9 Observations About the Practice and Process of Online Therapy, Page 5

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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.

The seemingly straightforward act of requesting permission from a client to use session material for research or teaching purposes acquires additional subtleties when all material is automatically recorded verbatim. Whereas a f2f practitioner might ask permission to record a specific session, an online counsellor might request permission to draw on an entire body of material potentially stretching back through months or even years of verbatim records. A client may in effect give retroactive permission to use material far into the past, material which normally would not even exist in f2f settings.

This raises special considerations not only for ensuring that consent is well informed, but also for managing the therapist’s own behaviour: as soon as an online practitioner forms the intention to request permission, he thereby becomes aware that what he writes right now may at some point in the future be used for publication or teaching. This creates an asymmetry with the client, who may not know in advance that a given exchange could ultimately be published. Such asymmetries do not normally arise in f2f practice, where the potential for publication does not exist until both parties have become aware of it and explicitly agreed to it: again, f2f material does not normally become available for publication retroactively.

The Client ‘Stack’

In f2f practice, a given hour is scheduled and ‘owned’ by a specific client; analogous ‘session times’ for email counselling clients do not usually exist. Incoming emails stack up, and the counsellor acquires a new responsibility: deciding how much time to allocate to which client, and in what order.

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In my experience, seeing multiple unanswered emails in my inbox prompts reflection not only on the external mechanics of which email to handle first (e.g., comparing relative lengths of outstanding emails, time available, response time commitments, etc.), but also on my own internal processes as I hold several clients in awareness at the same time:

  • Of these clients, what would it be like for me to respond to each one right now?
  • Which client do I want to respond to first?
  • What feelings, thoughts, or assumptions come bundled up along with my personal preference to respond to a given client first?
  • What role does my sense of the relative difficulty of working with each client play in influencing the order in which I respond?
  • Do I simply need more time to reflect on a given client’s email before responding?
  • Do I have a financial incentive to respond to a given client sooner or later than I otherwise might?

Except via some prescriptive algorithm which would dictate mechanistically how I am to organize my replies, I cannot imagine these and related questions ever disappearing from practice. And while the questions themselves might seem quite obvious at first blush, their ‘answers’ (or, rather, the exploring and reflecting they prompt) rarely are.

Client Contact and Representing Experience

Assumptions about time which apply to f2f practice break down in the case of email counselling, posing particular challenges for representing accurately and honestly the work online counsellors do.

In f2f practice, the assumption that client and counsellor meet once per week (or more for psychoanalytic practice) for roughly an hour offers a good start for interpreting statements like “I have completed 12 weeks of work with this client”. By contrast, statements about the calendar time duration of email counselling are, without further qualification, close to meaningless: one cannot justifiably assume anything about how frequently counsellor and client exchange emails, how much they say in those emails, or how much time they spend reading and writing. Similarly, reporting an online practitioner’s “years of experience” appears to me at best meaningless and at worst misleading. It particularly risks grossly misleading audiences who are less well informed about the realities of online practice, such as less experienced colleagues or members of the public who may mistakenly believe that years imply something about actual experience.

My procedure of recording the number of words exchanged with each client is designed in part to address these pitfalls of interpretation. When I referred earlier to 715,000 words of counselling, this reflects the total of new words (excluding quotations from previous emails) written by each client and by me. It excludes introductory, contracting and other administrative communications; casual queries and one-off requests for feedback or support; simple ‘question answering’; and supervision services: it represents only bona fide ongoing counselling with individual clients. While certainly not perfect, this method of logging client work is both quantitative and meaningful in ways that talk about calendar time or client numbers is not.

Note that word counts do not translate directly across the modalities of f2f, email and chat. For a given duration of time, the relative ease of verbal speech suggests f2f work may expend more words and cover more territory; while its asynchronous nature and unlimited time for reflection may allow email work to pack more meaning into fewer words. Like email, chat suffers from the ‘keyboard disadvantage’ and requires more time to communicate a given number of words than f2f — Day & Schneider (2002) report a chat session mean of roughly one third of the 6000-word f2f session mean — yet it lacks email’s advantages for conveying more meaning with fewer words.

While the relative ‘amounts of counselling’ enabled by different modalities are not yet clear, it is clear that describing online counselling experience in familiar f2f terms like years or weeks risks grossly misleading one’s audience. Two brief articles (Mulhauser 2005a, 2005b) address in more detail ethical issues raised by some online practitioners’ penchant for reporting their experience in years or in numbers of clients.

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