More and more people are seeking mental health services through web-based computer and smartphone applications, with and without the involvement of trained mental health professionals. As current and future clinical psychologists, we must critically explore the advantages and disadvantages that online mediums pose for our therapy practices as they become infused into healthcare.

What are the major upsides and drawbacks to online therapy from the client’s and therapist’s perspectives?

Saving Time and Space, but Losing Contact Face-to-Face

For clients and therapists, the option to connect online offers numerous advantages by overcoming obstacles related to time and distance.

This means greater accessibility to:

  • Clients living in remote areas with fewer centers offering mental health services
  • Clients with rigid schedules, or lack of means, preventing regular visits to a therapist
  • Clients with physical conditions making travel difficult
  • Clients stigmatized by living with mental illness and discouraged from regularly visiting a therapist
  • Clients who may become highly distressed with the notion of coming face-to-face with strangers, even mental health professionals

For clients with specific needs, online therapy appears to be a boon for accessibility, convenience, and comfort.

However, exclusively engaging in online therapy with your clients has major drawbacks.

For instance, it is possible that some clients (e.g. with depression, or agoraphobia) may become dependent on online interactions instead of face-to-face, which could perpetuate symptoms related to fear of real-life social interactions. When considering online therapy, serious consideration must be given to minimizing any negative impact this mode of delivery might have on the client’s symptoms or their therapeutic trajectory.

Another major drawback is that in an online session, your options to respond to a crisis situation are severely limited. For example, when suspecting suicidal ideation in a client during an online session, you would not be able to directly assist the client in implementing a safety plan or escort them to a clinic or a supportive family member.

The advantages of proximity and safety in conducting face-to-face therapy are lost in the virtual world, and therapists must be mindful of when it is inappropriate to sacrifice these advantages for the purpose of easy access and/or comfort.

Long-Distance Therapeutic Relationships are Hard to Maintain

Many lines of research on psychotherapeutic factors have found the therapeutic relationship, or alliance, to be the single most important factor predicting successful outcomes. This clinical relationship is often characterized by the empathic presence of the therapist, the agreement between client and therapist on tasks and goals, and the building of a bond. One implicit element is the importance of simple social interactions wherein people identify and respond to emotional cues through vocal tones, facial expressions, and body language.

On the surface, clear audio and video quality would be a minimal requirement to have an opportunity to pick up on verbal and nonverbal cues. But is this sufficient for the vital therapeutic element of empathic presence? This may depend on the client’s personality, presenting problems, and the therapist expertise.

Both parties in a web-conference typically have to look at their screen, not into their webcam, to see the other person, which means they cannot make mutual eye contact. Lack of eye contact means losing an important nonverbal cue that shows you are attending to your client and trying to understand them.

Other issues include technical glitches that cause delays or brief interruptions in the audio and video quality. These may seem small but can be consequential if they undermine the therapeutic experience.

Online therapy leaves an important question up in the airwaves: can empathy be carried, and felt, through a mic, speaker, and webcam?

Ultimately, it may require a trial-and-error approach to find out whether a relationship based on online interactions can work for you and your client. Research on the relationship between therapeutic alliance and web-based interventions is mixed [1, 2], and more comparison studies of online and face-to-face therapy are needed.

It is possible that there are hidden relationship strengthening factors in using online platforms given the many ways it allows people to connect.

This brings us to the final major consideration for the conduct of online therapy…

Therapy on Demand

If you and your client choose to embrace online therapy, you can potentially broaden your channels of communication to include text messaging, emails, and the sharing of multimedia content.

This could materialize as:

  • Exchanging supportive text messages outside of therapy sessions
  • Brief email updates on between-session progress
  • Exchanging relevant audiovisual content

While these activities may be beneficial to the therapeutic process and relationship, they raise issues of unclear boundaries and limits of confidentiality.

It may become ambiguous or difficult to manage the range of communications with your client, and extending these courtesies may prompt inappropriate expectations in the realm of social media. Furthermore, in an age where private online content leaks are commonplace, the exchange of sensitive content on the web or in text messaging is a risky move for therapeutic relationships.

Interestingly, text-based communication has arguably become the dominant avenue of communication in this day and age, prompting attempts to make mental health care follow suit.

Web-based and smartphone applications such as Talkspace, BetterHelp, and 7 Cups of Tea offer live chats and text-based connection with a therapist or supportive listener. Their greatest selling points are (1) quick, private access to mental aid and (2) cost-efficiency. However, there is currently little empirical evidence for their effectiveness.

Some clients of the millennial and future generations will want their therapy on-the-go, preferably on their computer or smartphone.

There is a high likelihood that the more society adapts to living seamlessly through internet and smartphone technology, the more individuals will want their therapy delivered through these mediums. While text-based therapy platforms have attracted a range of mental health professionals, many are understandably skeptical and concerned about their use.

Some clients and therapists may appreciate the ability to exchange well thought-out, carefully worded messages and take their time to understand a message before responding.

On the other hand, text-based therapy completely eliminates non-verbal cues, rendering both clients and therapists with only the words on the screen with which to recognize emotional expressions or reactions (emojis notwithstanding). This places considerable restrictions on empathic responding and limits how well the two parties can get to understand each other’s personalities and intended meanings so that they can work together effectively.

As a client, it is impossible to replace the presence of a highly trained, attentive, and compassionate professional in front of you while undergoing therapy. And as a therapist, it is vital to be able to notice your client’s behaviors and reactions and also extend warm, empathic support through your presence.

Nonetheless, online therapy introduces new and exciting possibilities of connecting and working with clients of all kinds all over the world.

As there is currently no standard mode or model for administering internet-based psychological interventions; your decision on when and how to offer online therapy must be dealt with on a case-by-case basis.

References

[1] Cuijpers, P., Van Straten, A., & Andersson, G. (2008). Internet-administered cognitive behavior therapy for health problems: a systematic review. Journal of behavioral medicine31(2), 169-177.[2] Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J., Brackman, E. H., & Montgomery, G. H. (2012). The therapeutic relationship in e-therapy for mental health: a systematic review. Journal of Medical Internet Research,14(4), e110.

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Abid Azam

Abid Azam, (PhD candidate), is completing his doctorate in Clinical Psychology at York University, Toronto, Canada. He is currently a Research Trainee at the Toronto General Hospital (TGH) conducting research for his dissertation on the psychophysiological and psychosocial risk factors for the development of chronic pain after surgery. He is also a member of the Transitional Pain Service at TGH working on developing a perioperative intervention using Acceptance and Commitment Therapy to provide patients with cognitive-behavioral skills to prevent chronic postsurgical pain and long-term opioid dependence. He is a trained mindfulness leader and advocate of university student mental health, previously serving as president of the Healthy Student Initiative at York University. His professional affiliations include trainee memberships with the International Association for the Study of Pain and the Association for Contextual & Behavioral Science.

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