REVIEW
published: 11 February 2020
doi: 10.3389/fpsyt.2019.00993
Ethical Issues in Online
Psychotherapy: A Narrative Review
Julia Stoll , Jonas Adrian Müller and Manuel Trachsel *
Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
Background: The provision of psychotherapy over distance using technology is a
growing market reaching many patients and therefore the risks and benefits need to be
known by all psychotherapists whether they themselves practice online or not. This
comprehensive review of the main ethical arguments for and against different forms of
online psychotherapy aims to enhance discussion of ethical issues in this growing area.
Methods: A search of three databases (PubMed, PsycINFO, Web of Science) was
conducted in August 2019 using a specific search protocol yielding 249 publications.
Edited by:
Cynthia H. Y. Fu,
University of East London,
United Kingdom
Reviewed by:
Warren Mansell,
University of Manchester,
United Kingdom
Janardhan Y. C. Reddy,
National Institute of Mental Health and
Neurosciences, India
*Correspondence:
Manuel Trachsel
manuel.trachsel@uzh.ch
Specialty section:
This article was submitted to
Psychological Therapies,
a section of the journal
Frontiers in Psychiatry
Received: 16 September 2019
Accepted: 13 December 2019
Published: 11 February 2020
Citation:
Stoll J, Müller JA and Trachsel M
(2020) Ethical Issues in Online
Psychotherapy:
A Narrative Review.
Front. Psychiatry 10:993.
doi: 10.3389/fpsyt.2019.00993
Results: Of 24 ethical arguments in favor of online psychotherapy and 32 against, the top
five ethical arguments in favor of online psychotherapy were (1) increased access to
psychotherapy and service availability and flexibility; (2) therapy benefits and enhanced
communication; (3) advantages related to specific client characteristics (e.g. remote
location); (4) convenience, satisfaction, acceptance, and increased demand; and (5)
economic advantages. The top five ethical arguments against engagement in online
psychotherapy were (1) privacy, confidentiality, and security issues; (2) therapist
competence and need for special training; (3) communication issues specific to
technology; (4) research gaps; and (5) emergency issues.
Conclusions: The findings may be of help to practitioners in deciding whether to engage
in online psychotherapy, and in informing patients about risks and benefits, improving
ethical guidelines, and stimulating further ethical discussion. The findings are
argumentative and qualitative in nature, and further quantitative research is needed.
Keywords: online psychotherapy, telepsychology, telepsychiatry, ethics, technology
INTRODUCTION
Technological innovation has led to rapid change in many professions, bringing both benefits and
challenges. Since the late 1990s, a growing body of research has addressed issues related to online
psychotherapy. To begin, that research focused mainly on the usefulness of online psychotherapy
before shifting in emphasis to situations in which online psychotherapy might be used, with a view
to evaluating the strengths and shortcomings of this approach (1).
The Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2)
define telepsychology as “[…] the provision of psychological services using telecommunication
technologies […]” (p. 792), which may be synchronous (real-time) or asynchronous, including
“[…] telephone, mobile devices, interactive videoconferencing, e-mail, chat, text, and Internet […]”
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Ethical Issues in Online Psychotherapy
(p. 792). The service can be standalone or an adjunct to
traditional psychotherapy. The various terms used to describe
such services generally refer to psychotherapy delivered remotely
using some form of communication technology. In this review,
the term online psychotherapy encompasses all such
terminological variants, including telepsychology [see (2)],
telepsychiatry [see (1)], online counseling [see (3)], behavioral
telehealth, telemental health [see (4)], internet therapy [see (5)],
internet counseling, online practice, online therapy, e-therapy,
cyber-counseling, cyberpsychology, e-social work [see (6)], and emental health [see (7)]. These terms may differ slightly according
to professional context or technological modality.
The practice of online psychotherapy reflects the rapid
evolution of technology and may include the use of “virtual
reality, augmented reality, intelligent wearable devices, and
artificial intelligence applications” [(8), p. 125]. As these
technologies are still in the early stages of development, they
are not included in this review. The present review includes
online psychotherapy conducted by psychiatrists, psychologist,
and social workers. Nurses are not included because of
differences in their education and legal restrictions on the
scope of their work.
As a growing number of patients seek online psychotherapy,
therapists must consider the related ethical issues (3) and should
be able to participate in this ethical discussion (9). For example,
one important feature of a thorough process of informed consent
is knowledge of risks and benefits in making a fully informed
decision (10). One of the main barriers to further
implementation of online psychotherapy is the uncertainty
around ethical and legal issues (1), which are increasingly
addressed in ethical codes of conduct (11).
The aim of this review is to summarize the main ethical
arguments for and against the provision of online psychotherapy
to further ethical discussion within the relevant professions, and
to facilitate the development of comprehensive ethical guidelines
to underpin the practice of online psychotherapy. This in turn
will help practitioners in deciding to offer this form of
psychotherapy and in helping their patients to make a truly
informed decision about engaging in online psychotherapy. The
present review is not about the quantity or volume of
publications in which specific ethical arguments are discussed;
rather, our concern was to identify the main ethical arguments to
date as a sound basis for future discussion.
Psychological Index Terms for PsycINFO); for details, see Full
Search Code in Supplemental Material). The search code was
validated by an expert librarian at the University of Zurich.
Publication titles and abstracts were screened according to
defined selection criteria (for details, see Publication Selection
Criteria in Supplemental Material).
The main ethical arguments were extracted from the selected
publications by JS, clustering text passages according to main topics.
JM read the selected publications independently and clustered the
publications under these main categories (Table 1). Disagreements
were discussed and resolved.
RESULTS
The collection of publications in August 2019 in the three
databases PubMed, PsycINFO, and Web of Science and
selection according to the selection criteria resulted in a final
sample of 249 publications.
The final sample (n = 249) included 179 articles, 6 books, 55
book chapters, 2 doctoral theses, 5 book reviews, 1 brief
communication, and 1 item of correspondence. Among these,
there were 32 literature reviews, 2 systematic reviews (regarding
the socioeconomic impact of telehealth and guidelines in
videoconferencing), 6 editorials or introductions, 5 book
reviews, and 6 books (including 4 practice guides).
Additionally, there was one case study, one correspondence,
one research digest, one discussion, and one paper on ethical
reasoning. In total, 30 of the selected publications were empirical
studies, including 14 surveys and 6 website analyses. Six related
to specific mental illnesses, one was a comparison of in-person
and online psychotherapy, two included practitioner interviews,
one was a study protocol for a meta-analysis, and one related to a
practitioner discussion forum. Among other notable features of
the final sample, 18 included guidelines, and 25 focused on
specific countries.
The selected publications ranged across disciplines that
included psychology (70), psychiatry (33), psychology and
psychiatry (2), social work (12), and telemedicine (6). The
remaining publications (125) related to psychotherapy in
general, with no specific disciplinary focus. In terms of
technological modality, these included email (13), telephone
(5), videoconferencing (28), text-based methods including
email and chat (14), email and text messages via cellphone (3),
mobile phones (3), text messages (1), email and social media (2),
and videoconferencing and mobile phones (6). The remaining
173 related to communication technologies in general rather
than any specific technology or mode of communication.
Table 1 summarizes the main ethical arguments (24 pro
and 32 contra) extracted from the final 249 publications,
organized by number of mentions. The next section
describes the various categories. For clarity, the summary does
not include all discussion points, and reference is made to only
one publication for each ethical argument. For further
information about the arguments, readers are referred to the
source (Table 1).
METHODS
Publications were collected in August 2019 from three databases:
PubMed, PsycINFO, and Web of Science. These were selected on
the basis that the topic relates to medical, psychological, and
ethical issues.
To construct the search protocol, the research question was
structured in terms of three topics: ethics, psychotherapy, and
online. Synonyms and main terms for these three fields were
selected, and a search code was constructed for each database
(including MeSH terms for PubMed and Thesaurus of
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TABLE 1 | Ethical arguments in favor and against online psychotherapy.
Ethical arguments in favor of online psychotherapy
Increased access, availability and
flexibility
Therapy benefits and enhancements
in communication
Client characteristics
Convenience, satisfaction,
acceptance and increased demand
Economic advantages
Anonymity and privacy
Eliminating barriers to engage in
psychotherapy
Therapeutic relationship
Online teaching and supervision
Reducing stigma
Patient empowerment and
increased patient control
Worldwide and cross-border
psychotherapy
Emergencies
Adaptability of services and
personalized care
Adherence and compliance
1–6, 8–23, 25–61, 63–70, 72–81, 83, 84, 86–105, 107–112, 114–229
1–43, 45–49, 51–58, 60, 61, 63–74, 76–79, 81–98, 100–102, 104–109, 111–115, 117, 119–124, 126, 128–158, 160, 161,
163, 165–167, 169–179, 181–188, 190–193, 196, 197, 199–217, 219–237
1–4, 10–25, 27–37, 39–54, 56–61, 64, 66–68, 71, 72, 74, 76–84, 86–107, 110–121, 123, 125–131, 133–140, 142–148, 151,
152, 154–159, 161, 163, 168–172, 175–188, 190–198, 200–205, 207–209, 211–213, 215–217, 219, 222–224, 226, 228, 238
1–3, 5, 8, 10–19, 21–35, 37–46, 48, 50–53, 55–57, 63–70, 72–74, 76–78, 80, 81, 83, 84, 86, 88–92, 94–96, 100, 101, 104,
106–108, 111–113, 115, 118, 120–122, 128–130, 132, 134, 135, 137, 139–141, 143, 144, 146–148, 152, 153, 155, 156,
159, 160, 163, 165, 169, 170, 172, 175, 176, 178–180, 184–188, 190–194, 197, 200, 201, 203, 206, 207, 209–213, 215,
217, 219, 223, 224, 226, 231, 235, 236, 238
1, 3–5, 8, 10–16, 18, 20–24, 27–37, 39, 40, 42, 43, 45, 46, 49, 51–53, 56–58, 64–68, 73–78, 81, 83–88, 90, 91, 93, 96,
101–104, 107, 108, 110–112, 116–124, 126, 128–132, 134–136, 139, 140, 142–152, 154, 161, 162, 164, 165, 169, 170,
173, 175–179, 182–185, 187, 189–193, 197, 200–202, 207, 208, 210, 212–214, 216, 218–224, 226, 228–231, 238
3, 10, 11, 13–16, 18–23, 25, 27, 29–31, 33, 35, 37, 38, 41, 42, 47, 51, 56–58, 61, 64–67, 72, 76–79, 84, 86, 87, 89, 91, 95,
96, 98–101, 103, 105–107, 112, 115, 117, 120, 121, 128, 130, 133–135, 137, 139–141, 144, 146, 148, 149, 152, 155, 156,
158, 159, 163, 169–171, 176, 178–187, 189, 192, 198, 200, 201, 204, 207, 211, 212, 216, 217
3, 5, 10, 12–16, 19–23, 25, 27, 29–33, 35–37, 41–43, 47, 51, 56, 58, 59, 61, 64, 66, 67, 69, 76, 77, 84, 86, 87, 89, 91, 92,
95, 96, 101, 102, 107, 109, 111–113, 117, 121, 128, 130, 132, 134, 135, 139, 140, 154, 156, 158, 159, 161, 163, 169, 170,
173, 176, 179, 181, 184, 185, 189, 194, 195, 197, 204, 213, 216, 217, 219, 224, 238
1, 3, 10–12, 14–16, 19, 20, 22, 23, 29–31, 35, 37–40, 43, 47, 49, 54, 56, 60, 61, 64, 66, 68–70, 72, 74, 78, 84, 85, 91, 94,
102, 107, 113, 117, 119, 121, 122, 124, 128, 133, 137, 139–141, 143, 144, 146, 147, 152, 154, 156, 161, 171, 172, 175–
179, 181, 184, 186, 189, 197, 204, 209, 211–213, 215–217, 219, 224
1, 8, 14, 19, 21, 22, 32, 34, 35, 38–40, 42, 43, 45, 47, 48, 51–55, 60, 66–68, 74, 78, 83, 87, 88, 91, 94, 98, 99, 103, 104,
117–119, 130, 131, 134, 147–149, 156, 166, 169, 171, 172, 175–178, 181, 184–187, 191, 193, 200, 203, 204, 207, 211–
213, 215, 222, 227, 229, 230, 234, 236, 238
3, 5, 8, 10, 11, 13–16, 19–23, 29, 31–33, 35, 36, 41, 42, 45, 51, 56, 64, 76, 78, 84, 86, 89, 91, 92, 95, 96, 101, 107, 109,
113, 133–136, 139, 140, 155, 156, 163, 171, 178–180, 182, 184, 191, 194, 204, 211, 216, 220, 224
1, 3–5, 7, 16, 19, 20, 30, 39, 42, 43, 49, 51, 52, 58, 60, 61, 69, 72, 74, 76, 78, 79, 81, 83, 86, 88, 90–92, 100, 104, 107,
113, 128, 132, 147, 156, 157, 169, 171, 177, 178, 184, 185, 187, 193, 196, 200, 204, 207, 208, 211, 216, 218, 219, 224,
238
7, 12, 13, 19–21, 23, 25–27, 31, 32, 35–37, 45, 48, 50, 51, 57, 58, 61, 70, 76, 89–91, 99–103, 105, 113, 117, 118, 120,
127, 136, 138, 142, 146, 159, 163, 165, 169–171, 175, 176, 178, 181, 185, 200, 202–204, 211, 219
1, 3, 5, 12, 15, 19, 23, 25, 30, 33, 36, 37, 39, 42, 48, 49, 54, 57, 58, 61, 64, 69, 76, 80, 87, 91, 92, 97, 103, 104, 111, 113,
117, 126, 128, 132, 134, 139, 143, 148, 159, 168–170, 185, 193, 196, 207, 211, 212, 215, 216, 226
1, 5, 7, 19, 21, 22, 30, 35, 39, 44, 45, 57, 86, 107, 108, 132, 135, 142, 152, 169, 175, 219, 224, 227, 228
1, 8, 11, 13, 19, 20, 31, 46, 56, 72, 82, 88, 90, 93, 94, 114, 122, 132, 166, 175–177, 216, 219, 224
Opportunities for research
7, 13, 32, 43, 47, 52, 58, 61, 66, 67, 79, 83, 87, 108, 120, 121, 146, 185, 200, 203
Unethical not to provide online
psychotherapy
Freedom for therapists
29, 48, 52, 67, 103, 142, 155, 158, 159, 205–207, 216, 231
17, 29, 49, 50, 67, 96, 107, 169, 187, 197, 200, 216
Enhancing accountability
42, 51, 52, 55, 150, 184–186, 204, 207
Protection of the therapist
23, 31, 53, 97, 143, 196, 207, 217
Social media
7, 26, 40, 54, 103, 155
Diminishing intimacy
12, 55, 67, 217
Informed consent
56, 57, 72, 117
Prohibition against free market
58
Ethical arguments against online psychotherapy
1–3, 5–20, 22, 23, 25–39, 41–74, 76–82, 84, 85, 87–105, 107, 108, 110–114, 116, 117, 119–122, 124, 127–134, 137–144,
Privacy, confidentiality and security
146–150, 152–155, 157–181, 184–195, 197–201, 203–214, 216–219, 221–223, 225–236, 239–248
issues
Therapists' competence and training 1–3, 5, 6, 8–12, 14–16, 18–27, 29–33, 35–39, 41–53, 55–58, 60–74, 76–78, 81, 82, 84, 85, 87, 89–96, 100–105, 107–110,
112–114, 116–122, 124–134, 137–144, 146, 147, 149, 150, 152–167, 169, 170, 172, 174–181, 184, 186–191, 193–197,
200, 203–206, 210–213, 218, 219, 221, 223–229, 232–235, 239–242, 244, 246–248
Communication issues
2, 3, 5, 7, 9–17, 19, 20, 22, 23, 25–35, 37, 39, 41–48, 51, 52, 55–61, 63–70, 72–74, 76–81, 84–95, 97–103, 105, 107, 111–
113, 115–120, 124, 126–132, 134, 136–144, 146–150, 152–159, 164–181, 183–189, 191–193, 195–197, 200, 201, 203,
204, 206–209, 211–213, 216, 217, 219, 223–227, 230, 232–236, 239, 241–244, 247–249
Research gaps
1–3, 5–7, 9, 11, 13–19, 22–24, 27–35, 37–39, 41–43, 45–47, 49, 51–61, 64–74, 76–80, 82, 84–92, 96, 98, 100, 103, 104,
107, 111–114, 117–119, 121–124, 127, 128, 130–132, 134, 137, 140–144, 146, 147, 149, 151, 152, 154–158, 164, 169–
173, 175–178, 180, 181, 183–185, 187, 189, 191–197, 201, 203, 204, 207, 211–220, 224, 227, 228, 231, 233, 235, 237–
239, 241, 244, 245, 249
(Continued)
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TABLE 1 | Continued
Ethical arguments against online psychotherapy
2, 3, 5, 9–13, 15–19, 22, 23, 25, 27, 28, 30–32, 34–37, 41–43, 45, 48, 50–61, 63–77, 79, 80, 84, 88, 89, 91–95, 97, 98,
101–105, 111, 113, 114, 116–120, 124, 126–129, 132–134, 137–140, 143, 144, 146, 148–150, 152–156, 158, 159, 162,
164, 165, 167–169, 174–176, 178–181, 185–187, 189, 191, 192, 195–199, 201, 203, 204, 206–209, 211, 212, 216–219,
223, 225–227, 234, 235, 241–245, 247
Informed consent issues
1, 2, 6, 9–12, 14, 16, 18, 19, 22, 23, 25, 27–30, 32, 35–37, 41, 43–46, 48, 49, 51–58, 60, 63–67, 69–74, 77, 78, 81, 84, 88,
89, 91, 94, 95, 102–105, 113, 114, 116–121, 124, 127, 129–134, 138–142, 144, 146, 148–150, 153, 155, 158–161, 163–
167, 169, 171, 173–175, 178–181, 183, 184, 186, 187, 189, 191, 192, 194, 195, 197, 199, 201, 203, 204, 206–212, 218,
219, 221, 223–228, 231, 233–235, 241–244, 247, 248
Technological competence
1–3, 5, 9, 11, 12, 14, 15, 19, 20, 22–25, 27–32, 35, 37, 41, 43–45, 48–53, 56, 57, 59–71, 73, 74, 78, 80, 81, 87, 89–95, 101,
104, 105, 107–110, 112–114, 116–122, 124, 128–130, 132, 134, 138–142, 144, 146, 147, 150, 152, 153, 155, 156, 159–
161, 163, 164, 166, 167, 169, 174–182, 184, 188, 189, 191–193, 197, 200, 201, 203–206, 211–214, 219, 223, 225–227,
229, 230, 232, 234, 239–241, 245–247
Absent or incomplete guidelines
1, 3, 4, 7, 9, 10, 12, 14–16, 18, 20, 22–24, 28–32, 34–37, 39, 42, 43, 45–50, 52, 53, 55, 57, 59–61, 63–65, 67, 68, 70–75,
77–81, 84–87, 89–91, 93, 94, 96, 97, 100, 102–105, 107, 110, 112, 113, 116, 118, 120–122, 129–131, 134, 136, 137, 140–
143, 146–150, 152, 154, 155, 157–159, 161, 165, 169–173, 176, 177, 180, 181, 185, 186, 189, 191, 192, 194–196, 198,
203–205, 207, 212, 213, 216, 217, 223, 224, 226–228, 231, 233, 235, 237, 239, 241, 243–245, 247
Legal issues
1–4, 6, 9, 10, 12, 13, 15, 16, 18, 19, 23–27, 29–32, 35–37, 41–45, 49–51, 53, 55–59, 61, 64–68, 70, 74–77, 79, 84, 85, 87,
89–94, 96, 97, 102, 105, 107, 108, 111–114, 116–119, 121, 124, 126, 128–131, 134, 136, 137, 140–144, 146, 148–150,
154, 155, 158, 159, 161, 164, 167, 169–171, 173, 176–180, 183, 185, 186, 189, 191, 195, 196, 200, 201, 203, 207, 210–
212, 214, 216–219, 221, 223–225, 227, 229, 231, 237, 239, 243–245, 247
Practicing across borders
2, 3, 6, 9, 10, 12–20, 22, 23, 25–27, 29–32, 35–37, 41–43, 45, 48–51, 53, 55–59, 61, 64–77, 79, 85, 87, 89–92, 94, 96, 97,
99, 100, 102–105, 109, 113, 114, 116–120, 128–130, 133, 134, 136, 137, 140, 142, 143, 146, 148, 149, 154, 155, 158,
159, 163, 164, 168–171, 173, 174, 176, 180, 181, 183, 185, 186, 189, 191, 195–198, 200, 201, 203, 204, 210–212, 218,
221, 223, 225–227, 229–231, 239, 243–247
Patient characteristics
2, 3, 10–13, 15–20, 22, 24, 26, 27, 30–34, 37, 39, 41–45, 48, 51–53, 58, 59, 61, 63, 64, 66–74, 76–78, 80, 81, 84, 87–89,
91, 92, 95, 97, 103–105, 107, 112–114, 117–122, 128, 131–133, 137, 139, 140, 142, 144, 146, 148, 150, 152, 153, 155,
156, 158, 159, 163, 168, 169, 174, 176, 177, 179–181, 184, 185, 191–193, 195, 196, 198, 204, 208, 209, 211, 212, 214,
216, 217, 219, 223–226, 235, 236, 238, 239, 248
Technical issues
1–3, 10, 11, 13, 16–20, 22, 23, 26, 29–32, 34, 36, 37, 39, 41, 45–48, 51, 52, 56, 57, 59, 62–67, 69, 71, 73, 76–79, 84, 89–
91, 94, 95, 101, 103–105, 111, 113, 114, 116, 117, 119, 120, 127–129, 131–134, 137, 139–142, 144, 147–150, 152, 153,
155, 156, 158, 162–164, 166–169, 171, 174–176, 178, 180, 181, 183, 184, 186, 189–192, 197, 200, 203, 204, 209–213,
217, 219, 223, 225, 226, 232, 235, 236, 239, 243, 244
Payment and insurance issues
2, 3, 6–10, 12, 15–17, 19, 20, 22, 23, 25, 26, 29–32, 35–37, 41–43, 45, 48, 53, 55, 58, 59, 64–71, 73–77, 84, 88–91, 94, 95,
99, 100, 105, 113, 114, 116–119, 124, 128, 129, 133, 134, 137, 138, 140–142, 146, 149, 150, 154, 155, 158, 159, 162,
164, 166, 167, 169, 171, 173–177, 179, 180, 188, 191–194, 197, 201, 203, 207, 208, 210, 211, 216–219, 221, 223–225,
230, 239, 241, 243–245, 247
Therapeutic relationship issues
1, 3–5, 7, 11–13, 15, 16, 19, 20, 22, 23, 26–28, 30–32, 34, 35, 37, 39, 43–49, 51, 52, 54–56, 58–61, 63–68, 72, 75, 78–81,
84–87, 90, 91, 93, 94, 100, 102–104, 107, 111, 113, 118, 120, 126, 128, 130, 132–134, 136, 139, 141–143, 146, 147, 149,
153, 155, 156, 158, 159, 169, 171, 172, 174, 175, 181, 184–186, 188, 189, 191, 195, 197, 199, 201, 203, 204, 207–209,
211–213, 217, 230, 233, 239, 245, 248
Availability and access issues
1, 5, 7, 9, 10, 12, 15, 18–20, 22, 23, 26, 29, 30, 32, 35, 37–39, 41, 42, 44, 45, 47, 48, 51, 54–58, 60, 61, 64, 65, 67, 69, 73,
74, 77–81, 84, 87–89, 91–93, 95, 101, 103–105, 113, 114, 117–119, 121, 124, 126, 129, 130, 132, 134, 144, 149, 150, 152,
153, 155, 156, 158, 160, 163, 164, 167, 169, 172, 174, 177, 180, 181, 184–189, 191, 193, 195, 199–201, 203, 204, 206,
207, 211–213, 223, 225–227, 234, 235, 238, 239, 241, 242
Identity and verification issues
3, 5, 9, 11–13, 16, 19, 22, 23, 25, 27, 29, 30, 32, 35, 37, 41–43, 45, 47, 51, 55–59, 63–73, 75–77, 79, 84, 89, 91, 92, 95,
96, 98, 100–105, 107, 112, 113, 116, 117, 119–121, 126–129, 134, 137–140, 144, 146, 148–150, 154–156, 158, 159, 162,
164, 169, 171, 172, 177, 179–181, 183, 186, 191, 192, 194, 195, 197–199, 201, 203, 204, 206, 210, 211, 223, 225, 226,
230, 234, 235, 241, 242, 245
Image, tradition and therapists'
1, 5, 13, 15–17, 19, 24, 28, 29, 32, 37, 39, 43, 47, 50, 52, 54, 58–60, 66–68, 72–74, 78–80, 82, 84, 89, 91–93, 96–98, 104,
attitude
107, 108, 110, 112, 113, 124, 131, 134, 137–139, 142–144, 147, 148, 150, 155, 156, 158, 159, 172, 180, 184–187, 191,
195, 197, 200, 203, 207, 211, 216, 217, 219, 224, 226, 227, 233, 243–245, 249
Misuse and harm
12, 15, 18, 19, 23, 29, 30, 33, 37, 41–43, 47, 51, 55, 56, 58, 59, 61, 64, 70, 72, 74, 78, 81, 84, 85, 87, 89, 94, 95, 101–103,
105, 107, 117, 119, 120, 124, 133, 136, 138, 143, 146, 148–150, 156, 177, 180, 181, 184–186, 195, 200, 203, 223, 239,
244
Boundary issues
2, 3, 10, 16, 19, 26, 31, 38, 39, 48, 51, 54, 56–58, 60, 63, 67, 71, 73, 74, 80, 82, 88, 89, 93, 95, 103, 113, 120, 124, 126,
130, 133, 134, 136, 143, 155, 156, 160, 172, 174, 177–179, 188, 189, 191, 192, 206, 211, 223, 225–228, 236, 239, 242
Comparability to in-person treatment 1–3, 7, 14, 16, 19, 29, 30, 32, 33, 39, 42–44, 46, 56, 57, 64, 66, 67, 70, 72, 76, 80, 81, 84, 86, 90, 91, 104, 111–114, 117–
119, 126, 134, 136, 155, 159, 179, 191, 192, 195, 198, 201, 203, 204, 221, 226, 233, 244, 245, 247, 249
Increased costs
1, 3, 9, 12, 16, 21, 23, 32–34, 36, 39, 42, 45, 48, 49, 51–53, 58, 61, 64, 65, 68, 83, 87, 89, 91, 97, 99, 101, 128, 129, 132,
143, 144, 147, 154, 159, 162, 169, 171, 180, 201–204, 207, 213, 214, 219, 223, 229, 231, 239, 248
Increased liability and litigation
3, 15, 22, 23, 29, 32, 35–37, 42, 52, 57, 59, 67, 68, 70, 74, 77, 80, 89, 92, 94, 96, 97, 113, 124, 126, 129, 130, 134, 142–
144, 158, 164, 165, 169, 180, 181, 183, 189, 194–198, 201, 207, 218, 231, 233, 243, 245
Emergency issues
(Continued)
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TABLE 1 | Continued
Ethical arguments against online psychotherapy
Negative influence of technology use 5, 7, 10, 20, 47, 54–56, 60, 61, 64, 66, 67, 69, 72, 84–86, 95, 98, 108, 109, 115, 121, 128, 133, 134, 137, 140, 152, 157,
158, 166, 169, 172, 179, 181, 203, 211, 216, 217, 223, 237, 249
Social media
2, 3, 10, 18, 26, 48, 54, 57, 60, 63, 69, 71, 93, 103, 105, 113, 120, 130, 134, 155, 157, 160, 164, 172, 174, 188, 189, 205,
206, 211, 223, 226, 227, 242, 247
Financial gain
9, 23, 25, 27, 30, 44, 45, 49, 58, 59, 72, 76, 81, 85, 90, 92, 100, 102, 103, 117, 120, 126, 130, 144, 164, 169, 180, 186,
189, 208, 224, 226, 241
Loss of therapeutic control
16, 17, 26, 28, 41, 45, 48, 57, 60, 63, 73, 80, 86, 124, 126, 130, 134, 138, 164, 166, 181, 196, 207, 208, 211, 217, 247
Adherence issues
10, 11, 16, 20, 41, 69, 75, 87, 101, 103, 132, 152, 154, 156, 165, 169, 187, 191, 196, 208, 211
Online supervision and teaching
issues
Dependence and loss of control by
the patient
Autonomy issues
2, 19, 54, 66, 116, 126, 157, 159, 186, 226, 236, 239
28, 45, 48, 60, 81, 132, 134
Dehumanization
15, 28, 68, 89, 90, 178
Stigmatization
29, 91, 113, 138
48, 58, 88, 107, 177, 206, 207, 216, 219
The publications are depicted in numbers (for full citation, see References).
Ethical Arguments in Favor of Online
Psychotherapy
Client Characteristics
Online psychotherapy can be especially useful for clients living in
geographically remote, rural, or otherwise underserved areas
where few or no therapists are available [see (21)], as well as
for homebound or mobility-impaired patients [see (22)]. Access
to traditional in-person services may be limited by the
psychiatric condition itself, as in cases of agoraphobia, anxiety,
or other illnesses that restrict physical encounter, and online
psychotherapy again offers a possible solution [see (23)]. Online
psychotherapy seems especially appropriate for patients with
mild or moderate symptoms [see (24)], but might also be a viable
tool for patient in acute crisis with no possibility for immediate
in-person care [see (25)].
Increased Access, Availability, and Flexibility
Online psychotherapy can improve and enhance access to health
care services and evidence-based care, especially for those living
in rural or remote areas and populations that are underserved for
other reasons [see (12)]. Services can be accessed anywhere and
at any time, allowing greater flexibility [see (13)]. This is
advantageous for both therapist and patient, enabling
immediate and timely care [see (3)]. Online psychotherapy
may also facilitate more frequent contact between patient and
therapist [see (14)], and as more therapists are available to the
patient, specialist care is easier to access, and the range of services
is wider [see (1)].
Convenience, Satisfaction, Acceptance, and
Increased Demand
Therapy Benefits and Enhancements in
Communication
Online psychotherapy is perceived as convenient and
comfortable by patients and therapists alike [see (26)], not
least because of the greater flexibility it offers in terms of
location and time [see (27)]. Online services have gained
increasing acceptance among patients and therapists [see (28)],
who express satisfaction with this approach [see (15)].
Unsurprisingly, then, demand and interest is on the increase
among both patients and practitioners [see (29)].
According to a growing number of favorable research findings,
online psychotherapy can be as efficient, effective, and efficacious
as traditional therapy (or more so) [see (1)]. Multiple therapeutic
orientations and modalities are translated into online
communication, but cognitive behavioral approaches seem to
be most appropriate or the easiest to transfer [see (15)]. For
example, during an in vivo exposure, the therapist could
be virtually present [see (16)]. However, also other
psychotherapeutic orientations such as psychoanalysis assess
and discuss ethical issues of practicing online [see (17)]. Online
psychotherapy offers a viable alternative to in-person treatment
but can also be used as a supplement or adjunct [see (18)]. This
affords new opportunities for creative approaches involving
different models of therapy and technological modalities, and
additional online material (websites, videos, etc.) are easily
integrated into therapy [see (19)]. Data recording and
documentation of the online therapeutic process is also easier,
allowing treatment, treatment stages, and therapeutic techniques
used by therapist and patient to be revisited [see (20)].
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Economic Advantages
Online psychotherapy is reported to be more cost-efficient
[see (30)], with the potential to reduce healthcare costs for
patients, therapists, and society as a whole [see (31)]. As a
single therapist can reach more patients, especially in
underserved populations [see (32)], long waiting lists for
face-to-face treatment can be reduced [see (33)], offering a
possible solution to the workforce shortage in mental health
provision [see (34)]. Online psychotherapy might pose a
solution to an undersupply in mental health care in various
regions of the world, especially in low- and middle income or
developing countries, for example, in India [see (34)].
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Anonymity and Privacy
and other forms of telephone emergency care are long
established and proven practices [see (37)].
Because online psychotherapy can be provided anonymously and
one is not seen entering the therapist's office [see (20)], it can
enhance the patient's sense of anonymity and privacy [see (13)].
Perceived or actual anonymity may lead in turn to reduced
inhibition and greater openness in discussing emotional topics
[see (35)].
Adaptability of Services and Personalized Care
Online psychotherapy can offer services that specifically match
patients' needs [see (19)], facilitating genuinely patient-centered
care [see (44)] and individualized treatment and technology
options [see (45)].
Eliminating Barriers to Engagement
By reducing or eliminating barriers such as fear of social stigma,
online psychotherapy can reach patients who might never have
sought traditional in-person therapy [see (36)]. This might serve
as an entry point to the mental health system, including
traditional in-person therapy as a possible next step [see (37)].
Adherence and Compliance
Levels of adherence, attendance, and compliance as good as or
better than in-person treatment can be achieved using online
psychotherapy [see (46)].
Opportunities for Research
Therapeutic Relationship
Online psychotherapy offers unique opportunities for research
[see (32)]; for example, email-based therapy automatically
creates a written record, which can be used for research
purposes [see (47)].
The therapeutic relationship established in online psychotherapy
is commonly perceived as equal to or better than in-person
therapy, and an established therapeutic relationship can be
enhanced using online communication [see (38)].
Unethical Not to Provide Online Psychotherapy
Online Teaching and Supervision
Failure to provide online psychotherapy to vulnerable people
who need it can be seen as unethical—for example, patients
living in rural or remote areas with few or occasional local
options [see (48)].
Technology-mediated communication can contribute positively
to teaching and supervision and facilitates inter-professional and
inter-collegial exchange worldwide [see (39)]. Online
psychotherapy conducted by email or other text-based
communication automatically generates a record of the
sessions [see (32)], and a videoconferencing approach enables
sessions to be videotaped [see (40)] for later supervision.
Freedom for Therapists
Online psychotherapy can afford the therapist greater freedom
[see (49)], including more professional opportunities and a better
balance between professional and private life [see (50)].
Reducing Stigma
Enhancing Accountability
Any stigma, stigmatization, or perceived stigma associated with
seeking mental help services or concerns about being stereotyped
can be reduced or eliminated by online psychotherapy. This may
in turn help to address barriers to traditional psychotherapy such
as concerns about anonymity and privacy [see (41)].
Online psychotherapy increases the accountability of both
therapist and patient, not least because it is easier to keep
records and to make transcripts available to both parties [see
(51)], reducing the potential for malpractice and litigation
[see (52)].
Patient Empowerment and Increased Patient Control
Protection of the Therapist
Online psychotherapy empowers the patient because, for
example, it is much easier to move to another therapist [see
(42)], giving the patient more control over their therapy [see
(43)]. This reconfigures the balance of power between therapist
and patient, making the interaction more collaborative [see (20)].
Security issues raised by risky environments or when
communicating with potentially dangerous patients can be
reduced by online service provision [see (53)].
Social Media
Worldwide and Cross-Border Psychotherapy
Offering unprecedented opportunities for access and connecting
with patients and other therapists, social media can be a useful
therapeutic tool [see (54)].
Online psychotherapy can be provided from anywhere, without
regard to geographical boundaries, state lines, national borders,
or time-zones, allowing therapists to reach patients who are, for
instance, temporarily abroad [see (19)].
Diminishing Intimacy
As the distance provided by technology inhibits physical
proximity, online psychotherapy can help to reduce the risk of
patient-therapist (sexual) intimacy [see (55)].
Emergencies
Online psychotherapy can be useful for emergencies and crisis
interventions. As compared to traditional in-person therapy, it
may provide more immediate access to services, and disclosure of
suicidal or homicidal tendencies may be easier online [see (19)].
In the context of crisis and suicide prevention, suicide hotlines
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Informed Consent
The informed consent process can be enhanced by online
communication—for example, web pages can be revisited (56),
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Emergency Issues
with links to additional information resources or technical
material and translation into different languages [see (57)].
Questions also arise as to whether an emergency or crisis
situation involving threat to self or others can be detected and
addressed where patient and therapist are at different locations
[see (67)]. Other ethical issues regarding emergency or crisis
situations include verification of patient identity and location
[see (68)], technological difficulties [see (69)], and cross-border
practice [see (70)].
Prohibition Against Free Market
The view that one should not engage in online psychotherapy is
legally problematic because it restricts trade and the ethical right
to a free market (58).
Ethical Arguments Against Online
Psychotherapy
Informed Consent Issues
In light of the many differences from in-person therapy (e.g.
technical, legal), online psychotherapy requires a particular form
of informed consent [see (71)]. However, it might be difficult to
determine whether the patient is legally able to give consent or to
assess their mental capacity to do so [see (72)].
Privacy, Confidentiality, and Security Issues
Among concerns about privacy, confidentiality, security, and
safety in online psychotherapy [see (59)], one relates to the use of
unsecured websites or unencrypted communication tools, like
commercially available software [see (60)] that is easily hacked
[see (61)]. Data security may also be compromised when
technology fails [see (62)], with potential breaches of
confidentiality that might extend beyond the therapist's control
[see (63)].
Technological Competence
A therapist's lack of technological competence and patient and
therapist awareness of their respective skills are important issues
in this context, as discomfort or fear of using technology is not
uncommon [see (73)].
Therapist Competence and Training
To provide online psychotherapy, training is needed to ensure
appropriate technology-related competences, as well as clinical
and therapeutic competences specific to the online setting. In
particular, the therapist would require knowledge of ethical
approaches and guidelines, as well as specific legal
requirements and policies [see (18)]. In general, therapeutic
skills in in-person contact do not automatically translate into
online therapeutic skills [see (32)]. At present, standards are not
well defined, and there are few training or education programs
for online psychotherapy, which is not included in most
traditional curricula [see (64)]. In relation to working remotely
with patients in other countries, the therapist would need to be
familiar with international laws and legal requirements in the
patient's jurisdiction, and additional cultural competences might
also be required [see (65)].
Unresolved jurisdiction and few or no specific laws governing
licensing, certification, training and education, informed
consent, and cross-border practice are problematic issues for
online psychotherapy [see (74)].
Communication Issues
Practicing Across Borders
Among negative issues, one of the most widely discussed is the
absence of non-verbal cues in the therapeutic interaction,
especially when using text-based media but also when using
telephone or videoconferencing, which may lead to
misunderstandings and miscommunication [see (20)]. If a
therapist were to miss some important item of clinical
information, the whole diagnostic process and psychological
assessment could be impaired [see (28)]. The use of e-mail in
this context can undermine the conversation in terms of time lag
and lack of spontaneity, and it may prove difficult to express
empathy, warmth, and feelings [see (64)]. For these reasons,
online psychotherapy may not be appropriate for all therapeutic
approaches and modalities [see (66)].
Many issues arise in relation to online psychotherapy conducted
across state or national borders, including legislative, licensing,
and cultural differences [see (30)]. For instance, it may be unclear
whether the therapy is seen to take place at the patient's or the
therapist's location, raising such questions as which jurisdiction
is responsible when a problem arises or which regulates
professional practice in the event of a violation [see (75)]. The
therapist may not even know or cannot be sure where the patient
is located, especially if they choose to remain anonymous [see
(76)]. Cultural differences between patient and therapist might
influence the communication itself by different cultural
behaviors or language use resulting in different interpretations
of the behavior and potential misunderstandings [see (30)].
Research Gaps
Patient Characteristics
Many authors claim that there is insufficient research in support of
online psychotherapy or that there are too many knowledge gaps,
especially with regard to effectiveness, efficacy, and long-term
outcomes and as compared to in-person treatment [see (30)].
Online psychotherapy may not be suitable for all patients,
clinical conditions, psychiatric disorders, and problems; it may
sometimes be contraindicated, especially in the case of severe
mental disorder, or for patients who are highly dysfunctional
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Absent or Incomplete Guidelines
Regulatory guidelines and standards of practice or care in this
area are considered incomplete or absent. Guidance by legal or
regulatory bodies is also lacking, especially in terms of global or
international regulation of cross-border practice, and the absence
of specific ethical guidelines or codes of conduct for online
psychotherapy leaves many ethical questions unanswered
[see (42)].
Legal Issues
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and/or pose a threat to themselves or others [see (16)]. A
patient's inability, diminished competence, or discomfort when
using technology might also be considered a barrier [see (15)].
technology might seem social, conversational, or less formal,
and the flexibility of location and time might lead to
communication in inappropriate locations or at odd times, as
the therapist might be tempted to communicate while on
holidays, traveling, or while ill [see (26)]. As another potential
threat to boundaries, therapists and/or patients might use search
engines to explore private information [see (82)].
Technical Issues
Technical difficulties and failures are major concerns in this
context, possibly leading to frustration and anger, which may be
distracting or disturbing [see (73)].
Comparability to In-Person Treatment
Payment and Insurance Issues
One important open question is whether online psychotherapy is
truly comparable to in-person treatment, and whether it can
replace traditional in-person therapy. Many authors have
expressed doubts in this regard, to the extent that some believe
online services may prevent patients from seeking more suitable
traditional therapy [see (56)].
Payment, reimbursement, fee structure, and billing for online
psychotherapy raise many questions, such as how interruption or
technical failure will be handled [see (77)]. Another important issue
is whether insurers will cover online psychotherapy in general, as
well as instances of malpractice or liability, which may become
especially complicated across state or national borders [see (68)].
Costs
Therapeutic Relationship Issues
Online psychotherapy entails some initial costs for the therapist,
which may make access to online psychotherapy services too
expensive for some patients [see (68)]. These initial costs could
make it difficult to implement online psychotherapy in some
low-income and developing countries [see (83)].
Many authors have questioned whether an effective and
successful therapeutic alliance can be developed solely through
technology [see (78)] and whether the well-known benefits of the
therapeutic relationship might disappear or diminish in online
psychotherapy [see (79)]. Other issues raised in this include
absence of non-verbal cues and lack of intimacy [see (51)].
Increased Liability and Litigation
Therapists who provide an online service may be more exposed
to litigation and increased liability, as for example in crossborder cases [see (29)].
Availability and Access Issues
Because technology often creates a sense of permanent access,
this may become a problem, as the therapist cannot and will not
guarantee this [see (60)]. Response time and delays are also an
important issue, especially in emergency situations [see (80)].
Additionally, accessibility (for instance, in terms of technology,
devices, connectivity, and applications) may be restricted for
people of lower socioeconomic status or for those unable to use
the equipment [see (32)].
Negative Influence of Technology Use
Online psychotherapy may contribute to internet overuse and
ultimately internet addiction [see (47)], potentially increasing
social isolation [see (84)] and exposure to unregulated and
misleading health-related or other information [see (85)].
Social Media
Identity and Verification Issues
The use of social networking sites poses new ethical challenges
and invites potentially unethical interactions in the context of
online psychotherapy, such as friend requests from patients [see
(57)] or problematic self-disclosure [see (18)].
As it may be difficult to verify the identity of the patient (or the
therapist) online, deception or fraud is a possibility—for
example, a therapist might inadvertently treat a minor without
parental consent [see (64)].
Financial Gain
Image, Tradition, and Therapist Attitude
There is a danger that online psychotherapy might be conducted
for financial gain without due regard to the best interests of the
patient [see (27)].
Many therapists have a negative view of online psychotherapy
and are clearly concerned or strictly against it, with poor
reported satisfaction and acceptance among therapists [see (1)]
and concerns that online psychotherapy might damage the
profession's image [see (58)].
Loss of Therapeutic Control
Online psychotherapy may risk loss of therapeutic control [see
(86)]—for example, in relation to the patient's location [see (57)].
Misuse and Harm
Adherence Issues
Unethical, malign, or abusive behavior may be easier online [see
(81)]—for instance, practicing without a license or without
appropriate training, or even pretending to be a therapist [see (23)].
Compliance and adherence to therapy may be undermined in an
online setting, given the ease of dropping out, logging off,
hanging up the phone, or terminating the connection [see (87)].
Boundary Issues
Online Supervision and Teaching Issues
Online psychotherapy may make it more difficult to maintain
professional boundaries, posing a threat to the professional
relationship—for example, an interaction mediated by
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Supervising and teaching online raises a number of specific
ethical issues and questions [see (66)].
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Patient Dependence and Loss of Control
from breaches of intimacy boundaries and enhance the
accountability of both patient and therapist. Additionally, online
psychotherapy offers new opportunities for research, teaching, and
supervision, enhancing the informed consent process, offering new
opportunities through the use of social media and might give good
assistance in emergency situations. Online psychotherapy might
even improve and extend the therapeutic relationship.
One of the biggest and most discussed disadvantages of using
psychotherapy is the risks with regard to privacy, confidentiality,
and data security. Online psychotherapy creates new challenges to
therapist competences which brings about the need for new forms
of training and education, especially technological competences
regarding many technical issues that might occur. Technological
competence is not only needed by the therapist, but also by the
patient. New communication skills are needed and particular
attention must be paid to the development of the therapeutic
relationship regarding the many boundary issues that might
occur. Difficulties herein are put up by new access and availability
issues and the loss of therapeutic control. Broader research, new
guidelines, and a consideration of legal issues in general are needed
especially regarding the practice across borders of nations, new
payment and insurance issues, challenges to the informed consent
process, dealing with emergency situations, enhancing the
identification process of the therapist and the patient, and
selecting patients that are suitable for online psychotherapy. The
comparability to in-person treatment might be questioned and
some fear danger to the image of psychotherapy. Therapists might
fear increased liability and litigation. Online, new forms of misuse
are possible and charlatans might utilize this kind of psychotherapy
to achieve financial gains. Other feared disadvantages of online
psychotherapy are the dehumanization and stigmatization of
patients, patient dependence, and loss of patients' autonomy. New
adherence issues might occur regarding the ease of ending an online
session. Online supervision and teaching and the use of social media
raise further ethical questions. Extensive costs might be faced by
patient and therapists, when using online psychotherapy, for
example, to set up the new technologies. Last but not least, the
negative influence of technology itself might endanger its users.
This review has a number of limitations. First, only articles in
English and German were included. However, only fourteen of
the articles that were found to meet the search criteria were in a
different language and therefore excluded. Among the emerging
In online psychotherapy, the patient may experience less control
(58), and the process may foster dependence [see (88)].
Autonomy Issues
Online psychotherapy may hamper patient autonomy [see (28)]
—for example, a patient may experience a sense of intrusion
when receiving online psychotherapy at home [see (81)].
Dehumanization
Online psychotherapy may lead to dehumanization of the
therapeutic environment [see (89)] or of the patient if
experienced as intrusive by someone who is already vulnerable
[see (90)].
Stigmatization
An online setting may promote inadvertent discrimination or
cultural insensitivity by masking important cues [see (91)].
DISCUSSION
Online psychotherapy offers many advantages like benefits for the
therapeutic process and the therapeutic communication itself, also
by being more convenient than traditional settings of
psychotherapy. Both many patients and therapists seem to be
satisfied with the use of online psychotherapy. Not surprisingly,
this kind of psychotherapy is increasingly being used. Online
psychotherapy promises to solve economic pressures by being
more cost-effective, offering a solution for workforce shortage
problems and increasing access to necessary psychotherapy for
many different populations suffering from mental health problems
who might be difficult to reach such as patients living in rural areas.
Reducing barriers to engaging in psychotherapy by reducing stigma,
being able to attend online sessions anonymously thus enhancing a
sense of privacy, reaching patients worldwide and across borders are
other advantages of online psychotherapy. Conducting
psychotherapy online gives the possibility to adapt services to
specific patients offering more personalized care, enhancing
patient control, and empowering the patient resulting in more
adherence to and compliance with the treatment itself. The specific
setting of online psychotherapy gives the therapist more freedom
and offers physical protection, but might also protect the patient
TABLE 2 | Recommendations for practice.
•
•
•
•
•
•
•
•
•
•
•
•
•
Thorough protection of privacy of the patient, ensuring confidentiality, and security
Engaging in special training and establishing special competence needed when conducting online psychotherapy, such as technological competences
Being aware of communication challenges of the respective medium used, such as missing of non-verbal cues when using email
Preparing for emergencies, for example, by establishing emergency plans, and being prepared to contact a local professional being able to intervene if necessary
Being aware and reassure the true identity, age, and location of the patient
Giving the patient the opportunity to reassure the true identity of the therapist and his/her certifications
Set up an exhaustive informed consent form and thoroughly discuss all the risks and benefits with the patient in order to enable her/him to make a truly informed
decision about engaging in online psychotherapy
Clarifying fee and insurance issues
Being aware of boundary issues with regard to the establishment and maintenance of a professional therapeutic relationship online
Offering adequate anonymity and privacy to help eliminating barriers in engaging in psychotherapy
Adapt services to the particular needs of the patient, thus offering personalized care whenever possible
Be open toward further research on online psychotherapy, especially in cross-border online psychotherapy
Support and welcome the establishment of new guidelines for conducting ethical online psychotherapy
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TABLE 3 | Recommendations for future research in online psychotherapy.
•
•
•
•
•
•
•
•
Systematic research on the efficacy, effectiveness, efficiency, and comparability of online psychotherapy to in-person psychotherapy regarding different
technologies, different mental disorders, and severity of symptoms
Translatability of different therapeutic orientations in online psychotherapy by assessing efficacy, effectiveness, efficiency, and comparability to the in-person setting,
alterations needed, and suitability of different technologies for the respective therapeutic orientation
Possibility and applicability of certain clinical practices like online prescription, diagnosis, assessment of suicidality or homicidality, assessing decision-making
capacity for informed consent regarding the usage of different technologies
Assessing which client characteristics are suitable for online psychotherapy and which are contraindicated, also regarding different technology use like videoconferencing or e-mail, as standalone or adjunct to in-person sessions, particular handling of homicidal or suicidal patients
Research regarding cross-border, worldwide, and cross-cultural practice by assessing legal issues, influence of cultural factors, language and communication
difficulties, patient-therapist fit, malpractice, payment and insurance issues, acquirement of special competences
Assessing the changes in the therapeutic relationship due to different communication technologies used in online psychotherapy and the new forms of abuse that
might appear or be possible in online psychotherapy compared to in-person psychotherapy
Research on additional skills needed by psychotherapists in the online setting compared to the in-person setting, assessing the questions who might be suitable to
become an online psychotherapist, who might train them, and what kind of education programs might be suitable in which form
Data security issues assessing secure ways of communication using different technologies, also regarding secure data storage and secure online payment
research topics not included in this review are online training
and supervision, social media, avatar, second life, robots and
bots, artificial intelligence, computer-mediated (self-help)
therapy, psychology-related smartphone apps, internet-based
group therapy and telecare, online forums, open chat, therapy
for older adults, therapy for children and adolescents, and
marriage and family therapy.
It is beyond the scope of the present review to offer exhaustive
recommendations for clinical practice or how these ethical risks
might be resolved in practice, and further systematic research
should more fully address this topic. For some recommendations
directly deducted from the results of this review, see Table 2.
Counting the frequency of arguments does not clarify their
relative importance; to evaluate their true weight, a more
quantitative survey of experts' ratings is needed. Without that
deeper understanding, the risks and benefits reviewed here
remain anecdotal and qualitative, with only limited validity (92).
In future systematic research on efficacy, effectiveness, and
efficiency of online psychotherapy is needed and practice
guidelines, legal and ethical frameworks need to be developed.
Further research in the fast growing field of online
psychotherapy seems vital. Some important topics requiring
further investigation are summarized in Table 3.
risks and benefits of online psychotherapy if they are to make
well-informed decisions and act in the best interests of their
patients. Even if they decide not to offer such services themselves,
they should be equipped to provide information about online
psychotherapy that enables patients to make a well-considered
decision about using such services.
AUTHOR CONTRIBUTIONS
JS and MT designed the review and developed the search
strategy. JS and JM were involved in search, exclusion, and
argument extraction processes. JS and MT wrote and edited
the final article, which was reviewed and approved by JM.
ACKNOWLEDGMENTS
Special thanks to Sabine Klein, expert librarian at the University
of Zurich, who reviewed the final search code and provided many
useful inputs, and to Jörg Zemp, librarian at the Institute of
Biomedical Ethics and History of Medicine, University of Zurich,
who assisted us in locating the full-text publications that were
not directly available.
CONCLUSION
If trained psychotherapists choose not to participate in the new
and emerging field of online psychotherapy, it seems likely that
charlatans will emerge to meet the ever-growing demand,
perhaps driving professional psychotherapists out of the
market (37). For that reason, psychotherapists from all
professional backgrounds must be properly informed about the
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found online
at: https://www.frontiersin.org/articles/10.3389/fpsyt.2019.
00993/full#supplementary-material
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
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February 2020 | Volume 10 | Article 993