04 Sep

How does meeting online impact the therapeutic relationship? by Kate Dunn

THERAPY TODAY
Volume 22
Issue 8
October 2011

A BACP seed corn research project explores the effects of meeting online on the therapeutic encounter and relationship

Online counselling has been developing rapidly in recent years. It reflects the technological age in which we live, embracing the opportunities that computerisation offers for diversifying and extending modes of communication between client and counsellor. It has wide-ranging applications, from asynchronous text-based interaction to live chat, perhaps involving a web-cam, or even virtual representation through a meeting of avatars. There can be a tendency in the technological world to ‘improve and update’ continuously, with things moving so fast that we may sometimes fail to fully appreciate the richness and distinctiveness of a particular application, unless we stop and consider it more slowly and in more detail.A study, supported by BACP seed corn research funding, has been made of one of the earlier applications of online counselling – asynchronous counselling by email – with the aim of increasing our understanding of the therapeutic relationship as it emerges within this specific approach and considering its implications for wider practice. It is hoped that the findings may help those involved in the design of innovative online resources to recognise where particular and unique benefits exist for clients and counsellors and to keep these firmly in mind whilst developing ever-more sophisticated technological tools and programs.

Background
In 2007 we piloted the provision of brief asynchronous online counselling (through the exchange of up to eight weekly emails) in the university counselling service where I work. This was introduced to extend counselling opportunities to students who might be away from the university for practical reasons, such as being distance learners or away on placement. At the same time it was also hoped that it might appeal to some who could be reluctant to attend face-to-face (f2f) sessions for reasons of shame, stigma or embarrassment. In 2007 Walker1 suggested that online counselling offers potentially new opportunities for those ‘silently suffering, often in extreme distress, who desperately need services that do not exist and who rarely find a voice through research projects’ (p60).

The response to the pilot was encouraging and I was moved by the frequency with which students expressed strong, positive feelings about the whole process of email counselling and particularly the therapeutic relationship and changes that they felt resulted from this. The majority requesting email counselling stated that they would not have approached f2f services, usually for the reasons suggested above. I became aware of a number of instances where a small number of email exchanges led initially-reluctant clients to request a f2f meeting, a suggestion not necessarily initiated by their online counsellor. The pilot scheme was extended and developed and I became eager to research these interactions more formally, as they indicated that some of the students responding represented exactly the group described by Walker.

Research has indicated that working alliances in online counselling can be as strong as those in f2f services.2, 3 It has also been suggested that there are particular features of online text-based counselling that are unique to that process and offer something which may be facilitative in a different way from anything that occurs in f2f counselling.4 Features such as ‘disinhibition’ and ‘telepresence’ have been already identified as significant.5 It seemed from things that they had written to me that my online clients shared my curiosity about these and other phenomena and this encouraged me to consider undertaking a reflexive and qualitative exploration into their experiences.

Method
Practitioner research studies understandably present considerable ethical challenges for the researcher. They also offer unique opportunities for valuable collaboration and investigation, as stressed by McLeod.6 It felt important to me to offer these clients a chance to have their voices heard and feelings more widely acknowledged by further exploring their experiences with them directly. Taking heed of Bond7 and with support from the research department at BACP, I devised a qualitative interview methodology that preserved the anonymity of these former client participants even from me as their researcher and that, through its delivery by email, mirrored the medium of communication that had been used for their counselling (full details of the research process are available from the author). In order to reduce the bias and limitations that would inevitably arise if I limited the research only to my own practice, I also approached counsellors delivering email counselling in other university services to see if they would be interested in reflecting on their experiences of the process and relationships in their online work. Ten former clients and six online counsellors subsequently completed a two-stage semi-structured interview process and the interviews were then analysed using interpretative phenomenological analysis (IPA) as developed by Smith et al.8 (This methodology enables the respondents to become co-researchers within a mutual search for meaning, creating a shared narrative. It is a heuristic method of enquiry resulting from a social constructionist and postmodern ontological approach. It is inductive rather than deductive and seeks to construct rather than break down ways of understanding the experience.)

Findings
Four main areas of focus emerged within the study: the situation and process of the counselling, thinking and feeling while contemplating or engaged in counselling, self and relationship in and out of counselling, and change through counselling. These were considered at three stages: before, during and after email counselling.

Within the first area of focus, participants stressed the value of anonymity and the openness that arises from the disinhibitory nature of the medium, emphasising the role these things have in helping to overcome feelings of shame and embarrassment. The ‘location’ and ‘situation’ of the counselling were explored (with participants highlighting the value of imagination and fantasy and identifying a feeling of control) and these factors were considered alongside the importance given to boundary-setting, security and confidentiality. The existence of a permanent record of all that has been said was noted by clients as being invaluable and reassuring; it added a depth and permanence to the process that, for some, surpassed the transience of the f2f encounter.

‘One of the best things about email counselling… is that you can read back over the reply again and again. This helped me and I did it a lot…’

Within the second area of focus, an extremely important factor for clients and counsellors was having ‘time to think’, something repeatedly mentioned. It seemed to empower the participants:

‘The additional time allowed me to consider what was being said… I have a tendency in life to snap and say the first thing that comes into my head…’

‘I also liked the way that I was not expected to reply … the same day… it helped that I had a week to think about what was being said…’

Anonymity, coupled with this greater control over thinking space and time, helped clients to overcome feelings of shame and embarrassment. This led to increased self-monitoring which enhanced reflective processes.

When considering self and relationship, feelings of increased power, control and choice were repeatedly described. These led to mutuality, collaboration and trust, something subsequently borne out by the client participants’ eagerness to participate in the research. Friendship between counsellor and client was often described, despite the anonymity and asynchronous nature of the relationship. (Heightened self-consciousness and low self-confidence in interpersonal situations were frequently cited as the predominant reasons for seeking online rather than f2f counselling.)

Consideration of the possibility of meeting in person and what this might mean for both client and counsellor prompted varied responses. Some online counsellors choose not to meet any of their clients f2f, preferring to preserve the online relationship alone. However, half of the client participants who responded to the study were those for whom at least one f2f meeting had occurred and client feelings about this were wide ranging:

‘I thought it would make us seem closer… I met the counsellor at the last session and this strengthened the relationship… I thought (it) made it better and more honest…’

‘…it made the experience a lot more real to me…’

‘…I had been picturing her completely wrong! …she was a big help and seeing her in person made no difference to that…’

One online counsellor described how moving from f2f to online counselling had helped a deeply traumatised client to express in words aspects of her experience that had proved overwhelming in the f2f relationship. The change in both medium and relationship seemed crucial in helping this young woman.

Focusing on change, participants described behavioural, emotional and relational changes which occurred during and after their email counselling as well as the development of new insight into self and relationships. Many also referred to their counselling as a period of transition:

‘Soon after the counselling, I met some great friends at university and my life changed dramatically, which I am sure the counselling contributed to.’

Discussion
This study is limited in scope and targets a specific client group who are generally familiar with and positive about technological modes of communication. A third of those clients contacted offered to participate; this felt like a significantly high proportion and suggested powerful responses to their online counselling experiences which were predominately very positive. It would be wrong to generalise these findings to the general population, however this group may give an insight into what could be possible for others if offered opportunities to engage in online counselling. The asynchronous approach explored here clearly overcame barriers for clients by providing safety, control, anonymity, disinhibition, time to think and a permanent record of their engagement in counselling.

Counselling online offered transitional space for clients within the therapeutic relationship which felt particularly relevant for this young client group at their particular developmental stage. Their sense of identity both intra- and interpersonally may be undergoing considerable transformation, which can lead to confusion and distress. It was clear that for some, this transitional space provided a stepping stone which helped them progress towards a position of being able to speak aloud about inner feelings and to ‘bear’ the presence in the room of the other person; indeed for some, it created a desire for meeting.

The place of fantasy and creative use of imagery and metaphor within online counselling may be an area worthy of further exploration. Participants felt strongly that both elements enriched their overall experience. It is possible that online counselling may help in the development of mentalisation skills, thus stimulating activity in particular neurological pathways which can lead an individual towards greater psychological wellbeing and maturity.9 Within the counselling relationship, the idealisation of the internal image held of the counsellor, followed by a meeting with an all-too-human, real-life individual, who is nonetheless the same person, may help in the acceptance of relationships and people who are ‘good enough’ both now and in the future.

Future research might target clients for whom online counselling proves to be unhelpful or who reject it from the outset; this project failed to attract participants from these groups, who could provide further helpful information about online therapy and a balancing viewpoint.

It could also be interesting to explore whether this approach might have potential for cross-cultural application, helping clients to overcome practical barriers of location, time and language at the same time as facilitating therapeutic relationships which might otherwise prove challenging or impossible in a f2f setting.

It is important, when developing new technological approaches, to recognise which specific features of these approaches impact positively on therapy, and how; and to capitalise on these at the same time as striving to minimise the shortcomings created by the lack of physical presence as it occurs in the f2f encounter.

Kate Dunn is a counsellor at the University of Portsmouth. Email kate.dunn@port.ac.uk

References:
1. Walker M. Mental health treatment online. Digital Inclusion Team commissioned report. November 2007.
2. Hanley T, Reynolds DJ. Counselling Psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy. Counselling Psychology Review 2009; 24(2):4-12.
3. Cook J, Doyle C . Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. Cyberpsychology and Behaviour 2002; 5 (2): 95-105.
4. Fenichel M et al. Myths and realities of online clinical work. Observations on the phemomena of online behavior, experience and therapeutic relationships. A 3rd year report from ISMHO’s Clinical Case Study Group 2002. [Online] Available from: http://www.fenichel.com/myths.
5. Fink J. How to use computers and cyberspace in the clinical practice of psychotherapy. Northvale, NJ: Aronson; 1999.
6. McLeod J. Doing counselling research. London: Sage; 2003.
7. Bond T. Ethical guidelines for researching counselling and psychotherapy. Rugby: British Association for Counselling & Psychotherapy; 2004.
8. Smith J, Flowers P, Larkin M. Interpretative phenomenological analysis. London: Sage; 2009.
9. Allen J, Fonagy P, Bateman W. Mentalizing in clinical practice. Arlington, USA: American Psychiatric Publishing; 2008.