Seeing A Virtual Shrink

When Rita Lowitt, a Berkeley marriage and family therapist, isn't meeting clients in her office, she's treating them from home. Some nights, she might comfort a nervous new mom. Others, a stressed-out CEO or a fortysomething with a disappointing sex life. Her clients share their most private feelings, but Lowitt can't see their tears or hear their sighs. She may not even know what time zone they're in. Confused? Lowitt is counseling people online. "We're all more pressed for time, trying to avoid despair," she says. Internet counseling is "immediate, it's focused, it cuts to the chase."

It had to happen someday. Buy online. Date online. Visit the shrink online. Everything, it seems, is a virtual commodity--as long as you have a keyboard and credit card. Five years ago, only a handful of therapists offered e-mail counseling and interactive chats; now, there are whole clinics of them, like here2listen.com, where Lowitt practices. An estimated 250 to 300 counseling sites exist, charging anywhere from $1 a minute to $150 and up for a month of e-mail. In the age of the Prozac fix, more will likely emerge as therapists seek new ways to market their trade. As clients begin to tap in, concerns are mounting: Is online therapy ethical? Legal? Dangerous? It's clearly gaining attention. At a recent meeting of the American Psychoanalytic Association, members discussed the Internet in one room, Freud in another. Some groups, like the American Counseling Association, have issued guidelines for practice. Others are taking note from a distance. "This is an emerging area" with potential pluses and minuses, says the American Psychological Association's Russ Newman. "We're watching and we're interested."

Anonymity may be the virtual couch's greatest appeal. Martha Ainsworth, who logged on from a hotel room during a stressful business trip, had tried face-to-face therapy but found it inhibiting. E-mail freed her psyche. "I feel less self-conscious if someone isn't looking at me," she says. That doesn't surprise researchers. Back in the 1970s, Dr. John Greist of the University of Wisconsin Medical School found that when it came to talking about nosebleeds and chest pain, patients revealed the same information to a human interviewer as to a computer. But when the topic was sexual function or substance abuse, "they started telling the computer a whole lot more," says Greist. Writing, instead of talking, may also help focus feelings and speed resolution. "You can cry and type at the same time," says Lowitt. "You can't necessarily cry and talk at the same time." For counselors, there's more time to reflect. "I think my responses are more powerful," says Peter Chechele of cybertherapy.com.

Convenience is also key. Clients can log on for a chat or an e-mail when they're most overwhelmed--in their pajamas on a Saturday night--or from small towns, where finding a therapist can be not just traumatic, but impossible. Tricia Griffin, 26, needed help coping with her grandparents' death, but had little free time. Plus, "it's a big step to admit that your problems are too big to handle alone," she says. Griffin liked the format of online counseling: "It didn't feel formal, like I was going in and sitting on a leather couch." And she loved the cost--$70 for an hour of chat, compared to $100 and up in-office. Therapists like Jef Gazley, "sick to death of managed care," like the financial incentive, too: "It's between me and the client again."

But at what cost? Online counseling may work well as an adjunct or first step to face to face, critics say, but it obliterates the pillars of traditional therapy. "Therapists rely not only on what is said, but what is not said," says Dr. Lisa Mellman of New York's Columbia Presbyterian Medical Center. Visual cues like wringing hands, tapping feet and tears speak for trapped emotions. Dr. Sandra Walker, a psychoanalyst, says she knew an alcoholic client was relapsing when "the cologne got stronger and stronger." For many patients, in-person interaction is crucial. One 30-year-old with bipolar disorder, who goes by the screen name Sibbul, says she'd never visit a virtual counselor. She relies on a therapist to read her state of mind--her hunching when she's depressed, her nervousness when she's manic. Online, she says, "it would be too easy to lie."

Responsible online counselors say that while their services may be therapeutic, they are in no way comparable to face-to-face therapy and should never be used as a substitute. Still, the what-ifs abound. What if a client hooks up with someone who isn't qualified or doesn't have his best interests at heart? Ainsworth had a great experience but she knows the pitfalls, so she started a consumer site,www.metanoia.org, which tracks therapists' credentials. And then there's the nightmare scenario: what if a suicidal patient sends e-mail to a therapist who has logged off? Confidentiality glitches are also worrisome: What if communication crashes while a client is discussing her fear of rejection? Can therapists licensed in Iowa treat patients in Maine? If so, is there a crisis plan in place? Howard Brown, CEO of 4therapy.com, says the risks are still too great; for now, his site offers only referrals for face-to-face therapists. Without standards, says M. Gregg Bloche, a Georgetown law professor, online Web sites are "ticking time bombs when it comes to liability."

For now, Carol Chase, 45, may be the most suitable online client. She has ongoing office visits with Jef Gazley, but she's also exchanged e-mail with him and has even done video sessions from home. Once, while writing about an argument with her husband, Chase had a breakthrough. "As I was typing it, I thought, 'I don't need to send this'," she says. "I know exactly what happened." That boosted Chase's self-esteem--and then she logged off.