E-therapy: Session on a virtual couch

Will cyberanalysis create Freud's ideal psychotherapist -- an invisible one?

In this story: Shortening disclosure time An approach with limitations RELATED STORIES, SITES

By Douglas Herbert, CNN.com Europe writer

LONDON, England (CNN) -- With $65 (£44) and a credit card, Web surfers with existential woes can book a 55-minute session on Dr. Russell Razzaque's virtual couch.

The UK-based psychiatrist heads a small but pioneering team of analysts offering real-time Internet counselling to clients who are too busy, too ill or just too shy to reveal the workings of their psyche face to face.

Razzaque's site, cyberanalysis.com, is at the vanguard of a budding movement to promote the Web as a stigma-free venue for probing sensitive problems from sexual dysfunction to broken relationships to stress disorders.

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Many of the site's visitors are newcomers to the world of psychotherapy, lured by the relative anonymity of the Web environment.

Among other services, the site publishes a regular newsletter and information on common mental health disorders, and offers a public chat room and an employee assistance program.

But cyber-therapy -- or "e-therapy" -- is a trend with a few bold-faced caveats.

Most online psychiatrists, Razzaque included, are quick with disclaimers that "e-therapy" can never substitute for traditional counselling. A patient's body language and voice can provide a therapist with vital clues about motives driving subconscious behaviour -- clues that are either absent or impossible to detect in Internet-based dialogue.

Cyberanalysis.com warns in stark red lettering that Web-based therapy is not appropriate for those with suicidal tendencies or other serious psychoses.

Yet conducted properly -- and given proper patient screening beforehand -- Web psychiatrists say e-therapy can enhance treatment by shortening the period of time it takes patients to disclose their problems.

Psychonet.fr is one of many Internet-based counselling services

In Razzaque's online practice, a patient and analyst convene at a pre-arranged time in a password-secured chat room in which only they are privy to what the other is saying.

Between sessions, patients keep an "e-diary" of their thoughts and feelings that offers the therapist an extra analytic tool.

"You can come to conclusions in two exchanges that might otherwise take seven or eight exchanges to make," said Razzaque.

"The number of exchanges may be less, but the actual degree of progress may be more."

For all its promise, though, Web therapy remains only a tiny niche market in Europe.

A combination of ethical and cultural factors, along with social policies favouring more conventional forms of mental health treatment, have kept the growth of e-therapy in check.

Even in the United States -- generally seen as a year or two ahead of Europe in the arena of electronic commerce -- only 5 percent of Americans divulge their medical records online, according to Hellen Omwando, a specialist in European healthcare e-commerce at Forrester Research.

Europeans, Omwando said, are less inclined than their transatlantic peers to seek psychiatric help. Add to that regulatory restrictions in Europe and the fact that medical care is often free and readily available in many countries, and the incentive to turn to the Internet for help is lessened.

"European regulations are such that consumer protection law is stringent," Omwando said. "In France, certain doctors can't give certain kinds of advice online." In addition, she noted that "a lot of psychiatric help can be received free of charge off-line in (Europeans') home countries."

As a result, where European online counselling sites do exist, they are mainly in the form of informational portals, often oriented towards teenagers, on topics such as abortion or drug addiction.

Unless European mental health sites are able to incorporate themselves into larger medical portals, they are likely to have trouble generating the revenues to justify their existence over the long term, Omwando says.

Even proponents of online therapy are careful to stress its limitations.

Storm King, a trainee psychologist with the U.S.-based International Society of Mental Health Online (ISMHO), said about half of the online patients queried in a recent survey had been referred by their analysts for further treatment in the brick-and-mortar world.

King also sees hidden perils in therapeutic sessions in which analysts may place too much clinical faith in the written messages they receive from an unseen client.

"Writing is a slower process, and it does tap the psyche of the people doing it," King said. "We are all conditioned from a very long history of reading the printed word to assume that it represents the well-thought-out and carefully edited views of the writer.

"What's happening on the Internet is conversational text. There's more room for editing, more careful thought, but it's still conversational. A mental health worker who is not trained in the psychology of text-based relationships can do more harm than good."

Anne Solenn Le Bihan, a psychotherapist with the Hôpital Psychiatrique de Créteil, who advises cyber-clients on Psychonet.fr, a French site, says her role is limited to a single, half-hour advisory session. To strive for anything more ambitious, she believes, would be professionally irresponsible given the constraints of the Web.

"This is not psychotherapy on the Internet," she said. "That wouldn't be possible -- the analytical framework simply isn't there." Instead, Le Bihan said she tries to draw a client out on basic issues during the "orientation" session.

"A woman might say she has sexual problems with her husband. I'll ask how long the situation has lasted."

Le Bihan rejects the notion that the physical absence of the psychoanalyst helps boost a patient's confidence.

"In a real face-to-face session, there comes a moment when the patient is lying on the couch and doesn't see the psychoanalyst.

"But even when he's lying down and doesn't see the analyst, he knows he's there. That allows for regression, it's reassuring, and at the end of the session when he gets up and sees the analyst again that provides some closure to the session."

Multimedia Assistant Miguel Castro contributed to this report.

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November 1, 1999

Cyberanalysis.com
Forrester Research
International Society for Mental Health Online
Psychonet.fr

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