Week of July 11, 2001

In this age of cyber-everything, it's hard to imagine anything that can't be gotten on-line, and that includes mental health information and services. In this hour, we discuss Internet mental health in terms of treatment, ethics, privacy, law and money. Guests include: psychologist and researcher John Grohol of HelpHorizons.com; clinical psychologist and attorney Dr. Russ Newman, executive director for the professional practice for the American Psychological Association; attorney and psychiatrist Dr. Gregg Bloche, professor and co-director of the Georgetown/Johns Hopkins Joint Program in Law and Public Health; and Internet pyschotherapist Dr. Richard Sansbury, who has also practiced traditional therapy for more than 20 years. Web consultant Martha Ainsworth reads excerpts from her own on-line therapy.

The idea of on-line mental health services, begins host Dr. Fred Goodwin, is something he hadn't given much thought to. Like so much about the Internet, it requires looking at things from a different perspective. He compares it to on-line dating. Like this form of virtual interaction, seeking psychological help on-line seems to lack important human components - eye contact, reading faces, observing body language. On the other hand, perhaps there are advantages. Some people may be more comfortable when they can maintain a sense of anonymity.

Next, Internet consultant Martha Ainsworth reads e-mail messages that she wrote to an on-line therapist in 1995. The Infinite Mind's Bray Porr reads the therapist's responses.

"Emotionally isolated is how I fell today," reads Ainsworth. "I'm not totally alone there. You're with me … talking is hard for me … I think that's why it's easier for me to talk you this way." "I am here for you," the therapist responds.

"We both know there are limits to cyberspace connections, but let's continue to stay in touch while you work through this."

Martha Ainsworth has developed a Web site that tracks Internet therapists at www.metanoia.org.

In a roundtable discussion covering the spectrum of on-line mental health issues, Dr. Goodwin is joined Dr. John Grohol, Dr. Russ Newman, Dr. Gregg Bloche and Dr. Richard Sansbury. Dr. Newman (attorney and psychiatrist; executive director for professional practice for the American Psychological Association) says that in a survey about Internet use for mental health purposes, two-thirds of the respondents said they would seek mental health information on-line.

Dr. Grohol (psychologist, researcher, founder of www.mentalhelp.net, contributor to www.drkoop.com) agrees that interest in this area is growing. In fact, points out Grohol, four of the top ten health topics searched for on the Internet are mental health-related.

On-line support groups, notes Grohol, began in the late 1980s. Of the thousands of mental health web sites that exist today, most of them began as outlets for individuals to tell their own stories and share their experiences and what they've learned from them with others.

Dr. Goodwin asks about the issue of accuracy. How can we judge the legitimacy of mental health information on the Internet? Grohol says that people need to be aware of whose behind a specific web site. We should watch out for relationships between web sites and their sponsors, which doesn't necessarily, but could signal biased information. If a pharmaceutical company, for example, touts the effectiveness of certain drug on its web site, that may not be an unbiased point of view.

Dr. Newman refers to an informational pamphlet created by the American Psychological Association, designed to help consumers judge web sites for themselves. (To get the free brochure "Dot Com Sense," call 1-800-964-2000 or visit www.dotcomsense.com. )

For all of the lack of credible information on the Web, Newman praises the Internet for its potential for helping people educate themselves about mental health issues.

Dr. Gregg Bloche (professor and co-director of the Georgetown-Johns Hopkins Joint Program in Law and Public Health) joins the discussion with some thoughts about the concept of "buyer beware." "Some of the most vulnerable people in America," says Bloche, may be the most likely to use these services and the least likely to be able to judge them. Furthermore, they may erroneously view these services as a doctor-substitute. The responsibility, he says, is in the hands of the people behind these sites, who need to be clear about what they can offer.

Next is the issue of privacy - Bloche thinks the risk isn't as great at people may think, in part because of encryption technology. A more reasonable thing to worry about isn't isolated to mental health sites. Some companies track Internet users for advertising purposes, by placing "cookies" on a user's hard drive. These companies say they don't track individual users though, just the overall data.

The distinction between getting a car on-line and getting mental health information on-line is an important one, says Newman. The latter needs to be completely private, he says, pointing out that people with psychiatric diagnoses may be upset to receive advertising solicitations about medications or services. Bloche observes that it is extremely important to remember that whenever you use the Internet, you're leaving an electronic trail. So the potential is there for other users to find out what kind of information you've been searching for. There's no Internet-patient confidentiality.

Dr. Richard Sansbury joins the conversation, talking about his experiences as a cybertherapist through his web site, www.headworks.com. After more than 20 years practicing tradition therapy, Sansbury started an on-line practice about two years ago. He corresponds with people through e-mail and promises to respond with 48 hours, although it's usually sooner. An advantage of this system is that he has time to go over the e-mails carefully and compose a thoughtful response. He calls the people he works with on-line "users" instead of "clients" and says there is a difference. "A user can be sending e-mails while they are dressed in a chicken suit," says Sansbury, "and I will never know that." He calls what he does "virtual therapy," and insists that it's not the same thing as "traditional psychotherapy." Still, he maintains that it is "clearly therapeutic."

In response to this, Bloche says, "I think that we're playing with fire here." A face-to-face evaluation is crucial and without being able to look at a patient to determine his or her state of mind at the time, he says, and it's possible that a virtual therapist could miss signs, for example, of agitation or hypomanic behavior in a bipolar person approaching a psychotic break. The outcome could be especially disastrous, says Bloche, if Sansbury takes up to 48 hours to get back to a person who may be distressed but may not seem so in an e-mail.

Grohol references a Surgeon General's report that shows that most people with mental health disorders do not seek treatment. He sees on-line therapy as a means of potentially reaching those people. Dr. Newman points out that the field of on-line therapy is so new that it's too early to judge whether it is good or bad.

Sansbury is asked next about whether transference seems to occur in his e-mail exchanges, and says that it seems to occur much more rapidly. Transference - a vital concept in therapy - occurs when a patient starts behaving as it the therapist is an important figure from their past, providing the therapeutic relationship with additional material for work. Newman, from the APA, says the jury is still out about whether e-mail transference is a good thing.

Once a fact-to-face evaluation has taken place, says Bloch, the Internet can be effective in follow-up. Newman says that it can also be useful for people who don't otherwise have access to mental health professionals, particularly those in remote locations.

Goodwin asks Sansbury about existing therapy patients using the Internet for a second opinion. Sansbury thinks there's nothing wrong with this, but encourages users to tell their therapists because the issues need to be dealt with face-to-face.

Because on-line therapy is written, as opposed to verbal, asks Goodwin, does a user need to be comfortable typing and writing? Sansbury says many of his "users" say they are more comfortable not facing the therapist. But Bloche worries that this is another area where the tech gap is manifested, denying poor people, for example, access to these services. applications may be different.

Goodwin asks about the issue of credentials and licensing. Grohol says in 1997 he, along with Martha Ainsworth, developed a therapist background-check service called Credential Check, and now the service is also provided by his site, www.helphorizons.com.

Sansbury tells a story about a user who he says was "paranoid" about working with someone they couldn't see. In this instance, he recommended that face-to-face therapy would be more appropriate. On the other hand, he recounts a depressed user who has improved a lot through their e-mail correspondence. Newman challenges Sansbury about whether what he did in that instance is "psychoeducation" or "psychotherapy." Sansbury reiterates that what he does is not traditional therapy-"exclamation point," and that the type of cognitive behavioral therapy he practices is highly psychoeducational in any case.

What's new and still needs to be weighed, says Bloche, is the effectiveness of on-line therapy. The ethics of a doctor-patient relationship, however, are not new.

Health iInsurance is not a part of Sansbury's operation, and he prefers it that way. Without the third-party of the HMO or health insurance company involved, privacy is increased. The flip side, says Newman, is that there's a risk that health insurance companies could encourage this type of therapy because it's cheaper, even where it may not be appropriate.

Grohol says that after all, there's no standard for checking credentials for an on-line therapist. Consumers need to call state licensing boards and do their own research.

(The Infinite Mind's Dr. Fred Goodwin discussed "Cyberpsych: Mental Health on the Internet" on CNN. Click here to read more.)

· Back to the The Infinite Mind Index