E-therapy potentially offers all the benefits of conventional face-to-face counseling at a fraction of the cost.
It’s convenient, widely available, and advancing along with technology, but how does it work?
As internet-based therapy becomes more popular and widespread in its practice, we look at what it is, what’s involved, and the research findings on its efficacy. Here are some of its pros and cons, and the ways in which e-therapy has been used to treat anxiety and depression for better wellbeing and mental health.
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What is E-Therapy? A Definition
E-therapy has become the official term for ongoing online interactions between a therapist and client. In e-therapy (Bloom, 1998; Ainsworth, 2000 in Manhal-Baugus, 2001: 4):
…client and counselor are in separate or remote locations and utilize electronic means to communicate with each other.
Sucula and colleagues (2012) give a similar definition:
E-therapy is defined as a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these.
In contrast to face-to-face therapy, client and counselor use video chat, email, VR tech, or a mix of these media to communicate and help the client overcome challenges and difficulties.
Therefore, e-therapy is designed to help a client deal with specific, well-defined challenges with a certified mental healthcare professional’s support primarily through digital communication modes (Manhal-Baugus, 2001).
Examples of such challenges are anxiety-related disorders, post-traumatic stress disorder (PTSD), and social and specific phobias (Olthuis, Watt, Bailey, Hayden, & Stewart, 2016), which may be treated using similar interventions as those used in a face-to-face context. The difference is that such interventions are delivered digitally.
It is important to note that e-therapy does not encompass public forums, blogs, or group emails. Rather, when conducting e-therapy, a therapist gets actively involved with a client to form a continuous, professional counseling relationship through communications that are (Ainsworth, 2001; Postel, de Haan, & De Jong, 2008):
- Synchronous – taking place at the same time (e.g., live chat);
- Asynchronous – taking place back and forth over a while (e.g., email); or
- A combination of both.
In addition to the distinction between synchronous and asynchronous therapy methods, therapists may choose to conduct e-therapy as part of a blended care approacch to supporting their clients.
Blended care refers to a mixture of online therapy (e-therapy) and in-person treatment. Its underpinning logic is that psychological treatment can be made more accessible by delivering at least part of an intervention online.
Therefore, if you are a therapist considering the move to providing e-therapy, rest assured that you need not dive in all the way. Instead, you can adopt a blended care approach to steadily digitize aspects of your therapy practice.
An Example of E-Therapy Using Quenza
There are a range of different technologies, platforms, and software packages that can support practitioners in providing e-therapy. Indeed, these tools can have the advantage of making therapy more accessible and convenient for clients, while also helping keep clients more engaged and committed to achieving their therapy goals.
To illustrate, we’ll now consider an example of how a therapist might integrate e-therapy into their practice via a blended care approach using the digital platform Quenza.
Quenza is an easy-to-use online tool that allows therapists to digitize and automate many of the asynchronous aspects of their practice. This platform is commonly used by therapists who conduct face-to-face counseling sessions with their clients but wish to supplement these with activities that clients can complete digitally and in their own time, such as questionnaires, assessments, or self-paced video lessons.
To illustrate, let’s consider the fictional example of a client named Louise.
Louise has recently commenced CBT therapy to begin working through challenges with social anxiety. Her hope in undergoing therapy is that she may gain the confidence to start making new friends and expanding her social networks.
In order to make the most of their face-to-face time together, the therapist recommends a blended care approach to treatment, and Louise agrees. The therapist therefore assigns Louise a customized pathway of self-paced digital activities, designed and delivered through the platform Quenza (pictured below).
After their first in-person session, the therapist sends Louise her first activity — a standardized social anxiety assessment. This questionnaire is sent to Louise’s Quenza account to complete at her convenience via her smartphone or tablet.
The therapist receives the results of the questionnaire on her own device as soon as it is complete. While the therapist gets to work planning how she will discuss Louise’s results at their next in-person session, Louise is automatically sent the next activity in her Quenza pathway — a video lesson introducing the symptoms and treatment options for social anxiety disorder.
A few days later, in the lead-up to her next therapy session, Louise is automatically sent the third activity in her pathway — a reflection exercise in which she describes a recent event that triggered her social anxiety.
Upon receiving the results, the therapist plans to conduct a roleplay with Louise during their next therapy session. During this roleplay, they will explore alternate cognitions and behaviors Louise could have invoked during the anxiety-provoking interaction, providing Louise with some alternative ‘scripts’ she can draw on in similar future interactions.
As you can see, the therapist has used the blended care, e-therapy platform Quenza to complete much of the initial legwork in Louise’s treatment and has plenty to discuss with Louise in her next in-person session. It has also provided Louise initial information about her psychological condition and reassurance that various treatment options are available to help her.
This is just an example of how you might integrate a blended care approach into your counseling practice using a platform like Quenza. If you’d like to learn more about Quenza as a tool for providing customized blended care, take a look at our Quenza Interventions article.
The Ethics of E-Therapy
Several ethical issues have been raised around the practice of e-therapy. Interestingly, but perhaps unsurprisingly, many appear to stem from the fact that both synchronous and asynchronous ways of interacting are heavily text-based.
Before we consider some of the specific ethical challenges associated with e-therapy, note that e-therapists providing services through text-only communication channels should always undergo specialized professional training.
This training should enable the e-therapist to translate in-person therapy practices effectively to a text-only platform and recognize the signs that a client may need more intensive in-person support (Brennan & Ohaeri, 1999; Ruwaard et al., 2009).
It is more challenging to verify a client’s age, and it can be tougher for therapists to ensure their clients are fully aware of the potential risks the practice can involve (Recupero & Rainey, 2005).
This issue is increasingly being addressed using online e-therapy consent forms sent digitally as part of a standard set of client intake materials.
Blended care tools such as Quenza can facilitate the design and distribution of these standardized digital materials.
The benefits of providing digital informed consent documents are that they can facilitate better documentation and record-keeping for practitioners.
They can also allow clients to absorb important information at their own time and at a pace that suits them, which is preferable to their feeling rushed at the beginning of their first therapy session.
However, therapists should always take care to provide consent forms such as these in conjunction with a discussion and opportunities to ask questions about e-therapy’s potential risks (Childress, 2001).
Risk of Unlicensed Practitioners
Where there is demand for e-therapy – which there is, thanks to its convenience – there will also be a supply of practitioners available to meet that need. One of the key concerns around online therapy is that when not enough trained, certified therapists offer their services, then online consumers may turn to unqualified therapists on the internet (Childress, 2000).
If professional services are to be delivered, therefore, it is mainly down to practitioners to step up to meet this need by embracing modern technology. It’s also the user’s responsibility to practice diligence regarding their choice of an online therapist (Barak, 1999).
Difficulty Assessing Potential Harm and Risk
Online counseling comes with unique practical risks such as confidentiality breaches (due to hacking, legal record subpoenas, password loss, and so forth). Researchers have argued that the text-based nature of email therapy, in particular, allows for a higher chance of miscommunication regarding these risks.
It also remains possible that such risks aren’t entirely understood by the practitioners themselves, leading academics to calls for more professional discussion groups which allow e-therapists to share information and come up with solutions (Childress, 1998).
To read about the pros and cons of e-therapy a little more, we’ve included a separate section a bit later on.
The growing demand for e-therapy needs to be matched with legislative changes that can ensure practitioners are licensed to counsel individuals in different areas (Prabhakar, 2012). Clients receiving therapy from practitioners without a relevant license, that is, may not have legal rights for compensation or redress (Seeman & Seeman, 1999).
Can it Help With Mental Health Problems?
Some studies have indeed found some evidence that online therapy – guided internet CBT specifically – can be useful as a means of extending treatment to those who can’t access conventional therapy.
Here, a few findings on e-therapy applications for treating depression:
- As a standalone treatment; and
- Alongside face-to-face therapy.
Let’s zoom in a little closer at some of the research on e-therapy for anxiety and depression.
E-Therapy for Depression
Although the vast bulk of available studies look at its efficacy in treating anxiety disorders, e-therapy has been used for some depression-related conditions.
One promising study by Ruwaard and colleagues (2009) used the Depression scale of the Symptom Checklist and Beck Depression Inventory to find clinically significant and persistent improvements in well-being, anxiety, and depression levels in participants who underwent e-therapy.
Participants in the 11-week-long online therapy had no face-to-face communication with their therapists; nonetheless, they reported their interactions to be pleasant, personal, and that they grew with time.
How Does It Work?
Internet-delivered psychotherapy based on CBT models seems to be the most common form of e-therapy for depression, according to research.
- Using a combination of homework assignments, online lessons, and discussion forums, Perini and colleagues (2009) found a substantial decrease in major depression symptoms in participants who underwent e-therapy compared to a ‘wait-list’ (control) group.
- Building on this, Titov et al. (2010) examined the effects of guided e-therapy on majorly depressed patients when a clinician gave them treatment. They found that e-CBT had more of a positive impact when participants received clinician’s guidance rather than unguided prompts to participate.
- A third example from Kessler and colleagues (2009) split participants into two groups – one group received regular treatments, and another received regular treatment and internet-delivered CBT through online chat. Four months later, 20 more of the e-CBT group participants met the depression improvement criteria compared to the non-e-therapy group.
In general, the use of e-therapy for depression seems to be effective as long as professional clinicians are guiding their patients through the process. With randomized controlled trials to refer to and a growing body of literature, we can likely hope for some more extensive studies soon that will reveal more.
Treating Anxiety with E-Therapy
Internet-delivered anxiety therapy has been used for a host of different conditions, from panic disorder and agoraphobia to GAD, social phobia, and PTSD (Olthuis et al., 2016) – and the results are promising.
In one example study, Paxling and colleagues’ 2011 study of 89 participants placed roughly half into an 8-week guided e-CBT program and the other half into a control (waitlist) group. All had been screened and reported symptoms of Generalized Anxiety Disorder (GAD) using established questionnaires such as the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990).
During the eight weeks, the e-therapy group worked through text-based treatment modules and relaxation techniques with a therapist. Eight weeks later, the treatment group showed a marked, significant improvement in their anxiety-related symptoms compared to the control group.
How Does It Work?
Patients tend to undergo a range of different treatments in research studies, such as Internet CBT, e-counseling, computer-automated feedback groups, chatroom interventions, online treatment programs with lessons and homework, or a combination of the above.
A few examples of randomized controlled trials suggest that it can play a role in reducing several of the key symptoms in the short-term, at least:
- Internet-based treatment was found to reduce panic, general anxiety levels, and fear of panicking for individuals with panic disorder (up to a week later) (Richards et al., 2006);
- Olthuis and colleagues (2016) present evidence suggesting that therapist-supported internet CBT has a similar effect to face-to-face therapy in decreasing anxiety; and
- Spek et al. (2007) suggested that e-therapy for anxiety may have more substantial results than e-therapy for depression, although they may be affected by the degree of counselor support each participant received.
Andersson and colleagues (2005) point to many more similar results in a review of the literature, arguing that while e-therapy for anxiety looks promising, much more extensive studies are needed for more conclusive results.
Pros and Cons of Online Therapy
Summing up what we know about e-therapy so far, we can come up with several pros and cons. It may not be everyone’s cup of tea, but as technology and medical practice both advance we can undoubtedly expect to see a lot more of internet-based treatments.
- Guided e-therapy by a licensed, trained counselor tends to use the same established models as conventional face-to-face interventions – CBT, guided relaxation exercises, and internet psychotherapy (Hunt, 2002).
- It’s cost-effective – compared to traditional therapy, and particularly for those without the right insurance for counseling (Olthuis et al., 2016);
- E-therapy is convenient, requiring little to no travel for those who can’t or don’t want to leave home;
- According to most empirical studies we’ve looked at, there’s also ample evidence supporting its efficacy – when counseling is guided by a trained practitioner. There’s room for these studies to be improved upon in terms of sample size and diversity, but from what we have now, e-therapy appears to have some promise.
- While more widely available to clients than conventional therapy, online treatments are still limited to those with access to computers and the internet. It’s also only realistic for those who can use digital technology with a certain level of proficiency (Oravec, 2000).
- Boundary issues are potentially a concern for practitioners; without the professional limits of a designated meeting time and place, some researchers argue that therapists face a higher risk of over-messaging or harassment (Hunt, 2002).
- Miscommunications are more likely with text-based communications over the internet, in the absence of non-verbal and contextual cues.
- E-therapy involves more ethical issues around confidentiality, informed consent, and data leakage, although advancements are being made to overcome these.
E-Therapy Training: Getting an Online Therapy Certificate
As demand builds for e-therapy, more institutions are offering credentials and certifications for those who want to help from home – but expect to be asked if your therapeutic license is valid.
If you’re curious to find out more about the standards for online practice, relevant ethics, and suggested principles, the International Society for Mental Health Online (ISMHO) has developed a set of guidelines.
They address issues such as (ISMHO, 2019):
- Informed Consent – e.g., avoiding misunderstandings and counselor privacy;
- Operating Procedures – e.g., practice requirements, evaluation, and records;
- Emergency Procedures; and
- Further ethical guidelines.
The ISMHO standards are based on existing guidelines and ethical principles from organizations such as the American Psychological Association (APA) and the National Board for Certified Counselors (NBCC).
A Take-Home Message
The key advantage of e-therapy lies in its versatility – it’s accessible, affordable, and convenient while continuing to rely on tried-and-tested frameworks to deliver quantifiable results. Its demonstrated efficacy in treating depression and anxiety is perhaps where virtual therapy shows the most treatment, but some ethical issues remain.
As with any other new-ish means of interacting through technology, e-therapy still faces ethical snaggles that will need to be overcome for the practice to gain more widespread traction.
Therapists and academics will need to overcome jurisdictional barriers, confidentiality issues, and the genuine potential for miscommunication that e-therapy presents, but as more and more research emerges, we can hope to expect promising things.
What do you think of e-therapy? Have you tried it? Do you practice it as a counselor? Leave us your thoughts in the comments!
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- Ainsworth, M. (2000). Metanoia: The ABC’s of internet counseling. Retrieved from http://www.metanoia.org/imhs
- Andersson, G., Bergström, J., Carlbring, P., & Lindefors, N. (2005). The use of the Internet in the treatment of anxiety disorders. Current opinion in psychiatry, 18(1), 73-77.
- Barak, A. (1999). Psychological applications on the Internet: A discipline on the threshold of a new millennium. Applied and Preventive Psychology, 8(4), 231-245.
- Bennett-Levy, J., & Perry, H. (2009). The promise of online cognitive behavioral therapy training for rural and remote mental health professionals. Australasian Psychiatry, 17(sup1), S121-S124.
- Bloom, J. W. (1998). The ethical practice of Web Counseling. British Journal of Guidance and Counseling, 26, 53-59.
- Brennan, S. E., & Ohaeri, J. O. (1999). Why do electronic conversations seem less polite? The costs and benefits of hedging. In R. N. Tayler (Chair), Proceedings of the International Joint Conference on Work Activities, Coordination, and Collaboration (pp. 227–235).
- Childress, C. (1998). Potential risks and benefits of online psychotherapeutic interventions. International Society for Mental Health Online. Retrieved from http://www.ismho.org/issues/9801
- Hunt, S. (2002). In favour of online counselling? Australian Social Work, 55(4), 260–267.
- International Society for Mental Health Online. (2019). Suggested Principles for the Online Provision of Mental Health Services. Retrieved from https://ismho.org/resources/archive/suggested-principles-for-the-online-provision-of-mental-health-services/#Qualifications
- Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., & Peters, T. J. (2009). Therapist-delivered Internet psychotherapy for depression in primary care: a randomised controlled trial. The Lancet, 374(9690), 628-634.
- Manhal-Baugus, M. (2001). E-therapy: Practical, ethical, and legal issues. Cyber Psychology & Behavior, 4(5), 551-563.
- Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495.
- Olthuis, J. V., Watt, M. C., Bailey, K., Hayden, J. A., & Stewart, S. H. (2016). Therapist‐supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews, (3).
- Oravec, J. A. (2000). Online counselling and the Internet: Perspectives for mental health care supervision and education. Journal of Mental Health, 9(2), 121-135.
- Paxling, B., Almlöv, J., Dahlin, M., Carlbring, P., Breitholtz, E., Eriksson, T., & Andersson, G. (2011). Guided internet-delivered cognitive behavior therapy for generalized anxiety disorder: a randomized controlled trial. Cognitive Behaviour Therapy, 40(3), 159-173.
- Perini, S., Titov, N., & Andrews, G. (2009). Clinician-assisted Internet-based treatment is effective for depression: randomized controlled trial. Australian and New Zealand journal of psychiatry, 43(6), 571-578.
- Postel, M. G., de Haan, H. A., & De Jong, C. A. (2008). E-therapy for mental health problems: a systematic review. Telemedicine and e-Health, 14(7), 707-714.
- Prabhakar, E. (2012). E-Therapy: Ethical Considerations of a Changing Healthcare Communication Environment. Pastoral Psychology, 62(2), 211–218.
- Recupero, P. R., & Rainey, S. E. (2005). Informed consent to e-therapy. American journal of psychotherapy, 59(4), 319-331.
- Richards, J., Klein, B., & Carlbring, P. (2003). Internet-based treatment for panic disorder. Cognitive Behaviour Therapy, 32(3), 125-135.
- Ruwaard, J., Schrieken, B., Schrijver, M., Broeksteeg, J., Dekker, J., Vermeulen, H., & Lange, A. (2009). Standardized web-based cognitive behavioural therapy of mild to moderate depression: A randomized controlled trial with a long-term follow-up. Cognitive Behaviour Therapy, 38(4), 206-221.
- Seeman, M. V., & Seeman, B. (1999). E-psychiatry: the patient-psychiatrist relationship in the electronic age. Cmaj, 161(9), 1147-1149.
- Spek, V., Cuijpers, P. I. M., Nyklíček, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological medicine, 37(3), 319-328.
- Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J., Brackman, E. H., & Montgomery, G. H. (2012). The therapeutic relationship in e-therapy for mental health: a systematic review. Journal of medical Internet research, 14(4), e110.
- Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PloS one, 5(6), e10939.
- Titov, N. (2011). Internet-delivered psychotherapy for depression in adults. Current opinion in psychiatry, 24(1), 18-23.