Article in the monthly magazine "Psyche & Brain" (April 2012) How does someone come up with the daring idea to offer online therapy? We asked this question to the initiator Paul Koeck, MD, who turned out to be a man with a plan.

What gave you the idea to start with online self-help?

Koeck: In the end, it all goes back to some dreams I had in my early years. Around my fifteenth I became fascinated with the question of how people change. This was a case of personal interest in how people are put together, but there also was a desire at play to help people to feel better. When I studied medicine and management later on, the wish to leave something behind that is larger than myself was born, something which could maybe outlive me by 40 or 50 years. I had been a therapist for a while when I got the feeling that I had reached my limit. That is why I started looking for business models which made it possible to do even more. These were not so easy to find, but at a certain point I realized I had access to a lot of knowhow in the form of personal contacts with well-known therapists around the world, who I had started to contact already when I was fifteen years old. (laughs) Together with those people I started to think about what was possible, and in the end online self-help was the winning idea. My most important driving force is to offer people an extra choice when they feel that they need help. Luckily I had gotten familiar with software in my past as a business coach, and thus I started up this project about 3,5 years ago. The development has taken much more time than I originally expected that it would, but by February last year, the website was officially launched.

Were you sure that online self-help could be successful?

In the start, the idea that interested me most was to look at which the working elements are in other forms of therapy. For example, I had the idea that something was off about the scientific assumption that the empathy of the therapist would be the decisive factor in whether or not therapy works. If it was so, then online help would of course not have any effects. My question was: why do people invest time and money in therapy? Do they want a relation with me? Hopefully most do not, right! They come to me because they are looking for a solution, and the personal contact is a helping factor, but not the whole solution. Later, scientific research showed that empathy is a decisive factor in the engagement to change something about yourself. That means: if you can find your intrinsic motivation somewhere else and you receive proper guidance, than you do not need the empathetic relation per se. Because of this reason I was first unsure about letting you test the program: the motivation which you need to pay for a month of online self-help was missing in you, as you had no crucial problem. That is why I made you make a list of things on which you want to work, on order to simulate this feeling to some extent.

But can a piece of software really help people?

I believe that many people can be helped if the right questions are asked and a daily moment of self-reflection is built into their routine. This way they can think: 'Is my rocket still flying toward the moon?' It is sometimes said that an airplane is off its course 99% of the time. That is why the pilot needs to constantly adjust and check it. If people know where they want to go, then they are on the right track already. Some people can immediately formulate such a goal, while others can use the program with the right questions in order for them to pick a path. And after 30 days, they are able to think in a future-focused manner again, and to formulate their goal. What does a therapist do, what does our software do? It makes people think of these three questions: What do I want? What can I already do? And what helps me to reach what I want to reach using those talents? It is as simple as that.

What surprised you most when the website had been launched?

The fact that most people who make use of the program indicated that they had not been looking for professional help beforehand. This goes for 90%! A large group of users has found the website when surfing the web, looking for information regarding the problems they dealt with. I started with the idea that many people who could use some help simply do not end up at a therapist. You could say: lost souls. In my practise, I have noticed that it takes years for some people to effectively end up at therapy after they had received a referral. My father, who was a doctor himself, once said to me that it could take 1,5 or 2 years for people to gather the courage to look for psychological help. And then you wonder: 'has this person had to suffer for such a long time from a problem which can largely be solved in a short time?' Of course, the question of how to reach these people remains. You may not communicate too much. Sometimes, the time simply is not right. I remember that one client came to me for help with the grieving process after the sudden passing of her husband. After a few sessions she suddenly told me: "It is enough." I was very surprised, but she was worried that the therapy would diminish her feelings toward her husband. I told her that I respected her choice and that my door was open in case she ever wanted to continue. Ten years later she called me with the message: 'I think that I am ready for it now.' The whole philosophy is to give people an extra choice. And the self-reflection in the program must strengthen the feeling that they always have options to choose from in their lives.

Did you expect that the program would have such a quick effect?

No, not at all. I went from the idea that we might have to adjust the program constantly for maybe ten years to reach the effect it has had. I only realized its effect when speaking about the results to some colleagues, who told me: 'But Paul, these are very similar to the results found in modern forms of short therapy.' That is why we started to scientifically process the results this summer already. In order to make correct comparisons possible, we built in a standardized list of question with 21 questions in total, the internationally validated Depression Anxiety Stress Scale (DASS 21). The results of this test are sent to the users each week in the form of three meters. When looking at the graph, it can be seen that the average user has 27% less stress after one week. After two weeks, this lies at 37% and after week three we see 54%. I first thought that my calculations were incorrect when looking at the results! I called our programmer directly, who knows all about statistics as an engineer, to check the numbers. (laughs) After 5 weeks, the average user has a stress reduction of 77%. And the majority comes close to these scores, meaning the results are representative. Some clients from my practise also follow the program, so that I would get extra feedback. Often they find one or two months enough, but to my surprise I have noticed that some decide to go for another month, some four months later, because they find that the mindset has not stuck with them well enough.

What about security and privacy?

Security is very important for us. That is why our main programmer has followed a course in security and encryption techniques with an American professor who advises the Pentagon, among others. And every half-year, we revise our security according to the newest security norms, as these quickly evolve. Furthermore, you will have noticed that we mainly ask solution focused questions, meaning that very little sensitive information is requested which could be misused in a worst case scenario. Even the Pentagon admits that its security is not perfect! When it comes to privacy, the entire content of the online therapy falls under the medical confidentiality, as I am a doctor myself and took the Hippocrates oath. All employees sign a confidentiality agreement as is done in hospitals, while they do not have access to sensitive information. Only the main programmer has access to the database, and he is under contract and thus bound to the same medical confidentiality. Other developers who write modules for us, never have access to the source code or database. We are very rigid when it comes to that. Both from deontological perspective and out of self-interest: which doctor would refer people to 15Minutes4Me if the trust in the confidentiality has been breached?

Is the program unique of its kind?

As far as I know, it is. I do not think that there are any other programs which attempt to approach the therapeutic process of self-reflection. And at international congresses I have not heard anything about similar software, either. A large advantage is that the users can get started right away. With traditional therapy, it often is so that one needs to wait for a few weeks before the intake conversation and after that it takes a few weeks before the first session is held. This makes starting more difficult. For us, it is however difficult to differentiate from purely commercial initiatives. Building up trust is therefore key.