Online therapy poses great risks

By Lynn H. Collins, Ph.D.
September 1, 2007



Many professional psychologists are wary of providing therapy online because the Internet is vulnerable to hacking and because they are not convinced that one can conduct therapy effectively via text. Psychologists are also concerned about the difficulty of verifying clients’ identities and therapists’ credentials and unclear or non-existent interstate and international regulation.

The public, however, is largely unaware of these issues and is already actively seeking and participating in therapy online. They experience it as useful, economical, anonymous and more accessible than weekly in-person sessions. Some may never have begun therapy if this format were not available. Its “texting” format may appeal to young clients, as well as to those familiar with online dating.

What is our responsibility as psychologists to ensure that this medium is used in a way that optimizes its potential contribution to public welfare? How can we better ensure that the public can make informed decisions regarding online therapy?

Some of psychologists’ current concerns are more warranted than others. Many express concerns about how effectively therapy can be conducted online. There is mounting evidence that online cognitive-behavioral therapy can be effective with patients suffering from depression, anxiety, social phobia and post-traumatic stress disorder. Additional research is needed to better understand how to optimize its accessibility and effectiveness. If we are interested in ensuring the effectiveness of online therapy, we need to clarify how to train psychologists in online therapy (as well as assessment and other techniques within psychologists’ scope of practice) and how to assess competence in its use since it does require additional knowledge, techniques and skills beyond those of traditional face-to-face or telephone therapy.

Risks to confidentiality of Internet communications are misunderstood and underestimated. E-mail communications of all kinds can be accessed within the clients’ or therapists’ computers and as they pass through servers (where they may be stored) by the ISP, employers or the government. Businesses and government agencies use data-mining programs to search records for specific content. Even online therapy conducted via secure web sites is vulnerable to keystroke recording software, may create subpoena vulnerable records or may be hacked.

Some therapy sites claim that their therapy sessions are secure when they are not. We need more regulation of the technology required for online therapy, from regulations pertaining to who can open and read e-mail, through what level of security is required for sessions (e.g., encryption level).

Most practitioners available online describe themselves as professional counselors, social workers or other kinds of therapists. Training and credentials are often not possible to ascertain or verify. Even if psychologists have no interest in practicing online therapy themselves, they should take a more active role in determining the future use of online therapy in the interest of promoting and protecting public welfare.

We need to develop a registry of therapists that allows patients to verify the legitimacy of therapy sites and the identity, training and credentials of online therapists. Similarly, we need to develop a mechanism for establishing clients’ identities so that psychologists know they are not communicating with a client’s associate instead of the client and for dealing with establishing clients’ locations in emergency situations.

It may never be possible to regulate the practice of online therapy because it is practiced across state and national boundaries. The differences among state laws regarding the scope of practice of various professions, age of consent for therapy, Tarasoff issues, child and elder abuse reporting are a challenge to interstate practice and international practice issues present far greater challenges and may require the involvement of the World Health Organization, among other international groups. Some of the professional challenges are the inconsistencies in the types of training and certification/licensure required to practice in mental health related fields in different countries.

International regulation would require international cooperation, and even then it would be nearly impossible to prevent rogue online therapy centers from operating. It may, however, be possible to launch an international public information campaign regarding the practice of online therapy. At the very least, we need to establish consent procedures that inform patients and therapists of the risks involved in online therapy.

The needs of consumers and the financial and humanitarian interests of practitioners around the world drive the practice of online therapy. Even if online therapy is deemed too risky, it is virtually impossible to stop. Discussion of many of the issues above has already begun within the American Psychological Association and The International Society for Mental Health Online.

It will no doubt continue within other professional organizations and various legislative bodies. It is important that psychologists’ voices contribute to the inevitable international dialogue on the practice of online therapy to ensure that consumers are protected.

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Lynn H. Collins, Ph.D., is associate professor of psychology at La Salle University and a fellow of the American Psychological Association and the Association for Psychological Science. She currently serves on the Pennsylvania Psychological Association’s Electronic Media Communication Committee and is the moderator of several local, national and international listservs.

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