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RUNNING HEAD: ONLINE COUNSELING
Online Counselling: A Review of the Literature
University Victoria
ED-D 561
Online Counseling: A Review of the Literature
With the development of the internet and the associated communication tools that have been developed and are in common use on the internet counselors now have a new medium to conduct therapy (Lovejoy, Demireva, Grayson & McNamara, 2009; Rummell & Joyce, 2010). Online counseling is comprised of two main types—synchronous and asynchronous (Haberstroh, Parr, Bradley, Morgan-Fleming & Gee, 2008:Lovejoy et al., 2009, Schultze, 2006). Asynchronous counseling involves text based transmission of messages that are delayed by time, usually email or posting boards whereas synchronous counseling is instantaneous and involves modalities like real time chat, group chat, voice messaging or video conferencing. Literature to date retrieved from Ebscohost, though mentioning video conferencing appears to be deficient in research in regarding video conferencing type therapy.
The literature deals almost exclusively with text based modalities though teleconferencing is discussed it is not included in the scope of this paper as it is a different modality then internet text based therapy. The literature uses many names to describe therapy that is conducted through the internet; these include online therapy, etherapy, online counseling, cybertherapy or therap-e-mail (Wright, 2002). The literature agrees that online counseling is a modality of counseling that has come into being due to technological developments and needs to be discussed and researched. To highlight the need for these discussions an online support service called Samaritans which answers mental health email enquires received 36 500 e-mails in 2000, 72 000 in 2002 and by 2006 they had received over 184 000 emails (Samaritians, 2004, 2007, in Hanley & Reynolds, 2009). Other issues that the literature highlights are whether or not online counseling can develop an effective therapeutic alliance to produce lasting change. Qualitative research describes the experiences of online therapy from counselor and client perspectives, and finally though some licensing agencies have started to develop ethical guidelines they focus mostly on informed consent (Rummell & Joyce, 2010) ethics and the lack thereof are discussed as some of the challenges of internet therapy. To address these issues this paper will discuss the chanlanges of online therapy, the advantages of online therapy, the research regarding the ability to establish a therapeutic alliance and finally a brief discussion of the ethical considerations involved in online theapy.
Challenges of Online Therapy
The current literature highlights a number of problems that online counseling has compared to face to face counseling. These are missing nonverbal cues or body language that a therapist uses in therapy, misreading the email or instant messaging board, the time delay involved in email or the disjointed instant messaging that can happen with slow internet connections and finally the technical skills of the therapist or client. Other draw backs to online counseling will be addressed with the discussion of the ethical considerations of online therapy.
Nonverbal Cues
Every practicum counseling student is taught to look for the discrepancy between what the client is saying and their body language. The client may be talking about something that is extremely painful but be smiling or even laughing about it. Nonverbal communication is a vital source of information for the counselor and the therapy process (Tepper & Haase, 1978; Trepal, Haberstroh, Duffey, & Evans, 2007). One of the criticisms of online therapy are that these missing cues are detrimental to the counseling experience both for the therapist to understand the client but also for the client to feel accepted and understood (Rummell & Joyce, 2010;Hanley & Renolds, 2009; Stummer, (2009). Wright (2002) in her paper linking online text therapy to the proven benefits of writing therapy challenges the very idea of being able to compare online therapy with face to face therapy in that it is a totally new medium that needs to have its own research and validation. In short she challenges therapists to self reflect on their resistance to this new form of therapy. Is it fear of change or lack of knowledge that causes this resistance? This is supported by Haberstroh et al. (2008) with their qualitative study from the perspective of the counselor in that the one participant claimed that the felt a loss of control without access to the nonverbal cues.
Rummell and Joyce (2010) put forward that it may be an advantage to not have the nonverbal body language coloring the counseling experience. Personal experience of the writer working with an individual with multiple sclerosis found that body language was not reliable as the this particular disease affects body movements, facial expressions and posture. Body language may also be a problem working cross culturally as postures and gestures do not have the same meaning in different cultures (Marsh, Elfenbein, & Ambady, 2007).
Misreading
One important aspect that is taught in counseling psychology is the ability to paraphrase the client’s story and attached feelings to ensure that the client has been understood correctly. The immediacy of feed back from the client as to whether or not they are understood correctly is lost with asynchronous online therapy (Trepal et al., 2007). To help overcome this problem Trepal et al. suggests that emails or chat sessions focus on only one topic at a time. This will make better use of the session, due to slower pace of chat sessions, and to avoid overwhelming the counselee with a plethora of questions in one single email. Trepal et al. also suggest modeling appropriate, clear, concise communication in the text, like stating emotions clearly.
Time Delay
Online therapy that is conducted through email has an inherent time delay. It may be hours or days between communications. Instant messaging sessions are slower paced than face to face sessions and may be ambiguous when one is thinking about a response or processing what was said leaving the client or counselor wondering if the other has disconnected (Haberstoh, Duffey, Evans, Gee, & Trepal, 2007). Wright (2002) defends the time delay in asynchronous text therapy because it is like writing therapy that is commonly used as a therapeutic tool and that the time delay allows the client to process the content of the message and be able to work at their own pace in assessing the comments and responding.
Skills
One final area that is commonly addressed in the literature is the ability of both the client and the therapist to use technology adequately to access chat rooms, email or log on to secure sites. The ability of therapist or client to be able to type adequately to facilitate therapeutic communication is also a concern. Finally the ability to be able to communicate effectively in a text medium is required to be able to engage in this type of therapy (Rummell & Joyce, 2010; Hanley & Reynolds, 2009, Trepal et al., 2007).
Advantages of Online Therapy
The literature about online therapy discusses a number of inherent advantages that are involved in online therapy as opposed to face to face therapy. These include the process of therapeutic writing, disinhibition/anonymity and increased power of the counselee, convenience and increased access as well as reduced cost.
Writing is Therapeutic
Therapeutic writing is a process that is used as homework in face to face counseling (Trepal et al., 2007). Journaling is a process that is widely used by many to help relieve daily stress and to provide release from uncomfortable emotions (Wright, 2002). The process of writing has also been described by research participants as effective as the interventions used by the therapist (Haberstroh et al., 2007; Schultze, 2006).
Disinhibition/anonymity
Disinhibition is a process described in the online counseling literature as a phenomenon where the client moves very quickly to intense personal disclosure (Fletcher-Tomenius & Vossler, 2009;Habersroh et al., 2008; Haberstroh et al., 2007; Schultze, 2006). Online therapy provides for a safe anonymous atmosphere in which clients experience more power in the therapeutic relationship (Haberstron et al., 2007; Schultze, 2006). The issue of power will be discussed in the following section.
The anonymity of online counseling has the effect of allowing the client to disclose embarrassing or shameful feelings/acts/problems in the security of their chosen environment. The client has the luxury of not having a therapist sitting across the room who may judge them or have a negative reaction to the disclosure. As a result researchers are finding that clients disclose important information earlier then face to face session and as early as the first email or chat session (Fletcher-Tomenius & Vossler 2009; Haberstroh et al., 2007; Young, 2005). Opponents and those who have concerns about online counseling see anonymity as a negative aspect of this medium counseling and removes the important process of connection (Rummell & Joyce 2010). This will be addressed in the section on ethics of online counseling.
Power
One aspect of online counseling that is seen as a benefit of online therapy is the increased power that clients have over the therapeutic process. Schultze (2006) describes the increased power that online clients experience. The client has the ability to end the process, in an instant messaging setting, without having the social pressure that would be required to walk out of a counselor’s office. With email the client has time to write and reread the email before sending it. This gives the client more control over what they disclose and how much they disclose and when they disclose (Stummer, 2009; Leibert, Archer, Munson & York, 2006; Schultze, 2006). Conversely Haberstroh et al. (2008) report that the same processes that give power to the client leave the therapists feeling a loss of power in the counseling process. This relates back to the position put forward by Wright (2002) that online counseling is different than face to face and reservations or opposition expressed may be more the therapists problem rather than online counseling being a poor medium for counseling.
Convenience/Accessibility/Cost
Online counseling is, by nature, flexible. Many clients report that one of the reasons that they chose online counseling was for the ability to engage the process at a time that was convenient for them and not during regular business hours (Young, 2005; DuBois, 2004). Others describe accessibility as a major advantage to online therapy (Rummell & Joyce 2010; Trepal et al., 2007; Young, 2005; Schultze, 2006). The increased accessibility to therapy services for those who may be shut ins, or who have caregiver responsibilities that would not afford them the ability to access traditional services. Those who live in rural or under serviced areas would also benefit from the accessibility of online therapy. Those with hearing impairments may also benefit from online counseling. Contrary to this DuBois (2004), who has an online practice as well as face to face practice, reports that the majority of his clients do not come from those who cannot attend traditional counseling but from those who choose the online medium.
Finally the issue of cost is seen as a positive aspect of online counseling. Young (2005) reports that counseling sessions can cost as little of 60% that of traditional counseling. DuBois (2004) reports that many of the people who visit her website are looking for affordable or free counseling. Furthermore Dubois theorizes that people expect online counseling to be free because there are so many sites that offer free information and other free services online. Dubois also states that because online counseling is in its infancy it may not be perceives as a professional service which highlights the need for research to prove the efficacy of this form of counseling.
Therapeutic Alliance
One of the most debated concerns of online counseling is whether or not the therapist is able to develop a therapeutic relationship of sufficient quality to effect change (Cook & Doyle, 2002). It has been theorized that due to the lack of nonverbal cues that it would be difficult to build a therapeutic alliance with the clients (Fletcher-Tomenius & Vossler, 2009). How does one convey caring and empathy or build trust in a relationship that is solely text based?
Hanley (2009) in a study of 46 young people aged 11-25 found that 17.4% had formed a high therapeutic relationship, as measured on the therapeutic alliance quality scale, while 58.7 had an alliance of medium quality and 23.9 reported the therapeutic relationship as low. Less than one quarter of the sample rated the therapeutic alliance as poor. A study of 81 people seeking online counseling, by Leibert et al. (2006), found that though therapists were able to form a working alliance it was of poor quality than the alliance formed in face to face studies. Hanley & Reynolds (2009) in their review of the quantitative literature, regarding the therapeutic alliance in online counseling, found that four out of five studies reported a therapeutic alliance that was of greater quality than what the literature reports for face to face counseling.
These findings are not surprising when coupled with the fact that clients have more control over the counseling process and that they tend to disclose sensitive information earlier. One variable that may influence the working relationship with the client is the client’s perception of the therapist. Habersrtoh (2010) found that the use of informal language and commonly used abbreviations and emoticons had a negative effect on client perceptions of the therapist’s professionalism and trust which may lead to a poor quality working alliance.