In order to address emotional and/or personality difficulties or disorders, a trained individual intentionally forges a professional relationship with another person (who is seeking help). This process is known as psychotherapy. Using internet-based technology, online psychotherapy (OPT) or e-therapy is provided via video calls, audio calls, text messages, and/or emails.
To deliver treatment or counseling sessions remotely, tele-psychotherapy is a more general word that refers to the use of either telecommunication (i.e., telephonic) or internet-based digital communication means. Because OPT is a relatively newer type of tele-psychotherapy that people in psychological distress have increasingly used to get help during the COVID-19 pandemic, we will explicitly focus on it in this paper.
The improved availability, acceptance, and cost of psychotherapy provided through internet channels are likely factors in the growing popularity of psychotherapy among the general population.
OPT can be given to those with restricted physical mobility, in remote or rural places, or while seated comfortably in one’s home or office at a time of one’s choosing (for both the client and the therapist). Additionally, clients can select from a variety of available online psychologists based on their comfort level and preferences (e.g., language or gender of psychologist).
The stigma associated with seeking assistance by going to a mental health expert (such as a psychologist) at a hospital or clinic is also lessened.
It also complies with the public health recommendations made for containing the COVID-19 pandemic, such as physical separation and limiting travel to and from containment zones. 3 However, it’s critical to take into account any restrictions, moral dilemmas, or potential risks related to OPT practice. Here, we discuss some of these significant issues that are unique to the OPT or counseling services provided during the COVID-19 pandemic and provide some recommendations for how to handle them.
OPT efficacy:
India has more cultural diversity and socioeconomic and digital literacy disparities than many high-income western nations. The psychological distress caused by fear of COVID-19, social dislocation, daily routine disruptions (e.g., school/college/office closures), financial hardships, increased caregiving burden, and/or loss of loved ones during the pandemic is contextually different and may respond differently to conventional OPT or counseling.
Online cognitive behavior therapy appears to be equally effective as in-person counseling for depression and anxiety.
Most of this research was done in western countries before COVID-19, therefore extending their conclusions to India is risky. Thus, OPT’s effectiveness, equivalency, acceptability, implementation issues, and cost-efficiency in rural and urban India must be studied.
OPT is also unsuitable for treating acute psychiatric diseases or crises, like as active suicidal ideation, which requires in-person counseling.
For instance, people with severe depression and/or psychotic symptoms may fear they are being watched and that anything they post online will be used against them, making OPT difficult for them.
A person with serious psychiatric illness would need ongoing surveillance and quick psychological care during extreme suicidal ideations or discomfort (e.g., severe anxiety episodes, early morning awakening) at unusual times even between online sessions.
Even with OPT service scheduling flexibility, this may not be viable. Develop a method to follow such a person seeking OPT and help them receive emergency psychiatric services by contacting their verified emergency contact (if accessible) or intimating the local police and/or government officials to rescue them. However, India currently lacks legal guidelines to ensure this.
Internet/Technology Limitations:
Any OPT needs a reliable internet connection and convenient access to a digital device. Online audio–video communication requires high-speed internet to eliminate latency or signal disturbances that could slow therapeutic sessions. The client and therapist must both be digitally literate and technologically competent to engage in OPT. Many Indians may not meet these requirements.
During the COVID-19 epidemic, many homebound people have used internet-connected devices for communication (social media), work from house, education (online classes), and leisure (viewing videos and playing games). 10 Thus, OPT may strain socioeconomically disadvantaged persons who already lack internet-based digital equipment.
Even with the above internet- and digital-technology requirements, OPT falls short of face-to-face therapy. Many people are uncomfortable talking to a therapist online for long periods of time.
Some therapists also worry that online treatments like guided exposure and response prevention therapy, interoceptive exposure exercises, the cognitive conceptualization of a case by drawing a panic circle, or the triad of emotional experience are less helpful than in-person therapy.
Despite a smooth online video conference, nonverbal cues including tone inflections, gestures, body position, eye gazing, and/or proxemics may be missed during an online session.
These cues might help the therapist understand the discomfort and other information. Some patients may skip the session by turning off their audio or video due to a bad internet connection or gadget malfunction, resulting in misinterpretation and reduced therapeutic effectiveness.
In addition, basic behaviors like providing the patient a tissue to wipe tears during an emotionally charged discussion or emphasizing with the patient, which can strengthen the therapeutic bond, are rarely available in an OPT session. Human touch and a relaxing environment have been shown to improve mental health.
Data Security and Ethics:
OPT is still developing in India, with many customers and therapists switching to the internet because of the COVID-19 pandemic. Thus, many OPT therapists lack training in online psychotherapy interventions and technology. This may cause internet therapists to practice differently.
OPT care may be substandard without universal training or standards. 8 Many therapists and clients are unsure how to handle other ethical issues related to OPT, such as the limits on online information confidentiality due to factors beyond the therapist’s control 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).
Therapists must walk a fine path to sell OPT services ethically and effectively online (e.g., through social media or online telemedicine platforms). Under tele-psychotherapy norms, using one’s photo or disclosing personal information is considered misbehavior. 8 OPT is generally done on third-party sites, clients’ WhatsApp accounts, or therapists’ emails.
Online platforms may unethically acquire clients’ personal data (cookies, IP address, mobile number, etc.) and use it for targeted advertising without their consent. This online data may be vulnerable to third-party theft and hacking. 3 The therapist should also keep basic records of psychotherapy sessions or services under the Mental Health Care Act in India. 15 The law does not mention OPT. It does not require basic safety standards for OPT or data storage. 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. 16 Further, there is a risk that vulnerable people in psychological distress might receive unaccredited online counseling or psychotherapy by inadequately trained or unqualified therapists. 17 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. 18 Moreover, on 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 the impression that they are interacting with a real therapist. 19 Apart from the obvious ethical concerns, there is insufficient evidence about the effectiveness of these chatbots in the available literature.
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 post-pandemic era but they urge mental health professionals, policymakers, and other stakeholders to discuss ways to make it safer and more reliable for clients and therapists.
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