Can internet-based/internet-delivered psychotherapy

effectively replace conventional live psychotherapeutic

interventions?
Ma du Toit
University of Stellenbosch: Honours in Psychology
Psychotherapy: Dr. E. Lesch

Can internet-based/internet-delivered psychotherapy

effectively replace conventional live psychotherapeutic
interventions?
Contemporary technology has made it possible for people to
retrieve vast amounts of information on the World Wide Web. For those
with access to the Internet, it is common to look up medical concerns or
symptoms, including psychological problems (Hesse et al., 2005). Within
the last two decades, a new treatment modality, often called Internet
therapy, online therapy, cybertherapy or e-therapy, has emerged whereby
clinicians deliver cognitive behavioural therapy (CBT) to clients online
(Andersson, Carlbring, Berger, Almlv, & Cuijpers, 2009; Andersson et al.,
2013b). Andersson et al. (2008) gave the following definition of Internet
therapy:
A therapy that is based on self-help books, guided by an identified
therapist which gives feedback and answers to questions, with a
scheduling that mirrors face to face treatment, and which also can
include interactive online features as queries to obtain passwords in
order to get access to treatment modules. (p. 164)
This therapy is mainly provided in text form on websites but may be
additionally supported by e-mail, forums, chatrooms or even
videoconferencing (Andersson et al., 2009; Barak, 1999). Various studies
have found internet-delivered psychotherapies to be as effective as
traditional face-to-face treatment of depression and anxiety disorders
(Bergstrm et al., 2010; Hedman et al., 2011a; Johansson & Andersson,
2012; Kiropoulos et al., 2008). In a country like South Africa, where the
burden of mental health severely outweighs the services available (World
Health Organisation, 2014), internet-based therapies could be the
potential solution. Unfortunately, a limitation of the approach is that
potential clients require internet access and need to be literate to receive
the therapy (Andersson et al., 2013), and less than half of the South
African population does not have access to Internet (Statistics South
Africa, 2015).
In this paper, I will discuss internet-delivered psychotherapy as a
possible substitute for conventional face-to-face treatment with reference
to the topical issues in the field. I will give an overview of the
psychotherapeutic elements required for Internet therapy to function
effectively and how these conditions differ from traditional interventions.
Furthermore, I will examine the relevance of such a modality in the
context of South Africa and how it may be successfully applied.
Critical Issues
The mass of evidence supporting internet-based therapy is
increasing. Earlier research had methodological flaws such as high
dropout rates and small sample sizes which prevented conclusive results
(Andersson et al., 2009; Taylor & Luce, 2003). However, more recent
studies are predominantly adhering to the revised recommendations
detailed in the CONSORT statement (Moher, Schulz, & Altman, 2001),

improving the reliability of findings (Andersson et al., 2009). In order to

gage whether internet-based psychotherapy is a viable alternative to
conventional live interventions, researchers are asking the following
questions: (1) how sustainable are the effects of Internet therapy in the
long term?, (2) what are the factors that contribute to the effectiveness of
the treatment format?, and (3) what are the ethical issues related to
internet-based therapy?
The studies by Andersson et al. (2013a) and Hedman et al. (2011b)
found that internet-delivered CBT (ICBT) proves effective up to three and a
half years after treatment for anxiety and depression. Unfortunately,
Andersson et al.s (2013b) trial with a 3-year follow up is currently, to my
knowledge, the only controlled long-term follow-up study on this topic. It is
therefore necessary to do further controlled research on the long-term
effectiveness of internet-delivered CBT. Nonetheless, there are various
aspects of ICBT that may contribute to sustainable effects after treatment
(Andersson et al., 2013a).
They are: (a) the text modality of the psychotherapy, which allows
the client to revise their treatment at leisure, even after the therapy
course is over; (b) the lack of a possibly stressful therapeutic
environment, such as an in-person session with a therapist or a group
therapy meeting, which amy affect the in-take of knowledge; and (c) the
comprehensiveness of the course according to CBT-protocol, which is
more effective than a shorter treatment, even in face-to-face treatment
(Andersson et al., 2013a). Research has also demonstrated that patients
more readily share their symptoms online in comparison to live interviews
(Taylor & Luce, 2003).
It is imperative the clients entering Internet therapy be accurately
diagnosed (Andersson et al., 2009). Though there are websites that offer
mental health assessments, individuals who score more than a certain
programmed amount will be advised to consult a mental health
professional (Taylor & Luce, 2003). The purpose of proper screening is that
the client selects a treatment program according to their problem. For
example, an individual who presents with symptoms of depression will
likely not benefit as much from an Internet therapy program designed for
people with Obsessive Compulsive Disorder (OCD) than they would from
treatment fitting their needs. While a psychotherapist would be able to
adjust his or her expertise according to the patients problem in a face-toface appointment, an Internet therapy program tends to be structured to
address a specific disorder.
Another impactful factor that contributes to the effectiveness of
online psychotherapy is the duration of the intervention (Andersson et al.,
2009). Compared to the duration of in-person therapy, where clients may
attend therapy for years and have the choice to terminate treatment at
will, internet-delivered treatment has a set time frame. The participants in
Carlbring et al.s (2005) study on panic disorder reflected after their
treatment that the short time period of six weeks induced stress in that
they could not keep up with the condensed schedule. In order to further

minimize stress of clients, the online program should be easy to use and
understand (Andersson et al., 2009). Ease of navigation and a clear
organisation of content are essential.
Andersson et al. (2009) make a final suggestion concerning the
effective implementation of Internet psychotherapeutic interventions. It
appears that therapeutic support and guidance is a fundamental
component of a working e-therapy model, even in minimal quantities
(Spek et al., 2007). Guidance from a therapist can take the form of
communication via telephone, e-mail, or videoconferencing (Andersson et
al., 2009). In Spek et al.s (2007) meta-analysis of ICBT interventions for
depression and anxiety, it was found that therapist support more than
doubled the effect of the treatment compared to unguided programs.
Debate still exists as to exactly how much support is needed in Internet
therapy.
A major issue in the field of internet-based psychotherapy is ethics
(Hsiung, 2001). Privacy is the prevailing concern, since even passwordprotected programs cannot guarantee absolute confidentiality (Taylor &
Luce, 2003). The client may also be in danger of being misled, as it might
be difficult to judge whether the therapist is competent and properly
trained or licensed (Botella, Garcia-Palacios, Baos, & Quero, 2009). Another
ethical dilemma is the increasing expense of the necessary technology to
access web-based treatment (Botella, Garcia-Palacios, Baos, & Quero,
2009). The high costs of computers, video equipment, and internet access
limits the treatment to only those who can afford it.
Psychotherapeutic Conditions
Carl Rogers (1957) outlined six conditions necessary for
psychotherapeutic change to occur: (1) there is psychological contact
between therapist and client, (2) the client is in a state of incongruence
(p. 95), (3) the therapist is a genuine, open person without incongruences,
(4) the therapist unconditionally accepts the client and their experiences
as valid, (5) the therapist empathises with the client, and (6) the client is
at least somewhat aware of the therapists positive regard and
acceptance of them.
Practising psychotherapy through the Internet requires the
reproduction or adaptation of these conditions. It is the first condition, the
contact between therapist and client, which has changed most drastically
from a traditional face-to-face approach. E-therapists maintain contact
with their clients through various different forms of online communication,
including to e-mail, internet relay chat (IRC), videoconferencing, bulletin
boards, discussion forums, and more (Castelnuovo, Gaggioli, Mantovani, &
Riva, 2003; Suler, 2000). Suler (2000) organised the various pathways for
achieving contact into five qualities of communication, namely
synchronous/asynchronous, text/sensory, actual/imaginary,
automated/interpersonal, and invisible/present. The contact between
therapist and client in internet-based therapy can therefore vary
immensely, depending on the method of communication used.

The second and third conditions associated with an effective

psychotherapeutic environment involve the congruency of both therapist
and client. In a face-to-face situation, a clinical psychotherapist would
easily be able to identify incongruences within a client. This may be
slightly more difficult to recognize in the text format of the clients
exercises and reflections. However, basic psychotherapeutic techniques
can generally be suitably applied using online tools (Castelnuovo et al.,
2003). For example, a client can describe their emotions and cognitions
about a certain event through writing without damaging the therapeutic
power of the exercise.
In fact, participants in Cook and Doyles (2002) study on the
working alliance in e-therapy discussed in detail their feelings of
disinhibition during the treatment. They commented that the online
medium afforded them the opportunity to express themselves freely, in
contrast to a face-to-face session where they might feel the therapist is
judging them (Cook & Doyle, 2002).This relates to the conditions of
unconditional positive regard. If a client does not feel wholly accepted by
the therapist, they will not share deeply and therapeutic change will not
occur (Rogers, 1957).
Whether live empathy can be reproduced authentically via the
Internet is debateable. Some of Cook and Doyles (2002) participants
noted positive experiences of the client-therapist relationship in Internet
therapy. Suler (2000) describes the zone of reflection (p. 152) which
entails the time both therapist and client have to reflect on the feedback
they receive before formulating a reply. For the therapist, this reflective
thinking increases their understanding of the clients inner world (Rogers,
1957; Suler, 2000). However, it is important to note that non-verbal cues
are lost in text format, which may inhibit the clients ability to perceive the
therapists empathy and positive regard (Suler, 2000). Though in general,
the alliance between client and therapist tends to be strong in internetdelivered interventions (Knaevelsrud & Maercker, 2007).
The South African Context
South Africas high levels of chronic illness and mental illness has
been called an epidemic (Mayosi et al., 2012). Crime, violence, and
substance abuse are psychosocial problems in the country that adversely
affect mental health, especially in rural communities (Chersich & Rees,
2010; Mayosi et al., 2012). Though the state of mental health services has
improved since 2009, there is huge room for improvement (Mayosi et al.,
2012). According to the World Health Organisation (WHO, 2014), Africa
had the lowest amount of mental health beds and smallest mental health
workforce per 100 000 people in the world. Of those hospital beds, 97% of
the patients use them for less than a year, despite what their psychiatric
needs may be (WHO, 2014). There is a need for mental health services to
reach poorer communities in South Africa, which government aims to
address by increasing psychiatric treatment by 30% by the year 2030
(Mayosi et al., 2012).

With the lack of services reaching mentally ill people in need of

help, internet-delivered psychotherapy would seem like a possible remedy.
Regrettably, the countrys lack of widespread internet access prohibits the
implementation of such interventions. Only 48.7% of South African
households have at least one member who has access to the Internet,
where only 10% of those households have internet at home (Statistics
South Africa, 2015).This implies that only a small, probably wealthy
portion of the South African population would benefit from internet-based
psychotherapy.

References
Andersson, G., Bergstrm, J., Buhrman, M., Carlbring, P., Hollndare, F.,
Kaldo, V., Waara, J. (2008). Development of a new approach to
guided self-help via the internet: The Swedish experience. Journal of
Technology in Human Sciences, 26(2/4), 161-181. doi:
10.1080/15228830802094627.
Andersson, G., Carlbring, P., Berger, T., Almlv, J., & Cuijpers (2009). What
makes internet therapy work? Cognitive Behaviour Therapy, 38(1),
55-60. doi: 10.1080/16506070902916400.
Andersson, G., Hesser, H., Hummerdal, D., Bergman-Nordgren, L.,
Carlbring, P. (2013a). A 3.5-year follow-up of internet-delivered
cognitive behaviour therapy for major depression. Journal of Mental
Health, 22, 155-164.
Andersson, G., Hesser, H., Veilord, A., Svedling, L., Andersson, F., Sleman,
O., Carlbring, P. (2013b). Randomised controlled non-inferiority
trial with 3-year follow-up of internet-delivered versus face-to-face
group cognitive behavioural therapy for depression. Journal of
Affective Disorders, 151, 986-994. doi: 10.1016/j.jad.2013.08.022.
Barak, A. (1999). Psychological applications on the Internet: A discipline
on the threshold of a new millennium. Applied & Preventive
Psychology, 8, 231-245.
Bergstrm, J., Andersson, G., Ljtsson, B., Rck, C., Andrewitch, S.,
Karlsson, A., Lindefors, N. (2010). Internet-versus groupadministered cognitive behaviour therapy for panic disorder in a
psychiatric setting: A randomised controlled trial. Journal of
Affective Disorders, 136, 459-468.
Botella, C., Garcia-Palacios, A., Baos, R. M., & Quero, S. (2009). Cybertherapy:
Advantages, limitations, and ethical issues. PsychNology Journal, 7(1), 77100.

Chersich, M. F., Rees, H. V. (2010). Causal links between binge drinking patterns,
unsafe sex and HIV in South Africa: Its time to intervene. Int J STD AIDS, 21,
2-7.
Hedman, E., Andersson, G., Ljtsson, B., Andersson, E., Rck, C., Mrtberg,
E., & Lindefors, N. (2011a). Internet-based cognitive behavior
therapy vs. Cognitive behavioral group therapy for social anxiety
disorder: A randomized controlled non-inferiority trial. PLoS ONE,
6(3), e18001. doi: 10.1371/journal.pone.0018001.
Hedman, E., Furmark, T., Carlbring, P., Ljtsson, B., Rck, C., Lindefors, N.,
& Andersson, G. (2011b). Five-year follow up of internet-based
cognitive behaviour therapy for social anxiety disorder. Journal of
Medical Internet Research, 13(2), e39.
Hesse, B. W., Nelson, D. E., Kreps, G. L., Croyle, R. T., Arora, N. K.,
Viswanath, K. (2005). Trust and sources of health information: The
impact of the Internet and its implications for health care providers:
Findings from the first Health Informational National Trends Survey.
Archives of Internal Medicine, 165, 2618-2624.
Hsuing, R. C. (2001). Suggested principles of professional ethics for the
online provision of mental health services. Medinfo, 10, 296-300.
Johansson, R., & Andersson, G. (2014). Internet-based psychological
treatments for depression. Expert Review of Neurotherapeutics,
12(7), 861-870. doi: 10.1586/ern.12.63.
Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., &
Ciechomski, L. (2008). Is internet-based CBT for panic disorder and
agoraphobia as effective as face-to-face CBT? Journal of Anxiety
Disorders, 22, 1273-1284. doi: 10.1016/j.janxdis.2008.01.008.
Knaevelsrud, C., & Maercker, A. (2007). Internet-based treatment for PTSD
reduces distress and facilitates the development of a strong
therapeutic alliance: A randomized controlled clinical trial. BMC
Psychiatry, 7, 13.

Mayosi, B. M., Lawn, J. E., Van Niekerk, A., Bradshaw, D., Karim, S., &
Coovadia, H. M. (2012). Health in South Africa: Changes and
challenges since 2009. The Lancet, 5-19. doi: 10.1016/S01406736(12)61814-5
Rogers, C. R. (1957). The necessary and sufficient conditions of
therapeutic personality change. Journal of Consulting Psychology,
21, 95-103.
Spek, V., Cuijpers, P., Nyklek, 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, 319-328.
Statistics South Africa. (2015). General household survey. Pretoria, South
Africa: Statistics South Africa.
World Health Organization. (2014). Mental health atlas 2014. World Health
Organization.