Online Therapy: How Does it Work When You Can’t See Them?

When I mention that I have an online therapy practice, I sometimes get a knee-jerk reaction — something like “oh that’s interesting…however does it work without seeing them, though?”

Online therapy can look like a “sign of the times” — a contemporary, flexible alternative to that inconvenient business of turning up at an office once a week at the same time, giving the client control as to how much time they wish to buy and when and how they want to use it. It has the air of a faceless service, something private and anonymous that can be hidden away, a kind of sanitised version of “real”, messy therapy, which involves more than disembodied minds.

Embodiment Online

I use my physical reactions and senses of situations and people quite consciously in my work, so you might think I would be the first to say “but how can you really get a sense of someone without seeing them?” In face to face work indeed, everything communicates: the tone of voice, the interplay of eye contact, shifts of position, the presence the person carries with them as they enter the room, differences in posture, clothing or expression between sessions. These are all dense and complex pieces of information.

However, there are many forms of ‘online presence’. Apart from wildly differing styles, lengths and frequencies of emails, in online discussion boards I often have the odd sensation of a certain “energy”, for want of a better word, seeming to come off the screen as I open people’s posts. That is also communication and it is also dense and complex — so much so, that I could not tell you how that physical sensation of warmth, say, or chill is produced. It has something of the mystery of a real encounter. Of course, it is one.

Emotional Connections Online

In any case, my online therapy experiences have run the relationship gamut, from very intense emotional connections to more distanced co-operative working relationships, much as in face to face work. There are some differences between online and face to face therapy, and, while there is quite a lot of relevant material around the internet on these differences, here are some which have personally struck me.

One of the main advantages is that both client and counsellor have to work harder. Although the well documented “disinhibition effect” may give the client a “head start” — many people find it easier to ‘open up’ unseen, in the privacy of text, (part of the reason that Freud’s patients lay with their backs to the therapist). It is also, however, well known that tone is hard to convey in email and misunderstandings are relatively common. I hazard the theory that this often happens when the recipient starts to, to use psychoanalytic terminology, “project” onto the sender — reading into the text attitudes which are not “really” there, or rather imputing to the sender motivations that the sender does not recognise or intend.

This could make online therapy by email of special interest to psychoanalytic practitioners, who consider the heart of the work to be the transference relationship between the therapist and patient. The psychoanalyst was traditionally considered a “blank screen” on which the patient could project significant others and work through feelings. In online therapy the metaphor of the “blank screen” has become a literal reality!

Yet, while elements of transference may well be present in misunderstandings, and a lot may be learned in their resolution, I work hard to make sure they arise as little as possible. This means that, without the clues given by my presence, (although they, of course, may also be misinterpreted), I have to say more. I have to make more of my thoughts and attitudes explicit, both to myself and to the client. I have to spell things out, and signal the tentativeness of my responses and suggestions, as I have no idea of how they are being received; I cannot spot the look on the client’s face when I have misunderstood. I think this extra-explicitness is good. It also makes me less of a blank screen than I might be in the flesh. Not being a psychoanalyst, I think this is good too.

My way of doing online therapy is via email. The element of reflection and the distancing, yet concentrating, effect of writing, can be of therapeutic benefit in themselves. In a previous post (see “Online Therapy for Introverts”), I say more about how online therapy seems tailor made for some personality types.

Online therapy levels the playing field, too. It is less potentially invasive and intimidating for people who have experienced being painfully stereotyped or dismissed through their appearance, or speech, or for those who are anxious about social encounters. Mobility and hearing are not issues, although literacy is. Clients in isolated rural areas or living abroad are in an equal position to those in their home countries and in major cities. Clients can choose therapists from anywhere in the world, according to their feeling of “fit” with them. This “fit” seems to be a high predictor of the success of the therapy.

This feeling of fit, or lack of it, can be quite clearly physically sensed. However much we may fear that something essential about our humanity is being “taken from us” by technology — I do not think it is so easy to lose. “It” — the complexity of human experience in our senses, bodies, minds and hearts — adapts to fit the channel of communication. It’s the same therapeutic process, whether we are in the same room or not.

As far as I am concerned, online therapy is definitely the “real thing”.