Psychology and the Internet: Where are we and where to from here?

The term ‘tele-health’ was used by Glueckauf and colleagues (2003) to define “the use of telecommunications and information technologies to provide access to health information and services across a geographical distance, including (but not limited to) consultation, assessment, intervention, and follow-up programs to ensure maintenance of treatment effects” (p. 160). A range of related terms have also infiltrated the vernacular of psychologists in discussing specific remote or Internet-based psychological services, such as ‘e-mental health’, ‘e-therapy’ and ‘e-counselling’. Rapid progress in computers, smartphones and other information technologies has seen the Internet fast become a primary means both for communication between individuals and for managing and gathering health information. This progress is reflected by the growing sophistication of the community with respect to the Internet and related technologies. Such factors make it possible to provide health and mental health information to groups that might not normally present for services.

As such, the Internet is a fertile environment for the expertise that psychologists offer across a range of spheres, including health and mental health practice, education and training, research and development, and occupational, social and policy spheres. In particular, the Internet offers a potent modality for facilitating communication between experts and consumers and, as such, can be used successfully to disseminate health information and evidence-based psychological treatments. In addition to providing multiple opportunities for psychology and psychologists, it is imperative that psychologists engage with online developments in order to imbue the area with the professional standards and evidence base associated with our profession and discipline. This article gives an overview of some of the benefits and challenges, existing and likely future services, and possible applications within the Australian health system.

Dissemination of psychological resources and expertise via the Internet

Over the years, numerous authors have identified types of psychological services that can be provided via the Internet and the sorts of capabilities that can facilitate such provision. Such services and capabilities are broadening rapidly with technological advances, improved accessibility for technology through the community, and increasing sophistication amongst psychologists and related professions with respect to use of technologies. Reflecting the broad purview of psychology, Barak (1999) reviewed a range of Internet resources that relate directly to psychology, including:

• Information about psychological services and psychological concepts and issues, which could facilitate prevention or resilience and augmentation of wellbeing
• Psychological tests and assessments
• Psychological advice through e-mail or e-bulletin boards
• Self-help applications, which also include online structured psychological treatments
• Email-based personal counselling and therapy
• Real-time counselling through chat, web telephony, and videoconferencing
• Group-based counselling, inclusive of support groups and discussion groups
• Psychological and social research.

As technological advances have multiplied (e.g., smartphones, tablets, virtual reality platforms, apps, etc.), so too have the types of available and potential psychological services that can be facilitated through the Internet. For instance, Barak, Klein and Proudfoot (2009) have since included games, virtual environments, podcasts and even simulated therapists in their review of the range and types of capabilities or facilities that can facilitate psychological services via the Internet.

Psychological therapy

With specific reference to psychological therapy delivery, the balance between the contributions of software and human therapist vary, ranging from fully automated online self-help programs used without therapist guidance, through use of self-help materials with some therapist support (e.g., by email), to the Internet being used primarily as a communication modality for therapist interaction. Castelnuovo, Gaggioli, Mantovani and Riva (2003) distinguished between synchronous computer-mediated communication which is simultaneous in real time (e.g., videoconferencing and text-based relay chat), and asynchronous communication, which is not immediate, as reflected in email interactions or via electronic notice boards where users post messages on specific topics. Suler (2000) had earlier identified up to five dimensions for understanding how psychotherapy could be conducted through the Internet, local networks and private computers (synchronous/asynchronous, text/sensory, actual/imaginary, automated/interpersonal, invisible/present). He considered that the “various dimensional elements can be combined and sequenced in a variety of ways in order to design a therapeutic encounter that addresses the specific needs of individual clients” (p.151).

More recent technological developments allow individualised content depending on personal client preferences or even algorithms based on structured online assessments. Sensory elements (e.g., audiovisual content), downloadable content, synchronous or asynchronous feedback, and use of imagery and even avatars have augmented engagement with programs. The advent of social media allows opportunities to promote peer interaction, while multimedia and video-chat capabilities facilitate opportunities for remote contact, exposure, modelling and personal stories of lived experience. Of course, the introduction of the National Broadband Network is likely to increase technology-based capabilities and capacity, decrease technical costs and improve accessibility and, therefore, increase opportunities and use of the Internet for psychological services.

The research literature has been overwhelmingly supportive of the efficacy of online treatments. Case studies, randomised control trials and meta-analyses have all shown online treatment to be safe and effective, although therapist-assisted programs tend to be more effective than those that are automated or self-help (Bennett-Levy, Richards, Farrand, et al., 2010). However, maintaining engagement with treatment remains an important issue and there is a need for psychological research to conceptualise the processes involved in engaging people in Internet-delivered therapy, in the same way that the therapeutic relationship has been conceptualised in traditional therapies. There are likely to be important differences in how people use the Internet, how the absence of usual social cues impacts on therapeutic interactions and in behavioural change models.

Incorporation into routine delivery

Online services are not necessarily a substitute or an alternative to face-to-face psychological assessment or therapy; rather, they can be a resource that can be added to traditional treatment offerings or can be prescribed as part of a stepped care plan of intervention. The blending of therapist input and automated programs represents an important element of future treatment delivery. For instance, given limits to the number of rebated psychology sessions through Medicare, it might be possible to provide psychoeducational material to clients via the Internet prior to the commencement of formal treatment. Alternatively, follow-up and relapse prevention could be facilitated through structured automated or therapist-assisted online programs, through audio/videoconferencing or chat communication, or even through online moderated support groups. Meanwhile, computer-mediated communication provides a means of increasing the accessibility of specialist expertise. For instance, psychologists with specialist skills for complex disorders can service people in rural or remote areas via videoconferencing whilst they are being supported face-to-face by professionals in local communities.

The combinations are as endless as the available options and the resources of the psychologists and the client. However, the development of models of care may require consideration of subsidies, rebates or vouchers for specific combinations of service, for instance, via stepped- or managed-care funding models. Such models of care will need to consider workforce data which supports an increasing unmet need for psychological services (Health Workforce Australia, 2014), with greater competencies in psychological assessment, conceptualisation and treatment required as complexity and comorbidity increase.

Leadership from psychology

Already, over the past 15 years, the psychology discipline and profession have been at the forefront of developments in this space, particularly with regard to psychological treatment and assessment via the Internet. The expertise of psychologists has been instrumental in developing and disseminating evidence-based assessments and interventions, as well as training and supervision applications. Psychologists have also led clinical trials to evaluate Internet-based treatments, working within multi-disciplinary frameworks to facilitate dissemination of these applications across various domains (e.g., working with technology experts and general medical practitioners through primary care networks to disseminate anxiety treatments; working with consumers within a recovery framework by moderating online discussion groups, etc.) and translating research findings into policy (e.g., Australian Government Department of Health and Ageing, 2012; Christensen, Griffiths & Evans, 2002; Griffiths Blomberg & Christensen, 2003). In more recent times, online services have been advanced beyond the high prevalence disorders, using professionals and peer supports, utilising frameworks that go beyond therapy (e.g., recovery, prevention, early intervention) and operating across health and mental health, social wellbeing, environmental (e.g., climate change) and even political applications.

The APS has developed a guide to assist members to navigate Internet-supported psychological interventions. In addition to giving an overview of the types of Internet-supported interventions that are available, this resource also covers some of their strengths, issues and limitations. The resource further points to websites that provide information about the quality of the online interventions. For instance, the Health On the Net Foundation (www.hon.ch), a non-profit and non-governmental organisation accredited to the Economic and Social Council of the United Nations, offers advice on how to assess the quality of information on relevant websites. Beacon from the Australian National University (www.beacon.anu.edu.au) is an Australian portal independently assessing various online treatment websites and supporting the accuracy and reliability of the information these sites provide. Mindhealthconnect (www.mindhealthconnect.org.au) is another portal that brings together Australia's leading online mental health providers and allows people to find trustworthy mental health information.

For more information on Beacon and mindhealthconnect see - Online mental health resources: What’s available and do they work?.

Australian developments

Australia is one of the world’s leaders in e-therapy with e-interventions spanning the spectrum from mental health literacy, public health/health promotion, at risk/early intervention, and treatments for symptomatic and clinical disorders. The Australian Government’s e-mental health strategy (Department of Health and Ageing, 2012) has supported the development and maintenance of various online and remote psychological treatment services (see boxed information). Embedding the use of e-therapies within the national health and mental health system and developing staged models of care is the next priority.

Establishing an e-mental health support service to work with primary health care providers is essential to maximise the return on investment in e-therapies to date. Important components of such a service should include: provision of linkages and referral pathways between the primary care and e-therapy sectors, as well as between e-therapy services and emergency services; promotion of e-mental health services to consumers and professionals; establishment of secure online environments; establishment of appropriate funding frameworks and evidence-based stepped-care models of treatment that combine the various technological and communication modalities across demographic and cultural groups; and facilitation of relevant workforce training and support. Generalist and specialist psychological skills have a role to play in such a service from the perspective of research, training and supervision, e-therapy practice, support and promotion. Finally, psychologists have relevant skills in facilitating public health evaluation of the cost-effectiveness and the most efficient ways in which Internet-based psychological services can be integrated into the health and mental health systems.

Quality assurance

Maintaining the quality of e-mental health services is an important way to support consumers and clinicians. While a quality assurance framework, inclusive of appropriate clinical governance arrangements, will need to integrate general quality assurance systems within the health and mental health systems, numerous issues will need attending to in the Internet space. These include maintaining privacy and the security of personal information, developing standards of training and practice, upholding ethical standards, and maintaining safety and referral procedures for clients in acute distress. Furthermore, an ongoing research and evaluation agenda will need to incorporate the development of a system-wide evaluation framework.

Psychologists have long advocated for the development of ethical and quality guidelines relating to Internet services (e.g., Griffiths et al., 2003; Kluge, 2011). Various authors and professional bodies outline general recommendations for dealing with clients via the Internet (e.g., APA, 2013; Kraus, Zack & Stricker, 2004; Proudfoot et al., 2010), including differential strategies for dealing with specific clinical presentations. The APS has developed highly regarded Guidelines for providing psychological services and products using the Internet and telecommunications technology (available from http://www.psychology.org.au/for-members/resource-finder/resources/ethics/Ethical-guidelines-psychological-services-internet).

Given ongoing unregulated development of health websites and mobile applications, which are rarely designed with psychotherapeutic or health behaviour change models in mind (Sama, Eapen, Weinfurt, Shah & Schulman, 2014), psychologists have a key role in providing leadership in designing and developing quality interventions and in maintaining the quality of services (e.g., through supervision and training, development of standards and guidelines, etc.).

Challenges

Future challenges revolve around professional issues, keeping up with advances, and the development of viable business models to support Internet-based psychological services. With the characteristic fast-paced developments in this space and the growing sophistication of the community with regard to the Internet and related technological applications, psychologists urgently need to define our role and delineate our professional boundaries and competencies in this space. This is particularly important given the multidisciplinary nature of research and development activities, the cross-professional requirements of e-therapy, and the increasing involvement of quasi-professionals and consumers. The fine-tuning of existing inter-professional models of practice will need to become a priority. As such, we need to identify where in our training courses we include the development of relevant competencies and what level of competence we require of psychologists. In addition, we need to facilitate models and content for supervision. Most importantly, the incorporation of e-skills into our models of professional practice and our professional psyche needs to be fast-tracked if we are to maintain leadership in this field as a workforce. This could be facilitated through support for relevant professional interest groups, training activities through the APS Institute, peer supervision groups, etc.

Keeping up with technological advances, new applications, and consumer needs will challenge the way in which psychologists work with the Internet and technology. We will need the support of our professional bodies to keep us updated and informed about developments in the ‘e’ space. Given the generally slow pace of uptake of such developments amongst practitioners, there will be a need for assistance and encouragement, as has been reflected in government support for general medical practitioners to facilitate uptake of communication technologies. Additional business challenges relate to expectations about what consumers are prepared to pay for online versus face-to-face services, and the extent to which fee-for-service online assistance is different to information that is available free online. Initial economic evaluations of both therapist-assisted and automated e-therapy programs have been promising, but we need to evaluate cost savings of integrated models of e-therapy within health and mental health services and the community.

Conclusion

In sum, the Internet has revolutionised the way people communicate and manage information, and Australian psychology has led research and innovation in its use for disseminating mental health information and services. As the Internet continues to be embedded within all of our lives, the next phase is to embed and integrate these innovations into routine psychological practice, to keep up with the technological advances, and to better inform the community as to how to access and use the array of available evidence-based psychological resources.

The first author can be contacted at [email protected]