Assessing a Person's
Suitability for Online Therapy
were developed by the Clinical Case
Study Group of the International Society for Mental Health Online.
They outline some basic issues in determining a client's suitability for
online psychotherapy. Although they are designed mostly with text-based
therapy in mind (e-mail, chat), many of these guidelines apply also to
other online methods of communication (e.g., internet telephoning, video
conferencing). "Suitability" refers to a variety of factors, including
the person's preferences regarding online therapy, how suggestible the
person is within a particular communication modality, his or her skills
in communicating within that modality, and the potentially therapeutic
aspects of that modality for the person. Because there are many possible
formats for online clinical work, as well as many different theories of
psychotherapy, these guidelines are not intended to be exhaustive or definitive.
Hopefully, clinicians will adapt these ideas to the unique aspects of each
of their online psychotherapy cases.
the assessment, the clinician needs to keep in mind the ethical issues
regarding online therapy, such as those described in the suggested
principles of the International Society for Mental Health Online. As
these suggested priniciples indicate, it's important to inform clients
about issues regarding privacy, the potential benefits and risks of online
therapy, and possible safeguards. The client's ability to understand this
information and his/her attitudes regarding these issues could be important
determinants of the client's ability to benefit from online therapy.
1. What communication
methods are adequate or preferable for assessing the client?
has a variety of communication methods for conducting the initial assessment
of the client: in-person, video-conferencing, phone, email, and instant
messaging or chat. Clients may have a preference for this initial contact,
which may in itself be of diagnostic significance. Clients interested in
online therapy may prefer a text-only setting for this first contact. They
may feel more comfortable in that setting, be more able to express themselves,
or wish to maintain some anonymity. Clients' preferences need to be considered
along with the potential advantages of conducting the assessment using
different communication methods. Combining different methods during the
assessment process will yield more comprehensive and qualitatively different
information about the client's personality and behaviors. Face-to-face
and/or phone interviews should be encouraged during the assessment phase,
although these methods may not be absolutely necessary in every case. Assessment
within the preferred medium may be sufficient if communication within that
medium is accurate and efficient.
client with the communication method that will be the medium for therapy
is important. However, the clinician should consider the possibility that
the client may benefit from therapeutic work in communication environments
that are NOT his or her stated preference. It also is possible that the
person may benefit from therapy that includes more than one environment
(face-to-face, phone, email, chat, etc) - which means that the treatment
will involve more complex variables regarding contact time and format than
traditional in-person therapy. The client's preferences, skills, and attitudes
regarding work within multiple environments will be important factors to
2. How might
the person's computer skills, knowledge, platform, and internet access
affect the therapy?
The ability to
benefit from online therapy will be partly determined by the client's computer
skills and knowledge, especially if the communication setting involves
installing and learning new software and/or hardware. If the person seems
to communicating efficiently and accurately within the setting of choice,
no further assessment of the person's skills may be necessary. If therapy
will move to another setting, it is important to assess the extent to which
an online client is able to effectively use the computer hardware and software
at his/her disposal to communicate in a manner which feels natural and
allows for nuance in describing and expressing oneself. Part of the assessment
process might involve a trial stage in which the therapist and client test
out the communication pathway between them, without yet having established
a commitment to the therapy. Some questions to consider include the following:
-- Does the person
demonstrate adequate knowledge of his/her computer system and internet
-- Is the person
motivated and capable to experiment with new communication environments
-- Is the person's
computer system compatible with that of the clinician?
-- What kind of
internet access does the person have?
-- Where is the
client accessing the internet (home, work) and does this present any problems
regarding privacy or any technological difficulties (e.g., firewalls that
limit internet activities)
-- If the client's
internet access is problematic, are there viable alternatives (e.g., a
web-based e-mail account)
3. How knowledgeable
is the person about online communication and relationships?
The ability to
benefit from online therapy will be partly determined by the person's familiarity
with the technique and psychological aspects of online communication. First-hand
participation is valuable, as well as the person having read about the
internet and talked to others about it.
-- What is the
person's lifestyle in cyberspace?
-- What experience
does the person have with communicating online?
-- If the person
has online relationships or belongs to online groups, what have these social
activities been like?
-- In what settings
did these relationships develop and for how long?
-- What other
activities does the person pursue online, and what is his/her attitude
about life in cyberspace?
4. How well
is the person suited for the reading and writing involved in text communication
If the therapist
will be working with the client via typed text, assessing the clients experience
with reading and writing is important. A person's reading and writing skills
may not be equivalent, but both are necessary for text-based therapy. Some
people may prefer reading over writing, or vice versa, which could have
a significant impact on text-based communication. Assess the person's motor
and cognitive skills for reading and writing, as well as the person's psychological
experience of these activities. What does reading and writing mean to the
person? What needs do these activities fulfill? It may be helpful to discuss
how the person's attitudes and skills regarding in-person communication
compare to those regarding text communication. When assessing the person's
suitability for text communication, it's important to remember that developing
and enhancing the person's reading and writing skills may be intrinsic
to the therapeutic process.
is a different experience than e-mail, it's important to determine the
client's skills and preferences regarding these synchronous versus asynchronous
methods of communication, as well the person's potential to benefit from
these different methods. It may be informative to ask the client to complete
a writing exercise that is relevant to the type of online therapy being
offered (e.g., a summary of the history of one's life, a description of
a scene related to the presenting complaint, an essay about one's personality
or family members, an objective description of a specific problematic behavior).
to consider during the assessment stage include the following:
-- Does the person
like reading and writing?
-- What kinds
of experiences has the person had with reading and writing?
-- What do reading
and writing mean to the person?
-- Are there any
known physical or cognitive problems that will limit the ability to read
-- How well can
the person type?
-- Does the person
enjoy in-person and phone conversations. Why?
-- How does the
person feel about the spontaneous, in-the-moment communication of chat/IM
as opposed to the opportunity to compose, edit, and reflect, as in e-mail?
-- Might there
be therapeutic benefits of using chat, e-mail, or some other method of
text communication even though the person may not prefer that particular
5. How might
previous and concurrent mental health treatment affect online therapy?
If the person
has been in therapy before, this will have created some impressions and
expectations of what therapy is like. It is important to assess how these
impressions and expectations are influencing the person's attitudes about
online therapy, especially if the communication method will be different
than that used in the previous therapy. Inquire about what type of therapy
it was, the therapist's style of intervention, the duration of the therapy,
the goals and outcome. Compare these factors to what will be offered in
the online therapy. If the person currently is involved in other online
or in-person mental health treatments, how will this influence the therapy?
6. How might
personality type, presenting complaint, and diagnosis influence the person's
suitability for online therapy?
This is a complex
topic that deserves more clinical research. A separate set of guidelines
could be devoted to it. One basic issue is the level of care a person may
require (see Stofle's
description). People who need full or partial hospitalization with
close observation and supervision may not be appropriate for online therapy.
The level of care a person requires also may change over time, thereby
requiring that the clinician assess the person's history of level of functioning,
and then periodically reassess the client during the therapy. As a rule
of thumb, severe pathology and risky behaviors - such as lethally suicidal
conditions - may not be appropriate for online work. Tendencies towards
poor reality testing and strong transference reactions may become exacerbated
in text communication, thereby making them difficult to manage and potentially
destructive to the treatment. People with borderline personality disorders
often challenge the boundaries of therapy, which can be especially problematic
in e-mail communication and when combining different methods of communication.
The clinician may need to set very clear rules about when, where, and how
therapy takes place. The structure offered by online therapy may attract
people who experience problems with impulsivity, internal emptiness, splitting,
and aggression which otherwise get acted out in the comparatively unstructured
social world of cyberspace. More clinical research is needed to determine
what types of significant pathologies might be treated online, and how.
disorders and types (antisocial, narcissistic, schizoid, avoidant, paranoid,
depressive, manic, masochistic, obsessive-compulsive, histrionic, dissociative)
may lead to valuable information about how these people react to various
forms of online therapy. Will avoidant and schizoid people fare well in
the potentially anonymous environment of text conversation? Will the projective
mechanisms of paranoid people be overly exaggerated in text communication?
Can people with dissociative tendencies benefit from work across communication
settings - or by participating in online groups - or will such work amplify
those tendencies by encouraging fragmentation into different online persona?
More clinical research is needed to answer these questions and refine the
can be valuable in assessing the psychopathological factors that might
influence the efficacy of online treatment. If it's not possible to arrange
in-person testing, online tests could be an easy-to-access supplement to
the assessment interview. Hopefully, in the near future, professionally
managed web sites will become available that offer diagnostic tests as
an aid for online therapists. When using online tests, consider such factors
as accessibility, affordability, user-friendliness, security of test results,
compliance with ethical principles, reliability, and validity.
Of course, many
assessment principles that apply to therapy in-person also apply to online
therapy, but will not be reiterated here. In addition, the type of online
therapy being offered (psychodynamic, cognitive, behavioral, humanistic,
etc.) will determine the types of questions raised during the assessment
stage. Whether a person might benefit from a particular style of therapy
will be partly determined by how that style of therapy operates in an online
7. How might
physical and medical factors affect online therapy?
Does the person
have any visual, auditory, speech, or motor disabilities, or any chronic
medical condition? Is the person on medications? If so, how might these
disabilities and medications affect the person's motivation for and ability
to utilize online therapy? Some people are drawn to text communication,
where there is no face-to-face contact, because they prefer to hide their
physical appearance. Does the person present any signs that possibly indicate
a medical condition that needs to be assessed in-person by a physician?
Although text communication can be effective in assessing some psychiatric
symptoms, other symptoms rely heavily on face-to-face cues (e.g. flat affect,
motor retardation, degenerated physical appearance, slurred speech, tremors,
etc.). If any auditory and visual cues are essential in assessing the person's
condition, the clinician will need to contact the person by phone or face-to-face,
or refer the person to another professional to complete the assessment.
8. How might
cross-cultural issues affect the therapy?
It is very likely
that the online clinician will receive requests for therapy by people from
other countries and cultures. In these cases clinicians must determine
whether communication will be significantly hindered by differences in
language, and whether they are familiar enough with the person's culture
in order to effectively conduct psychotherapy. Although cross-cultural
issues are also important in in-person therapy, such issues may be unique
and magnified in an online therapy when the client is living in a country
that is geographically distant from the therapist.
9. What other
online resources might be appropriate to incorporate into a treatment package?
A wide variety
of potentially therapeutic resources are available online, including informational
web sites, support groups, mental health message boards, self-help instruction,
and experiential software. The assessment process might include an explanation
of these resources to the client, and then a determination of whether the
client is interested in or could benefit from them. The goal is to determine
whether a multi-modal treatment plan might be therapeutic, and if so, what
might those modalities be.
will not be appropriate for all people seeking help. In these cases, the
online practitioner should have the skills and resources to make appropriate
referrals. When the practitioner determines that high risk or other factors
indicate that a person is best served by seeking immediate treatment within
his or her locality (e.g., for suicide prevention, medication assessment,
etc.), such a referral or assistance in finding an appropriate referral
should be provided.