A Response to the Clinical Social Work Federation Position Paper on Internet Text-Based Therapy

July 24, 2001

Dear CSWF Committee Members:

I commend you for your careful and deliberate consideration of ethicaland practical issues in conducting "psychotherapy" online. However, assomebody who has studied psychotherapy outcome research for over 20years, I am well aware of the difficulties in ascribing "effectiveness"to psychotherapy in general, however it is defined, much less on thebasis of the venue in which it takes place. Therefore, like many otherswho have written publicly and privately to me and my organization, itseems rather biased to single out one particular treatmentmodality--the ill-defined "online psychotherapy"-- as beingparticularly problematic in terms of ethical or technical limitations.

Yes, even well past 1995-96, when your commission first began todiscuss this looming possibility, there remains particular concernabout confidentiality, privacy, and authenticity, as well as the legaland regulatory issues insofar as professional licensing. But it isprecisely these issues which have been increasingly explored andaddressed by both mental health professionals and consumers. There isgrowing recognition, among members of professional organizations, thatwhile there are definitely grave risks inherent in "online treatment"there is also an incredible potential benefit in providing services tothose who are geographically isolated, socially anxious, physicallydisabled, or fearful of stigma for seeking help, information, andsupport. To name a few. The Internet exists, and it can facilitate thework of professionals, with the potential for a myriad of benefits toconsumers, far beyond telephone hotlines or "therapy".

Most of the recent research of which I am aware, and my experience as aparticipant in an ongoing (online) Clinical Case Study Group since1999, suggests that very few if any qualified, licensed mental healthprofessionals are simply "doing therapy" online in the same exact wayas would occur face to face. It's impossible, of course, to have thesame multi-sensory, real-time feedback, or nearly so. And nobody wouldargue that it's ethical to practice in an area in which one does nothave training and competency, which is perhaps even more essential forthose who are experienced therapists but not necessarily familiar withthe issues specific to online work, including the extra precautionsregarding ethical considerations, and experience in communicatingeffectively via text. The latter, of course, is nothing novel. Freudpracticed "bibliotherapy" via (snail) mail, and in the 20th Century, itbecame common for behavioral oriented therapists to issue "homeworkassignments", keep journals, and otherwise employ various tools andtechniques. There is now a growing body of evidence to suggest that infact some very positive outcomes have been facilitated by onlinetreatment modalities. (See, e.g., the appended brief bibliography).

So why should text-based "therapy" be singled out as the root of allevil? Clearly, it can be as harmful as poorly conducted office ortelephone therapy, but need not be. And just as certainly, thepotential for combining office visits, sharing journals, or "touchingbase" while therapist or client is away for extended periods, forexample, is profound.

In fact, to my knowledge the manner in which most "online therapy" isconducted, is not as a pure form of something totally new and alien toour species, but the wonderful expression of people who are reachingout in new ways to form therapeutic relationships, however defined, andto find support groups, information, and referrals to localpractitioners. Therapists continue to use their understanding of humanrelationships, thinking, and behavior--online and off-- and some haveover the past several years learned to hone skills in providing"read/write/reflect" therapies, rather than "listen/talk/reflect". Thistype of work is being done by more and more of your membership, and byyour colleagues in psychology, counseling, nursing, psychiatry,marriage-family therapy, and other helping professions. There is noquestion but that many clients are being helped by the guidance,advice, self-help, and professional consultations by experts in mentalhealth who just happen to be accessible via the Internet.

But, you seem to ask, "is it therapy?...Can you prove it works?"

Perhaps the most broadly applicable study to date, lauded by theAmerican Psychological Association, and others, was the recent ConsumerReports study which focused on "consumer satisfaction" as a majorcomponent of outcome, and ended up sparking an ongoing dialogue about"effectiveness" versus "efficacy". Semantics and research design aside,"the people" seem to believe that professional mental health treatmentworks to improve quality of life, and a huge cross-section of peopledescribed all sorts of "therapies" as efficacious.

I do believe in the year 2001, there is a growing consensus among bothconsumers and practitioners that technology has fundamentally changedhow one defines communication between people, and effectivecommunication certainly must still be an enduring requirement foreffective psychotherapy.

The feedback I am seeing on online discussion lists is that yourposition undermines the conscientious efforts of many mental healthprofessionals to become skilled in providing sensitive, empathic, andethical services to those who seek them, by basically dismissing thepossibility altogether. Many of the same consumers who spoke on behalfof the value of "therapy" would (and do) say the same thing aboutonline support, information, self-help, and counseling. And so who isto say to the countless numbers of people who do believe that onlineservices and resources are "therapeutic", that they are wrong?

The International Society for Mental Health Online is seeing increasingnumbers of new members from organizations such as yours, some of whomhave recently expressed anger and dismay with your position paper. Ourposition is that online mental health professionals should not only beevery bit as qualified as offline practitioners, but have additionaltraining, competencies, and skills which facilitate ethical,professional practice. We recognize that there will be opportunists,both licensed and unlicensed, who will offer services with little or nopreparation for dealing with the exigencies specific to online work,and this is why our membership includes not only mental healthprofessionals, but consumer advocates as well. We recognize thatresearch, continuing education, and ongoing peer support for developingappropriate skills and outcome measurements are essential, and this isin fact the reason for our existence, and our growth.

Again, while I can agree with your highlighting the need for caution,and the special considerations online work brings with regard toethics, I cannot agree that the good work being done by so manyconscientious colleagues cannot be ethical, or therapeutic. I wouldurge you to re-consider the tone of your position paper as well as whatmany view as it's overly rigid and simplistic, one-dimensional view ofonline mental health services. Please visit the ISMHO website(www.ismho.org) and look at our Suggested Principles for online mentalhealth practice, and read about the diverse types of work being doneonline, as presented by the Clinical Case Study Group project. Considerthe NBCC code of online ethics, and the more pragmatic ethicalprinciples enshrined within other large professional associations.While I can see that your paper is well-intentioned, and carefullyconstructed, I cannot see that it has made the transition into the 21stcentury, given that Internet-facilitated communication is now a part ofdaily life, for better or for worse.

Thank you for giving me this opportunity to respond.

Michael Fenichel, Ph.D.
President, ISMHO

Online therapy outcome studies

Many case studies of online (text-based) therapy have been presented,in conferences or published articles. These have clearly demonstratedthe successful impact of such intervention.

In addition, numerous published articles provided empirical evidencefor the success of online support groups in broad spectrum of problemareas. The absence of specific therapeutic intervention and theapplication of a therapeutic technique, however, characterize supportgroups. A professional does not necessarily lead them. They are basedon factors of general emotional support, encouragement, advice, and soon, all through online text-based interactions.

Online (text-based) therapeutic interventions, however, are based onapplications of psychological principles by a trained professional. Thefollowing is a sample of published studies that were carried out toexamine the effectiveness of such interventions. The description israther very brief; full details may be found in the originalpublication (in alphabetical order).

• Celio, A. A., Winzelberg, A. J., Wilfley, D. E., Eppstein-Herald, D.,Springer, E. A., Dev, P., & Taylor, C. B. (2000). Reducing riskfactors for eating disorders: Comparison of an Internet and aclassroom-delivered psychoeducational program.Journal of Consulting & Clinical Psychology, 68, 650-657.

  Twenty-seven women with severe eating disorders were treated by onlinereading program, posting personal journals, and emails with programmoderators, and compared to two control groups. Results showedsignificant improvement of the treatment on most dependent measures.

• Cohen, G. E., & Kerr, A. B. (1998). Computer-mediated counseling: An empirical study of a new mental health treatment. Computers in Human Services, 15(4), 13-27.

  Twenty-four undergraduate students treated for anxiety about personalcounseling through an online chat with a counselor and compared toface-to-face intervention. Results indicated significant decrease ofanxiety level in both groups, and similar evaluations of interventionsessions and counselors.

• Klein, B., & Richards, J. C. (2001). A brief Internet-based treatment for panic disorder. Behavioural & Cognitive Psychotherapy, 29, 113-117.

  Eleven panic-disordered clients who were treated by Internet-based textmaterials were compared to 12 controls who used self monitoring only.Results showed that, on all measures, the online treatment wassignificantly effective.

• Lange, A., van de Ven, J-P. Q. R., Schrieken, B. A. L.,Bredeweg, B., & Emmelkamp, P. M. G. (2000). Internet-mediated,protocol-driven treatment of psychological dysfunction. Journal of Telemedicine and Telecare, 6,15-21.Also published in:Lange, A., Schieken, B., van de Ven, J., Bredeweg, B., Emmelkamp, P. M.G., van der Kolk, J., Lydsdottir, L., Massaro, M., & Reuvers, A.(2000). "Interapy": The effects of a short protocolled treatment ofposttraumatic stress and pathological grief through the Internet. Behavioural and Cognitive Psychotherapy, 28, 75-192.

  Twenty-four students who suffered from PTSD (of various antecedents)were treated through assessment questionnaires, essay writing, andemail correspondence with therapist over five weeks. Results showedsignificant improvement at the end of intervention as well as at 6-weekfollow-up.

• Robinson, P. H., & Serfaty, M. A. (2001). The use of e-mail in theidentification bulimia nervosa and its treatment. European EatingDisorders Review, 9, 182-193.

  Twenty-three women with Bulimia Nervosaor Binge Eating Disorder were treated via email. A 3-month follow upshowed significant improvement in symptoms and severity of problem, aswell as in depression.

• Stroem, L., Pattersson, R., and Andersson, G. (2000). A controlled trial of recurrent headache conducted via the Internet. Journal of Consulting and Clinical Psychology, 68, 722-727.

  Twenty people who suffered from recurrent headaches were treated viaemail. They were compared with waiting-list controls. Results showedsignificant reduction in headache only in the treatment group.

• Tate, D. F., Wing, R. R., & Winett, R. A. (2001). UsingInternet-based technology to deliver a behavioral weight loss program. Journal of the American Medical Association, 285, 1172-1177.

  Thirty-three people were treated for overweight by behavior therapyconducted through the Internet (self-monitoring diaries, emails, forum)and were compared to equivalent 32 people who were treated byinstructional websites only. Results showed significant reduction ofweight for the behavior therapy group, and change was significantlysuperior to the comparison group.

• Winzelberg, A. J., Eppstein, D., Eldredge, K. L., Wilfley,D., Dasmahapatra, R., Dev. P., & Taylor, C. B. (2000).Effectiveness of an Internet-based program for reducing risk factorsfor eating disorders. Journal of Consulting & Clinical Psychology, 68, 346-350.

  Twenty-four women were treated for eating disorders through astructured 8-week intervention delivered through a discussion on theInternet. They were compared with a control group. Treated groupimproved significantly on several measures and, unlike the controlgroup participants, continued to improve at follow up.

• Zabinski, M. F., Pung, M. A., Wilfley, D. E., Eppstein, D.L., Winzellberg, A. J., Celio, A., & Taylor, C. B. (2001). Reducingrisk factors for eating disorders: Targeting at-risk women withcomputerized psychoeducational program. International Journal of Eating Disorders, 29, 401-408.

  Fifty-six women were treated for body image dissatisfaction, disorderedeating patters, and preoccupation with shape/weight using a PC-basedsoftware and an online bulletin board (forum) and compared to controls.Results showed significant improvement in most outcome measures at theend of intervention and at follow-up.

Professor Azy Barak
University of Haifa