Globalization, Mental Health Ethics, and Woody Allen

Three words in an article about outsourcing in yesterday’s New York Times got me thinking about globalization, mental health ethics, and Woody Allen.

The article predicts that consumer services will be the next wave of offshoring, using tutoring and personal assistant services as examples. But it quotes Nandan M. Nilekani, co-chairman of Infosys, a leading outsourcing company, as bullish about additional opportunities – “even psychological counseling.”

This is sure to happen soon. To get a sense of what is already happening enter “internet based psychological counseling” in your favorite search engine and look at the sponsored links. Counselors are actively marketing themselves and their services. Prices are posted clearly. 24/7 access is a major selling point.

During my psychiatry residency a patient voiced this fantasy: “You met me in the clinic, introduced yourself as ‘Dr. Sabin,’ and took me into an office. How do I know that you are not a bum off the street who put on a tie and is pulling off a hoax?” At least my patient could see me and know that I existed, whether bona fide resident or bum off the street.

As a medical student I had learned of an experiment that could never get by an Institutional Review Board now. Subjects were offered “psychotherapy” via speaking into a tape recorder. They were told that a “therapist,” who they would never meet, would listen to their recordings. At the end of the experimental “treatment” they were quizzed about outcome and feelings about their “therapist.” Many had improved and voiced positive attitudes towards their “therapist.” The web offers an ideal way to put this unethical experiment into practice.

I have used email in my work with patients (who I also see in the office) for at least ten years. Some people can express themselves more fully and listen better without face to face contact. (That is why Freud initially sat behind the couch.) For others, convenience is key. And for people with limited mobility, the Internet can be a savior.

As enthusiastic as I am about the ways in which web-based applications can support mental health practice, I worry about the Wild West ethics that will emerge. Psychiatry, psychology, social work and other mental health professions have developed robust ethical frameworks. Clinicians may not adhere to their profession’s code, but expectations are clear, and there are mechanisms for enforcement.

Not so with the web. A medium that brings together clients with depression, anxiety, and the full range of mental health problems, with invisible and unaccountable vendors of therapy, is ripe for exploitation and abuse.

Because offshore counseling services will elicit a higher level of wariness then the friendly looking U.S. based online counselors who tell us about their families and church affiliations, they may impose a higher level of quality control and transparency.

The best educators about the risks in online therapy will probably be our comedians. We can look forward to seeing what Woody Allen – the master satirist of psychotherapy – comes up with. It won't be long before comedians riff about the rights and wrongs of therapists having telephone sex with their patients!