How Much Online Therapy Really Goes On? Part 2

A Suggestion for Quantifying the Volume of Online Therapy Activity

Rather than allowing members of the public or one’s colleagues either to be misled (see “How Much Online Therapy Really Goes On? Part 1”) or to remain none the wiser about a practitioner’s activities as an online therapist, I personally think it’s preferable to report the actual amount of online therapy work done, not the amount of calendar time that passed while doing that online therapy. This quantifiably distinguishes the range of actual practitioner experience from the range of years of being a practitioner.

In the case of online therapists who work via chat, video, or other synchronous technologies (where ’synchronous’ means that the communications take place in ‘real time’, with client and practitioner meeting together at the same time), the most straightforward way of doing this seems to be just to refer to the number of hours spent communicating with clients — exactly as one would do when reporting the number of hours spent in face-to-face work with a client.

In the case of online therapists who work via email or other asynchronous technologies (where ‘asynchronous’ means that the communications happen one after the other, in series, and usually not with the client and practitioner meeting at any specific time), quantifying actual volume of online therapy work is trickier. After all, the amount of clock time which someone might spend reading or writing emails is open to arbitrarily large variation, a characteristic which is not shared with face-to-face work or online therapy done via chat, where the amount of time is objectively reflected on the clock.

In referring to my own online therapy and online counselling practice, which is email-based, I have always preferred to quantify my activities in terms of words. So, for example, during 2004 I completed just under 500,000 words of online therapy/online counselling work with individual clients. This number reflects the total of words that clients write and the words that I write in reply. It excludes quotations (and quotations of quotations, etc.) which appear in emails, it excludes purely administrative communications like intake procedures and making arrangements for holidays, and it excludes the once-only exchanges or requests for information that I sometimes have with people who write to the site. In other words, the number reflects the amount of real online therapy or online counselling that goes on, with continuing clients who stick around for awhile, and it excludes everything else.

Purely in terms of volume, this is comparable to around 5 doctoral dissertations.

What are the Problems With Reporting Online Therapy Experience in Actual Words?

Of course, reporting experience in actual volume terms is not without its problems. For example, sometimes 100 words can be harder to write in one situation than 500 words in another situation, and arguably the 100-word chunk might count as ‘more’ online therapy or online counselling than the 500-word chunk. The same goes for reading: more volume does not necessarily equal more therapeutic value.

In addition, differences in fundamental counselling style might skew volume figures noticeably, in ways that they might not skew hours in face-to-face practice. In other words, ways of working that involve significantly different amounts of talking in a face-to-face session will probably result in different word volumes during online practice, even though the comparable hours of face-to-face work might be the same.

Similarly, volume reporting might be more difficult for practitioners who routinely supply their clients with copies of materials they have previously written. Should this be counted just like any other exchange of communications, or excluded completely, or something in between?

Finally, perhaps the greatest weakness of reporting online therapy experience in this way is its lack of familiarity for the average consumer. Most people who do not write professionally (and who are not students) probably have limited experience with writing text of a given length, and so 10,000 words of online therapy exchanges might seem fairly indistinguishable, in terms of personal experience, from 50,000 words or 100,000 words. For most people, years of experience or numbers of clients probably seem more comprehensible; but, as explored here, the problem is actually that far from being comprehensible, such numbers are essentially meaningless. So, for my part, I’d rather go with a method that is open, honest and transparent — but unfamiliar — in preference to a method that is meaningless at best and deeply misleading at worst. While more words exchanged between client and online therapist may not equal more therapeutic value, it’s a darn sight closer than anything like ‘years’ or client numbers.

And as far as reporting synchronous online therapy work is concerned, I can’t think of a single reason not to report hours, just as in the case of face-to-face working. (There is still a problem of interpreting the result, since an hour of chat is probably not equivalent to an hour of face-to-face work, given that most people cannot type as quickly as they can speak. However, this is a problem of interpreting the number, rather than a problem of objectivity in the measure itself.) My failure to imagine any reasons not to count hours doesn’t mean there aren’t any reasons not to, it only means I can’t think of any; but the reasons not to rely on years or client numbers are pretty clear and unequivocal.

The ‘Real’ Problem With Transparency in Describing Online Therapy Experience?

I’ve asked around among fellow mental health practitioners — for example, in the International Society for Mental Health Online — to try and get some idea of how much actual online work other practitioners do. I would have imagined that if anywhere would be full of people actually doing online therapy, the ISMHO would be it. I don’t think it is.

A few practitioners have been happy to concede that they haven’t worked with a client online in a long time, or that they have never seen more than two or three concurrently. One reported being quite busy with chat-based clients but was happy to discuss the topic only after checking to be sure I wasn’t just fishing for data about how much money she was making. No one was willing to come forward with a quantitative statement of experience. Mostly, the topic was just met with silence. Given the rarity of ISMHO discussions which emerge directly from online clinical practice, as distinct from discussions about how one might get started in the field and other topics one step removed from actual online working, I suppose I shouldn’t have been surprised. Besides, ISMHO never has been a professional organization of people doing online therapy; it is an open organization for anyone interested in mental health online.

However, my experience with trying to discuss online therapy work with other practitioners, plus my own surveys of other sites trying to sell online therapy (see “How Much Online Therapy Really Goes On? Part 1”), do suggest one possible explanation for the ‘real’ problem with describing online therapy experience transparently. Namely, with actual online clinical experience so thin on the ground — including among many who bill themselves as ‘experts’, or ‘pioneers’ of the field — could it be that practitioners would simply prefer not to let members of the public know exactly what kind of online experience they have?

Conclusions About Online Therapy Experience and Reporting it Openly, Honestly and Transparently

The first part of this article explored how difficult it is to make any sense of claims about online therapy experience phrased in terms of years or numbers of clients. I suggested that since this observation will probably be fairly basic to online therapists who have a fair amount of experience, it seems like one of these two alternatives is probably true: either practitioners who talk about numbers like their years as online therapists haven’t actually done enough online therapy to realize how unhelpful such numbers are, or they actually do realize it but choose to withhold more informative details when discussing their experience. In my view, neither alternative reflects very well on the state of the field.

So what can be done about it? This second part of the article has suggested two simple alternatives:

1. In the case of synchronous online therapy or online counselling, such as that done via chat or video, simply report hours, just as in face-to-face counselling.
2. In the case of asynchronous online therapy or online counselling, such as that done via email, report word counts (excluding quotations and other chunks of text which would artificially inflate the impression of actual online therapy being done).

There are probably many things I haven’t considered in coming to the views I’ve expressed in these two articles, but from where I sit right now, it seems to me that there are very few good reasons for not reporting online therapy experience in a quantitative and transparent fashion such as I’ve described here, and plenty of reasons for avoiding the usual “I’ve been an online therapist for X number of years”, or “I’ve provided online therapy to Y number of clients”.