9 Observations About the Practice and Process of Online Therapy, Part 3

Asynchronous Therapeutic Process

Two Dimensions of Email Communication

In terms of its constitutent verbal exchanges, real-time face-to-face (hereafter, 'f2f') dialogue unfolds along the single dimension of time. A written session transcript captures this linearity, recording the words spoken first by one person, and then the other, each in turn. While the underlying subject matter might be very complex, and the topics visited in highly non-linear fashion, the actual flow of dialogue emerges linearly through time.

By contrast, the asynchronous dialogue of email counselling generates an intrinsically two-dimensional process, which develops both within and between emails. The 'turn-taking' of dialogue on a given topic occurs in one dimension across separate emails, while the narrative of each participant expands in a second dimension within a single email. Further, each email itself typically incorporates multiple distinct threads developing simultaneously, as each participant responds in-line to material previously written by the other.

So, whereas a segment of f2f discussion may be captured by a few contiguous pages of session transcript, representing (say) 20 minutes of exchange, a segment of email discussion may occur via scores of 200-word fragments distributed over weeks of separate 2,000-word messages. Concatenating those fragments in sequence linearizes the content specific to a given discussion thread, but fails to capture any interactions occuring at the same time with related threads developing in parallel: if ordinary f2f dialogue unwinds as a single thread tracing a path through a complex space, email dialogue unwinds as multiple threads tracing paths through a similar space -- while at times coming together, intertwining, and separating again.

Only in the limiting case of very brief, single-sentiment or single-idea emails, does an asynchronous exchange reduce to anything resembling the 'tit-for-tat' linear dialogue of two people conversing each in turn.

Certain advantages counterbalance the challenges of carrying on multiple parallel discussion threads. For example, glimpsing the broad message the client is conveying through an entire email, taken as a whole, may allow me to target responses to each individual expression (paragraph, etc.) within an email in a way that is at once mindful of the details of that expression itself and its contribution to the overall picture the client is creating.

Modalities and Memory

Usually, online work lacks the spatio-temporal cues sometimes employed in conceptualizing individual f2f clients like "the woman I see first on Tuesday afternoon", or "my last client at the University on a Friday". Having fewer of these memory associations and triggers with text-based clients, I often find it comparatively more difficult to recall details about each. This may actually help me to encounter each client with 'freshness', as if hearing that individual for the very first time — exactly the opposite of what I would have expected about work conducted in a context of automatically generated, verbatim written records.

However, that 'freshness' also brings with it a disadvantage: discussions sometimes need more repeating or in-depth exploration to help them settle in, both for me and the client. Things don't seem to 'stick' as well in email as f2f. Alison, a 30-year old reflecting on new things she was learning about herself, mentioned:[2]

I think the worse part of the discoveries though, is how often I have to rediscover something! Those little nuggets of wisdom that I unearth don't often stick.

I have sometimes wondered whether differences I notice in my own memory of f2f as compared to text-based encounters might be partly explained by the multi-modal nature of the former and the neurophysiology of long term potentiation and memory creation. When I mentioned this in my reply to Alison, she startled me by replying that her experience of email-based working was essentially tactile in nature:

That's interesting, I wonder if there is a way to incorporate another sense… I've always been better at incorporating tactile and sight. …To me, this is mainly just a tactile experience. Half the time I don't even look at the screen while I type…

Given that Alison and I worked together virtually every week for some 15 months, the role of our respective memory characteristics was not at all trivial, and we discussed specific ways she could involve that additional sensory modality to aid memory.

Additionally, asymmetry in the speed with which a complex expression can be read -- as compared to spoken (slower) or written (slower still) -- appears to reinforce the general truism that ideas or insights originating with the client are better retained than those coming from the therapist: the former demand a more significant investment of the client's time to generate and write than the latter, which may be read only briefly. The empirically established primacy of client contributions to therapeutic change (Tallman & Bohart, 1999) appears to be amplified and underscored in this asynchronous medium.

Constraining Momentum Versus Deepening Momentum

While limitations of memory play an important role in the emergence of a therapeutic process via asynchronous communication, so too does an opposite factor: the 'momentum' created by seeing the same material in an email more than once, such as when one participant's words have been partly or wholly quoted in a new email. (Imagine reviewing the previous session's written transcript with a f2f client, before every single office hour.)

I distinguish between constraining momentum, which tends to limit the introduction of new material into the discussion by providing a tempting 'template' into which each successive reply can be fit; and deepening momentum, which encourages keeping to a given topic even as we engage with it in greater and greater depth. A conceptually attractive analogy for constraining momentum is the so-called 'watchdog effect' of quantum mechanics, referring to the fact that the very act of repeatedly observing a quantum system restricts that system's state from changing.

The distinction between constraining and deepening momentum bears directly on the challenge of appropriately articulating empathic responses. Only rarely can these be simple re-statements of what the client has already expressed. I cannot 'just' sit and listen or nod or repeat verbatim, relying on body language or presence to communicate deep engagement with a client; usually, it must be articulated textually in something other than simple cut-and-paste fashion.

The risk of generating constraining momentum -- and the appeal of deepening momentum -- creates for me a relentless nudge in the direction of deepening and expanding the empathic response. Perhaps more than any other single counsellor factor (as distinct from client factor), it is the skill of textually conveying empathic understanding in such a way that momentum tends to deepen the exchange, rather than constraining it, which separates effective online practice from the mere application of prior f2f skills to the online environment.

Self Selection: A Free Bias Toward Effective Working?

Self selection can induce bias into everything from election results to consumer surveys and scientific studies: solicit participants on the basis of their interest in a given topic, and expect results to be biased to the extent that the set of people interested enough to participate may not represent the population as a whole.

A similar phenomenon appears to exist in online counselling, with several clients having mentioned choosing to work with me specifically because my approach appeals to them. Others have described feeling as if we'd already had a session before we began. Benjamin, an engineer in his late twenties, put it simply:

When I read your web site, I at least knew something about you before we start[ed], and that's important to me. I liked what I read about your approach to therapy, as well, so I came back and signed up. You said in your e-mail that I could start wherever I want, but to tell you the truth I've got so much on my mind that I don't even know where to start.

But even at this early stage, Benjamin already felt sufficiently at ease that he did make that start, and we exchanged tens of thousands of words over 4 months.

Non-random (i.e., informed) counsellor selection by clients amounts to client self selection for a service in which they are already predisposed toward confidence of a positive outcome. While this is no guarantee of one, evidence (Tallman & Bohart, 1999) certainly suggests it helps.

Naturally, clients working f2f can read about practitioners before selecting one too, but those seeking an online therapist can compare not just a small set from their geographically local vicinity, but a large set from all over the world. Therefore, I would expect the phenomenon of self selection to be more prevalent for those seeking online counselling than for those seeking f2f counselling.

This raises an interesting ethical question: should self selection bias be courted deliberately, by increasing the information available to clients about an online practice?

Continue to email-based counselling in practice...