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How do clinicians become familiar with best practices online? For the past 5 years, researchers have investigated Internet-based mental health services, but most providers do not know how to utilize the data (Day & Schneider, 2002; Fisher & Fried, 2003; Gillispie & Gackenbach, 2006; Grohol, 1998; Mallen, Bay, & Green., 2003). While there are criteria for evaluating the accuracy and professionalism of online mental health sites, much of what passes for etherapy or patient education is questionable. The stakes are high for consumers with urgent mental health needs because they often do not know how to determine whether a site is legitimate or not. Patients often want their therapists to review this information that they found on the Internet (Morahan-Martin, 2004).

The International Society for Mental Health Online (ISMHO) is one of the earliest professional resources specifi cally designed to help consumers and professionals survey the most scientifi cally vigorous mental health sites online. It offers good resources and search tools for the clinician and consumer. The ISMHO, a nonprofi t organization, was formed in 1997 to promote the understanding, use, and development of online communication, information, and technology for the international mental health community. It currently has over 200 members from as many countries. The Society helps clinicians become expert in cyber-psychological issues, offl ine and online. Opportunities for research, training, case consultation, and cyber-practice guidelines are disseminated to members. The ISMHO provides discussion forums where clinicians can consult about Internet-related professional issues or benefi t from the case conferences of other professionals. It also educates the consumer about online therapy. Online therapy sites that belong to this organization must comply with the ISMHO mission and criteria for Internet psychology.

Another strategy to help professionals connect with legitimate health sites is to look for the equivalent of an online seal of approval. The Health on the Internet Foundation Code of Conduct (HONcode, 2005) is an online consumer service that reviews health websites for professionalism and accuracy. HONcode

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was established in 1995 as the fi rst international society dedicated to helping consumers fi nd health information from the most reliable and up-to-date sources. Currently, the HONcode website offers information in 29 languages. It lists all known hospital health information websites as part of an online resource to

consumers from anywhere in the world. In addition, HONcode specializes in what they call “cross-border talk” health and research conferences, and case consultation for health professionals and consumers in 72 countries. Any Internet health- based organization or private practitioner that wants to offer services online and wishes to belong to HONcode must adhere to the Web standards devised by their Board of Directors, health professionals from 17 countries. However, there is no system that is able to monitor or ensure members’ compliance. The HONcode seal signals to readers that this particular website complies with the following legal and ethical guidelines:

1. Authority: Differentiates between medical fact and opinion.

2. Compatibility: Works to support face-to-face relationships with other health providers.

3. Confi dentiality: Websites exceed legal jurisdictional health information privacy.

4. Attribution: Clear references, accurate links, and updates of clinical information displayed at the bottom of page.

5. Justifi ability: Claims regarding treatments are supported by evidence.

6. Authorship: Webmaster displays e-mail address clearly.

7. Sponsorship: Support for website clearly identifi ed, including identities of all commercial and noncommercial organizations.

8. Honesty in Advertising: If advertising is a source of funding, it will be clearly stated and presented to viewers in a manner that differentiates it from the original material created by the organization operating the site.

There is one problem, however. As legitimate as the HONcode’s reputation is, little is known about how the average person interprets such seals of approval. Most consumers either do not know about these online consumer protection organizations or do not use them. Unfortunately, researchers have identifi ed a major problem in the way online health information websites are accredited; evidently, these trusted seals often “promise more than deliver” (Burkell, 2004, n.p).

E-Health, Telehealth, and Telemedicine (2001) by Marlene Maheu, Pamela Whitten, and Ace Allen, was written for clinicians considering online therapy. The authors predicted that advancements in telecommunications technology would “reshape the standard of health care and revolutionize the way patients consumed therapy” (pp. 2–4), but so far, this has not happened from a professional stand- point. In addition, troubleshooting potential clinical problems online referred exclusively to medical models of tele-health and text-only communication for therapists. Their advice for risk management to mental health clinicians is that

10 Cyber Shrinks: Expanding the Paradigm

therapists comply with tele-health laws. But, here’s another double bind for clinicians, state Boards of Psychology have determined does not include Internet- based psychological practice at this time (Barnett & Sheetz, 2003; American Psychological Association, 2004).

Riva’s (2005) review of virtual reality (VR) explores the effi cacy of online therapy. He found 371 articles written in the past 3 years showing VR is an effective behavioral and psychotherapeutic treatment modality for those who suffer from specifi c phobias, depression, obesity, male erectile disorders, and cognitive disorders. Riva explains that the immersion of VR assists with the process of change for the patient on sensory, visual, emotional, and cognitive levels. VR therapy is a reinforcing experience that serves as a catalyst for new learning, cognitive restructuring, and behavior change.

Perhaps the best news about online psychology concerns traditionally disen- franchised peoples. Recent studies suggest that effectiveness of online therapy may

be greatest for those who are either reluctant to participate in treatment for fear of stigma or negative career effects, or for those who are unable to meet in person. Online treatment appears to also be effective for trauma and stress-based condi- tions; however, more research is needed (Andersson et al., 2005). Online group and individual therapy also show positive results with the following behavioral health problems: smoking cessation, weight loss, eating disorders, headaches, panic attacks, maintaining physical exercise goals, tinnitus, diabetes, bedwetting, and post-cancer and heart attack recovery treatments (Ritterband et al., 2003). Ritterband and his colleagues reviewed Web-based, behavioral treatment models for patients who pre- ferred receiving help from their own homes. They received a combination of psycho-educational and interactive CBT interventions online. Interestingly, while all the groups studied showed symptom improvement, signifi cant gains as a result of online therapy were reported for even traditionally diffi cult problems: the weight loss and trauma patient groups.

Finally, Ritterband and colleagues do acknowledge that developing Internet interventions “is an arduous, sometimes tedious, and always time-intensive process” (p. 530). It necessitates an interdisciplinary approach but once completed, the pro- tocol can be utilized for many patients. In addition, once the disorder is identifi ed as appropriate for the Internet, interventions are operationalized, that is, broken down into measurable components, and evaluation mechanisms built into the program so revisions can occur based on users’ treatment success. For patients who suffer from debilitating problems such as panic, posttraumatic stress disorder, diabetes, or other health-risk behaviors, the multimedia aspect of online treatment coalesces the power of multimodal learning strategies simultaneously. Internet therapies are highly structured, personalized, self guided, and engaging, thus increasing mean- ing and effi cacy for the patient. These states create continual feedback loops that encourage self monitoring and more patient involvement in tracking treatment gains (p. 531).

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