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3 General considerations for online counselling

3 General considerations for online counselling

The different types of technology-based or online counselling can be situated along a continuum: services involving a strong human interaction component (’high-human factor’, such as video/audio-based counselling) sit at one end, and standalone interventions involving no human interaction (‘high-tech factor’, including many mental health apps) sit at the other.

This high-human factor vs. high-tech factor continuum provides a useful orientation to understand the commonalities and differences between these services, and what can be offered when employing each of them.

Activity 8: The high-human factor–high-tech factor continuum

Timing: Allow approximately 5 minutes

Drag and drop each service type to the correct place on the high-human factor–high-tech factor continuum.

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These different types of technology-based counselling are all delivered beyond the traditional in-person format via the internet or phone line. When you practice phone or online counselling, it is important to be aware of the specific properties and challenges of the therapeutic work in this environment.

3.1 The online disinhibition effect

When you use the internet, you might have notice that online communication can differ from face-to-face conversation: people will do or say things online they would rather not in person. Online, they seem to feel less restricted and more willing to express themselves openly.

This phenomenon has been described as online disinhibition effect (Suler, 2004). It can be:

  • benign, such as sharing personal feelings and supporting strangers online
  • toxic, such as cyberbullying, social loafing, harsh criticisms, anger, hatred or threats in online forums.

The effect can broadly be explained by the greater anonymity online, as well as the lack of visual, auditory and contextual cues such as information about social status or ethnic background. This seems to make people feel both less vulnerable (for example, to external judgment of their self) and less responsible for their actions.

Activity 9: The online disinhibition effect in therapeutic context

Timing: Allow approximately 10 minutes

How could the online disinhibition effect influence working with clients online or on the phone?

a. 

A client discloses intimate information more quickly than they would in a face-to-face session.


b. 

Both clients and counsellors are more open or willing to talk about difficult or stigmatised topics.


c. 

The quality of the therapeutic relationship will be negatively impacted.


d. 

A client brings up issues that they have never talked about before in a face-to-face session.


e. 

A client is more prepared to openly disagree with the counsellor.


f. 

A client is likelier to miss a session or forget to pay for it.


g. 

A client is less concerned about how they are perceived by the counsellor.


The correct answers are a, b, d, e and g.

Discussion

Research shows that clients in online counselling tend to disclose issues that they may not so readily bring to face-to-face counselling, and that they can be more direct and divulge problems very quickly in this medium (Fletcher-Tomenius and Vossler, 2009). There is also evidence that they become less concerned about how they are perceived by the counsellor (Gibson and Cartwright, 2014). We have no evidence that the online disinhibition effect has a negative impact on the therapeutic relationship or on client motivation.

The consequences of the online disinhibition effect are especially relevant in text-based online counselling and (to a lesser degree) in phone/videoconferencing counselling. In the following section you will learn more about the specifics of developing and maintaining an effective therapeutic relationship online.

3.2 The online counselling relationship

Building and maintaining a good therapeutic relationship might feel challenging if you have never practised beyond the face-to-face format.

Depending of the type of online therapy, you will have fewer cues available to you when you communicate with your client: non-contextual and non-verbal cues in text-based online counselling, for example. You might be worried that you could miss any subtle cues that you often pick up in the counselling room. You might also wonder how it might feel to (virtually) enter your client’s private space – for example, on a Skype call – and how this could potentially affect or shift the therapeutic boundaries.

Pause for reflection

How do you feel about relating to you clients online or on the phone? Are you worried about any of the issues listed above or the risk of miscommunication in this medium?

While it might take some time to adapt to the new medium, research shows that it is possible to establish and maintain an alliance that is sufficient to facilitate psychological change (Hanley, 2012; Berger, 2016). Facilitated by disinhibition processes and feeling safe, clients have been reported to have quickly developed a good and trusting relationship with their online counsellor (Fletcher-Tomenius and Vossler, 2009; Ersahin and Hanley, 2017).

Counsellors and clients seem to be able to compensate for the lack of cues (for example, in text-based online counselling) and instead create mental representations of each other that help to build the therapeutic alliance (Suler, 2010). However, counsellors who work with clients online should be aware of a potential shift of control and power balance in this context.

Activity 10: Power and control in technology-based counselling

Timing: Allow approximately 10 minutes

How do you think issues around control and power balance differ in online counselling compared to face-to-face provision? Make a few notes in the space below.

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Discussion

Clients in different types of online counselling typically report a shift of control over counselling processes and interventions, for example about. how much clients want to disclose (Fletcher-Tomenius and Vossler, 2009; Gibson and Cartwright, 2014).

In videoconference counselling, clients commented that ‘the enhanced control and personal space that they feel in video therapy can enhance the therapeutic alliance’ (Simpson and Reid, 2014, p. 295). The increased degree of autonomy can also mean that clients have more control over session timing and endings: for instance, a session can be ended with a mouse click.

This shift of power and control can potentially be empowering for clients; however, for counsellors new to online counselling, it might take some time to become accustomed to.

Finally, because it seemed odd not to recognise this when talking about the therapeutic relationship, the coronavirus crisis will affect engaging in online counselling currently. ‘The constant fear, worry, uncertainties and stressors in the population during the COVID-19 outbreak’ are recognised by the World Health Organization, which consequently has specifically targeted efforts towards mental and psychological health and wellbeing during the epidemic (WHO, 2020, p. 3; see also Huang, 2020). As counsellors, it’s likely that you are already thinking about the potential manifold impacts of such widespread fear and anxiety on your clients, on yourself and hence on your counselling practice. For example, you might be thinking about:

  • the question of what the right ‘depth’ of counselling should be (for example, focus on support versus trauma work)
  • how to approach planned endings and respond to unplanned endings, including considering what happens if client or counsellor falls ill and what it means if the end of counselling coincides with the country being caught in a pandemic.

Additionally, for clients with whom you previously worked face-to-face, it will be important to discuss how they feel about the fact that their counselling has had to become technology-mediated, and how they are experiencing this new at-a-distance counselling relationship.

3.3 Research on technology-based counselling

Before engaging in online counselling it’s important to consider the research. Is this form of counselling really effective?

Activity 11: Efficacy of online counselling: what does the research say?

Timing: Allow approximately 15 minutes

Read the following information:

  • Videoconferencing counselling: Various case studies have suggested that videoconferencing counselling can be an effective means of treatment delivery (Simpson, 2009). The frequent practice of integrating video and face-to-face sessions seems to show that videoconferencing might be seen more as a complement to face-to-face psychotherapy rather than as a substitute (Cipolleta et al., 2018).
  • Text-based online counselling: Research evaluating text-based online counselling generally tends to support the effectiveness of the interventions (Barak and Grohol, 2011; D’Arcy et al., 2015). In their meta-analysis comparing face-to-face and online therapy (based on 14 studies and 9764 clients), Barak et al. (2008) found no significant differences between therapy delivered face-to-face and online. Some evidence based on qualitative research suggests that online counselling might be a more comfortable and less threatening experience than a face-to-face session, which could be especially relevant for clients who experience social anxieties (Suler, 2010; D’Arcy et al., 2015).
  • Computerised/internet-based therapy programs: The evidence base for internet-based interventions in common mental health has significantly expanded in recent years; there are now more than 200 controlled trials for a range of disorders and conditions (Andersson, 2018). The evidence shows that these treatments often result in similar outcomes as conventional face-to-face psychotherapy (Berger, 2016; Fenger et al., 2016). Calbring et al. (2018) found that CCBT (computerised cognitive behavioural therapy) and face-to-face CBT (cognitive behavioural therapy) produced equivalent overall effects for psychiatric and somatic disorders (based on 20 studies and 1418 clients).
  • Mental health apps: Apps on smartphone and available online are developed and changed at such a pace that it is difficult for researchers to evaluate the tools and their effectiveness in routine care (Bennion et al., 2017). While there is some evidence that well-designed and empirically-based applications have the potential to improve outcomes for users, the evidence of the effectiveness of many of these tools is still lacking (Anthes, 2016; Martinez and Farhan, 2019).

Use the space below to identify areas with strong or weak research evidence.

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Discussion

There is sound research evidence supporting the effectiveness of text-based online counselling and computerised programs. For other types of technology-based counselling, such as many mental health apps, the evidence for their effectiveness is still lacking.

In the following section you will be introduced to the main forms of technology-based counselling on the high-touch–high-tech continuum, starting at the high-touch end with counselling using online video and audio platforms.

You should now move on to Topic 4: Counselling using videoconferencing platforms .