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Article Excerpt
Abstract. Psychotherapy and counselling services are now available on-line, and expanding rapidly. Yet there appears almost no ethical analysis of this on-line mode of delivery of such professional services. In this paper I present such an analysis by considering the limitations on-line contact imposes on the nature of the professional-client relationship. The analysis proceeds via the contrast between the face-to-face case and the on-line case. At the core of the problem must be the recognition that on-line interaction imposes a physical barrier largely permitting only those disclosures of self we choose to make available, and greatly restricting the range of involuntary features and behaviours. I show why this is problematic, first, for the development of a close professional-client relationship, with particular emphasis on such failures as diagnosis and monitoring of the patient. Second I describe the importance of the development of professional character, and of how the on-line environment fails to provide a context for such character traits to emerge and develop.
Introduction
The internet revolution has a full head of steam. According to Daniel Marschall (2002, p. 51), "[a]s of June 2000 ... the Internet Economy directly employed more than three million US workers." On-line banking and shopping, internet-facilitated finance and investment transactions, on-line education practices, virtual sites for social interaction and other on-line supported activities are commonplace. This revolution provides us with rich data for an analysis in social philosophy. Since many of our work and social transactions can be undertaken on-line, sometimes in real time, we can view on-line life as a kind of deficit study. Roughly we can ask what effects there are on the nature and value of interpersonal relationships when we subtract the conditions of face-to-face human contact. Using this methodology I want to consider the effects of on-line exchanges for professional life. I want to consider how the on-line environment affects aspects of professional character, and I want to consider how it affects aspects of the professional-client relationship. In order to do this, I focus on cases of on-line therapy and counselling.
Let's first consider the kinds of professional services that are in fact provided on-line. There are of course many information sites whose function is merely to direct potential clients to available clinics or individual therapists for face-to-face appointments. But the interest here is those sites whose purpose is to provide on-line therapy sessions. There are an array of such sites with names such as "HelpHorizons.Com", "Find-A-Therapist.Com, "On-lineClinics.Com" and many more. Such sites cater for all manner of problem. A brief search revealed that one may obtain on-line therapeutic sessions in relation to, although not limited to, the following:
What is advertised in these websites is the ability of a client to engage in one-on-one or group sessions on-line with a trained professional. The mode of contact is generally by email, facilitated either by simultaneous or time-delayed communication, though sometimes voice or webcam facilities are made available. Chatroom style communication is also an option. (1) Such services attract professional fees, though in a tiny percentage of cases the therapy provided attracts a fee only if the client is satisfied with the service. Typically the kinds of counsellors offering assistance on-line are psychologists, psychiatrists and social workers. Now in order to maximally capture the ethical dimensions at stake in the on-line arena for these different professions I will refer to all such services under the umbrella term of 'e-therapy'; this appears to be the term of choice for those involved. A website called "Metanoia" (http://www.metanoia.org/imhs/index.html) contains a list of sites for "e-therapy", as well as providing something of a general resource for issues surrounding its uses. According to Martha Ainsworth, the Director of Metanoia, which specialises in on-line psychotherapy,
On-line counselling--"e-therapy"--is when a professional counsellor or
psychotherapist talks with you over the Internet, to give you
emotional support, mental health advice or some other professional
service ... E-therapy is a viable alternative source of help when
traditional psychotherapy is not accessible ... for some people, it's
the only way they can get help from a professional therapist ...
Etherapy is not psychotherapy. It should not be compared to
psychotherapy. It is not a substitute for traditional psychotherapy.
Working with a therapist in person is still better. But many people cannot or will not see a therapist in person. E-therapy is a form of counselling which, though it falls short of full-fledged psychotherapy, is still a very effective source of help ... Managed care and the mental health industry sometimes make it difficult for people to get the care they need. When traditional systems fail them, many people are turning to the Internet. (viewed September 1, 2004).
The limits and benefits of e-therapy are usually made clear by those in practice. On the one hand it is claimed not to be a proper substitute for face-to-face therapy. To the extent the on-line environment might prevent accurate diagnoses or effective treatment, advice is given to attend a professional service in the flesh. On the other hand, it is claimed to be a "viable alternative" to traditional services. Indeed, it is sometimes claimed to have advantages. For example, the relative anonymity of an email therapy session is thought to reduce such things as the embarrassment or humiliation in a face-to-face session that would compromise a client's capacity to effectively disclose what is on his or her mind. And then there are a range of hindrances to accessibility such as the tyranny of distance, the capacity to afford a therapist, the pressure from loved ones to avoid attending a therapist, a physical disability that might prevent travel, the stigma associated with therapy, problems involving timetabling of sessions, and so on. Since an e-therapy session can be carried on from home, or a local computer terminal, it is claimed most of these problems are avoided, or at least lessened.
In this paper I do not want to downplay some of the claimed advantages of e-therapy. What I want to do is get clear about its limits. I want to contrast the on-line professional environment with the face-to-face professional environment in order to evaluate the nature and value of both of them. I certainly think there is a place for e-therapy, and for the reasons that are often put forward by the e-therapists themselves; but it is important to know clearly the nature of the professional relationship that may be established on-line in order to properly evaluate its limitations.
Before proceeding, a word about what I will not talk about. The paper will focus quite narrowly on the moral aspects of the professional character that may be disclosed within an on-line environment and of the professional-client relationships that may be formed there. It will not consider the question whether, all things considered, the consequences of replacing, or enhancing, ordinary human contact with computer substitutes (at least across some range of cases), is to be preferred. It will also not address any wider sociological aspects of the general trend to introduce IT into these areas of life. Thus in this paper I remain neutral on these larger questions, and it should not be inferred from the failure to replace a range of moral elements of human contact relations that computers should not have some role to play, especially in supplementing existing arrangements. Finally, I will have nothing to say about the very important question of accountability. E-therapy is a global phenomenon. As a patient one will tend to choose a therapist on-line according to need, cost or reputation, and these factors are largely independent of geographical location. My e-therapist, therefore, may not come under the governance of his or her professional body in this instance, or at least, I may have no recourse to legalistic redress in case I am overcharged, subject to fraudulent behaviour, or in case the professional service I receive is not up to scratch. These are critical issues, deserving of attention, but space prevents treatment of them here.
Effects of the on-line environment on professional character...
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