minute test to help interpret your moods. I took it, and it’s not bad – on a par with standard questionnaires in self-help books. In other words, it might help clarify whether you need treatment – but obviously can’t provide warm, supportive feedback.

Another online assessment tool is being developed by Healthcare Technology Systems (www.healthtechsys.com) and is already available by telephone (1-800-813-2364). I took this, too, and for some reason, found it more disconcerting to punch in answers on the phone pad than to click on a computer form.

Still, it’s not assessment that’s really controversial in virtual psychotherapy, it’s the idea of being analyzed by a therapist you can’t see. This drawback might change with the advent of video-audio transmission via the Net.

Many therapists draw a distinction between using e-mail occasionally to stay in touch with patients they already know and conducting therapy between strangers on the Net.

Dr. Russell Lim , a psychiatrist at UC/Davis in California, uses e-mail in the former way. “I’m a pragmatist,” he says, and is quite willing to try “whatever works in real life.”

He uses e-mail with a patient who lives far away and comes in every other week, just as some therapists use the telephone to stay in touch when necessary. “Without the Internet connection,” he says, “the point might be lost.”

Other therapists, like University of Chicago psychiatrist Dr. Robert Hsiung (www.dr-bob.org/tips) haven’t used the Net yet for individual counselling, but do run virtual self-groups. For instance, Hsiung puts patients with similar problems in touch with each other and is excited about the “potential to do something more directly clinical online.”

But when virtual contact is the only or the primary mode of therapy, numerous questions arise, including the issue of online confidentiality.

Hsiung, for instance, acknowledges that “e-mail isn’t totally secure or confidential. You hope people realize that, but maybe not.” E-mail is fine for innocuous things like re-scheduling an appoinment, he says, but patients should “think twice before sending out sensitive information.”

But the “biggest drawback to online versus real life [therapy] is you don’t get the nonverbal cues, which are a big part of communication,” acknowledges psychologist John Grohol, who runs the mental health section of drkoop.com.

That means the therapist can’t detect a telltale whiff of alcohol on a patient’s breath, or the dirty clothes and hair of someone who’s too depressed to bathe, adds Dr. Ronald Pies, a Tufts University psychiatrist.

And if the therapist and patient have never met, it could be downright dangerous to perform therapy online, warns Gerald Koocher , chief psychologist at Children’s Hospital in Boston.

“The difficulty is when you don’t know who you’re dealing with or what the reality of the situation is,” he says, which is particularly crucial for patients who may be suicidal.

“Do you know who they are and where they are? Do you know how to get emergency services to them? If someone is in your office, you can call the police. If you’re on the phone and you know where they live, you can call intervention for them. If they’re on the Net, you may not know who you’re talking to or where they are or what the nearest emergency facility is.”

Patients, of course, are equally “blind” as to who an Internet therapist really is. “Anybody can hang up a shingle on the Net,” says Pies, which raises the risk of both bad therapy and fraud.

Moreover, psychiatrists, psychologists and social workers are licensed state by state. If if you were harmed by online therapy offered by someone in another state, where would you file a complaint or sue for malpractice?

Even www.metanoia.org, a website that offers lists of online therapists and does some checking of credentials, admits on its site that “if something goes drastically wrong as a result of your interaction with a therapist online, at the present time, you probably have little or no legal recourse against the therapist.”

In fact, metanoia concedes that e-therapy is not really therapy, though it says “it can definitely be therapeutic.”

Despite the serious drawbacks, some believe cybertherapy is an idea whose time has come.

“I personally think this technology has the most potential to improve the rates of treatment and overall quality of treatment of any technology since antidepressants,” says Dr. Joshua Freeman , a psychiatrist at UCLA and medical director for mental health at mediconsult.com.

As it is now, he says, “the system is failing if it insists on providing a certain type of treatment that most people don’t get.”

Besides, a number of studies suggest that some people feel more comfortable – and are more honest – when they’re “interviewed” by a computer rather than a human, especially about sensitive issues.

A 1987 study by University of Wisconsin researchers, for instance, examined the scores of 150 psychiatric patients on diagnostic interviews given both face to face with a trained interviewer and on a computer. A significant majority “liked the computer interview better and found it less embarrassing,” the researchers concluded.

Other studies compiled by Dr. John Greist, CEO of Healthcare Technology Systems, suggest that people may feel more comfortable confessing problems with alcohol, drug or sexual function to a computer because they can think before they answer and don’t have to worry about keeping a professional waiting. People with “social phobia” may also prefer a computer.

So where will all this lead? Let’s hope not too far.

Okay, online self-diagnosis tests are fine. And in a pinch, an online shrink might be better than none, though it’s inappropriate if you’re seriously ill or suicidal.

But basically, therapy is a complex, subtle human endeavor that would lose something essential in cyberspace.

In other words, I side with psychologist Barry Schlosser, who runs a consulting firm in New Haven called Clarity Consulting Corp. E-therapy, he says, is not “ready for prime time.”<


www.healthtechsys.com (for information oncomputerized mental healthassessments)

www.mediconsult.com (for mental health assessment – click on depression, then on “mind health tracker”)

www.drkoop.com (for information on depression and other mental health problems)

http://mentalhelp.net (for information on mental health problems)