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Psyber Psychiatry, Commentary

E-therapy: Alerting patients to the benefits, risks

If you’re receiving unsolicited e-mails from prospective patients crying out for help, read on.

Vol. 1, No. 11 / November 2002

E-mail is fast becoming a key medium for addressing interpersonal and other therapeutic needs. E-therapy delivered via e-mail and other media offers convenience and a sense of privacy that can break down barriers to treatment for persons grappling with the stigma of mental illness or an emotional problem.

E-therapy is not a substitute for psychotherapy or psychological counseling, nor should it be confused with those modalities. By helping the patient resolve life and relationship issues under the guidance of a qualified professional, however, e-therapy can be a worthwhile adjunct to psychiatric treatment. E-therapy is best for significant but not critical issues that result in adjustment disorders, such as frustration over not receiving a promotion or job offer.

In additional to counseling via e-mail, e-therapy also takes the form of telemedicine; “ask-the-expert” Web sites; office-based therapy supplemented with e-mail, instant messaging or private chat programs; and online group treatment.

Benefits and drawbacks

Convenience is a major advantage of e-therapy. For people with limited mobility or who are leery of entering a mental health facility, e-therapy provides access to psychological services that would otherwise be unavailable. For patients with anxiety disorders such as social phobia, e-therapy abolishes the initial barrier to treatment.

When asynchronous communication such as e-mail is employed, e-therapy provides time for reflection on issues raised in the previous message. While traditional therapy offers a more free-form process, e-therapy allows the user to organize and carefully examine his or her thoughts and feelings.

Since the need for social interaction and nonverbal cues is eliminated, the salient issues may be addressed quickly and without distraction. Also, links to educational material can easily be embedded within messages, providing immediate access to information not available in traditional face-to-face therapy.

Depending on which e-mail program is used, e-therapy is also potentially more confidential and can be performed more anonymously than traditional therapy.1 For example, a patient can use a Hushmail ( account, which provides secure e-mail messaging.

But many of these benefits double as major drawbacks. For one, most e-mail programs/services are not secure, subjecting patients to possible breach of confidentiality as evidenced by Carnivore, a program that enables the FBI to intercept electronic communications without detection.2 Use of a virtual private network allows users to establish a two-way encrypted channel of communication and reduce the chances of intrusion.

The asynchronous nature of text-based communication can also be detrimental. A miscommunication cannot be immediately clarified and can leave the patient feeling more rejected or isolated than before.

Also, the social and nonverbal cues that may facilitate the communication’s context are not available. Without these cues, emergencies such as suicidal ideation may go undetected. For that reason, patients who are suicidal should be advised against e-therapy. Also, since the therapist is not “present,” e-therapy should not be used to address issues that raise intense feelings.

More research needed

Information on the efficacy of e-therapy is limited. According to preliminary data on Metanoia-an online mental health consumer guide ( of 450 patients who have tried e-therapy found it very helpful, 32% found it somewhat helpful, and 8% found it not helpful.3

Stephen Biggs, MA, a doctoral candidate in clinical psychology at York University in Toronto, is conducting a more formal assessment of the consumer’s experience with online mental health services.4

Helping patients choose an e-therapist

E-therapists-mostly psychologists, marriage and family therapists, and licensed clinical social workers-are fairly easy to find on the Web. Interestingly, a recent Web search using the term “e-therapy” turned up only one psychiatrist from among 30 names, although more MDs may offer online therapy as the modality gains acceptance.

Because most state laws governing licensing do not address e-therapy, a patient dissatisfied with his or her e-therapist has no legal recourse. Therefore, advise patients to proceed carefully. John Grohol, Psy.D, founding president of the International Society for Mental Health Online (ISMHO), recommends that patients sign or consent to a counseling agreement and a privacy statement, which clearly delineate responsibilities and operating procedures.5

Online resources such as Metanoia and ISMHO ( offer advice on choosing a qualified e-therapist. Metanoia, for example, offers a directory of e-therapists6 and explains what to look for-and avoid-in a therapist. Site creator Martha Ainsworth notes that Metanoia only lists therapists who have credentials, a degree, and/or a license to provide therapy. ISMHO’s Suggested Principles for the Online Provision of Mental Health Services7 also spells out what services patients should expect from an e-therapist.

Finally, although cyberspace has a global reach, advise patients to choose an e-therapist who lives within driving distance if possible. That way, the patient can consult the therapist in person if a crisis arises.

Related resources

  • Hsiung RC (ed). E-therapy: case studies, guiding principles, and the clinical potential of the Internet. New York: W.W. Norton & Co., 2002.
  • Fink J. How to use computers and cyberspace in the clinical practice of psychotherapy. Northvale, NJ: Jason Aronson Inc., 1999.


The author reports no affiliation or financial relationship with any of the companies whose products are mentioned in this article.


1. Grohol JM. Best practices in e-therapy: clarifying the definition. Available at: Accessed Oct. 30. 2002.

2. FBI Programs and Initiatives-Carnivore: Diagnostic Tool. Available at: Accessed Nov. 4, 2002.

3. Metanoia Internet Therapy Survey Results. Available at: Accessed Oct. 30, 2002.

4. Biggs S. E-therapy Study. Available at: Accessed Oct. 30, 2002.

5. Grohol JM. Best practices in e-therapy: legal and licensing issues. Available at:

6. Metanoia Directory of Internet Psychotherapists. Available at: Accessed Oct. 29, 2002.

7. International Society for Mental Health Online. Suggested principles for the online provision of mental health services. Available at: Accessed Oct. 30, 2002.

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