How does email therapy stack up against tradition face-to-face counseling?

“I thought I was the super student as everyone else did – always getting high grades, good fun on a night out, a decent part-time job – but the ever-building exam pressure during my degree really took its toll. I developed an eating disorder halfway through my final year and had frequent panic attacks.”

Anna, a Geography graduate from a top London university, eventually sought help from the student support services weeks before her all-important exams. “I didn’t have the time to see a counsellor in person, so I was offered counselling by email. For me, it was the most convenient way to deal with my anxiety and eating problems.”

Anna’s treatment involved a seven-email exchange with a university counsellor. She was given practical strategies to cope with exam stress and an understanding of the thinking patterns associated with bulimia. “I couldn’t believe how accurately my counsellor could express how I was feeling in an email,” she says. “My eating hasn’t quite returned to normal yet, but the key thing was I was more relaxed going into the exams and came out with a degree.”

Hard Times

Anna’s story is among many of students experiencing mental health problems at college or university. An independent study by The Times in 2007 found that the number of students seeking counselling at Bristol University had increased by 29% in a five-year period, and that British universities are having to spend £30 million a year to treat a range of psychological issues, from substance misuse, depression and exam anxiety, to eating disorders and bullying.

Email counselling, as in Anna’s case, is emerging as an accessible and cost-effective alternative to traditional therapies. Several UK universities – including Sunderland, Warwick, Edinburgh, Cardiff, Portsmouth and Manchester – now offer counselling by email, sometimes free of charge, as part of their support services. For students unable or unwilling to access face-to-face services, the option to communicate via email with a psychologist is an attractive one.

“Students and young adults are naturally comfortable talking about their thoughts and feelings online, so it makes sense to offer email as a way to engage in counselling conversations,” says Professor Stephen Palmer, Chair of the online counselling working group. “It’s also an easier way to receive professional advice and support in between studying and socialising.”

There are any number of circumstances where email therapy might be the more suitable option for a busy student. Plymouth University’s counselling team encourages those who are away from university on a work or field trip, experiencing an illness or disability that makes it difficult to attend in person, or has an irregular schedule, to consider counselling by email.

For many undergraduates, the university experience can be an understandably challenging one. “At this key stage of life, students are searching for their identity,” says Debbie Johnson, acting director of the Student Counselling Service at Bristol University. “Many students come to university with expectations of how it’s going to be and they become anxious when they’re not having a good time.”

Common Sense

Email counseling is one way of helping those experiencing difficulties to look at the bigger picture. “Just to appreciate that life is full of highs and lows, and that other people are going through the same thing, can be reassuring,” says Phillip Hodson, a spokesman for the British Association for Counseling and Psychotherapy. “It’s important for students to know that there is a difference between feeling very low and being clinically depressed.”

He explains that dealing with exam stress by email, for example, could take a straightforward approach. “The counselor might simply encourage the student to appreciate that passing or failing exams is not a life-or-death situation. It’s more about imparting wisdom, facts and common sense than using special tricks of the psychological trade.”

Mr Hodson believes that email counseling comes into its own as a way to help male students in particular. “It has the potential to connect with young men who are notoriously unwilling to sit on a therapist’s couch. You simply wouldn’t reach them any other way.” The Samaritans, which launched its own email support service in December 2002 and receives an average of 300 emails a day, noted in a research study that a third of young men between 18 and 24 would rather use email to talk about their problems.

Potential Pitfalls

Despite such advantages, some practitioners caution against branding email counseling as a replacement for face-to-face therapy. Professor Palmer says: “Counseling online comes with its own challenges, and the therapist and client need to be aware of some of the possible difficulties they may encounter.” Universities are beginning to recognise the unique nature of treating students in this way; Warwick University assures its students that all counselors are professionally trained with a specific, additional qualification in email counseling.

Some clinicians, including Dr Greg Mulhauser of The Counseling Resource Center, believe that it could be very frustrating for a client to wait for a counsellor to reply on email, which is asynchronous – i.e. not based in real time. “You could look at it another way,” says Cedric Speyer, Clinical Supervisor of E-Counselling for Canadian EAP provider, Shepell·fgi. “That the delay gives the client valuable time to digest and reflect on what’s been said in the emails. They can print the text and refer back to the advice within at their convenience.”

Some traditional practitioners claim that counselling by email lacks a key part of therapeutic relationship by keeping the patient and therapist at a physical distance. The concern is that by not being in the same room as the client, the counsellor might miss some crucial non-verbal cues. As Dr Mulhauser warns, “Without that grin or frown, that raised eyebrow, that softened voice or dead-pan delivery, figuring out which meaning is intended can be a real challenge.”

Mixed Signals

Even for the experienced online practitioner, assessing a student’s problem in the first place can be tricky. “It’s vitally important to accurately grasp the student’s real issue, especially in the case of severely depressed or suicidal individuals,” says Professor Palmer, who recommends an initial webcam session before starting treatment. “The warning signs can be lost in an email, which could have disastrous consequences.”

Online practitioners don’t see this as a barrier to treating people effectively. “Why is it so hard to believe that a client cannot be emotionally authentic and a therapist empathic and insightful in text?” asks Cedric Speyer. “Our experience as online clinicians, as well as our personal experience with relationships on the Internet, demonstrates that some individuals are more honest, more uninhibited, and more expressive in writing than face-to-face.”

Mr Speyer and other email counsellors strongly believe that without all of the social assumptions that happen automatically when you meet someone in person – judgements based on appearance and expressions, for example – the client and therapist can get straight to the heart of the issue and connect at a deeper level. “For young female students in particular, it can be reassuring that their physical attributes play no part in the communication.”

Future of E-Therapy

Not surprisingly, the concept of delivering psychological treatment online has already been taken a lot further than email. New ways to conduct therapy over the internet are rapidly emerging – such as instant messaging (’chat-based’ therapy), online support groups and videoconferencing – that blend sound, text and visuals in real time. Even the act of blogging is thought to be therapeutic for some, and Sheffield University now incorporates creative writing alongside its other support services.

The world of “cybertherapy”, as it is sometimes known, is growing fast. It is already possible to “attend” a counselling session within the virtual environment of Second Life, whereby the client and therapist communicate through their avatars.

Cedric Speyer appreciates the value such internet-based therapies can bring if they attract more people who need help, especially students who are native to this domain. He makes the point, however, that many of these approaches still require the client to stick to an appointment time, “which eliminates the core benefit of email counselling – that it works around you.”

Whether these newer methods survive remains to be seen. Email counselling meanwhile is already firmly established as a permanent adjunct to traditional university support. Many counselling services, often small and overloaded, find that providing email therapy is an economical way to help more students as effectively as face-to-face sessions.