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With managed-care companies and more consumers
moving online, psychologists are poised to offer Web services.
Still, questions loom about the quality of services and
information provided on health-related sites.
BY LISA RABASCA
Monitor staff
A
25-year-old woman wakes up in the middle of the night feeling
anxious. Unable to sleep, she logs on to her computer and
stumbles upon a self-help site that asks her to fill out a
10-question survey about her troubles. In the morning she
receives an e-mail suggesting she might have an anxiety
disorder and is invited back to the site to learn more about
the disorder, join an online self-help group or seek advice
from a counselor through e-mail.
But who's scoring her test, monitoring the self-help
group and giving her advice? Is the "counselor" a licensed
clinical psychologist qualified to treat anxiety disorders? Is
the Web site sponsored by a pharmaceutical or managed-care
company?
The problem, psychologists say, is there's usually no
way to know. Counselors can range from high school graduates
to doctoral-level practitioners, and while most Web sites
disclose their sponsors, consumers don't always know how much
influence advertisers have over the site's content.
And, that's not the only problem: Psychologists say
there's no definitive proof that mental health services
provided via e-mail or chat rooms work.
While the Internet likely will be used to provide a
range of information and services such as mental health and
psychoeducational information, there's not much known about
whether "self-help" or other kinds of psychotherapeutic
services are effective, "over the wire," says David Nickelson,
PsyD, JD, director of technology policy and projects, and
special assistant to the executive director in APA's Practice
Directorate.
"For example," he says, "there's no good evidence that
you can provide interpersonal or dynamic psychotherapy
services over the Internet and know they're as effective as
face-to-face services."
Yet despite these concerns, the growth of the Internet
is leading more consumers to search for mental health services
online and managed-care companies are gearing up to respond.
Advocates claim that consumers who in the past have shied away
from face-to-face therapy are willing to give psychotherapy
online a chance. And anticipating these opportunities, scores
of psychologists are launching their own Web sites.
Virtual replacing reality
Managed-care firms see the Internet as a means to
improve their bottom line. Money once invested in managed-care
companies is being pumped into Internet health-care sites.
Meanwhile, health-maintenance organizations are partnering
with Internet companies or starting their own Web
sites.
"The investment money, venture capital and stock
investments are drying up in managed care," says Russ Newman,
PhD, JD, APA's executive director for practice. "But these are
big for-profit companies and they aren't going to go away just
because there's not enough money available. Instead, they're
going to transform themselves to be financially successful,
and they're looking to do that through the Internet."
Kaiser Permanente, for instance, recently launched a $2
billion project to move its administrative operations to the
Internet to improve the quality of care and save tens of
millions of dollars a year, the company reports. Plans call
for Kaiser to create digital medical records that will
electronically link its hospitals, clinics and providers, and
develop customized Web sites for major clients and
administrative purchasing. Industry analysts predict that
other health plans will follow Kaiser's lead as market
pressures intensify and consumers demand more services and
information.
Economists further predict that as more people receive
services online, fewer brick-and-mortar stores and offices
will be built. Last year, 17 million U.S. households shopped
online, according to Forrester Research, an independent
research firm. Forrester estimates that the health-care
industry will reach $370 billion in online transactions by
2004.
That's not surprising, given that 22 million people
looked for health information on the Web in 1998 and mental
health tied with dermatology as the topic consumers most
frequently searched for online, says Leigh W. Jerome, PhD, a
clinical psychologist and behavioral telehealth research
scientist in Kailua, Hawaii. Psychological services provided
on the Internet range from basic information about specific
disorders, to self-health sites that assess a consumer's
problem, to full-blown psychotherapy services such as
assessment, diagnosis and intervention delivered online through e-mail or
videoconferencing.
Poised and ready
Not surprisingly, psychologists are already trying to
stake out a corner of this exploding market. Many
psychologists have formed partnerships to develop counseling
and mental health Web sites.
One such Web enterprise is Epotec, which contracts with
employee-assistance programs and managed-care
companies--including CIGNA and United Behavioral Health--to
offer online behavioral services. Currently,
2 million
clients have access to the site, where they can learn about
goal setting, loss and grief, stress, coping with change,
depression, worry and anger management.
"Our programs really focus on behavior change and use
cognitive-behavioral therapy skills and training," says
Richard D. Flanagan, PhD, co-founder and chief clinical
officer of Epotec. "The programs are all based on proven
approaches to behavioral change."
For instance, a client with stress-management problems
can read basic information about stress on the site, or sign
onto a self-assessment program that appraises a person's
stress level and develops a personal plan to help him or her
deal with it.
Another psychologist-run Web venture is Here2Listen, a
Web site that connects practitioners and clients to
psychological services provided by
e-mail and
videoconferencing. The site registers providers, checks
credentials and connects licensed practitioners with clients
online, according to Gunny Cho, Here2Listen's CEO.
"We are working closely with licensed counselors to
assist them in bringing part of their practice online so that
our community of counselors will be available to address
people's needs," says Cho.
But what about quality?
Most experts agree that what's currently being offered
online is not traditional psychotherapy. However, some say it
fills a niche for consumers who are reluctant to seek
treatment.
Many consumers aren't getting help because they don't
want to deal with insurance plans, the inconvenience of
scheduling appointments and the cost or social stigma
associated with psychotherapy, says John M. Grohol, PsyD, vice
president of an Internet start-up in Texas that plans to offer
online therapy services. Online therapy offers clients a
degree of anonymity and the convenience of 24-hour services,
he says.
But, APA officials caution that in most instances, it's
still not known if services provided over the Internet are as
effective as face-to-face interventions.
"One of the primary questions in evaluating this type
of activity is whether services that are delivered in this way
are at least as good as in-person services that would
otherwise be available," says Geoffrey Reed, PhD, APA's
assistant executive director of professional practice.
For instance, he says, for American Indians on isolated
reservations, military personnel in remote locations, prison
inmates and homebound individuals, services delivered from a
distance might be the best available. But services provided by
e-mail shouldn't be seen as a substitute for face-to-face
services.
Further, says APA's Nickelson, clients who receive
Internet-based services might not have the same outcomes as
clients receiving face-to-face therapy and may not seek
additional help if their online therapy fails.
"If that's the case," he says, "they're still not
getting the services they need."
Concern about the quality of health-related Web sites
is why the Practice Directorate is developing materials to
help consumers evaluate mental health information provided on
the Web, says Russ Newman. An initial brochure--still under
development--will give consumers five questions to ask
themselves as they look at a Web site to determine the quality
of information, confidentiality and whether commercial
interests are influencing the content and the degree to which
a site purports to be informational but is actually offering
services.
For instance, says Nickelson, if a drug for treating
depression is advertised on a Web site that offers information
about depression, is the site trying to sell the drug or
educate the consumer about depression?
Similarly, many people use the Internet because they
think they're getting information anonymously but many Web
sites put a "cookie" or a piece of information on the
visitor's computer to track use and see what other sites the
consumer visits.
If a consumer, for instance, researches schizophrenia
and bipolar depression and then does research on getting a
mortgage, will the mortgage company be able to track the sites
this consumer visited? What will it do with the information?
The consumer also might start receiving e-mail from
pharmaceutical companies about drugs to treat bipolar
depression, says Nickelson.
Psychologists need to be there
Despite these concerns, psychologists can't afford to
ignore the Internet, says Jerome of Hawaii. Inevitably, she
says, telehealth will be used to provide routine psychological
services, and "if we shun the technology then someone else
will fill the vacuum and they may not have the same ethics as
us," she says.
Psychologist Marlene Maheu, PhD, agrees that
practitioners could get shut out of the market, especially if
managed-care companies are the only ones offering
psychological services on the Internet.
"The Internet is going to be an even more powerful tool
for managed-care companies to ratchet-down our fees or
sidestep us altogether," says Maheu, director of telehealth
for the California School of Professional Psychology and
publisher of two health-related Web sites. She predicts
managed-care companies will hire unlicensed or master's-level
providers at a less expensive rate than psychologists to be
"lifestyle managers" and interact with patients online in a
way that won't be regulated by state licensing boards.
But perhaps the most important reason for psychologists
to increase their involvement on the Internet is that
consumers are continuing to demand access to more and more
Internet services.
"Not everyone is going to like this kind of
interaction," says Grohol of Texas, "but it will take its
place among the psychotherapy offered today, like group
therapy versus one-on-one therapy. Some will choose this over
face-to-face therapy."
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