Online Shrinks

I was home, depressed with the flu New Year's Eve 1998--and did what many other unfortunates did that holiday: I signed onto an AOL chatroom in search of some therapeutic banter on the crucial inanities of life.

But what I found was "Dr. Michael"--a credentialed therapist. And he wasn't asking me my opinion on the Grammys.

"How are you really feeling?" he asked.

That was a little more than I was looking for, but, the truth is, I had toyed with the idea of counseling for over a year but had never made room for it in my schedule or budget. Over the next hour, in private Instant Messages, I shared with the Florida-based psychologist the intricacies of my recent break-up with my boyfriend of four years. When we signed off, he said, "Talk to you tomorrow?" (There was no mention of money.)

Dr. Michael, 43, sent me his resume, and I called his offices in Florida to verify his identity. He passed the test. We ended up chatting about my gripes and goals one evening a week for the next year--for free. At the time, his wife was ill and nearly unconscious. The two were homebound, and he had become lonely and depressed. "Giving therapy online is more gratifying than short-lived Internet frolicking," he told me. "Anyway, I went into therapy because I like to help people."

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Many therapists have flocked to the Web for a whole slew of reasons, resulting in 200 "online therapy" and online counseling sites offering access to about 350 online counselors. Since 1995, psychologists of varying stripes and credentials have offered everything from "Answers to three questions for free" to "submit a question about sexuality for $75" to private chatroom meetings for $40 an hour, to three months of unlimited e-mail therapy for $300. In addition, there are thousands of support groups, moderated by some type of therapist, organized around every conceivable need, ranging from depression to infidelity and trauma. Most online therapists also maintain conventional, face-to-face practices.

A growing number of people are depending on Web for emotional support, advice and counseling for bargain basement prices, right from their living room, during any of the 24 hours in a day. And the need is dire, says veteran online counselor David Sommers, Ph.D. Online counselors are reaching victims of abuse and trauma who are too embarrassed to look someone in the eye as they share their struggles. In fact, this text-based, faceless medium tends to put all people at ease--victims or not. "There's no eye contact while confessing insecurities or sins," says Sommers. Moreover, he adds, online counseling, with its varied pricing, reaches people who can't afford standard therapy fees.

But, for me, the best part was this: I was a freelance writer at the time, and our meetings were conveniently mobile. We continued therapy while I traveled, and even after I moved about the city. Such convenient access to therapy is unprecedented.

And since you can save your correspondences, "It's like having a hug inside your computer that's waiting for you whenever you need it," says Martha Ainsworth, an Internet communication specialist and founder of www.metanoia.org--a private, nonprofit website that explains and celebrates the virtues of online counseling.

Already, experts estimate that there are thousands of online support groups attended by tens of thousands of people. And they predict that online counseling--be it group chats with a therapist moderating, e-mail correspondence, private Instant Messaging, or video-conference technology, for which a quantum leap forward is considered imminent will be ubiquitous within five years.

At least one university is paying heed to what may be the reshaping of psychotherapy. Allen Calvin, Ph.D, president of the Pacific Graduate School of Psychology, has introduced what may be the first program in the country training psychologists in "telehealth." Beginning in the fall of 2000, students will be taught how to provide mental health guidance online.

BUT IS IT "THERAPY"?

Most therapists and academic institutions remain suspect of the new field. The term itself, "online therapy," is considered inaccurate and offensive by many psychologists. Smart Tentoni, Ph.D., coordinator of the Norris Health Center at the University of Wisconsin at Madison, says that "Internet therapy" is an oxymoron. "Psychotherapy is based upon both verbal and nonverbal communication," he says. "Without seeing the person, it is impossible to get a full sense of that person's situation in order to adequately render therapeutic advice to them."

According to John Grohol, Psy.D., the director of MentalHealth. Net, one of the most comprehensive guides to mental health online, many online providers do, in fact, call themselves counselors rather than therapists. The most conservative among them say they offer mere "advice," while others use the weightier, though clunky term, "behavioral telehealth." But from his five years of online counseling experience, Grohol contends that, "Online relationships are just as real and intense as they are in the real world. So it's no surprise to me that people are trying to establish therapeutic-type relationships over the Net." But, he adds: "Whether it's therapy or not, I do not know."

This issue is not the point, according to Ainsworth, who feels that psychologists should open their minds to the new reality. "It's time to concentrate on research and begin to train innovative therapists to meet the needs of the next generation," she says. "We should be looking at the numbers of people who are being helped by online counseling--and how to improve it--rather than getting hung up on terms."

Ainsworth admits, however, that online counseling is not for everyone. If you're going to receive counseling by e-mail or chat, she warns, "you should be comfortable expressing yourself in writing." Also, she says, it's not for people who are in the midst of a serious crisis--where facial cues, body language and tone of voice become vital--although it is especially attractive to them. Many online practitioners regularly refer dozens of people in crisis to traditional therapists in their area or to The Samaritans (www.samaritans.org.uk), trained volunteer counselors in England who specialize in handling crises online.

PROBLEMS, PROBLEMS

While the professionals behind quality counseling websites state their limitations up front, drawbacks to Web "therapy" abound: There is no systematic guarantee that the self-proclaimed therapist is legitimate or licensed to practice in your state; there are numerous possibilities for compromising privacy; there are endless technological glitches; and there are complicated payment and legal concerns.

In terms of judging a counselor's legitimacy, there have been no reported arrests for practicing without credentials online, and, so far, there has been no reported litigation against an online-therapy provider. And yet there are no diplomas to review on the office wall. Still, there are private websites that will research the background of any person calling him or herself an online therapist (see www.metanoia.com).

But "licensed" and "licensed to practice in your state" are separate matters. Cyberspace, elusive by nature, transcends state and international borders, rendering it quite difficult to apply and impose enforceable codes of conduct. Worse, case law and statutes regarding client/doctor confidentiality regulations differ from one state to another. For now, though, online counselors and lawyers agree that the online counselors should be held responsible for adhering only to the legal and ethical boundaries of the state in which they are licensed to practice.

Meanwhile, critics say that no online therapist can promise confidentiality to any client because of the limitations of the medium. While some Web browsers supposedly ensure that e-mail will be delivered unread by outside parties, not all do. And even though e-mail within the United States is legally protected in a manner similar to that of the U.S. mail, the same is not true for e-mail sent from private offices; companies electronically store information passing through their computers, and employers can read any message in their systems.

But Ainsworth says that online therapy is just as safe as talking to a therapist in person--"both are very confidential, and neither is 100% perfect." People can see you go in and out of doctors' offices, files are left unlocked and sometimes walls may be thin, she says. Still, for those concerned, she recommends one of the few sites that uses a secure messaging system, offering the same level of protection that online banks use. One of the first mental health sites to address security issues is the new, highly sophisticated Here21isten.com, which links clients to counselors of varying degrees and fees, and is advised by psychologists from Stanford, Harvard, Brown and other leading universities.

The most sticky and ominous issue yet is payment, says Michelle Weft, Ph.D., who conducted research on online counseling three years ago with her colleague Larry Rosen, Ph.D. "Some therapists would tell their clients, 'Pay me what you think it's worth,'" Weil reports, saying that therapists then end up trying to prove they're worth the money. "This creates an unhealthy power structure," she explains, in which a therapist's desire to win a client's approval may affect his or her treatment.

Although the kinks of Internet counseling have yet to be ironed out, it is the very experimental nature of the medium that attracts some therapists, people who sacrifice profit for the discovery of uncharted territory. The sacrifice ultimately proved too great for Sommers, who left the Net to open a more lucrative, traditional practice.

"Online therapy is as time consuming as face-to-face therapy, but pays substantially less," he explains. He did most of his online counseling pro-bono or according to a sliding scale.

Sommers went into the field and communicated with at least 350 people via email--some for as long as a year--to "see if online counseling was doable and if it could have had any meaning." Five years later, "It's not an Amazon.com," he says. "It is viable, but in no way would I make the case that Internet counseling is complete. You're missing the real person."

"The Internet allows those who cannot obtain rye therapy, for financial or physical reasons, to seek instant advice or get quick and discreet information," he adds. And for that, it seems to be working.

TAKING MATTERS INTO MY OWN HANDS

It had been over a year since Dr. Michael's wife recovered, and we had lost touch. I missed having therapy at my fingertips and had new boyfriend issues to work out. Again, with no time to fight the New York City subway system at rush hour, I wondered if there was another kind, affordable and reliable counselor out there for me in cyberville.

With a $1,000 budget, I signed on. I searched the Web for an "online therapist," and the first of the dozens of sites that popped up was www.sexology.org, run by Peter Gardos, Ph.D., a young psychologist who entered cyberspace "because of its promise of reaching an exponential amount of people."

There, for the "reduced" fee of $75, I was to get, within three days, a credentialed psychotherapist's response to a sex-related question. I did have an actual question, one so private that I had never asked it of anyone before. I spent 45 minutes describing it. It was unpleasant. But I input the credit card numbers and sent the query off.

Days, weeks, passed with no word. Finally, after I inquired, I received an email from Gardos, explaining that the website had malfunctioned. He sent me an apology and refunded my money.

Gardos, who answered a few hundred sensitive sex queries on his site over three years, finally shut the site down. "Computer glitches were a continuing frustration for me. Every now and then I would discover that my server ate the last week's worth of queries."

But Gardos perseveres online in another ways. "I haven't had a face-to-face client in years," he said. He makes his living mostly through online sex columns published on sexuality, about, corn, and live Q & A on www.thriveonline.com.

Technical glitches, such as delays in message transmission, regularly intervened in my private chatroom sessions with Eugenie Connall--known as "Jane" onscreen--a 44-year-old therapist who provides online counseling to about a third of her clients. With Jane, the guidance was worth its infuriating moments. And she absorbed the loss of time. In fact, Jane never charged me at all.

Jane and I clicked fight away. I found her e-mail address, Askashrink@aol.com, and fee ($70 an hour) posted openly on several websites devoted to mental health information.

Like my meetings with Dr. Michael, we jumped right in and got directly to the gut issues: jealousy problems with my new boyfriend. She was attentive, direct and dependable. I felt an ease reminiscent of the days I sat in offices, facing open-eared, credentialed professionals. Jane and I had a few over-the-phone sessions, which reinforced her realness. Jane, like Gardos, supplements her income by facilitating chatroom discussions. Her specialty is infidelity.

After about two months of twice-weekly chats, I felt I had worked through my problem. Her guidance helped me face the conflicts in my life more constructively.

A few months later I asked Jane why I had never received a bill. She said that once she realized I would be a short-term case, she didn't feel it was necessary.

When my boyfriend and I had another episode, I sought counseling again. After doing another Web search for "online therapist," I found a website with a unique approach: Pay $300 up front for a "quick and successful program tailored to your individual needs." I read their code of ethics and terms of agreement, then I was supposed to "give as much information about my past and present" as I could to an unspecified recipient. I mustered four arduous hours to tell my life story to a complete stranger, by e-mail. I peppered it with questions. I couldn't wait for the response.

The director of the site, Dr. Bill, a middle-aged man who requested not to be identified in this article but whose credentials as a psychologist I verified (Ph.D. from the University of Missouri in 1973), replied only with more questions. I responded. I got more questions. This was not gratifying.

I needed feedback, I wrote to him. Dr. Bill, who boasted a 100% online counseling clientele, responded at length in his next e-mail. A dialogue began. I became increasingly comfortable, and we started a biweekly correspondence. It wasn't always easy. But his feedback was different--he forced me to take more responsibility for the dysfunction of my relationship. He challenged my thinking, and sol endured.

But our momentum was broken in our second month when he vanished with no explanation. After a nearly three-week hiatus, he re-emerged, explaining that his e-mail was jammed, and my messages had gotten through only that day. I couldn't get back into the flow of therapy. Dr. Bill has since decided to take a more permanent break from counseling online, and the website he worked for has since disbanded.

One new website is taking a bold approach to solving the technological bugs. "Our site keeps track of how long you've been in session, and if there are glitches, we'll absorb the loss," says Gunny Cho, a lawyer-cum-entrepreneur, CEO of Here21isten.com. Already hundreds of clients have signed up for counseling at posted fees. Within a few months, the site expects to offer "video-conferencing therapy," the only kind of online counseling winning most experts' approval.

This is not surprising to Robert Glueckauf, Ph.D., of the University of Florida, In 1998, he found that video-conferencing counseling was as effective as traditional therapy. Glueckauf, whose results will soon be published in Rehabilitative Psychology, directs the newly formed Center for Research on Telehealth and Healthcare Communications, the first research center devoted to therapy of electronic means. Like Glueckauf, many psychologists wary of online counseling believe that videoconferencing therapy will be a viable, common practice in just a few years.

In the meantime, little research exists on the value of text-based online therapy. When Glueckauf issued a call for papers on the subject, he received a mere 12 responses, only one of which proposed to look at text-based communications. There is, however, one major project under way. The International Society of Mental Health Online (www.ismho.org) was formed in 1997 to promote the understanding, use and development of online communication and other information technology for the benefit of mental health. The group is conducting an investigation into online counseling's benefits and limitations.

No matter what they find, though, thousands of experimental, trusting, Internet-friendly types will continue to go for it anyway, finding solace, compassion, direction--and hopefully fewer and fewer infuriating glitches--along the way.

At Your Fingertips: Five Online Options

ASK-A-QUESTION: A client writes to a counselor with a detailed question or problem, and then receives a customized solution.

GOOD: If you have reasonably well-defined problems that can be explained in a few paragraphs or less.

BAD: If the nature of your problem is complex, overwhelming, or has persisted for an extended period of time.

ONGOING PRIVATE CHAT: The counselor and client chat privately through Instant Messaging, usually for hour-long intervals.

GOOD: If you are struggling with nontraumatic issues, such as job or relationship stress, and if you enjoy writing.

BAD: If you are suffering from severe depression, trauma, or drug or alcohol addiction, when facial cues and body language are vital.

VIA E-MAIL: The counselor and client correspond via e-mail messages.

GOOD: if you want to be able to unload at any time. Also, e-mail counseling can compliment a traditional therapy relationship and can keep the two in contact long after the session's end.

BAD: If you feel uncomfortable writing about your issues at length.

SUPPORT GROUPS WITH A COUNSELOR: Participants join chats, most of which are administered by professionals at mental health-related websites.

GOOD: If you are struggling with something severe and feel alone; if you could benefit from immediate feedback from fellow sufferers, but are too embarrassed to meet face to face; or if you have little or no access to fellow sufferers.

BAD: Online support groups pose some of the most contentious legal and ethical issues of all online therapies since minors--or anyone else for that matter--can easily sign on to the free site and lie about their age or situation. [To obtain therapy of any kind, minors must submit parental consent forms.]

VIDEO-CONFERENCING: Like private chatting, the counselor and client usually meet for hour-long intervals but can actually see and hear each other through cameras (available now for $50 to $200).

GOOD: If you want the counselor to be able to fully evaluate you--tears, intonation and all.

BAD: Visuals are still poor. Experts anticipate clear communication within one to three years.

THE 10 NET COMMANDMENTS

PSYCHOLOGY TODAY does not officially endorse online therapy, but if you are going to take the leap, make sure your online counselor follows these guidelines, adapted from the American Counseling Association, www.counseling.org/gc/cybertx.htm:

1. Counselors must inform clients of the limited security of their correspondences.

2. A client must be informed of all counselors and professionals who have access to the website, and whether their information is secured by an encryption code.

3. Upon conveying the "risks" of online therapy to a client, the professional counselor should execute a client waiver by which the client acknowledges that he or she has been informed of potential hazards.

4. On the website, counselors should state clearly that therapy is impeded by the counselor's inability to read facial and body-language cues.

5. The emotional and intellectual capability of the client must be of foremost concern when a therapist agrees to counsel a client online.

6. Despite the global reaches of the Internet, counselors may provide services only in states where they are licensed to practice.

7. Legally, the online therapist must confirm that his or her liability insurance covers the services provided over the Internet.

8. The counselor must verify that the potential client is above the age of a minor.

9. If the client is underage, written consent is required from the minor's legal guardian or representative.

10. Clients should perform a credential check on any therapist found online (consult www.metanoia.com).

PHOTO (COLOR): From left to right: Licensed counselor Jane Connall treats a third of her clients over the Net. Online veteran David Sommers, Ph.D., says that Web counselors reach victims of abuse and trauma who are too embarrassed to look someone in the eye when sharing their struggles. Peter Gardos, Ph.D., an online sex therapist-guru, turned to cyberspace for "its promise of reaching an exponential number of people."

Rebecca Segall is the senior editor of PSYCHOLOGY TODAY.

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