Imagine a dot.com referral service that allows consumers to select a psychotherapist in their state of residence. You register, and eagerly await referrals. Within a month, you receive an email referral from someone at the far end of your state.

The email describes the details of how a prospective patient "had to punish" her elderly grandmother for not eating and not bathing last night. The consumer is requesting your professional services for managing her anger toward her grandmother. The note describes the punishment in enough detail that you have reason to report her for elder abuse. You have her name, street address and telephone number, as well as that of her grandmother. The consumer awaits your response. You look at the website documentation, and they suggest you "follow your state protocols" or "dial 911" for all emergencies. What do you do?

The unwitting clinician in the above scenario is in a difficult position. Depending on state laws, reporting the patient could be mandatory. However, such a report is fraught with complications, and risk of losing or alienating the patient is high. Duty-to-warn situations, such as the one above, can leave the untrained and uninformed practitioner at increase risk for malpractice when operating in email with unknown, unscreened, unseen and unheard prospective patients.

Yet, the assimilation of technology is a requirement for almost any industry seeking to maintain a viable position in today's global marketplace. Psychotherapy is no exception. Practicing psychotherapy online is inevitable. Technology will increasingly enhance our ability to offer services to patients who are unable or unwilling to use existing face-to-face services because of geography, disability, finances, work schedules, and a variety of other life circumstances. Yet, as we can see with the above vignette, barriers to such practice are becoming more salient.

While technology has leapt ahead of our ability to develop a body of research and clear legal, regulatory or ethical guidelines for the remote practice of psychotherapy, many earnest clinicians are seeking guidance to expand their practices without incurring additional risk. Making sense of often-conflicting informational sources is time consuming and anxiety provoking. Therefore, this article will give a brief outline of barriers to using telecommunication technologies, and suggest a risk-management model that takes advantage of the telEhealth literature to carve a path through those barriers.

Barriers to Using the Internet for Psychotherapy

Barriers to the immediate practice on the Internet include a variety of factors. Only those of direct relevance to the practitioner are discussed in the following section.

Economic Drivers

The Internet continues to explode, with worldwide estimates from the NUA tracking firm to currently be at 407 million users. Commerce.net predictions are that the number of users will be over 765 million by the year 2005. The majority of Internet users search for health information and services. Mental health is the topic of many Internet searchers, with a recent Harris poll showing that information about "depression" was the most frequently accessed health topic, and that 4 of the top 10 accessed health topics had a primary or secondary behavioral component. It is only reasonable to assume that this trend will continue, as people can easily find health-related information without the embarrassment of speaking to a professional or religious community leader to find the answers to their personal questions. Telecommunications technologies are being transformed into social networking technologies as people form communities to find answers and support for the problems that plague their everyday existence.

The online mental health delivery system, however, is sorely lagging in development. Service delivery models suggested by many dot.com mental health websites put the practitioner at risk. Many such websites are developed with more of an eye toward making a profit than delivering services that would benefit both the patient and practitioner. For example:

• Some web-based businesses require that a practitioner sign a service agreement that not only holds the practitioner responsible for any and all malpractice liability, but explicitly indemnifies the dot.com.
• Some web-based businesses encourage practitioners to work with anonymous patients.
• Some web-based businesses encourage practitioners to ask the patient to dial "911" for all emergencies, including suicide or homicide.
• Some web-based businesses offer consent agreements and disclaimers, but the effectiveness of such agreements on web pages is questionable.
• Some web-based businesses verify the practitioner's credentials and state of licensure, they do not verify the consumer's state of residence. The practitioner, then, does not have evidence of a consumer's location when delivering services. Yet, the professional may be responsible for practicing out of state, even if consumers misrepresent themselves.

While some companies are beginning to offer creative services to both practitioners and consumers, there is tremendous opportunity for those with creative and innovative minds. Examples of promising models include http://masteringstress.com/, http://copewithlife.com/, http://www.egetgoing.com/, http://nicotinefreedom.com/ and a host of other services that offer self-help, self-directed interventions, to be augmented by the services of a professional in the real world.

Training

Most practitioners are not trained to use advanced telecommunications equipment, and therefore do not fully understand the legal, ethical or practical ramifications of using such technologies. Text-based environments, such as email and chat rooms, are the only current types of communication supported by web services offering any form of confidentiality. Most practitioners have not had graduate training regarding psychotherapeutic contact in text-based environments (email or chat). Practitioners are generally taught to conduct assessment and treatment using auditory (voice amplitude, rate of speech, stuttering or hesitation) and visual cues (eye contact, blushing, fidgeting), not textual cues. Practitioners are also not typically aware of the numerous ways in which their own computer privacy can be compromised by computer savvy patients.

Utility

Many technology developers have not yet developed helpful products and services for psychotherapists. Existing technologies often require more time and energy than traditional service delivery.

Confidentiality

Computer and Internet security and confidentiality are easily compromised. Breaches of privacy are rampant. For example, many practitioners do not know how to completely remove patient files from their own computer hard drive, how to secure email transmissions to protect patient confidentiality, or how easily a patient can install a "Trojan Horse" program into the practitioner's computer to download the contents of the practitioner's computer onto a remote computer.

Legal protections for patients and practitioners are still in flux. While federal standards to protect the transmission and privacy of medical information are currently being developed, compliance is not yet mandatory for many such standards. A number of Internet businesses are using the current, relatively unregulated interval to gain a foothold on "market share," while testing various business models with naïve practitioners.

Attentiveness, Distraction and Privacy

From the clinician's perspective, it is more difficult to determine if a person is fully attentive or distracted during the therapeutic interaction when using technology. Practitioners therefore need to be trained or otherwise experienced in the various possibilities for misinterpretation when working with each specific technology before offering services to the public.

Duty to Warn Situations

While many practitioners are trained in crisis management through the telephone, they not trained in crisis management through email or chat rooms. Training with one technology does not automatically amount to training in another. Furthermore, conclusive research into the efficacy of any treatment mediated by email or chat room has not yet been conducted. While the lure of existing technology may be strong, the duty to protect patients must be stronger.

Many dot.com developers also conveniently encourage practitioners to "follow state law" when dealing with duty to warn situations, but state laws are not yet developed in most states. Moreover, some dot.coms encourage practitioners to "refer suicidal or homicidal patients to 911." Many practitioners are not comfortable with such arrangements because they know that these patients are typically reluctant to engage law enforcement officials to stop them from their intended actions.

Linguistic and Cultural Competence

With worldwide connectivity brought by the Internet, consumers from remote areas of the planet can easily make contact with a clinician. The clinician's familiarity with colloquial expressions, idioms, and local variations of word usage can be crucial when working with mentally ill, suicidal or homicidal patients.

Similarly, cultural norms, local traditions, and religious rituals can all play important roles in the lives of clients and patients. To offer behavioral and mental health care in the absence of such information is questionable practice.

Local Events and Emergency Backup

A related issue is that of the clinician needing to have awareness of local area events that might influence the emotional state of consumers of Internet services. Similarly, it is the responsibility of the professional to have adequate emergency backup systems in place before offering services to consumers, even if patients do not think such backup relevant or important.

Reliability of the Connection

Unfortunately, reliability of contact is lessened significantly when delivering services through telecommunication technologies as they currently exist. Backup must be developed.

Research

By 1998, behavioral health care via videoconferencing accounted for nearly one fifth of all telemedicine consultations in the United States. Other studies of current telEhealth programs nationwide show that nearly one half involve some type of mental health service. This high utilization rate makes behavioral telEhealth the fastest-growing area of telEhealth. Such studies have been reported in the behavioral healthcare literature for approximately 40 years. Much of these findings are related to videoconferencing and/or computer mediated self-directed programs that augment traditional psychotherapy.

Pilot programs investigating two-way, interactive videoconferencing generally use a model based on local evaluation of a patient by a clinician, with consultation or referral to a remote specialist who is accessed through videoconferencing. These studies are most often conducted in controlled settings with small and often relatively homogeneous patient subgroups (not global population, such as found on the Internet).

Computer medicated self-directed programs have also been shown remarkably effective for treating a variety of disorders. Successful programs tend to regularly involve the intervention of a psychotherapist, rather than being exclusively patient-driven.

Of particular note is that only a few studies have examined the clinical utility of using email or chat rooms with patients. These reports typically are anecdotal and inconclusive. Furthermore, research has not shown the efficacy of any assessment instrument to rule out serious mental illness in the worldwide population accessible through an Internet website.

Risk Management Suggestions

The dubious practice of offering psychotherapy to unknown consumers worldwide without the proper research to establish the utility, efficacy and reliability of email and chat rooms with any clinical population is fraught with pitfalls. However, the risk management procedures outlined below may also be considered potential solutions for practitioners seeking to deliver services to remote patients using videoconferencing. These protocols have been used as the basis for delivering psychotherapeutic services via videoconferencing technologies for several decades. Suggestions include:

Obtain Training

Before proceeding to deliver services through technology, be sure to obtain training from recognized training organizations or specialists in proper use of specific technologies to conduct psychotherapy with behavioral health patients.

Referrals

Be cautious about accepting referrals exclusively in email. Accept referrals and conduct early assessment with patients by using the telephone. Verify state of residence of all remote patients by asking for proof.

Initial Assessment & Consultation

It is wise to follow the precedent set in telEhealth and telemedicine programs when seeking to deliver remote services. Require face-to-face contact for assessment and diagnosis before using technology of any kind to deliver psychotherapy. Obtain a fully detailed consent agreement. Use videophones or dedicated videoconferencing equipment. When using the Internet, only use technologies that are encrypted (encrypted video technology is not yet developed for the Internet.)

If face-to-face assessment by a specialist is not possible, conduct full assessment with the assistance and presence of a local, non-specialist practitioner during videoconferenced evaluation of the patient. Obtain agreement from the local practitioner to act as backup in the case of emergency.

Email Exchange

If public Internet-based email is used, these suggestions may be helpful for licensed psychotherapists:

• Have an existing professional relationship with the patient.
• Provide the patient with informed consent about the use of email. Have your consent form indicate that:
  • contact in email has not been proven to be a validated approach to conducting psychotherapy;
  • if you engage in communication with the patient in email, you may be acting outside the existing standard of care for your profession; and
  • confidentiality problems exist, and that acceptable cures for those problems involve encryption.
• If the patient does not want to use encryption or work through a website offering encryption, do not ask patients to sign away their basic rights of privacy and confidentiality.
• Specify the type of inquiry you will address in email, (i.e., setting or rescheduling appointments, giving titles of books or webpages, giving referrals to other professionals).
• Explain the ease with which email can be intercepted not only on the public Internet, but by family members and friends of the patient.
• Inform patients of whom else might be seeing their email communications to you, and who might be responding to their requests in your place (supervisor, office manager, office assistant).
• Let the patient know when you typically will respond to email, and what to do if they do not get the response they anticipate. Make backup plan for when email is not received as expected, i.e., have the patient telephone you if upset or worried.
• Print all copies of email sent to and received from a patient. Place these hard copies in the patient's paper file.
• Choose patients wisely when experimenting with new procedures. Email may not be a particularly good medium for highly reactive and potential dangerous patients such as those with borderline personality disorder, paranoia or dissociative disorders.
• Because state licensing laws differ from state to state, do not assume that sending email to a patient in another state is acceptable under practice regulations for that state. Inform yourself of the legal requirements for each state involved when sending email to patients. If you choose to work in email with patients you have never met face-to-face, require them to verify their state of residence. Ask your attorney approve your verification procedure.
• Do not refer to colleagues who do not use your level of precaution when communicating with patients in email.

Economic Drivers

Do not assume that a well-funded dot.com company or webmaster has your best interest in mind. Given recent market pressures, economic survival is questionable for most of these companies, and your protection is not necessarily their highest priority. It therefore is suggested that you thoroughly examine the service agreements offered by behavioral and mental health care dot.coms. If you plan to develop your own website, be sure to get a written contract with your website developer regarding security and confidentiality of the files that will be kept.

Manage Your Risk

Regardless of the vendors you hire to mediate contact through technology with your patients, describe your intended treatment protocols and their rationale in writing. Send copies of all agreements, disclaimers, consent forms, and treatment protocols to your attorney. Seek the advice of your peers, and send a copy of these documents to your local, state and national ethics boards, malpractice carriers and licensing boards. Ask them all to respond to you in writing about the legitimacy of the professional services you intend to deliver to the public. While you may not obtain direct approval for the services you plan to deliver, you will have documented that you sought the advice of your peers in developing your innovative services.

A series of lawsuits will undoubtedly clarify legal and ethical matters for our professions. Be prepared. The above activities will take you a few hours, and can prevent years of litigation.

Conclusion

There are innumerable growth opportunities for psychological practice through telecommunication technologies. However, email and chat rooms remove the diagnostic and clinical (auditory and visual) cues relied upon by traditional practice. They have not been shown effective by well-designed research, and are accessible by people from around the globe, with widely differing cultural and linguistic characteristics. Practitioners have not been trained to use these technologies to serve such a varied population. Until these services are adapted to meet the legal and ethical requirements of mental health professionals in these unprecedented circumstances, it is imprudent to use email and chat rooms to establish or maintain psychotherapeutic relationships with unscreened, undiagnosed, unseen, unheard and unknown consumers through the Internet.

However, it is not only reasonable but also exciting to consider the possibilities for psychotherapy afforded by technology. A successful model has been developed for the remote delivery of mental and behavioral services in healthcare using two-way, interactive videoconferencing. Numerous pilot projects in behavioral telEhealth have set a precedent that requires an initial face-to-face assessment, diagnosis, backup procedures, and a patient consent agreement in conjunction with videoconferencing to conduct a wide range of traditional psychotherapeutic functions with patients, their families, and their other healthcare practitioners. Research has also shown the efficacy of computerized, self-directed programs when used in conjunction with traditional clinical care. These technology-based interventions The use of these technologies have been documented and shown effective in numerous situations with various types of patients.

Yet, the need for continued research is obvious. We need better international screening tools for determining who will benefit from remote treatment, especially on the Internet. We need to identify which clinicians will be best-suited and most comfortable delivering services through these technologies. We need legislation to support our work and protect practitioners as well as patients. We need clear practice and treatment guidelines for use with various technologies and patient populations.

At the individual level, and as with all other new areas of practice, it is wise to seek consultation, obtain specialized training, and familiarize ourselves with the literature. It is reasonable to follow a behavioral telehealth model that has been shown effective through credible research. It is prudent to document that we have sought the advice of our peers.

The most important risk is that if we do not become active in shaping and developing new technology for our professions, others will. Propelling us to quicken our step rather wait, our competition in the healthcare arena poses yet another and perhaps more daunting threat. Rather than leaving our fate to be determined by business minds or inexperienced clinicians, the future of our professional rests upon the traditional, seasoned psychotherapist/researcher who can lead the march of identifying the salient aspects of the therapeutic relationship for mediation through technology. Where are our leaders? When will they appear? We need them now. The challenge is great, and so it the opportunity.

About the Author:

Dr. Marlene Maheu is a licensed San Diego psychologist, and the Director of Telehealth and E-health for the Alliant University, where she is developing a post-doctoral certificate program in telEhealth. She has served as the California Psychological Association's Presidential Telehealth Task Force Chair. She served the American Psychological Association's Committee on Professional Practice Standards (COPPS), and is Co-chair for APA Division 46, Task Force for Media & Telehealth.

As President of E-health Interactive, Inc., Dr.Maheu is a national consultant, trainer and speaker for professionals interested in developing technology-based healthcare services. She is Editor-in-Chief and founder of http://selfhelpmagazine.com, an award winning online electronic magazine, with over 7,000 daily readers. She is also lead author of a newly released text, E-health, Telehealth and Telemedicine: A Practical Guide to Startup & Success. This resource guide is currently available through http://telehealth.net