Therapy in Your Pajamas?
NASW's Private Practice Committee Takes a Look at E-Therapy
By Jason Summerfield, MSW
Imagine treating a client in another country without ever leaving your house. If you practice online counseling, this is a possibility. Providing clinical services over the Internet is an issue which has been receiving increased attention from mental health professionals in recent years. Despite the fact that there is little professional consensus, and even less empirical research on the matter, it’s happening now. More and more clinicians are considering the potential of the Internet in facilitating their practice.
Scott Cohen, LICSW, LMFT, of Scott Cohen Associates in Framingham, is one social worker who has successfully inte-grated the Internet as a valuable component to his practice. Cohen recently shared his knowledge when he presented on the Pragmatics and Ethics of Practice in Cyberspace during the Chapter’s Private Practice Committee’s October meeting.
Online therapy, or e-therapy as it has come to be known, is essentially a communication between a professional and a client via an electronic medium such as an email exchange, live chat, video conferencing, or message boards. However, beyond this common characteristic, clinicians online have many new possibilities, with few professional practice resources to draw from. As Cohen asserts, "we really don’t have clear guidelines yet."
The majority of mental health organizations (such as NASW, the American Psychological Association, and the American Association of Marriage and Family Therapists) have thus far assumed a fairly impartial position in ad-dressing e-therapy, citing the relative infancy of the practice medium and the need for further research. However, NASW did release a Social Work Practice Update titled Online Therapy and the Clinical Social Worker which reviews some of the advantages and disadvantages of working with clients online. It is worth noting that the NASW Insurance Trust has stated "Online social work therapy is covered under the professional liability insurance policy offered by the Trust, however, it is not encouraged and is very high risk."
While the verdict is far from in on e-therapy, two organizations, and a handful of professional pioneers, have taken up the challenge of developing explicit standards for online practice: the American Counseling Association has published Ethical Standards for Internet On-line Counseling (see www.counseling.org/gc/cybertx.htm), and the International society for Mental Health Online (www.ismho.org) stands alone as the primary organization devoted to technology integration in mental health.
Understandably, this new treatment paradigm has been met with concern, if not skepticism, from many mental health professionals: how does a clinician online know who the "client" really is; how do you ensure confidentiality; what do you do in an emergency; is your license valid in cyberspace; what can really be accomplished with electronic communication; and the list goes on. Nevertheless, other professionals are intrigued by the new possibilities which electronic interaction holds. In fact, Cohen encourages most of his clients to communicate with him online.
Online counseling opens up a whole new treatment paradigm for communicating with clients, developing new interventions, and expanding services to individuals who otherwise would not, or may not be able to, access a mental health professional in person. With the added convenience which e-therapy affords both client and clinician, and the availability of reliable security options such as encryption, counseling online looks pretty attractive.
However, despite the exciting novelty which may draw both consumers and clinicians to meet on the web, the decision to move your practice online should not be made hastily. As asserted by John Grohol, Psy.D., a researcher and international expert in the area of mental health and technology, "folks shouldn’t understand this as just some new-fangled thing that anyone can or should do, just because they can. It takes an understanding of the processes involved and an appreciation for its benefits and limitations before doing it." (See www.psychcentral.com/best/ for Dr. Grohol’s Best Practices in E-Therapy).
E-therapy skeptics frequently state that online therapy "will never replace in-person treatment." This assertion may well be the case; however it is not the point. In fact, some thinkers in the area of mental health online, such as Grohol, emphasize that online correspondence with a client should not be regarded as "psychotherapy" in the traditional sense, nor is it to be considered a "treatment" for severe and persistent mental illness. Rather, therapy with an online client may be more appropriately regarded as a form of "counseling" for general life challenges such as stress and relationship difficulties.
Another important distinction to make in the e-therapy discussion is the fact that the practice implications change significantly depending on whether the clinical relationship begins online or in-person. While the idea of initiating and maintaining contact with a client solely in cyberspace raises many professional, ethical, and perhaps legal issues, using the Internet as an adjunct to traditional in person treatment seems fairly pragmatic.
Cohen clarifies that he only uses email correspondence with clients whom he has previously met in person. This message is an important one, because with all of the provocative ethical scenarios which the discussion of online counseling lends itself to, the fact is that electronic communication can be utilized as an adjunct means to facilitate a standard face-to-face clinician-client relationship — where an assessment, rapport, emergency protocols, and clinical goals, have already been established in traditional fashion before online correspondence begins.
With electronic correspondence as an adjunct to in-person treatment, clinicians can review client updates in-between regular sessions, or send psycho-educational materials and homework exercises; clients can work on journaling, complete assessments, and increase the time between in-person sessions, or phase out in-person sessions altogether, if appropriate.
Most mental health professionals draw from a variety of practice options in order to meet the unique needs of a given client; online correspondence is simply a new addition to the many clinical tools available for facilitating client goals, reaching new populations in need of services, and promoting desirable outcomes. The manner and degree to which in which technology is ultimately employed in practice — like other treatment methods and modalities — is a matter of clinical judgment and emerging professional standards.
E-therapy embodies diverse issues which may be optimally viewed through the social work systems lenses of policy, practice, research, and ethics. This reality presents social work with a precious opportunity to assume a pivotal role in shaping progressive developments in the field of mental health. Like it or not, e-therapy is here and will continue to develop with or without our input. How we ultimately shape the standards of integrating technology and practice is a challenge before us as individual practitioners, as well as a profession.
Jason Summerfield currently works as an outpatient mental health clinician at Wayside MetroWest Counseling, and provides consulting and web design services for health and human service organizations. He has also worked in e-commerce business. He can be contacted at jsummerf(at)rcn.com.
FOCUS Newsletter - January 2001
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