Online therapy - A minefield of treasures

An interview with John Grohol, President of the International Society for Mental Health Online (ISMHO)

By John Soderlund

What are the key issues you think therapists should consider in deciding whether to set up an online presence to complement their practice, either to conduct therapy online or simply to market themselves?

Those are two very different things with what I hope are two very different goals. Every therapist should have a Website; there's no excuse in this day and age not to have one or a few pages describing who you are, your background, your approach to treatment, directions to your office, office hours, office contact information, and even a picture.

Online therapy, or e-therapy (a term I coined), is a new and exciting area of practice that is growing by leaps and bounds. However, some of the legal issues surrounding practice online have not been fully decided, so it is important for a therapist to ensure they understand their state or country's licensing or registration laws.

What are the technological options available to therapists in respect of online therapy and what would you recommend they use (i.e. e-mail, chat, video-conferencing)?

There are four main methods of doing online therapy or counseling:

- E-mail

- Chat

- Web-based messaging

- Video-conferencing

E-mail is the simplest and most prevalent in use today. Everybody who's on the net readily has access to e-mail, making it easy to use. Because e-mail is asynchronous, both people don't have to be logged on at the exact same time to have a conversation, making it ideal for introspective replies. The downside to e-mail is that it is an insecure medium, making it largely inappropriate to actual e-therapy. That's not stopping people from using it today in this fashion, but it is not the ideal modality. People share e-mail accounts, e-mail resides on external, commercial servers, and e-mail can be easily hacked. e-mail can be encrypted (i.e. muddled by use of a code unreadable to anyone without the code's key), but because such technology is not built into most people's e-mail software, it is rarely used and somewhat difficult to setup.

Chat is also used, although not nearly as widely. Because both people have to be logged in at the same time, it requires more scheduling and the time involved is very similar to real-time, except that time it taken up by typing. If you're not a good typist, and neither is your client, chat is probably not a good option. Make sure you if you use chat, you either use an instant messenger application (which is fairly secure), or a private chat room on a system you know and trust. Chat logs, like e-mail, can be maintained by the system administrator, making security a concern also.

Web-based messaging is something newer and just catching on. It allows a client and therapist to interact in a secure, Web-based environment on a trusted, third-party host. You'll see and hear a lot more about these kinds of services in the next year, because they offer the best of e-mail (asynchronous communication) while ensuring security. It operates much like Web-based e-mail, except that it is secure.

Video conferencing is the most expensive option here -- in terms of cost, time, and setup. Equipment in this area has traditionally been proprietary, with incompatible formats, although that has changed in recent years. Internet-based video is still typically slow, small, and of low quality. While this technology is improving every year, most people still do not own a Webcam or similar device, and fewer still are comfortable with the idea of sitting in front of a camera.

It is a very different feeling from having a client sit in front of you in the same room, for both the therapist and client, and takes a fair amount of skill and training to do well.

Much is said about the inadequacies of online therapy because of the absence of physical cues. How do you respond to this?

A lack of physical cues is nothing new in providing services to help people. Suicide helplines are the most-used crisis intervention method by people who are actively suicidal, and that is done entirely over a telephone. While granted you do have a person's voice, you're still missing those important visual cues. So people have been helping people without the visual cues for decades.

So what makes up for the lack of visual cues? Three things - convenience, cost, and the disinhibitory factors related to online communications. Convenience is a no-brainer, because through e-mail or Web-based messaging, a client can write whenever a new idea or emotion or something they're grappling with strikes them. Any time, day or night.

Cost can also be decreased as some therapists choose to do this as their main modality of practice. No more office costs and the overhead is drastically reduced. The last factor is the most important, however. People's communications on the Net are more disinhibited than they are in real life. I can speak of issues of importance and concern to me, as a client, much more freely, openly, and quickly online than face-to-face. Clients get to the point in e-therapy in the first correspondence. There is no need for sessions upon sessions of getting to know one another and feel comfortable with each other before the real therapy begins.

 

Continued on the next page...

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