From April 2002 NASW NEWS
Copyright Š2002, National Association of Social Workers, Inc.

Internet-Based Therapy Draws Criticism

The document contains many caveats about text-based Internet practice.

By John V. O'Neill, MSW, NEWS Staff

The Clinical Social Work Federation drew sharp criticism after publishing a position paper opposing text-based online therapy, a form of treatment practiced by some social workers and other mental health professionals and one that has drawn great interest from many others.

The federation's five-page document contains many caveats about text-based Internet practice, calling it "fraught with risks and hazards for both clients and clinicians."

Among areas of concern in the paper, written by Renee Lonner and reviewed by a four-member committee, are:

That confidentiality is impossible to ensure when information is transmitted over the Internet, "at least at this point in time and perhaps ever."
That the issue of documentation poses significant risk for clients and clinicians. The existence of a "real time" record of the client-therapist interactions provides a very useful document for attorneys to subpoena.
That "there is no assurance that the presenting information delivered online is accurate . . . no empirical evidence that providing therapy services online is effective."
That "given the high potential for harm to the consumer such as breach of confidentiality, misdiagnosis because of limited or incorrect information and jurisdiction issues (practicing, perhaps unwittingly, in a state in which one is not licensed), it would not be a surprise to see some licensing boards, in the near future, caution against or prohibit online counseling except for specific, unusual situations."

Text-based Internet therapy was tested against 10 interdisciplinary principles for professional practice in "telehealth," developed by an American Psychological Association group, and found lacking, said Lonner.

"Managed care," says the paper, "has already served to diminish the commonly accepted vehicle for change in mental health—the therapeutic relationship—and online therapy, as a tool, serves to nearly eradicate it."

The federation's statement drew rebuttals from many social workers and others familiar with text-based online therapy.

The paper presents an "overly rigid and simplistic, one-dimensional view of online mental health services," wrote Michael Fenichel, president of the International Society for Mental Health Online.

"There is growing recognition, among members of professional organizations, that while there are definitely grave risks inherent in online treatment, there is also an incredible potential benefit in providing services to those who are geographically isolated, socially anxious, physically disabled or fearful of stigma for seeking help, information and support," said Fenichel.

There is a growing body of evidence to suggest that some positive outcomes have been facilitated by online treatment, he said. His organization takes the position that online professionals should not only be every bit as qualified as off-line practitioners, but have additional training, competencies and skills that facilitate ethical, professional practice.

Social work online expert Susan Mankita of Miami, Fla., said the federation's position paper is "supported by vague, undocumented assertions."

Social workers, who are uniquely qualified to practice online therapy, could be driven away and not contribute to the knowledge base of online therapy, she said. "What a shame, when other professional mental health groups are encouraging the development of sound practice guidelines, outcome studies and theoretical exploration."

The relative anonymity of the Internet can increase the willingness of clients to take a chance on therapy and explore previously protected areas, said Mankita. "The missing visual and social cues, often perceived as a barrier to effective clinical understanding, can also work to free both the therapist and client of preconceived notions, through which new opportunities to relate can be explored."

"Theory, research and practice knowledge already abound, and I encourage [the federation] to consider encouraging their clinician members to read what's out there and make responsible decisions for themselves," Mankita said.

The tone and theme of the paper "appear to be a reactionary response by the old guard," said Ed Newman, a Sacramento, Calif., social worker. "I don't believe that any one modality is superior to another, but each has its indications and contraindications. Perhaps that is what should be explored in lieu of a generalizing statement based in academic and cultural myopia."

There have also been many supportive messages for the position paper from social workers, said Lonner in an interview. The position paper is not opposed to Internet therapy as an ancillary treatment after face-to-face contact is made, she said; it is opposed to totally text-based therapy.

Without the ability to ensure confidentiality, to know for sure who the client is, and without informed consent, which would be compromised because identification is impossible, online therapy fails to meet the ethical and professional standards of care for the clinical social work profession, she said.

"The first issue is, 'Do no harm.' The second issue is, 'Are you going to heal?' she said. "We haven't passed, 'Do no harm.'"

NASW has published a Social Work Practice Update, "Online Therapy and the Clinical Social Worker," listing the pros and cons of Internet therapy.

NASW's Professional Liability Insurance program provides coverage for Internet and telephone practices. However, the Insurance Trust cautions policyholders to keep abreast of methods of practice, to take great care to prevent a breach of privacy, and that there may be different requirements or licensure in the various states.

For the federation's paper: www.cswf.org/therapy.html. For details about the NASW Practice Update: www.socialworkers.org/practice/update/online.htm

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