This work is a chapter for the Academic Press book "Psychology and the Internet", edited by Jayne Gackenbach. Copyright and all rights therein are retained by Academic Press. This material may not be copied or reposted without explicit permission. (Copyright 1998 by Academic Press).
Cite as;
King, S. A & Moreggi, D. (1998). Internet therapy and self help groups - the pros and cons. In J. Gackenbach (Ed.), Psychology and the Internet: Intrapersonal, Interpersonal and Transpersonal Implications (pp. 77-109). San Diego, CA: Academic Press.
Internet therapy and self help groups - the pros and cons.
V. Therapy Online.
The use of the Internet to provide mental health services is controversial. Even the name of what to title this new field is a matter of opinion. Online therapy, cybertherapy, email therapy have all appeared in the popular press. Behavioral Telehealth is the term preferred by members of one professional organization that is currently considering the ethics of online therapy. For our purposes here the term online therapy will be used to discuss all forms of synchronous and asynchronous Internet mental health efforts, where the stated goal is the establishing of some form of therapeutic contact. There are many sites on the web that offer one time email responses to questions, for a fee. These types of services are more like a psychology talk radio program, and will not be covered here. A compilation and description of currently available web sites that offer online therapy services is maintained at http://www.metanoia.org/imhs/ by Martha Ainsworth. This site is a "comprehensive, independent consumer guide to the psychotherapists and counselors who provide services over the Internet."
Future trends in interactive therapeutic contact will most certainly utilize real time video connections. Currently, email exchanges offer an alternative that can be used to establish a transformitive relationship between a client and a therapists. People who can not or will not present for f2f treatment are availing themselves of online interactive services. The manner in which these relationships can be ethically implemented is not clear (King, 1997b). Once a professional relationship has been established, the licensed clinical psychologist or mental health professional has a responsibility to the welfare of the client It is unclear how this can be executed completely by email. A web based discussion among parties interested in the application of ethical guidelines in the providing of online therapy is facilitated by Dr. Marlene Maheu, and is available at http://cybertowers.com/cgibin/ethics_forum.cgi
Despite the ambiguous guidelines for online therapy, it has been practiced for a number of years. The following quote from 1994 succinctly addresses some of the driving forces behind the expansion of psychological services to the Internet net; "Welcome to the cybercouch, a brave new world where Sigmund Freud meets Bill Gates. Driven by a medical system that begs for cost containment, many mental health professionals are looking for ways to offer their patients more for less, and technotherapy fits the bill. Using computers as an adjunct to, or even in place of, traditional therapy for all but the most severely mentally ill, they find, not only speeds up the therapeutic process, but in some cases makes it more effective. " (Kelley, 1994).
Online therapy sites may be best suited for people who are having difficulties with daily living. Online therapy consumers are advised to be aware of several concerns, among them;
1. The therapist identity; the therapist who wishes to remain anonymous should be avoided;
2. Fees; check out the details before committing to any financial agreement;
3. Payment; to be safe with using a credit card one should give their number over the phone instead of over the Internet;
4. Security and privacy; people should try to find a therapist who uses encryption to ensure confidentiality. (USA Today, Feb. 26, 1997).David Sommers, a clinical psychologist, has provided an online email therapy service for several years. On his web page (http://nicom.com/~davids/pageone.htm) he states online therapy may be suitable for you under the following conditions:
If you have economic barriers to traditional psychotherapy, i.e., can't afford it.
If you initially want a little distance in any sort of therapeutic relationship
If you live in a remote area where therapists are not readily accessible
If you have a physical disability which makes getting to traditional therapy too difficult
If you are thinking about entering traditional therapy but first want to get a sense of what it might be like
Research is just beginning to focus on the pros and cons of online therapy, and the quality of services provided by online therapists. A recent article by Sampson, Kolodinsky & Greeno (1997) included several studies that investigated the practices of online therapists. In one study, they searched the web and found that many counselors who were offering online services did not identify their professional credentials, nor did they specify the subject area of their degree. When the practitioners degree was specified, it often was not revealed in which field the degree had been granted in. The Internet consumer user in search of an online therapist can be misled by a therapist who has an M.S. after their title, and assume that this degree is in counseling, when in fact it could be in anything. Sampson states that clients who receive information by computer tend to believe that information, and therapists are obligated to ensure the validity of the information they present to the on-line community. Another study done by Sampson et al. stated that there were 275 practitioners currently offering direct counseling services over the Internet. Sampson addresses confidentiality problems and suggests that the central issues involved are; security of data storage, unauthorized access, and the need for therapists to be educated about appropriate security measures. If a therapist is working with a client that is geographically remote, the therapist should try to be aware of the conditions that exist locally for that client which may have an impact on their relationship, such as natural disasters or political unrest. Local cultural norms vary as well, and unawareness of these differences can be problematic. "For example, a geographically remote counselor may be unaware of traumatic recent local events that are exacerbating a client's reaction to work and family stressors . . . If a counselor encounters an unanticipated reaction on the part of the client, the counselor needs to proceed slowly, clarifying the clients perceptions of their thoughts, feelings, and behavior" (Sampson, et al., 1997, p. 210). This last point is critical, the lack of f2f visual clues can engender harsh misunderstandings. The therapist can check with the client to see if their interpretation of the message was what the therapist intended. Sampson further stated that credentialing concerns are unresolved at this time, and that it is not clear how any enforcement of credentialing requirements could be implemented. One concern with using email is the potential for clients to devalue email messages appearing on their computer screen. The therapist must be alert for, and be prepared to deal with, occurrences where an intended communication is misinterpreted as the result of the lack of tonal cues in email.Using the net as an adjunct to family therapy, where there is one member geographically distant, is a viable option (King, Poulos & Engi, 1998). When making initial arrangements to use email in family therapy, the on-line therapist should secure the clients' agreement to contact the therapist if their interpretation is unsettling. An example of using the Internet as an adjunct in f2f therapy comes from the first authors experience. This case reveals the potential to help some clients in a new and innovative manner using the Internet. The client was a middle aged man suffering from a debilitating, progressive, fatal genetic disorder. Part of his presenting complaint was an inability to talk openly with his family members about the emotions he was experiencing. This client was also seen in individual sessions. Referrals to local f2f support groups for this condition were ineffective. This client was still ambulatory, and stated that going to the f2f groups discouraged him rather then helped him, because he saw there people who were more progressed in the disorder. He did not want to be reminded that powerfully of the disabilities his disease would incur. The client agreed that he could benefit from hearing about others' experiences coping with this condition, and the emotions that arose. The client had Internet access, and several of his family members were knowledgeable about email and the web. A search of the Internet found there were no online support groups for this rare genetic disorder. In cooperation with several Internet associates, a new email discussion group was created by the therapist for sufferers of this disorder. It was a general, open list for any concerned person: sufferers of this disorder, their families, and doctors treating these patients. Shortly after joining this online support group, the client started reporting in his f2f therapy sessions about events occurring in the lives of fellow online group members. The client was amazed and relieved to read that others struggled with the same interpersonal difficulties he had been experiencing. He related in therapy that having located information on the Internet regarding his disorder, and finding others experiencing the same issues as himself, provided him with information and a perspective that he was previously unaware of. By the end of therapy, the client reported that the process of sharing Internet information and online self-help with his family had "opened the door" to discussions of his own personal feelings and intense emotions.
Several populations can be identified as having characteristic that make them a good candidate to benefit from online therapy. There is obvious potential in using the Internet to assist the treatment of people with Generalized Social Phobia (GSP), Avoidant Personality Disorder (APD) or Agoraphobia (King & Poulos, 1998). Fear of embarrassment, overwhelming anxiety surrounding the missing of social cues, and the inability to risk rejection are some of the characteristics of people with GSP and APD. An obstacle in addressing these social anxieties is the fact that the solution lies somewhere in the problem. Repeated social encounters which reinforce successful interaction for the client is one of the determining factors in alleviating the anxiety and thus treating the condition. "The quintessential aspect of social phobia is that, despite the fact that an individual is made anxious by social encounters, they cannot be avoided" ( Bond & Siddle, 1996). The use of online Internet therapy is an opportunity for the therapist to communicate with the client in a manner more spontaneous than scheduled weekly visits. Both client and therapist have the option of reading and responding at their convenience. As a adjunct to the scheduled visits, online therapy provides an opportunity to participate in the client's on-going therapy. "The client gains the immediate benefit of writing out his concerns and thereby "experiences" the value of processing his anxieties under the guidance of the therapist on a more frequent basis than weekly visits would allow. The psychologist who is knowledgeable in the dynamics of Internet interpersonal relationships is in a position to encourage the client with GSP or ADP to interact with others on-line as part of the treatment plan. The professional is obligated to inform the client of the pros and cons of such interactions as they pertain to the client's recovery. The opportunity to monitor on-line groups without necessarily participating gives such clients the chance to control the incidence of potentially embarrassing social interactions while still engaging in the sense of social presence. This is one of the therapeutic goals for these types of disorders. Using the Internet as a means of acquiring new social skills can raise the self-esteem and confidence of this population and result in their being more willing to engage in non-Internet situations." (King & Poulos, 1998 p. 31).
Resources and educational information which therapists have either located or actually created on the WWW can be shared directly with clients. Clients with hearing impairments can participate in text-based chat counseling sessions, and blind clients who might not otherwise get services can use audio applications (Kirk, 1997). Until more empirical data on email therapy is available, therapists need to proceed slowly and assist one another in evaluating their cases to ensure that clients are receiving quality care. The use of email by therapists to consult with each other, and other mental health professionals, is a growing practice. This creates a broader population of online professionals to consultant with, and provides a means of specialized referrals and the exchange of hard to find information. The opportunity for therapists to consult with others disciplines, such as medical doctors, becomes more readily available when done by email. These benefits of using advanced communication technology in clinical practice open up new ways of providing quality care to clients.
An interesting aspect of online therapy is the dynamics of the use of computers. People who do not type are excluded. People from a low SES background are not going to have the resources to invest in a home PC. There are factors that make sitting alone at a computer screen an experience far different from f2f therapy. In an article titled "Virtual Psychotherapy?" Fred Cutter (1996) states; "Additional factors are the implicit permission granted by the monitor or television set. Television folkways over the last 50 years in the USA have built up an expectation that it never hurts and always provides the viewer with pleasure in a non-demanding way. These regressions would be worthy of analysis and working through of defenses as in the mode of traditional psychotherapeutic interpretations." (Cutter, 1996).
V. A. Clinical Concerns of Online Therapy.
The "hyperpersonal" aspect of computer mediated communication has been explained as the manner in which people "selectively" present themselves and then are "selectively" responded to. On a positive therapeutic note, this hyperpersonal manner of communication can create an environment where a client can more easily present a salient therapeutic issue. Because the communication is selectively presented, the client can bring a personal, or psychological problem, to the online therapist earlier on in therapy, or in more detail, than in f2f therapy. The embarrassment factor is less salient for the client. For example, a client being counseled for a relationship problem may be more inclined to express a concern like an erection problem, because the potential for embarrassment is well below that of f2f contact. In this way this hyperpersonal aspect of online therapy can further the therapy process, and bring to the surface salient issues faster for the client The disadvantage of this type of communication is, because the communication is selective, a client can also do the opposite and avoid salient material. A client can omit crucial information about themselves, their problems, and their feelings, making it almost impossible for the therapist to know, or detect, a resistance to disclose. The potential for the therapist to pick up on the clients resistance, which is often detected in nonverbal behavior, such as looking away, shifting in a chair, and other body language, imposes a handicap that therapists must face.
When a client presents for treatment one of the first things that a therapist does in the initial diagnostic interview is a mental status exam. A mental status exam is based on visual clues such as; the manner in which a client is dressed and groomed; an assessment of their rate and tone of speech; their orientation to time, place, and person; the clients thought content; the appropriateness of their eye contact; and an assessment of any existing odd mannerisms. Components such as thought content and flow of ideas can be assessed through a text based communication, however, these other aspects, particularly those that are done visually, can not be assessed by an online therapist. This handicap severely limits online therapists ability to accurately diagnosis the clients overall presentation, as well as their initial presenting complaints. This further exacerbates problems in developing a treatment plan and assessment of appropriate treatment. It is also worth noting that it is important for therapists to realize and accommodate for the lack of face to face presentation that a client is receiving from the therapist. For example, is the therapist coming across in an empathetic and supportive manner? How can this be assessed?
V. B. Survey data.
In the fall of 1996, the first author posted a survey to the web that was designed to anonymously solicit information from providers and from consumers of online therapy. This research was approved by the institutional review board of Pacific Graduate School of Psychology for it's ethical use of human subjects. The survey ran from October 1996 through April 1997. Participation was solicited by sending email to online providers that were found by searching the web. They were requested to direct their clients to the survey for consumers of their services. Valid responses were received from 30 providers and 35 consumers. A complete description of the statistical analysis of the data from this survey is beyond the scope of this chapter, but results are presented here that highlight the major findings.
Consumers reported seeking help for a wide range of problems, from Dissociative Identity Disorder to depression or family problems. Over 75% responded "yes" to the question "Do you feel your online therapist truly cared about you?" Nearly 70% reported that the service was worth the cost, even though some paid as much as $100 for 5 email messages from the therapist. One person was charged 50 dollars an hour. The average rating of therapist was 6, on a scale of 1 to 10, with 10 being the highest level of satisfaction. In just over half the cases the consumer was given the recommendation to seek local professional help for their problems. One 16 year old female who identified herself as having a diagnosis of Dissociative Identity Disorder, a severe psychological disorder, stated she lived over 60 miles from the nearest f2f therapist and was very satisfied to fine help online.
The convenience of this method was the most often cited reason for choosing online therapy. Additional comments from consumers concerning the pros and cons of the service they received included the following;
"I live in a remote area with no immediate support group and I just moved here so I am all alone."
"Positive- writing caused me to organize thoughts. Negative-slow give and take"
"I have a hard time trusting someone I can't see"
"the anonymity of this method"
"In a manner of speaking, Chat rooms are effective Role Playing environments and one can explore to find the Jungian definition of truth as well, just by typing honestly, ..."
"don't have to worry what the person is trying to understand"
"it was more comfortable for me"
"minimal contact means a minimum of information. strong possibility of self-editing by the receiver..."
"I was able to express my anger in front of my regular therapist after practicing with the Internet therapist."
"to enhance my present in person therapy and deal with anger issues in a safe nonthreatening way"
"it was easier to talk about some things when the therapist was not physically present."The providers of online therapy answered a different survey questionnaire that assessed such items as their background. Answers to this question included the following responses;
Marriage and Family Certified Counselor
licensed psychologists
Masters level doctoral student
Attorney
extensive research in depression, mental illness and neuro anatomy pharmacology, etc etc
None at all
none, the peer counselors in this organization help others with their own personal experience or ideas
trained crisis counselor
other masters' level degree
Licensed Mental Health Counselor
board eligible psychiatrist
rape crisis counselor; survivor of various forms of violenceWhen providers were asked if they had any ethical concerns about providing therapy online, the following were some of the responses given;
"the basic ethical concern of "do no harm." I *strongly* believe that this medium is not conducive to "therapy." The therapist can not be available for emergencies. The therapist is not able to do a complete assessment which must include a mental status"
"I provide PGP encryption. I check before I send a reply to a shared email box. I warn that employers may read mail, and advise people to delete messages."
"1. Email is all self-report which may be biased by client skills in writing and self-expression; 2. increased possibility of deception by clients because of no face to face contact slients"
"The potential for misunderstanding or miscommunication at either end of the communication."
"privacy. I won't provide "therapy", I will provide expertise/opinions"
"Although I never give any specific advice without also advising face to face counseling with a professional, there is less chance to respond to feedback in the cases where I might be misunderstood."
"Not knowing whether the person received the reply. Being able to respond in a timely manner."
"Ethical , licensing, legal, malpractice, what to do if the subject reported suicidal ideation, etc. Have done nothing except very general supportive counseling and urged the person to seek professional help"V. C. Ethical concerns.
There are considerable legal, ethical and professional issues in providing mental health services via the Internet. There is no governing body that can monitor the quality of care provided online, or the competency of the professionals providing treatment. The lack of guidelines for providers is of concern for several reasons. "A poorly informed consumer in crisis who has a history of mental health difficulties will be an easy target for incompetent or fraudulent Internet counseling service providers" (Sampson, 1997). More harm may be done to the consumer then good, especially if marketing considerations take precedence over clinical, legal, and ethical considerations.
There are disorders that present with symptoms that should automatically preclude the use of text based therapy. The National Board for Certified Counselors, Inc. (NBCC) has developed a set of standards for the ethical practice of what they call WebCounseling, (posted at http://www.nbcc.org/wcstandards.htm) The standards include this one, "Webcounselors need to mention at their websites those presenting problems they believe to be inappropriate for WebCounseling. While no conclusive research has been conducted to date, those topics might include: sexual abuse as a primary issue, violent relationships, eating disorders, and psychiatric disorders that involve distortions of reality."
Suicidal ideation would seem to fit in this category too. This does not mean that an online therapist should automatically turn away anyone presenting with suicidal ideation. If a suicidal person was unable to utilize any form of f2f intervention, then online therapy may be the last resort. The Samaritans is an organization that works with suicidal people. In England, they have a program set up to receive anonymous emailings from depressed, suicidal people. Their initial reply to inquires about their services states "Callers are offered absolute confidentiality and do not lose the right to make their own decisions (including the decision to end their own lives)." The reference to how e-mail anonymity has helped the Samaritans efforts is indicative of the differences between Internet suicidal ideation's and that of more traditional settings. On the Internet, the exact location of the poster is usually unknown. A suicidal member of an online forum can type their intentions to kill themselves and be assured that it would take a considerate effort on the part of the readers of that note to intervene. Such interventions have occurred, as news reports indicate. It is not know if the anonymity makes the such declarations of intent more likely to occur
.
Sagan (1995) states "...self given 'fictional' names are the ruler rather than the exception online" (p. 78). The Internet provides an arena where an individual can create a personality character, not unlike a writer imagining the main character in his new novel. The difference is that you have to be consistent in your deception and imagination if you want to be taken seriously by others. Non commercial Internet Service Providers (IPO's) are used mostly by an academic and professional population. The commercial IPO's, which sometimes provide content for members only, have a much larger percentage of women. It is in these non-professional forums that the highest frequency of deception occurs. An example of the concerns that are set forth by this gender imbalance among Internet users is the online services to populations such as survivors of sexual abuse.Finn & Lavitt (1994) note that group therapy has become uniquely suited to the clinical needs of survivors of childhood trauma. Group therapy is helpful in facilitating the development of trust, the recovery of lost memories, and providing an opportunity for survivors to have a shared experience. Childhood sexual victimization creates a plethora of adult symtomology, ranging from diagnosis such as Dissociative Identity Disorder to anxiety and depression. Mental health professionals that specialize in the area of treating sexual abuse survivors have come to recognize that self help groups can often serve as an adjunct to, or substitute for, individual treatment. Although self help groups do not replace professional expertise, their ability to provide personal growth and development of quality of life experiences can be invaluable for both the survivor and the therapy process. Considerable research has been done in defining the type of help that self help/mutual aid groups provide. A number of benefits that have been identified include; sharing ideas and resources, participating in dialog to see different sides of an issue, disclosing what is considered to be 'taboo' subjects, the feeling of not being alone with the experience of tramatization, over coming alienation and isolation, the development of inspiration and hope, and developing social networks (Finn, et al., 1994;). Most women, who have a sexual abuse problem, and are seeking help online, use a commercial service where being deceived is a risk. It is important for psychologist and mental health workers to understand the nuances of online interactivity, so that they can best help a client who is involved with others online. The responsibility of protecting this particle type of population from further abuse falls on the shoulders of online professionals that are involved in working online with sex-abuse victims.
A recent article in the APA Monitor conveyed the concerns of behavioral telehealth providers. It was noted that many clinicians, including telehealth enthusiasts, feel that there is difference in the quality of treatment conducted online compared to f2f treatment (APA Monitor, Aug., 1997). Most of these differences stem from the lack of face to face contact. Video-conferencing is considered to be the future in bridging this gap (Holmes, 1998). Video technologies can provide a visual communication, but the effectiveness, and/or therapeutic value of these techniques for the delivery of psychological services has not been systematically studied to date.
The International Society for Mental Health Online (ISMHO) was formed in 1997 to promote the understanding, use and development of online information and technology for the international mental health community. This is a new organization, open to all interested parties. See http://www.cmhc.com/ismho/ for information on this organization. Below is the list of initial goals, as stated in the ISMHO charter;
2.1 The purpose of the ISMHO is to promote the understanding, use and development of online communication, information and technology for the international mental health community. To achieve this purpose, the activities of the ISMHO shall include:
2.1.1 Aid and stimulate mental health professionals and others in the development of new online technology and applications.
2.1.2 Educate mental health professionals and others about existing online information and communication technologies and applications.
2.1.3 Explore and develop the use of computer assisted communication in the work of mental health.
2.1.4 Highlight endeavors by members consistent with the goals of the Society.
2.1.5 Provide online discussion forums and news concerning the work of mental health online. 2.1.6 Develop standards for online interactions between mental health professionals and consumers.
2.1.7 Help coordinate technological efforts amongst its members.
2.1.8 Work to stimulate grants and other funding for the development of information and communication systems and technologies specific to mental health online.
2.1.9 Promote the development of online databases of information, information and communication tools and software which are easily accessible to all mental health professionals and which will serve to advance the profession and discipline of online mental health and research.
2.1.10 Encourage other professional societies, associations and interest groups to allocate resources to the investigation, development and promulgation among mental health professionals of online resources and online technologies.
2.1.11 Provide advice to legislative bodies and governmental agencies concerning the use, potential limitations, needs and benefits of online resources which have been formed with significant input from its members.
2.1.12 Promote information and education on confidentiality, privacy, pseudonymity, and anonymity issues online.V. D. Diagnostic Considerations.
Text based communication has the potential to be misleading and misunderstood. For example, just as borderline personality disorder has often been over diagnosed f2f, in the presentation of neurotic like symptoms, especially among woman, the same can occur online. One symptom of a diagnosis such as histrionic personality disorder is the use of exaggerated language and grandiose choice of words in f2f communication. Displaying this symptom online could be perceived as the individual being better educated, or even gifted, by their prophetic written communication. A worse misinterpretation would be for someone who was in fact shy in f2f communication, but a gifted writer or perhaps poet, and this person may be misdiagnosed as histrionic. One might argue what is the difference? The difference is three fold. First, having a histrionic presentation is obviously seen as a life long dysfunctional and self destructive way of communicating ones emotions. A diagnosis of a personality disorder is a severe one to make on any individual. To quickly label someone with such a diagnosis would be considered premature, unethical and unprofessional. Second, a person who had a gift to communicate in a written word could be judged as being pathological because the communication, and the only communication, that is being scrutinized is the written text. Third, on a more positive note, if the client was in fact shy or inhibited in there ability to communicate socially in face to face interactions, yet could communicate through a text based arena, this would present as a good target for treatment. Not only could the client have some way of communicating their thoughts and feelings in an environment that they feel safe in, the treatment goal of helping them with their face to face communications can be explored early on in treatment, or more aggressively
Having a mental illness often goes hand in hand with poor decision making and poor judgment. A man with a psychotic disorder is not expected to make sound decisions on his own at any given moment, due to symptoms such as delusions and hallucinations. Anyone seeking help for psychological distress should not be criticized or judged to be the cause of the difficulties or circumstances, and professionals must aspire to address a clients concerns with empathy and care. To misdiagnose a mental disorder almost always means that a misinterpretation of the appropriate treatment. The field of psychology uses the diagnostic guidelines outlined in the DSM-IV as a standard criteria for diagnosing all known psychological disorders. It is not unheard of for a client with schizophrenia to be misdiagnosed with bipolar disorder at any given point throughout their illness. When it comes to treating psychological disorders online, these types of misinformed judgments can be further exacerbated.
The limits of the Internet need to be discussed with potential clients. Clients should be informed that online communication is not completely secure. Email communications often leave a permanent record. It is easy to save notes to a file. There is a greater potential for therapist/client communications to fall in to the wrong hands. It is also true that "...in some cases the Internet can be *more* confidential -- the patient is never seen entering a psychologist's office. The anonymity and privacy of Internet communications are features that encourage some persons to seek needed help via the Internet, who are reticent to do it any other way. Although much hype is created in the media about Internet security, the practical fact is that in over a decade of communicating online, neither I nor anyone I know has ever had an e-mail intercepted by other than its intended recipient." (Ainsworth, 1996)
An example of the type of services currently being provided is given here;
From http://www.halcyon.com/drburck/welcome.htm"We at OnLine Counseling Service understand ourselves as a clearing house for people who - for whatever reason - dare not make the first step into the healing process on their own, who fear stigmatization and prefer anonymous contact as a first step towards comprehensive therapy. We do not offer therapy but offer our knowledge and training to provide guidance in a "pre-therapeutic" environment by empowering you to make an informed decision about the resources available and help you to find the therapy forms tailor-made for your special needs. We are open for all your questions, and the anonymity of the Web is your protection. We are a team of dedicated individuals - students, teachers and professionals - who devote their time, effort and expertise. For a small fee to cover our expenses, we will assist you along your difficult way. However, the services we offer are NOT intended to replace direct consultation with a licensed professional. First contact and consultation will be free of charge. "