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Online Therapy

Why work online? The pros and cons for the psychologist and for the client

Bertus Swanepoel

Introduction

If one considers the way the world has changed with the development of digital technology, it is only reasonable for psychologists to adapt to these changes and consider what the pros and the cons are in doing therapy online.

Since the start of the wide use of internet a lot of myths and perceptions needed to be answered and changed regarding online therapy. According to Barak et al. (2002, p438) “Online therapy has shattered three of the basic premises of therapeutic interaction, which is that it must always, by definition, be based on (a) visible (f2f) contact, (b) talking, and (c) synchronous (real-time) interaction”. Seventeen years have passed since this quote and research has quantitively as well as qualitatively explored the topic of online therapy further.

This essay is an exploration of current research to investigate the pros and the cons for the psychologist and the client in doing therapy online to keep on answering concerns, misperceptions and myths. It will be an ongoing task within the online therapy fraternity to keep improving the understanding and treatment effectiveness of online therapy as well as the developing technologies that can be used to alleviate human suffering I will mainly describe the pros and the cons of online therapy in a general sense where it is applicable to all four types of media (audio, video, chat and email). I will however be more specific about the pros and the cons of specific media where the studies were more focused.



Pros for the psychologist in doing online work

In doing online psychotherapy or counselling the psychologist has the option to see clients nationally and internationally from the comfort of their own home which in turn gives the psychologist the freedom of location to work from (Novotney, 2017).

Online therapy makes it possible for psychologists to have a full-time practice with only owning a laptop or computer and can therefore also save a lot of unnecessary expenses in running a practice. The psychologist can also have more flexibility with his/her time schedule as transport to and from an office is eliminated (Cherry, 2019).

If a psychologist struggle with illness or disability which impairs physical movement, online work will be a very attractive alternative to make a living despite these possible barriers (Cherry, 2019).

Another option for psychologists in doing online work is to get accredited with an online agency where there are well regulated processes and support for the psychologist. High levels of accountability for the therapeutic process are in place at agencies where the psychologist can have more peace of mind and confidence in the professional nature of the online service offering with supervision and online contracting in place and available (Weitz, 2016).

Considering the younger generation and the ease with which they use the internet, it might be beneficial for the psychologist to explore this alternative to face to face therapy where some clients will be willing to engage with a therapeutic process because of the familiarity with the medium which can provide a form of emotional safety (Hanley, 2009).

In considering the asynchronous nature of email therapy, the psychologist can also reflect more thoughtfully about the content of what the client has written and formulate more penetrating and helpful questions for the client (Harrad, Banks, 2019).



Pros for the client

Some clients are very reluctant to go and see a psychologist in a public setting and will be more open to see a psychologist in the comfort of their own home. Homebound, geographically isolated and stigmatised clients might fall under this category (Barak et al., 2002).

The client might also appreciate the flexibility in not having to commute to see the psychologist. Clients who live in very isolated geographical areas or in under-served areas might also benefit from telephone or internet assistance by a psychologist (Bee et al., 2008). In one study it was found that students who received video therapy because of the distance they live from the university, reported positive changes regarding their mental health problems. They were also more comfortable with video therapy compared to previous in-person therapy sessions (Simpson, Guerrini, Rochford, 2015).

Some clients will feel more secure and open to reflect their personal concerns and challenges when receiving online therapy (Tidwell, Walther, 2002). The client have dissociative anonymity in the online world which leads to the disinhibition effect (Suler, 2005). This disinhibition effect sometimes assists the therapeutic process when a client goes deeper and more quickly using asynchronous email therapy compared to face to face therapy (Suler2005). Shame can also be reduced in online therapies where the client is not seen and thus possibly be more vulnerable in sessions (Suler, 2005).

With email therapy, it might be beneficial for the client to see their own thoughts and feelings in writing and therefore become more aware of what the real issues in their lives are. Dunn (2012) reports changes after email therapy with a transition regarding the client’s behaviour, emotions and relationships occurring because of insights gained through email sessions. Dunn (2014, CH4 p6) also reports “We wondered whether asynchronicity might reduce the quality of the therapeutic alliance in terms of immediacy and authenticity. The actual experience reported by many participants has demonstrated this to be a false premise. From the outset the striking power of the relationships that emerged in these email exchanges surprised both psychologists and students alike and was specifically commented upon by almost all involved.”

Another big positive about doing online sessions is the variety of psychologists which the client can choose from. The client might get access to specialists in a certain area of concern whereas these specialists might not be easily accessible or available where the client lives. The client can thus literally have access to the best psychologist for their needs in the comfort of their own home.



Cons for the psychologist

The psychologist needs to understand the difference in doing online work compared to normal face to face counselling, because it might not be a natural transition from the one to the other. The different media used in online work can pose some difficulty for the inexperienced psychologist and extra training might be needed to understand the synchronous and asynchronous options within online therapy (Utting-Simon, 2017).

A psychologist needs to be adaptable when unforeseen technological glitches happen and the same technology that can be so useful can sometimes frustrate the therapeutic process through bad internet connection. It is very important that the psychologist know how to handle these glitches professionally without damaging the therapeutic relationship (BACP, 2015-2019).

The assessment of suicidal risk and possible harm should also be handled and measured carefully when one is doing online work. The psychologist must be extra careful not to practice outside his or her scope of practice and with a possible suicidal client it is very important that safety measures within the online environment are in place if needed (Martinez-Martin, Kreitmair, 2018).

Another possible con for the psychologist working online with audio, chat and email is the inability to read and assess body language and facial expression whilst having a session with the client. This might lead to inaccurate assumptions about the client’s emotional state and situation. With asynchronous media like email and chat the absence of tone of voice as well as body language might also affect the psychologist’s understanding and interpretation of what the client is trying to convey. The psychologist might find it more difficult than anticipated (Novotney, 2017).



Cons for the client

The available technology might frustrate the client during the therapeutic process and for the vulnerable client it might be difficult to be transparent when there are technical glitches like bad online connection during the session. The client might also doubt the privacy and confidentiality of information shared during an online session and encryption of software used for sessions needs to be thoroughly investigated. (Berger, Skinner 2009)

It is also very difficult for the client to cross examine the credibility of the psychologist’s qualifications and expertise, especially if the psychologist is not accessed through an online agency (Cherry, 2019). Any person can pose themselves as a professional and the client might be opening themselves up to some charlatan trying to make money online.



Conclusion

There seems to be more pros in doing online therapy for both the client and the psychologist although more research is needed in numbers and scope to build larger evidence in the online therapy field (Hanley, Reynolds, 2009). More randomised control trials can assist in doing robust research in the field to discover more pros and cons.

Research might need to focus more on the impact that online therapy has on the psychologist and how psychologists can be supported in doing online work more effectively.

Because of the quick expansion of technology and the increased demand for psychological services, online therapy is here to stay (Pelling, Richardson, Simpson, 2015 p 250). It is however important not to focus too much on the development of sophisticated media and technology rather that to see where special gains can be made for the benefit of both the client and the psychologist (Dunn, 2012).



References

BACP (2015 - 2019). Working Online in the counselling professions. Good Practice in Action 047. Lutterworth: British Association for Counselling & Psychotherapy. https://www.bacp.co.uk/media/2162/bacp-working-online-supplementary-guidance-gpia047.pdf [Last accessed 12/06/2019]
BACP (2015 - 2019). Working Online in the counselling professions. Good Practice in Action 047. Lutterworth: British Association for Counselling & Psychotherapy. https://www.bacp.co.uk/media/2162/bacp-working-online-supplementary-guidance-gpia047.pdf [Last accessed 12/06/2019]
Barak, A., Fenichel, M., Jones, G., Meunier, V., Munro, K., Suler, J., Walker-Schmucker, W., Zelvin, E. (2002). Myths and Realities of Online Clinical Work. CyberPsychology & Behavior. Volume 5, Number 5, 2002. Mary Ann Liebert, Inc.
Bee,P.E., Bower, P., Lovell, K., Gilbody, S., Richards D., Gask, L., Roach, P. (2008). Psychotherapy mediated by remote communication technologies: a meta-analytic review. In: BMC Psychiatry. 2008;8:60. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-8-60 [Last accessed 05/01/2019].
Berger, M. & Skinner, A. (2009). Psychological services over the internet. The British Psychological Society Professional Practice Board.
Dunn, K. (2012). A qualitative investigation into the online counselling relationship: To meet or not to meet, that is the question. Counselling and Psychotherapy Research: Linking research with practice. 12:4, 316-326.
Dunn, K. (2014). The therapeutic alliance online. In: Weitz, P. (Ed.). (2014). Psychotherapy 2.0: Where Psychotherapy and Technology Meet. London: Karnac.
Hanley, T. (2009). The working alliance in online therapy with young people: preliminary findings. British Journal of Guidance & Counselling. 37:3, 257-269
Hanley, T., Reynolds, D.J., (2009). Counselling Psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy. Researchgate.
Harrad, R. & Banks, N. (2016). Counselling in Online Environments. In: Attrill, A & Fullwood, C. (Eds.). (). Applied Cyberpsychology: Practical Applications of Cyberpsychological Theory and Research. Palgrave Macmillan: UK
Martinez-Martin N, Kreitmair K. (2018). Ethical Issues for Direct-to-Consumer Digital Psychotherapy Apps: Addressing Accountability, Data Protection, and Consent. In: JMIR Mental Health. 2018;5(2):e32
Pelling, N.J., Richardson L., Simpson, S.G., (2015). Introduction to the Special Issue “Telepsychology: Research and Practice”. Australian Psychologist. 50, 249-251.
Simpson, S.G, Guerrini, L, Rochford, S. (2015). Telepsychology in a University Psychology Clinic Setting: A Pilot Project. Australian Psychologist. 50, 285-291.
Suler, J. (2005).The Online Disinhibition Effect. International Journal of Applied Psychoanalytic Studies. Contemporary Media Forum. Whurr Publishers Ltd. Vol. 2, No. 2, 2005
Utting-Simon, S. (2017). Working Online. In: Private Practice. BACP Private Practice Journal. Spring 2017. p.04.
Weitz, P. (2016). Week 4 teaching session notes. Working online within agencies and organisations or using existing platforms



Web Resources & Links

Cherry, K. (2019), Advantages and Disadvantages of Online Therapy. Verywellmind, https://www.verywellmind.com/advantages-and-disadvantages-of-online-therapy-2795225
Tidwell, L. C., Walther, J.B., (2002). Computer-mediated communication effects on disclosure, impressions, and interpersonal evaluations: Getting to know one another a bit at a time. APA PsycNET. https://psycnet.apa.org/record/2002-15321-001
Novotney, A. (2017) A growing wave of online therapy. The flexible nature of these services benefit clients and providers, but the onus is on psychologists to make sure they comply with federal and state laws. https://www.apa.org/monitor/2017/02/online-therapy


Futher Reading:

Why work online? The pros and cons for the therapist and for the client - by Bertus Swanepoel
Presentation notes : Creative approaches in working online and use of online resources - by Bertus Swanepoel
Article review: Telepsychology in a University Psychology Clinic Setting: A Pilot Project. Simpson, S.G, Guerrini, L, Rochford, S. (2015).- by Bertus Swanepoel

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