The Internet as Therapist
by John L. Miller,
the past five years the mental health field met the Internet,
became familiar with it and many of us are now learning to work
in an electronic world. The Internet has been around for more
than twenty years. For many years, research scientists and the
military for defense largely used it and it only became widely
available with the invention of hyperlinking. Linking
creates the World Wide Web (WWW) and allows users to navigate
from page to page with the click of a mouse. The Web basically
ties together information from around the world and allows anyone
with a computer and the ability to log on access to the information.
so activities in the field are about sharing information,
healthcare stands to reap huge gains as Web technology is
more widely used. Much of healthcare involves the sharing
of patient* information with stakeholders, including primary
care providers, specialists, payors, labs, and hospitals.
The Web provides a remarkable solution to linking these entities
together. In addition to publishing patient education and
improving patient care, continuing education for professionals
will also become easier through online courses dealing with
issues relevant to each practitioners specific needs.
(*The term patient is used generically in this article to
include patients and clients.)
must learn about online technology in order to meet the needs
of todays empowered, e-health consumer. It is estimated
that almost one-third of the $1.3 trillion spent on healthcare
today is wasted by the inefficiencies of the current, paper-dependent
system. As practitioners learn to utilize the Internet, their
practices and the treatment they offer will become more cost-effective.
Today, the WWW brings a marvelous, desktop tool to the field
that can be used to improve the quality of care to patients.
For the first time in history, with the use of this electronic
teaching tool, practitioners have instant access to best
treatment information, expert consultations and established
treatment guidelines. By providing access to more efficient
care for patients and timesaving tools for practitioners,
e-health tools hold the promise of driving down traditional
What is e-health?
means any form of healthcare information made available over
the Internet. For some consumers and/or patients, e-health
includes searching for health-related information at Web sites
, filling their prescriptions at drugstore.com
, or taking depression assessments online
. For others it means interacting with practitioners
via e-mail or directly through videoconferencing.
is driving e-health?
is expected to grow dramatically in the next few years and
there are several major factors to consider including:
- Public Policy
numbers of Internet users are rushing to find health information
from health-related Web sites. The number of U.S. adults using
the Internet to find health information surpassed 98 million
this year and that is twice as many as just two years ago.
Over 50% of all Internet users seek health
information on the Web and after finding the information,
the top three actions they take are:
- Urge a friend or family member to see a doctor
- Ask their doctor
about a specific medication
- Make a treatment
that more than 60% of those seeking online health information
express a desire to communicate by e-mail with their practitioners.
One study predicts that the “competition for e-health consumer
mind share will be fierce.”
Cyber Dialogue reports that 29% of respondents
to one of their e-health studies said, “They would be likely
to switch doctors to use a Web site operated by their physician’s
to Laurie Flynn, executive director of the National Alliance
for the Mentally Ill (NAMI), mental health sites are among
the five most popular health sites on the Web.
Flynn states, “The anonymity appears to
allow people to seek information and move more rapidly toward
diagnosis and treatment.”
Some of these people become empowered patients
and as they become savvier they expect more from their practitioners.
Even seasoned practitioners, who do not recognize this fact,
run the risk of losing patients to their colleagues who endorse
the e-health movement and who welcome increased patient participation
in treatment decisions.
believe the baby boomers, who have been so successful at changing
other areas of our economy, will lead the charge to change
healthcare from practitioner-centric to consumer-driven. Speaking
of the baby boom generation, Regina E. Herzlinger, Ph.D.,
professor at Harvard Business School and author of “Market-Driven
Health Care,” said, “They’re the ones who have changed the
rest of the economy and they’re very interested in health
care. There’s no reason for any rational person to believe
that they’re going to say, “Oh no, leave health care in the
hands of these people who are going to tell me what to do.”
Today’s consumers simply won’t accept that.”
search engines and niche health portals furnish patients access
to the same scientific databases, clinical information, and
other sources that their practitioners often lack sufficient
time to study. Practitioners should be reminded that, in contrast
to the many conditions of which they must demonstrate
expertise, patients usually have only one disorder
to study. Some practitioners refer to patients who become
particularly knowledgeable about their conditions as “board
Nicholson, professor at Wharton School of the University of
Pennsylvania, recently reported about patients who visit their
doctors carrying health information they have retrieved from
the Internet. Nicholson says, “What’s interesting is the number
of times the patient walks away with a lower evaluation of the
doctor. Why? Perhaps because he or she doesn’t think the doctor
is up-to-date. In some cases patients say they are thinking
about finding a new physician because of that impression.”
As mentioned previously, a majority of patients
would like to receive their health information from their practitioner’s
Web site. However, only a minority of practitioners offer a
personal Web page to their patients. Internet companies like
provide Web pages for their physician
and nurse members. Our company, athealth.com
specializes in publishing comprehensive
online directory pages to help mental health practitioners meet
the needs of their patients.
it took television over 25 years to reach mass penetration
of consumers in the U.S., it took the Internet only seven
Two factors adding impetus toward the building
of a “wired world” are advertising and investment dollars.
Advertisers focused on health-related Web sites expect their
total spending to exceed $265 million by 2002.
Investors also provide capital to entrepreneurs
with solid business plans for companies promising to deliver
e-health more efficiently than traditional forms of care.
major driving force toward e-health is the increasing amount
of personal dollars consumers are spending for their healthcare.
Trends show that consumers are picking up a larger percentage
of the price of their healthcare and it is believed that this
movement will increase as care becomes more managed and employers
introduce defined contribution plans. In the end, as employees
contribute more of their personal dollars toward their healthcare,
they will demand more cost-efficient, high quality care from
parity for mental healthcare works it way through state and
federal legislatures access to and demand for care is likely
to increase. The Internet and its Web technology may provide
anonymity and easier access to mental health information, assessment
and treatment to a large segment of our population that presently
is not receiving care. Online tools may provide major benefits
to practitioners wanting to broaden their reach of their traditional
healthcare is very complex, e-health will come of age through
evolution, not by revolution. All of the major beneficiaries
of e-health recognize that it is essential to weave online
e-health tools into the “information technology challenged”
healthcare system. However, because of complexities it will
take longer for healthcare to adopt Web technology than other
sectors of our economy. Some of the main obstacles facing
e-health include privacy, security, authentication and professional
specific technical aspects of privacy, security and authentication
are beyond the scope of this article. However, patients have
the right to expect that their online health information remains
private and they must be guaranteed that those who provide e-health
are qualified professionals. Acknowledging these facts, technology
companies are spending huge sums of money to insure that online
interactions between patients and their practitioners will be
secure. Already, much of the technology is in place to insure
that the patient’s paperless medical chart will be more private
than the traditional paper chart. Today, as the chart moves
from the file cabinet to exam room, laboratory, front and back
office, it can be read by many healthcare staff, many of whom
are not directly involved in patient care. Online technology
permits medical personnel various levels of password-protected
privileges. For instance, the front office staff privileges
only allow viewing of the patient’s demographic and billing
information but not the clinical record.
organizations are developing standards that will allow practitioners
to safely utilize online e-health technology with patients.
The International Society for Mental Health Online (ISMHO)
, promotes “the understanding, use and development
of online communication, information and technology for the
international mental health community.”
The ISMHO, in conjunction with other professional
organizations such as the Psychiatric Society of Informatics
, published the “Suggested Principles for
the Online Provision of Mental Health Services.”
Included in the report are topics dealing
with informed consent, standard operating procedures and emergencies.
Last July, the American Medical Association (AMA) published
the “Guidelines for Patient-Physician Electronic Mail.”
The report addresses the main obstacles
to the usage of e-mail between practitioners and their patients,
of the enormous amount of resources being invested, benefits
will begin to outweigh the obstacles associated with e-health.
Some of those benefits include:
Insuring privacy and confidentiality of patient information
appropriate standards for security
patient education material about using e-mail in their care
- Risk Assessment
- Early Intervention
- Treatment Adherence
will become easier for patients to find information about
their illnesses and disorders on the Web as new user-friendly
search tools are developed. Today, about 50% of U.S. homes
have Internet access. Patient education opportunities will
increase dramatically as access to the Web increases and more
patients are able to log on. Already, many patients visit
their practitioners with articles they printed from their
favorite health-related Web sites. These patients want and
they need help interpreting the online information they find.
They look for practitioners willing to partner with them in
their healthcare decision-making process. This new proactive
information-seeking patient stands in stark contrast to patients
of a former era, who were more passive and less involved and
who expected their practitioners to direct their care.
sites providing online assessments are beginning to be used
by e-health users. In addition to Web resources like Prozac.com
, which offers brief depression assessments,
there are sites like Paxil.com
, which provides an online version of SPIN,
the Social Phobia Inventory. CopeWithLife.com,
according to its authors, “is for people
who want to cope with their depressive symptoms, as well as
the stresses and anxieties that hamper their emotional health.
It helps you when you need it, on your own schedule, with
or without a doctor's care.”
COPE was developed by nationally recognized
psychologists and psychiatrists, Lee Baer, Ph.D. Associate
Professor of Psychology, at Harvard Medical School, John H.
Greist, M.D. Clinical Professor of Psychiatry, University
of Wisconsin Medical School, and Isaac Marks, M.D., from the
University of London. COPE is reported to be an “effective,
confidential and convenient” self-help program to aid those
using the program.”
insuring security with the use of encryption and authentication,
e-mail will become increasingly important to practitioners.
For example, Joel Yager, M.D., Department of Psychiatry, University
of New Mexico, uses e-mail with some of his patients with
eating disorders. Many of his patients live in rural New Mexico
and they drive long distances for their appointments. Dr.
Yager receives an enthusiastic response from many of his young
patients who utilize e-mail to communicate with him between
their scheduled office visits. Younger people, who are growing
up with the personal computer, find fewer obstacles with online
technology associated with healthcare. 
and mailing lists are popular forms of e-mail for patients
and practitioners to enhance the exchange of health information.
publishes a free, weekly e-newsletter,
Friday’s Progress Notes, for more than 44,000 mental health
practitioners. Each issue focuses on a specific mental health
topic. An issue dedicated to drug abuse can be viewed online
at the newsletter archives
. The e-newsletter, which will soon offer
continuing education, is delivered to the practitioner’s desktop
and saves important research time by providing professionals
with current Web resources related to each week’s topic. Mailing
lists such as one offered by the International Society of
Mental Health Online provides its subscribers with daily e-mails
containing the dialogue of professionals discussing issues
associated with e-health. Professionals interested in subscribing
to the free service should send an e-mail to email@example.com.
Include the word “subscribe” without quotes in the subject
line and include your e-mail address in the body of the e-mail.
people, especially those under 25 years old, are very comfortable
with the use of live chat or online discussion groups. An
increasing number of patients find very valuable support online
from others suffering from the same mental disorders. An example
of this popular discussion forum is the alcoholism discussion
where participants trade information
about their disorder, its diagnosis and its various forms
of treatment. On about.com, at least four online AA meetings
are scheduled each day. One of the meetings, called “Serenity
by the Cybernet AA Chat,” offers four online rooms to meet
the needs of alcoholics seeking help.
Ainsworth is the host of the Web site Metanoia.com whose mission
is “to dissolve barriers that separate people who need help
from caregivers who could provide it.”
The site emphasizes that, “Online counseling
is not a substitute for traditional psychotherapy. If you
can visit a therapist in person, you should.”
Metanoia does not have online professionals
on their staff, but there are links to practitioners who do
offer online counseling and an online tutorial is provided
to help patients search for competent therapists.
the value of using Internet tools to augment face-to-face
treatment in the office setting is widely recognized, “online
therapy” remains very controversial for a majority of mental
health practitioners. Ethical issues abound as professionals
struggle to set legitimate standards for e-health. Many patients
are willing to share personal health information online even
though their privacy may not be secure. Worse yet, vulnerable
patients may use some Web services where the credentials of
the “professional” have not been authenticated and/or credentialed.
For instance, the online practitioner, who is bound by the
rules of the state in which he or she resides, may be engaging
with a patient in another state in which the practitioner
is neither licensed nor certified. Also, using today’s online
tools without proper safeguards, the severity of a patient’s
depression or suicidal intent might be missed or, without
accurate authentication, a child or adolescent, who claims
to be an adult, could engage an online counselor in totally
inappropriate “sex therapy.”
British Journal of Guidance and Counseling reported a situation
where a male therapist named “Alex” disguised himself as a
female therapist named “Joan.” After gaining the trust of
online patients, “Alex” revealed himself and his “experiment”
much to the dismay and hurt of those with whom he interacted.
offers phone consultation and online chat
sessions. They publish lists of their online Counseling and
Consulting Staff. After selecting an online counselor, site
visitors may click to the “Lobby” where they can schedule
a phone call or Internet chat with the professional. A charge
of $20 is made to their credit card for the first 20 minutes
of the chat session. Here2Listen.com
offers “e-counseling.” At this site online
therapists’ names are published along with their degree, the
institution where they studied, state license number, areas
of expertise, theoretical orientation, and the fee for a one-half
hour online session. eTherapy.com
recently opened to manage mental health
services of the “highest levels of legal and ethical responsibility”
for online practitioners. Therapists manage
their own Web practices and eTherapy.com generates revenues
by charging a small administrative fee for each session. Therapists
are restricted to working only with clients from states in
which they are licensed and they are required to complete
an online practice training program.
, labeled the “virtual clinic” is
an online videoconferencing tool being developed for family
practitioners. The application, which will be tested using
tech savvy Microsoft employees later this year, is designed
to be “an accessible, trusted mentor and provider of health
information and medical services for employees who work in
a high-tech corporate environment.”
In a recent demonstration, a mock
patient seated at his personal computer in his office interacted
with Bill Crounse, M.D., co-founder of this e-health venture.
The total time spent by the patient to “see” his doctor was
less than ten minutes. The online interaction saved more than
two hours work time that the employee would normally spend
driving to and from the doctor’s office and the time waiting
for his appointment. A very important component of DrGoodwell.com
is that the practitioner will be paid a fee for his or her
time online. Employers are likely to endorse this type of
e-health, which promises to improve employee productivity.
If employers and employees sign on, it is also very likely
that practitioners will learn to use the technology.
spite of these examples, some experts in e-health agree that
practitioners are wise to wait for their professional organizations
to develop standards before assuming the risk of providing
e-health care. To facilitate this process, the U.S. government’s
Health Insurance Portability & Accountability Act (HIPAA)
is scheduled to take effect over the next couple of years.
HIPAA addresses much of the privacy, security and authentication
issues of e-health.
with the use of online applications, practitioners can receive
continuing education with a steady stream of daily information.
We can benefit, already, from Internet tools permitting us
to focus on topics that are highly relevant to our practice
settings and clinical interests. In addition to receiving
our education from traditional sources such as textbooks,
home study and live conferences, practitioners can logon to
our favorite Web resources between patients to check the latest
references relating to the “best practices” or expert treatment
guidelines relating to a particular disorder. For instance,
the American Psychiatric Association (APA) publishes several
guidelines including, “Practice Guideline For The Treatment
Of Patients With Substance Use Disorders: Alcohol, Cocaine,
Opioids” on their Web site.
These guidelines can provide a source of
reassurance to the practitioner that he or she is providing
care within a standard recognized by experts in the field.
clinicians find mailing lists delivered by e-mail to be extremely
useful as a noncredit source of, what this author refers to
as “continuous education.” During the last two years of my
outpatient psychiatric practice, I subscribed to several mental
health-related mailing lists. One of these, called the “Psychopharmacology
Mailing List,” was an ongoing source of very practical information.
Each day, the mailing list provides the e-mail dialogue between
experts pertaining to the use of psychotropic medications.
These experts included not only academicians but also many
clinicians, who were “in the trenches” practicing psychiatry.
Ivan Goldberg, M.D., who is from New York, moderates the list
and he helps to keep the subscribers’ discussion focused on
other mailing lists relevant to mental disorders and their
treatment can be found at Web sources such as L-Soft
Visitors to the site can search for mailing
lists dealing with their favorite topics. For instance, a
search for “addiction” yields eight specific mailing lists
including, “Academic and Scholarly Discussion of Addiction
Related Topics,” “Breaking Free: Newsletter of the Addiction
& Recovery Forum,” and “Women and Addiction Research Network.”
The number of subscribers to each of these lists number from
27 in “Women and Addiction” to 7,714 in “Breaking Free.”
Web sites offer accredited, online, continuing education (CE)
courses. Sites specifically offering courses for mental health
professionals include the Hazelden Distance Learning Center
for Addiction Studies (DLCAS), athealth.com and Behavioral
Healthcare Community’s Continuing Education Online. Hazelden
Foundation in association with DLCAS,
presents instructors, including Dennis
Daley, Melody Beattie and Craig Nakken, to its online audience.
About 30 courses pertaining to addiction are listed in their
and Behavioral Healthcare Community’s Continuing
are Web sites that provide CE for a broad
range of mental health topics professionals. Athealth.com
links its weekly newsletter, Friday’s Progress Notes, directly
to some of its CE/CME courses and will be adding online discussions
moderated by experts to enhances their courses.
CE allows practitioners to receive an important part of their
education conveniently from their office or comfortably from
their home day or night. Additionally, by saving travel expenses
and time out of the office practitioners are showing a rapidly
growing demand for online CE.
including mental health, is struggling with the introduction
of Web technology into practitioner’s lives and the lives
of his or her patients. With the desire to provide high quality
care to those we serve, practitioners are increasingly endorsing
online information and education. E-health will grow as practitioners
are assured that when they engage with their patients online
they will “do no harm.”
Cyber Dialogue and Deloitte Consulting,
Q1 2000 Study
Where will the Road to E-Health Lead?
Ten E-Health Trends” , First Consulting Group, C. McGoldrick,
S. O’Dell, An Emerging Practices Industry Review, May
The Emergence of the E-health Consumer,
Deloitte Consulting and Deloitte & Touche, 1999
Health Industry and the Internet, New
York, NY: Jupiter Communications, 1999
Ibid; Personal communication
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