The future is upon us, particularly in how we provide counseling.
Since the dawn of psychology, geographical obstacles have been a hurdle for effective counseling.
Throughout the decades, many mental health practitioners used technology to overcome geographical distance to reach their clients. This has included letter writing, telephone counseling, and online technology such as email (Robinson & Serfaty, 2001; Castelnuovo, Gaggioli, & Riva, 2001).
Even videoconferencing was researched for group counseling as far back as 1961 (Wittson, Afflect, & Johnson, 1961).
With a variety of technological options available, plus a global population desperate for a safe alternative to face-to-face consultations, the online counseling vision of the future is here. Now is the time when online counseling is making its mark, and we dive into this fascinating topic by providing you a short overview, recommendations, and software you can use in your practice.
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This Article Contains:
- What Is Online Counseling?
- Does It Work? A Look at the Science
- Blended Care Approaches Using Quenza
- 7 Proven Benefits of Online Counseling
- The Disadvantages
- Online Counseling vs Face-to-Face Counseling
- How to Do Online Counseling
- Ethical Considerations
- Useful Software for Your Online Practice
- A Look at Group Online Counseling
- A Take-Home Message
What Is Online Counseling?
Online counseling has been defined by Richards and Vigano (2013) as:
The delivery of therapeutic interventions in cyberspace where the communication between a trained professional counselor and client(s) is facilitated using computer-mediated communication (CMC) technologies, provided as a stand-alone service or as an adjunct to other therapeutic interventions.
It can include email therapy, facilitating asynchronous communication between therapist and client (Richards & Timulak, 2013), or chat-based services, enabling synchronous, real-time communication (Dowling & Rickwood, 2013).
Videoconferencing technology within the online counseling space is something we may have some familiarity with. Have you ever used Skype or Zoom to chat with family members, friends, or work colleagues?
These are the same applications used in online counseling. Formally, videoconferencing counseling tools can be defined as “synchronous, real-time video chat interfaces that allow for both video and auditory information to be shared concurrently across geographical distances” (Backhaus et al., 2012).
Does It Work? A Look at the Science
If each individual’s experience of online counseling is subjective, how could it possibly be measured to see if it works or is effective?
Its effectiveness may depend on the type of treatment being used, such as Cognitive-Behavioral Therapy (CBT) or psychodynamic psychotherapy, as well as the type of setting.
Researchers Andersson and Titov (2014) discuss that online counseling, specifically chat-based counseling, can be ideal for those in outpatient settings with anxiety disorders, body image concerns, or social phobias who need further personal growth and fulfillment. However, they suggest that it may not be appropriate for those hospitalized with psychiatric disorders.
The key point is that online counseling can be most effective for those clients who wish to improve from an already higher functioning state.
Therapeutic alliance has been studied to show online counseling’s effectiveness. This concept goes back decades and shows how well a client and therapist establish rapport to begin therapy (Rees & Haythontwaite, 2004).
There is a concern that a therapeutic alliance won’t be established because of the computerized, remote environment. It could be difficult to facilitate warmth and empathy with a client because of their unfamiliarity with technology, whether using a smartphone or desktop software (Rees & Stone, 2005).
Further, while engaging in a range of interventions from psychoanalytic work to hypnotic work, nonverbal cues were hindered when young and elderly people engaged with videoconferencing therapy (Simpson, Deans, & Brebner, 2001; Simpson, Morrow, Jones, Ferguson, & Brebner, 2002).
Cipolletta, Frassoni, and Faccio (2017) analyzed conversations of therapy sessions in Italy to determine if they established therapeutic alliances. They found that while videoconferencing was seen as positive from the client’s point of view, it was not without issues, including lack of motivation to use the technology following internet connectivity issues.
From what science says about online counseling to its practical application, let’s look at the benefits and disadvantages of engaging in online counseling.
Blended Care Approaches Using Quenza
Given the pros and cons of online counseling, many therapists have adopted a blended care approach to working with their clients to leverage the benefits of face-to-face contact and new digital technologies.
Blended care involves a mixture of online therapy (e-therapy) and in-person treatment.
The thinking underlying this approach is that psychological treatment can be made more accessible by delivering at least part of an intervention online.
For instance, many therapists will conduct face-to-face counseling sessions with their clients but supplement them with activities that clients can complete digitally and in their own time. Quenza is one such tool that can facilitate this blended care approach.
As an example, the therapist has designed a reflection exercise in Quenza for the client to complete following their in-person therapy session.
Other examples of a blended care approach might be if the therapist were to invite their client to complete self-paced educational modules based on the aims of the therapy, such as on topics like mindful breathing or boundary-setting.
Using Quenza, the therapist may then combine these modules into a unified pathway for the client to complete over several weeks, with automatically scheduled reminders for the client and deadlines that both the therapist and client can track via Quenza’s smartphone or desktop app.
This is just a few examples of how you might integrate a blended care approach into your counseling practice using a platform like Quenza.
7 Proven Benefits of Online Counseling
When seeing a therapist in person, clients can fear that while commuting to the session, an acquaintance may spot them (Ebert et al., 2016).
Anonymity, particularly when clients don’t have to travel or risk being seen, can contribute to a client’s sense of empowerment. These clients may have otherwise avoided seeking counseling.
2. Flexible appointments
Clients often feel stressed when trying to attend a therapy session because of work or family obligations. Flexibility is key, and this particularly applies to online counseling sessions either in the morning or throughout the evening. The adaptability of online counseling is a vital benefit for both therapist and client alike (Schuster, Pokorny, Berger, Topoco, & Laireiter, 2018).
An additional benefit of timing flexibility is that it gives the therapist more time to prepare for sessions. The same applies to the client, who can now optimally use their time and not waste it commuting.
3. Bridging distances
Particularly in the world of videoconferencing counseling, despite therapy being conducted at a distance, the client can feel more connected (Janssen et al., 2015).
Why? Even when looking at a therapist through a computer screen, the client can be reminded of an in-person session through eye contact and the therapist’s undivided attention.
4. Helping underserved populations
Online counseling enables therapists to save time and travel costs, which affect the practice’s bottom line. More therapists can now offer reduced-cost sessions, particularly to low-income populations. This can aid public sector services that would normally see underserved populations (Kleiboer et al., 2015).
It is important to note that underserved populations include those who cannot travel to therapy, such as clients in home care and with disabilities.
5. Cost saving
Cost-saving benefits apply to both the therapist and client. Although saving on transportation costs is an obvious benefit, another cost-saving benefit for the therapist is tax deductions. If the practitioner works from home, electric or gas bills can often be written off.
If a practitioner transitions to full-time online counseling, they can give up their office rental and reduce the need for administrative staff.
Inadvertently, online counseling encourages therapists to streamline administrative work, moving from offline paperwork and storing cabinets full of documents to digitalized storage (Vincent, Barnett, Killpack, Sehgal, & Swinden, 2017).
Traditionally, a therapist would have clinical notes and accounting records on paper. As more therapists engage in online counseling, new practice management software has led to wider information sharing among physicians and therapists (with client consent). In addition, information pertaining to past and current treatment of clients can be accessed more quickly.
7. Device portability
Having sessions on different devices can be extremely valuable to clients and therapists. Think about all the technology around you today: your mobile phone, computer, tablet, and TV. These are all devices that can be used in online counseling.
A client can access their therapist from their mobile phone while at home, from a computer screen while at the office, and a TV or tablet during a family therapy session. In essence, the therapist’s office is always within reach.
There are a few disadvantages with online counseling, irrespective of the medium used.
1. Missing problems in the therapeutic process
Since this process differs depending on the type of therapy, problems can occur.
With CBT, where homework is often assigned to clients, a missing element is the in-person explanation of how to complete homework. Also, therapeutic processes can be slowed by the client not receiving the homework in the first place (Lundgren et al., 2016).
When engaging in person-centered counseling, a therapeutic alliance can be more difficult to achieve online. Key factors, including unconditional positive regard and congruence that comes through the use of eye contact and witnessing verbal cues, can get lost in online counseling, particularly when engaging over email and chat (Reese et al., 2016).
2. Data security
Data security issues, particularly with sending and receiving clients’ homework containing sensitive information, can lead to anxiety. Both the therapist and client may be unsure if sensitive, confidential information was received and stayed secure (Salleh, Hamzah, Nordin, Ghavifekr, & Namyandeh, 2015).
Some have also questioned whether sessions or data sent on videoconferencing platforms are secure (Conway & O’Connor, 2016).
These disadvantages and collective anxiety can be mitigated when seeing the client in person, as data is physically handed between therapist and client. Fortunately, there are ways to counteract these disadvantages, and these will be explained further on.
3. Avoidance of a difficult situation
When engaging online, the computer becomes a physical barrier between the client and therapist. Some clients, including those with substance use issues, will use this to avoid discussing or disclosing their condition (Siegel et al., 2017). They may try to avoid an uncomfortable discussion by shutting off the computer abruptly or not showing their face.
When in the same room as a therapist, the client can feel more secure, and avoidance or escape from a sensitive topic can be harder to achieve.
4. Dealing with crisis
Different therapists may have different policies on whether they work with clients in crisis online. If a client is in an immediate crisis and actively engaging in self-harm, a therapist can monitor the crisis from afar, but only do so much.
If a therapist is with the person physically, they can stay with the client until appropriate emergency services are called.
Online Counseling vs Face-to-Face Counseling
There are key differences between online and face-to-face counseling, but is one more effective than the other?
The concepts of therapeutic alliance and verbal cues have been researched when comparing online and face-to-face counseling.
Recent research (Leibert & Archer, 2005; Audet & Everall, 2010) found that clients’ continued requests to integrate online sessions with face-to-face meetings is seen as a complement to face-to-face therapy rather than a substitute for it.
Day and Schneider (2002) conducted one of the most prominent and well-known studies comparing videoconferencing to other media and face-to-face sessions. They studied a community of 80 clients aged 30–50 and assigned to one of three different psychotherapy platforms: face-to-face, real-time videoconference, and telephone.
After completing five therapy sessions, measures were taken of working alliance with counselors and overall satisfaction of their experience. The results showed that clients who were not in face-to-face therapy reported higher scores on an index of client participation that involved their activity level, initiative, and trust.
The results of this analysis determined no significant differences and overall positive findings among all three treatment groups.
How to Do Online Counseling
There is more than one way to engage in online counseling, but try the following as a guide.
1. Create safe spaces
It is important for therapists and clients alike to carve out a safe space in which to engage with online therapy. As a therapist, you should use a separate room. If you conduct your sessions from home, look out for distractions that may come from family members or pets.
Even though online counseling has the advantage of being flexible and available across different devices, it is important to replicate online what you do in person, as best as possible.
If you are going to engage in online counseling using your mobile phone, stick to this medium and technology. If email therapy is your preference, stick to that. The more consistency you provide yourself and the client, the more productive your online counseling experience will be.
2. Proper administrative procedures
To negate data security concerns when exchanging emails, good online counseling practice necessitates establishing when to send and receive documents. Personal data leakage can be disastrous and hinder the client–therapist relationship (Kolmes & Taube, 2016), so establish a set routine or time when the client will be ready for email correspondence.
Follow up with a client after sending an email to confirm that the information has been received. It is important to let clients know what you do with paperwork received from them, how it is stored, and where it is kept in case it is ever asked for via data protection requests.
Further to this point, data storage is extremely important. Knowing that you have a security-compliant practice management software system to store data is crucial. As a measure of practice, when you receive information from or about a client, make a habit to store that information right away rather than putting it off.
Work through the awkward phases that may arise when using new technology. If you are engaging in chat-based therapy, know that clients may have expectations about what constitutes a timely reply.
If conducting therapy via videoconference, recognize that it can feel awkward and frustrating if the connection fails and the session abruptly ends.
Establish boundaries and set expectations in advance for what to do with clients in these events. Let them know when to expect a response in chat-based therapy and that you will call to reconnect the videoconference should there be an interruption.
Be prepared to receive feedback from clients at different times, not just during the session as with face-to-face therapy.
It can help the client to communicate thoughts via email to a therapist throughout the week when engaging in online counseling, rather than waiting to show the therapist in person.
However, this is all the more reason to establish boundaries with clients from the beginning about when it is appropriate to receive emails and when you are likely to respond.
5. Practice naming emotions
Online counseling presents the challenge of not explicitly seeing what a client is trying to communicate with their body, particularly over email and chat.
When engaging with clients in online counseling, you may not see or read their nonverbal cues or body language accurately. Having clients become more comfortable describing their emotions can help alleviate this challenge.
The ethics of how technology is used can concern both clients and therapists. As online counseling relies on technology, the following ethical considerations need to be made.
Privacy is a major concern for therapists and clients alike. Privacy and confidentiality are often discussed when getting consent from a client, and ethics from overseeing bodies like the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the United States or General Data Protection Regulation (GDPR) in Europe are often cited when using specific software platforms for your practice and sharing data to outside organizations.
2. Informed consent
Many therapists who may not meet clients in person or in real time ask clients to read their terms and conditions as a way of understanding consent and how data is used when collecting information.
This presents an ethical issue as the therapist is not there to answer questions as they come to the client, and the language in these terms might be too technical.
To alleviate this, make sure the language reading level is not too high, have bullet point information, or share computer screens and discuss points when providing clients with these terms via videoconference (Martinez-Martin & Kreitmair, 2018).
Useful Software for Your Online Practice
With ethical issues in mind, here are four software solutions used by practitioners that can facilitate safe and secure practice management.
Several of the challenges we have discussed associated with online counseling can be overcome using the tool Quenza, which was designed from the ground up to support a blended care approach to online counseling.
First and foremost, Quenza is both GDPR and HIPAA compliant, facilitating secure interactions between you and your clients using personal PIN codes and 128-bit encryption.
Quenza also makes assigning homework tasks simple and intuitive. Using the Quenza app, you can design your own questionnaires, take-home exercises, and assessments or draw on the platform’s growing library of pre-loaded activities to keep your clients engaged in between sessions.
You can also incorporate multimedia throughout any activities you create, such as guided audio meditations or video lectures.
Any activities you create using Quenza are contained within their own easy-to-use application that your clients can access using their personal computer, smartphone, or tablet. As the counselor, you can also view the results of any activities your clients complete instantly, rather than waiting until their next session to receive them in hard copy.
Finally, your activities will never be forgotten as you can schedule and send push notification reminders for your clients to complete them at any time via the Quenza app.
2. Power Diary
Power Diary is HIPAA and GDPR compliant.
It is an all-in-one practice management software that allows therapists to manage bookings and see clients via secure video conferencing software. It also has a booking platform that allows clients to make appointments themselves.
3. Therapy Notes
Therapy Notes is a similar platform, though only HIPAA compliant.
It offers similar features as Power Diary, and also comes with a to-do list if you have many tasks in your practice.
Thera-link aids small- to medium-sized practices, offering separate office manager accounts for administrative use.
Besides having videoconferencing capabilities, it also has a waiting room with music for clients to wait in.
A Look at Group Online Counseling
If you wonder if group online counseling is feasible, Weinberg (2020) conducted research looking into this very subject and came up with the following findings based on an examination of online counseling and group research.
1. Therapeutic alliance
Two key aspects of establishing the alliance between therapist and client include agreeing on goals and agreeing on tasks. These can be achieved in online counseling groups, but the quality of the relationship still needs more research and insight.
2. Technological limitations
When engaging with a group in person, maintaining eye contact and observing behavior are easier. However, with online counseling, the absence of a full body view can be an obstacle, and the difficulty of achieving eye contact can be problematic for therapists and clients.
Compared to offline group therapy training, group online sessions may require further training and experience that is not available yet. Despite the move of many group sessions from in person to online, the aspect of facilitating the transition has not been studied heavily.
A Take-Home Message
Now more than ever, online counseling can reach the unreachable. It is an instrument to impact a society that desperately needs intervention and someone knowledgeable and trained to talk to.
If you have not yet made the move, the pros and cons above should reassure you that online counseling has been researched and proven beneficial in most scenarios.
The software listed includes applications specifically built to bridge the geographical divide, and there are many more available with additional customer relationship management and even accounting functionality. As always, start with research to make an informed decision.
Finding the right software, deciding on its usability, becoming familiar with it, and training your clients are but minor hurdles to overcome. Be aware of how information should be shared, the ethical implications of working online, and how to deal with clients who feel uncomfortable using technology.
Now is the time to challenge yourself and make use of technology to provide online counseling. Please share what has worked for you in the comments section below.
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