The online meeting of minds

Evidence is mounting that counselling and psychotherapy services can be delivered effectively online

PEOPLE ARE using the internet nowadays to do their banking, keep in touch with friends and even to find true love, so perhaps it is not too surprising to discover that some are also looking online for ways to deal with issues that stop them from living a full life.

While online counselling may still be in its infancy, particularly in the Republic, demand is growing for services even though experts remain divided on whether it can be useful in helping individuals to work through personal problems.

A recent study undertaken at the University of Bristol has concluded that Cognitive Behavioural Therapy (CBT) is effective when delivered online in real time by a therapist.

The results of the study, which are published in the latest issue of The Lancet, show that nearly two-thirds of clients who were invited to take part in an internet-based psychotherapy programme for depression completed five or more therapy sessions, a substantially higher rate than would be expected with in-person therapy.

In addition, clinical benefits were bigger than generally seen with computerised self-help programmes, and similar to those with traditional in-person psychotherapy.

The researchers say that the results indicate that online counselling could be used in future to broaden access to CBT in primary care.

“Real-time online CBT offers the flexibility and responsiveness of face-to-face CBT and is appropriate for people with severe symptoms. It affords an opportunity for reflection and review as part of the therapeutic process, which could enhance its effectiveness,” says David Kessler of the NIHR National School for Primary Care Research, based at the University of Bristol.

Despite such studies, the majority of therapists in the Republic have tended to steer clear of the internet for a number of reasons including ethical and accreditation issues, technological limitations and a widespread belief that online-based psychotherapy must be far less effective than face-to-face sessions.

As more people begin to live their lives online, pressure is mounting on counsellors and psychotherapists to start delivering services via the internet. However, most therapists are unlikely to do this in the near future due to concerns over just how helpful online counselling can really be in assisting clients.

“Given that all the research shows that it is the therapeutic relationship which accounts for at least 40 per cent of the reported change in therapy then one would wonder what kind of relationship one could have online,” says Mary Lalor, vice-chairwoman of the Irish Council for Psychotherapy (ICP), an organisation which represents more than 1,040 psychotherapists across a number of modalities.

“So much goes on in the therapy that is unspoken and so there are questions regarding how one can account for that in an online relationship and how it would affect the quality of the work that is being done.

“There are also other issues to consider such as confidentiality and questions around people’s online identity. How does a client know that the people they are communicating with are who they say they are and how can they be sure that everything they say or write remains confidential? These are all areas that need further consideration,” she adds.

Such deliberations are taking place with organisations such as the Irish Association of Counselling and Psychotherapy (IACP) currently drawing up guidelines. In the interim a number of online counselling services have already been established in Ireland.

While not discounting the benefits of traditional counselling, those behind the services are adamant that real therapeutic relationships can be formed via the internet and many of the studies undertaken so far suggest that they may be right.

Much of the research into internet-based counselling has tended to focus on how emotion can be conveyed online with multiple studies showing that there are a number of non- verbal devices that can be used to convey emotion including simile, metaphor, poetry, emoticons (icons or smiley faces), etc.

“It is possible to develop a working therapeutic relationship online. While much of what happens in a face-to-face counselling session such as body language, eye contact and tone of voice are absent, there are satisfactory ways to overcome this,” claims Declan Fitzpatrick, a psychotherapist and one of the people behind Counsellorsonline.ie, a new online service.

“Anyone who uses e-mail or instant messaging regularly will be familiar with the various ways in which we can communicate what we mean and how we are feeling; the use of emoticons, capital or bold text and abbreviations such as LOL are some common ways in which we can do this,” he adds.

Some studies have found that internet-based psychotherapy may be particularly beneficial to individuals who have experienced heavy trauma such as abuse who might benefit from the disinhibition and perceived anonymity that are usual in online communication.

Others have concluded that online counselling can be a vital resource for those living in rural communities or who have disabilities or phobias which may make it difficult for them to visit a therapist in person.

Fitzpatrick acknowledges that online counselling is not for everybody and is not suitable for all psychological problems but he is convinced of its effectiveness in helping individuals, no matter what model of psychotherapy is used.

“Many people have great difficulty in bringing themselves to discuss their problems with another person face to face. This is often due to feelings of shame or guilt or indeed the perceived stigma often felt in attending a therapist.

“Online counselling can be very helpful in this regard, allowing the person to feel safe enough to discuss their problems without risking some of those overwhelming feelings,” he said.

Other supporters of online counselling are also keen to stress alternative advantages to working with clients via the internet instead of in person.

“The written and considered nature of the therapeutic communication can take on a unique character and can facilitate therapeutic engagement in ways which are impossible in face-to-face work,” says Richard Boyle, a psychotherapist with a technology background who has been involved in building secure systems for online counselling.

“An example of how written counselling offers advantages which are unavailable in face-to-face work is the ability to review all previous work to date by simply scrolling through the written exchanges. This can prove to be an increasingly valuable resource for both counsellor and client to refer back to as the therapeutic relationship progresses, guarding against repetition and effortlessly ensuring the accountability of both parties,” he adds.

Another possible benefit of internet-based psychotherapy lies with the ease with which information can be shared online. One such example of how this works in practice is offered by the Student Counselling Centre at Trinity College Dublin.

The service, which has been running since 2005, enables students to sign up to join an online community. They can then anonymously post a message which will be responded to by a counsellor but that may also be viewed by other members of that community.

According to Derek Richards, a psychotherapist and researcher at TCD, the service which is running at just two other universities in the world, has proven to be extremely successful with students.

“Our research suggests that allowing the community to see individual submissions and responses has benefits. It works as much as a psycho-educational tool as it does as a therapeutic intervention,” says Richards.

“Research carried out in Greece and Switzerland where the other online programmes are running has found that while the number of users of a community increased over time the number of messages decreased. This is attributed to the fact that increasingly users find answers from already published data and therefore do not need to ask questions themselves.”

Richards argues that while most practitioners in Ireland have been slow to embrace the internet, this is changing and will continue to do so.

“There is a growing recognition that online counselling can be effective and an expectation from clients that it be made available, and so it is likely that more therapists and counsellors will begin to offer it in some form soon ,” he concludes.