As the Internet grows, so does its use by mental health professionals and by clients seeking mental
health services. Drawing on his own experience as an example, the author describes how the
Internet can enhance clinical practice. Social service professionals can utilize the Internet to
provide a supportive forum for patients grappling with issues of self-identity; facilitate
communication between therapist and client; provide community education about mental health
issues; provide referrals to local social service professionals; market a private psychotherapy
practice; and provide patient billing, scheduling, and record keeping.
Key Words: Internet, cyber counseling, psychotherapy, e-mail
A recent front-page article in the New York Times entitled "Online Therapy: An Arm's Length Approach"(Almer, April 22, 2000) drew attention to the growing phenomenon of how the Internet is being used by consumers and mental health professionals. For the past several years I have used the Internet and e commerce as valuable tools to market my practice as well as an additional tool for contacts with both existing and potential clients. Later in this column I will elaborate on the specifics of how the Internet has become a vital component of my work. Therapeutic contacts with existing patients via e mail has enabled some of these patients who felt reluctant to telephone between sessions to contact me without feeling as if they are violating the boundaries of our professional relationship. The advent of and ethical implications for professional mental health consultation over the Internet has not escaped the professional associations. "This form of communication is very important because we have overcome the basic limitations of space and distance-- and those are definitely worth overcoming," said Dr. Zebulon Taintor, chairperson of the American Psychiatric Association's Committee on Telemedicine. (Almer, April 22, 2000) But Miriam Coleman, head of the Policy and Practice of Clinical Social Work Committee of the National Association of Social Workers, said that privacy issues related to the Internet would have to be remedied before her group would recommend online treatment. (Almer, April 22, 2000)
It is fairly common knowledge that the Internet has been a rich resource for individuals struggling with their gay/lesbian/bisexual/transgender (g/l/b/t) identities and who are desperate for positive educational material and resources, as well as peer support. A particularly useful and relevant role that the Internet assumes is that of a lifeline for those isolated queer individuals who live in remote areas or who feel too stigmatized to seek out support or mental health treatment in their locales. One group for whom this is especially true is g/l/b/t youth as illustrated by the case of Corey Johnson, also reported in the New York Times (April 30, 2000). Johnson is a high school student in Middleton, Massachusetts. He is also a jock and a prominent member of his school football team. He found other gay high school students to talk with in the Planetout.com chat rooms for gay adolescents, including other gay high school athletes. For years he has exchanged e-mail messages with a gay right guard who lives in Chicago. He is quoted as saying that this chat room and cyber correspondence helped keep him sane during the time prior to his having told anyone he was gay, when he was so depressed and anxious that sleeping was difficult and his grades had fallen (Lipsyte, NY Times, April 30, 2000). Johnson's use of the Internet to help him move towards accepting his gay identity is not an isolated one.
My professional use of the Internet began over ten years ago when I first got an e-mail account and various clients asked if they could reach me via e-mail. By adding my e-mail to my business cards and advertisements I was making my e-mail as public as my office telephone number, and clients responded positively. It soon became clear that for such mundane communications as schedule changes, or questions about billing or insurance claims, an e-mail worked just as easily as a phone call. I soon began to incorporate e-mails into the treatment of certain patients. Initially it was with clients who were highly anxious and needed some additional contact between sessions. I found that their sending me an e mail upon which I could then reflect and respond, proved a most useful therapeutic tool to increase the therapeutic contact in a way that was beneficial to them and did not feel intrusive to me.
I routinely suggest to patients that if they want to or feel the need to be in contact with me between sessions they should feel free to e-mail me. I also tell patients that if they awake from a particularly significant dream, instead of jotting it down and bringing the dream into a session, they can send me an email upon awakening. This would give me time to think about it in advance of the session. During the course of therapy, at my encouragement, clients send me brief e-mails if something very pertinent to what we are working on happens between sessions. I find that the immediacy of these e mails, which are often written in primary process, provides the opportunity for a glimpse into a deeper level of my patients' unconscious than is frequently available if they are recalling feelings or events from the perspective of several days past. This brings a welcome additional complexity to treatment. E-mails are useful tools for patients who are struggling with impulse disorders. By teaching them to send me an e mail rather than confronting someone or doing something they will later regret, is an important step in their learning to tolerate the discomfort and/or anxiety that usually precipitates an episode of impulsive acting out.
The other way that e-mails have been useful in my practice is with patients who travel extensively. I have a lot of executives and theater people as clients. It is not uncommon for these people to routinely travel on business or be out of town acting in or directing shows, thus necessitating their frequently missing sessions. Normally in circumstances like this I try to arrange a telephone session in order for my client not to miss his or her regular session. But when people are traveling in Asia, Central or South America or Europe due to the numerous time zones as well as their work schedules while abroad, telephone therapy is not always practical. In situations where a phone session is not pragmatic, I often suggest that the individual take the forty five minutes that would have been a session and sit down and reflect on the issues we are working on, and what ever feelings or practical issues are arising, and then compose a lengthy e mail to me. When I receive the e-mail I save it and then read it through several times before commenting on aspects of it and e-mail the person my response. While this is obviously not as ideal as a face to face or even a phone session, it keeps the therapeutic interaction alive. I bill the patient for the cost of one session each time this happens, and I never bill for brief phone contacts or e-mail exchanges.
For several years I have been the Online Mental Health Expert at www.Thebody.com which is the world's largest HIV/AIDS web site. In this capacity I respond to approximately 20-25 e mail questions each month pertaining to the mental health aspects of HIV and AIDS. Many of the questions are from frightened individuals who seek reassurance that their very low risk behavior has not exposed them to HIV. A large number of questions concern psychotropic drugs and whether they might be useful. I am careful never to attempt to diagnose an individual based on material contained in a one-time e-mail. I often do reflect back to him or her that it sounds as if they are depressed or anxious and it would be a good idea to get the name of a skilled mental health professional from their primary care physician or from their local AIDS Service Organization (ASO) in order for them to have their condition and symptoms properly assessed and treated. Many people are isolated and need encouragement to reach out to their local ASO for referrals. At times I feel like a combination Dr. Ruth, Dr. Joyce Brothers and mental health guide or coach, urging people into therapy or at least to have a consultation.
Once I put up my web site, I felt as if my professional use of the Internet had really matured. I began by paying a consultant to design a web site containing a description of my practice, all of my articles, summaries of my books, links to other gay/lesbian and HIV/AIDS web sites, and a direct e mail link to me. Within a few months I was able to upload new material to my site directly without the services of a web professional. Once I got my web site listed with the major search engines I was up and running. The web professional embedded HIV, AIDS, gay men, homosexuality, male couples, gay sexuality, and queer in the metatags of my web site, thus enabling the search engines to locate my web site as a resource for queer mental health and HIV/AIDS. (Metatags are hidden key words in a web design that alert search engines to the content area within a site.) Since I moved my site from being hosted by AOL to another server in June 1999, I have logged over 35,000 hits to my web site. Although only about 4,000 individuals have actually accessed any of the information contained in the site, I find these numbers staggering.
The web site has been a tremendous boon to marketing my practice. People searching for a gay therapist in Manhattan can locate my web site, read some of my articles and if they like what they read and are interested in exploring a consultation with me, can either e-mail or call me to discuss setting up an initial consultation. On an average month I get about one call or e-mail from a potential new client who has found out about me through the web and wants to discuss coming in for an appointment. Most of these people do not turn into actual consultations or new referrals, but enough have that it more than pays for the cost of my web site. A web site is not an expensive proposition. To register a domain name costs $35 yearly. The cost of having my site hosted, which includes a small amount of technical support when I require it, is $50 monthly. I consider this an excellent investment. Since I put up my site, every week I get e mails from people around the world with questions about being gay or asking if I know of a referral to a good therapist in a location near them.
The final way that I have integrated the Internet into my practice is through the use of a practice management software package that includes electronic billing and a scheduling module. For clinicians participating in managed care networks, the practice management software has easy ways to keep track of authorized sessions and for submitting outpatient treatment reports (OTRs) and continuing treatment authorization requests. It is even possible to install a module for accepting credit card payments. I keep my entire practice on my computer. All of my patient face sheets, sessions, notes, and billing information are easily managed with a few clicks of my mouse. There are windows for both progress notes and medication notes, as well as a complete DSM IV in order to list a diagnosis with two clicks of a mouse. Submitting claims or bills to insurance companies is also literally just three clicks of a mouse per patient per month. The time it takes insurance companies to pay me is now between 7 and 14 days from the day my claims are electronically submitted, as opposed to four to ten weeks when I sent in hard copies. One of the ways that electronic billing speeds the reimbursement process is by automatically checking for errors in the form both before they are electronically sent and once the clearinghouse has received the claim but prior to submitting it to the insurance company. Within hours of sending an electronic claim I receive back a notice form the clearinghouse either accepting the claims or informing me of exactly what is not correct so that I can correct it quickly. With paper claims, a misspelling or other error on the HCFA 15 claim form can delay payment by an additional two to four weeks since the form is mailed back to the provider and has to be returned by mail after being corrected.
Obviously it is imperative that I back up my data on a daily basis. I do this both to a zip drive as well as to a floppy. As an added protection, I installed my practice management software on my laptop computer in addition to my desktop. That way, if my hard drive crashes or some other catastrophe caused by cyber gremlems occurs I can always restore the data to my laptop from the floppy disk. This has happened to me on two different occasions and having the data backed up and available to use within a few minutes averted a major practice nightmare.
Each mental health discipline's professional journals contain advertisements for various practice management software programs. For the past five years I have used Therapist Helper which I find ideal. It is constantly being updated and improved. Their technical support hotline has been superb. Therapist Helper is the second program I have used. The first was DOS based and never upgraded to a windows based operating system. There is a wider choice of programs if you are on a PC rather than a MAC system, but there are programs available for MAC based systems.
In summary, I have found the Internet to be an invaluable tool for managing my practice and for enhancing the service I can offer my clients. t is cost efficient and having a paperless office is environmentally friendly as well. It has streamlined my record keeping and simplified all of the scheduling and book keeping aspects of a private practice.
Almer, E. (2000, April 22). Online therapy: An arm's-length approach. New York Times, pp. 1,
A11.
Lipsyte, R. (2000, April 30). Icon recast: Support for a gay athlete. New York Times, pp. 1, 24.