Finding a therapist used to mean receiving a referral or recommendation, then scheduling an appointment, getting dressed, and fighting traffic. For someone struggling with depression or anxiety, facing burnout, or already juggling a hectic schedule, each of these steps can act as a barrier to accessing therapy.
Online therapy promises rapid access, lower costs, and no need to get dressed or leave the house. For therapists, it’s an easy way to access more clients and serve the greater good. Online therapy, however, raises significant ethical concerns, most notably the challenges of protecting clients’ privacy. Therapists must be mindful of state ethical guidelines and laws and embrace best practices for helping people they may never meet in person.
Teletherapy and Online Therapy Today
Teletherapy is rapidly evolving. A few years ago, online therapy primarily occurred over email. Now, most clients expect real-time interactions with highly responsive therapists. Indeed, rapid access to a therapist is a primary reason many clients seek online therapy. Some common delivery methods for online therapy include:
- Self-help programs through an app. Increasingly popular among people who want to improve their mental health, these programs are often developed by therapists or rely on expert therapist insight.
- Teletherapy through video chat. This modality closely mimics traditional therapy but allows clients to access therapists from virtually anywhere with an internet connection.
- Text therapy. Some therapists offer text messages of encouragement or support as part of a larger program. Others allow their clients to text them quick questions. Text therapy is not a comprehensive treatment approach and usually happens as part of a broader treatment program.
Research into the effectiveness of online therapy is ongoing, but several studies suggest that high-quality online therapy can be just as effective as in-person treatment. A 2014 randomized controlled trial, for example, found online cognitive behavioral therapy (CBT) could be as effective as traditional therapy in the treatment of depression. A 2015 analysis of medical residents found that doctors who received four 30 minute online counseling sessions reported fewer suicidal thoughts.
Are There Any Limitations to Online Therapy?
Online therapy can increase access to psychotherapy to people who might otherwise never have sought therapy. It also presents some limitations. Some of those include:
- Privacy. If therapy is not delivered across a secure, encrypted channel, third parties could access sessions or session notes. If a therapist uses an app that logs a user’s IP address, this could also present confidentiality issues.
- Practicing across jurisdictions. Every state and therapist licensing board has its own guidelines about practicing across jurisdictions. In many cases, therapists may not be authorized to deliver therapy to clients who live in states where the therapist is not licensed to practice.
- Duty to warn. Therapists generally have a duty to warn third parties if they believe a client presents a threat. They must also report suspected child abuse. If the therapist has never met a client or does not know the client’s physical location, it may be difficult for a therapist to meet their ethical obligations.
- Establishing rapport. For some therapists, establishing a strong rapport with a client may be more difficult when they don’t meet with the client in person. Therapists should be mindful of their own limitations and consider new strategies for developing a strong therapeutic alliance.
Hilary Akman, LPC, LMHC of Davie, Florida offers online counseling as a part of her services. She highlights privacy, convenience, and flexibility for clients as some top benefits of online therapy. When asked about potential drawbacks, she explains, “The biggest drawback is technological glitches. Sometimes connection can be lost. I always tell my clients that if we were meeting in an office setting, I would never get up and leave the session; similarly, I would never end our online session. So if we get disconnected, they can understand it is a computer issue and are given instructions as to what to do next, usually logging back in.”
Ethics of Providing Online Therapy: Key Points
Therapists starting an online practice should check local licensing board rules for limitations and guidelines. State laws vary greatly and change quickly, so it’s important to consult a reliable source in your state. Some general ethical guidelines that can help include:
- If you participate in a teletherapy app, know the app’s policies. Ensure those policies comport with state laws and with your own practice norms. Only work with apps that can fully secure client data and that endorse treatment approaches that are evidence-based and ethical.
- Take proactive steps to secure client data. Only provide therapy across a secure connection. Inform clients about the privacy risks inherent to online therapy. It’s especially important for them to know that people they live with who can gain access to their computer may be able to gain some information about their therapy sessions—especially if sessions are recorded or if session notes are stored anywhere on the computer.
- Be mindful of scope of practice issues. People seeking online treatment, like other clients, may present with a range of issues. If a client reveals an issue which you are not equipped to treat, refer them to another therapist.
- Practice good informed consent. Be clear about fees, treatment goals, treatment expectations, and your privacy policies. If you treat children or adolescents, follow your state’s rules for permission to treat and informed consent.
- Know your clients. Get basic information such as their name and contact information, and explain how you will use this information. Depending on the facts of the case and the state in which you practice, you could be held liable for harm to a client or the harm a client causes if you do not follow your ethical obligation to report abuse and warn of danger.
- Set clear expectations for communication. Online therapy does not mean you have to be accessible 24/7, yet boundaries can break down in an online context. So let a client know when and how frequently they may contact you and what they should do if they experience a mental health emergency.
Starting an Online Practice?
An online practice may allow you to reach people who need therapy the most—people too depressed to drive to sessions, those with overwhelming schedules or very young children, and people who feel anxious about going out in public or meeting a therapist in person.
An online practice can also add a new stream of revenue. GoodTherapy offers a wide range of resources to therapists at every stage of their career, including those starting an online practice. Join today to be included in our online directory, so clients seeking teletherapy can easily find you.
- Guidelines for the practice of telepsychology. (n.d.). Retrieved from https://www.apa.org/practice/guidelines/telepsychology
- Novotney, A. (2017). A growing wave of online therapy. Monitor on Psychology, 48(2), 48. Retrieved from https://www.apa.org/monitor/2017/02/online-therapy
- Reynolds, D. J., Stiles, W. B., Bailer, A. J., & Hughes, M. R. (2013). Impact of exchanges and client–therapist alliance in online-text psychotherapy. Cyberpsychology, Behavior, and Social Networking, 16(5), 370-377. doi: 10.1089/cyber.2012.0195
- Wagner, B., Horn, A. B., & Maercker, A. (2014). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal of Affective Disorders, 152-154, 113-121. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0165032713005120?via%3Dihub