Psychotherapy may be understood as a therapeutic process in which a trained person
deliberately establishes a professional relationship with another person (seeking help) for
the purposes of treating emotional and/or personality problems or disorders.
Online psychotherapy (OPT) or e-therapy is delivered using internet-based technology
through a video call, voice call, text messages, and/or emails. Tele-psychotherapy is a
broader term and involves using either telecommunication (i.e., telephonic) or internet-based
digital communication mediums to deliver therapy or counseling sessions remotely. In this
article, we will focus on OPT specifically because it is a relatively newer form of
tele-psychotherapy that people with psychological distress have increasingly used to seek help
during the COVID-19 pandemic.
The possible reasons for this growing popularity among the general public are the
increased accessibility, affordability, and acceptability of psychotherapy offered over online
mediums. OPT can be provided in remote or rural areas and to people with limited physical
mobility while sitting comfortably in one’s home/office at a time of their choice (for both
the client and the therapist). Further, the clients can choose from a large pool of available
online psychologists depending upon their preferences and comfort (e.g., language or gender of
psychologist). It also helps in reducing the stigma attached to seek help by visiting a mental
health professional (e.g., psychologist) at a hospital or clinic. Additionally, it is
compatible with the public health guidelines (e.g., physical distancing, restricting travel to
and from a containment zone, etc.) recommended for controlling the spread of the COVID-19 pandemic.
However, it is important to consider limitations, ethical issues, and potential risks
associated with the practice of OPT. Here, we explore some of these important challenges
specific to the OPT or counseling services being offered during the COVID-19 pandemic and
offer a few suggestions to address them.
Effectiveness of OPT
Compared to many high-income western countries, India has great cultural diversity and
significantly different socioeconomic and digital literacy levels among its people. Further,
the psychological distress arising from the fear of getting COVID-19, social dislocation,
daily routine disruptions (e.g., closure of schools/colleges or offices), financial
hardships, increased caregiving burden, and/or loss of loved ones during the pandemic is
contextually different and might respond differently to conventional OPT or
counseling.[4, 5] Available literature
suggests that online cognitive behavior therapy has similar efficacy compared to in-person
therapy for treating depression and anxiety disorders.[6, 7] However, almost all of these studies have
been conducted in western countries during the pre-COVID times, and caution is needed while
extrapolating their findings to the Indian context. Thus, there is a need to conduct
research assessing the effectiveness, equivalence, acceptability, implementation-related
challenges, and cost-effectiveness of OPT in India’s rural and urban settings.Further, OPT is not appropriate for treating people with serious psychiatric illnesses or
in crises (e.g., a person with active suicidal ideation), which are likely to require close
and direct treatment through in-person therapy.
For example, people with severe depression and/or psychotic symptoms like the
delusion of persecution leading them to believe that their actions are being continuously
monitored and anything shared by them online would be used to harm them and would not be
very amenable to OPT. Similarly, a person with severe psychiatric illness would require
constant supervision and desire immediate psychological support during periods of intense
suicidal ideations or distress (e.g., severe anxiety episodes, early morning awakening) at
odd times even in the intervening period between the scheduled online sessions. This might
not be possible even with the greater flexibility in the timing of services offered by the
OPT. There is a need to develop a system for tracking such a person seeking OPT and help
them access emergency psychiatric services by either informing the verified emergency
contact listed by the person (if available) or intimating the local police and/or government
authorities to rescue them. However, there are no standard guidelines or legal framework to
ensure this in India at the moment.
Constraints Related to Internet or Digital Technology
A stable internet connection and easy access to a digital device (e.g., mobile, computer)
are necessary for any OPT. Additionally, high-speed internet is often needed when online
audio–video communication is done, to avoid lag or disruptions in signal, which could hamper
the progress of therapy sessions. Further, digital literacy and a certain minimum level of
technological competence are needed for both the client and the therapist to ensure adequate
engagement in OPT. However, a significant proportion of people in India might not fulfill
these prerequisites.
Further, during the COVID-19 pandemic, there has been an increase in the use of
internet-based devices for communication (e.g., social media), work from home, education
(e.g., online classes), and entertainment (e.g., watching videos and playing games) purposes
by many people restricted to their homes.
Thus, OPT might put further strain on people from a socioeconomically disadvantaged
background who are already likely to have limited access to internet-based digital
devices.Even when the above-described internet- and digital-technology-related requirements are
met, OPT falls short of traditional face-to-face therapy in certain aspects. Many people
would not be comfortable speaking through a screen for long durations and might not feel the
same level of comfort in sharing their inner thoughts and feelings online with the
therapist. Similarly, some therapists have also expressed concerns about the relative lack
of effectiveness of several techniques employed by them online (e.g., guided exposure and
response prevention therapy, interoceptive exposure exercises, the cognitive
conceptualization of case by drawing a panic circle, or triad of emotional experience) as
compared to in-person therapy.[11, 12] Also,
despite an online video conferencing without any disruptions, during an online session,
there are chances of missing nonverbal cues like change in tonal inflections, gestures, a
shift in body posture or eye gaze, and/or proxemics, which might otherwise play an important
role in communicating distress and other information to the therapist in the conventional
offline therapy. Some patients might engage in avoidance behaviors by switching off their
audio or video during the session on the pretext of poor internet connection or device
malfunction, resulting in faulty interpretation and/or reduced therapeutic effectiveness.
Further, simple acts of giving a tissue to the patient for wiping tears during an
emotionally charged discussion or emphatic posturing by the therapist toward the patient,
which might play an important role in strengthening the therapeutic alliance, are seldom
possible in an OPT session. The important role played by providing a human touch and a
soothing physical environment in promoting the overall mental well-being of individuals has
been well-documented.Many people might find it difficult to get a safe and suitable place at home for OPT
sessions, especially with more people often staying at home because of the closure of
schools/colleges and offices or social distancing during the COVID-19 pandemic. This could
be particularly problematic when sensitive topics or issues related to family members or
people living together need to be discussed (e.g., child sexual abuse, domestic abuse, and
personality disorder). Someone barging in at home during an ongoing session could lead to
interruptions during a critical point in the session and also compromise the privacy of
information shared during the session. This is a critical issue in situations where the
client might not want to disclose about therapy to their family members, or there is the
risk that they might not allow the patient to continue with psychotherapy. Thus, the
important functions of providing a “safe place” and “holding environment” served by the
therapist’s office in traditional in-person therapy are often missing in the virtual world
of OPT.[12, 14]
Ethical and Data Safety Concerns
The practice of OPT is still in the early stages of development in India, with a sudden
shift to online medium for several clients and therapists because of the COVID-19 pandemic.
Thus, many therapists are practicing OPT without adequate training in delivering
psychotherapeutic interventions online and without adequate knowledge about the
technology-related aspects involved. This could lead to nonuniformity in practices or
services delivered online by different therapists. In the absence of uniform training or
established standards for OPT, there is a risk of delivering suboptimal care to people.
Similarly, many therapists and clients are not sure about how to handle several other
ethical issues related to OPT, such as the limits on the confidentiality of the information
shared online because of factors beyond the control of the therapist, or the payment of fees
(e.g., before or after the session, fees for an otherwise free call or message to clarify
any doubts or urgent issues between follow-up sessions). There is also a tight rope walk in
having an ethical yet effective advertisement for OPT services offered by therapists over
the digital medium (e.g., social media or online telemedicine platforms). While providing
information about the online services is permissible, the use of one’s picture or other
personal information disclosure is likely to be construed as misconduct under the existing
tele-psychotherapy guidelines.
OPT is often conducted using third-party online platforms or personal social media
accounts (e.g., WhatsApp) or emails of clients and therapists. The online platforms might
collect personal information (e.g., cookies, IP address, mobile number, etc.) of the
clients, and later use this information either themselves or through sharing with other
third parties for targeted advertising, without their explicit consent or understanding, in
an unethical manner. The online data shared during this might not be fully safe and is prone
to theft and hacking by third-party sources.
Further, the therapist should maintain basic records of psychotherapy sessions or
services delivered as per the extrapolation of traditional psychotherapy practice standards
under the Mental Health Care Act in India.
However, the law does not explicitly mention OPT. Neither does it lay down the
requisite minimum safety checks to be followed while conducting OPT or storing data related
to it. We suggest using a Health Insurance Portability and Accountability Act
(HIPAA)-compliant online platform or dedicated personal communication mediums with at least
double-encryption of data and password-protected access, till the government drafts formal
safety norms.
Risk of Fraud
Unverified links (e.g., links shared through unsolicited email or personal message,
website/ weblink being flagged as unsafe by user browser, etc.) offering OPT services could
be used for phishing scams. Similarly, sharing personal information (e.g., date of birth) or
digital account-related information (e.g., credit card number) over unverified OPT platforms
(i.e., a new platform whose authenticity could not be established by the user based on the
available information to him/her) could be used for hacking and/or fraudulent transactions
from the persons’ account.
Further, there is a risk that vulnerable people in psychological distress might
receive unaccredited online counseling or psychotherapy by inadequately trained or
unqualified therapists.
These sessions could do more harm than good to the users. Although online advertising
about the quality of their services by doctors, including mental health professionals, is
prohibited under the code of ethics laid down by the professional governing body in India,
several platforms promote their services online by displaying ratings and/or reviews by
their users. There is a risk that these reviews available online are by paid users or bots
and might misguide people.
Moreover, at some online platforms, chatbots based on artificial intelligence
technology might be used to provide counseling and therapy services to people, without their
explicit knowledge and/or consent, giving them an impression that they are interacting with
a real therapist.
Apart from the obvious ethical concerns, there is insufficient evidence about the
effectiveness of these chatbots in the available literature.
The Way Forward for OPT
There is an urgent need to regulate the practice of OPT by developing minimum standards for
the practice of tele-psychotherapy. The available international and national guidelines for
tele-psychotherapy (though not mandatory or legally binding) should be popularized among the
mental health professionals and the general public, to promote awareness about the suggested
good practices in OPT.[21,
22] The general public
should be made aware of various limitations of OPT services, limits on the confidentiality
of information shared online, possible need to contact nearby health emergency services for
any physical or mental health crisis, and the right to withdraw or stop sessions at any time
if they are not comfortable. There is a need to promote awareness among the general public
about who all are qualified to practice psychotherapy or counseling and about the existing
accreditation systems for psychotherapists in India. For example, details of all clinical
psychologists trained at institutes recognized by the Rehabilitation Council of India (RCI)
are maintained in the Central Rehabilitation Register. Without RCI registration, practicing
as a clinical psychologist or counselor in private, government, or nongovernment settings is
prohibited under the RCI Act of 1992.
Also, therapists with registration or license from other countries might not be
allowed to practice in India. Thus, therapists should be encouraged to share their
qualifications and RCI number with clients prior to the start of OPT. Further, there should
be an online database maintained by the professional bodies or government agencies, where
details of all psychologists or counselors with necessary qualifications to practice in
India could be accessed and verified by users. For example, the National Board for Certified
Counsellors in the United States of America is a nonprofit licensing organization that
certifies counselors adhering to their strict policy and standards (displayed publicly on
their website) for delivering psychotherapy services remotely, among other things.
These steps would help the clients ascertain the authenticity of the service provider
and ensure some degree of standardization in the quality of psychotherapy services offered
online. This should be complemented with the development and starting of short-training
courses for existing psychotherapists in India to impart the necessary psychotherapeutic and
technological skills and knowledge necessary for delivering OPT effectively, along with
sensitization about the relevant ethical and legal issues associated with the practice of
OPT. Lastly, the Mental Health Care Act, 2017 should also be amended to incorporate
guidelines related to the delivery of tele-psychotherapy services (including OPT) in India
and provide mechanisms to address any further issues arising out of the practice of
tele-psychotherapy.
Conclusion
The authors acknowledge the important role of OPT services in meeting the huge demand for
mental health services during the COVID-19 pandemic and postpandemic era but would like to
draw the attention of mental health professionals, policymakers, and other stakeholders
about the urgent need for discussion about possible ways to make it more safe and reliable
for both the client and the therapist.