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Online Therapy? Not Yet

At the same time that Martha Ainsworth was having a major life concern, she was sent on a business trip requiring her to be on the road for several weeks. It was 1996, which is a long time ago in e-history, but Martha was what Internet researchers call an "early adopter;" she had been communicating via computer networks even before there was public access to the Internet. So, it followed that Martha would seek help for her personal problem online.

"I felt I wanted to do some personal exploration with the help of a therapist. I was traveling so I looked on the Internet. I found about 12 Web sites where therapists were offering various levels of service," she said. "One resonated with me. We ended up communicating daily by e-mail for about two years. It was probably one of the most significant and powerful relationships I have ever had."

Martha's experience led her to become a consumer advocate on mental health issues and she is now behind - a Web site for those seeking information and advice. Martha is mentioned as a success story by many therapists who operate in cyberspace because she is one of the few recipients of online therapy who will publicly talk about her experience. That's the point: most people choose online therapy because of its anonymity; and that is why online therapy sites are proliferating.

There are now about 200 Web sites devoted to mental health issues and about 350 individual therapists on the Web, but they are all virtually unregulated, many are unlicensed, and, some would say, unethical, depending on what level of service they promise to provide. There are also no studies determining whether online counseling works, there is no specific training for online therapy and everyone agrees it will probably never take the place of face-to-face sessions.

"My concern is that e-mail psychotherapy with unknown patients directly violates the ethics code that clearly states that we have to have training, experience and supervision in an area before we offer ourselves out to the public, and that our methods have to be based in scientific research," says Marlene Maheu, clinical psychologist and director for the Telemedicine Training Program at the California School of Professional Psychology. Her self-help and psychology magazine is online at

Psychologists also are trained to use visual and auditory cues when diagnosing and treating patients. If you can't see the anxiety on your patient's face or hear the depressed tone in their voice, how can you treat them properly? "You can't ask them if they are schizophrenic or homicidal," says Maheu.

Researcher Larry Rosen of has been looking at people's reactions to technology for the past 15 years and although he avors taking advantage of as many high-tech resources as possible, he is skeptical when it comes to online therapy.

"For many it's incredibly beneficial. I hear story after story of people who without the Internet would be lost. But for others, it can be problematic. Anybody can set up a Web site and say 'I'll help you.'"

He even questions the idea that when online, you are anonymous.

"By just going online and getting advice, your problem may show up all over the Internet with your name on it. Journalists can go in and quote you," he warned, and advertisers can track your movements and even find out private financial information if the site is not properly encrypted.

Although reports from unsatisfied customers are hard to come by, Rosen says it is common for e-mail counselors to suddenly disappear from their sites, or for their sites to go dead, leaving patients having to "start all over with someone else."

"Almost everybody agrees that you can't do actual psychotherapy on the Internet," says Martha Ainsworth. "But just because it's not full-blown psychotherapy doesn't mean it's not helpful."

And, John Grohol of, a researcher on e-therapy, says "People directly ask questions of other human beings and get answers back rather than doing hit-or-miss searches on the Internet."

Many in the mental-health care industry also believe technology will develop in the next few years that will mean more person-to-person-like encounters that may revolutionize mental health services online.

Ainsworth points out that she has been a watchdog on the industry for many years and "my observation is that it is very effectively self-regulated. I haven't seen any examples of online therapists doing anything outside the bounds of what they do in their regular office," citing and as examples.

Ethical guidelines are now being developed. One such set of guidelines by the Internet Health Coalition was prompted by ethical questions raised last year in the operations of the site and is now getting feedback from professionals and consumers before being finalized The International Society for Mental Health Online also has approved suggested principles for the online provision of mental health services

Kimberly Young, executive director of the Center for Online Addiction and author of Caught in the Net, sees Internet mental-health inervention as a crisis-management tool.

"A lot of times people have specific problems and want specific answers." And, sometimes these problems are directly related to the Internet. "There's an irony to it. It makes sense that if there are issues online (such as Internet addiction or problems with online relationships), people will seek help online.

"What I've seen of online therapy, it has a place."

She and others point out that Internet therapy can help those in rural areas with little access to mental health care, those in foreign countries seeking English-speaking therapists, and those like Martha Ainsworth who are on the road a lot.

Ainsworth, by the way, never talked face to face with her therapist in the two years they communicated via e-mail but she has since met him and she still refers back to their e-mails when she needs to.

"I would compare it to keeping a journal in that every day when I wrote him an e-mail I explored my thoughts and feelings in great depth.

"But usually when you keep a journal it doesn't talk back to you. He challenged me. The fact that we communicated by e-mail, I think, made me feel like he was inside my head and present in my life."

By Danna Walker
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