Does online counselling work?
Ever since deciding to move my practice from Vancouver to the Comox Valley, I’ve gone back and forth on the idea of offering online counselling. Will it work? Will I be able to be as effective for my clients as I am in person? How do I make sure to uphold our rigorous privacy standards? Luckily, I am not the first to wonder these things. Here’s what the research says about online counselling:
Benefits of Online Counselling
Accessibility. Conducting counselling online means that specialized psychological services are available to a much wider range of people. There may not be a counsellor in your town who can help with relationships, for example, or OCD. Try telling the new mom who suspects she has post-partum depression that she should take a couple hours to head across town for some therapy! Online mental health services are not limited to a specific time and/or place, giving clients in even remote areas unprecedented access to everything from general counselling to highly specialized treatment. Folks who take advantage of online counselling may need it for the very reason they would need to speak to a counsellor - they have phobias or anxieties that prevent them from leaving the house. Interestingly, the gender disparity that is represented in attitudes towards traditional counselling (i.e., women view counselling more favourably) is not represented when studying attitudes towards online counselling: surveys show men are at least as positive towards online counselling as women.
Disinhibition. You may be more likely to disclose and/or disclose more quickly due to the disinhibiting effect that online interactions have. Some things are just easier to say when you’re alone! Especially in asynchronous communication (counselling over email or chat), clients can attend counselling without worrying that they will be discriminated against because of their gender, sexual orientation, age, race, or physical appearance. Without this anxiety, and without anyone else around them, clients may feel able to express themselves in text in ways that they would not express themselves in person. In fact, the research shows that the mechanism of change may be slightly different in online counselling, whether by video or by text. Whereas research shows us that the therapeutic alliance is a major part of change in traditional counselling, that may be outweighed by the depth of emotional experience that can be achieved when clients feel more disinhibited, as in online counselling. That clients a) receive counselling despite the fact that they might never go in person and b) express themselves in a way they normally do not means that online counselling provides an emotional advantage that offsets the loss of social cues.
Positive outcomes. There are no statistically significant differences in satisfaction rates between online and traditional counselling. Contrary to what might be assumed, online clients report an effective therapeutic alliance: they still feel close to and understood by their counsellor, even when not in the same room. Studies show that online counselling may be more effective than face-to-face counselling whenever you find clients who have trouble reaching out for help - people who are socially isolated; people with physical disabilities; people who self-report high social stigma regarding going to counselling. Online counselling has also proven particularly effective in the treatment of eating disorders, where early promising studies led to a research trend and a subsequent wealth of data. For these clients, the most beneficial counselling relationship is the one they can form online.
Risks of Online Counselling
Therapeutic relationship. Research conducted in the 1980s and 1990s concluded that if a cohesive therapeutic relationship is not present in face-to-face counselling, clients are much less likely to achieve their counselling goals. It is understandable, then, that many people are wary of online counselling because of the perceived lack of therapeutic relationship - that personal, physical presence that they are looking for. Good online counselling is able to translate this presence to the screen.
Loss of social cues. Researchers believe that the online therapeutic relationship is most at risk due to the loss of non-verbal social cues that are usually exchanged between client and counsellor. Counsellors may seize on a therapeutic moment when they see clients shift, cry, or raise their volume; similarly, clients may sense empathy when they see their counsellor lean forward, tilt their head, or soften their tone. How the lack of social cues impacts the therapeutic process seems to depend on the client. Some clients are better at conveying and interpreting emotional expression through online counselling; for others, their counsellor may recommend that in-person counselling is the best fit.
Confidentiality and privacy. In Finn and Barak’s (2010) survey of practitioner attitudes towards online counselling, only 62% reported confidence in their ability to maintain their online client’s confidentiality. Emails can be forwarded or copied; videos can be recorded; phone calls can be overheard. Your counsellor loses control over the privacy of the counselling space when you aren’t sitting in their office.
Technological know-how. It’s important for both client and counsellor to be technologically proficient enough to actually conduct counselling online. And what if the internet goes down? Expectations need to be set ahead of time to make sure everyone’s on the same page if technology breaks down.
Keeping on top of the research surrounding online counselling means that I can offer it to my clients in a confident, safe, and effective manner. I’ve had to tell some clients that they aren’t a good fit for online (or even phone) counselling, as one or both of us is lacking the necessary emotional connection. I’ve also had to make sure that the technology I use is in line with professional and legal guidelines for maintaining clients’ health records - the program I use for video counselling, Zoom, has a server based in Canada. Overall I’m loving online counselling, and clients tell me they appreciate how surprisingly “normal” it feels!
References
Baker, K. D., & Ray, M. (2011). Online counseling: The good, the bad, and the possibilities. Counselling Psychology Quarterly, 24(4), 341–346.
Canadian Psychological Association. (2006). Draft ethical guidelines for psychologists providing psychological services via electronic media. Retrieved from http://www.cpa.ca/aboutcpa/committees/ethics/psychserviceselectronically
Finn, J., & Barak, A. (2010). A descriptive study of e-counsellor attitudes, ethics, and practice. Counselling and Psychotherapy Research, 10(4), 268–277.
Gamble, N., Boyle, C., & Morris, Z. A. (2015). Ethical practice in telepsychology. Australian Psychologist, 50(4), 292–298.
Harris, B., & Birnbaum, R. (2015). Ethical and legal implications on the use of technology in counselling. Clinical Social Work Journal, 43(2), 133–141.
Richards, D., & Viganó, N. (2013). Online counseling: A narrative and critical review of the literature. Journal of Clinical Psychology, 69(9), 994–1011.
Rummell, C. M., & Joyce, N. R. (2010). “So wat do u want to wrk on 2day?”: The ethical implications of online counseling. Ethics & Behavior, 20(6), 482–496.