A number of consumers turn to the internet to seek relief from mental distress. Research (Fox & Fallows, 2003) has found 21% of internet users search information on depression, anxiety, and other mental health issues. At the same time, a number of clinicians are engaging in the practice of “e-therapy” over the Internet. E-therapy is now used by a range of professionals and applied to a vast array of problems and conditions. Bischoff (2004) believes the interest in online based counseling is growing due to several reasons: technology is becoming increasingly sophisticated, the technology is becoming more affordable, and people are becoming more comfortable using technology as a means of communication. Furthermore, the telecommunications system will continue to increase in quality and affordability, and this will be associated with an increased user comfort. According to co-authors Lana Hunter and James Tobin, this will make it important for professionals in the mental health field to become familiar with the format and application of e-therapy available as a method of mental health treatment and the ethical and legal issues involved in choose technology as a treatment medium.

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E-therapy: a critical review of practice characteristics and ethical standards.
Lana Hunter and Prof. James Tobin, Ph.D.
American School of Professional Psychology at Argosy University, Orange County – Doctor of Psychology in Clinical Psychology Program
Introduction
Discussion
References
Part I: A Descriptive Summary of Current E-Therapy
Practice
Part II: Ethical and Legal Standards in E-Therapy Practice
Contact information
The findings of the current study showed e-therapy is
being used to treat an array of problems and disorders
with diverse populations. Most of the studies used an
online program that is supplemented by clinician support
and these studies demonstrate a favorable outcome and
positive feedback from e-therapy clients. A majority of
studies utilized e-therapy procedures that upheld at least
some of the ethical and legal standards proposed, but
none of the studies met all of the criteria set forth for a
reasonable and sufficient threshold of ethical practice.
Issues regarding the format and application of e-therapy
practice, as well as ethical standards of practice that will
require more stringent efforts to uphold in the future, are
considered.
Purpose of the Literature Review
Methods
Lana Hunter
Graduate Student
Argosy University, Orange County
Email:
hunter.lana@gmail.com
Phone: (714)925-0750
Email:
jtobin@argosy.edu
Phone: 714-338-6200
James Tobin, Ph.D.
Assistant Professor of Clinical Psychology
Argosy University, Orange County
A number of consumers turn to the internet to seek relief from
mental distress. Recent research has found 21% of internet users
search information on depression, anxiety, and other mental health
issues (Fox & Fallows, 2003). At the same time a number of
clinicians are engaging in the practice of “e-therapy” over the
Internet. e-therapy is now used by a range of professionals and
applied to a vast array of problems and conditions. Bischoff (2004)
believes the interest in online based counseling is growing due to
several reasons: technology is becoming increasingly
sophisticated, the technology is becoming more affordable, and
people are becoming more comfortable using technology as a
means of communication. Furthermore, the telecommunications
system will continue to increase in quality and affordability, and this
will be associated with an increased user comfort. This will make it
important for professionals in the mental health field to become
familiar with the format and application of e-therapy available as a
method of mental health treatment and the ethical and legal issues
involved in choose technology as a treatment medium.
The purpose of this literature review is to first, offer a
comprehensive descriptive account of current e-therapy
practices and evaluate clients’ feedback of e-therapy
treatment. Secondly, to introduce a reasonable set of
legal and ethical standards to evaluate the ethical and
legal procedures by which current e-therapy is
conducted. The results will be used to formulate
standardized e-therapy guidelines . Standard guidelines
in practicing e-therapy would greatly help future
clinicians in learning about the strengths and
weaknesses of this modality, information about the
growth and extent of online practice, clients they might
encounter and the emerging research on e-therapy
outcomes. Educating future therapists about these legal
and ethical issues may ensure a higher standard of
ethical practice when practicing e-therapy.
Fifty studies that have published data on e-therapy
treatment were reviewed. The first part of the review
provides a descriptive summary of current e-therapy
practices, including sampling information, problem or
disorder studied, purpose of the study, type of e-
therapy, stated theoretical orientation, duration of
treatment, clients’ activity during treatment, and
clients’ subjective ratings of change and impressions
of the e-therapy experience. The second part of the
review presents 8 ethical and legal standards (e.g.,
informed consent, encryption of information, identity
verification, assessment for treatment, risk
management, boundary management, technology
use requirements, and follow-up care) with which e-
therapy practice procedures are evaluated.
•Age of study populations ranged from 10-75
years old from a diverse cultural groups
•most common presenting concerns include
anxiety and substance abuse conditions
• 35 of the studies evaluated the effectiveness of a
new e-therapy program when applied to specific
problem or disorder.
•The duration of e-therapy treatment ranged
anywhere from a single 2 hour session to as long
as 6 months.
• majority of e-therapy interventions are in the form
of structured online programs supplemented by
therapist-client email contact
•Clients were involved in a number of activities
ranging from reading to working on interactive web
pages to chatting online with a therapist.
•The stated theoretical orientation of 31 studies
was cognitive behavior therapy.
•44 studies showed evidence of improvement of
clients’ presenting concerns following e-therapy
intervention
•28 studies evaluated clients’ views of e-therapy;
favorable ratings highlighted the convenience of
accessing the online program any time, client
anonymity, and not needing to travel to an office
•disadvantages noted were website technical
difficulties and reported concerns about the
limitations of e-mail communication.
•42 studies obtained informed consent, eight
studies did not report obtaining informed consent.
•21 studies used encryption or other security
methods to secure their website and confidential
information.
•20 studies used a method of identity verification in
their studies to confirm their subject’s identity as
the person accessing the study website
•12 studies assessed study population through the
internet where questionnaires, measures, and
interviews where administered online through text,
2 conducted an assessment over the phone, and 5
studies used a face to face assessment method.
18 studies did not report a method of assessment
for the study.
•2 studies provided follow up care
•34 studies had procedures or protocols to
minimize treatment risk
•Boundary management in studies that involved
email exchanges varied from study to study, with
therapists requiring to respond to emails anywhere
from 24-48 hours.
•6 studies stated minimum reading requirement
but did not assess the clients for their reading
level. Fifteen other studies reported some type of
technological requirement the client must have to
participate in the study.
Bischoff, R. (2004). Considerations in the use of telecommunications as a primary treatment
medium: the application of behavioral telehealth to marriage and family therapy. The
American Journal of Family Therapy, 32, 173-187.
Fox, S. & Fallows, D. (2003, July 16). Health searches and email have become
more commonplace but there is room for improvement in searches and overall
internet access. Retrieved February 15, 2008, from
http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf
To research e-therapy articles, the EBSCO “expand”
database was utilized, which includes: PsycINFO,
Psychology and Behavioral Sciences Collection,
PsycARTICLES, and PsycEXTRA. In addition, local
university libraries will be accessed to research the
proposed topic, specifically the University of
California, Irvine, the University of California, Los
Angeles, California State University, Long Beach, and
University of Texas, San Antonio. Keywords used for
journal article searches included: e-therapy, online
therapy, web therapy, internet therapy, telehealth,
telepsychiatry, telehealth medicine, online
psychologist, online therapist, e-therapists, e-health,
e-mental health, online mental health, online
treatment, telehealth behavioral medicine, internet
therapist, web counseling, web health, and web
psychologist. Articles that investigated a form of e-
therapy treatment for a problem or disorder were
included. The final number of articles that met the
criteria were 50.