Do No Harm
The evaluation of the potential harms associated with any treatment intervention needs to be considered within the context of the potential benefits to be accrued from the intervention . Only by considering both the potential risks and the possible benefits can we appropriately evaluate a proposed intervention. The simple presence of risk does not necessarily preclude the use of an intervention if it is sufficiently justified by the potential benefits. With interventions that have a reasonable likelihood of being beneficial for the client, the important issue becomes for the therapist to understand the nature of the risks, to minimize the risks to the extent possible, to fully inform clients as to the nature of the risks within the context of the possible benefits, and then to allow the clients to make an informed decision regarding their treatment options.
In assessing the risks of online psychotherapy it is also important to note that in-person psychotherapy is not without risks. In-person clients can become sexually attracted to the therapist and vice versa; therapists can be incompetent in the delivery of services; the therapist's confidential records are vulnerable to being stolen or viewed by unauthorized persons even if stored in a locked office and a locked file cabinet; miscommunication can occur during in-person therapy; and clients receiving in-person therapy can deceive and mislead the therapist. The issues with the delivery of online psychotherapy (e-therapy) are the extent to which traditional risks are enhanced in text-based communication, the possible emergence of novel types of risks not present in face-to-face therapy, and the degree to which the potential benefits justify the possible risks.
The use of email to deliver therapeutic interventions opens several areas of potential risk to online consumers. Clients of online services can be at greater risk for breaches in confidentiality [16,17]. This increased risk to confidentiality occurs at the therapist's end, at the client's end, in the transmission of information, and in the potential for legal subpoena of records. Therapists using the Internet to deliver therapeutic interventions should evaluate the security of their websites and computers against outside intrusions that would compromise client confidentiality. These intrusions might include high-tech invasions by hackers downloading files from the therapist's computer, to low-tech intrusions involving the inappropriate availability of the client's email to the therapist's office staff or family members. Therapists using the Internet to deliver online psychotherapeutic interventions may wish to consider installing systems which use firewalls, passwords, and backup data storage systems to increase the security of email communications and to protect against the inadvertent loss of clinical files resulting from computer malfunctions.
Online consumers of mental health services must likewise consider security issues on their end of the communication. Other persons who have access to the client's email, such as employers or family members, may be able to read stored copies of the client's email or incoming email from the therapist. Additionally, human error in addressing email has sometimes resulted in email being sent to the wrong person. Inadvertently sending private information meant for the therapist to a friend or family member can result in embarrassing and painful situations for the client. Potential online consumers of mental health interventions need to be informed about these potential breaches of confidentiality in order to fully evaluate the possible risks versus the potential benefits of online psychotherapy.
Breaches of confidentiality can also occur as email is in transit. The potential vulnerability of email in transit may not, however, accurately represent its actual vulnerability in practice. While email may be intercepted in transit, it is unlikely that individual emails sent between private parties are actually intercepted and read from the incredible volume of email sent each day. Still, this potential breach in confidentiality needs to be understood and evaluated by clients before choosing to engage in online psychotherapy. Encryption technology can improve security of email communication, and online therapists may wish to make encryption of email routinely available to their clients.
Online mental health clients also need to consider the possibility that email records may be subject to subpoena. While professional communication with physicians and attorneys is considered legally privileged, it is unclear if this legal protection extends to psychotherapists. The standards for recognition of legal protection of privileged communication may also vary from one jurisdiction to another. Online psychotherapists should consider their policy regarding the disclosure of records in response to legal subpoena, and clients need to be informed about this possible breach of confidentiality.
The use of email to provide psychotherapeutic interventions also entails other risks to clients beyond those associated with the confidentiality of communication. For example, the loss of nonverbal cues significantly impedes the therapist's ability to make a full assessment and diagnosis. Important in-person cues, such as flattened or inappropriate affect, characteristics of speech, memory function, or physical evidence of a medical condition that may be associated with the psychological symptoms, are all lost in email communication. An impaired ability to make an adequate diagnosis will adversely affect the ability of online therapists to develop appropriate treatment plans and, as a result, the treatment interventions that are developed may be to the detriment of the client. Online testing may improve diagnostic capabilities , and gathering a full psychosocial history may be facilitated by online questionnaires; yet the loss of visual and auditory cues will still affect the therapist's diagnostic ability, and the impact of this diminished diagnostic capability needs to be carefully considered. Still, while problems making online diagnoses may limit the scope of issues appropriately addressed in online therapy, some types of online interventions, such as interactive journaling  or humanistic/existential approaches, may nevertheless be developed that are appropriate for delivery in a text-based format with some populations.
The increased potential for miscommunication in text-based therapy may also increase the risk of inadvertently harming clients and perhaps re-traumatizing emotional injuries disclosed during the course of online therapy. Text-based interactive communication is more vulnerable to miscommunication because it lacks the non-verbal cues associated with in-person communication that modify meaning and provide context for the interpretation of meaning. Furthermore, interactive text communication is not the normal means of interpersonal communication for most therapists trained in in-person psychotherapy. Therapists may therefore lack the writing skills needed to express subtleties of meaning through the written word.
Working with psychological issues typically involves addressing conflicting client motivations involving a desire for self-disclosure aimed at securing help for painful personal issues, and competing motivations directed toward maintaining interpersonal defenses to preserve self-esteem and prevent re-traumatization of emotional injuries. Interactive text-based communication often sounds harsher than intended. Online miscommunication may result in clients feeling hurt because they perceive the therapist's response as being critical or rejecting. Online clients also do not have the benefit of the interpersonal holding environment offered by the in-person relationship in which to interpret and integrate the therapist's comments, and injured online clients may be more likely to simply withdraw from the relationship into the blankness of cyberspace, taking their injury with them. Since nonverbal feedback cues that might signal the miscommunication, such as the client's body language and facial expression, are not available in email communication, online therapists may often be unaware of the miscommunication and therefore will be unable to address the client's injury.
This possibility of emotional injury and re-traumatization may be further exacerbated by the increased self-disclosure and disinhibition associated with online communication [9,19]. While increased self-disclosure may be helpful in some therapy circumstances, it may also involve clients prematurely moving past defenses designed to protect them against emotional injury and re-traumatization. This may leave them more vulnerable to injury should they interpret a therapist's communication as being critical or rejecting.
Clients in online psychotherapy may also be at increased risk of harm if the online intervention is not effective in creating change in the client's life, yet offers enough solace so as to reduce the client's motivation to seek more beneficial in-person therapy. Consumers of online mental health services are at risk in this case not because of a direct effect of the online intervention, but because the online intervention prevents them from seeking treatments that will more effectively address their needs. However, e-therapy may also serve as a convenient and helpful entry into the mental health system for many persons who might benefit from therapy but who are reluctant to begin in-person therapy because of the social stigma associated with psychotherapy, their anxiety of addressing emotional issues, and the physical inconveniences of scheduling in-person therapy sessions. For such persons, the convenience and perceived anonymity associated with computer-mediated communication may encourage them to contact an online psychotherapist. Their initial online therapeutic relationship may help demystify psychotherapy and facilitate their entry into in-person mental health treatment.
The ethical practice of e-therapy requires that therapists develop a thorough understanding of all of these issues. Online discussion groups dealing with Internet psychology can help therapists explore some of these issues. Yet, despite the therapist's professional evaluation of the issues involved with providing online therapeutic interventions, the ultimate issue is the degree to which the potential benefits justify the possible risks, and a decision on this issue can only come from a fully informed client. While mental health professionals can decide that the potential benefits associated with the intervention do not justify the risks, the opposite decision, that the benefits do justify the risks, can only be made by a fully informed client. Therapists seeking to provide online psychotherapeutic interventions must, therefore, be informed as to the potential risks so that they can take every possible precaution to reduce or eliminate those risks, and so that they can fully educate potential clients regarding the possible risks associated with e-therapy.
Providing Effective Interventions
While controversies exist as to what criteria should be used to evaluate the effectiveness of psychotherapy, in-person psychotherapy nevertheless has an extensive history and well-elaborated theoretical frameworks supporting its use. Both history and theoretical frameworks are missing from the practice of interactive text-based therapy, and it is currently unclear to what degree traditional therapeutic orientations and models can be translated into online, text-based communication. Most psychotherapy depends, to a greater or lesser degree, on the development of the therapeutic relationship [20-22]. However, it is precisely the nature of the therapeutic relationship that is most impacted by text-based communication.
The ethical practice of e-therapy requires the therapist to have a clearly delineated model of psychotherapy appropriate to delivery in a text-based format [7,18]. In the emerging field of online psychotherapy, it would also behoove the ethical practice of e-therapy if therapists remained close to empirically derived support for the interventions used until more experience is gained with regard to the medium of interactive text-based communication. Therapists providing online psychotherapeutic interventions should also contribute to the developing understanding of e-therapy by conducting quantitative and qualitative evaluations of the services they deliver.
Practicing Beyond the Boundaries of Competence
For psychologists, the Ethical Code of the American Psychological Association  specifically directs that psychologists should practice only within the area of their competence based on training and experience (Standard 1.04a); and that where standards for training do not yet exist, psychologists should " reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm" (Standard 1.04c; p. 1600). Psychotherapists trained in traditional psychotherapy need to carefully consider whether they are competent to practice in an interactive text-based format, and to evaluate by what manner and training they achieved their competence in this new communication medium.
Interactive text-based communication offers an entirely new communication format that differs significantly from in-person verbal communication. The nonverbal cues that in face-to-face communication provide valuable information that modifies meaning and aids interpretation of the communication are significantly absent in text-based communication. It takes considerable skill to communicate emotion and contextual intent solely through the written word. Text can often sound harsher than intended and, without contextual cues such as tone of voice and body language, text-based communication is more likely to be misunderstood and misinterpreted. With text-based communication there is also a greater likelihood of projective psychological material emerging in the absence of the physical presence which serves to ground in-person communication. Skill in verbal communication does not necessarily translate into skill in written communication, especially interactive text-based communication that involves a series of interpersonal interpretations within each exchange.
Without clearly delineated models for text-based psychotherapy, and without training in the subtleties of interactive written-word communication, therapists seeking to provide online psychotherapy need to carefully evaluate their current level of competence to practice in a text-based format.
Professional Accountability and the Redress of Grievances
Mental health professionals wishing to practice online also need to consider their legal authority to practice in a jurisdiction in which they are not licensed to practice . This issue extends beyond the legality of their activity to include the rights of clients to redress grievances.
The ethical practice of online psychotherapy must provide for the client's ability to redress grievances. Clients should be clearly informed prior to beginning an online therapeutic relationship about the regulatory agencies and professional associations governing the therapist's work . Still, simply being informed about oversight agencies may not offer online clients an actual ability to redress grievances when the therapist and client may live in separate jurisdictions separated by hundreds or even thousands of miles . For example, while it may be possible for a client in India to file charges with an ethics board or Attorney General located in the therapist's home jurisdiction of Wisconsin, the practical limitations imposed by distance and the financial resources needed to overcome such limitations may leave the client unprotected in fact.
Laws governing the appropriate practice of psychotherapy, such as ordinances governing the release from confidentiality to report child abuse, may also differ from one geographic jurisdiction to another. When the therapist and client live in two different legal jurisdictions with differing laws regarding the practice of psychotherapy, which jurisdiction's laws take precedence and govern the client-therapist relationship?
In order to avoid the many problematic legal and professional issues related to practicing psychotherapy online, some therapists may be tempted to define their online work as psychoeducational rather than psychotherapeutic. While some online work can legitimately claim to be primarily educational, therapists treating individual clients across multiple sessions should carefully consider whether their work is primarily educational or therapeutic. One of the central issues in making this distinction is whether the client perceives an individual professional relationship has been established. While it may be tempting to try and circumvent legal and professional liability for online work by defining it as psychoeducational, it creates significant ethical problems if such a definition misrepresents the service. Ethical problems can also arise if the online service being provided is held out as therapeutic on one web page, with a disclaimer of psychoeducational intent located on a separate web page. An ethically appropriate description of the online service must clearly, consistently, and accurately describe the intent of the service and the nature of the professional relationship involved.
The absence of physical presence also impacts the ability to verify identity. Without the ability to verify identity the issue of treating minors without parental consent becomes problematic. Therapists seeking to practice online must evaluate what steps will be taken to verify the age of clients so as to not treat minors without the knowledge and consent of their parents.
In addition, the issue of informed consent is closely related to the issue of disclosure. As discussed earlier, in order to make an informed consent to treatment clients need to fully understand the potential risks and benefits associated with an intervention. Specific risks that clients need to be informed about involve the possibility that inadvertent breaches of confidentiality may occur with online communication, the experimental nature of online psychotherapeutic interventions and the possibility of unknown and unintended consequences, and the potential for miscommunication in text-based communication .
In some ways, however, the Internet offers advantages in developing an informed consent process. Professional web pages allow for multi-faceted and multi-layered discussion of relevant issues which remain constantly available on the Internet for clients to review. Web pages can address issues such as the potential risks involved with online treatment and the theoretical underpinnings of the treatment. The discussion of informed consent through email also allows for a documented record of the informed consent process.
Crisis Intervention Planning
Online psychotherapists need to consider plans for addressing the variety of crises that may present in therapy including suicidal clients, physical and sexual abuse, threats to harm others, and the possible discovery that the client's issues would more appropriately be addressed with intensive in-person therapy or hospitalization. Prior to beginning a therapeutic online relationship, therapists may wish to discuss crisis plans and develop in-person referrals local to the client in preparation for possible future crises. Such crisis planning should include obtaining a verified valid street address and phone number that would allow the therapist to invoke the local police should such an intervention become indicated.
Therapists interested in providing online interventions also need to consider the possible boundary issues involved with establishing an online therapeutic relationship. For example, with instant message systems clients might be alerted every time the therapist is online and could send the therapist instant messages for chats every time the therapist signs onto the Internet. Clients might also access the therapist's personal web page or sign onto online discussion groups to which the therapist also belongs. In addition, some clients may continue to send the therapist emails after the termination of the relationship, and e-therapists will need to consider their response to such ongoing contact. Some clients may also use the Internet to harass or stalk current or former therapists.
Смерть ее веры в. Любовь и честь были забыты. Мечта, которой он жил все эти годы, умерла. Он никогда не получит Сьюзан Флетчер. Никогда.