Counselling on the keyboard couch

With the launch of NHS Direct, counsellors are saying it is only a matter of time before psychiatric advice will be offered online. But, as Mike Webber says, e-therapy is not a quick fix for everyone

You probably won't be surprised to hear that the latest US import to reach our shores has arrived, yet again, via the internet. In true Californian style, it seems that even therapy has now entered the digital age, with a plethora of counselling services now available online.

E-therapy is a serious and growing business. According to recent Department of Health statistics, there are 120,000 people waiting for mental-health treatment in the UK. In a recent survey, people suffering from phobias, anxiety and obsessive-compulsive disorders were asked what sort of treatment they would prefer. More than a quarter of them indicated that they did not want to go through their GP to get help, and more than a third of them said they would be willing to access therapy via the internet.

At the moment, online therapists are working mostly by e-mail, although it is being increasingly replaced by real-time chat over the Web. Those on the cutting edge have even begun to introduce video-conferencing as an option.

"E-mail is still the most common way therapists interact with patients online," explains Martha Ainsworth, a self-proclaimed e-therapy consumer watchdog, as well as a founder of www.metanoia. org, a mental health consumer advocacy and education website. Ainsworth is keen to break down barriers that keep people from getting the help they need, and she claims that using the internet is one way of dissolving those barriers.

Ainsworth has a background in crisis intervention and leading self-help support groups, both of which she has done online since 1982. She is also a founding board member and the president-elect of the International Society for Mental Health Online. She cites convenience and anonymity as two major factors that attract people to e-therapy.

"E-mail is especially preferred by people who like to write, and people who have very busy schedules. Working with a therapist by e-mail has some nice features. For one thing, you don't both have to make an appointment, or be in the same place at the same time. That means you can write to your therapist whenever you feel like it, even if it's in the middle of the night and you're in your pyjamas. Plus, you can save the e-mail from your therapist and go back and read it whenever you feel like you want to connect."

Without a doubt, one of the main attractions of e-therapy from the patient's point of view is the anonymity that the internet can provide. As a result, e-therapy can be especially helpful for people who are too embarrassed to phone a therapist or to visit a therapist's office. "Like it or not, society still attaches stigma to counselling, and many people do not want to admit to themselves that counselling is acceptable," Ainsworth says. "Some people still believe that if they see a counsellor, it means that something is wrong with them." Unsurprisingly, the people who use e-therapy the most are those who have never tried therapy before and are quite nervous about it; they feel safer talking to someone from the privacy of their own computer.

Dr Russell Razzaque, a UK-based psychiatrist, heads a small team of counsellors offering real-time e-therapy to their clients at www. cyberanalysis.com. "There are a lot of places in this world where people simply do not have access to psychiatric care," he says. "If patients accept that there are some limitations inherent with online therapy, if they choose their doctor very carefully, and if they are suitable candidates for online therapy in the first place, it can be a very effective means of getting help."

He adds that patients should check relevant credentials on the therapist's website and can confirm the validity of these with an independent third party, such as the Royal Society of Health or the Association of Professional Counsellors.

Some mental-health professionals feel strongly that it is not ethical for psychotherapists to interact with people on the internet. Many opponents believe that online counselling provides no real help at all, while some believe there is a possibility it could be harmful. Virtually every site warns potential users that web-based therapy is not appropriate for those with suicidal tendencies or other serious psychoses. Anyone in an abusive, violent relationship and anyone who is having thoughts of harming themselves or others is also invited to seek a more traditional form of therapy.

But what happens if such feelings or thoughts begin to surface mid-session, while the e-therapist is hundreds and possibly thousands of miles away?

"We make an initial assessment of every patient, and this includes a rigorous screening process," Dr Razzaque explains. "Once a patient has been screened in this way and has been deemed suitable for online therapy, they are very unlikely to undergo a complete turnaround in terms of their mental state. If such a case did come up, we would refer the patient to a local counsellor and would help with that transition."

An initial session with Dr Razzaque costs approximately £40, with subsequent sessions available at a similar price. In addition to the one-to-one, real-time chat, counselling sessions also include "homework" in the form of e-diaries, which are mailed to the counsellor for input in between sessions.

Even proponents of online therapy are careful to stress its limitations. Most online psychiatrists, Dr Razzaque included, are quick with disclaimers that "e-therapy" can never substitute for traditional counselling. A patient's body language and voice can provide a therapist with vital clues about motives driving subconscious behaviour – clues that are either absent or impossible to detect in internet-based dialogue.

"The lack of body language does present a challenge, and this is one reason why e-therapy is not appropriate for people with serious psychological problems," Ainsworth explains. "In certain situations, a therapist needs visual information. However, for many of the 'walking wounded' who are trying to cope with everyday change and loss, e-therapy can be a good first step."

The lack of e-mail confidentiality is another often-cited risk in e-therapy. But Ainsworth says, "That's no more an issue online than it is for face-to-face counselling. The majority of e-therapists today use bank-like safeguards to protect their electronic communications with their patients. There are human-error risks, but these are pretty much the same as for face-to-face therapy and can be minimised with appropriate cautions."

Dr Razzaque believes that the future is bright for e-therapy. "Just look at NHS Direct," he says. "Medical advice is now available online from the National Health Service, and it is just a matter of time before this general advice is extended to cover a range of specialities, including psychiatry. As things progress, face-to-face counselling will continue to have a major role to play, of course, but it will eventually just be one part of the overall process."

As the technology and bandwidth improves, Ainsworth believes that the use of internet video-conferencing for e-therapy will increase. "I think that will be a fundamental change," she says.

"Many people will continue to prefer asynchronous, text-based communication, but video-conferencing will open e-therapy for those who want visual contact and talking as opposed to writing. Video-conferencing has already proved effective in hospital settings, where there is access to expensive equipment. Most of us who just have a little webcam on our PC can't achieve a good enough result at the moment, but it will happen eventually."