Dr John Ashfield, a rural psychotherapist, has added these comments to discussions about the role of web doctoring in mental health (see previous posts for more info):

The use of internet technology must inevitably have a place in psychotherapy and psychological treatment of mental health problems and mental disorders – particularly in rural and remote areas where services are unavailable or hard to access due to the tyranny of distance.

I’m not sure about the basis for arguing equivalent effectiveness with face-to-face therapy, since the transtheoretical research (which is robust) on what works in therapy points to therapeutic alliance and extra therapeutic factors having greatly more importance than therapeutic information and technique.

Having said that, the approach Professor Andrews is suggesting appears enhanced by the particular clinical facilitation that is used – albeit on the internet and not face-to-face. The evidence of efficacy that he provides is persuasive.

However, perhaps there are a number of issues to be considered with this approach:

  • Has it been trialled with a less literate and less IT competent demographic?
  • How can we avoid internet therapy being hijacked for mere economy in the way that therapy is rapidly becoming manualised in North America – not because it is most effective, or because it is best for patients/clients, but because it is tidy and cost effective for insurers and budget conscious government agencies?
  • Gender is generally not sufficiently recognised for its vital importance in therapeutic practice. For example, the on-average female responds more favourably to linguistic engagement and communication (and therapy language); they are more socially oriented, verbally expressive, and for them, language is closest to the real. Shared activities occasion opportunity for verbal linguistic interaction.
  • Comparatively, the on-average male prefers verbal economy, he is more action oriented, and views presence and shared activity as closest to the real. Crucially, communication without physical gesturing, facial expressions, both voluntary and involuntary, may for him be deficient and much more difficult. For men, physical para-linguistic communication is very important – which is missing from telephone and internet based therapy, unless capacity for clear visual imaging is part of the technology – but even then, it is a poor substitute for face-to-face communication. How can this be addressed within internet therapy?
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