Net losses: What are the downsides of online therapy for problem gamblers and clinicians?

In my last blog, I briefly looked at the advantages of online therapy. However, the growth of online therapy is not without its critics. I may have given the impression in my previous blog that online therapy has nothing but positive implications. However, this blog briefly examines some of the main criticisms that have been levelled against online therapy. This loist is not exhaustive but hopefully covers the key concerns:

  • Legal and ethical considerations: As Internet counselling services grow, attention will have to be focused on the specialist construction of a legal and ethical code for this type of work. Cyberspace transcends state and international borders, therefore, there are many legal and regulatory concerns. For example, client/doctor confidentiality regulations differ from one jurisdiction to another. It may not be legal for a clinician to provide chat-room services to problem gamblers who are in a jurisdiction in which the clinician is not licensed. Furthermore, some problem gamblers may be excluded from telehealth services because they lack the financial resources to access the Internet. One potential ethical and legal dilemma is the extent to which service quality can be ensured. It is possible that individuals who register to provide counselling services online do not have the qualifications and skills they advertise. They may not even be licensed to practice. There are also issues regarding the conduct of practitioners engaged in all forms of telecommunication therapy. For example: issues of informed consent, the security of electronic medical records, electronic claims submissions and so forth. Therapy provided over the Internet holds promise but there is a need to check that it works and see to it that, if it is done then it is done well. Underlying guidelines that are applicable to all forms of counselling are that: (i) the therapist must be trained, supervised and accountable with qualifications that can be checked against a list held by a mainstream organisation, and (ii) the nature of the contract between client and practitioner must be spelled out so clients understand the boundaries of what they are receiving for what they are paying.
  • Effectiveness of online therapy: There are a growing number of evaluation studies that have examined whether online therapy is an effective treatment approach. With specific regard to problem gambling, my research colleague Dr. Gerry Cooper reported that about 70% spoke of how they benefited from their exposure to and involvement with GAweb, an online peer support group. An evaluation that I carried out with Dr. Richard Wood of Gam-Aid also showed that participants derived great benefit from using the online service and was particularly attractive for problem online gamblers (that are already comfortable with interacting online).
  • Confidentiality: Online therapy may compromise privacy and confidentiality, particularly if a skilled computer ‘hacker’ is determined to locate information about a particular individual. There is also some evidence that as more personal information is required of counselling sites online, the attractiveness of these sites is reduced. On the other hand, one of the things that the Internet is especially helpful with is its ability to afford the consumer the control over self-disclosure. In this way, individuals may overestimate the degree to which their information is safe and secure from computer hackers.
  • Encryption: No online therapist can confidently promise a problem gamblers confidentiality given the limitations of the medium. That being said, there are some sites that now offer secure messaging systems that offer the same level of protection as banking institutions. To protect confidentiality, care will have to be taken to prevent inappropriate and deliberate hacking into counselling sessions on the Internet. There will need to be a continuous upgrading of technology to stay ahead of hackers’ ability to breach security.
  • Complicated payment structures: Given the cross-national nature of the Internet, there may be complicated pay structures for problem gamblers to overcome when selecting a therapist. While universally-accepted credit cards might actually make payment easier (since one can use their credit card online and the credit card company will automatically calculate the currency exchange for the transaction), one may not immediately understand how much the online counselling has cost in their own currency. They may not know this until their credit card invoice arrives at a later date.
  • Cost-effectiveness to the therapist: For the therapist, there is the problem that online counselling may be as time consuming as face-to-face therapy with substantially less financial remuneration.
  • Identity problems: One of the major potential problems is that online problem gamblers may not be who they say they are, i.e., counsellors may not always know the true identity of their online clients (although identity is an issue only applicable to those services that are not anonymous). This is clearly a major issue since some assumptions (rightly or wrongly) are made by the clinician depending on what the problem gambler presents (including age and other demographics). However, to some extent, these issues also apply to telephone and face-to-face counselling as the therapist has to accept what is said at face value. Additionally, some might argue that merely responding to the words that a problem gambler chooses to use necessitates more focus on the part of the therapist. As a result, this may lead to a more democratic counselling environment. In other words, the role of therapist and problem gambler becomes more equal in this situation. Some therapists may have difficulty adapting to these new roles.
  • Severity of client problems: Some clients’ problems may be just too severe to be dealt with over the Internet. To some extent, there can always be contingencies, but because people can come from anywhere in the world and have a multitude of circumstances, online clinicians may be hard-pressed to meet everyone’s needs. It is important to acknowledge that this is not a panacea; that online help will not solve everybody’s problems (to be sure, those who are illiterate will likely have a difficult time of it without some additional support nearby). On the other hand, it is likely to go a long way in helping a great many more people than otherwise would have been the case.
  • Client referral problems: One obvious difficulty for the counsellor is how to go about making a referral for someone in a faraway town or another country. Once again, one would need to establish basic contingencies. Over time, it could be expected there would be many more international-regional clearinghouses regarding where to get immediate assistance, but to date it is very difficult to know what services are available for many parts of the world.
  • Establishing client rapport: It could perhaps be argued that there might be difficulty in establishing rapport with someone that the therapist has never seen. This is an interesting area where clearly more information is needed. One might also argue that because the problem gambler is in a more equal relationship with the therapist, they will feel more comfort. That is, since the problem gambler controls all of the personal disclosure levers, rapport might be established much more easily.
  • No face-to-face contact: Online therapy leads to a loss of non-verbal communication cues such as particular body language, voice volume and tone of voice. Furthermore, the lack of face-to-face interaction between problem gambler and therapist could result in a wrong referral or diagnosis. What is known about online communication where cues are filtered out, is that it typically takes more work to accomplish a task where more than one person is involved. It may be the case that with time and experience, therapists who work online will develop skills that will help them compensate for the absence of visual cues. For example, they might become much more skilled and precise with the words they choose to use.
  • Incomplete information: The written information provided in online therapy may be incomplete. Online therapy (via e-mail) may not allow the opportunity for immediate follow-up questions. Making a provisional recommendation or diagnosis is fraught with potential problems. For instance, a problem gambler may describe problems that are symptomatic of other more serious underlying disorders. However, diagnostic processes are quite heterogeneous practices even in face-to-face settings. Diagnoses are often provisional and therapists usually require more information to validate initial observations. In fact, clinicians might have better access to their clients through e-mail than trying to track them down face-to-face or exchanging telephone answer messages, should they need further information. Still, the information derived from problem gamblers in online formats may be unverifiable, more so than in face-to-face contexts.
  • Loss of therapist contact: Although perhaps more of a possibility than a reality, therapists can just ‘disappear’ only to re-emerge weeks later saying that their server failed and/or leave a problem gambler mid-therapy with little that the problem gambler can do about it. The same problem could occur with some clinicians in face-to-face settings although being online may be more of a problem in finding out what has happened.
  • Commercial exploitation: Consumers theoretically are not always as anonymous as they might think when they visit health sites because some sites share visitors’ personal health information with advertisers and business partners without consumers’ knowledge or permission. Some sites allow third-party advertisers to collect visitors’ personal information without disclosing this practice. As a result, visitors may get e-mails from advertisers about their products and services. Information can be collected during a variety of tasks including the visiting of chat rooms and bulletin boards, searching for information, subscribing to electronic newsletters, e-mailing articles to friends or filling out health-assessment forms. This allows third parties to build detailed, personally identified profiles of individuals’ health conditions and patterns of Internet use. In relation to gamblers, this is a real issue. By virtue of posting to places where problem gamblers talk to each other online with an accurate e-mail address shown, online gambling operators have the potential to collect such information in order to later send junk e-mail promoting their gambling websites. Other questionable and fraudulent marketing practices by online operators have also been outlined in my previous blogs.
  • Emergency situations: Being online and geographically distant has the potential to cause problems in an acute situation. For instance, if a clinician does not know where a problem gambler lives or can be located, they cannot call for help in the case of an emergency such as a suicidal threat.
  • Convenience: Although convenience was outlined as an advantage in the previous section, it can also have a downside. For instance, it may mean that the problem gambler is less likely to draw on their own existing coping strategies and use the online therapist as a convenient crutch (something which is actively discouraged in face-to-face therapy).

Hopefully this blog has redressed the balance of my previous blog on the positive benefits of online therapy. Anyone that seeks online advice, help, and/or treatment needs to carefully do their own cost-benefit analysis as to whether such an online service will be of direct benefit to them after taking into account some of the disadvantages outlined here.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bloom, W. J. (1998). The ethical practice of Web Counseling. British Journal of Guidance and Counselling, 26 (1), 53-59.

Connall, J. (2000). At your fingertips: Five online options. Psychology Today, May/June, 40.

Griffiths, M.D. (2001). Online therapy: A cause for concern? The Psychologist: Bulletin of the British Psychological Society, 14, 244-248.

Griffiths, M.D. (2005). Online therapy for addictive behaviors. CyberPsychology and Behavior, 8, 555-561.

Griffiths, M.D. (2010). Online advice, guidance and counseling for problem gamblers. In M. Manuela Cunha, António Tavares & Ricardo Simões (Eds.), Handbook of Research on Developments in e-Health and Telemedicine: Technological and Social Perspectives (pp. 1116-1132). Hershey, Pennsylvania: Idea Publishing.

Griffiths, M.D. & Cooper, G. (2003). Online therapy: Implications for problem gamblers and clinicians, British Journal of Guidance and Counselling, 13, 113-135.

Rabasca, L. (2000). Self-help sites: A blessing or a bane? APA Monitor on Psychology, 31(4), 28-30.

Segall, R. (2000). Online shrinks: The inside story. Psychology Today, May/June, 38-43.

Wood, R.T.A. & Griffiths, M.D. (2007). Online guidance, advice, and support for problem gamblers and concerned relatives and friends: An evaluation of the Gam-Aid pilot service. British Journal of Guidance and Counselling, 35, 373-389.

Wood, R. T., & Wood, S. A. (2009). An evaluation of two United Kingdom online support forums designed to help people with gambling issues. Journal of Gambling Issues, 23, 5-30.

About drmarkgriffiths

Professor MARK GRIFFITHS, BSc, PhD, CPsychol, PGDipHE, FBPsS, FRSA, AcSS. Dr. Mark Griffiths is a Chartered Psychologist and Professor of Behavioural Addiction at the Nottingham Trent University, and Director of the International Gaming Research Unit. He is internationally known for his work into gambling and gaming addictions and has won many awards including the American 1994 John Rosecrance Research Prize for “outstanding scholarly contributions to the field of gambling research”, the 1998 European CELEJ Prize for best paper on gambling, the 2003 Canadian International Excellence Award for “outstanding contributions to the prevention of problem gambling and the practice of responsible gambling” and a North American 2006 Lifetime Achievement Award For Contributions To The Field Of Youth Gambling “in recognition of his dedication, leadership, and pioneering contributions to the field of youth gambling”. His most recent award is the 2013 Lifetime Research Award from the US National Council on Problem Gambling. He has published over 600 research papers, four books, over 130 book chapters, and over 1000 other articles. He has served on numerous national and international committees (e.g. BPS Council, BPS Social Psychology Section, Society for the Study of Gambling, Gamblers Anonymous General Services Board, National Council on Gambling etc.) and is a former National Chair of Gamcare. He also does a lot of freelance journalism and has appeared on over 2000 radio and television programmes since 1988. In 2004 he was awarded the Joseph Lister Prize for Social Sciences by the British Association for the Advancement of Science for being one of the UK’s “outstanding scientific communicators”. His awards also include the 2006 Excellence in the Teaching of Psychology Award by the British Psychological Society and the British Psychological Society Fellowship Award for “exceptional contributions to psychology”.

Posted on September 18, 2014, in Addiction, Compulsion, Cyberpsychology, Gambling, Gambling addiction, I.T., Internet addiction, Internet gambling, Obsession, Online addictions, Online gambling, Psychology, Technological addiction, Technology and tagged , , , , , , , , . Bookmark the permalink. Leave a comment.

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