Introduction
The online environment has grown to become a much more important component of human communication in the last twenty years. Due to the advances and improvements in new technologies, computer mediated communication (CMC) is here to stay. More and more relationships are established and developed in cyberspace (Suler, 2003). The clientātherapist relationship, as a special human relationship, has not been immune to this trend. The integration between new technologies and psychotherapy has given way to online mental health delivery and e-therapy has become a convenient way to improve peopleās access to psychological support (Barak, Klein, and Proudfoot, 2009; Griffiths, Farrer, and Christensen, 2007; Casey, Joy, and Clough, 2013). Moreover, researchers have found that clients who feel stigmatised by their psychological condition are more likely to seek help online than in a face-to-face context (Castelnuovo, Gaggioli, Mantovani, and Riva, 2003). Affordability and cost-efficiency have also been highlighted as an advantage of e-therapy (Manhal-Baugus, 2001; Wells, Mitchell, Finkelhor, and Becker-Blease, 2007).
E-therapy: a new challenge
E-therapy has special characteristics and differences with traditional interventions and this fact has raised several concerns among professionals. Confidentiality and privacy, effectiveness of online treatments, and the quality of the relationship established through CMC are major issues regarding the provision of mental health support over the Internet (Perle, Langsam, Randel, and Lutchman, 2013; Barak et al., 2009; Wells et al., 2007; McClure, Livingston, Livingston, and Gage, 2005; Young, 2005; Castelnuovo et al., 2003).
New organisations such as ISMHO (International Society for Mental Health Online, http://ismho.org) have been created to deal with specific issues of online practice and several professional associations worldwide have provided ethical and professional guidelines and advice to their members on therapeutic interventions online (APA, 2010).
There are a number of different modalities to deliver e-therapy:
ā¢Email: time-delayed (asynchronous) and text-based communication. Non-verbal information is not available.
ā¢Videoconference: real-time (synchronous) and oral communication. There are some non-verbal cues available.
ā¢Real time chats: synchronous and text-based communication. Non-verbal cues are absent. Childline.ie and Drugs.ie are examples of live chats services in Ireland.
ā¢Web-based interventions: standard self-help programmes usually used as an adjunct to therapy or as a substitute when psychological support is not available. Examples are www.getselfhelp.co.uk, www.moodgym.anu.edu.au, or www.calmerseries.com. Non-verbal cues are absent.
The research to date has shown that online interventions can have potential benefits for specific types of clients and disorders (Perle et al., 2013; Germain, Marchand, Bouchard, and Guay, 2010). The majority of the psychologists and mental health practitioners studied have a negative attitude towards online interventions, and declare that they would not provide psychological support online (Perle et al., 2013; Casey et al., 2013; Wells et al., 2007). Data from recent studies suggests that the professionalsā negative perception of online interventions and its consequent low use, may be related to the scarcity of sound evidence regarding e-therapy and its potential benefits compared to face-to face interventions (Wells et al., 2007). Clinicians are in urgent need of good research in the field to provide evidence on the advantages and disadvantages of this method of delivering psychological treatments, and its impact in the quality of the therapeutic relationship and in the treatmentās outcomes.Specifically, findings of some studies have outlined that clients are ready to make use of these new tools, and have a positive attitude towards them. In fact, they report the establishment of a strong and positive therapeutic relationship in online interventions (Knaevelsrud and Maercker, 2007; Young, 2005).
One of the challenges current research should be able to face is to understand how therapists and clients establish a therapeutic relationship in the absence of non-verbal cues when therapy is delivered via text-based communication. Since early online interventions, email has been the most used modality online. Surprisingly, there are very few studies investigating whether it is possible to build a positive therapeutic relationship via email in the absence of non-verbal cues; most of the studies conducted have used small samples of inexperienced therapists due to the difficulty of finding a large and experienced number of therapists using email as a tool (Perle et al., 2013; Wangberg, Gammon, and Spitznogle, 2007; Rochlen, Zack, and Speyer, 2004).
The importance of the therapeutic relationship
There is consistent evidence of the link between a good therapeutic relationship and positive treatment outcomes (Norcross, 2002; Horvath and Bedi, 2002). Findings of some studies suggest that the therapeutic relationship accounts for nearly 30 per cent of the therapeutic outcome across all theoretical approaches (Fletcher-Tomenius and Vossler, 2009; Sexton, Littauer, Sexton, and Tommeras, 2005). Since early research on the topic, there has been a widespread consensus among researchers and clinicians about the importance of establishing and developing a positive relationship with the client in the therapeutic process. For the purpose of this study, the authors adhere to Cahillās model of the elements of the therapeutic relationship (Hardy, Cahill, and Barkham, 2007). This describes empathy, warmth, closeness, trust, genuineness, commitment, and agreement on goals as relevant components to the establishment, development, and maintenance of a positive therapeutic relationship.
The role of non-verbal behaviour in the conveyance of the above elements has consistently been highlighted in the academic literature and research. Findings in face-to-face communication and CMC research stress the role of non-verbal cues to communicate emotions and affection (Riordan and Kreuz, 2010), as well as closeness, immediacy, and intimacy (Kim, Frank, and Kim, 2014). Some of the studies claim that non-verbal communication might account for more of a receiverās perception of empathy, warmth and closeness than verbal communication does (Riordan and Kreuz, 2010).
E-therapy, e-mail therapy and the therapeutic relationship
When it comes to text-based interventions online, the question is whether it is possible to build a positive and strong therapeutic relationship in the absence of the non-verbal cues and the subtleties that characterise face-to-face communication. How do therapists perceive the emotional state of their clients, or the emotional relevance of some issues in the absence of non-verbal behavioural information?
Several studies have examined the impact of the lack of non-verbal cues in the conveying of acceptance, closeness and empathy. Riordan and Kreuz (2010) advised of the risk of ambiguousness and misunderstandings when non-verbal cues are absent but, at the same time, the findings of their study supported the claim that users adapt themselves to the lack of these cues and develop strategies to overcome this limitation. Kim, Frank, and Kim (2014) reported similar results on their study about emotional behaviour display in CMC. Acknowledging the difficulties of transmitting psychological closeness when non-verbal elements are absent, their results supported the claim that people have developed conventionalised expressions and paralinguistic cues to convey emotions and closeness.
Other studiesā findings, though, suggested that when users have less non-verbal information, they experience a sense of psychological distance and uncertainty that prevents disclosure and sharing (Kotlyar and Ariely, 2013; Barak and Gluck-Ofri, 2007). Some have also raised concerns about the capacity to convey the most relevant features of a therapeutic relationship in absence of non-verbal cues in online text-based communication (Dogg-Helagadottir, Menzies, Onslow, Packman, and OāBrien, 2009).
Results of research on the building of the therapeutic bond in text-based CMC do not seem to support those concerns. Barak, Klein, and Proudfoot (2009) concluded in their review of e-interventions that a good therapeutic relationship could be achieved online. Cook and Doyle (2002) reported no significant differences in the therapeutic bond between online therapy and face-to face therapy. Further studies seemed to support the claim that clients receiving treatments online can build a strong and positive relationship with their therapist (Yuen, Goetter, Herbert, and Forman, 2012; Germain et al., 2010; Kraevelsrud and Maercker, 2007). Roy and Gillet (2008), in their study about high-risk young people, found that email therapy was the only way to establish and develop a therapeutic alliance with a teenager who was difficult to communicate and work with. Moreover, experienced online therapists described the potential difficulties in establishing a strong therapeutic relationship in online text therapy as a myth (Fenichel, Suler, Barak, Zelvin, and Jones, 2002).
Rochlen, Zack, and Speyer (2004) and Manhal-Baugus (2001) conducted two studies where they made a systematic review of the advantages and disadvantages of online text-based therapy. From the therapistsā perspective, potential benefits mentioned were the opportunity to pay close attention to the communication process and enhance the qualities of a positive therapeutic relationship (Rochen et al., 2004); and the possibility of keeping a record of email exchanges between client and therapist that can be used to track the clientās progress or as reminders. Important limitations highlighted were incorrect assumptions or misunderstandings due to the absence of non-verbal and contextual cues, and the need for writing and technological skills to conduct email therapy. More recently, Sucala et al. (2013) made a review of the scarce current literature on the building of a therapeutic relationship online and reported that the results showed no significant differences between the therapeutic bond in text-based interventions and face-to-face interventions. More recently, Reynolds, Stiles, Bailer and Hughes (2013) found that clients and therapists rated the therapeutic relationship as equally strong or stronger in text-based communication than in face-to-face communication.
In summary, the research on the impact of asynchronous and text-based communication on the therapeutic relationship shows promising results, but it is scarce, and has focused mainly on the quality of the therapeutic relationship from the clientās perspective. Only three of the fifty-two studies reviewed referred to the therapistās perspective and, although there are some findings about the quality of the therapeutic relationship, there were none found which sought to address how therapists establish a strong therapeutic relationship in the absence of nonverbal information. The little research available also has important limitations: small sample size, recruitment problems, narrow demographic information, and the use of inexperienced therapists are the most salient. Every research effort in this field contributes to a better empirical knowledge of this phenomenon and will allow professionals to objectively assess the benefits and limitations of computer text-based therapies. The analysis of the therapistsā experience will provide useful information on how to deal with the special characteristics of email therapy.
