Better Living for Women, Families, and Communities:
A Review of Online Group Counseling for Postpartum Women
by Salit Shahak[1]
Background
In recent years, the intense growth of the internet, its accessibility and availability, changed the way people run their lives. This is true in a variety of ways, such as our social lives and friendships, the way we find information, and the way we run business (Antheunis, Valkenburg, & Peter, 2010; Bargh & Mckenna, 2004; Rainie, Purcell, & Smith, 2011; Weinberg, 2014). Moreover, the removal of geographical boundaries and the growing use of smartphones have led to a significant increase in the number of users (Purcell, Rainie, Rosenstiel, & Mitchell, 2011).
This increase in the availability of online communications has introduced new opportunities for the facilitation of a variety of mental health services for people in need of support (Barak & Suler, 2008; Cook & Doyle, 2002; Male, Fergus, & Stephen, 2017).
Women in the postpartum period are vulnerable to stress due to new tasks associated with their maternal role, along with dramatic psychological and physical changes (Beck, Gable, Sakala, & Declercq, 2011; Chen, 1994; Cheng & Li, 2008; Hung, Lin, Stocker, & Yu, 2011). Moreover, the gap between the expected feeling of fulfillment and overjoy of becoming a mother, and the actual reality of uncertainty and burden lead mothers to self-disappointment (Dennis et al., 2009).
Due to increased awareness of the extent and consequences of postpartum depression for women (Cooper & Murray, 1995) their children (Beck, 1999; Murray & Cooper, 1996), and their families (Beck, 2002; Boyce, 1994), and as demand for limited healthcare resources increases, it is particularly important to develop other means for help and support. Since most women entering postnatal period are healthy individuals, primary health care services seem like the most appropriate body to facilitate such efforts.
Accordingly, mental health professionals are faced with the dilemma of how to keep up with the competition while approaching the unknown influences of technology. The reality is that seeking help over the internet is not only occurring, but it also will likely increase in prevalence regardless of the potential drawbacks (Baker & Ray, 2011).
This review aims to shed light and call for further research on the new therapeutic discipline created under the radar and its alteration into an on-hand valid tool. Understanding this new arena will allow women, public mental health providers, and practitioners, a better understanding of concrete methods and tools, hence improved services and women’s overall well-being.
A changed world – an altered human experience
“The internet is the first thing that humanity has built that humanity doesn’t understand” —Eric Schmidt (Chief Executive Officer of Google)
According to Microsoft’s Gordon Bell and Jim Gray (as cited in Brown & Duguid, 2000), “By 2047…all information about physical objects, including humans, buildings, processes and organizations will be online. This is both desirable and inevitable” (p. 11). Indeed, in developed countries, such as the United States, Great Britain, Germany, Australia, Japan, and Canada, household use of the internet has exceeded 75% (Barak & Suler, 2008). In Israel, for instance, 82.5% of all households in the Jewish sector are connected to the internet, and this is more widespread in young scholars, as reflected in a study conducted by TIM (Eilam, 2011, in Dolev-Cohen, 2012).
The availability and affordability of the internet have been the cause of personal and social changes. Accordingly, there has been a dramatic increase in the number of human activities that have moved from the physical world to the online world, thus changing human culture, habits, priorities, governing, parenting, and so on (Barak & Suler, 2008; Male et al., 2017).
In fact, the ability to exist simultaneously in different situations and different places created a new world for people, a world with blurred boundaries and time limitations. Furthermore, online communication, perhaps the main attribute of this new world, holds a number of characteristics that make it very different from any other form of communication known to us prior to the invention of the internet. Significantly, this form of communication is not only different in a technical and practical manner, but also in the reality it creates. This new realty makes people who use it undergo psychological experiences that affect the way they think, feel, and behave, and by that creating a different human experience (Barak, 2007; Weinberg, 2014).
On the same note, the popularity of the internet, specifically of online social networking, has given rise to and evoked the power of groups. Online support groups have demonstrated success in terms of promoting adaptive coping and adjustment among caregivers and patients with various medical and psychological conditions (Chou, Liu, & Chu, 2002; Chu et al., 2011; Lieberman et al., 2003; Toseland et al., 1992; Winzelberg et al., 2003, in Male et al., 2017). Research further shows that online support groups make people feel at ease to connect with other people in time of need. This is, in part, what makes the internet an empowering agency for many individuals (Amichai-Hamburger, McKenna, & Tal, 2008, in Barak, 2010).
Furthermore, it has been demonstrated that online treatments provided with group support are more effective than those without any support (Spek et al., 2007). Therefore, it appears that the flexibility and outreach of the internet makes it an attractive addition to traditional face-to-face approaches to mental health.
The awakening of the power of groups puts emphasis on the importance of research as to how this power will be harnessed in favor of social support and aid.
Help is within reach—expanding possibilities for human connections and mental health
Alongside the intense technology and social development, the internet and other systems deriving from it became an efficient and convenient mean for consultation, support, and various psychological interventions. Yet, contrary to this rapid growth, all interventions still offer an adopted imitation of face-to-face traditional therapies (Barak, 2005).
Accordingly, mental health professionals and caregivers are faced with the dilemma of how to keep up with the competition while approaching the unknown influences of technology. The reality is that seeking help over the internet is not only occurring, but it also will likely increase in prevalence regardless of the potential drawbacks (Baker & Ray, 2011).
Research shows that internet health interventions are rapidly gaining empirical support, and to date internet interventions have been shown to help individuals stop smoking (Munoz et al., 2009; Shahab & McEwen, 2009), lose weight (Weinstein, 2006), reduce depression and anxiety (Griffiths et al., 2010), teach effective management of diabetes (McKay et al., 2002), and more.
In the case of online communication, which does not involve visual aids, the most evident and repotted communication characteristics people experience include anonymity; invisibility; lack of eye-contact; the ability to write interpersonal messages; flexibility of synchronicity; neutralizing of status; and easy reach of large populations. These characteristics enable people’s behavior to become more spontaneous, expressive, genuine, and open (Bargh, Fitzsimons, & McKenna, 2003; Bargh, McKenna, Fitzsimons, 2002; McKenna, 2007, 2008; McKenna & Seidman, 2005, 2006).
This may mean that a lot of this medium’s success is linked to its accessibility, ease, and possible anonymity. Therefore, it is understandable that people do use the internet when they seek information or help and it is not possible physically, or when they prefer to hide their identity.
While this reality is taking shape, and the internet is becoming a valid part of our well-being toolbox, research reviews show strong support for the value of online therapy in helping increase positive outcomes (Robinson & Serfaty, 2008; Spek et al., 2008). A meta-analysis conducted by Barak, Hen, Boniel-Nissim, and Shapira (2008) examined the effectiveness of online therapy and found a medium effect size, which is similar to the average effect size of traditional, face-to-face therapy. In a later study Murphy and colleagues (2009) reported no statistically significant difference in satisfaction scores for face-to-face and online clients (Murphy et al., 2009).
Research shows that internet-based interventions are effective in the treatment of major depression (Hedman et al., 2012), including maintenance treatments (Ebert et al., 2013; Ebert et al., 2014; Hollandare et al., 2011). For example, a systematic review (Richards and Richardson, 2012) of 19 controlled trials evaluating internet-based interventions for symptoms of depression in almost 3,000 participants found an effect size of d=.78. Furthermore, a recent meta-analysis found that internet-based cognitive behavioral treatments can have comparable effects to traditional face-to-face psychotherapy, even when they are compared directly to each other (Andersson et al., 2014).
Recent studies indicate initial evidence that online interventions are effective at lowering the incidences of depression (Muñoz, et al., 2012; Van Zoonen, et al., 2014) and specifically are effective at reducing the risk of PPD among non-depressed pregnant and postpartum women (Dennis & Dowswell, 2013).
Hence, in terms of human healing and support, the question of the development of technology versus the development of offered consultation and therapy calls for further research to determine if the online world, with all it has to offer, is being best exploited for the benefit of people seeking help and support and for professionals pursuing a valid tool to lean on.
Terminology and the history of online counseling
Literature shows various terms that are used to describe online counseling, including e-therapy (Manhal-Baugus, 2001), cybertherapy (Suler, 2000), online or internet therapy (Rochlen, Zack, & Speyer, 2004), e-mail therapy (Shapiro & Schulman, 1996), e-counseling (Tate, Jackvony & Wing, 2003), internet counseling (Pollock, 2006), web counseling (Urbis Keys Young, 2003), cybercounseling (Maples and Han, 2008), and therap-e-mail (Murphy & Mitchell, 1998).
Bloom (1998) defines online counseling as “the practice of professional counseling that occurs when client and counsellor are in separate or remote locations and utilize electronic means to communicate with each other” (p. 53). Alleman (2002) refers to online counseling as “ongoing, interactive, text-based, electronic communication between a client and a mental health professional aimed at behavioral or mental health improvement” (p. 200). Mallen and Vogel (2005) define online counseling as “Any delivery of mental and behavioral health services, including but not limited to therapy, consultation, and psychoeducation, by a licensed practitioner to a client in a non-face-to-face setting through distance communication technologies such as the telephone, asynchronous e-mail, synchronous chat, and videoconferencing” (p. 764).
These definitions suggest that online counseling can take many forms. On the same note, internet-based mental health interventions can include mental health information websites, online mental health screening and assessment tools, online support groups, individual therapy, group therapy and self-help programs (Ybarra & Eaton, 2005), as well as online forums, bulletin boards, and chat rooms (Barak, 1999; Fenichel et al., 2002). Virtual reality therapy (Luo, 2007) and online video game therapy (Wilkinson, Ang, & Goh, 2008) are two additional emerging online modalities. Online counseling may be provided as the primary treatment modality or as an auxiliary tool to more traditional forms of mental health treatment (Wells, et al., 2007).
Some (Castelnuovo, Gaggioli, Mantovani, & Riva, 2003) see online counseling as a transposition of face-to-face counseling online, with technologies mediating the therapeutic communication and affecting the process with their associated advantages and limitations. Others, however, (Fenichel et al., 2002; Grohol, 1999, 2001) assess that online counseling should be considered a new type of therapeutic intervention, a distinct way of engaging therapeutically, and therefore needing a different theoretical framework from face-to-face counseling. From this perspective, online counseling is considered a new, versatile, and flexible resource with the potential to complement and support other types of interventions.
The use of technology-assisted communications to deliver and enhance mental health interventions emerged in 2000 and has thrived rapidly (Pagliari, et al., 2005). This rapid development is based mainly on the belief that technology has considerable potential to improve the quality of intervention delivery and to increase the engagement of worldwide at-risk populations (Jones, 2014), mainly since these new technologies allow larger spread of evidence-based interventions by increasing accessibility and reducing costs (Jones et al., 2013, in Hall & Bierman, 2015).
Tangible mental health services first emerged on the internet as early as 1982, through online self-help support groups (Barak, 2004; Kanani & Regehr, 2003). The earliest known organized service to provide mental health advice to individuals online was “Ask Uncle Ezra,” a free service offered to students of Cornell University that has been in operation since 1986 (Ainsworth, 2002). Later on, in mid-1990s, John Grohol developed a free mental health advice website (Young, 2005). The first known fee-based internet mental health service was established by Sommers in 1995 (Skinner & Zack, 2004). In the same year, Needham became the first practitioner to offer e-therapy via real-time chat (Ainsworth, 2002). By the late 1990s, counsellors began practicing online counseling in addition to their private practices (Young, 2005).
The emergence of information technology over the past decade, its widespread use at a reasonable price throughout the world, and the relative success of “user-friendly computers” that allow more people to use computers are significantly reflected in the field of psychology (Barak, 1999). Psychology (and related professions) joined this trend modestly toward the end of the 1980s (Ishak & Burt, 1998). The field of psychology is now discovering the great opportunities inherent in this medium, such as the use of the internet for approaching people more easily to initiate social change (Sampson, 1998), consulting with youngsters and adults (Casey, 1995), and generally contributing to mental health care by means of consultation and supervision (Smith, 1998).
The integration of internet technology into the practice of psychotherapy is an innovative method for increasing accessibility and affordability in the provision of mental health treatment. This method will probably further develop and increase alongside other fields (such as e-commerce and education), relying on the internet to increase outreach and effect, and therefore calls for ongoing wide research.
The Prevalence and Scope of Online Counseling
It is difficult, if not impossible, to estimate the current prevalence of online counseling. However, it is clear that the supply and demand of this form of treatment have increased dramatically. To reference such increases in supply and demand, a Google search on “online counseling” done in 1997 by Sampson, Kolodinsky, and Greeno (1997) produced 4,000 websites; the same search done in 2007 by Amani (2007) yields 273,000 websites. In 2009, Haberstroh (2009) found over 4,000,000 websites, and my current search conducted in June, 2017, led me to over 29,000,000 websites! This superficial yet transparent search, which points an astronomical growth in the past 20 years, indicates extensive progression in this field.
Internet counseling has indeed gradually grown and expanded, offering therapy for both serious and minor disorders, and for dealing with everyday life (Grohol, 2004). Ainsworth (2002) reported that there has been a steady increase on her nonprofit website, from 12 to more than 250 private-practice websites, representing more than 700 therapists, since 1995.
DuBois (2004), a clinical social worker, explored the demographics and clinical characteristics of her own online counseling clients. Of the 217 clients surveyed, 15% were males and 85% were females. 16% of clients were 13−19 years old, 28% were 20−30 years old, 23% were 31−40, 25% were 41−50 and 6% were 51−60. Despite the fact that her practice was based in Canada, most people seeking online counseling through her website lived in the United States. The issues that people cited as their primary reason for seeking online counseling included relationship issues with partner (55%); depression (13%); low self-esteem (6%); and anxiety (5%).
While research demonstrates strong support for the value of online therapy in helping increase positive client outcomes (e.g., Robinson & Serfaty, 2008; Spek et al., 2008), a meta-analysis conducted by Barak, Hen, Boniel-Nissim, and Shapira (2008), which examined data from 92 internet-delivered therapy studies, found several criticisms raised by both professionals and nonprofessionals: the effect of the loss of cues on the process of therapy and consequently whether counseling can occur in such a context; ethical issues, and in some cases their potential legal implications regarding the delivery of online counseling; and practical issues have arisen concerning training for conducting online counseling and concerns about relying on technology.
In spite of the strong criticisms, from its beginning the various technology-delivered psychological interventions have flourished. Barak and colleagues (2009) state that this is likely due to several factors including:
- Increasing acceptability of the internet as a legitimate social tool
- Computer hardware and software developments (especially in relation to ease of use, privacy protection, and online communication capabilities)
- Development of ethical guidelines by various professional organizations
- Growing research
- Establishment of online training for professionals
Forms and Characteristics of Online Counseling
Counseling and the whole field of mental health is currently in an era of change as computer-mediated and other developed services are evolving and developing, even ahead of an established research base. While this field works to match research with practice, Lundberg (2000) fittingly noted:
Counselors are still groping for an effective merger between an increasingly technological world and a profession that is practiced through very personal contact. More fundamentally, human service professionals are still trying to understand just how human relationships change when they are mediated by computers. (p. 142)
The rapid development of technology, which made human life even more intense, calls for a search for means to supplement face-to-face counseling services, or replace them altogether. Ainsworth (2002) divides the forms of online counseling into four categories:
- E-therapy: ongoing helping relationships that take place only through internet communication (i.e., email, synchronous chat)
- Mental health advice: professionals respond to inquiries online, without a continued relationship
- Assisting services: the internet communication is used in addition to traditional face-to-face services
- Telehealth and Telepsychiatry: using videoconferencing systems to work with patients as an extension of clinic or hospital care
Barak and colleagues (2008) identified three factors that differentiate among the many online therapeutic modes:
- The employed method of online services, involving either an ongoing therapeutic relationship through human connection or self-help or web-based type of therapy utilizing a structured plan provided by a computer-based program or facilitator.
- The time in which the service is offered, synchronously or asynchronously.
- The type of technology supporting the service offered (i.e., through text, audio, webcam, or a combination).
According to Barak (1999), there are 4 main types of online counseling: (1) single-session psychological advice through email or e-bulletin board, (2) ongoing personal counseling through email, (3) real-time counseling through chat, web telephony, and videoconferencing, and (4) synchronous and asynchronous support groups, discussion groups, and group counseling.
Psychological advice through email or e-bulletin board: a mental health professional (mostly) offers specific information to another individual who has a specific concern (Manhal-Baugus, 2001). There are numerous websites offering advice to users on on various psychological issues (e.g., parenting, sleeping disorders, depression, sex, addiction, etc.). The correspondence between users and advisors could be fully discrete or could be published on a public electronic bulletin board.
Ongoing personal counseling through email: in this method, no face-to-face interaction exists. Also, in contrast to the traditional therapy, in which a therapist and a client meet periodically, the rate of communication exchanges through emails may vary and could be highly responsive (even several times a day). Moreover, therapeutic exchanges may include direct quotations from current and previous messages, since all verbal expressions are documented in email exchanges. Yet messages may be not spontaneous; since there is time delay between messages exchange, it allows both a therapist and a client to think, plan, and edit before sending out their emails (Barak, 1999).
Real-time counseling through chat, web telephony, and videoconferencing: Studies show that approximately 50% of practitioners who offer online counseling use real-time interactive communication methods, including chat rooms, web telephony, and videoconferencing (Laszlo, Esterman & Zabko, 1999; Maheu & Gordon, 2000). When using chat technology, users log on to different chat rooms and view written dialogs. Web telephony makes real time speaking over the internet possible, users use speakers and a microphone to communicate with each other, which is similar to telephone conversations. Videoconferencing allows both verbal and visual real time interactivity by video equipment installed in each party’s computer station.
Synchronous and asynchronous support groups, discussion groups, and group counseling: The internet allows efficient group communications, in which a person delivers messages to a number of people in real time or in time delay. The availability of online group communication constitutes a new form of social support network (Davison, Pennebaker, & Dickerson, 2000). There are different types of group communication on the internet, including: newsgroups, chat rooms, discussion groups, and web forums (Barak, 1999).
Advantages and Disadvantages of Online Counseling
Research shows that online counseling has both potential advantages and disadvantages. Amongst its notable advantages:
Disinhibition
The most widely reported finding from researchers studying the interpersonal aspects of online interactions is the disinhibition effect (Lapidot-Lefler, 2012). People who engage in online communications tend to feel uninhibited in many ways, a feeling that facilitates fast, intimate disclosure and honest, frank responses (Lapidot-Lefler, 2012; Sproull & Kiesler, 1995). Joinson (1998) found that participants who completed psychological measures using the internet were less socially anxious (based on the social anxiety measure), and scored lower on the social desirability scale. It was apparent that users of online self-help groups tend to be less concerned about being judged negatively by their fellow online group members, than they would be when discussing these matters with friends and family in person.
Accessibility
Online counseling has much less restriction in terms of time and space than traditional face-to-face counseling. Online, clients can contact their counselor whenever they have access to a computer or smartphone, and can do so from the comfort and privacy of their own home. This way, those who live in remote areas and do not have access to qualified professionals can take advantages of the large number and variety of services available on the internet (Griffiths, 2001; Murphy & Mitchell, 1998). Furthermore, individuals who have urgent problems can seek counseling online immediately, without having to bear the wait for the appointment (Barak, 1999; Griffiths, 2001). The ability to use online counseling is also an option for people in need of therapy who are forced to refrain from using traditional psychological services because of physical or psychological difficulties, difficulties in transportation, personal handicap, sickness, shyness, social phobia, and avoidant personality disorder, etc. (Fenichel, et al., 2002; Griffiths, 2001). For these reasons, perhaps the most notable and discussed advantage of online counseling is its potential for increasing access to mental health services.
Anonymity
The online world offers a degree of perceived anonymity by allowing users to communicate without face-to-face interactions, or without even knowing each other’s identifying data (Griffiths, 2001; Grohol, 1999). A person can get in a chat room or send e-mail to any number of online therapists using a false name or by maintaining anonymity. Because of anonymity, potent social factors as physical attractiveness, vocal characteristics, ethnicity, and social skills are neutralized (Davison, et al., 2000). An individual can share and discuss personal issues, mental health problems, and relationship difficulties online and experiences less threat, given the continuing stigma exhibited in many parts of society toward mental health problems (Grohol, 1999). It is therefore possible that this form of interaction will provide a unique opportunity for people who are not likely to use traditional forms of professional services. For example, Yeh and Krumboltz (2001) found that Asian Americans were more willing to participate in exploring personal growth issues in an online support group format than a traditional face-to-face format.
Suler (2000) also stressed that, in online counseling, being “invisible” can reduce or eliminate the stigma associated with seeking mental health services. It may also be easier for patients to disclose information about themselves via the computer since certain social markers such as age, gender, and ethnicity are removed. Honesty and sincerity may also increase, as clients may feel less defensive and vulnerable when they cannot see the therapist (Maples & Han, 2008). The possibility of staying anonymous while involved in online communication leads to disinhibition and results in a more authentic behavior by the user (Bargh, McKenna, & Fitzsimons, 2002). This phenomenon is manifested in revealing hidden emotions, fears, and expressions of hate or anger (Barak, 2006; Suler, 2004). In accordance, several researches show that online interactions call for the manifestation of the “true self” more than its physical equivalents (Bargh, et al., 2002).
Cost-effectiveness
Online counseling is cost-effective for clients. Office visits with mental health professionals can cost as much as $200 per session, while online therapists are charging a range of approximately $20-80 for an email response and $25 fees for a 60-minute chat session (Sleek, 1997).
Convenience
Online counseling services can be provided at any time of day, and clients can send messages whenever they feel most in need of, or interested in, therapy (Manhal-Baugus, 2001). Moreover, online counseling can be accessed from anywhere in the world having internet access (Maples & Han, 2008). As mentioned earlier, it also allows physically or mentally impaired individuals to access therapists from the comfort of their home. From the therapist’s perspective, it allows more flexibility in their work schedules (Suler, 2000).
Time Delay
While the time delay inherent in asynchronous communications can be viewed as a disadvantage of e-mail counseling, it allows both counselor and client the time to compose a thought or question that precisely reflects the concern or issue. There is no pressure to think quickly; the client can reply when he or she is ready to reply (Suler, 2000).
A Permanent Record
One of the advantages of counseling by e-mail, chat, or any other form of written or recorded counseling is that the entire history of the communication in therapy can be available to both the client and the counselor. Clients and counselors can re-read or re-listen to these conversations as reminders, encouragements, confrontation, etc. (Barak, 1999; Murphy & Mitchell, 1998). Murphy and Mitchell (1998) further suggest that committing a problem to written format, such as e-mail, helps the client to analyze their situations by formulating a clear problem statement and reading and re-reading it for emotional clarity and accuracy. Bibliotherapy, for instance, including both reading and writing, has been used by therapists to facilitate clients’ self- disclosure, ventilation, and externalization of problems that promote self-awareness (Barak, 1999). Furthermore, with the entire therapy existing as text or audio, supervision is made easier. The client is as present for the supervisor as for the therapists (Murphy & Mitchell, 1998). Therefore, the capacity for easily documenting and archiving counseling dialogue online seems to be beneficial for both clients and counselors.
Client Autonomy and Empowerment
Online counseling gives people the freedom and the ability to say whatever they want to say, whenever they feel the desire to share, and to initiate contact. Hence, online counseling also has the potential to enhance patient autonomy in the therapeutic relationship, thus decreasing the power differential between client and therapist (Yager, 2001).
Some of the noticeable disadvantages and limitations of online therapy are: one of the main difficulties reported regarding this important development, which allows us to reach information quickly and easily, is the relevancy and accuracy of the information (Weinberg, 2014). When people use information they retrieve from the internet, they trust it is reliable, and they further lean on that information to promote decisions (as important as choosing a doctor or a nanny for their kids). With the current absence of “internet police,” people always put themselves at risk when relying on internet information.
Another concern is the potential for breaches of confidentiality, since information given online is not always safe from hackers and other dangers. Confidentiality breaches can occur in many ways: e-mails may be misdirected by typos in the “to” field or intercepted by computer hackers (Recupero & Rainey, 2005). On the same level, other people may have access to the client or practitioner’s e-mail, such as employers or family members; confidentiality issues also arise with respect to the storage of transcripts of online counseling sessions by either the therapist or the client (Mallen, Vogel & Rochlen, 2005).
Another limitation of online counseling is the lack of nonverbal cues (Manhal-Baugus, 2001). All non-verbal information, including tone of voice, body language, and facial expressions of the client, are important in building relationship in counseling and understanding not only the content of a story but the underlying meaning (Manhal-Baugus, 2001). Some forms of online counseling may offer this (i.e., videoconferencing) but most other forms, like email and synchronous chat, do not allow nonverbal information.
The lack of visual and vocal cues can result in difficulty, or even inability, for therapist and clients to establish a strong therapeutic relationship (Cook & Doyle, 2002). In addition, therapists traditionally rely on non-verbal cues in order to interpret what clients may be feeling or thinking (Maples & Han, 2008). Lack of access to non-verbal behavior may also make it difficult to evaluate and diagnose disorders. Users, however, found ways to offer supplemental information through text using colors, capital letters, and emoticons (Alleman, 2002).
Although access was noted above as an advantage of online counseling, it can also be viewed as a limitation, since online counseling is only available for clients who have access to computer and internet.
At the same time access to online services is increasing around the world, online counseling requires that clients and counsellors have the skills necessary to utilize the chosen method of communication efficiently (Maples & Han, 2008). In addition, in the case of textual communication, both therapist and client must be fairly good readers and writers.
Finally, while time delay was seen above as an advantage in the case of e-mails and other text based communications, it can also alter the nature of the counseling process (Rochlen, Zack, & Speyer, 2004). Time delay can lead to frustration on the part of the client. It can also lead to uncertainty, which in turn may result in many questions and self-doubt. If a client is cut off with no means of reconnection, it can create feelings of isolation and alienation (Maples & Han, 2008). Although as mentioned earlier, many of the interventions are available at no or low cost (such as psychoeducational websites, blogs, smart phone applications, and interactive, self-guided interventions), online counselors and other practitioners often charge prices similar to in-person treatment.
Effectiveness of Online Counseling
As mentioned earlier, Barak, Hen, Boniel-Nissim, and Shapira (2008) conducted a comprehensive review and meta-analysis of all empirical articles published up to March, 2006, that examined the effectiveness of online therapy. The overall effect size was found to be 0.53 (medium effect), which the researchers state is quite similar to the average effect size of traditional, face-to-face therapy. This average effect size was found across different intervention methods and approaches. In the 14 studies that compared internet and face-to-face interventions, there was no difference in effectiveness. This meta-analysis clearly demonstrates the potential of internet-based interventions, particularly web-based self-help interventions
Hence, it appears that online counseling holds great potential in helping people by offering direct, convenient access to resources that people might otherwise not have, especially since nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Kessler et al., 1996; Regier, et al., 1993, in Barak & Grohol, 2011). In fact, internet-based interventions provide the outreach dimension mental health services have always sought. As previously noted, this method of therapy offers individuals increased privacy and anonymity, and can offer a cost-effective method that more readily addresses persons living in isolated geographic areas, even reaching disenfranchised and minority populations (Changrani, et al., 2008).
Ethical, Moral and Legal Issues
Ethical concerns have been at the center of the debate regarding the practice of online counseling. There are several ethical and legal issues associated with providing online counseling services.
Confidentiality: With respect to the delivery of online counseling services, threats to confidentiality exist at two levels: during and after communication (Kanani & Regehr, 2003). For example, misdirecting e-mails, or computer breaking by hackers (Recupero & Rainey, 2005).
Jurisdiction/Culture: When the client resides in a different jurisdiction than the therapist, it is currently unclear which laws apply—those of the jurisdiction in which the therapist is providing the counseling services or those of the jurisdiction in which the client resides (Kanani & Regehr, 2003). Some states in the United States have regulatory policies that suggest that cyberspace is not a geographical location, and insist that therapists will be construed to be practicing professionally in the jurisdiction where services are received (Fenichel, et al., 2002).
In addition, without the ability to view non-verbal cues, practitioners may miss important clues and make incorrect assumptions regarding the client’s cultural identity. The potential lack of appreciation of cultural issues that affect clients may limit counselor credibility or lead to inappropriate counseling interventions (Sampson, Kolodinsky & Greeno, 1997).
Boundary Issues: Clients may interpret the availability of e-mail to mean that the counselor’s door is always open (Peterson & Beck, 2003). Zur (2008) explains that “there is an expectation that anyone with an e-mail address is instantly available and responsive, 24/7, therapists included” (p. 2). In addition, e-mailing and texting appears to encourage familiarity and spontaneity, which can lead to misunderstandings about the nature of the relationship between the counselor and the client (Bailey, Yager, & Jenson, 2002).
Skill: Codes of ethics require that, in order to provide a particular client service free of professional misconduct, counselors must be competent in their chosen practice modality and have sufficient education to declare their expertise (Kanani & Regehr, 2003). At the same time, counselors and therapists may not possess the relatively high level of technological understanding of computers that is required for online counseling. Moreover, most practitioners have not had specific training in psychotherapeutic contact in text-based or online environments.
Identification: Providing counseling services over the internet can provide challenges with respect to client identification (Fisher & Fried, 2003). In situations where there is no pre-existing relationship between therapist and client, the therapist may be unable to determine with certainty whether the client possesses the appropriate mental capacity to consent. Similarly, given the prevalence of youth using the internet, there is a possibility of individuals under the age of 16 using online counseling services without parental consent (Shaw & Shaw, 2006).
Qualifications: The use of the internet makes it easy for professionals without sufficient credentials to offer counseling services (Barak, 1999). It may also be difficult for consumers to make an accurate and informed decision about which online counseling service is professional and good and which is not (Griffiths, 2001).
In 1995, the American Psychological Association defined the ethics code applicable to therapists using telephone, teleconferencing, and internet services (Shapiro & Schulman, 1996). The National Board for Certified Counselors (NBCC) developed standards for online practice (Bloom, 1998). These can be seen as early attempts to address ethical concerns and regulate the delivery of online counseling practice. The development of ethical guidelines seems crucial for the contribution for regulating and standardizing the practice of online counseling.
However, despite the developments that have occurred in recent years, studies show that the reality of online counseling is undefined. Finn and Barak (2010) conducted a study of 93 e-counselors attitudes, ethics, and practice, and show that 62% of e-counselor were confident that their online sessions were confidential, 24% somewhat confident, and 14% not at all confident. They also point that only 28% of practitioners felt it important to confirm the identity of their users. Almost one-fourth (26%) had encountered a situation where a client was a danger to themselves or others. However, and worryingly, less than half (46%) reported it to an appropriate authority (Finn & Barak, 2010).
You are not alone – A better outreach for more people
The 2015 Stress in America Survey reveals that, although on average Americans’ stress levels are trending downward, it appears people are still living with stress levels higher than what considered being healthy. As aptly said by APA CEO Norman B. Anderson “This year’s survey continues to reinforce the idea that we are living with a level of stress that we consider too high.…All Americans, and particularly those groups that are most affected by stress—which include women, younger adults and those with lower incomes—need to address this issue sooner than later in order to better their health and well-being” (p. 9).
This could be the result of more knowledge and education of the public (once again thanks to the internet), better assessment tools or social and cultural pressures typical to modern times. In the US, about 50% of the population is characterized as having a psychiatric disorder during their lifetime (according to one or more criteria of the DSM-IV) (Kessler & Wang, 2008). This means that out of a population of about 300 million people, 75 million are suffering from emotional disturbance in a given year. In average, approximately 33% of mental health seekers actually receive such treatment (Kazdin & Blase, 2011).
As described by Vogel, Wester & Larson (2007) there are several reasons that can shed light on why people do not seek mental counseling or therapy:
- Fear of being stigmatized
- Cost of treatment
- Difficulty in keeping the routine of traditional treatment due to work or lifestyle (Barak, 1999)
- Inconvenience in personal exposure
- Difficulty of finding an available professional nearby
- Lack of belief in treatment
- Difficulties in mobility
- Fear of intimacy and fusion (Levine, 2000)
- Norms and cultural values
Professional literature point out that, even if there will be a dramatic change in terms of public education, which will push all people in need to seek professional help, the offered private and public services will not be able to supply such demand (Grey, et al., 2001). In a recent study, Kazdin & Blase (2011) demonstrate this reality in the US. Their study shows that 700,000 reported professional therapists and consultants can only reach approximately 1/3 of those in need. This means that even if the numbers of professional mental caregivers will be doubled, it would not be sufficient for the population’s needs. This proves that developed countries need to revolutionize their perception of public mental health in order to keep up with the population’s growing needs.
Populations with unique needs, such as mothers in the postpartum period, who otherwise do not reach out for support (as described by Vogel, Wester & Larson, 2007), can make use of internet’s availability, low cost, and anonymity to receive counseling, therapy, and group support. Countries that will invest in research into the effectiveness of online counseling, and thereby allow the development of methods and tools, will improve their health services, and by that their citizens’ well-being.
Motherhood—Adjusting to a New World
Overall, the adjustment to motherhood is a major life change that poses common challenges for women all over the world. For some new mothers, these common challenges are further worsened by having to cope with Postpartum Depression (Barr, 2008).
The postpartum period was aptly conceptualized by Chen and colleagues (2006) as “being reborn” in their study on mothers’ experience of going through postnatal depression. In this study, researchers show postnatally depressed mothers often go through 4 stages of coping with the loss of self or loss of former identity and attachment to their new lives as mothers:
(1) shattered role identity,
(2) feeling trapped and breaking down,
(3) struggling for self-integrity,
(4) regaining vitality.
This study shows that the main need expressed by women is for a reflective listening to help them adjust to the process of being reborn; an internal process of painful growth represented by motherhood and striving to protect the real self, in order to maintain emotional health while enabling personal development (Chen, et al., 2006).
Postpartum Distress
The Diagnostic and Statistical Manual of Mental Disorder (DSM-V) does not recognize postnatal depression as a separate diagnosis; rather, patients must meet the criteria for a major depressive episode and the criteria for the perinatal-onset specifier. The definition is therefore a major depressive episode with an onset in pregnancy or within 4 weeks of delivery.
The literature describes three types of postpartum distress: postpartum blues, postpartum depression (PPD), and postpartum psychosis (Glavin, et al., 2010). Symptoms of postpartum distress vary from woman to woman, but generally include emotional lability, depression, insomnia, confusion, fatigue, appetite disturbances, feelings of worthlessness and hopelessness, extreme anxiety, guilt, diminished interest or pleasure, decreased concentration, inability to make decisions, and suicidal ideation (Beck, 1992; Letourneau, et al. 2007).
Major depression is a chronic mental health problem that affects up to 16% of individuals worldwide during their lifetime (World Federation for Mental Health, 2012). It is the leading cause of disability among women (Ferrari, et al., 2013) and, compared to men, women are at higher risk of experiencing major depression during their lifetime (14.0% vs. 7.3%) (Steel, et al., 2014).
So, on the one hand, the postpartum period is a time of biological, psychological, and social change that can contribute to personal enrichment, maturity, and happiness; at the same time, it may also cause psychological distress (Bener, Gerber, & Sheikh, 2012). After childbirth, women may experience a number of physical and psychological stressors. Physical stressors may include perineal pain, backaches, urine problem, hemorrhoids, fatigue, sleep deprivation, and nursing problems. Psychological stressors include the pressure to return to pre-pregnancy weight, sexual changes, concerns about the maternal role, feeding the newborn, growth and development of the newborn, unpredictable behaviors or sudden sickness of the newborn, relationships with partner and family, and the lack of social resources and support (Beck, Gable, Sakala, & Declercq, 2011; Chen, 1994; Cheng & Li, 2008; Hung, Lin, Stocker, & Yu, 2011).
In addition to the harmful impact these symptoms can have on mothers, there is a harmful effect on their children, who are at increased risk of developing behavioral problems and experiencing developmental delays (Beck, 1999). Therefore, depression in the postpartum period is a devastating problem for the new mother and family; it may increase the risk of subsequent maternal depression, which in turn increases the risk of child behavioral problems (Brennan, et al., 2000).
The actual prevalence rate of postpartum stress among women is unclear, but studies report that approximately 10% to 15% of postpartum women are affected by maternal mental health problems, including depression, anxiety, and stress during the year following childbirth (Glavin & Leahy-Warren, 2013) with rates as high as 20% in low- and middle-income countries (O’Hara &Swain, 1996). Several thousand women are affected by this condition each year, thus the World Health Organization–United Nations Fund for Population Activities (WHO−UNFPA, 2013) declared maternal mental health as a fundamental and important aspect in achieving the Millennium Development Goals.
Postpartum stress has also been shown as having a dyadic nature and spiral character, shown by growing distress that becomes overwhelming and spirals through a series of emotions, including feeling trapped, angry, panicked, and isolated (Wood, et al. 1997). This mode was aptly described by Beck (1993) as walking the fine line between sanity and insanity.
The frequency of depressive and anxiety disorders during pregnancy and postpartum is evaluated at 11−12% (Le Strat, Dubertret, & Le Foll, 2011). At the same time, since depressive symptoms in pregnancy are often confused with symptoms of pregnancy itself, they remain undiagnosed and untreated (Grigoriadis, et al., 2013; Mauri et al., 2010). Truly, approximately 50% of cases go undetected and, consequently, untreated (World Federation for Mental Health, 2012). This puts emphasis on the importance of developing a professional support tool, adapted to new mothers unique needs.
Interventions, Support, and Postpartum Distress
Postpartum distress may be among the most common complications of childbirth (Cox, 1989) and increased risk of depression following childbirth has been reported (Cox, et al., 1993). Various studies reported postpartum depression rates ranging from10−15% with rates as high as 20% in low- and middle-income countries (Glavin & Leahy-Warren, 2013; O’Hara & Swain, 1996).
A recent meta-analysis, which included 28 randomized controlled trials, showed that pre- and postpartum psychological interventions reduced the number of women who developed postpartum depression (Dennis & Dowswell, 2013).
Research shows that the use of interventions is effective at lowering the occurrence of depression (Muñoz, et al., 2012; van Zoonen, et al., 2014) and is effective at reducing the risk of PPD among non-depressed pregnant and postpartum women (Dennis & Dowswell, 2013). Various treatment methods, such as individual and group psychotherapy, and pharmacological treatments, have been shown to be effective in the treatment of postpartum depression (Driscoll, 2006). At the same note, delay in treatment has long-term negative consequences: it puts women at risk for recurrent and/or chronic depression (Andrews-Fike, 1999) and leads to higher levels of child behavior problems (Brennan, et al., 2000). On a public level, delay in treatment has an economic effect as well.
Several barriers to detection and treatment are described: women lack knowledge about PPD; they deny or minimize their symptoms; they assume their problems are common after giving birth; or they are not aware of the treatment options. Health professionals can also act as barriers to care if they underestimate the symptoms, or offer treatment that is not suitable for the women (Dennis & Chung-Lee, 2006, Dennis et al., 2009). Barriers among clinicians and in the health care system, as well as economic and personal factors, were reported to cause low treatment rates among a sample of at-risk women (Horowitz & Cousins 2006).
Technological Development Creates Social Affordance
Online support groups are considered the predecessor of online counseling, as Skinner and Zack (2004) noted: “The enduring success of these groups has firmly established the potential of computer-mediated communication to enable the discussion of sensitive personal issues” (p. 435). Some groups are therapeutic (a professional therapist treats a small group of people) or supportive (participants provide each other with various types of help, usually nonprofessional) in nature, while others are strictly psychoeducational and informational (Barak, 2004; Kanani & Regehr, 2003; Skinner & Zack, 2004).
A systematic review of online health interventions found that participants of online support groups valued the prompt communication among support group members and the convenience of “anytime and anywhere” access to care (Griffiths, et al., 2006). Online support groups are used to obtain support and information by people who are coping with physical and mental health-related conditions (Barak, et al., 2009). Such groups can provide “just in time” support, overcome geographic barriers, facilitate open discussion of health concerns, and reduce social isolation by providing opportunities for sharing information and providing practical advice. The anonymous nature of online groups makes participants, particularly those dealing with health-related stigmatization, feel safe, and creates an environment for open discussion of topics that may be perceived negatively by others (Braithwaite, et al., 1999).
Modern life creates an increased burden on women from career demands, while at the same time offering decreased traditional assistance (i.e., help with housework, care of family members), and contributes to the difficulty and social isolation experienced by women in general and new mothers in particular. New mothers experiencing the postpartum period for the first time desperately seek health information and social support from formal and informal sources (Sword & Watts, 2005, in Evans, Donelle, & Hume-Loveland, 2012). Social support has indeed been shown to have positive influence on women’s experience of pregnancy, childbirth, and postpartum. Peer support and self-care activities are recommended for postpartum mothers experiencing depressive symptoms (Dennis, 2010). Furthermore, peer support is considered a preventive strategy for PPD among women at risk. According to Dennis and colleagues (2009), women who received peer support had half the risk of developing PPD at 12 weeks postpartum than those in the control group.
Moreover, the fact that online counseling is obtainable at a relatively low cost, and enables flexibility in physical location, allows new mothers better and easier access for support. It is therefore suggested that online counseling, in a support group setting, could serve as an accurate supplementary support and counseling help tool for women in postpartum period. At relatively low cost and probable high outreach, while using trained professionals, this should serve as suitable helping modality for all new mothers, and thus assist in preventing postpartum depression and elevating women’s well-being. This calls for further research that will examine the effect on women’s depression levels and overall well-being, and the effect it has on their immediate surroundings (baby, family, community).
Summary
The discussion surrounding technology’s role in the future of therapy brings into question the traditional understanding of counseling. Until a decade ago, counseling was normally considered to occur between a client, or group of clients, and a professional who shared the same physical space. According to Fenichel and colleagues (2002oi Issue ds of Postpartum Women), “online therapy has shattered three of the basic premises of therapeutic interaction, which is that it must always, by definition, be based on: (1) visible (face-to-face) contact, (2) talking, (3) synchronous (‘real time’) interaction” (p. 1). The current view of counseling is changing to accommodate new types of counseling that do not necessarily consist of these basics. Fenichel and colleagues (2002) argued that, regardless of how we define therapy processes and outcomes, the documented successes of online counseling are undeniable.
The postpartum period is a time-limited experience that is characterized by substantial physiological and psychosocial adjustments and changes. Normally, giving birth signals a time of great joy, but this extreme change in life may also bring sadness and pain. The reported prevalence of postpartum depression (PPD) is around 34% in Western women, depending on definition, assessment, and time since delivery (Evins et al. 2000).
The negative impact of depression on the well-being of the mother and her ability to care for a newborn child underscores the importance of identifying and treating women in a timely manner. Unfortunately, even in developed countries, half of the cases go undetected and, consequently, untreated (Barrera, Wickhama, & Muñoz, 2015; World Federation for Mental Health, 2012).
Initial evidence show that online interventions can be useful to postpartum women who are already struggling with depression (Danaher, et al., 2103; O’Mahen, 2013). Moreover, research shows peer support is considered a preventive method for postpartum depression among women at risk (Taggart, et al. 2000, Dennis, 2003, Scrandis, 2005, Shaw, et al., 2006; Dennis, et al., 2009). This suggests that an online group counseling system can serve as an efficient tool for health bodies to treat and support new mothers all over the world.
Moreover, research shows online counseling has the potential to address many of the barriers identified with PPD treatment, such as transportation difficulties and childcare challenges (Goodman, 2009). On the same note, it has been shown that depression incidences can be lowered by prevention interventions (Muñoz, et al., 2012; van Zoonen, et al., 2014) and consequently will reduce the risk of PPD among non-depressed pregnant and postpartum women (Dennis & Dowswell, 2013).
However, despite growing evidence that PPD can be effectively treated and possibly prevented, this condition is still undetected or untreated in many women (Dennis, et al., 2009). Therefore, internet-based interventions can offer the outreach dimension mental health services desperately need. Hence, online group counseling is worth investigating as a method to treat postpartum women, as it potentially addresses many of the barriers identified with PPD treatment (Goodman, 2009). Furthermore, since it has been shown that depression incidences can be lowered by prevention interventions (Muñoz, et al., 2012; van Zoonen, et al., 2014) and consequently will reduce the risk of PPD among non-depressed pregnant and postpartum women (Dennis & Dowswell, 2013), it is therefore suggested further studies should investigate the effectiveness of online counseling for postpartum mothers in a support group setting.
A human life starts with a mother. Our first and most profound experiences in life are formed through our mothers. I therefore suggest we investigate more means for improving mothers’ well-being at the very start of motherhood. As shown in research, online group interventions are effective at reducing symptoms among new mothers with moderate to severe symptoms of depression (Danaher, et al., 2013; O’Mahen, et al., 2013). In addition, mothers supporting other mothers is considered a preventive strategy for PPD among women at risk (Dennis, 2010; Dennis & Dowswell, 2013).
I believe, that given the advanced fast growth of online interactions and use, the more we understand the opportunities and risks this new mode offers the better we can harness it for the overall well-being of our societies. I hope this will lead to a practical change in counseling paradigms.
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