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E-Therapy

Chapter · January 2010

DOI: 10.4018/9781615209675.ch118

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 E-Therapy
Catarina I. Reis
Polytechnic Institute of Leiria, Portugal

Carla S. Freire
Polytechnic Institute of Leiria, Portugal

Josep M. Monguet
Polytechnical University of Catalonia, Spain

Abstract

Nowadays, information and communication technologies (ICT) are being used in the mental
health field to improve the quality of the services provided. Several studies refer both advantages
and disadvantages for these practices. E-therapy appears as a new way to help people in their
life and existing relationships, and there is proven evidence that online therapy helps, for
instance, to reduce depression symptoms. It is also seen as a complement of the technological
and traditional techniques, to improve the effectiveness and efficiency of the therapeutic process.
As a matter of fact, some people tend to be more comfortable with the computer than in face-to-
face therapy. Besides patients and physicians, other direct players could be found in this domain,
namely, families and caregivers. All players will be directly affected by the use of existing
services and thus, a correct assessment of the effectiveness of e-therapy solutions and studies is
required. eSchi is a multimedia portal that enables an e-therapy setting for schizophrenia
patients. Currently under development, the system is described and future trends in the area are
depicted.
Introduction
E-Therapy is a new concept that has been receiving growing attention both by the scientific
community and by the general public.

World governments are reassessing their health funding system to increase mental health
assistance, since, more than ever, it is regarded as the key question to a healthier population. On
the other hand, emerging information and communication technologies (ICT) are being
reinforced to bridge the info-technology divide that still currently exists.

Therefore, the most obvious step to take is provide mental health services via emerging ICT, as
already happens for some general health services. E-Therapy is the establishment of a therapeutic
session using ICT. This concept allows a patient and a therapist to access distinct activities,
available online, and engage in a therapeutic session with a slightly distinct contour from the one
in a traditional practice setting.

In this chapter the authors aim to provide a consistent summary of the existing literature on e-
Therapy, presenting the major players implicated and chief advantages and shortcomings. The
authors propose a list of items that will enable the effectiveness assessment of this type of
service; followed by a set of guidelines for the design, implementation and deployment of an
effective e-Therapy service. eSchi is an e-Therapy tool, currently under development, that is
presented as a case study and analyzed according to the effectiveness assessment items proposed.
Finally the authors present future trends in the provisioning of e-Therapy services.
Background
E-health, or electronic health, describes the provision of health services over a wide range of
electronic amenities, like electronic health records or health information networks. According to
Le (Le, 2007) this term covers two large areas: health informatics – related to applications and
databases that can record data to conduct analysis and to provide support to health care; and
telehealth – related to the delivery of health information or care to a recipient, e.g.
videoconferencing.

Telehealth, also known as telemedicine, means medicine at a distance and thus it’s not a new
concept. Guler (Guler & Ubeyli, 2002) refers the use of the analogue telephone to transmit
electrocardiograms (ECGs) and electroencephalograms (EEGs) in the beginning of the twentieth
century; National Aeronautics and Space Administration (NASA) has used remote monitoring of
astronauts since 1960 (Guler & Ubeyli, 2002) and some (Myron & Irene, 2004) state NASA as
the pioneer in the area. It is difficult to state a specific date to the beginning of telemedicine;
imperative is to refer that new information and communication technologies have brought a new
breath to this concept. Nowadays, telemedicine can be defined as the use of ICT to provide
medical information and services, like health information, assessment, diagnosis, education and
other services across geographical distance (Guler & Ubeyli, 2002), (Myron & Irene, 2004),
(Castelnuovo, Gaggioli, Mantovani, & Riva, 2003). According to this definition it is possible to
state that the fundamental concepts of telemedicine are related to basic principles of
telecommunications and Internet-working of computer systems: the use of communication
software, like email and web browsers; and forms of telecommunication like videoconferencing,
remote data monitoring and file transfers (Guler & Ubeyli, 2002). ICT is changing so fast (Le,
2007) that new products and services are becoming available all the time (Guler & Ubeyli, 2002).

The application of telemedicine requires the integration of new tools (Guler & Ubeyli, 2002) so
people involved have to go through an acculturation process. This, according to Le (Le, 2007) “is
a process in which people of a different cultural and social discourse have adapted to
accommodate a new discourse” (p. 1195) and can bring positive or negative experiences. To aid
the acculturation process it is important to train and educate people involved. Indeed, they do not
have to become experts to use telemedicine systems, but they must be ready to use them (Guler &
Ubeyli, 2002), (Castelnuovo, Gaggioli, Mantovani, & Riva, 2003a), (Kanani & Regehr, 2003).

The health context is quite extensive and ICTs have not covered it all, despite the growing effort
in this direction. The mental health field, despite some use of ICT, still has many uncovered
fields where it is possible to explore the potential of these new technologies. In fact, there has
been a great interest in introducing new technologies in this field, usually referred as
telepsychiatry or e-mental health (D. M. Hilty, Luo, Morache, Marcelo, & Nesbitt, 2002),
(McGinty, Saeed, Simmons, & Yidirim, 2006), (Agence d’évaluation des technologies et des
modes d´intervention en santé (AETMIS), 2006), (K. M. Griffiths, Farrer, & Christensen, 2007),
(Gadit, Amin A. M., 2006). The goal is to allow an equal access to therapies and counselling, as
well as other services, to those who may suffer from mental disorders and, for some reason, do
not feel encouraged to seek face-to-face professional help.
E-Therapy is an emerging term in this direction that provides professional help in health services
like information, assistance, counselling, therapy, and others via email, video-conferences, virtual
reality technologies, chats, etc (Manhal-Baugus, 2001).

There are several terms to this type of support, like Internet based therapy, online therapy,
cibertherapy, web counselling and many others. Despite the amount of designations and terms, at
the end, they all mean the same (Heinlen, Welfel, Richmond, & O'Donnell, 2003). According to
Manhal-Baugus (Manhal-Baugus, 2001), the term e-Therapy has been described as a process of
interacting with the therapist online and over time when patient and therapist are in separate
locations and use electronic means to communicate. As a result, Manhal-Baugus defines e-
Therapy as “a licensed mental health care professional providing mental health services via e-
mail, video conferencing, virtual reality technology, chat technology, or any combination of
these.” (p. 4). For the purpose of the chapter and the eSchi application, the authors have chosen to
use the term e-Therapy and the above definition, from this point forward.

According to Wangberg (Wangberg, Gammon, & Spitznogle, 2007), psychotherapists’

theoretical bases may influence the tendency to embrace or reject e-media. Despite patient-
therapist relationships may be emphasized by dynamic-oriented approaches, that are based on
transference processes occurring in an established relationship and are typically used in group
therapy, psychotherapists who practice this approach seem to hold more negative attitudes
towards e-Therapy. On the other hand, psychotherapists who practice cognitive approaches
appear to hold more positive attitudes towards e-Therapy. Cognitive approaches are the basis of
some of the most well known online therapy programs. It’s important to refer that e-Therapy does
not intend to modify theories of already existing approaches, but can affect the patient-therapist
relationship (Castelnuovo et al., 2003). E-Therapy can occur at home and facilitates
communication between patient-therapist to a friendlier mode minimizing the therapeutic process
(Barak, 2007), (Lester, 2006), (Recupero & Rainey, 2006). According to Kanani (Kanani &
Regehr, 2003), there is already evidence of highly intimate-professional relationships over the
Internet that became closer in less time than those in face-to-face sessions.

These are some of the advantages and shortcomings in the usage of e-Therapy that are well
known from the literature. Both advantages and shortcomings can be seen as conducts or barriers
to the design, implementation and adoption of e-Therapy. Thus, they will be depicted in a
subsequent topic regarding effectiveness assessment and guidelines to e-Therapy.
Major Players
e-Therapy intends to decrease the existing dependency on the therapist (Castelnuovo et al., 2003)
and by providing a service through electronic communication mediums, enables patient
empowerment. Patients will soon be able to autonomously complete a set of activities that were
previously prepared by their therapists.

Besides patient empowerment and within this context, it’s possible to identify several players
(Liberman, Hilty, Drake, & Tsang, 2001) that have distinct roles under specific situations:
• Patients – e-Therapy clients who are looking for help for their condition;
• Families and caregivers – may be seen as providers for home support for patients;
• Specialist Physicians (include psychiatrists and psychologists) – who promote specialized
medical support for patients;
• Other Medical Staff like nurses or therapists – can provide more general medical support
for patients, as well as counselling, etc;
• Community – in general – that should give patient support in everyday tasks, besides
avoiding their social stigmatization.

Whenever there is a service there is always someone that provides the service (provider) and
someone that consumes it (consumer) (Castelnuovo et al., 2003). Usually, and particularly in e-
Therapy, a patient is regarded as a client - the consumer of the service - while the physician is
seen as the provider of the service (Barak, 2007; Castelnuovo et al., 2003; M. Griffiths & Cooper,
2003; Grolleman, van Dijk, Nijholt, & van Emst, 2006; Kanani & Regehr, 2003; Wangberg et al.,
2007).

By enhancing the patients’ comprehension of their own disorders, e-Therapy improves their
adherence to treatment and health outcomes (W. H. WHO & WONCA, World Organization of
Family Doctors, 2008).

The families or caregivers that act as the “provider” and at home (Grolleman et al., 2006) play an
important role supporting patients taking their medication, as well as helping in their daily tasks
(W. H. WHO & WONCA, World Organization of Family Doctors, 2008).

Primary care workers should guarantee that a patient is being followed, ensuring the coordination
of health workers, service settings, and time (W. H. WHO & WONCA, World Organization of
Family Doctors, 2008).

The community may have an important role contributing to patient welfare. People, who suffer
from mental conditions, also suffer with the fear and prejudice of others. The stigma increases
personal pain which contributes to social exclusion (European Commission, 2005). This results in
a low adherence to treatments and decreasing clinical and functional outcomes.

Organizations, institutions and communities can also be seen as players or even as a set of
players. The most common communities generated around e-mental health services are the
patients’ communities that, sometimes, encapsulate caregivers and families. However, sometimes
families and caregivers exist in independent communities. Primary care practitioners, experts and
medical staff can be seen as a large medical community.
There are many players that are involved and contribute to patients welfare, since people who
suffer of mental disorders have multiple needs related to health and even to other common things,
like employment, education, etc (WHO, World Health Organization, 2007).

There’s a clear need for education and training of all these players regarding mental health issues.
E-Therapy may have an important role contributing not only to the patient’s treatment but also to
educate her and all surrounding her. Thus, several sites (points of service), that are reachable
using e-Therapy, namely: hospital emergency rooms, schools, patient’s homes, forensic facilities
and even the battlefront (McGinty et al., 2006) should be considered as places to deliver e-
Therapy.

In a common e-Therapy setting there is usually a patient that “consumes” the therapy session
provided by the “physician”. Nevertheless, in the near future, new contexts could appear and
evolve, namely: the family or caregiver that takes in the role of the “provider” in a family setting
– at home (Grolleman et al., 2006) or even a first primary care provider that is trained to conduct
an e-Therapy session by an outsider expert in the field (Castelnuovo et al., 2003).
Effectiveness: Assessment and Guidelines
Effectiveness is the power to produce a decisive effect. It is a measure typically employed in
assessment of the telepsychiatry area. It is used to find: what technology is used; how it is
integrated with other services (already existing or non-existing); what are the costs; how it
compares to other services and their quality (D. M. Hilty, Liu, Marks, & Callahan, 2003).

Telepsychiatry has already proven to be effective regarding quality of care, satisfaction

(Ganapathy, 2005) and education. It empowers patients, providers and communities, but it is still
premature to claim that it is cost-effective (D. M. Hilty et al., 2003). There are recommendations
to evaluate telepsychiatry’s effectiveness given by (D. M. Hilty et al., 2003).

There are reports on guidelines for telepsychiatry services in general (D. M. Hilty et al., 2002;
Lauriks et al., 2007; McGinty et al., 2006; Todis, Sohlberg, Hood, & Fickas, 2005). There is also
published work for email practices (Gadit, Amin A. M., 2006) and electronic records – such as
the Medical Data Index (MDI) (Pheby & Thorne, 1994). As far as institutions are concerned,
there are several sites that provide guidelines and recommendations such as the International
Society for Mental Health On-line (ISMHO) and the Psychiatric Society for Informatics (PSI)
(Dyer, 2001), the Canadian Psychiatric Association Web site (www.cpa-apc.org), the National
Guideline Clearinghouse (www.guideline.gov) and the American Psychiatric Association
guidelines (www.psych.org) (Styra, 2004) – and for government sites – Australia (Christensen,
Griffiths, & Evans, 2002), Canada (Agence d’évaluation des technologies et des modes
d´intervention en santé (AETMIS), 2006) and USA (Styra, 2004).

Some authors (Agence d’évaluation des technologies et des modes d´intervention en santé
(AETMIS), 2006) reused Hilty’s recommendations (D. M. Hilty et al., 2003) to create Guidelines
and Technical Standards to advice and support National Health Systems (Canada) and adapted
the items to the national reality that they were facing. For example, costs estimates should be
based on the assumption of two-weekly e-Therapy sessions and physical infrastructures should be
assigned to other activities, such as teleteaching – already a reality in Canada – in order to share
costs.

In the literature reviewed, a specific set of universal recommendations and/or guidelines to be

followed in e-Therapy could not be found. The most natural step is the creation of a set of
universal guidelines in order to accomplish the best high-quality e-Therapy service possible. To
truly assess such a setting, the items to be used to measure its effectiveness include the way e-
Therapy is conducted and its outcomes.

Thus, the authors propose a new set of assessment items for e-Therapy settings, based on the
existing recommendations for telepsychiatry (D. M. Hilty et al., 2003) and the most relevant
assessment recommendations and guidelines found in the literature.

Quality of Care
The assessment of the quality of care, as depicted by Hilty, includes randomized controlled trials
(RCT) with prospective data collection and a comparison group and/or baseline data. RCTs
should include observed outcomes, the changes in clinical health status, the effects on the
patients’ quality of life, diagnostic quality and changes to the therapeutic process.
The quality of care provided by online psychotherapy (Agence d’évaluation des technologies et
des modes d´intervention en santé (AETMIS), 2006; Childress, 2000; Christensen et al., 2002)
must demonstrate no significant difference between the one provided in face-to-face contexts.
There is ample evidence, published as RCTs, which shows that evaluation services are being
provided with satisfactory levels of quality similar to those in face-to-face settings (Neufeld,
Yellowlees, Hilty, Cobb, & Bourgeois, 2007). Conducting scientific research and publishing the
results also helps in the improvement of the quality and quantity of information regarding the
illness and its treatment.

Patient’s outcome assessment is usually done using valid tests, scores and scales that physicians
apply on a daily basis during traditional therapy sessions (Solari et al., 2004). The use of well-
validated assessment scales, capable of detecting changes on patients (Pheby & Thorne, 1994)
it’s also a directive. Symptoms can also be assessed using structured instruments available
through informatics systems. Care can be improved and errors could be reduced through the use
of effective informatics systems (Trivedi, Kern, Grannemann, Altshuler, & Sunderajan, 2004;
Young, Mintz, Cohen, & Chinman, 2004). Nevertheless, evidence exists that there is no record of
an improvement by the isolated use of computer-assisted memory and attention retraining (Solari
et al., 2004).

The definition of a treatment algorithm (Adli, Bauer, & Rush, 2006) to follow in
psychotherapeutic sessions works as a guideline in two distinct aspects. First, the major goal of
the treatment is defined jointly with the clinical instruments used to adjust and/or assess
outcomes. Second, Critical Decision Points (CDPs), the instants when a therapeutic
adjustment/assessment should occur, are defined. However, care should be taken when defining
the CDPs and the adequacy of a specific algorithm to a given patient.

Online group psychotherapy assessment should include process variables such as activity,
belongingness to the group and receiving therapist feedback as well as the textual dimensions
available through specific tools (Linguistic Inquiry and Word Count - LIWC) (Haug, Strauss,
Gallas, & Kordy, 2008). In fact, the continuous monitoring of patients during a session can
provide valuable information to improve the therapeutic processes (Haug et al., 2008).

Email and all text-based communication mediums suffer from the loss of non-verbal cues that are
extremely important to the therapists’ assessment and diagnosis procedures. Flattened or
inappropriate affect, characteristics of speech, memory function, and physical evidence of a
medical condition might all be associated to the psychological symptoms of a patient (Childress,
2000). It has no contextual intent and it is extremely hard to develop a writing skill that somehow
overcomes the misunderstanding that is prone to occur in such situations. Thus, online therapy
might prevent an accurate diagnosis because it can be hard to examine the exact signs of the
disorder.

Education and Empowerment

Hilty’s view of the Education item is the interventional aspect where there is a change in
knowledge and/or skill set; didactics and case based teaching and a change in patients’ outcomes.
No direct statement was found regarding these specific issues for e-Therapy. But, the authors
have found statements that can be classified as an in-between this and another item -
empowerment. As a matter of fact, Hilty describes the Empowerment item according to three
distinct levels: patients, primary care providers and community; in the sense of reducing time to
consultation, improved access to specialists and informal education.

One of the major concerns regarding education and empowerment is the quality of the
information that is available. As far as generic e-mental health web sites, for instance, depression
web sites (K. M. Griffiths & Christensen, 2002) and the ones regarding substance use disorders
(Copeland & Martin, 2004) are reported has having low quality of information (K. M. Griffiths &
Christensen, 2002) and as being harmful to uninformed users (Copeland & Martin, 2004). While
other authors (Christensen et al., 2002) report that information is not always correct, since
sponsors and potential conflicts of interest are not disclosed. With the growing number of web
pages that exists and the ones which are created every minute, a person may have difficulty
finding the online help to his/her specific problem (Recupero & Rainey, 2006). It may also be
difficult to a patient to make an informed choice considering services reputation (M. Griffiths &
Cooper, 2003). On the other hand, all the information should be on a standard format that is easy
to reuse (Pheby & Thorne, 1994). This format should not only be considered at the technological
level, but also, and most importantly at the semantic and medical level.

E-Therapy settings usually have a secure and restricted access, but there should be a concern with
providing reliable content. Trust issues arise: patients trust the information of a physician’s
recommended web site (K. M. Griffiths & Christensen, 2002). Thus, patients should be guided
and assisted to choose the most accurate information (K. M. Griffiths et al., 2007), (Styra, 2004),
(Graeff-Martins et al., 2008). This is more challenging for physicians that should interpret and
select the right information sources in order to guide their patients (Styra, 2004). Besides, there is
a growing need to restore the public’s trust into medical and healthcare websites and perhaps the
solution should be to effectively regulate web sites and the medical/health industry (Dyer, 2001).

The provider of the service should have general and specific expertise to conduct a session (D.
M. Hilty et al., 2002) and should follow adequate procedures to get the key component(s) of the
record to provide them to the consulting physician (D. M. Hilty et al., 2002), (Styra, 2004).
Everyone involved in the consultation should follow the accorded time constraints (D. M. Hilty et
al., 2002). When establishing communication standards that might, for instance, prevent the
abusive use of email as consultation medium (Gadit, Amin A. M., 2006), patients and physicians
should receive instruction on their rights and duties and should adhere to them. They should also
be trained regarding the technical and procedural aspects of the service (D. M. Hilty et al., 2002),
making them fit to use the technology (McGinty et al., 2006). Bridging the information divide
and improving ICT literacy is a need (Christensen et al., 2002).

Every application developed to provide health content to the Web should use the DISCERN
instrument. It has already been used as a website quality indicator (K. M. Griffiths &
Christensen, 2002) and provided similar results to the quality of site content. Basically it allows
an inexperienced person to rate several aspects of written health treatment information: extent of
the treatment alternatives – risks and benefits; degree of balanced and unbiased information;
documentation of areas of uncertainty.

Many patients find self-help groups where they can meet and exchange experiences lessening
symptoms of isolation (Castelnuovo et al., 2003). They can also exchange information such as
written, visual, audio or recorded material that can be used in a treatment program (Castelnuovo
et al., 2003a). This kind of treatment program can be self-administered by patients with or
without guidance, which may decrease the dependency on the therapist (Castelnuovo et al.,
2003), (Castelnuovo et al., 2003a).

Access
This can be considered as one of the most wide enclosing assessment items. Hilty described it as
whether or not there was increased access to care and a description of the kind of care. The
authors have decided to include all the findings in the literature concerning the barriers of using
e-Therapy, considering them as difficulties to access the service. These were then subdivided into
two sub items: (1) Resistance to change and technology literacy and (2) Legal, Privacy, Security
and Ethical Issues.

• Resistance to change and technology literacy

Ganapathy (Ganapathy, 2005) states “What is required is not implementing better technology and
getting funds but changing the mindset of the people involved.” (p. 860). In fact, one of the major
barriers of implementing telepsychiatry is in the way both patients and psychiatrists adapt to new
technology, and not the installation of the technology by itself (Agence d’évaluation des
technologies et des modes d´intervention en santé (AETMIS), 2006).

This usual resistance to change by individuals and/or organizations leads to technology illiteracy
and costs (McGinty et al., 2006) in the implementation of e-Therapy. The technology illiteracy
should be fought by educating every possible user in the use of the technology and reinforcing its
importance in their life quality (Christensen, 2007; Finn, 2002). Nowadays, this illiteracy is
diminishing and the Internet is becoming more accessible than ever (Christensen et al., 2002;
Heinlen et al., 2003; Kanani & Regehr, 2003). To carry out e-Therapy, therapists are not required
to be experts in technologies but they need to be prepared to face technologies to know when and
how to use them in patients’ welfare.

The technology to be used in the services should already be clinically proven and, for each
consultation, technology should be matched to the service and needs of the patient and
corresponding treatment (D. M. Hilty et al., 2002).

On the other hand, people that have mobility limits, time constraints, special needs, those termed
“socially unskilled”, and that do not have access to the needed mental health services can be
served through online delivery (Kanani & Regehr, 2003), (Heinlen et al., 2003), (M. Griffiths &
Cooper, 2003), (Finn, 2002). E-Therapy breaks out space boundaries, reaching out for
underserved population across geographical distance and enhancing the quality of health
information anytime and anywhere (Castelnuovo et al., 2003), (Barak, 2007), (M. Griffiths &
Cooper, 2003). These technologies and services are limited to some centers, given that experts
are not available in smaller and more rural hospitals (Ganapathy, 2005). Actually, Internet
interventions regarding mental health treatments could be wider implemented (after regulation
issues are solved), providing a low cost solution to the public health system, especially in
countries with large rural areas (e.g., USA and Australasia) (Copeland & Martin, 2004),
(Antonacci, Bloch, Saeed, Yildirim, & Talley, 2008), (Christensen et al., 2002). Other
underserved areas are the correctional facilities, where telepsychiatry can be seen as an
appropriate option to deliver services to institutionalized patients (Antonacci et al., 2008).
e-Therapy is mainly practiced over the Internet and, that, can carry some problems like temporary
service disruption or other associated problems. In remote areas the transmission may not be the
one desired (M. Griffiths & Cooper, 2003), (Finn, 2002).

• Legal, Privacy, Security and Ethical Issues

There are always, security, privacy and confidentiality issues that should be considered for the
type of services that exist in the mental health field, especially for those that use the Internet
(Farrell, Mahone, & Guilbaud, 2004).

Experts (Christensen et al., 2002) identified privacy issues as the constant tension between the
need to access health records and the need to secure them.

Anonymity is a concern for most users of e-mental health services (Richards & Tangney, 2008)
regarding social stigma. Thus, online interaction might solve this issue (Recupero & Rainey,
2006) and help working out the inhibition questions of receiving support (Kanani & Regehr,
2003), (Barak, 2007), (Wangberg et al., 2007), (Lester, 2006), (Heinlen et al., 2003), (M.
Griffiths & Cooper, 2003). In fact, some people disclose their problems more openly to a
computer system then to other people (Christensen, 2007). For instance, correctional facilities
patients will hardly benefit from the same privacy that a typical outpatient has in a
patient/physician session, since they are typically accompanied by a staff member (Antonacci et
al., 2008).

But, anonymity, besides having many advantages, can also raise some questions related to the
honesty of the users. Therapists might have difficulty to verify some facts like age (Kanani &
Regehr, 2003), (Heinlen et al., 2003), (Finn, 2002; M. Griffiths & Cooper, 2003), appropriate
mental capacity for obtaining treatment consent (Kanani & Regehr, 2003), (M. Griffiths &
Cooper, 2003) and to evaluate the potential violence of a patient. Sometimes families or
authorities should be contacted to report risks of suicide, homicide, child abuse, etc. (Kanani &
Regehr, 2003), (Finn, 2002; M. Griffiths & Cooper, 2003). Online therapists need to be aware of
all factors around the patients, like location, specific conditions, culture and others, because these
factors may lead to inappropriate counselling (Kanani & Regehr, 2003), (M. Griffiths & Cooper,
2003).

Telepsychiatry should be used with extreme care and should be avoided in emergency situations,
when the patient’s wellbeing, health or safety is at risk (Agence d’évaluation des technologies et
des modes d´intervention en santé (AETMIS), 2006). On the other hand, some patients are
contraindicated to undertake e-Therapy since they are considered violent, with a significant
emotional reaction to news or immediate risk for suicide (Agence d’évaluation des technologies
et des modes d´intervention en santé (AETMIS), 2006), (Christensen, 2007).

Like patient’s confidentiality, data security is crucial (Ganapathy, 2005), (Recupero, 2005).
Losses of data should be prevented; encryption mechanisms (Ganapathy, 2005), (Styra, 2004), all
accesses recorded and secure electronic signatures (Gadit, Amin A. M., 2006) should be used to
prevent unauthorized access (Childress, 2000).
Email implies, such as most of the services that use the Internet, severe security concerns, that
may go from hackers to family members: eavesdropping, identity theft, invasion of privacy,
message modification, false messages, message replay, unprotected backups and repudiation
(Gadit, Amin A. M., 2006), (Styra, 2004). Besides these technological concerns, there is also a
liability issue pending in what concerns the response time to messages. Since email is typically
an asynchronous communication medium, there could be some unexpected results (liability risks,
such as suicide attempts) when a physician fails to answer an email message in the specific
timeframe that was expected by the patient. This implies that there should be firm instructions to
both parties to what are the appropriate timeframes to the email communication (Gadit, Amin A.
M., 2006), (Childress, 2000) and for the confidentiality issues as well (Styra, 2004). For urgent
demands, patients should use more adequate mediums such as the telephone (Gadit, Amin A. M.,
2006).

Another major barrier resides in the lack of legal and regulatory directives that holds back the
implementation of these services. The lack of regulation might lead to mental health provider
resistance in their use (Christensen et al., 2002). Legal issues regarding the clinical responsibility,
adequacy of client/patient to treatment (e.g., suicidal risk), therapist licensing and treatment
effectiveness are raised with the e-Therapy approach (Finn, 2002; Heinlen et al., 2003; Kanani &
Regehr, 2003; Recupero & Rainey, 2006). Since some of these issues don’t occur in a normal
setting, informed consent should be obtained from competent patients, able to avail themselves
and in writing (Agence d’évaluation des technologies et des modes d´intervention en santé
(AETMIS), 2006), (Gadit, Amin A. M., 2006), (Childress, 2000), (Recupero, 2005). Some
drawbacks referred (Gadit, Amin A. M., 2006) specifically when using email were: authenticity
of both parties; validity of the information exchanged; distinct expectations of both parties;
keeping the quality of the care provided and managing the patient-physician relationship. But
these could also occur in face-to-face contexts (Gadit, Amin A. M., 2006) and with other
communication mediums such as the telephone or fax. All communication technologies can be
misused and misrepresentations or frauds are real concerns. The breakpoint arrives by opposing
potential benefits that justify the possible risks (Childress, 2000).

As far as licensing issues are concerned, there are several solutions that include a national (USA)
licensing system to assign the responsibility to the physician (Dyer, 2001). According to Dyer, e-
psychiatry considers that the patient is the one travelling to meet the physician, but in
telemedicine, it’s the opposite: it is the physician that travels to meet the patient. This has
implications on the physician licensing, since the first one brings no problems, the physician is
already licensed in its original place. The second approach severely limits the practice of e-
psychiatry and e-Therapy (Dyer, 2001). A possible solution should be to consider a special
licensing system where “cyberdocs” are licensed to practice in cyberspace.

The Medical Internet Ethics is an emerging interdisciplinary field that will try to achieve the full
understanding of the use of medical knowledge using the Internet and define the guidelines
required to conduct such practices (Dyer, 2001). All healthcare professional organizations have
ethical standards defined for their associates, but only few have yet started to address the new
concerns that the Internet and the conduct taken over this medium raise (Dyer, 2001). Mobile
phones, Personal Digital Assistants (PDAs), hand-held computers and wearable devices are being
developed and should be making an entrance in the e-Health arena. Ethical concerns should also
take these new forms of telecommunications into consideration (Dyer, 2001). Even when
guidelines are established, such as the National Board of Certified Counselors (NBCC) that
defined ethical practice of Web counselling, the fact is that, no one is obliged to follow them.
Cases of mal practice are common, either being it held by unethical professionals or strangers
(Dyer, 2001).

Some professionals might consider changing their definition of the service they provide from
online psychotherapeutic to online psychoeducational, since it implies less problematic medical
and legal issues. The central matter that can stipulate the difference between these two options is
whether the patient perceives that a professional relationship has been accomplished (Childress,
2000), (Recupero, 2005; Recupero & Rainey, 2006). E-Therapy patients may believe that the
same rules and ethics of traditional therapy are also applied in online therapy (Recupero &
Rainey, 2006). Patients’ rights are limited because legal rules for this kind of therapy are not well
established yet (Heinlen et al., 2003), (Finn, 2002).

Essentially, it is imperative to define how online mental health services should be provisioned
and how online relationships should be conducted (Christensen et al., 2002).

Costs
This is the assessment item that intersects all the others since every item is directly correlated and
somehow involves costs.

E-Therapy costs may be very attractive. Indeed, when compared with traditional psychotherapy,
online communication reduces expenses and enables cost effective interventions (Castelnuovo et
al., 2003), (Kanani & Regehr, 2003), (M. Griffiths & Cooper, 2003), (Finn, 2002), (Grolleman et
al., 2006).

There is no established funding model to reasonably support the implementation and maintenance
of e-Therapy initiatives (Christensen et al., 2002). As a result, providing free access might
augment the demand for these new services and significantly create more pressure on the already
overburden health system (Christensen et al., 2002).

On the other hand, Christensen (Christensen, 2007) states that, making Internet platforms freely
accessible, is one way to reduce the overall load. Costs with the technology involved in the
implementation of telepsychiatry solutions are not very easy to obtain, but there is a belief that
they can be compensated by the amount/volume of use of the services provided (Agence
d’évaluation des technologies et des modes d´intervention en santé (AETMIS), 2006). For
instance, telecommunication costs can be considered a sunk cost (McGinty et al., 2006) since
they can be shared between several types of applications besides the telepsychiatry services such
as email and Internet access.

There is a growing interest from country governments in the costs associated to mental health
programmes’ implementation and maintenance (Ayuso-Mateos, Salvador-Carulla, & Chisholm,
2006) and some are even taking the electronic mental health provision of services as a leading
goal in current policies (Christensen et al., 2002). Ample evidence shows that telepsychiatry
evaluation services can be provided economically (Neufeld et al., 2007), despite the high costs of
technology and that is still inaccessible to developing countries (Graeff-Martins et al., 2008).
Reimbursement is also an issue when online services such as diagnostic interviews, medication
management and psychotherapy must be a part of the organization and must be integrated with
the actual process of patient care and treatment (McGinty et al., 2006), (Recupero, 2005), (M.
Griffiths & Cooper, 2003). This is an important aspect of the e-service: to establish a suitable
remuneration for the services provided (Styra, 2004).

Satisfaction
As far as users’ satisfaction is concerned, there is evidence (K. M. Griffiths et al., 2007) that
users like online mental health interventions. Liking and disliking is a simple way of showing
satisfaction and, as far as patients are concerned, theirs is acknowledged upon evaluation of the e-
Therapy services used.

Players’ needs should be considered right from the start, even when designing the system
(McGinty et al., 2006). Every ICT solution should be developed within a dialogue between
developer and target-users in order to accomplish a more personalized, more helpful and fine-
tuned application for the users’ needs (D. M. Hilty et al., 2002; Lauriks et al., 2007). Focusing the
development without attending to the factors that involve the long-term adoption of the solution
will condemn the product/service (Todis et al., 2005). For instance, if users are not able to see
any real improvements in their life quality, why should they change and use a new system?
Therefore, it is critical to involve target users in the development process of such type of assistive
solution.

The flexibility that a new system shows, working as an always-on and trustworthy assistant that
can deal with appointments and prescriptions, is a major advantage in order to accomplish
physicians’ satisfaction (Christensen, 2007). For instance, patients and physicians who use email
have benefits (Gadit, Amin A. M., 2006), (Childress, 2000): patients can feel more comfortable
(disclose personal, complex and sensitive issues) than in face-to-face communications and
physicians can construct their email message in a more thoughtful and structured way. At the
same time, it’s easier to keep the medical record updated (emails are highly self-documenting).
Inclusive, some patients actually refer that they would switch doctor if they could communicate
with the new one using email (Recupero, 2005).

Nevertheless, physicians that have their email in public locations seldom receive large amounts
of solicited and unsolicited email asking for advice and information from prospective patients
(Recupero, 2005). This can increase the overall burden that their service already implies.

The assessment and evaluation of these web sites is sometimes made (Richards & Tangney,
2008) using statistical information gathered by the system. The data collected includes number of
page views, unique visitors, time spent per page, number of posts and replies, number of users
simultaneously in chat sessions and other demographic data from users. Online questionnaires are
also used and provide an easy way to ask for the data that is needed to complement the available
system statistical information. All this information relates to the user satisfaction of the system,
whether it is the patient or the physician. In order to ensure service satisfaction for every player
involved, the entire system structure should have regular technical maintenance and prompt
troubleshooting (D. M. Hilty et al., 2002).
One of the most important features of e-Therapy is that it allows synchronous computer mediated
communication (CMC), or in other words, real time communication between users via computers
(Castelnuovo et al., 2003) – videoconferences, chats,... - which means that patients might feel that
there is always someone on the other side that can help them.

Assessment Items Concerns

Quality of Care No significant difference to face-to-face contexts:
• patient’s outcome assessment - valid tests, scores and scales;
• treatment algorithm - specific clinical instruments applied to
explicit CDPs.
RCT studies (prospective data collection; comparison group and/or
baseline data);
Online assessment - continuous monitoring of patients; variables such as
activity, belongingness to a group and therapist feedback;
Text communications with non-verbal and visual clues inclusion.

Education and Empowerment Quality of the information:

• reliable, correct and adequate information;
• information in standard format (easy to reuse; both at the
technological and medical-semantic level);
• use of quality indicator instruments such as the DISCERN.
Expertise to conduct a session (even if it is not a consulting physician);
ICT literacy – formation and information on usage is required;
Self-help groups – information exchange, self-administered by patients.

Access
Resistance to change and
technology literacy
Legal, Privacy, Security
and Ethical Issues
Easy adoption of new technology;
Clinically proven technology matched to users’ needs;
Online delivery can overcome mobility limits, time constraints, and
provide services to special needs persons and “socially unskilled”;
Guarantee that online temporary services’ disruptions is minimized;
Anonymity should be granted - honesty and trust issues;
Avoid emergency situations in online asynchronous communications
(response times should be established);
Confidentiality and data security is essential (encryption mechanisms,
access records and secure electronic signatures);
Comply with legal, regulatory and ethical directives.

Costs Online communications reduces expenses;

Provide free access – to compensate the volume of services’ usage;
Consider reimbursement – establish suitable service remuneration.

Satisfaction Users like online mental health interventions;

Consider users’ needs right from the beginning;
Flexible systems with regular assistance (technical maintenance and
prompt troubleshooting) and collect statistical information regarding the
systems’ usage.
Table 1 - Summary Table for the Assessment of e-Therapy
eSchi – An e-Therapy Tool Case Study
The eSchi system is intended to be a set of multimedia tools, available through the Internet, to
enable schizophrenic patients’ train and rehabilitation (Freire, Reis, & Monguet, 2008). These
tools intend to serve patients in their cognitive rehabilitation, help therapists in their profession
and families and caregivers in their daily life. The main purpose is, in the process of
psychotherapy, to develop an e-Therapy tool.

Accordingly, in the context previously described, an e-Therapy tool is to be used under certain
conditions, depicted next, and should comply with the assessment items and considerations
referred.

“Schizophrenia is a mental disorder that makes it difficult to tell the difference between real and
unreal experiences, to think logically, to have normal emotional responses, and to behave
normally in social situations.” (MedlinePlus, 2008)

Schizophrenia patients present several cognitive deficits that include memory and thinking
problems (Elvevag, Maylor, & Gilbert, 2003). The symptoms appear as disorganized and slow
thinking; difficulty understanding; poor concentration and memory and difficulties expressing
thoughts. Schizophrenics also suffer from grossly disorganized behaviour that can range from
totally unpredictable agitation to inappropriate behaviour. Some of the most common examples
include little or no attention to personal hygiene, inability to organise meals, dressing in an
unusual manner or becoming agitated and shouting.

Another task easily forgotten by schizophrenic patients which has a severe impact in the patient’s
and his family and carers’ life, is to take the prescribed medication to help in the control of the
disease’s symptoms. In fact, the non-adherence problem is a major issue since it significantly
contributes to the possibility of relapse. This is of the utmost importance because relapses of
schizophrenic patient bring back not only the return of augmented psychotic episodes, but also
increases the risk of suicide (Zygmunt, Olfson, Boyer, & Mechanic, 2002).

Furthermore, direct evidence demonstrates the impairment of schizophrenic patients in several

cognitive abilities such as attention, awareness, memory, insight and judgment (Hogarty &
Flesher, 1999). The National Institute for Mental Health (NIMH - USA) established the
Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS)
initiative, having found in empirical support a few premises to make cognition a rationale for
treatment (Green et al., 2004). Some of the premises are: cognitive deficits of schizophrenia are a
core feature of the illness; cognitive deficits are related to the daily functioning of patients;
patients’ performance on cognitive tasks can be improved through psychopharmacologic
treatment. Based in multiple studies, the subgroup of the Neurocognition Committee of
MATRICS reached a consensus for a battery of clinical trials in the following cognitive domains:
Working memory; Attention/vigilance; Verbal learning and memory; Visual learning and
memory; Reasoning and problem solving; Speed of processing; and Social cognition.

Despite medication treatments being mandatory for schizophrenic patients, their symptoms are
usually improved through psychological interventions including the adherence issue previously
referred. Cognitive therapy for schizophrenia may engage patients in real life tasks, where the
therapist may help improving socialization and reinforce vocational skills of schizophrenic
patients (Beck & Rector, 2000; Vauth et al., 2005; Velligan, Kern, & Gold, 2006).

eSchi - Multimedia Portal for Schizophrenia Learning and Rehabilitation

Besides being an e-Therapy tool, eSchi will also be an e-Learning tool, since it will support the
therapy process and will also teach and train schizophrenic patients, and corresponding families
and caregivers, on how to acquire basic skills that were once lost because of cognitive deficits.

eSchi is designed as a modular system that at the time of writing has two nodes under
development: the patient module and the therapist module. While the patient module relates to
aspects concerning e-learning and the training of cognitive functions of the patients, the therapist
module is more dedicated to the management issues regarding patients and sessions.

Patients will first have to train their motion skills with simple games for the usage of the mouse:
moving objects around; clicking on specific places and dragging and dropping objects. Accurate
data regarding the patient performance, during the training, is to be recorded. Hence, it is possible
to know the patient behaviour during a specific activity.

Figure 1: Activity example - drag-n-drop: initial message; dragging area and activity completed

There are also basic cognition activities related to recognition and association of objects. In
recognition a stimulus object is shown to the patient for some seconds and after that time, the
stimulus disappears. Next, the patient will be presented with a set of distinct stimuli, and she
must identify what stimulus she has seen before. In association a stimulus object is shown
associated with other stimulus (for instance, milk associated with the colour yellow). When these
stimuli disappear, the patient will be presented with unrelated stimuli and the patient must
identify the previous relationship between stimuli.

Therapists will be able to manage information regarding patients’ data, see patients’ performance
and configure sessions and activities for the patients. Depending of the type of patient, the
therapist may choose an easier or more complex activity (game), with more or less time dedicated
per activity. After conducting the session with the patient, the therapist will be able to see the
patients’ performance during a specific period of time and program future sessions according to
the observed results.

Figure 2: Statistical information (sample) available in the system

Will eSchi produce a decisive effect?

The effectiveness of eSchi is yet to be found. Using the assessment items and guidelines
described above, the authors will provide their vision of the effectiveness of eSchi. Since eSchi is
still work in progress, the authors will explain the concerns and plans for the ultimate
effectiveness assessment of the system.

Quality of Care
The eSchi system will be assessed under a case study that will be conducted by the medical team
of the project at the Hospital San Joan de Déu (HSJD). Two distinct groups of patients (control
and study groups) will be observed and their data will be systematically collected for a specific
period of time. Patient outcomes will be measured using validated scales and instruments that the
medical team uses on a daily basis.
The multimedia activities developed for eSchi were all adapted from the traditional settings of
therapy sessions and tailored to the online environment. Thus, there should be no significant
difference between the quality of the care provided online, from the one present in face-to-face
contexts. Additionally, the act of a therapist creating a session, defining activities as building
blocks to be used in the therapy session can be regarded as the definition of a treatment protocol.
The protocol algorithm is built bearing a specific treatment goal in mind and defining adequate
CDPs, where the session assessment occurs. Furthermore, protocols can be reused or new ones
created for specific patients’ needs.

eSchi provides an integrated monitoring tool that enables the collection of valuable information
during sessions. The collected data will then be available for analysis and feedback improving the
therapeutic processes.

eSchi was designed to be typically used by a duo: patient - therapist or patient – family/caregiver.
Nevertheless, it can also be used by a single patient as long as she is more autonomous and able
to complete a session of activities defined by a therapist. Thus, whenever the system is to be used
by a pair, there is an option available that enables the therapist (or family or caregiver) to take
textual notes. The goal is to keep a record of all the visual and non-verbal cues provided by the
patient, observed by the person who conducts the session. How these cues are to be recorded
when eSchi is used autonomously by a patient, is still an open issue.

Education and Empowerment

In order to avoid technological resistance, continuous periods to train patients in the use of the
tool will be provided.

As far as the quality of the information present in the eSchi system, every informational item
(text, images, video and sound) was already in use and provided or agreed by a renowned
medical facility – HSJD. The authors also intend to apply the DISCERN instrument to assess the
systems’ website quality.

Both patients and their families and caregivers are obviously empowered by this system. Not
only patients will be able to conduct their sessions without leaving their homes, but family
members and caregivers will also be able to better understand their relative/carer therapy process.

Additionally, experts (specialized medical personnel – psychiatrists and psychologists) will be

able to have more quality time. Indeed, by reducing the amount of time to conduct a session, the
physician can devote more time to the analysis and preparation of the following sessions, for
instance.

Access
In order to deploy the eSchi system, special precautions with prospective barriers were
undertaken.

• Resistance to change and Technology access

A major concern at the beginning of the project was to avoid technology resistance. Thus,
everyone engaged would easily adapt to using new technology, perceiving improvement in their
life quality. When users don’t perceive the effectiveness of a system they will fail to use the
system.

The authors will define a training plan in order to accomplish the best results possible with the
medical team and the patients, usage of the system.

• Legal, Privacy, Security and Ethical Issues

Regarding legal issues, there is a need to obtain informed consent from patients that will enter the
study and the authorization from the ethical committee of their institution.

Since at an initial phase, eSchi will only be available in an intranet, security issues are contained.
Patient records will have restricted access and will not be integrally available. There is already
some digital records for patients that contain more information that the one that will be provided
by eSchi.

There are no regulatory directives concerning the adequacy of the treatment, clinical
responsibility and licensing issues for therapists. This is not a problem in eSchi because every
patient is already a patient seen by a known physician – so the professional relationship is already
established and secured by traditional ethics concerns.

eSchi has a built-in authentication system, limiting the access only to known users that provide a
valid username/password pair. It will also provide a secure and encrypted access using HTTPS
(HyperText Transport Protocol Secure) technology that enables a secure communication channel,
data encryption, authenticity certificates and signing.

When designing, implementing and deploying the system, the authors engaged into several
meetings with the medical staff that will use the final system. It was extremely important to
include them as a part of the entire process; to listen and take into consideration their ideas and
professional remarks.

Costs
All the direct costs allocated to the project will be exhaustively presented in a financial report
format. Indirect costs, despite being extremely hard to obtain, will also be referred in the same
report. These refer to some sunk costs of technology and personnel that already existed
previously to the implementation of the system.

Satisfaction
The authors will assess and request system users’ feedback, both from patients and physicians.

Direct observation of the system usage will be reported and the results will be used to improve
the overall system, regarding both the usage and information available. A comprehensive
questionnaire, to obtain user satisfaction, will be applied during stipulated instants of the study.

The eSchi system has a built in statistical module that keeps track of the system’s use, namely,
visitors (demographic data), time per session, number of tries in activities and access to the
information available.
Future Trends
While it is impossible to forecast the future, current emerging trends on the subject include
surpassing the barriers previously presented. The items to assess the effectiveness of systems
provide a good starting point for authors that refer trends and future options for e-Therapy (Bee et
al., 2008; de Graaf et al., 2008; de Sá, Carriço, & Antunes, 2007; Emmelkamp, 2005; Gega,
Marks, & Mataix-Cols, 2004; Kaltenthaler et al., 2006; Lauriks et al., 2007; N. Titov, 2007; N.
Titov, Andrews, Schwencke, Drobny, & Einstein, 2008; Weber et al., 2008). Their overall
improvement is referred as the most likely step to take, in the search of excellence.

Nevertheless, (Clarke, Lynch, Spofford, & DeBar, 2006) provides a more structured approach
and identifies three major trends for the future delivery of mental health services: new and
improved self-help approaches and bibliotherapy interventions; moving the services to primary
care, in addition (Weber et al., 2008) to the actual settings of mental health speciality clinics and
new methods to improve the quality of the services provided. Basically, they refer to the content,
to the setting and to the organizational and financial aspects.

Whether through books and pamphlets (bibliotherapy) or computer/Internet assisted technology,

reliable mental health information can be distributed by non-specialists and is usually
inexpensive. This type of information could easily reach for the more inaccessible group of
patients that, at least initially, prefer to address their own problems.

Moving these specialty services to a more common setting (such as primary care) could provide
stigma reduction and improve the quality of care, by augmenting the communication between
healthcare providers.

Quality indicators based on reliably assessed clinical and functional outcomes is a way to
improve the services provided. Another important aspect is the financial one, where initiatives
such as pay-for-performance is included, are needed, to truly make e-Therapy a reality.

Finally, there is space for the appearance of new models of stepped care; management of the
patient’s health care as a whole (both mental and medical chronic conditions); treatment
algorithms and guidelines.
Conclusions
Currently, e-Therapy is already becoming a reality that is being used mainly as a therapeutic
complement at traditional settings. Providing therapy through an online environment is yet a
process that should be accompanied by a physician. Both families and caregivers are receiving
attention in order to participate and assume their roles, the most likely step to happen, in the near
future.

Several authors’ present evidence of the effectiveness of e-Therapy solutions while others refer
that there is still much work to be done. In fact, and despite the current trends of ICT and the
Internet movement, that makes technology and communication available almost everywhere,
anywhere and for everyone, there are still many issues to solve. The quality of the care provided;
the education and empowerment of the players involved in e-Therapy, the access, costs and
satisfaction issues should be assessed in order to provide the best e-Therapy solution possible.

eSchi is a system, currently under development, that aims to provide an e-Therapy setting to train
and rehabilitate schizophrenic patients and that involves distinct players. Special care has been
given to the system design in order to tackle each of the already known issues regarding this type
of service provisioning.

For the near future, forecasts predict three major trends for the future delivery of mental health
services: new and improved self-help approaches and bibliotherapy interventions; transferring
services to primary care, besides (Weber et al., 2008) the actual speciality clinics of mental health
and new methods to improve the quality of the services provided.
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 Key Terms and Their Definitions
Mental Health – the condition of being sound mentally and emotionally that is characterized by
the absence of mental disorder (as neurosis or psychosis) and by adequate adjustment especially
as reflected in feeling comfortable about oneself, positive feelings about others, and ability to
meet the demands of life.
Cognition – refers to someone’s attention, awareness, memory (long-, intermediate-, and short-
term), general knowledge, abstract thinking ability, insight, and judgment.
Therapy – a therapeutic treatment; remedial treatment of mental or bodily disorder; a treatment
designed or serving to bring about rehabilitation or social adjustment.
e-Therapy – provisioning of mental health services via e-mail, video conferencing, virtual reality
technology, chat technology, or any combination of these mediums.
Internet – an electronic communications network that connects computer networks and
organizational computer facilities around the world.
ICT – (Information and Communications Technology - or Technologies) is an umbrella term that
includes any communication device or application, encompassing: radio, television, cellular
phones, computer and network hardware and software, satellite systems and so on, as well as the
various services and applications associated with them, such as videoconferencing and distance
learning.
Effectiveness – producing a decided, decisive, or desired effect (intent or purpose).

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