COMMENTS

Internet-mediated psychotherapy: Are we ready for the ethical challenges?

Priya Satalkar, Shivanshu Shrivastava, Avinash De Sousa

DOI: https://doi.org/10.20529/IJME.2015.058


Abstract

Advances in information and communication technology have facilitated the development of online psychotherapy. This form of psychotherapy would provide the developing world with better access to professional mental healthcare services. At the same time, it is prudent to carefully consider the various ethical, legal and regulatory issues involved in online psychotherapy. This paper highlights the major ethical issues involved in the use of online psychotherapy, whether conducted via e-mail, chat rooms or interactive video, and identifies practical solutions for the ethical dilemmas that exist. Many authors and organisations have expressed their opinions on the subject, but no consensus has evolved. The advice offered to psychologists is mostly skewed and the scarcity of literature available to those considering expanding their practice to include online psychotherapy is certainly a source of vexation. While reviewing the existing literature, this paper seeks to describe and discuss the major ethical issues in this area, particularly in India, but many of these issues will be equally applicable to any developing world settings.

Introduction

The rapid development in information and communication technology over the last few decades, coupled with technological progress in mobile and computer devices, have led to a significant increase in the accessibility and affordability of these services in developing countries (1). According to the diffusion innovation theory, the availability, affordability and accessibility of a new technology are critical in the case of any population, but it is also essential to assess how fast and how well the population accepts and adapts to a particular technology (2). Online psychotherapy is a prime example of how technology and society have interacted to provide mental health interventions, thus having an impact on the field of mental health. Though the terms online psychotherapy and internet-mediated psychotherapy are used interchangeably, we shall stick to the latter term for the purpose of this review.

According to the definition adopted by this article, internet-mediated psychotherapy is any type of professional therapeutic relationship that makes use of the internet to connect with a qualified mental health professional. The word “therapy” is used in the broad generic sense in which it is used by researchers and lay people. An internet-mediated psychotherapist is any qualified mental health professional who uses the internet as a medium for practice. There is still a great deal of confusion surrounding the exact definitions of all the terms mentioned above. The terms used are by no means limited to particular theoretical or therapeutic approaches. They are also not limited to practitioners with any particular licence or level of training and qualification. In India, rules regarding these matters have not been framed yet and where they have, they are fuzzy. This paper focuses purely on internet-mediated psychotherapy and excludes tele-health, telepsychiatry and telephone psychotherapy. In addition, it dwells only briefly on the literature regarding the process, efficacy of the practice and outcome data available. The paper does not discuss either research studies, or trials of the same. There is both positive and negative evidence on the use of internet-mediated psychotherapy. However, this is not the focus of this paper which, instead, addresses the socio-ethical dilemmas and challenges that this form of therapy will give rise to in the Indian context, both for patients and therapists.

In early scholarly work on internet-mediated psychotherapy, concerns were expressed about the people’s willingness to let audiovisual communication channels become part of their everyday lives. For this reason, it was initially felt that such a form of psychotherapy might be acceptable only in large hospital settings (3). In recent years, there has been an explosion in the amount of scientific literature on the subject, but this has not yielded any commonly accepted set of suggestions for the ethical practice of internet-mediated psychotherapy (4). Many researchers and organisations have offered their suggestions, but there are such wide variations in their advice that psychologists who consider expanding their practice to include online psychotherapy would be thoroughly confused (5). This paper aims to highlight the ethical issues surrounding the use of internet-mediated psychotherapy, ie psychotherapy that is conducted via e-mail, chat rooms or interactive video conversations, and to suggest practical solutions that can be implemented by psychotherapists interested in practising online psychotherapy.

Clinicians have always been wary of the dangers of introducing technology into psychotherapy. As early as 2002, some organisations had prohibited their members from practising internet-mediated psychotherapy on the ground that it is fundamentally opposed to a major requirement of psychotherapy – face-to-face communication (6). While some therapists feel that a face-to-face psychotherapy session is the only form of psychotherapy that is valid, others argue that internet-mediated psychotherapy, in its current form, is unethical, though the future will warrant its use (7). We feel that it is necessary to provide some concrete yet pragmatic suggestions for the ethical practice of internet-mediated psychotherapy to assist those who are already offering such therapy and probably find that their own professional code of ethics is not specific enough to steer them through the many inevitable dilemmas that they face (8).

Internet-mediated psychotherapy holds certain advantages for India. Since the internet and cellular phone technology have become more accessible and affordable, online psychotherapy can, indeed, improve the Indian population’s access to mental healthcare services. It could help to cover geographical areas that are difficult to reach and help people gain access to mental healthcare without boundaries and travelling constraints. It could serve areas that do not have enough local qualified mental health professionals. Internet-mediated rehabilitation services could be used to support local communities in areas affected by natural disasters. Finally, online psychotherapy could encourage people to seek mental health services as it is not associated with the social stigma of visiting a mental health clinic.

As members of the younger generation are more competent in the use of technology, they are more likely to be users of internet-mediated psychotherapy. Depression, suicidal ideas, stress-related problems and anxiety are the problems that we frequently encounter in this group. Further, a large number of adolescents may appreciate the benefits of such therapy. However, there are certain ethical dilemmas that arise in the case of adolescent psychotherapy, whether face-to-face or internet-mediated. Some of the dilemmas include issues of consent for therapy, confidentiality in case parents are not aware that the adolescent has entered into therapy and in some cases the need to have a relative who would confirm the information revealed by an adolescent and supervise certain aspects of treatment.

It would be interesting to see whether internet-mediated psychotherapy would be accepted socioculturally in India, where doctors and patients are used to face-to-face interaction. The needs of the urban and rural populations, as well as the resources and infrastructure available to them are definitely different. Mental health service providers will have to be sensitive to and familiar with these realities to be able to offer effective services for each of these population groups. However, there is no clear guidance, whether professional or ethical, on how to provide such services via the internet in India. Moreover, there are no structured training, licensing or accreditation processes, which are essential for any professional service. In this paper, while examining the issue of internet-mediated psychotherapy, we shall take a look at both the international and national ethical guidelines available. Our literature search revealed that there are no national guidelines for online psychotherapy by any professional body in India. In the absence of relevant literature from India, this paper draws heavily on literature mainly from the western world. The authors hope that this article sets off a debate within the mental health profession in India as well as in society, and generates further research on the topic.

Towards a definition and classification of online psychotherapy

Mental health professionals and psychologists define internet-mediated psychotherapy as any type of professional psychotherapeutic interaction that makes use of the internet to connect qualified mental health professionals and their clients (9). The exact definition is still under debate, but the definition mentioned above points to three critical components that online psychotherapy requires (i) a professional therapeutic interaction, (ii) a willing and consenting mental health professional and client, and (iii) a computer or any other portable device (mobile phone, iPad, smart phone) with internet access.

Various modalities of internet-mediated psychotherapy have been described in the literature. We shall summarise the main modes of online psychotherapy while highlighting their benefits and limitations. For a more detailed review of the subject, the reader will have to refer to other resources (10). It is worth noting that while the modalities are not mutually exclusive, there are differences between them and some overlap as well.

Synchronous/asynchronous internet-mediated psychotherapy

“Synchronous” literally means in real time. Most communication between therapist and client in this method is text-based, with the chat facility, or through an online phone conversation that may be video-based. When the therapist and client make synchronous appointments, they make sure that they are both online simultaneously and communicate either through video conference or internet telephony. This allows clients to feel the “real” presence of the therapist and the therapy might have greater success. If a video is being used, the therapist can assess the speech of the person, the pauses, changes of voice or tone, facial expression and affect. In the chat mode, he/she can gather non-verbal clues through the client’s use of emoticons, bold face, etc. The synchronous mode has a perceived advantage over the other modes, in that it makes it possible to maintain boundaries in the interaction between therapist and client and is limited to appointments fixed in advance.

Asynchronous text-based therapy often takes place via e-mail. Clients use this means of communication to express their feelings and thoughts, or to send essays to the therapist when in distress. It gives the client space and time to reflect and has advantages similar to those of journaling or reflective writing, with the additional benefit that the therapist is available when needed. The therapist responds to the client via e-mail at a time suitable to him/her. The regular exchange of e-mails between client and therapist allow the two to review and assess the progress of the therapeutic work done. These exchanges can be saved in their entirety as a record of the therapy. The time difference between therapist and client is not so worrisome as long as they have agreed on the amount of time that the therapist is expected to take to respond to the client. Many online psychotherapists have noted that clients were more open and spontaneous when expressing themselves through e-mail because they did not have to face the therapist. A major ethical issue involved in this mode of therapy is that of confirming the identity of the client. This is discussed later on.

Text/sensory internet-mediated psychotherapy

Text-based communication can be through e-mails, instant messages and chats, while sensory communication is via internet telephony or video phone calls using Skype. Nonverbal clues, such as facial expressions and affect, are likely to be lost in text-based communication. The therapist’s reply might also come across as formal and at times, harsh, making the client feel dejected or rejected. Sensory modalities compensate for these shortcomings to quite an extent and provide richer means of communication. However, it is more difficult to fully document these than text-based communication. Some clients express themselves better in writing, while others do better verbally. A thorough discussion is required before choosing the mode of communication that will work the best for the client. Both the client and therapist might need to be flexible and periodically assess the effectiveness of the chosen modality. In some cases, it might even be necessary to change the modality to suit the client’s needs and his/her underlying psychological problems.

Imaginary internet-mediated psychotherapy

Imaginary internet-mediated psychotherapy makes use of imagination- or fantasy-based communities in cyberspace. Various multimedia chat communities exist, both text-based and visual. In actual interaction, both the therapist and client retain their own identity, whereas in the imaginary method, the client is free to choose a chat avatar for himself/herself. An excessive focus on the imagination could be detrimental to certain patients, such as those with psychotic disorders, and therapists should be careful while choosing clients for this mode of treatment.

Automated/ interpersonal internet-mediated psychotherapy

Automated computer-based therapy might be a reality in the future, but the therapist will still be required to supervise and monitor such therapy, either in individual or group sessions. For the moment, however, we shall focus on the interpersonal modality, in which the therapeutic relationship between therapist and client is internet-mediated.

Internet-mediated psychotherapy in India

A few psychotherapists in every major city of India are practising internet-mediated psychotherapy, though the numbers are probably small and not in keeping with the demand/need for mental health services. Internet-mediated psychotherapy is used for therapeutic intervention as well as assessment. It is also used in some corporate and organisational settings. Patients prefer either chatting as a form of psychotherapy or skype-based counselling. Clients are not so much in favour of e-mail exchanges, except when the therapist is not available or if they want to communicate a huge amount of information before the next online session. This is because patients always prefer a live interaction in real time rather than a faceless string of e-mails. There is another set of clients who prefer face-to-face meetings interspersed with online exchanges, as the notion of a pure online interaction does not suit them well. This information is based on the experience of one of the authors (AD) with internet-mediated psychotherapy and his communication with other therapists who provide internet-mediated services.

Advantages of internet-mediated psychotherapy

The most frequently cited reasons in favour of the use of internet-mediated psychotherapy relate to its convenience and the fact that it can increase the access of underserved populations to mental health therapy (11). Internet-mediated psychotherapy can definitely benefit individuals who want to seek professional help but are apprehensive of the social stigma they will have to face. This form of psychotherapy can be accessed from any place that the individual finds safe and private, and his/her confidentiality is assured. Further, it can be a boon for those whose mobility or reach is restricted due to illness, physical disability or age, provided they are able to access and operate a computer and the internet (12). Internet-mediated psychotherapy is also useful for clients who travel frequently – they can remain in touch with the therapist while on the move and supplement these interactions with face-to-face sessions when possible. In addition, this modality is convenient for family sessions when the members of the family are scattered in different cities or countries (13). Despite these advantages, there is a dearth of research on whether Internet-mediated psychotherapy is an effective therapeutic modality (14).

Psychologists studying online behaviour have proposed and demonstrated the existence of an “online disinhibition effect” among those who write or speak online (15). This could be advantageous in that being online, gives clients a sense of anonymity and invisibility, and might encourage them to open up faster and share the most sensitive and personal issues. Many clients feel afraid to or threatened by the prospect of talking face-to-face as they fear that they will be judged or rejected by the therapist (16). Internet-mediated psychotherapy solves this problem because while clients can count on the “virtual presence” of qualified professionals, they do not have to face the therapist in person and can feel “invisible”. A positive experience with online psychotherapy might help such clients take the next step of continuing psychotherapy face-to-face, if needed (17). Yet another advantage of online psychotherapy is telepresence, which is a feeling (or illusion) of being in the presence of someone without sharing immediate physical space (18). The supporters of this form of psychotherapy highlight the advantages of text-only talk as this reduces distractions caused by the actual presence of another person and helps one focus on one’s problems (19).

Limitations and linked ethical challenges

Dehumanisation of the therapeutic environment

It is often argued that the relationship between the therapist and client is central to healing. Many psychotherapists reject online psychotherapy due to its dehumanising effect on the therapeutic environment. The lack of non-verbal clues in text-based online psychotherapy is a case in point. The therapist is unable to get a full picture of the client and hence, might not be able to pick up critical nuances that could help in modifying the therapy or even reassessing the initial diagnosis. It is argued that without the visual, aural or olfactory information that therapists are accustomed to, it is difficult to make a thorough diagnosis of the mental status of a client. E-mail cannot communicate the smell of alcohol on a man who denies having had anything to drink. E-mail does not capture the nervous body language of someone who is uncomfortable discussing a sensitive issue. In the absence of personal interaction, the client might perceive of the therapist’s formal replies as harsh and rejecting. These aspects related to the client and therapist must be taken into account before starting online psychotherapy.

Privacy and confidentiality

This is the most difficult and most crucial aspect of Internet-mediated psychotherapy. Let us begin by describing how to help protect the privacy and confidentiality of clients and the exchanges during therapy. As for the therapist, it is advisable that he/she invest in a good computer. The internet infrastructure should be sound. A strong firewall and password protection for e-mails and chat/messenger/phone facility, and provision for safe storage of notes of therapeutic exchanges are basic requirements. The necessity of having secure e-mail access should be explained to the client, who should also be advised to preferably use a home rather than a work computer. Clients should ensure that no one in their family has access to their private e-mail (e-mail pertaining solely to the online psychotherapy).The use of computers in cyber cafés should be discouraged for therapeutic purposes.

There are many simple things that clients can do to protect their confidentiality. Clients should always participate in online psychotherapy in a private room, where their family members are unlikely to intrude. This point should be of particular concern to the therapist when the case involves domestic violence. Clients can delete old e-mails, though they must keep in mind the fact that a deleted file isusually not destroyed but is, instead, marked and overwritten at a later date, which means that deleted files may be recovered (20). The therapist needs to be as explicit as possible when answering the client’s questions and giving him/her instructions. Such e-mails can be made considerably more secure through encryption. The encryption process often requires the installation of special software, and both therapist and client may be required to have the same software. Encryption greatly increases privacy and can be useful in confirming the identity of whoever reads or sends e-mails (21). However; encryption alone does not make online therapy safe and confidential. Increasing one’s security is perhaps the most difficult with the modality of video teleconferencing. Although the verification of identity is not a problem, preventing someone else from intercepting a video stream is usually difficult. Most of the time, video encryption is not possible or available. Ensuring the security of electronic communications can be an expensive undertaking, with no guarantee that the security is foolproof (22).

Confidentiality is a major issue in the context of mental health interventions in India as, unlike the West, there is a great deal of stigma attached to mental illness. In India, another reason why patients insist on the utmost confidentiality is that they fear that a psychiatric disorder would adversely affect their career. Employers and companies are not keen on hiring or maintaining employees who are psychologically ill. The human resource wings of most organisations are insensitive to the needs of such employees. If a patient uses an office-based computer for internet-mediated psychotherapy, the information may get leaked as almost all offices check on the employees ‘ computers. In case a patient opts for a home-based computer, it would be best to use a personal laptop, which is password-protected. If he/she uses a common computer, the family members may stumble upon personal, confidential matter discussed with the therapist and this may not go down well with some of them. For example, a woman may discover something she did not know about her husband or parents may learn something they did not know about their children. In the Indian context, it is also important (though not always legally binding) that mental illness be reported to the person’s employers or family if it is at a stage that may harm the patient or others. The implications of this for the patient, whether at work and/or in the family, are another issue that goes beyond the ethical realms of internet-mediated psychotherapy.

Identity verification when online

Verifying the client’s identity is always a difficult task when interacting online. This is of vital importance if therapists are to deal ethically with emergencies, such as possible suicide or homicide. Many authors agree that ethical internet-mediated therapy requires the therapist to have access to emergency resources near the client’s residence; these include another therapist or the local legal and police authority (23). It is a must to verify the client’s address, and some therapists have suggested that online therapists obtain the client’s credit card number to verify his/her name, address and phone number. If credit cards are used to pay for services, the therapist must have a secure system of accepting credit card payments to avert frauds. The therapist can also verify the identity of his/her clients by asking them to e-mail documents such as the copy of their birth certificate, driver’s licence or passport. A possible negative consequence of such measures is that the client may feel that the therapist is too demanding and mistrustful, which may discourage the former from seeking treatment or result in delays (24). The client may also feel that the information he/ she has divulged could be used against him/her. Sometimes, a child/adolescent uses a parent’s credit card number and passes himself/ herself off as an adult. This creates additional problems because online therapy without the explicit permission of the parents has ethical ramifications in the case of children and adolescents.

Some authors argue that internet-mediated therapy should be conducted in conjunction with face-to-face therapy, or that meeting the client should be a prerequisite so that his/ her identity can be verified by conventional means. The disadvantage of this is that those contacting the therapist from long distances would find it difficult to arrange a personal meeting. Limiting internet-mediated psychotherapy to local clients helps to avoid a multitude of ethical and legal dilemmas. It also becomes easier for the therapist to see clients in person, in case this is considered necessary or beneficial (25). Limiting internet-mediated psychotherapy to local clients, however, defeats the basic purpose of such interventions, which is to provide access to care in situations in which no care is available.

Choosing the right client for internet-mediated psychotherapy

There are currently no rules on the types of clients for whom internet-mediated psychotherapy is suitable. The general viewpoint seems to be that people with psychotic spectrum disorders or violent and aggressive personality disorders are better treated in person, though this conclusion is purely clinical. Some argue that internet-mediated psychotherapy is not appropriate for suicidal clients because it is difficult to ensure the patient’s safety in the online mode, and impulsiveness or dangerousness is tougher to assess. The therapist is the best judge regarding the kinds of cases he/ she wants to accept. If he/she refuses to take up a particular case, the decision and the reasons for it should be made clear to the client (26).

Need for technological know-how

In today’s world, psychotherapists are often technologically sophisticated, but those interested in practising online psychotherapy need to possess a relatively high level of knowledge of how computers work – knowledge that goes beyond a sound understanding of word processing and e-mail. This is because the therapist needs to be able to troubleshoot, when necessary. Computers are far from perfect and many kinds of breakdowns occur when transmitting information across networks. An online psychotherapist is expected to solve the clients’ questions about the relevant software and must know how to protect the patient’s privacy and confidentiality using the same software (27). The therapist may also have to be aware of cyber law to safeguard himself and his client. The ability to anticipate and prevent problems requires a sufficient level of knowledge, and there is no room for a crude trial and error approach.

A therapist must be skilled in whatever medium he/she is using and must be good at expressing himself/herself through text. A therapist using video teleconferencing must be able to deal comfortably with the occasional breaks in audio or video, a problem that is common with this technology (28). One can put more thought into something and be more focused while writing e-mails than while talking (since there is more time), but e-mails might lack spontaneity. Sarcasm, for example, is difficult to recognise in text and the person who replies might not take the time to consider the overall mood or tone of the original message, which could result in a serious misunderstanding. The impulsiveness that results from mimicking verbal banter is compounded by the online environment (29). A statement may appear rather bland online in a chat when typed but may have deep undertones and may be misinterpreted or replied in an incorrect manner by a therapist or client leading to further misinterpretations during the course of therapy. Changes of font, case or style, or the use of emoticons can be seen as parallels to non-verbal expression, though in crude terms, but they will convey the correct meaning only if both the client and the psychotherapists are aware of and use these conventions in identical ways thus ensuring correct interpretation of what is being conveyed (30).

As for clients, they need to be skilled enough to type (assuming that the therapy is text-based), spell correctly, and should possess grammar skills to communicate clearly because typing and grammatical errors might convey completely different meaning and distort the perception of both the client as well as the therapist. The client must be competent in technology and to handle the glitches such as accidental pressing of a wrong key during a session which could disrupt the flow of the therapy or even end the session abruptly (31).

Jurisdiction constraints and regulatory oversight

Challenges related to jurisdiction in cases of internet-mediated psychotherapy are well documented in the USA, where each state has different legal requirements regarding the disclosure of therapeutic exchanges in relation to suicidal tendencies, self-harm, child abuse and sexual abuse (32). In the context of India, the matter becomes complicated when the client and therapist are situated in different countries. In such instances, it is advisable to discuss crisis intervention before the start of therapy. The therapist needs to explain to the client that he/she has an obligation to report certain aspects of the therapeutic exchanges, e.g. issues such as suicidal tendencies, likelihood of harm to self or to others, and a history of sexual abuse or child abuse, to the authorities concerned, if legally bound. This issue is of critical importance if the therapist is based in India but the client is in the USA or the UK, as there might be confusion regarding which country’s laws will apply (33).

Lack of formal training

In India, the curricula for psychology, psychotherapy and psychiatry have not fully incorporated the elements of internet-mediated psychotherapy yet. There is no separate licensing system for providing this form of psychotherapy. In some places, therapists are required to acquire the necessary skills and qualifications on their own, which is quite expensive. The available guidance on the codes of conduct and responsibility from professional organisations provide limited information on online psychotherapy. Some other matters which require attention are guidance on the fees to be charged for online psychotherapy (besides the criteria for determining them), reimbursement from insurance companies, as well as the means of assessing the effectiveness of therapeutic intervention through internet-mediated psychotherapy. Though these issues are not fully applicable in the Indian context at the moment, it would be worthwhile to think about some of them while developing Indian guidelines for the practice of online psychotherapy (34).

Monitoring and accreditation of therapists

As internet-mediated psychotherapy takes root and grows in India, professional organisations of psychology and psychotherapy will have to play a larger role in ensuring that the services provided through online psychotherapy meet professional standards. There is a danger that people with some interest in or understanding of coaching, therapy or counselling, and who have access to the internet, will start to advertise themselves as professional providers of online psychotherapy. Without adequate monitoring, such services could mushroom everywhere, harming people rather than benefiting them. Professional organisations must issue guidelines and draw up professional codes of conduct to ensure that every therapist who is interested in providing online psychotherapy is well qualified, registered, carefully monitored and accredited so that the quality and authenticity of his/her services can be assured. This would be an essential step in the establishment of ethical and truly beneficial internet-mediated psychotherapy in India.

Advertisement of services

The information posted on an internet-mediated psychotherapy website should represent the views and experience of the therapist, and the therapist should be able to vouch for the quality of the information. Unpaid advertising in the form of links to other relevant websites or online resources is ethically less problematic provided the therapist’s authority and popularity is not used to help solicit business or to distort information available on the website. These websites may be informational in nature and posted so that clients have other sources of information, if they need more information. It is best to have a separate page for links to other sites to avoid giving the impression that the therapist has an official relationship with those sites. The therapist should regularly visit these sites listed to check the accuracy and quality of information provided (34).

Fees

The therapist must charge a fee for internet-mediated psychotherapy, though insurance companies may resist the idea of compensating for the fee. The fee may vary widely, depending on the services offered and the experience of therapist. Many therapists do not charge their clients for occasional telephone conversations, e-mails or online chats, particularly when they have already met the latter face-to-face. Psychologists should refer to the American Psychological Association’s code of ethical standards for further guidance on fee arrangements (35).

Disclosure forms and consent

The website should be designed so that information related to informed consent is easily accessible to clients. The disclosure of policies regarding online psychotherapy is equally important. This could mean that every new client receives the policy and is required to read and agree to it (36). We highly recommend that the therapist retains the copy of the signed inform consent form either as a scanned copy or in hard copy. The information on informed consent might include the following (37).

  1. There should be a detailed description of the services provided. Some therapists may try to avoid legal liability by describing the services as psycho-educational or being in the nature of coaching. If psychotherapy is not provided, then one must clearly mention what the client should expect.
  2. The website should acknowledge the non-validated nature of internet-mediated psychotherapy and the sparse research evidence in the area.
  3. The website should list the therapist’s degrees (or degree). It should also specify whether he/she is licensed and mention resources that the potential client can use to check his/her credentials. Fraud is much easier to commit when protected by the anonymity of virtual reality. Ethical online therapists should work hard to make their identities and credentials verifiable if they wish to maintain the public’s trust in internet-mediated therapy.
  4. Clients should be required to provide a proof of their identity and location. It is necessary for the therapist to know the location so that he/she can establish emergency resources.
  5. The limits of confidentiality and privacy must be specified. In addition, there should be suggestions on how to increase security.
  6. Clients should be given clear estimates of how soon the therapist will respond to their e-mails. Time frames should be clarified at the onset of the therapy-for example the client can expect an answer from the therapist within 24 hours during a work week. It might also be advisable to define clear boundaries when is it appropriate to contact the therapist by email, chat messages or short text messages. It is critical that both the therapist and the clients respect these agreements related to time and thus maintain the general professional boundaries even during internet-mediated psychotherapy.
  7. Clients should be provided with the phone number or address of the appropriate governmental or association office or department in case they wish to complain about the services rendered, assuming that they are considered psychological services that fall under the regulatory authority. Online practitioners should also disclose the unique nature of their practice to third-party payers. An insurance company may or may not approve of online services, and an online therapist could be charged with fraud if a disapproving insurance company believes it was misled into thinking that services were conducted face-to-face rather than online.
  8. The questions of whether a soft copy or e-signature is enough for the consent form and whether a hard copy must be stored with the therapist must be considered carefully. Another important point is that Internet-mediated psychotherapy and interaction may sometimes make it difficult for the therapist to judge whether the patient is competent to give consent; in many cases, a proper assessment of this is possible only in face-to-face interaction between client and therapist.

Emerging challenges in internet-mediated psychotherapy

Research in the area of internet-mediated psychotherapy is hampered by several factors. To begin with, there is an ambiguity in the definition of internet-mediated psychotherapy and a lack of consensus in this regard. Also, very little has been done to address the cross-cultural and transcultural issues that may arise with this form of psychotherapy. The rules, regulations, cyber laws, nuances of psychotherapy and legalities across nations need to be borne in mind. Further, an important area of research remains neglected: while several papers have debated the various benefits and limitations of internet-mediated psychotherapy, a good part of the debate has been based on perceptions and anecdotal evidences rather than trial-based data. It is very important to carry out empirical studies to address the limitations and benefits of this type of psychotherapy, and to see whether patients and clinicians perceive of them in the same manner as those who have written about them. In all likelihood, even ethics committees might be confused when it comes to evaluating research in this area due to lack of regulation and clarity on procedure, fees and tools to assess the efficacy of online psychotherapy. There is a need to develop consensus guidelines for internet-mediated psychotherapy in India, and also, standard operating procedures as far as consent, management of sessions, storage of therapy data, confidentiality and handling crisis situations are concerned. India has no guidelines even for routine psychotherapy, let alone internet-mediated psychotherapy

Conclusions

There is much controversy and debate over ethical issues in online psychotherapy. The therapist, on his/her part, must take certain steps to ensure ethical practice (38). The success of online psychotherapy depends on correctly identifying clients who could benefit, using an appropriate online mode of psychotherapy for them, and ensuring the safety, privacy and confidentiality of their personal information and data. This requires monitoring at various levels. Online psychotherapy also needs to be introduced in the formal training of mental health professionals and in postgraduate psychology courses. Professional organisations play a major role in building a system of online psychotherapy that can be trusted for its content and quality of services. Issues related to the confidentiality and privacy of clients and of therapeutic exchanges, and the interaction of these with legal and judicial requirements need to be studied further at the state or national level by establishing a dialogue between various experts from the mental health and legal fields, as well as by incorporating the experience of those who have already been providing online psychotherapy. We sincerely believe that a multi-stakeholder debate on ethical and legal issues around internet-mediated psychotherapy is critically needed where various real life scenarios, values, moral judgements and expert opinions can be discussed in details and consensus can be reached for the way ahead. The discussion needs to be coupled with willingness on the part of psychotherapists to risk sailing into the uncharted waters of internet-mediated psychotherapy, something that can be encouraged by taking steps to minimise the risk to both therapists and clients. The internet is here to stay and India is progressing at a blistering pace as far as the information technology sector is concerned. The time has come to use the virtual world and the internet to enable mental health interventions to go beyond national and state boundaries and reach those who need them.

Acknowledgements – Nil
Conflict of interest – Nil
Funding – Nil

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About the Authors

Priya Satalkar (drpriyasatalkar@gmail.com)

Institute for Bio and Medical Ethics, University of Basel, Switzerland

Shivanshu Shrivastava (shivanshu789@gmail.com)

Research Assistant

Desousa Foundation, Mumbai,

Avinash De Sousa (avinashdes888@gmail.com)

Founder Trustee, Desousa Foundation and Consultant Psychiatrist

Keywords

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