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Jewish World Review Sept. 4, 2001 / 15 Elul, 5761

Michael Long

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Internet-based psychiatry may mean relief for those who have shunned treatment -- MENTAL ILLNESS hurts. Unless one has personally experienced it, the pain and embarrassment is mostly unimaginable; a broken arm or a debilitating physical condition is quite apart from suffering that is invisible to the outside world. Disrupted thinking, irrational ideas, overwhelming tides of emotion-inside, they are crippling; but from the outside, they are frequently dismissed as weakness. And those affected are often caught in a cruel trap: the primary lay prescription is to "get your mind on something else," and the stigma attached to seeking professional assistance amounts to a sentence to suffer alone.

But today, psychiatric researchers are exploring a significant hope for connecting individuals in need with a new kind of help.

Dr. Daniel Z. Lieberman is assistant professor of psychiatry and behavioral science and director of outpatient psychiatry at the George Washington University Medical Center in Washington, DC. He is one of a few physicians and researchers using the Internet to expand the capabilities-and lower the cost-of psychiatry for those who have been previously unwilling or unable to take advantage of it.

"The Internet reaches people that the current system is unable to reach," says Lieberman. "Seventy percent of all mental illnesses go untreated. But this technology can help those people."

Internet psychiatry is, Lieberman says, potentially "dirt cheap." While a clinician charges upwards of $100 per hour, the cost of computer-assisted service is only about $1 per hour. In addition, access is available around the clock. And the Internet provides a level of anonymity previously unknown-a strong incentive for seeking help, given the age-old stigma associated with seeing a mental health professional.

So far, procedures focus mostly on identifying problems and gauging their severity, thus giving prospective patients information about the problem they may have, and encouragement to seek treatment. But some practitioners are moving toward the ultimate goal: online treatment. They are experimenting with interactive "therapy" via instant message and email, though the limits of current technology make that process at best only a substitute for face-to-face contact.

"When you exchange thoughts in written form, you lose an enormous amount of expression of mood," says Lieberman, noting that non-verbal cues in a conversation are often key in discerning a patient's problem. "The average person is not going to be able to communicate in writing what they would in person."

Anecdotal evidence is promising-some success has been seen among those whose travel prevents regular therapy visits-but there have been no controlled studies. Still, one U.S. insurance company has already agreed to pay for "therapeutic" email exchanges at the rate of $25 per iteration-only one-sixth to one-fourth the cost of an hour of traditional therapy, but in line with the typical (and paltry) co-payment for face-to-face sessions.

Lieberman's Internet research focuses primarily on addictions. His website,, is aimed at individuals concerned about their drinking habits. Based on their responses to a series of questions, users receive a personalized, text-based analysis of their drinking habits. Unlike online "quizzes," these questionnaires have been validated in scientific settings to ensure that their results follow the "gold standard" of a clinical interview performed by a trained professional.

This kind of diagnostic support and analysis is near the peak of the capacity of mainstream technology found in the home. However, the power of many psychiatric techniques rests in the trusting relationship that forms between a doctor and patient. So Lieberman sees psychiatry-at least for more than the simplest cases-remaining a real-time, interactive process requiring human contact. But, he notes, a fašade of humanity may someday be good enough for online treatment-if the fašade is real enough.

Computer-generated images are key to creating that virtual experience; recent advances have led to on-screen images that are indistinguishable from photographs of faces. In addition, AT&T's "Natural Voices" program, announced in July, includes a text-to-speech engine touted to completely and accurately reproduce natural human speech, free of the awkward aural ticks and gaps that mark current technologies. If scientists can perfect the sights and sounds of the therapy experience, the conversion of theories to computer code will be the last great hurdle.

"Being able to talk to a computer-that's much more inviting than filling in blanks. And it's going to have to be a part of the field," says Lieberman. It may also be the hallmark that brings HMOs and insurance providers to the table, using computer "visits" to screen for conditions whose treatments require personal contact with a physician. Such computer-based assistance may even administer "cures" in some cases, though Lieberman does not foresee such possibilities for at least half a decade.

Internet psychiatry represents the possible mainstreaming of a valuable discipline that for too long has been shrouded in rumor, innuendo, and myth. Ironically, the availability of high-quality treatment administered anonymously and in the home may create greater acceptance among the public at large of the reality of mental illness. This in turn would help lift the stigma that stops many individuals from seeking the help they need. Such welcome results will come from the power of evidence-the simple good news that people who need help are finally getting it.

JWR contributor Michael Long is a a director of the White House Writers Group. Comment by clicking here.


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© 2001, Michael Long