Etherapy: Ethical and Clinical Considerations

Lin Fraser EdD/MFT/NCC

Distance Certified Counselor/Member WPATH

Private Practice San Francisco, California

Abstract:

This paper provides background and exploratory material about ethical and clinical considerations regarding the use of etherapy in the care of transgender clients. A brief overview of the literature, its applicability and extrapolation to transgender clients, the rationale for etherapy, clinical and ethical considerations, both general and specific to transpeople, are described. Included in the discussion is an online psychotherapy case and commentary involving a Saudi-based American male-to-female transperson and a San Francisco therapist.

Key Words: etherapy, e-therapy, online therapy, web-based therapy, telehealth, transgender

Author Information:

Lin Fraser EdD/MFT/NCC/DCC

2538 California StreetSan Francisco, Ca 94115

linfraser@aol.com

http:/linfraser.com

415-922-9240

Introduction

Thia paper provides exploratory and background information about ethical and clinical considerations regarding etherapy (e-therapy, web-based therapy, online counseling, cybertherapy, telemedicine, on-line therapy, distance counseling, ecounseling, telehealth etc.) in the care of transgender clients. By way of background, I have recently been certified as a distance credentialed counselor (DCC#553) and have a thirty-year subspecialty as a licensed clinician doing psychotherapy with transgendered people and their families.

The training and written test for this distance credential was essentially a series of questions demonstrating: 1) the ability to apply and extrapolate evidence-based knowledge about etherapy to the applicant’s area of planned online practice i.e. the case for etherapy 2) knowledge of clinical and ethical concerns applied to etherapy, their myths and realities 3) how to conceptualize and think about an actual online clinical case and 4) knowledge of how and where to access information about continually changing legal, ethical and clinical considerations, both specific and general, in this growing, changing and often confusing environment. In my case, my area of focus was providing ethical online therapy for transpeople, hence the information included here is current, but may have updates by the time of publication. Although my credential is American with the potential for global certification, the conceptualization/way of thinking described in this paper is universal.

The purpose of this paper is to briefly cover the points listed above so that the reader will have a more informed understanding of the usefulness of etherapy in the care of transgender clients. Included in the discussion will be a Case Study that will examine and illuminate the points/topics under consideration in this new modality. This paper will not include a discussion of the efficacy of online evaluation and referral for hormones and surgery, as this remains an area needing further study and research specific to our community and can’t be extrapolated from known data.

Definitions/Methods of Delivery of Services

Etherapy (e-therapy, cybertherapy, e-counseling, online therapy, distance counseling etc.) normally refers to the provision of mental health services through electronic media. (APA, 2007) or “to the use of psychotechnologies to deliver therapeutic dialogues at a distance” (Maheu, et.al, 2005, p.5).

The main differentiating factor from traditional face-to-face- (f2f) is the medium by which the therapy occurs (Derrig-Palumbo & Zeine, 2005). In this case the medium is electronic, but the provider of services could be the same person. It is the method of delivery of service, rather than the service itself that distinguishes etherapy from more traditional f2f.

For example, the description of the distance-credentialed counselor on the Center for Credentialing and Education (2007) website is as follows:

A Distance Credentialed Counselor (DCC) will be nationally recognized as a professional with training in best practices in Distance Counseling. Distance Counseling is a counseling approach that takes the best practices of traditional counseling as well as some of its own unique advantages and adapts them for delivery to clients via electronic means in order to maximize the use of technology-assisted counseling techniques. The technology-assisted methods may include telecounseling (telephone), secure email communication, chat, videoconferencing or computerized stand-alone software programs.

Technology-assisted methods can be either synchronous or asynchronous and can be supplementary as well as complementary to f2f. Synchronous delivery methods include such interactions as real time Chat, IM (instant messaging) and Video Chat, text-based phone and or telephone (VOIP such as Skype). Asynchronous methods include email, via the Internet or phone.

Although it is beyond the scope of this paper to discuss technical considerations, it is presumed that any therapist providing these services will get the training necessary to be comfortable, knowledgeable and ethical using any of these delivery methods.

The Case for Etherapy

Timing and Access

The proliferation of the Internet concomitant with the burgeoning worldwide trans community online has set in place an ideal avenue to develop outreach and care online. One of our goals and missions is to advocate and provide care regardless of demographics (Brown, 2007). One problem of our population has to do with access. Many are geographically isolated and live in places where they may be stigmatized or even criminalized. The Internet knows no boundaries and has the capacity to reach even the most inaccessible of people as long as they have electronic access.

The infrastructure allowing fast, easy access is growing worldwide including in developing countries. It behooves us to provide care when and where we can and with the Internet, we can expand our clinical reach. Emphasizing this advantage, the dedication page of a seminal handbook on online therapy, states “for those who suffer from emotional distress and need better access to care” (Maheu et.al, 2005). Moreover, even where therapeutic care is accessible, access to competent specialists providing transgender care may be limited. Via online connections, specialists can provide care virtually anywhere either directly to the client or indirectly via training, consultation or supervision to local therapists who may be providing the f2f care.

Readiness and Appropriateness of Transpeople for online therapy

Moreover, etherapy has been shown to appeal and especially help a certain type of individual (Fenichel, et.al, 2004, Derrig-Palumbo & Zeine, 2005, pp 87-89), attributes shared by many members of our population. One criterion is technical comfort, if not a level of expertise. The exam for distance counseling included a comparison of the relative technological sophistication of both the target population (transpeople) and the provider (me) delivering the services. In this situation, the clients far outpaced the provider. Our population is known to be tech savvy and has already developed worldwide connections online.

What is missing in fact, is not the connections among transpeople themselves, or their knowledge of how to use electronic media, but the provider’s ability to provide ethical clinical services to them. It behooves us, I believe, to learn the clinical and technical skills to provide these services.

The knowledge, information and delivery models are already in place to provide ethical online psychotherapy to an ever-expanding global trans community. The mechanisms exist to deliver services and provide training to local licensed clinicians and/or community –based mental-health facilitators. The systems are already in place, we need to learn how to utilize them to expand our reach.

Moreover, trans people as individuals are highly motivated and want care from knowledgeable providers (Rachlin, 2002). Many transpeople won’t access therapy concerned that uneducated providers might misunderstand, pathologize or even harm them. What is anecdotally known is that many are highly intelligent, psychologically savvy and knowledgeable, having examined themselves for years, often alone and in secret (Fraser, 2003), and are thus candidates for depth work with a competent therapist. Many are quite comfortable with the written word and could benefit from text-based therapy.

Even for those who speak a different language, simultaneous translation of text is available online so that culturally competent clinicians could work with those who speak a different language.

Moreover, what is also known about web therapy is that it often appeals to those who are stigmatized and might otherwise not reach out for services due to fear or shame, certainly descriptors of a subset of our population. (Dellig-Palumbo & Zeine, 2005. p. 87).

Finally, the accessibility, ease, confidentiality and safety of the Internet foster a sense of safety and ability to self-disclose.

Convenience and Flexibility/Increased Containment

Another advantage of etherapy is that multiple modalities and delivery methods are available depending on preference of the client and creativity of the therapist. This offers possibilities to mix and match modalities, offering convenience, flexibility and individualized treatment. Each delivery method has its advantages (Ainsworth, 2001, APA, n.d., CCE, n.d., Dellig-Palumbo & Zeine, 2005, ISMHO Clinical Case Study Group 2000, among others) and the therapist can learn to utilize each most effectively depending upon preference, experience and the needs of the client.

A definite advantage for both client and therapist is mobility and continuous connection. The provider is free to be mobile as is the client and yet continue the work. With those who are doing f2f in combination with etherapy, knowing that the therapist is somewhat accessible when either are away for long periods or even in between sessions (this is at provider’s discretion and is part of the frame) reduces acting out behavior and other manifestations of anxiety. In this increasingly globalized society, a very mobile-therapist and client can maintain connection, contain sometimes very difficult material, and continue the work.

Also, online psychotherapy can be more convenient and flexible than f2f. A client can contact the therapist on their own time from wherever they wish. And the therapist can respond likewise within the agreed-upon frame.Moreover, the writers’ experience is that people really appreciate the ongoing connection and never take advantage of it, in fact the opposite occurs, the perceived ongoing connection actually reduces emergency contacts.

Finally, online therapy provides accessibility to clients who may be of limited means, a not unimportant concern, within the trans population (Whittle 2006).

Myths and Realities/Clinical and Ethical Concerns

Concerns about etherapy tend to fall into one of two categories, clinical or ethical/legal.

Clinical

Clinical concerns about etherapy relate to concerns about connection, relationship and the therapeutic alliance, and issues of risk management (confidentiality, emergency, identity of client).

The primary clinical resistance to etherapy relates to the inability to actually see /be in the same room with the client, hence being unable to visually discern nonverbal communication and other nuances central to f2f therapy. Moreover, many believe that mutual physical presence is necessary for the exploration of underlying considerations, not to mention the basic tenets of psychotherapy, such as the therapeutic alliance and the intersubjective connection that allows the client to feel safe. It is believed that this connection can only occur in the physical office.

Depth therapy considerations such as the development of a transference and immersion into deeper levels are presumed to only occur in the actual physical presence of a caring, nonjudgmental empathic other. Many people worry that somehow cyberspace seems limited and mechanical given the nature of the intimacy of f2f psychotherapeutic relationship.

The evidence, both from the literature (Fenichel et.al. 2004, Suler, 2007) and in the case described below, does not support these concerns.First, as technology advances, more online work will include video either by phone or computer, alleviating the concern about lack of verbal cues. (Maheu, 2005). Second, the efficacy of the written word should not be underestimated and text-based communications for certain clients (and providers) can be a powerful modality for the psychotherapeutic relationship. Concerns related to the therapeutic connection central to therapeutic alliance and moving to deeper levels are not borne out by those who have actually experienced the power of etherapy. (Fenichel et.al. 2004, Suler, 2007)

For example, as will be demonstrated in the case study in this paper, this ongoing connection in cyberspace allows a very protective and strong holding environment. Growth doesn’t necessarily operate on a schedule and some of the deepest revelations occur outside scheduled sessions. The felt experience for many is that the therapist is as close as the screen. It’s this sense of connection rather than the actual physical contact that seems to be important and is borne out by those who practice etherapy. (Suler, 2007) This connection between sessions can contain difficult material and allow the client to go deeper more quickly.

A detailed discussion of clinical concerns is beyond the scope of this paper. At this point, much of the literature is descriptive and often involves case studies of this evolving practice, with the recognition that more data based research is needed.

One excellent resource is a series of white papers, developed by ISMHO’s Clinical Case Study Group (ISMHO, 2000a), who presented a series of cases to each other over a three year period and then developed some conclusions about online therapy based on their shared experience and ongoing case consultation. These white papers, available online, contain valuable information, compiled by established leaders in the field. One article assesses a person’s suitability for online therapy (ISMHO, n.d.), another suggests clinical principles for the online provision of mental health services (ISMHO, 2000) and another, on the myths and realities of online clinical work, dispels such myths that therapy needs to be f2f, talking and/ synchronous. (Fenichel, et.al., 2004).

For those interested in more technical articles, with comprehensive lists of journal articles, Marlene Maheu’s 500 + volume titled The Mental Health Professional and the New Technologies with 37 pages of tiny font references may be of interest (Maheu et.al 2005).

It is important to recognize that information is evolving as more people practice and publish. The case study in this background paper on Revision7 is an addition to this tradition and is the first to my knowledge on the applicability of etherapy to a transgender client. Nevertheless, a quote from Case Study Group offers a direct parallel and might sound familiar in terms of the issues presented:

Several unique advantages exist in online work. Many have been described in the literature already, such as access for the homebound, geographically isolated, or stigmatized client who will not or cannot access treatment. One of our case presentations illustrated vividly not only the possibility but also the advantage of Internet-based therapeutic support. A pilot in the military, exploring sexual orientation and afraid of the potential impact of “coming out” and jeopardizing a military career, demonstrated how seeking help online was reassuring to the client in terms of confidentiality. The absence of geographic boundaries allowed the client to select a therapist who appeared to have the expertise and understanding needed in the client’s particular situation (Fenichel, et.al 2004).

From this case and the information herein presented, it is hoped that the reader might be able to imagine the clinical possibilities inherent in the cyber therapeutic connection as well as the multiple modalities it affords to individualize treatment /offer choice and potentially even offer more creative delivery of clinical services than more traditional f2f.

Another clinical concern has to do with risk-management, issues such as security, confidentiality, emergency backup, and reliability regarding the identity of the client. These can be resolved via encryption, a plan for what to do in an emergency, providing links to local services and the provision of an emergency local healthcare contact. Identity can be established via credit card payment and other software. As described in the above case, confidentiality may actually be increased via online rather than f2f for the kinds of concerns our clients present.

Ethical/Legal

The primary ethical/legal issue under consideration has to do with who can practice and where does one practice etherapy? Where is the therapy located? Where exactly is cyberspace? Much discussion concerns the legitimacy of crossing state, national and international boundaries or if boundaries even exist in cyberspace? The bottom line issue is how is the consumer protected?

This paper has, as an underlying premise, that people considering practicing etherapy, will be certified, licensed or otherwise covered by their regulatory boards to practice f2f therapy and etherapy (where the regulations are clear) and will provide this information to clients as part of the informed consent process.

For example, the provider’s website might include links to appropriate licensing and regulatory boards, as a way to verify their credentials. It is also presumed that, as in f2f, the practitioner will have familiarity with the ethics of their respective practices. The practice of etherapy far exceeds the various state regulatory and licensing boards ability to keep up with its exponential growth. Hence it falls upon providers to not only stay current with their respective regulations, but to also understand the thinking upon which ethical practice is based. Problems of licensing reciprocity exist and the location of cyberspace is generally undefined.

As an overarching principle, then, the reader is advised to stay current with their particular licensing board, professional association and country’s regulations as well as the thinking of those in the vanguard of this rapidly evolving medium. At a minimum, by keeping abreast of current information, a considered and knowledgeable decision about whether to participate can be made.

As an overview, the various regulations available today can be confusing, still unclear and contradictory. For example, Fenichel, in April 13, 2007 e-mail to the ISMHO membership addressed the “thorny problem of US licensing” saying that

The short version of the topic is that the patchwork of 50 states sets of rules now in place does not seem like it can remain standing—it is anachronistic, so it seems, out of step with the reality of how people interact with the world these days, often facilitated by the Internet.

Moreover, one’s particular state or even country’s governing body may not approve of what may be considered quite ethical from one’s professional association.Rules range from a commonsense approach such as the NCC Code of Ethics from the 1990’s that advises the clinician to use their best clinical judgment based on an extrapolation of ethics from f2f to online work or the American Psychiatric Association’s position statement on the Ethical Use of Telemedicine:

The APA supports the use of telemedicine as a legitimate component of a mental health delivery system to the extent that its use is in the best interest of the patient and is in compliance with the APA policies on medical ethics and confidentiality (APA Ethics Committee, 1995).

to a highly restrictive regulation, where, under such and such a license, the clinician can only practice etherapy if licensed in the location where the client is physically located. Hence, in this latter case the location of the therapy is where the client is located. Some countries (Italy, I believe, is one) do not allow the practice of etherapy at all. Others are quite liberal, like Britain, for example, that offers reimbursement for etherapy services provided by clinicians living both inside and outside the UK as long as they hold a UK certification (Personal e-mail communication, 2007). The US now has a CPT code (0074T) for online consultation with an established patient (Kraus, 2004).

Discussions are in place about a global credential (Clawson, 2007,p.4).) and the writer holds a national counseling credential and a distance counseling certification. Even so, their applicability in some locations remains unclear.

Maheu and her colleagues have drafted papers including principles, statements and philosophy for an international convention on telemedicine and telehealth (Maheu, et.al., 2005, appendix d – p. 451).

In general, regulations are slowly catching up to practice. In America, rural states are in the forefront, because their consumers desperately need access to services. “There are no national laws forbidding a therapist to treat someone outside of his or her state of licensure, though some state boards have taken a stand on where the therapy takes place” (Derrig-Palumbo & Zeine, 2005, p. 53).

To date, no legal case has been tested or tried to untangle the myriad regulations; hence services are provided without any certainty as to how a lawsuit might be played out. One case in California, (Zack, 2007) has recently emerged as a potential test case. A physician in Colorado prescribed medication (Prozac) online and across state lines to a person in California through a server in Texas without physically examining the person. The patient later committed suicide and was found to have had Prozac in his system. The writ petition against the doctor is a felony complaint about practicing without a license in California. Much discussion on the ISMHO (International Society of Mental Health Online) forum and elsewhere is ongoing as to whether this may become the “test case” with potential applicability to etherapy.

The reader is referred to the ISMHO website for articles and interesting and ongoing international discussions about ethics, liability and legality of providing etherapy.

Most discussions of ethics and codes of conduct seem to concur on a few general principles. First, as an overview, is the importance of maintaining a clear understanding of the ethics statement of one’s own professional organization, both in general and then specifically about etherapy if such standards exist. General considerations usually include, maintaining licensure, providing informed consent, maintaining an ongoing consideration of what is in the client’s best interest, providing access and nondiscrimination policies and operating within ones level of competence and training. These are underlying ethical considerations for all therapy, including etherapy. The therapist needs to be regularly asking whether what is being provided is in the best interest of the client and are they competent to provide it? Then, in terms of extrapolation to etherapy, for this particular client, given their particular situation, is etherapy the best available service? And is their condition within the therapists’ area of expertise or could they access more effective services elsewhere?

Certainly given these universal ethical parameters, the case for etherapy exists for trans clients due to the aforementioned accessibility problem and limited available expertise.

Aside from general ethical considerations, the therapist also needs to understand specific regulations and standards having to do with etherapy. Many professional associations provide versions of such. These are usually subsets of their ethics statements such as APA, APA, NCC, CAMFT (in America).

It is also important to check local and country laws, regulations, to see if any exist regarding etherapy. What may be found is a good deal of confusion, so each provider needs to consider carefully his or her own circumstances.

A major question in the DCC credentialing exam had to do with the ability to access information and knowledge of how to stay current. Links to useful websites will be included in the section following the case study.

As an example of current legal thinking about etherapy, included below is some commentary from an avoiding liability bulletin distributed by the writer’s liability carrier. It is written by Richard Leslie, J.D, an attorney specializing in the intersection of psychotherapy and the law. The following is his prudent advice regarding online informed consent and insurance coverage

Online Therapy-Disclosure(March 2006, Volume 1)…Whether or not required by state law or regulation, therapists who practice online therapy (e.g., intrastate) would be wise to make certain disclosures to the patient prior to the commencement of online therapy, and to obtain the patient’s written and informed consent prior to such treatment. Of course, if there is an applicable state law or regulation, therapists must follow the law or regulation in all of its detail. Since it can be reasonably argued that online psychotherapy can be considered new, innovative or experimental, it would be wise and prudent to obtain written informed consent, even in the absence of a state requirement.

One of the disclosures that is often required or, at a minimum, advisable, is a description of the potential risks, consequences, and benefits of online therapy. In one state, the telemedicine statute leaves it to the practitioner to determine what those risks, consequences and benefits actually are. Consequently, disclosures in that state and in other states will vary (where not specifically mandated) depending upon the technology used, the level of sophistication of the therapist and the patient/client, and the nature of the services being sought and rendered.

Certainly a disclosure about how confidentiality will or may be affected by services being provided over the Internet, and what steps the therapist will take or has taken to make sure that the communications between patient and therapist remain confidential, would be important.The patient should also be informed about how session records will be kept and how they may be retrieved or copied, to the extent that it differs from traditional record keeping practices. If therapy does not involve synchronous audio and video communication, but rather, written communication only, additional disclosures about the nature and process of the written communication should be considered. A therapist might also disclose the possible lack of certain clinical information about the patient because of the inability to see what might otherwise be seen in face-to-face therapy, and the possible consequences thereof (Leslie, 2006).

Online Therapy- Insurance Coverage(October 2005, Volume 1)Therapists and counselors often ask whether or not their malpractice (professional liability) policy covers them if there is a claim or lawsuit for alleged negligence in the performance of online therapy sometimes called Internet therapy or e-therapy). Because the answer to the question may vary from insurer to insurer, therapists should review their policy to see whether or not there is any exclusion or limitation pertaining to online therapy. If there is no limitation or exclusion, then coverage should exist (Leslie, 2005).

As an example, my insurer added my distance counseling credential to my policy for an additional seventeen dollars.

Case Study

What follows is a case from the writer’s practice that addresses the issues and considerations, both ethical and clinical, described in the previous sections. My client, “SH” has given permission to discuss her case, “ You also have my full consent to use all relevant documents regarding our therapeutic interactions, including hand written notes and copies of emails in any future paper, presentation, or publication regarding our telehealth activities (SH, 2005).

SH, then MH, an American living in Saudi Arabia contacted me via email in March 1998 and asked for an appointment during his (she was living in male-role at the time) home visit to the Bay Area. I saw him in my office in May. He was experiencing rather intensifying progressive gender incongruence and needed therapy to sort out his conflicting struggles. Married and the father of two (almost grown) children, and working overseas with no contact with any kindred spirits, he was becoming more and more depressed and agitated. The pressure on his psyche was intensifying and he was filled with guilt and shame. He was considering medical feminization, even though the consequences of a speedy transition could be quite dire from his perspective, and potentially quite dangerous if he went out dressed in Saudi. We saw each other several times before his return to the Middle East and he asked if we might continue the work via email.

This was my first introduction to etherapy in my own practice, although, over the years, I had worked with established clients over the telephone as time and distance considerations required. I had also recently joined a listserve about etherapy so I had some sense of the issues and concerns involved. MH was seeing and had been seeing a psychiatrist in Saudi since 1996 and had been in therapy with others in the past, but his psychiatrist had no knowledge of gender issues. I felt that as long as he continued to see his local therapist, and if the local therapist agreed that ongoing email contact between M and me might be helpful, then I would be willing to work with him on a trial basis and evaluate its effectiveness as we went along.

We discussed the tentative frame of the therapy, such things as fee structure, my availability, response-turnaround time of communications, contact information of his psychiatrist and next of kin, security of email etc., and agreed that these arrangements might evolve or change as the therapy progressed.

What I couldn’t have known at the time was that this would be the beginning of a whole new clinical experience, rich with depth and possibility. Although much less was available then in terms of knowledge regarding ecare, the thinking concerning how best to help from a distance has not really changed. The issues that were confronted are the same, as they would be confronted by anyone with their first eclient. Moreover, trans specialists are used to being ‘cutting edge” and on the forefront of new and challenging theory and developing new standards and therapies to meet the needs of an evolving population. The challenge of etherapy is no different.

Due to a confluence of factors, this first case proved efficacious. My client turned out to be ideal for this kind of work, technically savvy, much more so than her therapist, and she knew how to encrypt our communications. She was intelligent and actually quite brilliant with the written word. She was (is) psychologically oriented with the ability to connect experience and dreams to feelings as she wrote. She was literate and knowledgeable about symbols, attributes important to the type of Jungian work I do. Moreover, she was capable of a transference, and we were able to create a holding environment in cyberspace, which was especially important given the danger of being trans in Saudi.

These things I didn’t know of course initially. What I did know is that we had made a connection in my office, I felt there was a therapeutic alliance and that responding to her request would not harm her given that she had local backup. After our first session, even while she was in San Francisco, she (then he) emailed me her initial dream (very important in Jungian analysis) which contained strong imagery suggesting that her entire world was crumbling/ that the status quo as he knew it was tumbling down and he woke up crying.

So, the therapy began.

I checked my MFT licensing board in California and although they do now, at that time, they had no information on online counseling. I also checked the National Certified Counselors Ethical Standards (I’m also an NCC) for online work and they delineated a common sense approach recommending that as this is a new modality, the counselor needs to apply the same ethical principles as they would to f2f and then they listed the common sense principles.

As it turned out, the American Psychological Association (I’m a clinical member because my doctorate is in psychology although I’m not licensed as such in California) had its annual convention that summer in San Francisco, and I attended a three-day workshop in telehealth. By this time, I had been communicating online with SH several times weekly and was aware that it seemed to be helping. I shared this case to the attendees and workshop leaders, including the group leader, Marlene Maheu PhD, a psychologist in the forefront of the telehealth movement (see Maheu et.al, 2005), and to an APA attorney and APA ethicist. What they told me applies today and can help any new etherapist learn how to think conceptually.

First, what is most important as a bottom line (and this seems to be true in all clinical ethics-see links in the next section.) is what is in the best interest of the patient? Is providing etherapy to this person at this time in their best interest? In this case, clearly the answer was yes because I had an expertise she could not find in Saudi.

Two, does she have informed consent? And what does informed consent mean in etherapy? This may differ depending upon one’s professional association, but in the next paragraph, I’ve included S’s informed consent, which covers most bases.

Three, the lawyer said in terms of legal precedents, the best application would be the comparison to telephone therapy which at APA, required an f2f visit before commencing ongoing telephone work. In terms of case law, I was on solid legal ground as long as I saw her f2f first and then again from time to time. Current ethics do not require f2f contact; nevertheless an introductory f2f still makes common sense to me, although that may not always be feasible in terms of the trans population. In general, as mentioned before, it’s best to check one’s own specialty ethics, legal and licensing (state or country) regulations regarding how to proceed in your jurisdiction. Although there has been no test case as yet, the defense or prosecution will refer to case law.

Four, they suggested that I keep good records and seek ongoing consultation. With etherapy, one has a full transcription of the therapy so good record keeping is quite easy as is consultation. I had (have) both individual and group consultation, the latter being with Bay Area Gender Associates (BAGA), an ongoing consultation group of licensed therapists specializing in transgender identity issues, and I kept all apprised of the therapy on an ongoing basis.I reported the information I learned at the conference to SH, then MH, and s/he sent me the following “informed consent”

Dear Lin Fraser,

Please let this email be for whom it may concern verification that I, MH, an American citizen born on —- -, 194_ in ———, ——— do give fully informed consent to Lin Fraser of San Francisco, California, to practice gender identity therapy with me as a client via internet email through a new and experimental process sometimes termed “telehealth”. I understand that this is a new and somewhat unknown form of therapy, and that therapeutic outcomes are not guaranteed to be the same as might have occurred through the process of face-to-face therapy sessions. However, due to my remote living and working situation (in Dhahran, Saudi Arabia), and the complete lack of any alternative gender identity therapy in this country, nor any adjacent countries, I approached Lin Fraser by email early in 1998 to set up an appointment for me at the end of May. During our first two sessions in her office I asked her if she would be willing to counsel me as her patient via email when I was back in Saudi Arabia. She agreed to this arrangement, and we have been communicating on a daily basis since the beginning of June. We plan to have face to face sessions whenever my presence in San Francisco is possible, but due to my living in Saudi Arabia, this may only be possible a very few times per year.

Sincerely, MH

The therapy progressed over the next 6 months with numerous emails back and forth, much struggle on her part and a deepening of the internal work. Inclusion of the etherapy dialogue and progression is beyond the scope of this paper, but the text was as powerful and in many ways more powerful than f2f. There was more time for thoughtful reflection, and allowed a savoring and settling of the work during and between communications.

Per our initial agreement, I asked her to reflect upon and evaluate the work. Here are her words verbatim in December 1998:

Dear Lin, This is a brief personal evaluation of the therapy relationship we have had from early June through today (December 4, 1998) and my personal feelings as to the effectiveness of the process, how I feel it has benefited me.

I believe our tele-counseling process (“telehealth”) has been extremely effective in my situation, more so than much of the counseling I have experienced directly with two different psychiatrists face-to-face during the past fifteen years or so. If nothing else, it certainly has put me in a “journaling mode” like I’ve never experienced before, knowing that you would be reading my thoughts within a few hours, most of the time every day during July and August and September when I was going through heavy identity problems.

And now during a time the “problem area” seems to have shifted somewhat to the transition of our family unit, my relationship long term and future with my wife, TH, and both disclosure and the transition of my relationship with my son and daughter.

As far as I know, there are no psychiatrists or psychologists in this country (Saudi Arabia) with experience or skills such as you have and are able to draw upon in working with gender issues like mine.

You have been able to help me by being a constant and consistent listener and artful questioner. While I know you have often expressed some frustration at not being able to interact more directly and to visually see my body language as we dialogue, I also realize that there are some things that can be gotten into even deeper through writing words with feeling and care, sort of a verbal meditation, done in silence, fully focused. These include complex feelings and observations that are felt while being articulated.

Not a whole lot different than face-to-face therapy, I suppose, where certainly over 50% of the process is verbal (some might disagree).

We also of course should not discount the transpersonal dimensions, since I sit and meditate and think of you and my issues.I really believe that Internet email, which we are using as your communication medium between Dhahran and San Francisco, is highly effective in this dialogue, more so than traditional “snailmail”. One knows that the other person in the dialog will likely read what you have just said within a few hours, sometimes within minutes. This makes it a real “conversation”, almost like face-to-face but with the time-speed slowed down quite a bit.

Anyway, to be more specific, I feel that the following developments have been highly important to me during the past six months of telehealth gender therapy:

1. I feel I have transitioned from a state of great doubt, confusion, anxiety and emotional turmoil due to conflicting “identity feelings” to a state of relative peace, clarity of objectives, and a strong new sense of a single identity (through acceptance of my conflicted female feelings).

2. I have arrived at a clearer understanding and feeling of self-identity than ever previously in my life, as I am more able to accept more of my male and female elements simultaneously and/or in sequence, as situationally appropriate.

3. I have learned that it is possible to “slow down” the speed of my transition (which always is pressuring my psyche to “accelerate” the changes), to consolidate them and pause and digest them, and only then to go forward, and to use the emerging, though highly inexperienced/immature feminine elements of my psyche to shift my concern from exclusively focusing on myself, to being able to think more about others and how they feel and how they are impacted by my gender shifting.

Previously I was of course concerned, but with a much greater emphasis on fear (terror actually) and shame and tremendous guilt at “what I was doing to myself and how it would destroy both me and my family”. Those feelings of fear/terror/guilt kept me paralyzed, unable to act with “skillful means”. Now I accept S, and have experienced a vast polar shift from feeling “transgendered and damned” to feeling “transgendered and proud” (probably a sign of major immaturity here! But it feels good at this point!).

And feeling at peace with myself internally, I feel I have the solid inner foundation upon which to take a firm, stable stand to nurture, rebuild where necessary, and preserve where appropriate, our previous family relationships (I mean the intimate emotional/marital relationship with my wife primarily, but am entering the process, with your help, of including my children in the transition which must proceed from disclosure).

I think that all I want to say on the issue that you asked me to comment on, i.e. “could I provide an evaluation of our telehealth gender therapy process?”

Of course there are additional side benefits from this telehealth that are obvious, particularly that of having the entire therapy dialog/process (or 90% of it) in electronic text files for present and future reference during therapy and possibly later for research, ability to scan electronically for issues and patterns of resolution, etc.

Hope that has been enough for an A grade in “evaluation reporting”!

Hugs and a warm smile and a simple “thanks Lin!” “S”

After this quite comprehensive evaluation, the therapy continued via email until S returned to the States the following spring and we moved into a rather traditional f2f psychotherapy that was deeply enriched by the etherapy that had preceded it.

Over the next few years, she did transition. She completed medical feminization, went through an ultimately amicable divorce and is now happily partnered with another transwoman. She is close to both her ex-wife and children, is successfully employed and sees me occasionally as needed.

In her latest exchange (April 3, 2007) she talked about her happy relationships with her partner, her delight in her children, one married, one engaged, her upcoming retirement and move to a lovely new home, and her deepening spiritual commitment. Her only reference to her trans identity was the following:

On Palm Sunday I led the procession with Fr.______ at my side, the priest in front, as we sang a processional chant in Latin. A lot of irony here, as I first met Fr. ___ at the ancient monastery of ______, near _____, in _____, back in 1992 with my young family (I, as M, had a red moustache at the time). I don’t think he realizes that S used to be M, but one never knows with these monks…

Lots of interesting times in the life of S, no! No end in sight. I wish you and your family a joyous Easter!

S

Commentary on Case

From the foregoing, it is evident that S does indeed have a rich and fulfilling life, but given her situation when she first sought consultation, one wonders what the outcome might have been without etherapy. S describes it as a “lifesaver”.

Although she was a particularly good candidate given her technical and verbal prowess, the issues that emerged in her case are perhaps typical of many trans people living in remote areas where clinical expertise is unavailable.Moreover, although the etherapy part of her therapy is from 1998-1999, conceptualization, ethical issues and how to think clinically are the same today. What I went through would be similar for any beginning etherapist. For example, as the case evolved, I consulted ethical and clinical experts regarding pertinent information that was then available from APA, CAMFT and NBCC and sought ongoing clinical supervision, both group and individual.

Even though the thinking was less evolved than it is today, the process is the same, checking with licensing and regulatory boards, keeping abreast of ethics and maintaining consultation among colleagues, both more experienced and peer.

Moreover, more options exist now allowing synchronous communications such as IM, text or video chat rather than just the asynchronous format available in 1998. Hence, etherapy can be multimodal and individualized, offering both the advantages of a real conversation as well as the slowed-down quality and time for reflection allowed by asynchronous email.

An extensive discussion of clinical considerations as they apply to etherapy and specifically to this case as an illustration of distance work with a trans client is beyond the scope of this paper. What is presumed is that the reader can extrapolate for him or herself the general clinical issues involving both the frame and the process. The following will only be a very brief discussion of both.

The frame would include such things as screening. S was a particularly good candidate for etherapy as she was highly motivated, was comfortable with computers and text-based communication; she was psychologically oriented and could connect her feelings to both her conscious and unconscious experience. Moreover, she had the capacity to reflect and journal. She was responsive to the type of therapy I offered.

Other therapists of course, have other orientations, and the literature suggests most orientations can be adapted to etherapy (Derris-Palumbo & Zeine, 2005, pp5-38).

Other issues pertaining to the frame include informed consent (Griffin, 2006), security, confidentiality, encryption and other technical considerations. Arrangements need to be be made regarding emergency local backup, and links to local services, payment and fee schedule, frequency and length of contact, etc.

In terms of the clinical process, her commentary actually says it best and points to the potential power of etherapy. There is little to add, she mentioned many of the points suggested in the literature, the power of written word, the deep meditative process that can occur, the unbroken intersubjective client-therapist connection, the potential for containment for unhealthy impulses and the reality of the virtual office as a holding environment.

What is inferred in the “evaluation” is the strong transference that can also develop, even without the therapists’ physical presence. As an example, S told me that she had kept for months and referred to repeatedly (she put it on her mirror) an encouraging note I had sent to help her through a particularly difficult day. She also imagined me in her daily meditations and still calls on my image during conflict. In terms of countertransference, I held her just as strongly as any of my people in f2f work, sometimes more so. I wrote to her, both in response to what I felt she needed, but also when the muse struck.

The location of the therapy was both diffuse and everywhere, yet felt boundaried and nonintrusive. I responded at my own pace, respecting what I knew to be her needs, but also, since this had been discussed as part of the frame, in consideration of my own.

Basically, what her commentary describes is clinical evidence for the extrapolation and application of what is known about the benefits of etherapy to a trans client. Her descriptions of the benefits she received match descriptions in the general literature, with the addition of the benefits both typical and specific to trans identities. These include the slow consolidation and integration of a unitary gendered self, a movement from conflict, confusion, and guilt to clarity of objectives and relative peace, the development of a capacity to slow down the process to allow integration, a beginning sense of safety, and more of a capacity to consider the feelings of others.She also mentioned the usefulness of having the complete record of the therapy available then as a written review as the case progressed, an identification and discussion of what has happened during the work, goals reached and its potential use in the future. This complete record has been of obvious use in the preparation of this paper.

How to Stay Current/Links to Further Information

Even though clinical considerations may have changed little in the intervening years, much is evolving in terms of ethics, regulations, laws etc. Online therapy is growing exponentially and information about it is evolving.

As mentioned earlier, one requirement for any etherapist is the necessity of staying current. To keep up with this shifting information, information on the web is regularly updated. The reader is here referred to several excellent websites and forums. These include links to online professional associations, current information on ethics and the law, information about how to get more education including CEU’s, as well as general references in the field.The links below include only a smattering of the many websites available, but the list is inclusive of those referred to in this paper.

Two websites have been most useful; one is the International Society for Mental Health Online, which has links to several of the papers referred to earlier and other useful links regarding etherapy. One section includes a link to a member’s only forum, which offers threads to many interesting discussions on topics of interest to etherapists. For those interested in practicing online therapy, membership in this organization is recommended.

Another good website, is http://etherapylaw.com described on the website as “A clearinghouse for information on legal issues in online counseling”. This website, although very recent, and still evolving, covers legal/ethical issues pertaining to therapists. It is updated regularly and has been developed by one of the pioneers in etherapy, Jason Zack PhD, a psychologist who is currently a 3rd year law student at Penn. His website has received numerous accolades on the ISMHO forum. The ethics section on this website has links to many organization’s (ACA, APA (Psychology), NASW, AAMFT, ISMHO, APA (Psychiatry), ACTO) code of ethics, ethical principles and/or codes of conduct, both in general and specific to etherapy. It also has an international section that will cover issues of interest to non-American members. The following is a link to Canadian Psychological Association’s code of ethics for online therapy .

Several pioneers, such as Michael Fenichel PhD, Ron Kraus PhD & John Suler PhD have useful websites and also offer CEU’s in the field. Suler’s work has been particularly influential regarding the clinical/psychodynamic considerations described in this paper. He has written a classic in the field, an online book The Psychology of Cyberspace and offers CEU’s on the book, CEU’s Psychology of Cyberspace that includes a blog companion to this seminal work.Kraus’ company, OnlineClinics has a useful and general ethics code Guidelines for Mental Health and Healthcare Practice Online that covers many of concerns articulated in this paper.

Information on the national credentialing process for online therapy is on the Readyminds counselor credential website.Finally, an extensive list of articles on etherapy has been compiled by Azy Barak PhD, an Israeli pioneer and member of the ISMHO Study Group, entitled References Related to the Internet and Psychology. Another extensive reference list has been compiled by Marlene Maheu et al in her book, the mental health professional and the new technologies and she also has good informational website on telehealth and e-health.

Suggestions for Further Research

Ethics and efficacy of etherapy for hormone & surgery referralsOne issue that clearly needs further research is whether a clinician can ever make a competent assessment for a referral for medical masculinization or feminization without f2f work.While it is clear that the trans population is ready and can benefit from the provision of etherapy by competent knowledgeable clinicians, what is not clear is whether evidence exists that can be extrapolated to assessment and referral for surgery and hormones. Although literature exists supporting Internet assessment (Hyler, et.al. 2005), the data doesn’t offer enough of a parallel to draw conclusions for our purposes. Further research is needed in this area and we need more data specific to our field. At this point, “relying solely on web-based contacts with consumers as the exclusive basis for evaluation or referral is risky at best for both providers and consumers and does not meet the minimum Standards of Care guidelines promulgated by this organization” (Brown, WPATH website 2006). Therefore, this issue is beyond the scope of this paper, which has been limited to the efficacy of psychotherapy.More knowledge, more specific information and experience is needed, most likely gathered amongst trans providers.

Clinical

Etherapy clearly can be a useful modality for psychotherapy with transgendered people. It offers opportunities for multiple modalities and potentially enhanced and expanded, creative, tailor-made delivery of services.

What could be interesting in terms of further clinical possibilities and research might be the impact on transpeople of online immersive environments such as Second Life, or the experience of virtual identities, online virtual RLT, and immersive psychotherapies such as are already beginning in Second Life.

One question to be studied might be what is an identity in cyberspace and how does it relate to real life (Turkle, 1995) for the transperson’s identity and gender identity? What effect if any do immersive worlds have on gender identity? If a person is trying on various experiences of their gender identity, for example, in social networking spaces such as Frenzo, where one can personalize virtual 3D characters, how would that impact identity in vivo? These and other questions might be of particular interest to people who are already on the cutting edge of fluidity in their physical gendered selves.

References

Ainsworth, M (2001). E-therapy: history and survey. Retrieved May 18, 2007 from Metanoia website: http://www.metanoia.org/imhs

American Psychiatric Association Council on Psychiatry and Law (n.d.). Frequently asked questions e-therapy. Retrieved May 4, 2007 from APA website from http://www.psych.org/psych_pract/clin_issues/etherapyfaqs.cfm

APA Online (2007) APA Statement on services by telephone, teleconferencing, and Internet, a statement by the ethics committee of the American psychological association. Retrieved 05/04/2007 from http://www.apa.org/ethics/stmnt01.html

American Psychiatric Association Ethics Committee (1995). Position statement on the ethical use of telemedicine. Washington, D.C. Retrieved May 28, 2007 from http://www.psych.org/edu/other_res/lib_archives/archives/199515.pdf

Behnke, S. (2007). Posting on the Internet: An opportunity for self (and other) reflection (Electronic Version). Monitor on Psychology, 38(1), 60. http://www.apa.org/monitor/jano7/ethics.html

Brown, G.R. (2006). The ethics of online services: an opinion. Retrieved 6/25, 2006 from HBIGDA website http://www.wpath.org

Brown, G.R. (2007). Need for revisions to the version 6 Standards of Care section on medical care for incarcerated persons with GID, Invited paper for Revision 7 of SOC, submitted May 7, 2007.

Center for Credentialing and Education (n.d). Distance credentialed counselor (DCC). Retrieved May 18, 2007 from http://www.cce-global.org/credentials-offered/dccmain

Center for Credentialing and Education (n.d.). Distance counseling continuing education opportunities: Security strategies for distance counseling via e-mail. Retrieved May 18, 2007 from http://www.cce-global.org/credentials-offered/dccrecert/edopp

Clawson, T (2007, Spring). Reflections on NBCC’s first twenty-five years. The NCC, the national certified counselor [Newsletter], 23(2), 4.

Derrig-Palumbo, K., & Zeine, F. (2005). Online therapy: A therapist’s guide to expanding your practice. New York: W.W. Norton & Company.

ERIC/CASS Digest (2000). Ethics and regulations of cybercounseling. Retrieved 10/28/2006 from http://www.ericdigests.org/2001-3/ethics.htm

Fenichel, M. (2007). Re: [ismho members] Licensing-in the 50 states (USA), Retrieved April 13, 2007 from ISMHO website, members only forum http://health.groups.yahoo.com/group/ismho-members/message/16308

Fenichel, M., Suler, J., Barak, A., Zelvin, E., Jones, G., Munro, K., Meunier, V., & Walker-Schmunker, W. (2004), Myths and Realities of Online Clinical Work, a 3rd –year report from ISMHO’s Clinical Case Study Group, Retrieved May 18, 2007, from ISMHO website: http://www.ismho.org/casestudy/myths.htm

Fraser, L. (2003) The transgender phenomenon: psychodynamic viewpoint. Opening plenary from the proceedings of the 18th Biennial Symposium of the HBIGDA, Gent, Belgium, September 10-13.

Griffin, M. (2006, September/October). Revisiting Informed Consent. The Therapist, 35-44.

Hyler, S.E., Gangure, D.P., Batchelder, S.T. (2005). Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. CNS Spectrum Studies, 10 (5), 403-413.

International Society for Mental Health Online (2000) Suggested principles for the online provision of mental health services version 3.1.1. In White Papers. Retrieved May 18, 2007 from IMSHO web site: http:// www.ismho.org/suggestions.html

International Society for Mental Health Online (2000a). The online clinical case study group of the International Society for Mental Health online: a report from the Millennium Group, Retrieved May 28, 2007, from http://www.ismho.org/casestudy/ccsgmg.htm

International Society for Mental Health Online (n.d.) Assessing a person’s suitability for online therapy. In White Papers. Retrieved May 18, 2007 from ISMHO web site: http://www.ismho.org/casestudy/ccsgas.htm

Kraus, R. (2004). CPT code 0074T for online consultation-A revolution in healthcare delivery? Retrieved March 8,2007, from OnlineClinics Website: http://www.onlineclinics.com/pages/content.asp?iglobalid=44

Kraus, R., Zack, J., Stricker, G., (2004). Online counseling: a handbook for mental health professionals, San Diego: Elsevier Academic Press.

Leslie, R.S. (2005). At the intersection of law and psychotherapy, online therapy-insurance coverage. Retrieved March 2, 2007, from CPH and Associates Professional Liability Counselor Malpractice Website: http://www.cphins.com/LegalResources/BulletinArchive/tabid/66/cid/44/sid/49/Default.aspx

Leslie, R.S. (2006). At the intersection of law and psychotherapy, online therapy-disclosure. Retrieved March 2, 2007, from CPH and Associates Professional Liability Counselor Malpractice Web Site: http://www.cphins.com/LegalResources/BulletinArchive/tabid/66/cid/58/sid/47/Default.aspx

Maheu, M.M., Pulier, M.L., Wilhelm, F.H., McMenamin, J.P., & Brown-Connolly, N.E. (2005). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Lawrence Erlbaum Associates.

Malone, J.F. (2003). Working toward effective practices in distance career counseling. Retrieved October 31, 2006 from ERIC Digest Website http://www.ericdigests.org/20 03-4/career-counseling.html

Meyer III, W. (Chairperson), Bockting, W., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor, H., Gooren, L., Hage, J., Kirk, S., Kuiper, B., Laub, D., Lawrence, A., Menard, Y., Patton, J., Schaefer. L., Webb, A., Wheeler, C. (February 2001) The standards of care for gender identity disorders-Sixth Version, IJT 5 (1). Retrieved May 27, 2007 from http://www.symposion.com/ijt/soc_2001/index.htm

National Board for Certified Counselors. (n.d.) The practice of internet counseling. Retrieved December 9, 2006, from http://nbcc.org/webethics2

Online Clinical Case Study Group (n.d. continually updated). Hypotheses about online psychotherapy and clinical work, Retrieved May 18, 2007 from John Suler’s website: http://www.rider.edu/%60suler/psycyber/workinghyp.html

OnlineClinics (1999, updated February 26,2006). Guidelines for mental health and healthcare practice online. Retrieved May 18, 2007 from http://ethicscode.com/pages/698182/index.htm

Rachlin, K. (2002). Transgender individual’s experiences of psychotherapy. International Journal of Transgenderism 6(1). Retrieved Jan 27, 2007 from http://www.symposion.com/ijt/ijtvo06no01_03.htm

Rochlen, A., Zack, J., & Speyer, C. (2004). Online therapy: review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60, 269-283.

Skinner, A., & Zack, J. (2004). Counseling and the internet. American Behavioral Scientist. (12) 434- 447.

Smith, S., & Reynolds, C. (2002). Cyber-psychotherapy. (online psychotherapy). Annals of the American Psychotherapy Association, 5(2), 20-23.

Suler, J. (2007, continually updated/1st posted 1996). The psychology of cyberspace. http://www.rider.edu/~suler/psycyber.html.

Suler, J. (2000). Hypotheses about online psychotherapy and clinical work. Retrieved from http://www.rider.edu./~suler/psycyber/workinghyp.html

Turkle, S. (1995). Life on the screen: Identity in the age of the internet. New York: Simon & Schuster.

Whittle, S. (2006). A Future for Online Gender Identity Care Services? An Opinion. Retrieved 6/25 2006 from HBIGDA website http://www.wpath.org

Zack, J. (2007). Ethics. Retrieved May 18, 2007 from Etherapylaw website http://etherapylaw.com/?page_id=10

Filed under: Psychotherapy on August 15th, 2007