Therapy Online

A Practical Guide

Kate Anthony, DeeAnna Merz Nagel

• Publisher: SAGE Publications Ltd
• Year: 2009
• Print ISBN: 9780761940807, 9780761940791
• eBook ISBN: 9781446246337
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

"An enjoyable book that helps to bring counselling into the 21st century. Kate and DeeAnna have played a significant role in the development of online therapy and their enthusiasm for the subject matter, and experience as trainers and practitioners, comes through in this informative text."

Terry Hanley, Director of MA in Counselling, University of Manchester

The plethora of online services now available has led to a growing demand for practitioners to look beyond traditional face-to-face therapy and take advantage of the flexibility which email and the Internet can offer them and their clients. This guide gives up-to-the minute information and research, ethical and legal advice, on the practicalities of setting up or joining a service, and the essential therapeutic skills needed to be an effective online therapist.

Writing for an international audience, the authors discuss the issues for practitioners using the Internet today, as well as in the future. Basing their study on published empirical research, they address:

- text-based therapeutic interventions such as email, Internet Relay Chat and forums, from the perspective of different theoretical orientations, illustrated with a full length

case study

- new Ethical Framework for using Technology in Mental Health

- online supervision, online research; group therapy online

- the "business" of setting up in private practice or e-clinics

- other therapeutic uses of technology including use of video therapy, mobile SMS, telephone therapy, Virtual Reality environments, gaming and computerised CBT.

The authoritative guide to all aspects of being an online therapist, this practical text is a vital addition to any therapist?s library. It will also be valuable reading for anyone training to be a counsellor or psychotherapist in our increasingly ?electronic? world.

1

THEORETICAL ASPECTS
OF ONLINE THERAPY

INTRODUCTION

While it may seem elementary, we shall start with consideration of the definition of therapy itself. Many practitioners in the mental health field argue that online therapy is not, in the true sense of the word, psychotherapy or counselling. Penguin’s Dictionary of Psychology offers these definitions:

Counselling: a generic term that is used to cover the several processes of interviewing, testing, guiding, advising, etc. designed to help an individual solve problems, plan for the future, etc….var. counselling. (Reber and Reber, 2001: 162)

Psychotherapy: in the most inclusive sense, the use of absolutely any technique or procedure that has palliative or curative effects upon any mental, emotional, or behavioural disorder. In this general sense, the term is neutral with regard to the theory that may underlie it, the actual procedures and techniques entailed and the form and duration of treatment … in the technical literature the term is properly used only when the treatment is carried out by someone with recognized training and using accepted techniques … the term is often shortened to therapy …’ (Reber and Reber, 2001: 586–7)

Clearly, given these definitions, one can see that therapy delivered online, regardless of ‘techniques entailed’ or the ‘form and duration of treatment’, by a therapist with recognized training, is engaged in the art and practice of counselling and psychotherapy. It is important to bear in mind that online therapy involves a different method of delivery to more traditional methods, but the therapeutic process remains the same.

With that said, this chapter will discuss online therapy from the point of view of three major theoretical orientations, which experience shows work well online, albeit in different ways. The theories we shall concentrate on are psychodynamic perspectives, humanistic perspectives, and using cognitive-behavioural methods. Before even turning on a computer to access the Internet to provide a mental health service, it is vital to understand and appreciate how one’s basic theoretical orientation and beliefs – whether the practitioner provides therapy, welfare, advice-giving or just blogging thoughts for the interest of others – can be apparent as you exist in cyberspace.

There are themes common to all theoretical orientations within mental health, but an important knowledge if one wants to be an online practitioner is that existence in cyberspace requires a full commitment to knowing oneself thoroughly and being able to recognize dynamics that come into play as communication with others without a bodily presence takes place. To put this more simply, it is the ability to be oneself, without posturing or hiding behind words, that is one of the most essential factors in developing a therapeutic relationship when working online. To that end, it is this congruence with the actual self that enables a presence in cyberspace that is as fully part of an ‘I–You’ (Buber, 1923/1970) relationship as would occur when doing client work in the physical world.

When one sits with face-to-face clients, the successful relationship will only be possible if one can, within the boundaries of any therapeutic situation, be oneself. It is using the self to develop a mutual bond of trust and respect that will allow the client to use the relationship to explore their issues and work towards a better understanding of how those issues fit into their lives and can be coped with in order to sustain better mental health. The belief that the good therapeutic relationship between the client and the practitioner is the central element in enabling them to move on with their lives is generally considered to be an accepted position in the current therapy climate (Hick and Bien, 2008), and has a good evidence base in literature review as being the case in over 1,000 studies (Paul and Haugh, 2008).

Examining working in cyberspace from different theoretical perspectives and models is a fascinating process. It is sometimes easy to be sceptical about the modality being a fertile ground to develop a meaningful relationship with another human being or beings, when the relationship is conducted via a keyboard, mouse and screen. Critics of the online relationship as valid still exist (see reader’s responses to Nagel, 2008). And yet,

I believe I am the same person in cyberspace as I am within what is sometimes, paradoxically, called Real Life (RL). The fact that I exist within my writing over the Internet is what is important here, not the fact that I write. I use writing to convey myself to others because it is the easiest form of communication that currently exists on the Internet, just as the simplest form of communication face-to-face is the spoken word. I don’t use technology for my professional work for the sake of using technology; it is just the communication system that works best for me for that client at that time. (Anthony, 2009)

So, that stated, we can move on to consider how our knowledge of therapeutic theory can be applied to working with text, from a humanistic, psychodynamic and cognitive-behavioural perspective. It is for the readers to experience each facet of the theory for themselves as they travel through cyberspace and build their experience of client work, and learn to adjust their own traditional theoretical orientation to allow for the sometimes different meaning that can be brought to the theory when working in a non-traditional setting such as working online. It is an exciting and challenging arena for theorists to explore.

HUMANISTIC PERSPECTIVES

The humanistic, or person-centred, approach to counselling is one of the orientations that sits best with this modality of communicating with a client, for precisely the reasons stated in the introduction to this chapter – its intrinsic belief that it is the client and therapist relationship that is central to the work. In considering the origins of this orientation in the work of Carl Rogers, and his belief in the work being client-led rather than practitioner-led, it is easy to see the correlations with the history of online therapy. This similarity is seen in the modality existing, developing, and growing almost entirely because there is a type of client who demands it, whether for reasons of necessity or preference over face-to-face or telephone work. Online work is usually a client-led experience rather than a referral experience – it is the client’s choice if and how to work in this way.

Mearns and Thorne (1988) point out that person-centred counselling is often patronizingly thought of as an orientation that embodies everything that a good therapist should be anyway, ‘before, that is, they pass on to deploy much more sophisticated techniques which can really deal with the client’s problems’ (p. 5 emphasis in the original). In examining how person-centred or humanistic theory applies to online work before looking at aspects of CBT and psychodynamic theoretical application, it should be stressed that it is the integration of each orientation, as it applies to the professional development of the practitioner, that forms an ethical and effective way of working when using the Internet. One of the central tenets of humanistic work – the therapist’s use of the self – is also central to the online practitioner. In this way, we can see why online work is inappropriate for the novice or inexperienced therapist (Anthony and Goss, 2009) – without the journey to self-acceptance and love that is gained through training, personal therapy and experience in working with clients, it is dangerous to try to create and maintain a solid therapeutic relationship using only text. It is the belief in and love of the self that frees the therapist to convey the core conditions of Rogerian theory in a modality that seems to preclude it at first glance.

When working with text over the Internet, the therapist’s use of a strong, selfknowing persona is what enables the communication to free the client into therapeutic movement towards whichever place in their lives they want to be. The therapist’s trust in what they are experiencing as being valid and important, and conveying this to the client, is central to the work. Obviously, this needs careful choice of words, and usually plenty of clarification, to ensure that the client can feel the accepting and respectful understanding where traditionally it could be conveyed by a look, a gesture, or a tone of voice.

Empathy

One of the core conditions is that the practitioner is not only able to have an empathic understanding of the client, but can also communicate this to the client. When working with text, it seems obvious to state that the communication of empathy seems intensely limited – and indeed, early critics of the method indicated this, suggesting that practitioners were likely only to cut and paste the client’s typing in order to reflect back to them what the client was going through and ‘therapeutic interactions may be reduced to mere advice giving when face-to-face interactions are translated to the electronic medium’ (Pelling and Reynard, 2000: 71). This view negates the concept of what is going on in the text-based therapeutic relationship – that the relationship exists first and foremost, and the technological base for communication is incidental, through necessity or preference. It is often useful to have the ability to use the client’s words verbatim during the work, rather than attempting to paraphrase, sometimes erroneously, a previously expressed comment – but it dismisses the fact that the client is communicating with a human being rather than a computer program.

In many cases where the client has chosen to work online, there is already a sense of isolation in their lives for many different reasons. This could be the wheelchair user whose access to many physical spaces is already limited in a non-wheelchair friendly environment, the client with agoraphobia which means that leaving the house is difficult, or the client who cannot bear to communicate with another human being while being in their physical presence and having to look them in the eye. Being sensitive to clients’ situations and being able to put oneself into their shoes is a skill in itself, already familiar to the reader. But being able to convey this to a client through typed text, and therefore diminishing their sense of being alone, is a skill that takes time and training to develop. This development takes the shape of not only being able to communicate using the written word effectively, but also being able to trust that the empathy felt for the client is correct without the further physical clues that occur when working face-to-face. Furthermore, the client who exists in cyberspace need not be isolated when access to the rest of the world is available to them through technological solutions, and this can often have a positive affect on their lives outside cyberspace, for example, in gaining confidence within relationships. Add to this a therapeutic relationship that contains the core conditions, including empathy, and the client is no longer alone where it counts – in their thoughts and feelings about existing in the world.

Consider this response to a client whose lack of control over her anger leads to her destroying her possessions, and whose violence has led to isolation from friends and family. This client feels vulnerable in the face of her own behaviour and cannot understand why she breaks things and is seen as a person to be afraid of by those she holds close:

It is very difficult when we do not understand why we feel this way. Often we feel frightened, alone and unable to talk about these emotions. Then what can happen is that these feelings all become too much to keep inside … it’s like we need a way of releasing this pain. Sometimes our need to break things can reflect our own sense of feeling a little broken inside. (Brooks, 2003: 2)

This response from the therapist demonstrates how she has put herself in the client’s position and used her empathic skills to reflect back to the client that, not only does she understand, but that the client is also not alone in her feelings. For possibly the first time, another human being has recognized that there is a person who is hurting rather than one who wants to hurt. In addition, these words of empathic understanding now actually have a physical presence in that they exist on a screen and can be printed off and kept, which the client can then re-read when her feelings overwhelm her and know that not only is there someone who understands and supports her, but that she can often stop the behaviour by being able to examine her feelings rather than acting on them violently.

The client who has an empathic online therapist is no longer estranged from the human race. They are understood, have access to that understanding 24 hours a day in the printed word, and know that they are journeying with another human being with the skills and willingness to put themselves in their shoes and work together towards their better mental health. As the relationship grows and the communications flow, online therapists become more sure that their empathic understanding is true and will need less and less to check with the client that they have understood them correctly. In combination with the other core conditions of humanistic therapy, the written therapeutic relationship becomes extraordinarily powerful.

Unconditional positive regard

Conveying the potential for the therapist to have unconditional positive regard for the client is a process that can often start before any communication actually takes place when working online, through the use of the website to explain what this means and what regard the therapist already feels for the website visitor without having met them. This sounds facile, but it is the tone that is taken via the text while writing the website content that can convey this. Many people make the mistake of writing website content for themselves and how they would like to be, rather than being congruent (which we shall come on to) and writing for their potential client, considering the likely state of mind of the potential client. One can convey to the client that one expects to hear issues and problems that the client may feel embarrassed or ashamed of, and that as their therapist, one will think no less of them for having shared those issues. The website can state up front that the visitor is held in the utmost regard, that they are accepted and that there is a space for them to explore themselves and grow from the experience while being safe from being judged or ridiculed.

It is important to remember that the client can carry the therapist’s input, literally, at all times, and therefore the text must be carefully constructed to avoid any ambiguous meaning that the client can use to fuel any self-fulfilling prophecies that she or he may have. Conveying unconditional positive regard throughout the email or IRC session can aid the interpretation of the text around it, which is often misread, unconsciously, to suit the client’s agenda (Goss and Anthony, 2003). Acknowledging the client’s worth and one’s respect for them often renders misinterpreted text as incongruent and so the client will go back and re-read the text to better understand the meaning, as the misinterpreted text does not seem to ‘fit’ with their experience of the therapist thus far. In this way, the regard the practitioner holds for the client and the ability to ensure she or he understands this, underpins the whole tone of the text.

The online disinhibition effect (Suler, 2004), further defined in Chapter 2, often means that the more distressing or uncomfortable issues come up much earlier than they would in face-to-face sessions, and the practitioner may find that they are struggling with this information before they really ‘know’ the client and are able to feel that the unconditional positive regard is inherently in place. This process is crucial to the effectiveness of the therapeutic process – if one is not able to keep the reassurance of understanding and regard in place, the client will feel that they have ‘gone too far’ and they can be lost, since ‘disappearance’ on the Internet is facilitated so easily. It is important to indicate that, in the case of emails and forums, although a word count or length limit is appropriate, it does not mean that the content of the work is limited. Having unconditional positive regard for them means that you can trust that the pertinence of the work will emerge as the relationship grows, and that even where there is uncomfortable work going on at an early stage, this is not only expected, but welcomed.

Many humanistic or person-centred therapists will convey warmth and regard in a variety of physical ways, including smiling, appropriate touching, or leaning towards the client. Chapter 3 will focus on how this is done when working with text, but it is important to point out now that most of the physical tools that the person-centred therapist employs are entirely possible when working without a physical pre...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword Casey Truffo
• Acknowledgements
• Introduction
• 1 Theoretical Aspects of Online Therapy
• 2 Essential Skills and Considerations of Online Therapy
• 3 WorkingWithout a Physical Presence
• 4 Ethical Considerations
• 5 The Business of Online Therapy
• 6 Case Study
• 7 Training Online Therapists
• 8 Supervision, Research and Groups/Couples
• 9 A Look to the Future and Concluding Thoughts
• Index