Online Mental Health Therapy: CyberPsychology or CyberQuackery?

Berglund Authority Level 4

by Shawn Davis, Ph.D. <davissh@pacificu.edu>
about

Introduction

Imagine a day in the not so distant future when you can simply log onto your personal computer, pajamas on and coffee in hand, and discuss your latest stressors with a professional therapist located hundreds of miles away. Or engage in group therapy with individuals spread across the globe. Or finally reach peace with the assistance of a specialist whom you will never meet.

Sounds like science fiction? To get a bit more mileage from a tired cliché, "My friend, the future is now!"

What is e-therapy?

E-therapy or Internet Therapy refers to the delivery of mental health services exclusively via the Internet [1]. Online services of this sort are typically delivered in the form of e-mail communications, live chat rooms, discussion lists, blogs, or live audio or audiovisual conferencing.

This is in contrast to online mental health advice in which psychotherapists respond to a single question, or sometimes a number of questions, in depth as opposed to an extended therapeutic interaction.

Is e-therapy useful?

From the mid-1990s, there has been a rapid proliferation of online mental health services. This is likely due in part to the potential benefits that utilization of the Internet in therapy has for both clients and mental health practitioners.

E-therapy makes is possible for clients to access mental health services on their own schedule or who are unwilling to seek face-to-face services for a variety of reasons. This is an important point in that many still attach stigma to seeking mental health services. The Surgeon General's Report on Mental Health [2], stated that while one in five Americans has a diagnosable psychological problem, nearly two-thirds never seek treatment. This, combined with the fact that, "the complex and fragmented mental health service delivery system can create barriers to a full range of appropriate services" [2] makes E-therapy an attractive alternative.

E-therapy services are also beneficial in that they can be provided to clients in remote or underserved areas and to individuals who are physically unable to leave their homes. Also, online therapeutic approaches are useful for clients who are highly mobile since they can access these services from any location with Internet access. Furthermore, clients may have access to specialized practitioners who are not situated in their geographic region.

In regard to the practitioner, the delivery of mental health services via the Internet may give access to a larger pool of clients, make it feasible to develop more specialized practices, and allow for greater flexibility in work schedules. Furthermore, such services could make the practitioner available to the client during times of greatest need.

Is e-therapy effective?

Mirroring the Surgeon General's remarks, Przeworski and Newman state that more than 70% of individuals with anxiety disorders fail to receive adequate treatment every year and that forms of computer-assisted therapy such as e-therapy may be a means of overcoming many of the barriers to treatment [3].

As one might expect, a number of studies have examined the efficacy of online therapeutic approaches. For example, Anderson, Bergstron, Hollandare, Carlbring, Kalso, and Ekselius investigated the effects of Internet-based cognitive-behavioral therapy and found considerable improvement at a 6-month follow-up [4]. The authors conclude that Internet-delivered cognitive-behavioral therapy should be further pursued as either an alternative or a complement to traditional therapeutic approaches in the treatment of mild to moderate depression. Similarly, Clarke, Eubanks, Kelleher, O'Connor, DeBar, Lynch, Nunley, and Guillion detail the successful delivery of guided self-help programs for depression via the Internet [5].

In a recent publication, Derrig-Palumbo and Zeine specify key issues in online therapy such as relationship building, sensing "nuance" in communications with clients in the absence of nonverbal cues, and providing appropriate feedback [6]. The authors point to several psychotherapies that are already being utilized as promising online treatments (e.g., rational emotive therapy, cognitive-behavioral therapy, solution-focused therapy).

While early indications are that e-therapy might be beneficial for some people and in various situations, further investigation is called for to determine the full range of factors involved in the successful delivery of psychological services online.

What are the limitations of e-therapy?

Even though e-therapy has often proven successful, there are a number of inherent limitations that may serve to reduce its utility or effectiveness. Perhaps the most widely noted drawback to online therapy is the potential for miscommunication due to the lack of non-verbal cues. Inasmuch as effective therapy relies on an assessment of such non-verbal behavior, this may make it difficult to adequately assess, diagnose, and treat certain disorders. This, however, may become less of a problem in the future with technological and bandwidth improvements. It is likely that there will be an increased utilization of Internet videoconferencing in e-therapy.

Also of concern is the belief that clients may misrepresent themselves in an online situation, thus undermining the efficacy of the services provided. Although this is also a concern in face-to-face therapeutic situations, the anonymity currently inherent in online situations maintains this as a valid concern.

Furthermore, as in the delivery of online education, online therapeutic services are only available to those clients who have access to the Internet.

Online therapy is no different than other online interactions in that a critical evaluation of the source of the therapy must be carefully considered. Fewer safeguards exist for clients in therapy delivered via the Internet and it is often difficult to insure the confidentiality of online communications. The burden is truly on the individual to be an intelligent consumer of e-therapy. For a review of ways in which to evaluate health information presented via the Internet, please see my previous article in Interface [7].

It should be noted that e-therapy is not for individuals who are in the midst of a crisis situation nor is it the best way to assist people with serious psychological problems. If one is in urgent need of psychological services, it is best to contact a trained professional immediately.

Conclusion

According to Martha Ainsworth, online communication specialist and mental health consumer advocate, e-therapy is not currently a substitute for psychotherapy. E-therapy, however, "can be a viable alternative source of help when traditional psychotherapy is not accessible, if approached with caution" [8]. While Ainsworth stresses that e-therapy should not be viewed a substitute for therapy, she emphasizes that it does serve a valuable purpose in terms of emotional support, psychoeducation, and advice, all of which do help some people.

Do advancements in the delivery of therapy over the Internet mean the inevitable end of traditional face-to-face therapy? Probably not. In much the same way that the introduction of online education didn't spell doom for in-class instruction, e-therapy will likely find its role as a useful adjunct to traditional therapeutic approaches, especially for underserved, resistant, or distal populations.

ENDNOTES

[1] http://www.gingerich.net/etherapy.htm

[2] http://www.surgeongeneral.gov/library/mentalhealth/home.html

[3] Przeworski, A., & Newman, M.G. (2006). Efficacy and utility of computer-assisted cognitive behavioural therapy for anxiety disorders. Clinical Psychologist. Vol 10(2), 43-53.

[4] Andersson, G., Bergstrom, J., Hollandare, F., Carlbring, P., Kaldo, V., &Ekselius, L. (2005). Internet-based self-help for depression: Randomised controlled trial. British Journal of Psychiatry. Vol 187(5), 456-461.

[5] Clarke, G., Eubanks, D., Kelleher, C., O'Connor, E., DeBar, L. L., Lynch, F., Nunley, S., & Gullion, C. (2005). Overcoming depression on the Internet: A randomized trial of a self-help depression skills program with reminders. Journal of Medical Internet Research. Vol 7(2).

[6] Derrig-Palumbo, K., & Zeine, F. (2006). Online therapy: A therapist's guide to expanding your practice.

[7] http://bcis.pacificu.edu/journal/2007/01/davis.php

[8] http://www.metanoia.org/imhs/interview.htm