The therapeutic relationship can be one of the most powerful, healthy, dynamic, and sacred relationships between two people. This relationship can transform the challenges of navigating a life filled with loss, betrayal, sadness, and doubt, and can ultimately nurture healing, even when a cure is not possible.
Throughout my years of providing therapy to cancer patients and chronic pain patients, I have realized that in order for this healing to take place, both therapist and client must be present physically, mentally, emotionally, and even sometimes spiritually. I believe that therapy is an interconnected encounter between the self and the other — a professional interconnection needing the operation of all of the five senses to allow both the therapist and client to explore life and its challenges physically, in the present moment.
Yet for the last two decades, my notion of what makes a true therapeutic relationship has been somewhat challenged, transformed, and colored by the advance of internet therapy — a form of therapy that physically separates the therapist and client and redirects one’s eyes to pixelated computer screens.
But even though internet therapy challenges the traditional therapeutic model, research shows that it may stand as a valuable means of treatment for people worldwide who don’t have the time, money, or means of travel to access reliable forms of mental health care. But how can internet therapy provide the same, or different, kind of treatment that face-to-face therapy offers, and most importantly, can internet therapy nurture our sense of interconnectedness?
Internet-delivered psychological treatments have had a relatively short history. Since the mid- to late-1990s, numerous internet-delivered programs have been developed and tested for a broad spectrum of psychiatric and somatic conditions, some of which include anxiety, depression, post-traumatic stress disorder, and even insomnia. But today, the most common form of therapy that is being digitally delivered to clients over the internet is called “internet-delivered cognitive behavior therapy.” To date, most of the research investigating the clinical effectiveness of digitally delivered therapy programs has been on ICBTs.
ICBTs are generally based on traditional forms of cognitive behavioral therapy. This therapy aims at providing patients with the necessary skills needed to manage their moods and behaviors by identifying unhelpful thoughts. Patients can replace unhelpful thoughts such as “I am a total failure” with “I can succeed when I am motivated and strive to try harder”; in turn, these new thoughts can change one’s feelings and behaviors.
The rate of therapy is fully dependent upon the client and can take from anywhere between a week to many months. ICBTs on the other hand usually comprise of only six to 15 therapy modules, or text chapters, which are meant to mirror typical face-to-face cognitive behavioral therapy sessions, and require little to no therapist involvement. If available, therapist involvement usually consists of no more than 10 to 15 minutes of written feedback on completed homework assignments for each client per week. However, some internet-delivered therapies involve real-time chat- or video-based therapy, where both the client and therapist text or chat back and forth during the entire session.
Due to the fact that ICBT interventions can vary widely in both form and content whether they be based on problem-solving therapy, acceptance-commitment therapy, or attention-bias modification — researchers have had difficulty investigating the clinical effectiveness of a standardized form of ICBT on psychosomatic conditions. But it seems that no matter what form of ICBT is being delivered, early research has shown that ICBT interventions have promising clinical effects overall for both short- and long-term treatment outcomes.
A 2010 study published in the journal PLOS ONE showed that various forms of ICBT for anxiety and depressive disorders have the capacity to provide effective short- and long-term effects (even for up to 52 weeks without relapse) for conditions like social phobia, panic disorder, and major depression. The reasons for these positive effects are many. But if we begin to look at some of the current challenges for patients seeking mental health care, we may begin to understand the why and how of ICBT’s effectiveness.
Internet-delivered interventions can offer several advantages in the treatment of mental disorders. They provide a service that can be more accessible for individuals who live a long distance from mental health care institutions and can provide care to the elderly and disabled who may have restricted mobility. Internet-delivered therapy may also help with providing services to patients with fear of stigmatization and can be more flexible than face-to-face therapy in terms of allowing people to receive treatment on the weekends and outside of restrictive office hours.
Due to the fact that both patients and health care providers save money and time on traveling expenses and office space, internet-delivered therapy sessions are usually much cheaper than face-to-face sessions. Clients can engage in ICBT on their own without any input or reliance on a therapist who may even be gone on vacation. Yet would internet-delivered therapy be able to treat even the most complicated conditions, those with psychotic or traumatic features?
Post-traumatic stress disorder can be a severely debilitating condition and is associated with reduced quality of life, impaired social and occupational functioning, and considerable personal and societal costs. Even though adequate treatment is crucial for reducing PTSD symptoms, only a minority of individuals with PTSD receive the necessary treatment after experiencing a traumatic event. This can be due to myriad inherent avoidance symptoms — the patient may fear leaving the house or meeting other people. But researchers from the University of Amsterdam saw this as an important opportunity to investigate how ICBT may provide practical and effective at-home treatment for this patient group.
A 2016 study at the University of Amsterdam by Dr. Marit Sijbrandij, Ivo Kunovski, and Dr. Pim Cuijpers investigated whether ICBT could improve the accessibility of mental health care for individuals diagnosed with PTSD, compared to inactive-treatment patients and active-treatment patients. The ICBTs under consideration varied slightly in form and usually consisted of either self-help ICBT (without a therapist) and therapist-assisted ICBT. As they compiled the data, the researchers found that ICBT was in fact superior to both the inactive controls and active controls. However, what they did note was that the positive clinical effects in the studies analyzed were strongest when ICBT interventions were therapist-assisted and longer than eight sessions.