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From Psychotherapy to e-Therapy: The Integration ofTraditional Techniques and New Communication Tools in

Clinical Settings

GIANLUCACASTELNUOVO, M.S., ANDREA GAGGIOLI, M.S.,FABRIZIAMANTOVANI, Ph.D., and GIUSEPPE RIVA, Ph.D.

ABSTRACT

Technology is starting to influence psychological fields. In particular, computer-mediatedcommunication (CMC) is providing new tools that can be fruitfully applied in psychother-apy. These new technologies do not substitute for traditional techniques and approaches butthey 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 helpingpeople 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. Itis important to underline that e-therapy is not an alternative treatment, but a resource thatcan be added to traditional psychotherapy. The paper also discusses how different forms ofCMC 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 isneeded to evaluate all the pros and cons.

CYBERPSYCHOLOGY & BEHAVIORVolume 6, Number 4, 2003 Mary Ann Liebert, Inc.

INTRODUCTION

PSYCHOTHERAPY IS TRADITIONALLY BASED on face-to-face interactions or other settings that in-volve verbal and non-verbal language without anytechnological mediation. However, emerging tech-nologies are modifying these traditional settings.

As indicated by Norcross et al.1

in a recent studyabout the future of psychotherapy, as we transi-tion from the industrial era to an information era, itis imperative that we remain knowledgeable ofhow changes will impact psychotherapy, psycholo-gists and our patients and a growing percentageof 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 andoptions that are available to therapists. It is thus

important to study the impact of these changes asthey occur, and it is imperative that new technolog-ical competencies be developed as clinicians inte-grate these technologies into their research andpractice. Nickelson3 defined these scenarios withthe 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 representa new theoretical approach in the field of psycho-therapy: the traditional techniques (such as thecognitive reframing in the cognitive and behav-ioral approach) and the key features of an effectivepsychotherapy (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.

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can be used for enhancing the traditional treat-ments. Possible applications are extended supportin 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 thepsychotherapy. The focus is not upon the technol-ogy but upon the process of the psychotherapy, of

diagnosis, or of other psychological activities thatcan be enhanced with the use of technologicalmedia and tools.

As noted by Grohol,4 e-therapy is a new modal-ity of helping people resolve life and relationshipissues. It uses the power and convenience of the In-ternet to allow simultaneous (synchronous) andtime-delayed (asynchronous) communication be-tween an individual and a professional. This au-thor noted that it would be inappropriate tocompare it to traditional face-to-face psychother-

apy, assessment or traditional services,4

becausee-therapy is only a resource that can be added totraditional 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 wherespecialized staff and facilities are not widespread:in these situations, the Internet could be the onlysolution to allow daily health care. The AKAMAITelemedicine Program, in the case of Hawaii, andAlaska Telemedicine Program, in the case ofAlaska, are two examples.6

POSSIBLE APPLICATIONSOF e-THERAPY

The Interneta global computer network thatconnects ever-growing numbers of local networksand computersis now one of the predominantcommunicational tools. A number of psychologicalresources are already available for professionalsand lay users.2,6,7,8 There are two main areas in psy-

chotherapy where the Internet could provideenhancing solutions for clinical applications: indi-vidual therapy and self-help therapy.

Individual telepsychotherapy

Individual telepsychotherapy could be indicatedin many situations for remote psychological con-sultations. Although efficacy of the use of remoteconsultation in psychotherapy is not yet fully ex-plored, technological advances have allowed the

publication of some pioneering work with goodand promising results. Klein and Richards, for ex-ample, investigated the effectiveness of an Internet-

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. Thesystem, composed of three main parts, is a struc-

tured assessment protocol that gives the patient adiagnosis of his/her problem, a structured proto-col for the treatment of the pathology previouslydiscovered, and an outcome protocol that as-sesses treatment effectiveness at every intermedi-ate step.10

One of the possible advantage of using e-mail asan adjunct to therapy is the patients involvementin 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 aboutpersonal issues using e-mail than when they are ina face-to-face setting.

Also, in the outpatient treatment of anorexia ner-vosa, good results have been obtained using e-mailas a therapeutic adjunct.12 Results of this studyshowed a clinical improvement for all patients in-cluded in the experimental group. Furthermore,patients accepted the use of e-mail as a therapeuticadjunct, and they considered it fruitful.

Bouchard and colleagues13 used videoconferenceto enhance a cognitive-behaviour protocol for thetreatment of patients suffering from panic disorderswith 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) andmeasures of global functioning (trait anxiety, generalimprovement). Furthermore the authors noted that agood 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 contentis a treatment program (or part of it) that may beself-administered by patients with or without thetherapists 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

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40 well-designed outcome studies of self-help treat-ments. The overall conclusions were that self-helpis clearly more effective than no treatment at alland just as effective in most cases as treatment ad-ministered by a therapist.

In order to avoid indiscriminate use of self-helpmaterial that could strengthen (and not reduce) the

psychological problems, more research is needed.15Botella10 noted that this risk of worsening the trou-

ble instead of alleviating it depends on whether theinformation is offered without following a gradualtherapeutic process.

Online self-help groups

On-line self-help groups are composed by bul-letin boards, chat rooms, news, and discussiongroups 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 onsharing 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 thegroup addresses.

The principle at the core of these groups is thesharing of experiences, strengths and hopes be-tween members in order to solve their commonproblem. These groups offer both an alternative

and adjunct to the traditional psychotherapy ap-proach. Madara17 noted that possible advantages ofa self-help group are social support, practical infor-mation, shared experiences, positive role models,helper therapy.

The effectiveness of online self-help groups isgenerally high: different researches proved their ef-ficacy as support tools in the treatment of eatingdisorders,18,19 depression,20 and headache.21

Humphreys and colleagues16 noted that ethicalproblems have to be taken into account for psychol-

ogists in Internet-based groups:

Location: It is very difficult for a psychologistto competently execute ethical responsibilitieswhere on-line group members usually comefrom 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 clients computer(e.g., a family member) could sign into on-line

group psychotherapy by using the passwordand the name of the actual client. Individualscannot be easily identified over the Internet.

Privacy: Information exchanged in on-line selfhelp groups could be typed, recorded, copied,and distributed, reducing clients privacy.

However future technological developments(e.g., improved encryption systems) and practicaladjustments (e.g., restricting on-line group psycho-

therapy membership to local residents who can bescreened personally before therapy begins) couldsolve these problems.

NEW TOOLS IN e-THERAPY

As noted by Stamm,6 Psychologists do not haveto become technology specialists to be competentproviders 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 forthose who will be establishing their practices in thecoming decades.

However, in 1996, a survey on a sample of 213 Cal-ifornian psychologists showed that only a fraction ofpsychologists was making use of computers for any-thing other than simple word processing.22

Synchronous and asynchronous

computer-mediated communicationIn the interaction between therapist and patient,

synchronous and asynchronous computer-mediatedcommunications (CMC) could be fruitfully ap-plied.23,24 There are different possible scenarios: theclient and therapist could sit at their computers atthe same time interacting with each other at that mo-ment (synchronous CMC) or when communicationis not simultaneous (asynchronous CMC).

About asynchronous CMC, electronic mails(e-mails) are messages left by a sender in a re-

ceivers electronic letterbox, which the receivermust open before he can read the message; it can beused to facilitate electronic communications be-tween patients and care providers. According toYager,12 there are several reasons for which e-mailcan be considered as a positive enhancing tool intherapy. Firstly, e-mail increases the frequency andamount of time contact with clinicians and thera-peutic processes. Secondly, the emotional value ofe-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 isrepresented by the observation that quasi-daily e-mail reports require patients to be constantly aware

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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 whateverthey care to say. Emotions can be simulated, tosome 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 adequatefashion, difficulty to recognize urgent and troubledcommunications meriting phone and/or face-to-face contact.

In the field of asynchronous CMC, an importantrole is played by newsgroups, electronic notice

board on which users can post messages referringto a specific topic or area of interest. Users can readthe messages by opening the notice board, andsend their own messages in turn. As with e-mail,

there is no real-time link between the computers ofthe interacting subjects.Unlike asynchronous CMC, the most important

feature of synchronous CMC is that it does providea real-time link between users computers.23 Al-though the most frequently cited example is thevideoconference, 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 writtenmessages 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 allowsmore frequent patient-therapist communications,facilitating the tracking of a patients progress andeliminating 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, strengthsand hopes in order to solve their common prob-lems. These groups offer both an alternative andadjunct to the traditional psychotherapy arena.They have in common the fact that members partic-

ipate with the expectation of receiving emotionalsupport and finding new ways to help themselvescope with their shared problems. By far the largestsegment of these groups deal with substance abuseproblems (i.e., Alcoholics Anonymous).

Suler25 has analyzed the pros and cons of syn-chronous and asynchronous communication intelepsychotherapy. 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 conductvisually interactive electronic meetings between

one or more distant locations using video cameras,monitors, and communications. VTC can representa fruitful solution in rural areas, where mentalhealth services are limited,2,7 and patients tend to beundertreated, receiving treatment only in emergen-cies. Moreover, VTC can provide opportunities forclinical consultation, assessment, diagnosis, super-

vision, home health care, medication management,continuing education, and administrative review.

An important issue to consider in using VTC isthat 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 ofGhosh et al.26: no differences in the therapeutic al-liance were found when they compared 10 psycho-therapy sessions conducted by video conferencewith 10 sessions conducted face to face.

Unlike conventional telephone communications,

where parties are limited to only hearing eachother, video teleconferencing utilizes both audioand video communications enabling participantsto see and hear each other as if they were in thesame room. VTC operates with a camera, a monitorand a computer processor. According to Stamm,6

on the market there are different types of basicVTC: dedicated VTC units, desktop computer VTCunits that pass data via telephone lines or via theInternet and retrofit units that use existing televi-sions and telephones.

Shared hypermedia tools

Hypermedia can be described as on-line settingwhere networks of multimedia nodes connected bylinks are used to present information and manageretrieval.27 While a hypertext consists of textualinformation in the first place, hypermedia includemultiple information formats (such as visual ormusical) 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 differentmultimedia contents. Different users, who are si-multaneously browsing the same website, can com-municate with each other and share files or webaddresses. Furthermore, each user can get a con-stantly updated list of all the other online userswho are visiting the same website.29 Usually, a SHallows the user to conduct group and private chats,to exchange information and files, and even toshare the same web pages. On any website, SH

users can see a list of other users and talk withthem on group and private levels.


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One of the key advantages of SHs is the consoli-dation of different forms of CMC (e-mail, IRC) intoone fully integrated interface. Many SHs also havea search engine that can be used to find a user whomeets specific requirements (i.e., age, interests). Inthis 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 INCLINICAL PRACTICE

In order to evaluate the clinical effectiveness ofthese telemedicine tools, many dimensions have to

be taken into account. Fineberg and colleagues30

distinguished several process and outcome dimen-


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

Type of CMC Pros Cons

Synchronous The ability to schedule sessions defined The difficulties and inconvenience inby a specific, limited period of time; having to schedule a session at a

A feeling of presence created by being particular time, especially if thewith a person in real time; client and therapist are in very

Interaction may be more spontaneous, different time zones;resulting in more revealing, uncensored There is less zone for reflectiondisclosures by the client. the time between exchanges to think

Making the effort to be with the person and compose a replywith the possiblefor a specific appointment may be exception of lag, which offers a smallinterpreted as a sign of commitment zone for reflectionand dedication; In the mind of the client, therapy may

Pauses in the conversation, coming be associated specifically with thelate to a session, and no-shows are not appointment and be less perceived aslost as psychologically significant cues. an ongoing, daily process.

Asynchronous There are no difficulties in having to The professional boundaries of a

schedule a specific appointment time; specific, timelimited appointmentdifferent time zones are not a problem; are lost.

There is the simple convenience of There is a reduced feeling of presencereplying when you are ready and able because the client and therapist are notto reply; together in the moment.

There is an enhanced zone for reflection Some of the spontaneity of interactingthat allows the therapist and client to in the moment is lost, along withthink and compose a reply. what spontaneous actions can reveal

about a person.

There may be some loss of the sense ofcommitment that meeting with me

right now can create. Pauses in the conversation, coming late

to a session, and no-shows are lost aspsychologically significant cues(although pacing and length of replies inasynchronous communication mayserve as cues).

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sions that might appropriately be assessed byevaluators:

Technical capacitywhether a technology issafe, accurate, and reliable

Diagnostic accuracywhether a technology con-tributes to a correct diagnosis

Diagnostic impactwhether 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 impactwhether a technology in-fluences patient management or therapy

Patient outcomewhether a technology im-proves patients health and well being

However, a more detailed point-to-point analysisis 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 massivedistribution over the Internet. They are first in-tended to be effective, safe, accurate and reliablecommunication tools. Their success depends pri-marily on these aspects, including human-interface and ergonomic issues. Of course, thereare some differences concerning the level towhich each particular CMC tools meets these re-

quirements (i.e., not all CMC tools have a user-friendly interface).

Diagnostic accuracy and diagnostic impact. Despiteof the great range of communication features thatcharacterize most of this software, they cannot re-motely convey the richness of information (ver-

bal and non verbal) provided by direct, face toface (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 theelements more important to ensure a functional

relationship between therapists and patients. Therapeutic impact. CMC tools have the potential

to fruitfully influence both patient managementand therapy. This forecast is supported by theobservation that simpler Internet-related tech-nologies (i.e., e-mail or text-chat) have signifi-cantly and positively affected the outcomes ofmental 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-

ies in different therapeutic areas that reportedsignificant improvements of patient who wereincluded 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 andwell being. Although there is still a lack of exper-

imental and clinical outcomes evidencing the ef-fectiveness of CMC tools in psychotherapy, thesepreliminary results are encouraging.

CONCLUSION

E-therapy could represent a useful integrationbetween technological tools and traditional clinicaltechniques and protocols in order to improve theeffectiveness 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 widespreadchange in health-care organizations would be nec-essary in order to increase the use of e-therapytools.32 It is necessary to consider changes in theseareas: consultations and referral patterns, ways ofpayment, specialist support for primary healthcare,co-operation between primary and secondaryhealthcare, defining geographical catchment areas,and ownership of patients.33

Although the main problem for the success ofe-therapy is non-technical,34 actual technologyhardware, software, and transmissionis far fromperfect35: the main limits are insufficient imagequality, low framing rate, flickering, and delaysthat make working in front of a video terminal un-attractive and in particular very tiring. New trans-mission technologies, including Digital SubscriberLine (xDSL) and cable modem, promise to providerelevant increases in dependable bandwidth fora small increment of price. For the success of

e-therapy applications widespread access to the In-ternet is also required. Many applications currentlydemand 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 withoutthe same possibility to reach Health-care organiza-tions: in fact there are considerable differences inthe 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


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fact in e-therapy it is necessary to ensure a systemof control and protection.39 Although e-therapycan dissolve the geographical boundaries, in thecase 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 (InternationalSociety for Mental Health Online) that try to pro-vide different solutions: for example, e-mail en-cryption packages such as ZipLip or PGP (PrettyGood Privacy) or web-based e-mail systems suchas Hotmail or Hotbot can ensure protection (andconfidentiality) and can avoid dispersion of data.Moreover the verification of the clients identityand 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 informationis Credential Check (www.mentalhelp.net), whichis a neutral third organization that verifies theidentity and credentials of on line mental healthpractitioners.40 Most e-mail exchanges betweenpatient and provider involve discussions of per-sonal health information, which must be suitablyprotected from breaches of confidentiality andfrom manipulation.41 However the establishing ofa firewall and the introduction of HPC (HealthProfessional Card) can represent a good solution toavoid the risk of un-authorized access to the hospi-

tal server. In general, planning all activities inorder to ensure data protection is a key factor forthe spread of e-therapy.42

In conclusion, to enhance the diffusion ofe-therapy, further research is needed. More evalua-tion is required of clinical outcomes, organiza-tional effects, benefits to health-care providers andusers, and quality assurance. To date, the empiricalresearch 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, frompsychological and technological ones) in order toshare information, results, and ideas, and to createthese multidisciplinary teams.

ACKNOWLEDGMENTS

The Commission of the European Communities(CEC) supported the present workspecificallythe IST programmethrough the VEPSY UP-

DATED (IST-2000-25323) research project (www.cy-bertherapy.info).

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