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.
Drag and drop each service type to the correct place on the high-human factor–high-tech factor continuum.
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.
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:
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.
How could the online disinhibition effect influence working with clients online or on the phone?
A client discloses intimate information more quickly than they would in a face-to-face session.
Both clients and counsellors are more open or willing to talk about difficult or stigmatised topics.
The quality of the therapeutic relationship will be negatively impacted.
A client brings up issues that they have never talked about before in a face-to-face session.
A client is more prepared to openly disagree with the counsellor.
A client is likelier to miss a session or forget to pay for it.
A client is less concerned about how they are perceived by the counsellor.
The correct answers are a, b, d, e and g.
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.
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.
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.
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.
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:
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.
Before engaging in online counselling it’s important to consider the research. Is this form of counselling really effective?
Read the following information:
Use the space below to identify areas with strong or weak research evidence.
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 .