CYBERPSYCHOLOGY & BEHAVIOR

Volume 6, Number 4, 2003

© Mary Ann Liebert, Inc.

From Psychotherapy to e-Therapy: The Integration of

Traditional Techniques and New Communication Tools in
Clinical Settings

GIANLUCA CASTELNUOVO, M.S., ANDREA GAGGIOLI, M.S.,

FABRIZIA MANTOVANI, Ph.D., and GIUSEPPE RIVA, Ph.D.

ABSTRACT

Technology is starting to influence psychological fields. In particular, computer-mediated

communication (CMC) is providing new tools that can be fruitfully applied in psychother-
apy. These new technologies do not substitute for traditional techniques and approaches but
they could be used as integration in the clinical process, enhancing or making easier particu-
lar steps of it. This paper focuses on the concept of e-therapy as a new modality of helping
people resolve life and relationship issues. It utilizes the power and convenience of the Inter-
net to allow synchronous and asynchronous communication between patient and therapist. It
is important to underline that e-therapy is not an alternative treatment, but a resource that
can be added to traditional psychotherapy. The paper also discusses how different forms of
CMC can be fruitfully applied in psychology and psychotherapy, by evaluating the effective-
ness of them in the clinical practice. To enhance the diffusion of e-therapy, further research is
needed to evaluate all the pros and cons.

INTRODUCTION important to study the impact of these changes as

they occur, and it is imperative that new technolog-

P SYCHOTHERAPY IS TRADITIONALLY BASED on face-

to-face interactions or other settings that in-
volve verbal and non-verbal language without any
technological mediation. However, emerging tech-
nologies are modifying these traditional settings.
As indicated by Norcross et al.1 in a recent study
about the future of psychotherapy, “as we transi-
tion from the industrial era to an information era, it
is imperative that we remain knowledgeable of
how changes will impact psychotherapy, psycholo-
gists and our patients” and “a growing percentage
of psychotherapy will be offered by telephone,
videophone or e-mail.”1
As noted by Jerome and Zailor2: “emerging tech-
nology will perpetually alter the health care envi-
ronment, continuously changing the tools and
options that are available to therapists. It is thus
ical competencies be developed as clinicians inte-
grate these technologies into their research and
practice.” Nickelson3 defined these scenarios with
the word “telehealth”: the use of telecommunica-
tions and information technology “to provide ac-
cess to health assessment, diagnosis, intervention,
consultation, supervision, education and informa-
tion, across distance.”
It is important to underline that the possible in-
troduction of new technologies does not represent
a new theoretical approach in the field of psycho-
therapy: the traditional techniques (such as the
“cognitive reframing” in the cognitive and behav-
ioral approach) and the key features of an effective
psychotherapy (such as a good relationship be-
tween therapist and patient) are not put in discus-
sion in high-tech scenarios. In this frame, new tools

Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy.

375
376
can be used for enhancing the traditional treat-
ments. Possible applications are extended support
in particular steps of the clinical process (e.g., follow-
up) or as an augmentation of face-to-face commu-
nication during the central and final parts of the
psychotherapy. The focus is not upon the technol-
ogy but upon the process of the psychotherapy, of
diagnosis, or of other psychological activities that
can be enhanced with the use of technological
media and tools.
As noted by Grohol,4 e-therapy “is a new modal-
ity of helping people resolve life and relationship
issues. It uses the power and convenience of the In-
ternet to allow simultaneous (synchronous) and
time-delayed (asynchronous) communication be-
tween an individual and a professional.” This au-
thor noted that “it would be inappropriate to
compare it to traditional face-to-face psychother-
apy, assessment or traditional services,”4 because
e-therapy is only a resource that can be added to
traditional treatments.4,5
Another key issue to consider in the possible ap-
plications of e-therapy is the provision of appropri-
ate health assistance in remote areas where
specialized staff and facilities are not widespread:
in these situations, the Internet could be the only
solution to allow daily health care. The AKAMAI
Telemedicine Program, in the case of Hawaii, and
Alaska Telemedicine Program, in the case of
Alaska, are two examples.6
POSSIBLE APPLICATIONS
OF e-THERAPY
The Internet—a global computer network that
connects ever-growing numbers of local networks
and computers—is now one of the predominant
communicational tools. A number of psychological
resources are already available for professionals
and lay users.2,6,7,8 There are two main areas in psy-
chotherapy where the Internet could provide
enhancing solutions for clinical applications: indi-
vidual therapy and self-help therapy.
Individual telepsychotherapy
Individual telepsychotherapy could be indicated
in many situations for remote psychological con-
sultations. Although efficacy of the use of remote
consultation in psychotherapy is not yet fully ex-
plored, technological advances have allowed the
publication of some pioneering work with good
and promising results. Klein and Richards, for ex-
ample, investigated the effectiveness of an Internet-
CASTELNUOVO ET AL.
based intervention for people with panic disorder:
the treatment condition was associated with signif-
icant reductions in all variables, except anxiety sen-
sitivity and depressive affect.9
Botella et al.10 developed a telepsychology sys-
tem for the treatment of public speaking fear. The
system, composed of three main parts, is a struc-
tured assessment protocol that gives the patient a
diagnosis of his/her problem, a structured proto-
col for the treatment of the pathology previously
discovered, and an outcome protocol that as-
sesses treatment effectiveness at every intermedi-
ate step.10
One of the possible advantage of using e-mail as
an adjunct to therapy is the patient’s involvement
in treatment.11 Murdoch and Connor-Greene11 re-
ported two interesting clinical cases where thera-
peutic alliance and impact improved with the use
of e-mail homework reporting. The authors attrib-
uted this improvement to the fact that some pa-
tients have fewer problems when they talk about
personal issues using e-mail than when they are in
a face-to-face setting.
Also, in the outpatient treatment of anorexia ner-
vosa, good results have been obtained using e-mail
as a therapeutic adjunct.12 Results of this study
showed a clinical improvement for all patients in-
cluded in the experimental group. Furthermore,
patients accepted the use of e-mail as a therapeutic
adjunct, and they considered it fruitful.
Bouchard and colleagues13 used videoconference
to enhance a cognitive-behaviour protocol for the
treatment of patients suffering from panic disorders
with agoraphobia. According to the authors, tele-
psychotherapy demonstrated statistically and clini-
cally significant improvements of target symptoms
(frequency of panic attacks, panic apprehension, se-
verity of panic disorder, perceived self-efficacy) and
measures of global functioning (trait anxiety, general
improvement). Furthermore the authors noted that a
good therapeutic alliance was built also using video-
conference (and not real face-to-face interactions)
after the first telepsychotherapy session.13
Self-help therapy
Self-help information is characterized by written,
visual, audio, recorded, etc. material whose content
is a treatment program (or part of it) that may be
self-administered by patients with or without the
therapist’s guidance.10 The utility of self-help pro-
cedures has been acknowledged for a wide variety
of psychological problems, such as phobias, obe-
sity, sexual dysfunctions, and tobacco addiction.
Scogin et al.14 performed a meta-analysis review of
FROM PSYCHOTHERAPY TO e-THERAPY
40 well-designed outcome studies of self-help treat-
ments. The overall conclusions were that self-help
is clearly more effective than no treatment at all
and just as effective in most cases as treatment ad-
ministered by a therapist.
In order to avoid indiscriminate use of self-help
material that could strengthen (and not reduce) the
psychological problems, more research is needed. 15
Botella10 noted that this risk of worsening the trou-
ble instead of alleviating it depends on whether the
information is offered without following a gradual
therapeutic process.
Online self-help groups
On-line self-help groups are composed by bul-
letin boards, chat rooms, news, and discussion
groups operating within health-related web
pages, list servers (groups in which each individ-
ual message is copied and e-mailed to all sub-
scribers), and other electronic forum focused on
sharing and solving psychological disturbances.16
Some are simply unstructured discussion groups.
Others are led by an individual (usually a non-
professional) who shares the problem that the
group addresses.
The principle at the core of these groups is the
sharing of experiences, strengths and hopes be-
tween members in order to solve their common
problem. These groups offer both an alternative
and adjunct to the traditional psychotherapy ap-
proach. Madara17 noted that possible advantages of
a self-help group are social support, practical infor-
mation, shared experiences, positive role models,
helper therapy.
The effectiveness of online self-help groups is
generally high: different researches proved their ef-
ficacy as support tools in the treatment of eating
disorders,18,19 depression,20 and headache.21
Humphreys and colleagues16 noted that ethical
problems have to be taken into account for psychol-
ogists in Internet-based groups:
• Location: It is very difficult for a psychologist
to competently execute ethical responsibilities
where on-line group members usually come
from a broad geographical area, overall in situa-
tions of emergency (e.g., a client residing in an-
other state becomes suicidal).
• Identity: Without reliable systems of encryption,
an individual with access to a client’s computer
(e.g., a family member) could sign into on-line
group psychotherapy by using the password
and the name of the actual client. Individuals
cannot be easily identified over the Internet.
377
• Privacy: Information exchanged in on-line self
help groups could be typed, recorded, copied,
and distributed, reducing clients’ privacy.
However future technological developments
(e.g., improved encryption systems) and practical
adjustments (e.g., restricting on-line group psycho-
therapy membership to local residents who can be
screened personally before therapy begins) could
solve these problems.
NEW TOOLS IN e-THERAPY
As noted by Stamm,6 “Psychologists do not have
to become technology specialists to be competent
providers of telehealth services . . . However, to
best know when and how to use technology to sup-
port healing . . . psychologists will need more tech-
nology proficiency, particularly with computers,
than has been the norm. This is particularly true for
those who will be establishing their practices in the
coming decades.”
However, in 1996, a survey on a sample of 213 Cal-
ifornian psychologists showed that only a fraction of
psychologists was making use of computers for any-
thing other than simple word processing.22
Synchronous and asynchronous
computer-mediated communication
In the interaction between therapist and patient,
synchronous and asynchronous computer-mediated
communications (CMC) could be fruitfully ap-
plied.23,24 There are different possible scenarios: the
client and therapist could sit at their computers at
the same time interacting with each other at that mo-
ment (synchronous CMC) or when communication
is not simultaneous (asynchronous CMC).
About asynchronous CMC, electronic mails
(e-mails) are messages left by a sender in a re-
ceiver ’s electronic letterbox, which the receiver
must open before he can read the message; it can be
used to facilitate electronic communications be-
tween patients and care providers. According to
Yager,12 there are several reasons for which e-mail
can be considered as a positive enhancing tool in
therapy. Firstly, e-mail increases the frequency and
amount of time contact with clinicians and thera-
peutic processes. Secondly, the emotional value of
e-mail is relevant because patients can initiate con-
tacts when they feel most inspired and need most
to be in contact with their clinician. A third factor is
represented by the observation that quasi-daily e-
mail reports require patients to be constantly aware
378
of their behaviours and of being in therapy. Finally,
e-mail can reduce the emotional burden of patients
by encouraging and enabling them to say whatever
they care to say. Emotions can be simulated, to
some extent, by using symbolic or graphics expres-
sions (i.e., the emoticons). As underlined by Yager,12
there are also potentially negative effects, such as
lack of privacy in receiving e-mail messages, clini-
cian failure to respond in a timely and adequate
fashion, difficulty to recognize urgent and troubled
communications meriting phone and/or face-to-
face contact.
In the field of asynchronous CMC, an important
role is played by newsgroups, electronic notice
board on which users can post messages referring
to a specific topic or area of interest. Users can read
the messages by opening the notice board, and
send their own messages in turn. As with e-mail,
there is no real-time link between the computers of
the interacting subjects.
Unlike asynchronous CMC, the most important
feature of synchronous CMC is that it does provide
a real-time link between users’ computers.23 Al-
though the most frequently cited example is the
videoconference, the most widespread system is in-
ternet relay chat (IRC).
IRC is a form of synchronous CMC which en-
ables a group of users (a chat) to exchange written
messages and interact with each other in two dif-
ferent ways, by sending a message either to a speci-
fied user, or to all members of the chat.24 IRC allows
more frequent patient-therapist communications,
facilitating the tracking of a patient’s progress and
eliminating the need for an office visit.5 IRC has
been successfully used by self-help organizations.
The principle of the self-help group is that mem-
bers are allowed to share experiences, strengths
and hopes in order to solve their common prob-
lems. These groups offer both an alternative and
adjunct to the traditional psychotherapy arena.
They have in common the fact that members partic-
ipate with the expectation of receiving emotional
support and finding new ways to help themselves
cope with their shared problems. By far the largest
segment of these groups deal with substance abuse
problems (i.e., Alcoholics Anonymous).
Suler25 has analyzed the pros and cons of syn-
chronous and asynchronous communication in
telepsychotherapy. Results of this evaluation are re-
ported in Table 1.
Among synchronous CMC, video teleconferenc-
ing (VTC) is one of the most important tool for tele-
health.2,7 VTC allows participants to conduct
visually interactive electronic meetings between
CASTELNUOVO ET AL.
one or more distant locations using video cameras,
monitors, and communications. VTC can represent
a fruitful solution in rural areas, where mental
health services are limited,2,7 and patients tend to be
undertreated, receiving treatment only in emergen-
cies. Moreover, VTC can provide opportunities for
clinical consultation, assessment, diagnosis, super-
vision, home health care, medication management,
continuing education, and administrative review.
An important issue to consider in using VTC is
that patient acceptance is high, even when individ-
uals are acutely or chronically psychotic or agi-
tated.2,7 This result is confirmed by the study of
Ghosh et al.26: no differences in the therapeutic al-
liance were found when they compared 10 psycho-
therapy sessions conducted by video conference
with 10 sessions conducted face to face.
Unlike conventional telephone communications,
where parties are limited to only hearing each
other, video teleconferencing utilizes both audio
and video communications enabling participants
to see and hear each other as if they were in the
same room. VTC operates with a camera, a monitor
and a computer processor. According to Stamm,6
on the market there are different types of basic
VTC: dedicated VTC units, desktop computer VTC
units that pass data via telephone lines or via the
Internet and retrofit units that use existing televi-
sions and telephones.
Shared hypermedia tools
Hypermedia can be described as “on-line setting
where networks of multimedia nodes connected by
links are used to present information and manage
retrieval.” 27 While a hypertext consists of textual
information in the first place, hypermedia include
multiple information formats (such as visual or
musical) and animation elements. When hyperme-
dia are used as communication tools, they are de-
fined as shared hypermedia tools (SHs).28,29
SHs integrate the communication potential of-
fered by Internet with the richness of different
multimedia contents. Different users, who are si-
multaneously browsing the same website, can com-
municate with each other and share files or web
addresses. Furthermore, each user can get a con-
stantly updated list of all the other online users
who are visiting the same website.29 Usually, a SH
allows the user to conduct group and private chats,
to exchange information and files, and even to
share the same web pages. On any website, SH
users can see a list of other users and talk with
them on group and private levels.
FROM PSYCHOTHERAPY TO e-THERAPY 379

TABLE 1. PROS AND C ONS OF DIFFERENT TYPES OF CMC ACCORDING TO SULER25

Type of CMC Pros Cons

Synchronous • The ability to schedule sessions defined
by a specific, limited period of time;
• A feeling of presence created by being
with a person in real time;
• Interaction may be more spontaneous,
resulting in more revealing, uncensored
disclosures by the client.
• Making the effort to be with the person
for a specific appointment may be
interpreted as a sign of commitment
and dedication;
• Pauses in the conversation, coming
late to a session, and no-shows are not
lost as psychologically significant cues.
Asynchronous • There are no difficulties in having to
schedule a specific appointment time;
different time zones are not a problem;
• There is the simple convenience of
replying when you are ready and able
to reply;
• There is an enhanced “zone for reflection”
that allows the therapist and client to
think and compose a reply.
• The difficulties and inconvenience in
having to schedule a session at a
particular time, especially if the
client and therapist are in very
different time zones;
• There is less “zone for reflection”—
the time between exchanges to think
and compose a reply—with the possible
exception of lag, which offers a small
zone for reflection
• In the mind of the client, “therapy” may
be associated specifically with the
appointment and be less perceived as
an ongoing, daily process.
• The professional boundaries of a
specific, time–limited “appointment”
are lost.
• There is a reduced feeling of “presence”
because the client and therapist are not
together in the moment.
• Some of the spontaneity of interacting
“in the moment” is lost, along with
what spontaneous actions can reveal
about a person.
• There may be some loss of the sense of
commitment that “meeting with me
right now” can create.
• Pauses in the conversation, coming late
to a session, and no-shows are lost as
psychologically significant cues
(although pacing and length of replies in
asynchronous communication may
serve as cues).

One of the key advantages of SHs is the consoli-
dation of different forms of CMC (e-mail, IRC) into
one fully integrated interface. Many SHs also have
a search engine that can be used to find a user who
meets specific requirements (i.e., age, interests). In
this way, it is relatively easy for a therapist, for ex-
ample, to set up a group with common interests,
such as eating disorder or other mental illnesses.
Some SHs have a feature called “web tour” that is
very interesting for the possibility given to the ther-
apist to provide patients who are not familiar with
search/surf techniques in the Internet with rele-
vant information tailored to their needs.29
EVALUATION OF CMC TOOLS IN
CLINICAL PRACTICE
In order to evaluate the clinical effectiveness of
these telemedicine tools, many dimensions have to
be taken into account. Fineberg and colleagues30
distinguished several process and outcome dimen-
380
sions that might appropriately be assessed by
evaluators:
• Technical capacity—whether a technology is
safe, accurate, and reliable
• Diagnostic accuracy—whether a technology con-
tributes to a correct diagnosis
• Diagnostic impact—whether a technology pro-
vides diagnostic information that is useful in mak-
ing a diagnosis (e.g., after the telemedicine consult,
is face-to-face consultation still necessary?)
• Therapeutic impact—whether a technology in-
fluences patient management or therapy
• Patient outcome—whether a technology im-
proves patients’ health and well being
However, a more detailed point-to-point analysis
is needed to evaluate the clinical effectiveness of
CMC tools:
• Technical capacity. The technical capacity and de-
velopment of CMC tools are ensured by their ap-
plications for commercial purposes and massive
distribution over the Internet. They are first in-
tended to be effective, safe, accurate and reliable
communication tools. Their success depends pri-
marily on these aspects, including human-
interface and ergonomic issues. Of course, there
are some differences concerning the level to
which each particular CMC tools meets these re-
quirements (i.e., not all CMC tools have a user-
friendly interface).
• Diagnostic accuracy and diagnostic impact. Despite
of the great range of communication features that
characterize most of this software, they cannot re-
motely convey the richness of information (ver-
bal and non verbal) provided by direct, face to
face (f2f) interaction. The present and future chal-
lenge for CMC tools is to allow the remote recon-
struction of the clinical setting, at least for the
elements more important to ensure a functional
relationship between therapists and patients.
• Therapeutic impact. CMC tools have the potential
to fruitfully influence both patient management
and therapy. This forecast is supported by the
observation that simpler Internet-related tech-
nologies (i.e., e-mail or text-chat) have signifi-
cantly and positively affected the outcomes of
mental health sessions.31
• Patient outcome. Up to now, the majority of pro-
grams that have applied Internet related tech-
nologies for the treatment of mental disorders
have encountered positive, if not even enthusias-
tic, reactions by patients. There are several stud-
CASTELNUOVO ET AL.
ies in different therapeutic areas that reported
significant improvements of patient who were
included in Internet-supported therapy pro-
grams.31 Further research is needed to demon-
strate whether this technology (and related ones,
like SHs) can really improve patients’ health and
well being. Although there is still a lack of exper-
imental and clinical outcomes evidencing the ef-
fectiveness of CMC tools in psychotherapy, these
preliminary results are encouraging.
CONCLUSION
E-therapy could represent a useful integration
between technological tools and traditional clinical
techniques and protocols in order to improve the
effectiveness and efficiency of therapeutic process.
The impact of these new possibilities in psycho-
therapy might be very strong.
In the field of psychology, e-therapy has been
adopted only by a few clinicians, and a widespread
change in health-care organizations would be nec-
essary in order to increase the use of e-therapy
tools.32 It is necessary to consider changes in these
areas: consultations and referral patterns, ways of
payment, specialist support for primary healthcare,
co-operation between primary and secondary
healthcare, defining geographical catchment areas,
and “ownership” of patients.33
Although the main problem for the success of
e-therapy is non-technical,34 actual technology—
hardware, software, and transmission—is far from
perfect 35: the main limits are insufficient image
quality, low framing rate, flickering, and delays
that make working in front of a video terminal un-
attractive and in particular very tiring. New trans-
mission technologies, including Digital Subscriber
Line (xDSL) and cable modem, promise to provide
relevant increases in dependable bandwidth for
a small increment of price. For the success of
e-therapy applications widespread access to the In-
ternet is also required. Many applications currently
demand only moderate bandwidth and latency,
meaning that standard modem access to the Inter-
net, at 56 kbit/s may suffice.
Ensuring health-services “on-line” could also re-
duce gaps of quality in treatments between differ-
ent demographic groups,36 traditionally without
the same possibility to reach Health-care organiza-
tions: in fact there are considerable differences in
the access to psychological services in the world.
Other important issue to discuss is related to se-
curity, legal protection, and ethical aspects.37,38 In
FROM PSYCHOTHERAPY TO e-THERAPY
fact in e-therapy it is necessary to ensure a system
of control and protection.39 Although e-therapy
can dissolve the geographical boundaries, “in the
case of law, this feature is a potential problem.” 40
Possible actions in front of these issues are the eth-
ical codes of American ACA (American Counsel-
ing Association), NBCC (National Board for
Certified Counselors), and ISMHO (International
Society for Mental Health Online) that try to pro-
vide different solutions: for example, e-mail en-
cryption packages such as ZipLip or PGP (Pretty
Good Privacy) or web-based e-mail systems such
as Hotmail or Hotbot can ensure protection (and
confidentiality) and can avoid dispersion of data.
Moreover the verification of the client’s identity
and the relative procedure to determine if the ther-
apist is licensed, qualified and certified are ad-
vised by these ethical codes. Manhal-Baugus
underlines that “a site that offers this information
is Credential Check (www.mentalhelp.net), which
is a neutral third organization that verifies the
identity and credentials of on line mental health
practitioners.” 40 Most e-mail exchanges between
patient and provider involve discussions of per-
sonal health information, which must be suitably
protected from breaches of confidentiality and
from manipulation.41 However the establishing of
a firewall and the introduction of HPC (Health
Professional Card) can represent a good solution to
avoid the risk of un-authorized access to the hospi-
tal server. In general, planning all activities in
order to ensure data protection is a key factor for
the spread of e-therapy.42
In conclusion, to enhance the diffusion of
e-therapy, further research is needed. More evalua-
tion is required of clinical outcomes, organiza-
tional effects, benefits to health-care providers and
users, and quality assurance. To date, the empirical
research is not strong enough to objectively evalu-
ate all the benefits and limits of e-therapy.5 It is im-
portant to create groups of professionals with
know-how from different areas (in particular, from
psychological and technological ones) in order to
share information, results, and ideas, and to create
these multidisciplinary teams.
ACKNOWLEDGMENTS
The Commission of the European Communities
(CEC) supported the present work—specifically
the IST programme—through the VEPSY UP-
DATED (IST-2000-25323) research project (www.cy-
bertherapy.info).
381
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