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The emerging role of e-therapy: online services proving to be effective.

Even though most EAPs today have some kind of website presence, the use of online or web-based tools for the delivery of clinical services between EAP counselors and employees is far less common (Richard, 2009). However, e-therapy is advancing as a new practice model with early users being more prevalent among Canadian EAPs (Parnass et al., 2008; Wittes & Speyer, 2009).

One reason that e-therapy is likely to continue to grow is due to the strong research support that has emerged over the last decade that provides evidence of its clinical effectiveness, particularly for common types of mild to moderate mental cases that are often appropriate for EAP counseling services. This article provides a summary of some of this research and what it means for the EAP field.

What is E-Therapy?

Technological forms of mental health and addiction treatment are now widely available and are referenced by a variety of names: online therapy, cybercounseling, e-counseling, Internet-based therapy, among others (Christensen & Hickie, 2010). Online therapy has been defined as "any type of professional therapeutic interaction that makes use of the Internet to connect qualified mental health professionals and their clients" (Rochlen, Zack & Speyer, 2004).

The majority of online therapy today takes place via e-mail. E-mail is "asynchronous," meaning that communication does not take place in "real time" but rather in delayed exchanges between client and the therapist as they respond to one another--often within several days from the last contact. The practice of online therapy using synchronous live exchanges is not as prevalent. This format takes place in "real time," often using chat-based computer interfaces (e.g., via Instant Messaging--IM) or specialized website tools (e.g., via Skype and others) for live video-conferencing sessions between client and counselor (Richardson et al., 2009).

Other applications in this area feature the interaction of multiple clients at the same time for supportive group therapy, with the interaction managed by a counselor (Griffiths, Crisp, Christensen, Mackinnon & Bennett, 2010). As a result, a variety of Internet-based approaches for the clinical treatment of mental health and substance abuse disorders offer promising alternative and supportive methods for more commonly used in-person and telephonic modalities.

Is it Effective?

Perhaps contrary to current opinion among more traditionally trained clinicians, a growing body of international research indicates that Internet-based delivery of mental health psychotherapy services is actually as effective as traditional face-to-face treatment conducted in clinical offices for many common mental health conditions. There have been more than one dozen studies using a randomized control trial (RCT) experimental research design that have tested the general clinical effectiveness of Internet-based therapy approaches (Griffiths & Christensen, 2006). There are also twice as many additional studies that have been performed using a variety of less rigorous research designs. All told, the general finding from these studies is of positive clinical results, with many on par with traditional studies of in-person therapy (see reviews by Barak, Hen, Boniel-Nissim & Shapira, 2008; Reger & Gahm, 2009; Rochlen, Zack & Speyer, 2004).

For example, in one meta-analytic review of 12 studies involving over 2,000 individual cases, the effect sizes for Internet interventions were mostly in the medium size range of 0.20 to 0.50, which is similar to that often found in outcome studies of face-to-face (FTF) therapy (Spek et al., 2007). A second example specific to EAP comes from a recent Canadian study of EAP clients who were first assessed by telephone for risk and appropriateness and then assigned to either FTF or online counseling, which found no differences in clinical outcome measures between the two therapy modalities (Murphy et al., 2009).

The accompanying table on this page describes a major study using an RTC design that was published in the prestigious scientific journal, The Lancet.

These studies demonstrate that Internet-based clinical interventions are often able to produce favorable behavioral changes for a variety of mental health conditions. These kinds of services also are uniquely appealing as an access point for professional care for some people who may otherwise go untreated because they do not like certain aspects of FTF therapy and for those who already trust and use technology as an everyday part of their lives (Leibert & Archer, 2006; Young, 2005).

What is Appropriate for E-Therapy?

Most of the research on the effectiveness of e-therapy has focused on patients suffering from depression and has tested the use of cognitive behavioral therapy (CBT) (Andersson, 2009). Positive clinical outcomes for e-therapy have also been obtained for patients with disorders other than depression, including:

* Anxiety (Reger & Gahm, 2009);

* Eating disorders (Winzelberg et al., 2000);

* Panic disorder (Wims, Titov, Andrews & Choi, 2010);

* Post-traumatic stress disorder (Litz, Engel, Bryant & Papa, 2007); and

* Social phobias (Titov, Andrews, Choi, Schwencke & Mahoney, 2008).

However, cases involving the potential for crisis or suicide are not appropriate for online treatment.

Why is it Effective?

Given the lack of verbal and non-verbal interaction between the therapist and client, some may wonder how e-mail and related online forms of e-therapy can be effective. Obvious benefits include the ease of access, low or no cost, and sense of privacy that overcomes the stigma of going to a counselor's office--and yet these same benefits are shared by telephonic counseling. However, one of the reasons for the success of e-mail therapy is due to the therapeutic role of writing that is involved and the investment of time required for personal reflection (Heyman & Speyer, 2010). In addition, there is also the reinforcement of getting prompt feedback from one's therapist and the tangible value of having actual written notes of the issue and the clinical advice that can be referred to when one confronts problems or at-risk situations in the future.

Implications for EAP Clinical Staff

As with any advancement in clinical care, there are important ethical, professional, and pragmatic issues that must be addressed. Providing e-therapy is not the same as providing in-person or telephonic therapy. Many scholars have recognized the need for specialized clinical training and technical skills required for effective and ethical use of the Internet for mental health care delivery (Murphy, MacFadden & Mitchell, 2008). Clinicians providing e-therapy must also follow ethical guidelines as they apply to these new delivery modalities (Fisher & Fried, 2003). Please see the table at the end of this article for a listing of resources.

Finally, there is the important implication of licensing to consider in providing e-therapy services. According to the EAPA ethical guidelines (London, Nagel & Anthony, 2011), the geographical location of an EA professional should be clearly stated in the Informed Consent language. If the EA clinician is licensed within a specific jurisdiction, the statement of understanding that is shared with the client should state that the client understands that the services are provided under the laws or jurisdiction of the relevant country, state or region where the counselor resides.


Research indicates that Internet-based methodologies can be effectively used either as an alternative access route to mental health care or as a supplemental form of care. Certain sub-populations of employees and family members are also receptive to using technology-based mental health care services. Internet tools and wireless applications are becoming more sophisticated and safer for clinical use.

As a result, it is time for EAPs to consider engaging their organizational clients in discussions about how to go beyond just having a website with educational resources to also offering the option of technology-based mental health treatment services.

Research Study Example of Internet Treatment for Depression

A large RCT test was conducted in the general practice health care system in Great Britain (Kessler et al., 2009). It used an online, real-time CBT intervention for 113 patients, who were compared to 97 cases with care provided by a general medical practitioner. In this study, an in-person assessment of diagnosis and symptom severity was made, followed by a series of ten hour-long sessions of online text-based interaction with a therapist. After treatment, the number of patients whose depression symptoms improved was significantly higher in the online treatment group (38%) than in the usual care control group (23%). This effect was retained at the 8-month follow-up (42% and 26% respectively).


Andersson, G. (2009). Using the Internet to provide cognitive behaviour therapy. Behavior Research and Therapy, 47(3), 175-180.

Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2), 109-160.

Christensen, H., & Hickie, I. B. (2010). E-mental health: A new era in delivery of mental health services. Medical Journal of Australia, 192(11), S2-S3.

Fisher, C. B., & Fried, A. L. (2003). Internet-mediated psychological services and the American Psychological Association Ethics Code. Psychotherapy: Theory, Research, Practice, Training, 40(1-2), 103-111.

Griffiths, K. M., & Christensen, H. (2006). Review of randomized controlled trials of Internet interventions for mental disorders and related conditions. Clinical Pscyhology, 10(1), 16-29.

Griffiths, K. M., Crisp, D., Christensen, H., Mackinnon, A. J., & Bennett, K. (2010). The ANU Well Being study: A protocol for a quasi-factorial randomised controlled trial of the effectiveness of an Internet support group and an automated Internet intervention for depression. BMC Psychiatry, 10(20). Online publication. doi:10.1186/1471-244X-10-20

Heyman, C., & Speyer, C. (2010). The writing cure: Therapeutic effectiveness via the Internet. TILT Magazine: Therapeutic Innovations in Light of Technology, 1(1), 9-11.

Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., ... Peters, T. J. (2009). Therapist-delivered Internet psychotherapy for depression in primary care: A randomised controlled trial. Lancet, 374(9690), 628-634.

Leibert, T., & Archer, J. (2006). An exploratory study of client perceptions of Internet counseling and the therapeutic alliance. Journal of Mental Health Counseling, 28(1), 69-83.

Litz, B. T., Engel, C. C., Bryant, R. A., & Papa, A. (2007). A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. American Journal of Psychiatry, 164(11), 1676-1684.

London, M., Nagel, D. M., Anthony, K. (2011). An ethical framework for the use of technology in EAPs. TILT Magazine, l(6), 26-33.

Murphy, L. J., MacFadden, R. J., & Mitchell, D. L. (2008). Cybercounseling online: The development of a university-based training program for e-mail counselling. Journal of Technology in Human Services, 26(2/4), 447-469.

Murphy, L., Parnass, P., Mitchell, D. L., Hallett, R., Cayley, R, & Seagram, S. (2009). Client satisfaction and outcome comparisons of online and face-to-face counselling methods. British Journal of Social Work, 39(4), 627-640.

Parnass, R, Mitchell, D., Seagram, S., Wittes, P., Speyer, C., & Fournier, R. (2008, April). Delivering employee eCounseling programs: Issues and experiences. Presented at the Annual Institute of the Employee Assistance Society of North America, Vancouver, BC, Canada.

Reger, M. A., & Gahm, G. A. (2009). A meta-analysis of the effects of internet- and computer-based cognitive-behavioral treatments for anxiety. Journal of Clinical Psychology, 65(1), 53-75.

Richard, M. A. (2009). Cyberspace: The new frontier for employee assistance programs. In M. A. Richard, W. G. Emener, & W. S. Hutchison, Jr. (Eds.), Employee assistance programs: Wellness/enhancement programming, 4th Edition (pp. 288-292). Springfield, IL: Charles C Thomas.

Richardson, L. K., Frueh, B. C., Grubaugh, A. L., Egede, L., & Elhai, J. D. (2009). Current directions in videoconferencing tele-mental health research. Clinical Psychology: Science and Practice, 16(3), 323-338.

Rochlen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269-283.

Spek, V., Cuijipers, P., Nyklicek, 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(3), 319-328.

Titov, N., Andrews, G., Choi, I., Schwencke, G., & Mahoney, A. (2008). Shyness 3: Randomized controlled trial of guided versus unguided Internet-based CBT for social phobia. Australia and New Zealand Journal of Psychiatry, 42(12), 1030-1040.

Young, K. S. (2005). An empirical examination of client attitudes towards online counseling. CyberPsychology and Behavior, 8(2), 172-177.

Wims, E., Titov, N., Andrews, G., & Choi, I. (2010). Clinician-assisted Internet-based treatment is effective for panic: A randomized controlled trial. Australian and New Zealand Journal of Psychiatry. 44(7), 599-607.

Winzelberg, A., Eppstein, D., Eldredge, K., Wilfley, D., Dasmahapatra, R., Dev, P., & Barr, T. C. (2000). Effectiveness of an Internet-based program for reducing risk factors for eating disorders. Journal of Consulting and Clinical Psychology, 68(2), 346-350.

Wittes, P., & Speyer, C. (2009, May). Online counseling: A key component of 21st century EAP in a global economy. Presented at the Annual Institute of the Employee Assistance Society of North America, Denver, CO.

Resources on Internet-based Mental Health Treatment:


Anthony, K., Nagel, D.M., & Goss, S. (2010). The use of technology in mental health: applications, ethics and practice. Springfield, IL: Charles C. Thomas.

Centore, A. J. (2007). The therapist's clinical guide to online counseling and telephone counseling: The definitive training guide for clinical practice. Cambridge, MA: Author.

Jones, G., & Stokes, A. (2009). Online counseling: A handbook for practitioners. New York: Palgrave MacMillan.

Kraus, R., Zack, J., & Strickler, G. (Eds.). (2004). Online counseling: A handbook for mental health professionals. New York: Elsevier Academic Press.

Suler, J. (2009). The psychology of cyberspace. Online book available at:


Annals of Behavioral Medicine, 2009, Volume 38, Issue 1

Counselling, Psychotherapy, and Health, 2009, Volume 5, Issue 1

Journal of Clinical Psychology, 2004, Volume 60, Issues 2-3.

Psychotherapy: Theory, Research, and Practice, 2003, Volume 40, Issues 1-2


Research publications at e-hub e-mental Health Research & Development (Australian National University). Website:

Online Therapy Institute and TILT Magazine (Therapeutic Innovations in Light of Technology). Website:

By Mark Attridge, Ph.D., M.A.

Mark Attridge is an independent research scholar in the field of workplace mental health and is president of Attridge Consulting, Inc. in Minneapolis. He can be reached at (612) 889-2398 or or visit
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Author:Attridge, Mark
Publication:The Journal of Employee Assistance
Article Type:Cover story
Geographic Code:1USA
Date:Oct 1, 2011
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