The Australian government has recently released the report of the independent National Review of Tele Counselling and Web Counselling Services.1 Initiated by the Office of the Prime Minister in 2001, the review aimed to “take stock of the expanding and dynamic sector” and to describe the use, management, financing and role of web and telecounselling services. The report was commissioned in response to the recognition that the rapid expansion of these services created ethical, legal, funding, service delivery and education issues. The main findings of the review are summarised in the Box.

In Australia, telecounselling (communication by telephone between a counsellor and a caller) is a large, diverse industry provided by 131 not-for-profit organisations and an unknown number of commercial organisations or individuals. The largest provider, Lifeline, consists of a federation of 42 centres, employs 5000 volunteers and provides 24-hour service 7 days a week. Web counselling (synchronous and asynchronous communication online or through email between a counsellor and a user) is a smaller, newer industry, with 17 not-for-profit agencies providing services mostly directed at youth.

Two key points emerged from the review. First, many Australians use telecounselling services, although the benefits of the services have not been evaluated. Two of the largest service providers answer a combined total of about 850 000 telephone calls annually. (Precise estimates of numbers of users cannot be provided because individuals do not identify themselves, and may visit many times to the same or other agencies.) Despite this extensive use, the review confirmed that no randomised controlled trials (RCTs) have been conducted of the efficacy of web or telecounselling either in Australia or internationally.2 However, telecounselling as an adjunct to professional care has demonstrated effectiveness in RCTs3,4 and has been associated with changes in suicidality and mental health in uncontrolled evaluations.5

A second finding was that mainstream healthcare professionals, including general practitioners, refer patients to web and telecounselling services, although these services are not a formal part of the healthcare system. More than 20% of web and telecounselling agencies estimated that at least half their caseload was referred by healthcare providers, and reported that many calls relating to mental health were answered in the evenings or at weekends. Moreover, although crisis intervention is a component of the caseload, telecounselling agencies report that they are increasingly responding to a core group of individuals with ongoing mental health needs and loneliness. For Lifeline, less than 25% of callers were first-time callers, and across all of the agencies that were surveyed nearly 40% of callers had rung 20 times or more. Different counsellors in different locations talk to these individuals and are not privy to their concurrent medical service use.

These key findings suggest three directions for action. First, better integration of telecounselling within mainstream mental health services may be desirable. A core group of users will be better served by being linked to healthcare and other services (for example, accommodation) and by information being shared about concurrent service use. Although telecounselling and mainstream services may have different locations, one solution is to link Lifeline web or telecounselling directly to telepsychiatry services. Telepsychiatry provides consultations with formal healthcare services (either face-to-face using technology, or through email). Although telepsychiatry may be costly and difficult to implement in practice, the advantages are the potential for geographical reach, accessibility, responsiveness, Medicare cover for users, the provider’s attention to evidence-based care and the provider’s duty of care. Software that records user contacts with major community agencies and the healthcare system would be a great step forward, although issues of anonymity, consent, privacy and, importantly, user preference and acceptance need consideration. Access for rural users to affordable telephone and internet services also requires attention.

A second direction to consider involves implementing strategies for improving mental healthcare delivery within a web or telecounselling framework. There is a range of educational initiatives that allow high quality, evidence-based interventions to be delivered by non-specialists.6,7 This direction may involve integrating web or telecounselling with internet therapy and psychoeducation.

A third clear direction is the need to evaluate the effectiveness of web and telecounselling. Fee-based web counselling with specialists and non-specialists is readily available to users, and these services are likely to accelerate, driven by a body of consumers who use internet resources. There is now the opportunity to test the usefulness and effectiveness of web counselling before this proliferates further. The emerging managed-care models delivered by an engaged and organised workforce of experienced telecounsellors is an exciting research opportunity not to be missed.

Before the web and telecounselling review, no one knew the extent, quality or standards of delivery of these services, or even who used them. Now we know that these services are used frequently, both by the community and by healthcare agencies, and that they play a major role in managing vulnerable individuals with mental health problems. If telecounselling services are found to be effective, there is an urgent need to adequately support the sector and improve continuity of care between the systems. To date, telecounselling has been seen as non-core — a poor cousin to mental health services. However, given the development of communication technology, consumer empowerment, and the infrastructure, workforce, and capacity in the web and telecounselling sector, we foresee a central role for these services in delivering flexible, evidence-based, cost-effective help to the community.