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Examining the use of online mental health supports
Jerilyn J. Dressler
University of Calgary
SOWK 693
February 24, 2014

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Examining the Use of Online Mental Health Supports

The internet has become increasingly pervasive in the lives of people across the globe,
particularly those living in the developed world. It is unsurprising, therefore, that online supports
for those with mental health concerns are growing in numbers (Barak, Hen, Boniel-Nissim, &
Shapira, 2008, Chester & Glass, 2006). There are three variables which, combined, create several
options for online mental health support delivery. These variables include whether or not there is
communication between two individuals or if the service is self-help, if the support occurs in
real-time or is delayed (synchronous versus asynchronous), and individual versus group support
(Barak et al., 2008). Online supports range from informative websites to counselling via webcam, with several modalities in between including discussion boards, e-mail, and online and
SMS chat services. Given the myriad of options available for accessing mental health support
online, and the growing familiarity with the internet for both mental health practitioners and
those in need of mental health supports, online supports have the potential to help reduce the barriers experienced by those in need of mental health supports. The following pages examine the
literature evaluating online supports provided by mental health practitioners, with a focus on
their potential for reducing barriers to accessing mental health supports. Recommendations for
future research are included.

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Effectiveness of Online Supports
There are several reasons for which online mental health supports have been criticized,
including the lack of non-verbal communication garnered in face-to-face interactions (e.g. facial
expressions and body language), ethical considerations (e.g. security and confidentiality issues),

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unclear laws and regulations for online delivery of services, and technical issues interfering with
the delivery of services (Barak et al., 2008, Chester & Glass, 2006). Fenichel, Suler, Barak,
Zelvin, Jones, Munro, Meunier, and Walker-Schmucker (2002) describe the commonly held belief that it is difficult for a client and practitioner to form a working alliance online. Wells,
Mitchell, Finkelhor, and Becker-Blease (2007) surveyed 2098 mental health practitioners in the
United States and found that very few of them - just over 2% - provided services online. Practitioners primary reservations about providing mental health services online included concerns
about the confidentiality of client information, practitioner liability, clients providing false information, and not having adequate training to provide mental health services in an online environment. Those who were decidedly opposed to the provision of mental health services online
cited concerns about licensing (i.e. providing service online to individuals living in a state for
which the practitioner does not have a license to practice), lack of face-to-face communication,
and clients lack of internet access in addition to the concerns cited above. Some practitioners
feared that providing mental health services online could exacerbate misuse of the internet, similar to holding an AA meeting in a bar (Wells et al., 2007, p. 457). Despite these reservations,
60% of the practitioners surveyed expressed interest in learning more about the delivery of mental health services online. Wells et al. (2007) suggest that mental health professionals reluctance
to provide service online and criticism of online supports may be related to a lack of knowledge
about the provision of services online.
In regard to service users, lack of knowledge about online services has in fact been found
to impact perceptions of online services, with lack of knowledge negatively influencing individuals perceptions of such services (Casey, Joy, & Clough, 2013). Conversely, and as one might

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expect, experience using the internet (Handley, Kay-Lambkin, Inder, Attia, Lewin, & Kelly,
2013) and experience with both the internet and therapy (Skinner & Latchford, 2006) have been
found to positively influence individuals perceptions of online mental health services. Furthermore, Leibert, Archer, Munson, and York (2006) found that the more hours an individual spent
online each week, the more likely they were to access online counselling.
The benefits of providing counselling online, according to a group of practitioners experienced with online service delivery surveyed by Chester and Glass (2006), included providing
services to those in remote areas, convenience, decreased client defensiveness, and increased
flexibility. Despite these benefits, the practitioners were divided in regard to whether or not they
perceived online counselling to be as effective or less effective than traditional face-to-face
counselling - 57% versus 42%, respectively. None of the practitioners assessed online counselling as more effective than face-to-face counselling.
In spite of the criticisms outlined above, online mental health supports have been shown
to be effective in treating a variety of mental health conditions, including anxiety (Andersson,
Bergstrom, Carlbring, & Lindefors, 2005), panic disorder (Pier, Austin, Klein, Mitchell, Schattner, Ciechomski, Gilson, Pierce, Shandley, & Wade, 2008, Bergstrom, Andersson, Karlsson,
Andreewitch, Ruck, Carlbring, & Lindefors, 2009, and Richards, Klein, & Carlbring, 2003), depression (Leykin et al., 2011, Titov & Andrews, 2009, Perini, Titov, & Andrews, 2009, and
Lintvedt, Griffiths, Sorensen, Ostvik, Wang, Eisemann, & Waterloo, 2011), post-traumatic stress
disorder (PTSD, Klein, Mitchell, Gilson, Shandley, Austin, Kiropoulos, Abbot, & Cannard,
2009), and reducing problem drinking (Riper, Kramer, Smit, Conijn, Schippers, & Cuijpers,
2007). There is evidence that online mental health supports can reduce the number of emergency

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room visits, made in the early months of a newborn childs life, for example (Hudson, CampbellGrossman, & Hertzog, 2012).
Several of the online interventions - including those for depression, panic disorder and
PTSD - employed a self-help Cognitive Behavioural Therapy (CBT) treatment, with minimal
professional support via e-mail. Subjects receiving CBT treatment online experienced a significant reduction in symptoms (Bergstrom et al., 2008, Klein et al., 2009, Lintvedt et al., 2011, and
Perini et al., 2009), and high therapeutic alliance was noted in Klein et al. (2009). Pier et al.
(2008) found no difference between a group administered CBT online with face-to-face therapeutic support delivered by the subjects general practitioners, and another group, also administered CBT online but with therapeutic assistance delivered via e-mail by a psychologist.
Online mental health supports have been found to be equally effective as face-to-face
counselling. Barak et al. (2009) examined 14 studies comparing online with face-to-face interventions, and found no significant difference in the effect size of the online and face-to-face interventions. The authors found interactive online supports to be more effective than static, psycho-educational websites, and chat and e-mail more effective than forum and webcam. They also
found individual interventions to be more effective than those administered in a group. Richards
(2009) suggests that online mental health supports can be perceived as a gateway to other services, given nearly a quarter of research participants accessed traditional support after an initial
online contact.

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Satisfaction Ratings of Online Support

There are mixed reports in the literature regarding satisfaction ratings of online support.
Research conducted by Leibert et al. (2006) found that respondents reported they were often
satisfied with online counselling. Yet satisfaction ratings for online counselling were lower than
those for traditional, face-to-face counselling, with the difference being statistically significant.
Respondents ratings of their relationship with their counsellor was impacted by the modality
(online versus face-to-face), with ratings of online relationships being lower than ratings of faceto-face relationships. This is supported by the findings of Richards (2009), yet Richards et al.
(2003) did not find a significant difference between online and face-to-face therapist ratings.
Richards et al. (2003) also did not find a relationship between therapist rating and outcome of
treatment, suggesting that helping alliance may not be necessary for positive outcomes in online
counselling.

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Motivations for Using Online Supports
Online mental health supports have been described as acceptable, accessible, efficient
(both cost- and time-effective), a way to enhance clinical care, and as a way to impact public
health (Leykin, Thekdi, Shumay, Munoz, Riba, & Dunn, 2011). In a survey of 81 clients using
online counselling, Leibert et al. (2006) found that the most commonly reported reasons for accessing counselling online rather than face-to-face were convenience and privacy/anonymity.
There was a distinct divide between what respondents perceived as advantages and disadvantages of online counselling; for example, invisibility was identified as the biggest advantage by

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some and the biggest disadvantage by others. Some preferred invisibility as a way to feel safe
disclosing their concerns, while others lamented the lack of human contact in times of distress.
There are some cases in which online mental health supports are clearly preferred to faceto-face support. Men who have difficulty expressing their emotions have been shown to prefer
online supports, for example (Rochlen, Land, & Wong, 2004). This finding is particularly interesting and of note given mens underutilization of counselling services (see Addis & Mahalik,
2003). Youth accessing counselling online via the Kids Help Line in Australia reported preferring
the online modality to the telephone for several reasons (King, Bambling, Lloyd, Gomurra,
Smith, Reid, & Wegner, 2007). Their reasons for preferring online counselling included privacy no one could overhear their conversations - and an emotionally safe environment. Calling the
phone line was reportedly scary, and the youth could take time to formulate a response using
text. Despite online mental health supports often being targeted at youth, Bradford & Rickwood
(2014) found that youth showed a preference for face-to-face treatment, followed by no treatment at all. Only sixteen percent of their sample reported a preference for online treatments.
Several authors have found that online mental health support users are more likely to discuss more emotional or sensitive issues, like suicide and sexuality, compared to phone service
users, who are more likely to discuss day-to-day troubles (see Callahan & Inckle, 2012). It appears that the more anonymous the interaction is, the more disclosure of sensitive topics it yields.
Gilat and Shahar (2007) found that threats of suicide were much more common in an asynchronous support group (message board) compared to telephone support or online chat. Only one
study (Skinner & Latchford, 2006) found that those accessing face-to-face mental health support
had a higher tendency to self-disclose than those accessing support online. Richards (2009)

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found no significant difference between the issues presented in online counselling and those presented in face-to-face counselling.
What might contribute to an increase in self-disclosure of sensitive matters online? The
online disinhibition effect - a term coined by Suler (2004) - describes how individuals act in
ways online that they would not in face-to-face interactions. Suler outlines six variables that interact to create the online disinhibition effect: dissociative anonymity, invisibility, asynchronicity,
solipsistic introjection, dissociative imagination, and minimization of authority. Dissociative
anonymity describes the process through which a lack of identifying information online leads
people to separate what they do online with who they are in the real world. As with any type of
dissociation, this leads to behaviour that is not consistent with who the individual perceives
themselves to be or how they would behave in their life offline. Invisibility speaks to being undetectable while online - people may go places online that they would not if someone could see that
they were there. They also dont have to worry about how they or others look when interacting
online, and therefore have no need to fear others physical reactions to what they say and do (e.g.
facial expression and body language). Asynchronicity describes how online conversations via email or message board do not happen in real time. Others immediate reactions, generally serving
as a feedback loop, are absent and fail to modify behaviour as they would in a face-to-face interaction. Solipsistic introjection describes how people fill in the blanks with their hopes about
who the person on the other end of the conversation is. This leads to a sense of not communicating with someone else, but more like communicating with ones self. Dissociative imagination
refers to an online world created in a persons mind, where their online self (separate from their
real world self) resides. The most obvious example of this is simulated characters and worlds in

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online gaming; Suler specifies that this type of thinking can easily overlap into online social environments. Authority is minimized online due to usual indicators of authority being absent. That
is, the way those in authority dress, act, and the physical environment in which they exist is not
apparent. Suler speaks to personality being a significant contributing factor to the online disinhibition effect, with histrionic types being much more likely to act out with more intensity or selfdisclose in ways they would not in a face-to-face interaction.

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Barriers to Accessing Support
Barriers to accessing mental health supports have been well researched and documented.
Sareen Jagdeo, Cox, Clara, ten Have, Belik, de Graaf, and Stein (2007) examined the barriers
experienced by those in need of mental health supports in Canada, the Netherlands, and the United States. Many of the barriers experienced in these countries were perceived rather than structural, with those in need of mental health support in the United States more likely to experience
structural barriers (such as cost of treatment). The most commonly cited barriers to accessing
mental health support in all of the countries studied were that those needing support hoped that
they could fix the problem on their own, or that the problem would get better without help. Youth
were more likely to consider embarrassment about accessing mental health supports and fear of
involuntary hospitalization as barriers.
In research conducted with 165 college students at elevated risk for suicide, the most
commonly reported barriers to accessing support were the belief that treatment was not necessary
(i.e. their symptoms were not severe enough, 66% of respondents), a lack of time to seek treatment (26.8% of respondents), and that they preferred to manage their mental health concerns on

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their own (18%, Czyz, Horwitz, Eisenberg, Kramer, & King, 2013). The authors suggest that
youth and college-aged young adults may prefer self-reliance at this stage of their development
due to their growing need for autonomy. They note that stigma was relatively low on the list of
reported barriers to accessing treatment, with only 12% of respondents reporting it as a perceived
barrier. Czyz et al. (2013) describe the U.S. Public Health Services Health Belief Model (HBM)
as a framework to evaluate whether or not an individual is likely to seek treatment; the HBM
contends that the individuals assessment of threat (perceived susceptibility and severity), costs
(perceived barriers), as well as perceived benefits interact to determine health behaviour (p.
399). Using this model, one could assess that the college students did not perceive the threat of
their mental health concern, or the benefit of seeking treatment, great enough to seek treatment.
The stages of change (Prochaska & DiClemente, 1983, as cited in Tanielian, Jaycox, Paddock, Chandra, Meredith, & Burnam, 2009) may also be a useful lens through which to view
perceived barriers to accessing mental health supports. Several stages precede Action in this
framework describing behavioural change, including Pre-contemplation, Contemplation and
Preparation. Tanielian et al. (2009) found that only a quarter of adolescents who reported being
depressed also reported being in treatment. The adolescents who were not ready for treatment in
the 2009 study were most comfortable considering informal or self-help options. In addition to
there being several self-help options for mental health support online, the pervasiveness of the
internet and increasing comfort with its use could lead to a variety of mental health supports being perceived as similar to self-help options. Could online mental health supports be a way to
reduce the threshold at which those requiring mental health support seek treatment? That is,

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could online mental health supports make it more likely that those in the Contemplation and
Preparation stages access support?
Online supports have been proposed as a way to minimize barriers to accessing mental
health supports (Addis & Mahalik, 2003, Chester & Glass, 2006, Crutzen & de Nooijer, 2010,
Czyz et al., 2013, Dowling & Rickwood, 2013, Griffiths & Christensen, 2006, Handley et al.,
2013, King et al., 2006, Rochlen et al., 2004, and Suler, 2004). Considering adolescents are more
likely to experience shame and stigma as a perceived barrier to seeking mental health supports
(Sareen et al., 2007), it is conceivable that they would be more comfortable accessing mental
health supports online where they are spending more and more of their time and, presumably,
feeling increasingly comfortable (see Crutzen & de Nooijer, 2010). With half of mental health
conditions emerging by 14 years of age, and a quarter by 24, interventions directed at youth and
young adults should be considered a priority (Kessler, Berglund, Demler, Jin, Merikangas, &
Walters, 2005).

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Conclusion
It is clear that online mental health supports are effective, arguably as effective as face-toface supports. The research examining the effectiveness of online mental health supports has
been criticized for having few randomized control trials (Dowling & Rickwood, 2013), but this
writer found the research to be mixed, with several of them having randomized controls (e.g.
Lintvedt et al., 2013, Hudson et al., 2012, Perini et al., 2009, Pier et al., 2008, and Riper et al.,
2007). There are both obvious and unintended differences in online and face-to-face supports.
Fenichel et al. (2002) point out commonly held myths about providing mental health treatment

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online, and contend that concerns about online treatment can be reasonably addressed. One
method to ensure that professional, ethical guidelines are followed in providing online mental
health supports is to abide by the International Society for Mental Health Onlines Suggested
Principles for the Online Provision of Mental Health Services (2000). If the effectiveness of online mental health supports is not a valid concern and concerns as reported by practitioners can
be reasonably addressed, one is left to question why satisfaction ratings for online mental health
supports and preferences for online versus face-to-face mental health supports are highly varied
in the literature.
Richards (2009) argues that online counselling should not be seen as a replacement for
face-to-face counselling, but as an extension of/gateway to more traditional, face-to-face services. As demonstrated by Tanelian et al. (2009), those who are are not yet ready for face-to-face
treatment are willing to access self-help supports. Due to larger amounts of time being spent online and growing familiarity with the internet, online mental health supports could be perceived
as more similar to self-help options than traditional, face-to-face treatment. Online supports may
be able to impact the cost/benefit analysis of those needing mental health supports by reducing
the perceived costs of accessing treatment for those who, using the Health Belief Model framework, are unable to accurately assess the severity of their condition and their need for treatment.
Due to the anonymous, invisible, and easily accessible nature of online mental health supports,
they could be used to provide information and support for those who may not be ready for more
traditional, face-to-face treatment. Using the language of Prochaska and DiClemente (1983), online mental health supports could reach those in the Pre-contemplation and Contemplation stages
of the stages of change.

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Online mental health supports have been put forth as a way to reduce the barriers to accessing treatment, not only financial and geographical barriers but also not considering the concern severe enough to seek treatment and wanting to attend to the problem independently or
through more informal supports. Further research is required to determine if preferences for online mental health supports are related to readiness for treatment. This writer hypothesizes that
readiness for treatment is related to preference for online or face-to-face support; that those in the
Preconteplation or Contemplation stages may be more likely to prefer online supports as opposed
to those in the Preparation and Action stages of Prochaska and DiClemente's (1983) stages of
change, who could be more likely to prefer face-to-face supports. This research has the potential
to strengthen the argument that online mental health supports can and should be used to reduce
barriers in receiving treatment for mental health concerns.

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