American Psychological Association

109th Convention
San Francisco, August 24-28, 2001

Photo: (Left to Right) Kenneth Weingardt, Storm King, Jason Zack

2045 E-Therapy: Current Issues in Behavioral Telehealth

This report posted to the Current Topics and TherapyOnline list-servs

APA CONVENTION REPORT #2
Saturday, August 25, 2001

Asynchronously "live from San Francisco"-

Hi, here again from beautiful, sunny San Francisco...

"Psychology Online-- Current Issues in Behavioral Telehealth"

This presentation highlighted some of the issues involved in approaching online services from a business and service delivery perspective. A basic premise, however, was that many services being offered now or in the near-future, do not fall into easy categories nor do they necessarily fit people's preconceptions of what "online therapy" or "E-therapy" is, or how practitioners are actually providing services.

Last year John Grohol, Psy.D., known for his pioneering work with Mental Health Net, his work with leading telehealth providers, and a wide array of online mental health activities, obliged the audience by explaining what "E-therapy" IS... This year we had the pleasure of learning, "What is E-therapy NOT?"

Some of the things that eTherapy typically does NOT provide, according to Dr. Grohol, are traditional psychotherapy or counseling, nor treatment of most mental distorders, without a face-to-face evaluation. [My own paper on the Technical Problems with Online Psychotherapy addresses some of the reasons why transposing traditional therapy online is problematic.]

After an overview of the many modalities available online, both synchronous and asynchronous (including everthing from e-mail and chat rooms through video conferencing and VR treatments for anxiety disorders), Dr. Grohol turned to some of the many potential benefits which are so compelling as to fuel continued efforts to make these services widely accessible. Some of the benefits include confidentiality/privacy (with adequate protections!), affordable costs for both providers and consumers, convenience ("You can e-mail a dream" while it's fresh!) and a format which lends itself towards goal-focused treatment, with less chit-chat, more direct (dis-inhibited) discussion of what's really at the heart of daily problems. Dr. Grohol noted how in fact, e-communication is widely used also, as an adjunct support, rather than as the entire basis for treatment.

Dr. Grohol then discussed the risks inherent in online work, highlighting the lack of nonverbal cues, even for those who employ emoticons and are well-versed in e-mail. Also mentioned were legal/ethical issues, having "mostly to do with licensing" [but also involving some basic tenets such as "informed consent", emergency contact issues, etc.]. While Dr. Grohol was clear that he believes "we cannot hold a higher standard" for online than offline work, he did acknowledge that assessment of problems online "can be more difficult", and moreover, there remain serious "training issues" at this time, where very few people have the benefit of graduate training and/or continuing education specifically addressing the unique nature of online work.

Dr. Grohol, finally, looked at what's become of the dot-coms in recent months-- something discussed in more detail at yesterday's symposium on Behavioral Telehealth. (That report is at http://www.fenichel.com/ismhopanel2001.shtml) As for the future of the e-health *industry*, Dr. Grohol sees "consolidation & growth" along with development of training and treatment standards ("emerging even as we speak!"), and a gradual adoption of "evolutionary technology" as broadband access becomes more accepted and accessible and other technological advances shape our lives as well.

Storm King, one of the earliest and most prolific writers about online communication, addiction, and treatment (and a co-founder of ISMHO), gave a presentation entitled,

Online Therapy - Training and Quality Control Issues

After explaining that his name is real (from native American origins), Storm King went on to reiterate that "E-mail and chat room therapy is not 'therapy', it is 'e-therapy'."

Fortunately, rather than just focusing on the terminology, he went on to discuss how online work carries with it "a unique set of positives and negatives." The amount of online work being done in fact continues to grow, which he attributed squarely to consumer demand.

While presenting an historical overview suggesting how in fact the emergence of "technotherapy" (Kelley, 1994) has "fit the bill" for a multitude of people, King also stated categorically that "If the practitioner is not intimately familiar with the nuances of text-based relationships, the potential to do more harm than good exists". On the other hand, competent, sensitive online work has been demonstrated to be very effective in the treatment of social anxiety, and other related difficulties. He cited Craig Childress' (1998) observation that online consultation may also be beneficial for those whose presenting problems are "non-clinical".

King went on to describe the power of online communication while debunking the notion that one is not really relating to others online. ("You cannot have a relationship with 'nobody'"). Also, since one is missing many cues, and "the mind abhors a vacuum" it becomes very easy to project attributes into messages, which may be accurate, or may be distorted. Factors such as the "mood congruent effect" were described. (E.g., when one comes in tense from a dispute it is possible to interpret a benign or friendly message as hostile, etc.) Also, the increasingly well-recognized phenomenon of "disinhibition" was discussed.

One example where projection and distortion may be observed quite commonly, is that of online romance. When Mr. King asked "How many people know someone who's had a cyber-romance" about 80% of the audience raised their hands. This, he noted, was a phenomenon of great popularity, despite the fact that "99% of cues are missing", requiring use of internal projection. As another example of how nuance and mood can be easily mis-read, he offered the case of an e-mail message saying "I disagree", which can give rise to "all sorts of potential reactions".

Looking more closely at disinhibition, this too was seen as having both positive aspects (e.g., quicker self-disclosure) and negative aspects (e.g, acting out). King reviewed several of Walther's (1996) classic descriptions about how online correspondence may at times lead to idealized impressions of others, with individuals constructing mistaken attributes, and in turn selectively self-presenting. Online, emotional responses may be easily and unintentionally triggered by ambiguity and projection. [That last sentence is mine!]

On a more practical note, King also noted the inherent nature of text-based work as being dependent on not only Internet or computer skills, but writing skills, too. "If you are not adept at this medium, you have no business doing it". Even aside from doing things like therapy or counseling, but in everyday social interactions, it is the case that "typing off the top of your head" sometimes comes off not as conversational, but as "colder and more impersonal than the author intended." He cited the 1999 work of Azy Barak, who described a "unique mechanism" we employ in reading and writing email exchanges.

Finally, Mr. King spoke as to the unique ethical issues which have arisen in response to both the benefits and risks of e-Therapy, in particular. For example, a client now must be at least "partially responsible" in terms of maintaining confidentiality (given that text-based messages reside not only with the "e-therapist" but also on the computer of the client). Aside from confidentiality, issues of legal jurisdiction are unclear, while ethical dilemmas may become stickier with such questions as "when does a professional relationship exist".

Interestingly, at this point two comments from the mostly savvy audience were made, the first suggesting that unless records sent to the client were "read-only", this opens the door to liability issues, and the second explaining that it is possible for someone to change what was written and use it as evidence of malpractice.

Storm King next took a look at the global nature of online work as well as the importance of thinking about such serious matters as suicidality assessment. On one hand these are very real and vital concerns. OTOH, if the risks and preparation are seen as too great to proceed at all with providing *any* accessible online mental health services, then "who will be available" for those in need? (King, quoting from Gary Stofle) If we are going to proceed, which consumers seem to be demanding, then it is very important that those who do work on line be adequately educated and well trained.

Some of the suggestions for training include use of Sample cases, suggestions for a range of responses to typical online communications (e.g., "I think you might be missing the point"). Of major concern are the crisis management issues mentioned earlier, such as assessment of suicidality, and effective, ethical response. Some important things to consider when doing online work include obtaining real-life contact information, having a release to contact a primary care physician if necessary, and providing confidential communication (e.g, use of electronic signatures). [Not everyone is in fact suitable for online treatment, which is the topic of a recent paper by ISMHO's Case Study Group.] King noted also that things are not always as they seem when presented with suicidal content online. Disinhibition can play a big role here. But "difficulties with online assessment make it hard to know how severe the client's pathology may be."

Finally, Storm King re-iterated some of his favorite definitions of "anarchy", which is how he conceptualizes the Internet, underscoring the basis for his belief that the boundary-less Net is something truly unique. He ended with some words of advice: "The Information Revolution rolls on... don't let it roll over you."

Kenneth Weingardt, Ph.D., executive of Here2Listen.com, participant on NIH grant committes, and now involved in the business of "e-learning", presented on

The Business of Online Mental Health Interventions

Dr. Weingardt began with a broad overview of the state of E-therapy, first defining it as "electronically mediated one-on-one interaction with a psychologist or other mental health professional". He went on to discuss various business models now being seen, ranging from the private practitioner with a website (of which there are many) to private-practice e-therapists, to large companies.

Billing for services can take the form of fees paid by the minute, per response, or a wide variety of other pricing options. Some sites (one of which was discussed) may bill for "prep time" or even research and legal fees, and so one should definitely research a company before agreeing to any unusual payment contracts. Dr. Weingardt mentioned how Martha Ainworth's Metanoia site offers consumers a "comprehensive independent consumer guide".

Moving to larger-scale models, such as the e-Therapy clinics, Dr. Weingardt noted how the only survivors are adopting a "small business model" as opposed to large-scale dot-com projects driven by venture capital. One of the "Big 3" companies (his own, Here2Listen.com) was "headed towards bankruptcy" while "ETherapy.com just went down last week". So who will survive? Those who adopt a realistic business model and who offer three key characteristics:

Many therapists available
Thorough screening of credentials
Rigorous security safeguards

Other variations proving successful, within the small business model, include maintaining a directory, basing services on fees (transaction or registration), and offering "a virtual office space" with many automated functions and productivity helpers.

From a business perspective, what are some problems? First of all, "it's not scalable" -- i.e., you can't reach a million people no matter how well you market, with only 100 therapists, where maybe 5 will be online at any given time. Secondly, the profits are very thin, given the costs of security and infrastructure. Also, contrary to the assertions of some, "It's an unproven market. Sure, there is a need, but people don't utilize it... Who's to say they want your services?" Moreover, there are liability issues. Although no big cases have emerged (yet) Dr. Weingardt noted that within his dot-com, "there's always the thought--it's not a question of if we'll be sued, but when...".

Next Dr. Weingardt mentioned some of the trends which bode well for e-business. In California there is a continuing trend towards providing services for substance abusers online. Sometimes the product may be software-based, rather than human-intensive. One company, copewithlife.com, is said to have developed an "empirically validated, self-paced, self-help treatment for mild to moderate depression". It uses interactive voice response (IVR) technology to check severity of symptoms, sggest appropriate exercises, and monitor progress. (Payable in full, in "4 easy monthly installments". NB- This is NOT an endorsement!)

Another successful business model is tha of Epotec, who call themselves "the behavioral health care connection" and who are doing quite well by going after the EAP market. They now have as clients over 40 Managed Behavioral Healthchare Organizations, with services available to over 700 companies. A major focus is 2ndary prevention. They offer "secure, anonymous, self-paced, interactive programs".

So what does the future hold? Dr. Weingardt sees a continuation of the "historical stronghold" enjoyed by private pratitioners engaging in "e-therapy". He sees a great deal of potential but, agreeing with an earlier comment by Dr. Grohol, noted that "bandwidth is the issue" insofar as some aspects of online work. In terms of big dot-coms, at the moment there simply is "no more venture capital", though small business can grow slowly and steadily in this environment. While some larger providers remain strong (such as HelpHorizons), he also sees an enormous, emerging market for "self-paced, self-help web applications". He is very excited (and reported that his excitement is shared within NIH) by "the delivery of psychological or psycho-therapeutic content via the Internet". How do we break out of boxes, blend modalities, and create new opportunities from the options before us at this moment in time? "Imagine the possibilities..."

Jason Zack, Ph.D., former director of R&D for the now-defunct etherapy.com, currently with Ampersand Group, presented on the

Technological Issues in Online Counseling

Dr.Zack began, as fate would have it, by asking the same question I was going to ask 2 days later at my own presentation: How many people want to know "What's a browser?". Well, as I've observed myself in the past year, that question is asked much less. This audience clearly knew (with perhaps one exception).

Dr. Zack went on to present a basic outline of initial considerations for those who contemplate any type of online work. As a general rule of thumb, he suggested that

Technology befriends those with

time
money
patience

Of course, he said, "if significantly lacking one, you *may* be able to make it up with the others". He continued to present some other formulas regarding functions such as "frustration", for example, with a platform. He views a continuum of technological platforms, and sees them being used in different ways from the "first generation corporate suites" to newer generations, which are "not as fancy, but still around".

In terms of individual practitioners looking for the best personal option, Dr. Zack noted that there are also compromises available, such as sites which offer free templates and basic email and office management tools. Some of these are a trade-off, however, as they are relatively easy to get up and running but one lacks control and also absolute knowledge regarding privacy and other important issues.

Also as technological options for those who want to work online, ther are a number of what he termed a la carte tools to help with security and privacy. He mentioned that some services (e.g., Ziplip.com) offer encrypted e-mail, which stays on the site server, password-protected. For Chat, similar services exist, such as LivePerson.com (formerly Humanclick) and MercuryPrime.com. Video offerings include software such as iVisit, NetMeeting, and CU-SeeMe. (HelpHorizons uses NetMeeting.)

As for a web page (with "How do I make a web site" overtaking "What's a browser" in my recent experience!), Dr. Zack noted the wide range of options available ranging from a simple business-card style page and the domain name BobTherapist.com (or whatever), to very elaborate, theme-organized custom-design sites. In truth, there are only 4 requirements, which he laid out: (1) A domain name, via a registrar (2) a host, with a server (3) site contents, such as graphics and text, and (4) functionality, so that when it's all put together, it works. Required equipment includes hardware (computer, webcam, etc.), software (e.g., a browser such as IE 5.0, client software for various media, etc), security (such as a firewall and PGP), and a connection to an ISP. Of course, it's getting easier all the time. "With improvement in laptops, not only can the client be mobile, you can too." An audience member asked the relevant question, "Can video be encrypted?". Answer: No.

Other aspects of technology include the ability to easily do "virtual office administration", including scheduling, case management, billing, and client records. [APA's Director of Technology Policy and Projects spoke at the 2001: Cyberspace Odyssey panel about how new regulations are going to virtually demand that paper records be replaced with online filing.] Finally, services such as Paypal now allow very easy and inexpensive payment for just about anyone.

At the end of this presentation, the panel was opened to questions from the audience. The first was, "What cues do consumers use to make a choice of [online] psychologist?". Dr. Weingardt immediately replied "Price!". Dr.Grohol agreed, noting that one way of attracting business may be to allow the client to have one very low-cost consultation (e.g., $5 USD) in order for them to try the service and see what it entails. Dr. Zack added that having a video clip on one's web site makes a difference, and Dr. Grohol commented that just having a photograph can give a better sense of the therapist and help a client feel comfortable with a choice.

Another QUESTION: "What is the most popular form of online mental health services?" ANSWER: E-mail, by far, about 95% at HelpHorizons. [This closely matches a recent survey by APA, as well.] Aside from the ease and convenience, it is also seen as being the most cost-effective.

Last Question: Suggestions for limiting liability?

Answer: Practice only what you are competent [and licensed] to do, and stay within ethical/legal boundaries, such as they may be.

Current Topics in Psychology | APA 2000: Online Therapy | More APA 2000 | APA 2001 | 2002 | 2003

American Psychological Association

109th Convention San Francisco, August 24-28, 2001

109th Convention
San Francisco, August 24-28, 2001