Internet Psychotherapy: A Trend Waiting for Science and Ethics to Follow
By Abimbola Farinde, PharmD., MS (Walden University, Minneapolis, MN)
Submitted to theClinical Psychology Associates Articles and Archives
Accepted for publication with revisions 11/12/12. Published 12/16/12 Ernest J. Bordini, Ph.D., Editor
2121 NW 40th Ter. Ste B, Gainesville, FL 32605 CPANCF.COM
All rights reserved Clinical Psychology Associates of North Central Florida (352) 336-2888
Progressive changes have occurred in the field of psychotherapy including expansion of the range of clinical practice settings in which psychotherapy is delivered. Law, science and ethical guidelines have lagged. An emerging trend has been the use of technological, internet, and computer-based technologies to gather data, provide information, to aid in evaluation, and to provide psychotherapeutic services.
For quite some time the importance in psychotherapy for developing a strong relationship, establishing rapport, and forming an alliance with a client has been recognized (Brew & Kottler, 2008). The therapeutic relationship is important in facilitating compliance and tolerance of the difficulties of personal change. Even cognitive behavioral therapy depends on a good working therapeutic relationship (Leichsenring et al., 2006). The development of trust and a safe therapeutic alliance is considered to be an essential component for change (Ivey, Ivey, & Zalaquett, 2010).
The internet allows for people to “transcend time and geographic boundaries” to create new forms of human activities in the virtual world (Pergament, 1998, pp. 233). Provision of internet-based psychological services is a relatively novel development in the history of psychotherapy. The possible convenience and advantages for individuals residing in very remote areas is often-cited. Internet delivery of services may also benefit homebound individuals, those with significant transportation challenges, and those who suffer from fears of leaving their home or have difficulty with in person face-to-face interactions.
Health care cost pressures and the profit-motive may also contribute to interest in internet delivery of services. The risks and benefits of insurers utilizing low cost providers to penetrate an otherwise well-served community raises significant professional, ethical, and economic issues. Without the restrictions imposed by geography more and more managed care companies would be able to provide psychotherapy (Pergament, 1998).
While the adequacy of outcome measures to truly capture the differences and range of impact of face-face interaction and the therapeutic relationship delivered live versus on-line empirical studies have been conducted on internet-based treatment, some studies have shown improvement in depression ratings relative to a waiting-list control group (Kesssler et al., 2009).
Critics raise concerns about devaluation of the richness of traditional therapy and the interpersonal therapeutic relationship. Critics also raise significant ethical and legal concerns (Pergament, 1998) including jurisdiction, oversight, and maintenance of confidentiality and security. Professional organizations have raised ethical concerns involving use of internet technology to treat clients (American Psychological Association, 2010). Challenges involve conflicting opinions about which laws or even jurisdiction may govern a psychotherapist’s provision of services or which protect clients from harm (Pergament, 1998). Since online psychotherapy is a relatively new concept there is a risk that there would be a diminished level of care, documentation and security (Stricker, 1996).
Informed consent would likely require some disclosures that there is still much not fully understood both in terms of the efficacy of on-line psychological assessment or treatment and the laws and regulations governing it. Further concerns arise from the handling of emergencies or the potential lack of familiarity of an-online provider with local resources and providers for consults.
Certainly the science and ethics of providing internet therapy services will need to consider the ability of on-line methods and technology to challenge or capture human intricacies and nuance of what is ultimately a very personal interpersonal process and endeavor. Risks that the loss of nuances that can be important in sometimes complex diagnostic differential can become compounded by subsequent failure to provide the right treatment for the right diagnosis.
The risks of reduced efficacy, premature termination, or the perception that otherwise effective face to face services because of what may be lost for the convenience of the internet are probably not yet well-understood. Individuals may not pursue a more traditional face-to-face therapy due to a bad internet experience or the unsuitability of the internet for that specific problem or individual.
While the science including outcome and process measures may need to catch up to the technology and financial press to provide more healthcare for less, it is likely the concept will continue to grow and that wider and more convenient access to psychotherapeutic interventions may the potential will further expand greater mental health awareness and allow access for individuals who may face obstacles to traditional face-to-face therapies.
In response to much interest in the topic, the American Psychological Association joined with the Association of State and Provincial Psychology Board and the American Psychological Association Insurance Trust to create the Joint Task Force on the Development of Telepsychology Guidelines for Psychologists. The task of the group is to develop guidelines that will help psychologists to meet and understand ethical, regulatory, legal and other practice issues in telepsychology. Information about these efforts is available at: Telepsychology Task Force Progresses.
American Psychological Association. (2010). Ethical Principles of Psychologists and Code of Conduct. See: http://www.apa.org/ethics/code/index.aspx
Brew, L., & Kottler, J. A. (2008). Applied helping skills: Transforming lives. Thousand Oaks, CA: Sage Publications, Inc.
Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing and counseling: Facilitating client development in a multicultural society (7th ed.). Belmont, CA: Brooks/Cole, Cengage Learning.
Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., & ... Peters, T. J. (2009). Therapist-delivered internet psychotherapy for depression in primary care: A randomised controlled trial. The Lancet, 374(9690), 628-634.
Leichsenring, F., Hiller, W., Weissberg, M., &Leibing, E. (2006). Cognitive-Behavioral Therapy and Psychodynamic Psychotherapy: Techniques, Efficacy, and Indications. American Journal of Psychotherapy, 60(3), 233-259.
Pergament, D. (1998). Internet psychotherapy: Current status and future regulation. Health Matrix: Journal of Law-Medicine, 8(2), 233.
Stricker, G. (1996). Psychotherapy in Cyberspace. Ethics & Behavior, 6(2), 175.