From Couch to Keyboard: Cyber Therapy Booms

Medically Reviewed by Jacqueline Brooks, MBBCH, MRCPsych
From the WebMD Archives

Feb. 22, 2001 (Washington) -- It's a far cry from Freudian psychoanalysis on a couch, but, nonetheless, more and more Americans are using the Internet to access mental health counseling.

Web sites for emotional problems abound with trendy sounding name like "Headworks," "Conscious Choices," or "The Problem [email protected]". Another e-counseling venue, "Marriage Matters," features a cyber shopping mall and a pressroom.

It's estimated they get millions of hits -- many from the estimated one in five of us suffering from mental illness, and all at the price of $30-80 per hour session, which can be much less than traditional psychotherapy. But when all the emailing and chatting has been said and done, has anything been accomplished? Or have users actually been harmed by the process?

"The benefits are that millions of people are getting good information that they very likely would not access if it wasn't for the Internet. ... [The] bad news is that there is information out there on the [Internet] that does not promote good health," Michael Faenza, MSSW, president and CEO of the National Mental Health Association, tells WebMD.

Last week, the NMHA sponsored a 1-day meeting here, which included key mental health organizations and Internet specialists, to address some of the problems that online counseling has spawned. The major issues include varying quality of information on the sites as well as their objectivity (i.e., whether the offerings are unbiased research or simply disguised commercial material).

Confidentiality of e-discussions between therapists and patients also must be addressed, so people will feel free to reveal their innermost thoughts online, according to mental health professionals attending the event. Perhaps the key dilemma is how to protect these particularly vulnerable people from being exploited by fraudulent operators.

At the end of the day, the group agreed that in addition to all of these proposed reforms, there needs to be something like a "Good Housekeeping" seal of approval, so patients know what they're getting. Several online codes of ethics already exist, although it's not clear how many sites are adhering to these quality standards.

"Like with everything else in the world, there are charlatans out there, ... [but] the seller of a product or information wants to be perceived as credible," Mark Helmke, senior director of public affairs for NMHA, tells WebMD.

Although the Food and Drug Administration has made an effort to crack down on illegitimate online pharmacies that prescribe drugs without proper medical supervision, apparently no federal regulation specifically targets these mental health web sites.

And bad advice may come at a high price.

"Down the road there are all sorts of possibilities, and I'm pretty excited about some of them, but it's pretty much buyer beware at this point," says Ronnie Stangler, MD, chairwoman of the information technology committee of the American Psychiatric Association and a psychiatry professor at the University of Washington in Seattle.

Stangler tells WebMD of one horror story about a woman being treatment for depression. When the patient later turned to a credible-sounding web site for advice, an online psychiatrist told her that her doctor's diagnosis was wrong. It turned out the web site was sponsored by a drug company with its own agenda.

"Obviously, this [online] physician knew very little about the patient, ... so it's potentially very disruptive," Stangler tells WebMD.

Other mental health specialists are also dubious of meaningful therapy without direct contact.

"There's no accountability, no responsibility. ... It's very easy for a private practitioner [on the Internet] to hang out a shingle," Jerilyn Ross, MA, LICSW, tells WebMD. A participant in the meeting, Ross says that when she treats a patient for an anxiety disorder, she's liable. "But on the [Internet], I can open a site and say to people with phobias, 'Go jump off the balcony.' I can say anything," says Ross.

Still, online counselors like Judith Schwambach, PhD, of Evansville, Ind., feel they offer services of special value. "[We offer] the convenience of doing so, the anonymity, especially if these people suffer from phobias ... so they can just sit at their desk ... or wherever they have a computer and have the privilege of contacting a doctor," Schwambach tells WebMD. Computers also can help overcome the stigma of being treated, she says.

Schwambach offers both online and office counseling at $90 per hour for either service. "I welcome my people to check me out -- that I really am who I say I am," she says. However, Schwambach acknowledges that Indiana has no formal certification process -- only a PhD is required to do counseling. If there were a rigorous accreditation process for online counseling, Schwambach says she isn't sure she'd continue her 8-year practice.

Online counseling tends to focus on problems like depression, marital or sexual issues, and anxiety. Because of the distance between the patient and practitioner, it may be more difficult to handle emotional crises such as suicidal or violent tendencies.

Psychologist Richard Sansbury, PhD, of Calverton, Md., admits online treatment doesn't work well for those who are "paranoid" about private discussions over the computer. "They can't deal with the uncertainty that email exchange involves," Sansbury tells WebMD. That type of patient, he says, can obsess over what kind of person the therapist is, or whether the individual has a valid license.

"We are pioneers," says Sansbury. "There is much more not known than what is known. That's right on my web site: Before you contact me, understand this is an experiment."