As clinical social workers venture into the 21st century, they see changes in computer technology occurring at a rapid pace, offering diversity in the way we provide mental health services to patients and their families. For years we have conducted psychotherapy services in an office or hospital setting, over the telephone, and even in the private setting of a home bound patient. Now there is an emerging opportunity to provide psychotherapy services via the Internet. These Internet services have been referred to as e-therapy, online therapy, cybertherapy and Internet counseling. Whatever term is used, many clinical social workers are eager to use the Internet as a tool for communications with their patients, while others cautiously wait at the starting line to see what the finished product may look like.

NASW’s clinical social workers are asking, "Should I provide psychotherapy services over the Internet?" The answer to this question is not a simple one. Many argue that the information and support services offered online are not traditional psychotherapy. Further-more, there is a lack of evidence-based re-search to validate the safety or value of online therapy or prove that a face-to-face intervention is better than a script-to-script intervention. More outcome studies are necessary to determine the success of the treatment offered online before valuing it.

There are both advantages and disadvantages to providing psycho-therapy services on the Internet. Clinical social workers should consider all of the benefits and risks involved before making a decision to engage in this process.

Advantages

• Makes supportive services accessible to patients and their families in rural areas and those who are homebound and have access to a computer and the Internet.
• Provides anonymity, allowing patients who are reluctant to seek a face-to-face interview to obtain services.
• Encourages self-expression and removes the social stigma associated with seeking mental health services. Patients may feel more comfortable opening up and revealing sensitive issues.
• Provides supportive services to patients who may be experiencing temporary mental distress or who are high functioning.
• Is convenient to use and is accessible 24 hours a day.
• Can be an inexpensive way to deliver and receive services.
• Can be appropriate for screening and follow-up care.
  

Disadvantages

• Does not ensure confidentiality. Firewalls and other forms of security measures do not always protect privacy. Site visits and information may be collected and tracked by e-commerce and others. This also opens the clinical social worker to high risk of allegations of malpractice based on breach of confidentiality.
• Creates a high potential for misunderstanding of scripted information, which can result in malpractice exposure for incorrect diagnosis or treatment.
• Cannot ensure the true identity of patients who may misrepresent themselves or separate their online selves from their offline selves.
• Makes it easy to conceal emotions and information, which makes appropriate treatment and intervention difficult to accomplish.
• Is absent of nonverbal cues such as facial expressions, tone of voice, or physical appearance.
• Is limited to patients who can write expressively.
• Cannot ensure that providers have the appropriate education, training, and credentials to provide the service.
• Compromises quality services due to lack of face-to-face intervention.
• Is inappropriate with high-risk patients.
• Excludes patients who do not have the financial resources to gain access to the Internet.
• May delay or interfere with services because of incompatible computer equipment and computer crashes.
  

Providing Online Therapy Services

Clinical social workers who decide to engage in the provision of psycho-therapy services on the Internet should consider the following steps.

• Discuss your professional liability coverage for Internet-based psycho-therapy with your professional liability agency.
• Adhere to the licensing laws in the state(s) in which you are providing services. Some states may have limited provisions for interstate providers.
• Have an informed-consent discussion with the patient and document it in the record.
• Set boundaries for the patient and their use of psychotherapy services on the Internet.
• Familiarize yourself with all aspects of the functions of the computer and its programs.
  

Summary

Online therapy is not only a new mode of therapy that little is known about, but also a new market that clinical social workers may enter and establish their expertise. Online therapy is becoming increasingly popular; patients are seeking and requesting it at an alarming rate. There is limited evidence that the services do work and are effective. There is also much debate about whether face-to-face psychotherapy is comparable to online therapy. Should online therapy become one of your choices of practice, proceed with caution following the steps outlined above and be aware that you are placing yourself at a higher risk for malpractice litigation. Because clinical social workers are one of the major providers of mental health services in the nation, it is most fitting for us to be involved in evidence-based research, outcome studies, and other activities that may help answer the many questions about online therapy that are now unknown.

Additional Readings

• American Psychological Association. (2000). Psychology and the Internet. Monitor on Psychology. 31(4).
• Clarke, B. (2000). Testing the cyber-couch. Behavioral Healthcare Tomorrow. 9(1).
• Gackenbach, J. (Ed.). (1998). Psychology and the Internet: Intrapersonal, interpersonal, and transpersonal implications. San Diego: Academic Press.
• Jerome, L., DeLion, P., James, L., & Gedney, J. (2000), The coming of age of telecommunications in psychological research and practice. American Psychologist, 55(2).
• National Association of Social Workers. (2000). Technology and social work. In Social Work Speaks, NASW Policy Statements (pp. 292-295). Washington, DC: NASW Press.
• Wallace, P. (1999). Psychology of the Internet. New York: Cambridge University Press.

If you have questions or need additional information about online therapy, contact National NASW’s Division of Professional Development and Advocacy. Call (202) 336-8256.

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