E-therapy, the provision of mental health treatment through the Internet, poses many risks as well as benefits. This article addresses some relevant risks and benefits of e-therapy and discusses the practicality of using computers in the informed consent process. Although e-therapy has numerous proponents, no clinical trials have assessed its long-term effectiveness. To limit liability and to protect patients, e-therapy providers should disclose material risks as well as possible benefits and engage patients in an active dialogue. A thorough informed consent procedure enables patients to make an educated decision about whether e-therapy is right for them. In the future, e-therapy and informed consent online may become more common; in the mean time, clinicians must be prepared for e-therapy's uncertain legal status and allow . patients to decide for themselves whether or not to seek counseling on the,' Internet.
Advances in communication technology have begun to influence the physician-patient relationship and change the face of modern treatment. This change has manifested itself, in part, as e-therapy: the provision of mental health services over the Internet. Because e-therapy is a relatively new form of treatment with unique risks and benefits, this article describes some model content for informed consent between the e-therapy provider and patient.
While e-therapy may seem new-fangled, in that it utilizes the Internet for clinician-patient communication, its roots in correspondence therapy date back to the early days of medicine and psychotherapy. During the seventeenth and eighteenth centuries, physicians often relied on patients' written descriptions of symptoms, rather than on physical examinations, to make diagnoses (Spielberg, 1998). Freud corresponded with patients through letters, and some commentators note the historical link between correspondence therapy and modern-day e-therapy (Pergament, 1998). Some e-therapists also offer "snail mail" correspondence therapy (Therapy Session Website, 2004; Dr. Franklin Online, 2004). Despite e-therapy's antecedents, treatment through the Internet carries unique risks and benefits that warrant informed consent.
Scholars have compared e-therapy to radio psychology and advice . columns (Pergament, 1998; Shapiro et al 1996), and some analogize ; e-therapy to the practice of media psychology, in which mental health experts offer advice and commentary to a public audience, sometimes responding publicly to queries by audience members (Pergament, 1998; Shapiro et al 1996; McCann, 2002). Because media psychology is commonly accepted as a form of entertainment rather than clinical treatment, no provider-patient relationship exists between a radio psychiatrist and an individual who calls in to discuss his problems on the airwaves. Further- ; more, media psychologists "are the only clinicians allowed to practice outside of an established professional relationship" (Shapiro et al 1996), , and they are not held to the same ethical standards as those followed by psychotherapists (APA, 2003). However, unlike media psychologists, e-therapists regard themselves as providing therapy and not entertainment (Pergament, 1998).
E-therapy may be analogous to telephone-based treatment (Terry, 2002), frequently referred to as telemedicine. Telemedicine also often utilizes video technology to enable participants to see one another. The American Telemedicine Association defines telemedicine as "the use of medical information exchanged from one site to another via electronic communications to improve patients' health status" (American Telemedicine Association, 2005). When treatment is provided solely by telephone without accompanying video, the provider and patient cannot see one another; consequently, less information is exchanged. In 1985, the American Psychiatric Association opined that therapy provided almost exclusively by telephone was "unusual, inappropriate and not accepted medical practice. …