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

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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.

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.

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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?

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