determine whether a patient needs additional help.

Burtonsville, MD.-based Headworks.com peppers its Web site with disclaimers warning potential clients that if they experience symptoms of more severe conditions -- fatigue, loss of appetite, deep depression -- they would be better off making an appointment with a traditional therapist. Another prompt -- "If you are feeling suicidal, click here" -- directs Web surfers with more severe symptoms to the nearest emergency room.

Richard Sansbury, of Headworks, reports "Because there's no tone of voice or strategic pause to leaven the message, certain emotional disorders, like paranoia, could actually be made worse in text-only therapy, he said. With all those fears and self-doubts, paranoid people are going to be translating every written word into a criticism or an attack."

Speyer's related, "The first reply is the hardest to write because you are just putting stuff out there," he conceded. By the second message he had honed in on more core concerns.  But however carefully Speyer deconstructs his client's words, without a face-to-face meeting it can still feel like something is missing from the dialogue. The incomplete picture that results from online therapy can be dangerous, says Sharon Levander, a Los Angeles-based psychotherapist who toyed with the idea of e-therapy but decided against it. "When they come to you about a specific issue, there's often an underlying problem that needs to be addressed," she said.  Or worse, says Bloche, e-therapy could act as a sugar pill to the suicidal or homicidal, who very often aren't able to acknowledge when there is a problem. "I think people are going to get killed," he said.

There have been no reports of fatal e-therapy malpractice yet. But one online patient has come close, according to a recent report on the medical news Web site WebMD. A woman who was diagnosed with a multiple personality disorder decided to seek help online because she was reluctant to admit the severity of her condition, the report said. Through a chat group, she found someone who claimed to be licensed in two states, and continued counseling with him over several months. He told her things that she wanted to hear and made it easier for her to deny her illness, but she was getting worse, and eventually took an overdose of tranquilizers. When she recovered, she decided to look into her e-therapist's credentials and discovered he wasn't licensed to practice anywhere.

Even if an e-therapist has extensive credentials, for people with severe mental illness, "assessment and judgments are just beyond the capability of online doctors," said Bloche. He fears the day e-therapy gains more official recognition. Private and public health coverage is scant enough for the mentally ill, he says. "Anything that allows the government to rationalize doing even less to get people proper treatment and keep them out of the system is going to hurt society," he warned.  Instead, says Ainsworth, e-therapy is best left for people who suffer the normal losses and changes in life: relationships ending, parenting concerns and work stresses.
© 2007 The Washington Post Company