Online Therapy With Young People: What Happens in a Session, and What Works?

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Online therapy is a rapidly growing field, and research is barely keeping up with it. What actually happens in a session, and what specific behaviours might be consistently helpful?

In the British Association for Counselling and Psychotherapy journal, there is a fascinating piece of research by Williams, Bambling, King and Abbott entitled, “In-session processes in online counselling with young people: An exploratory approach” (Counselling and Psychotherapy Research, June 2009, 9(2): 93-100).

The research (an analysis of 85 transcripts of single sessions with young people as clients) was aimed at isolating the processes which take place during online sessions with young people, to what extent they fit in with models of face to face counselling, and which of these processes or types of response had the strongest effects.

The researchers identified two main domains in which the counsellors worked, rapport-building and task-accomplishment. Within the domain of rapport-building lay the “micro-processes” of encouragement, empathic statements and paraphrasing; the domain of task-accomplishment included information-seeking questioning, use of confronting language and challenging the client, feeling-oriented questioning to raise emotional awareness, discussion of solutions, and the presentation of follow-up appointment options.

The results indicated weaker effects for the “in-session behaviours that rely more heavily on verbal and non-verbal cues to be accurately interpreted” across the domains — that is, empathy, encouragement, feeling-oriented questions, and options for follow-up appointments. All these kinds of statements or propositions carry a clear risk of coming across as insincere, due to the complete absence of clues such as tone of voice and the look on the counsellor’s face. On the other hand, paraphrasing, confrontation and information-seeking questions were employed more often and with “strong, immediate effects”.

This difficulty in building rapport, and possible lack of emotional immediacy, as the authors of the study remark, is usually in online therapy research said to be offset by the well known ‘disinhibition effect’ of the online medium, which encourages people to ‘let down their guard’ and reveal more intimate feelings because of their invisibility and relative anonymity online.

On the other hand, as I see it, accurate paraphrasing carries the same clout as an “empathic statement” — it shows you have been understood, and confronting and challenging the client, with a strong positive effect, may well be a sign of deeper engagement and intimacy than the client simply receiving encouragement from the therapist. So the difficulty in building rapport may be exaggerated, due to the measures used to quantify rapport, or this may reflect difficulties with a particular kind of rapport online — difficulties in expressing warmth and care, for example when a client is upset. This kind of expression of intimacy and engagement I would argue is indeed harder to convey online, whereas warmth and care expressed through challenging the client is not so hard online.

As far as the disinhibition effect is concerned, my own observations, as an online therapist, face to face practitioner, and user of online discussion boards, are that while the disinhibition effect is certainly valuable in allowing people to let out various emotions or talk about various subjects which might be too embarrassing or intimate to talk about face to face, I don’t think you can confuse the positive effect of ‘getting it off your chest’ with the kind of relationship which can be built up by careful, empathic responding, the kind which is more easily conveyed in person, as well as the confronting, problem-solving engagement, which seems to work well online.

Am I saying that face to face therapy is necessarily the better option because those kind of “warmer” rapport building responses can be received by the client more effectively?

Not necessarily. Maybe the online counsellors and the young people concerned wanted different things. Maybe the young people were using an online service precisely to escape the presence of an attentive, empathically responding counsellor, and to concentrate on offloading the things they could not say anywhere else, exploring their meaning and accomplishing concrete tasks in order to fix their problem.

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I am aware that I am making assumptions here, but there is certainly a group of young people whose idea of getting effective help is very much like the one I outline above, without unwanted eye contact or the risk of feeling patronised by well-meaning adults. The online medium is a lot less emotionally loaded, and frankly less embarrassing. You can appear and disappear, control how much you reveal to a greater extent (e.g., choose not to mention that you are about to cry), and to a large extent use the counselling service the way you want to use it.

While my experience shows that it is possible to build a deep rapport in the medium of online therapy, this may not be required or desired by some clients, and maybe some young people seeking help are especially likely to fall into this category. In this case, online therapy with a flexible therapist might be the optimum solution.

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