9 Observations About the Practice and Process of Online Therapy, Page 1

Drawing on an evidence base of over 700,000 words of email-based counselling and therapy, this exploration highlights 9 simple observations about the practice and process of online therapy. This paper is available here as a series of brief web pages, or separately as a single PDF download.

Abstract

The underlying therapeutic process of online counselling via email displays novel qualities in terms of its dimensionality, the role played by empathy and momentum, the significance of memory and sensory modalities, and the influence exerted by self selection bias. Asynchronous online counselling also introduces novelties to the basic mechanics of daily work, including a need for awareness of the practice peak to mean ratio, some subtleties regarding client consent for research, challenges for handling client backlogs, and a problem of representing counsellor experience honestly. Despite all this novelty, however, it seems that no fundamentally new ethical territory has been created by the advent of online counselling; there is, rather, merely new technological territory which challenges us to grasp its ramifications for existing normative principles.

Keywords: Email, ethics, online counselling, online therapy, therapeutic process

Introduction

Writing letters to counselling clients is nothing new: Freud was exchanging correspondence with patients over a century ago. Nowadays, letters can be delivered with lightning speed via the internet, and email-based counselling, lumped together with counselling offered via other internet enabling technologies, has come to be known as ‘online counselling’ or ‘online therapy’.

Despite widespread use of these techno-centric umbrella terms, however, from the perspective of the underlying therapeutic process, counselling via an asynchronous technology like email seems to me to share little in common with counselling via synchronous technologies like internet chat or videoconferencing. With respect to therapeutic process, I believe chat is more akin to telephone counselling, and email is closer to writing paper letters, than chat and email are to one another.

That difference motivates my primary aim in this paper: offering observations about the practice and process of counselling specifically conducted via email, as distinct from online counselling understood broadly to encompass anything one might do with counselling and an internet connection.

A second aim is to keep those observations both relevant to daily practice and specifically prompted by ‘real life’ online experience. Reviews of the online therapy literature and private communications with authors widely cited in the field indicate that many who write about it — even some who teach it — have relatively little experience actually providing individual online therapy themselves. This does not make their observations or insights wrong, or unhelpful; far from it. But it does leave them incomplete, with many areas of exploration that practitioners could find helpful for developing online practice remaining under-represented in the literature.

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Even some otherwise excellent empirical work resists immediate application to daily practice, either as a result of being very specific and quantitative (e.g., Christensen, Griffiths & Korten’s 2002 web-based CBT), or instead being very general and qualitative (e.g., re-explorations of Kiesler, Siegel & McGuire’s 1984 observation that people communicating via computer may feel disinhibited). Examples from the middle of the spectrum and closer to daily practice are thinner on the ground (e.g., Day & Schneider, 2002; Lewis, Coursol & Wahl, 2004), while no online counselling research of any kind has yet to ‘arrive’ at all in reference volumes like the classic Bergin and Garfield (Lambert, 2004).

By keeping close to actual practice, I hope this paper will pass what I call the ‘today test’, the questions I ask myself when reading a paper: will this add to my understanding or awareness of myself, my practice, or the world around me in some way that I value? And will it initiate that process today — not next week when I get around to reading it again, or next month when I’ve had a chance to think about it, but today, right now?

After outlining my practice background, this paper continues with three main sections, covering the asynchronous therapeutic process, practice issues, and the ethics of online practice.

Practice and Website Background

CounsellingResource.com exists primarily to provide information about counselling, psychotherapy, and general mental health. A small area dedicated to my practice describes in detail how the service operates and suggests factors to consider before using it. Additional material covers my academic and professional background, work in technology, training in person-centred counselling, and practice philosophy.

To give an idea of scale, independent statistics from Alexa.com indicate the site currently reaches over twice as many visitors as that of the BACP, nearly three times as many as the Samaritans, one seventh as many as NHS Direct, and just one ninth as many as the American Psychological Association.[1] The counselling service itself has been contacted by people writing from all continents except South America and Antarctica.

Six months into online practice, I began logging total volumes of emails exchanged with clients. In the roughly 20 months since, I have recorded a total of 715,000 words of individual counselling. Again for scale, this falls somewhere between seven and 12 PhD dissertations, or a little more than the first six Harry Potter (Rowling, 1997) books combined; it is roughly 160 times the length of this paper.

To my knowledge, this represents the largest single-practitioner evidence base underlying any research yet published on individual online counselling.

Most clients exchange at least a few thousand words over a period of weeks or months, while some communicate regularly for a year or more; in view of these volumes, I implement a waiting list whenever concurrent client numbers exceed the low teens. This client profile contrasts sharply with that of other practitioners reporting many hundreds of online clients over a five-year period (Chechele & Stoffle 2003); one colleague privately claims thousands. Such figures imply, on average, significantly less work with each client — perhaps something akin to the brief support services offered by the Samaritans in reply to 99,000 email contacts in 2003 (Samaritans, 2005).

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