Net Gains for Mental Health

From The Times
March 3, 2008

The news that antidepressants may not be very effective could open the door for online therapy

Type “online counsellor” into any internet search engine and hundreds of thousands of results will appear: with a click of the mouse, and a glance at a screen, you, too, can be cured of your depression, phobias and eating disorders, go the claims. Unbelieveable? Perhaps not. A growing body of research has found that when - and this is crucial - it is carried out responsibly, and kept specific, online therapy is one of the most effective ways of dealing with the rising levels of mental ill-health.

That there is a need for treatments other than pills is undoubted. As many as one person in five suffers depression at some point. And of the estimated 1.3 million people who suffer from its severest form, only around 10 per cent receive treatment. According to Mind, the mental-health charity, many depressed patients wait a year or more before getting an appointment with a medical professional on the NHS. Now, though, there are other options, such as self-help CD-roms or, increasingly, online counselling with a professional via internet chatrooms and e-mail correspondence.

The evidence to support the validity of this new approach is mounting, notably in the area of computerised cognitive behavioural therapy (CCBT), an electronic version of cognitive behavioural therapy (CBT). In normal practice CBT works by helping people to unlearn obstructive and destructive thought processes and behavioural patterns. Similarly, CCBT uses prompts and cues to alter the way someone perceives and reacts to a given situation. So long as the online therapist belongs to a reputable body such as the British Association for Counselling and Psychotherapy (BACP), experts say there is no reason why mild depression should not be treated in this way. A study by City University in London indicated that more than three people in five with mild depression could stop treatment after eight days of the online approach. Another, by Swedish researchers, found that computer therapy is as effective as face-to-face treatment for moderate to mild depression.

Computer-based therapies have gained a positive reputation already, paving the way for web-related treatments, especially if the problem is specific. Two years ago the Government's own medical treatment watchdog, the National Institute for Health and Clinical Excellence (NICE), gave its backing to two computer-based packages proven by researchers to help to treat anxiety, phobias and mild depression: Beating the Blues, a self-help software package for treating anxiety and depression, and FearFighter, a web-based package aimed at people with panic and anxiety disorders or phobias.

FearFighter, developed in conjunction with Isaac Marks, Professor Emeritus of the Institute of Psychiatry (IoP) at King's College London, teaches patients to recognise the signs that trigger phobias and panic attacks in the hope that they will learn to prevent one. Patients need a referral for access and are also shown how to cope with their fears if an attack occurs. “Repetitive parts of the therapy are done by a computer, which can then make decisions based on their answers,” says Marks. “A computer can train them to think in different ways.” Once they have a logon ID number, usually issued by a practice nurse at their GP's surgery, and have received 15 minutes of training on the system, patients can access FearFighter from anywhere and at anytime, which is surely part of the appeal for the time-crunched.

At the IoP, experts are assessing the effectiveness of a similar treatment for people with eating disorders. In collaboration with Beat (formerly the Eating Disorders Association) and with funding from the Medical Research Council, they are conducting a trial among 13 to 20-year-old sufferers of bulimia nervosa to see if an interactive self-help program, Overcoming Bulimia, helps them to improve their behaviour. A separate study has already shown the computer program, which involves eight sessions and assigns an e-mail support clinician to each patient, to be successful in adults with bulimia. “It may appeal to younger women who don't seek help through conventional health service routes because they are ashamed about their abnormal eating patterns,” says Professor Ulrike Schmidt, who is heading the study. Results are expected later this year.

Phillip Hodson, a BACP spokesman, says that in many ways online therapy is one of the more promising developments of the internet because it opens up treatment options to people in rural areas as well as to those with a disability. “If you live in deepest Wales, say, your access to a counsellor is limited,” Hodson says. “There are more registered therapists in the London NW3 postcode area than there are in all of Wales.” Anyone who feels too stigmatised to seek treatment for a mental health problem might also benefit. “It has the potential to be particularly useful for young men who are notoriously unwilling to sit on a therapist's couch,” he adds. “If they can hide behind a computer screen, they feel less exposed.”

But there are inevitable pitfalls. As a profession, counselling remains unregulated, meaning that vulnerable people seeking help can easily fall prey to fraudulent practitioners. “Anyone can legally set themselves up as a therapist and it is especially common on the internet,” Hodson says. “It can be difficult for people to work out the good sites from the bad ones.” Dearbhla McCullough, a psychologist at Roehampton University in London, says that, in the wrong hands, approaches such as CBT are potentially dangerous.

“There are companies offering two-day courses in what is essentially quite a powerful psychological tool when used correctly,” she says. “Well-qualified CBT practitioners undergo two years of intense training. To be treated by someone who does not have this level of understanding could actually worsen a patient's mental health problems.”

Critics also argue that the anonymity of computer therapy provides a smokescreen for someone's true emotions, allowing them to hide rather than reveal their innermost feelings. There are also fears that people with psychiatric problems too complex to be cured by a computer, such as severe depression, bipolar disorder and suicidal tendencies, might gain access to a site that gives improper advice. Jesse Wright, a researcher in psychiatry at the University of Louisville who has studied the trend, says the click of a mouse is never going to replace human interaction. “A real-life therapist is creative in each situation, doing the things a computer can't, such as expressing empathy and responding to the idiosyncracies of a person's life situation and individual history.”

But the experience of the Buckinghamshire-based chartered psychologists Sue Wright and Nadine Field, both of whom work within the NHS, suggests otherwise. Having set up a service called Psychology Online, in which patients can receive real-time counselling via the internet, Wright says that she has been surprised at the responses of many of those who have used it.

“Because of the anonymity, we have found that people tend to reveal more about themselves online,” says Wright. “People with anxiety-based disorders often find it too traumatic to visit a counsellor in person. It is an approach that is also very good for conditions that might cause people to feel a degree of shame, such as drugs or alcohol addiction.”

Currently the subject of a trial by the University of Bristol, the site is being used by GPs who are referring patients with psychological issues to Psychology Online for free treatment. The hope is that this is another approach that may be adopted more widely within the NHS.

Hodson says that the Government is in the process of enforcing stricter regulations about psychological therapies that “should make it easier for the general public to ensure their own safety”. However, he adds, the internet remains riddled with loopholes. “People just need to be cautious and careful, doing research before they sign up for treatment online,” he says. “A good online therapist can be as beneficial as a session face-to-face in some circumstances. What you lose in eye contact with a therapist you can gain in other ways.”