Logging On for Psychotherapy

The explosion of the Internet allows people to use their computer for things that previously needed to be done in person. Now, communicating with friends and family, networking with business contacts, shopping, banking, and a host of other activities, can be done from almost anywhere in the world. While the convenience of these Internet activities is self-evident, is psychotherapy an appropriate trend to hit the Internet?

A recent issue of The Lancet reports that real-time online cognitive behavioral therapy (CBT) is effective in treating patients with depression. The study evaluated nearly 300 patients from 55 general practice clinics across the United Kingdom who had a diagnosis of depression. The patients were randomly assigned to either receive online CBT in addition to their usual care from the general practitioner, or be placed on an 8-month waiting list for CBT while still receiving their usual care. At the 4-month follow-up, 38% of the CBT group had recovered from their depression, compared to only 24% in the control group. After 8 months, 42% of the patients receiving CBT had recovered, compared to 26% in the control group.

Access to CBT is limited in many areas owing to distance to a major medical center, language barriers, and cost. Online CBT certainly addresses some of these concerns, increasing access to remote or underserved areas. Care could be provided in real-time from around the world. The flexibility and convenience of online CBT is attractive and practical for many patients. Still, can online CBT offer the benefits of face-to-face counseling?

Advocates of online CBT maintain that it offers more frequent contact with counselors, who could be available in a call-center or chat room 24 hours a day. Patients could access counselors at a moment of acute distress. Also, online sessions could alternate with in-person CBT sessions, or be used as step-down therapy for some patients. But, concerns about privacy and security loom, not to mention the clinical effectiveness, of such a model.

Also, patients benefit from being seen in person by counselors. Does the patient’s breath show signs of alcohol? Does the tiny tremor look like Parkinson’s Disease? Is the bruise a sign of domestic abuse? All of these assessments are lost in the virtual world of the Internet. But, the lack of face-to-face contact may encourage some patients to be more open and reveal more information about themselves.

Additionally, many “e-therapy” websites are emerging, which provide counseling, advice, and emotional support with little regulation or credentialing. Patients may be tempted to access these types of websites rather than seeking the services of trained, licensed physicians and counselors.

There are also programs that integrate a patient’s real life with a virtual life to provide counseling and therapy. In some of these so-called “interreality” programs, behavior in real life influences virtual life, and behavior in virtual life influences real life. Efforts are underway to use such a program to treat addictions. The clinical rationale and effectiveness of these scenarios are the focus of current debate.

Telehealth, in general, is an advance of modern medicine that brings the delivery of healthcare services and information to remote, underserved areas, as well as providing a venue for healthcare practitioners to monitor patients, share information, or participate in research. However, issues related to cost, insurance coverage, and government or licensing regulations limit the widespread implementation and acceptance of telehealth services. The same is true for online therapy services.

Many people with mental health issues do not seek treatment, so improving access and encouraging diagnosis and treatment are positive advances for mental healthcare. But, should important medical treatment be just another item on someone’s Internet to-do list? (Log-on to see the counselor in between uploading pictures to a social networking page and paying the credit card bills.) Still, new advents in technology and communication are shifting the paradigm of medicine and healthcare delivery, and if the Internet can provide a safe, secure environment to benefit patients, then patients and providers should get online.


Gorini A, Gaggioli A, Vigna C, Riva G. A second life for eHealth: prospects for the use of 3-D virtual worlds in Gorini, A., Gaggioli, A., Vigna, C., & Riva, G. (2008). A Second Life for eHealth: Prospects for the Use of 3-D Virtual Worlds in Clinical Psychology Journal of Medical Internet Research, 10 (3) DOI: 10.2196/jmir.1029

Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., Sharp, D., Araya, R., Hollinghurst, S., & Peters, T. (2009). Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial The Lancet, 374 (9690), 628-634 DOI: 10.1016/S0140-6736(09)61257-5

Palermo, T., Wilson, A., Peters, M., Lewandowski, A., & Somhegyi, H. (2009). Randomized controlled trial of an Internet-delivered family cognitive–behavioral therapy intervention for children and adolescents with chronic pain Pain DOI: 10.1016/j.pain.2009.07.034

Pomerantz JM. Clinical Responsibility and E-Therapy. Drug Benefit Trends. 2002;14:29-30.

Riva G (2009). Interreality: A New Paradigm for E-health. Studies in health technology and informatics, 144, 3-7 PMID: 19592718

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  • I reckon anything that gets people talking about their issues has got to be a good thing – online, over the phone, face-to-face.. anything!

    The more we are encouraged to be open and honest and share with each other in any kind of format about what’s really going on in our lives, the more opportunities we have to help each other as people.

    Great article, thank you!

  • Hi Jennifer,

    I very much agree with the potential of online counseling. I am CEO of BreakThrough, a startup that recently launched to connect providers with clients via video, phone, and web.

    We hope to spread awareness of the research that validates teletherapy works. For example, this analysis from Columbia University of 14 studies with greater than 500 participants found telepsychiatry as effective as in-person:


    We do not think teletherapy is best for everyone, but for those without the time, money, ability, or will, we think it is a much needed solution. The alternative for many is not going in-person, it is not going at all.

    Feel free to reach out if you would like to talk more.


    Mark Goldenson
    CEO, BreakThrough

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  • Hi! Thanks for posting this! For anyone interested in how online therapy can be delivered ethically, visit the Online Therapy Institute and check out our Ethical Framework for the Use of Technology in Mental Health.

  • Good to see the research. While there may not be such easy to collate evidence for depth psychology and psychotherapy using the online therapeutic relationship as the main focus of the work, from my practice in this field it can be done. The use of imagination is enhanced while writing, hence often the book is better than the film.

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  • sarah mae

    This post is truly helpful for people who really want to get their counselling started but don’t have all the time in the world to do so.

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Jennifer Gibson, PharmD

Jennifer Gibson, PharmD, is a practicing clinical pharmacist and medical writer/editor with experience in researching and preparing scientific publications, developing public relations materials, creating educational resources and presentations, and editing technical manuscripts. She is the owner of Excalibur Scientific, LLC.

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