9 Observations About the Practice and Process of Online Therapy, Page 2

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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.

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.

Try Online Counseling: Get Personally Matched

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.

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