Online Therapy
What is “online therapy”?
Online therapy was first described as the interaction over the internet between a client and a therapist. Online therapy can be conducted in real time (i.e. phone calls, instant messaging, or video calls) or be time-delayed (i.e. emails). You may also hear it called “web therapy”, “e-therapy”, “phone therapy”, “e-counseling”, “teletherapy”, or “cyber-counseling”.
The integration of information and communication technologies into counseling and psychotherapy is a process that is not yet complete, especially when it comes to online services. In many parts of the world, therapists often prefer therapy methods based on traditional in-person interaction with the client.
Although traditional psychotherapy methods provide satisfactory results with some groups of clients, technology's integration into every area of our lives has become a daily extension of verbal communication especially between teens, young adults and individuals who travel a lot. This leads traditional psychotherapies to make revisions that also address these newly defined needs.
As an evolution of counseling and psychotherapy, online therapy is an important tool that has many benefits compared to traditional methods.
Who may be a good candidate for online therapy?
- People who are abroad and prefer to receive counseling or therapy in their native language,
- People who have a full-time working life with limited flexibility,
- People who live in sparsely populated areas and/or areas without access to in-person therapy,
- People whose mobility is restricted due to physical disabilities or chronic diseases;
- People who want to get support from an expert working on a particular issue, or who want to talk to their preferred expert for a variety of reasons.
Just like our clients, we as psychotherapists have a unique style and personality. Also, we have different approaches in psychotherapy. As a clinician who believes in the healing power of the relationship we have with our clients in therapy, I think there may be situations where every therapist and every client can not be adequately aligned. Of course, there will be aspects of this situation that complicate the healing process. In this respect, I believe that it is important for clients to go on this journey with psychotherapists whom they relate with better.
Sometimes this therapist can live far away, and in this respect, online therapy can be a great option.
What are the benefits of online therapy?
- Setting up an online appointment is fast, easy, and flexible compared to in-person therapy.
- Compared to attending in-person sessions at a specific location, clients have the comfort of being able to receive therapy in their own homes or wherever they choose.
- Online therapy is available to everyone regardless of disabilities or obligations that prevent them from attending in-person therapy sessions.
- Online therapy can be a complement to in-person sessions.
- Not requiring transportation, especially in remote areas where access to public transit is limited or non-existent.
- To access experts who can provide the most appropriate support to their clients' situations and are resident in different cities, regions, or countries.
- It is easier for clients to book an appointment based on their therapists' availability.
- There are no waiting rooms or intermediary staff which provides greater privacy.
- Absence of intermediary staff (privacy-protective).
- It may be the first step in treatment for people with low or no motivation to go to in-person therapy.
- The ability to continue therapy without interruption when the client is unable to attend in-person therapy for any reason such as moving.
For those who have little time or travel frequently, getting therapy at their own home or office can be an advantage.
Whether in-person or online, psychotherapists need to improve their awareness of human diversity and their sensitivity to working with different groups of clients. Although this is an important element of both traditional and online therapy, the internet has the advantage of being able to translate and produce group-specific studies, especially in cases where delayed response can be achieved.
The internet also allows vulnerable groups who may be discriminated against in any way to research and access a therapist with whom they can have a safe relationship. Similarly the internet allows clients to search for a therapist they may feel safer with based on their own culture, beliefs, customs, and/or philosophies.
Some research in the field also shows that online interventions are preferred for both therapists and clients as they reduce travel times, costs, and waiting lists.*
Another issue reflected in research is that although the risk of mental health problems is high among young people aged 10 to 24, this age group is the least likely to receive professional treatment because of a range of difficulties. For this reason, online interventions (text-based online counseling, etc.) is thought to be an important tool for the protection of mental health, especially for youth.**
References:
* Wright, J., Stepney, S., Clark, J. A., & Jacob, J. L. (2005). Formalizing anonymity: A review. University of York Technical Report YCS 389.
* Marks, I. M., Mataix-Cols, D., Kenwright, M., Cameron, R., Hirsch, S., & Gega, L. (2003). Pragmatic evaluation of computer-aided self-help for anxiety and depression. The British Journal of Psychiatry, 183(1), 57–65.
** Navarro P, Sheffield J, Edirippulige S, Bambling M. (2020). Exploring Mental Health Professionals’ Perspectives of Text-Based Online Counseling Effectiveness With Young People: Mixed Methods Pilot Study. JMIR Ment Health;7(1): e15564
Is Online Therapy as Effective as In-Person Therapy?
There are many studies showing that online therapy is effective in treating various psychological disorders:
According to a study comparing the effectiveness of in-person therapy with online therapy in the treatment of depression, cognitive behavioral therapy methods were applied for 8 weeks and both forms of treatment were found to be equally beneficial (1).
In another clinical trial, the effectiveness of Cognitive Behavioral Therapy (CBT), which is administered in the form of online or in-person group therapy, was compared for panic disorder. For 10 weeks, online (n = 53) and in-person (n = 60) CBT-based group therapy was conducted with 113 clients. After treatment and 6 months of follow-up, the clients were again evaluated by a psychiatrist. The results of the study show that online CBT is equally effective with in-person CBT for groups, which is commonly used to reduce symptoms of panic disorder and agoraphobia (2).
According to a meta-analysis study examining the effectiveness of online therapy in the treatment of anxiety and depression, internet-based treatments have been found to be effective even during 1-3 months of follow-up (3).
Another review study that was published in 2008 on a meta-analysis of 14 papers published until 2006, was conducted with a total of 9,764 clients and examined the effectiveness of online treatment in different formats. A comparison between in-person and internet-based interventions (CBT, psycho-educational and behavioral interventions) showed no significant difference in effectiveness (4).
In another meta-analysis study, which examined many studies evaluating the effectiveness of web-based interventions, it has been shown that online interventions are just as effective as in-person interventions in treating a variety of mental health problems, including insomnia, depression, anxiety disorders, alcohol and substance abuse (5).
As the literature shows, the therapeutic effect of various types of technology-based interventions has been studied mostly through systematic reviews and meta-analyses. The results are certainly promising. More work is needed to assess the prevalence or effectiveness of online interventions or counselling services in the future.
References:
(1) Wagner B, Horn AB, Maercker A. Internet-based versus faceto-face cognitive-behavioral intervention for depression: a randomized controlled non-inferiority trial. J Affect Disord. 2014;152-154:113-121.
(2) Bergstrom J, Andersson G, Ljotsson B, Ru¨ ck C, Andreewitch S, Karlsson A, Carlbring P, Andersson E, Lindefors N (2010). Internet- versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting : a randomised trial. BioMed Central Psychiatry 10, 54.
(3) Hudnall, Cory P.; Humble, Ty C.; and Wilson, Seth M., “Meta-Analysis: Anxiety and Depression Measures in Online Therapy Treatment” (2020). University Presentation Showcase Event. 24.
(4) Barak, Azy, et al. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26.2-4: 109-160.
(5) Cuijpers, P., Marks, I. M., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer-aided psychotherapy for anxiety disorders: A meta-analytic review. Cognitive Behaviour Therapy, 38(2), 66–82.
(5) Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76(6), 909.
(5) Amichai-Hamburger, Y., Klomek, A. B., Friedman, D., Zuckerman, O., & Shani-Sherman, T.(2014). The future of online therapy. Computers in Human Behavior, 41, 288–294.
Who may not be suitable for online therapy?
Some psychotherapists do not prefer online interventions due to the fact that some methods used cannot be applied online. Scharff (2013) stated that there may be a gap created by the loss of the physical presence of the client and therapist in online interventions. In order to overcome this, he suggested that the client and therapist talk about how the situation affects them in each therapy session (1).
Among therapists whose therapy methods are suitable for working online, some may use online interventions as valuable tools to reach out to clients, while others avoid online services and may approach them with resistance and suspicion for different reasons. A common reason for this is that online therapies may not be suitable for clients who do not feel comfortable with using technology or for some clients who are in a critical situation such as being suicidal. Another reason is believing that it may be difficult to protect borders on online interventions. Furthermore, they are concerned about the protection of privacy.
For the first concern, it is important for therapists to be aware of the possibilities of technical problems, to be prepared and to inform the client by considering them as another component of the therapeutic intervention. It may be necessary to create an alternative plan for connection problems that may occur and to keep time a little more flexible, especially during the first session.
At the same time, the therapist must ensure that the client complies with the type of intervention provided online in terms of technology use, knowledge, and skill before starting online interviews. A similar situation can be manifested in the therapist's relationship with technology.
It is essential for therapists to feel in control of the system and feel safe during the use of online interventions in order to progress the therapy in a healthy way.
We often see that, due to their familiarity with online communcation, young people adapt to online therapies faster than elderly people. According to a study researching the point of views of mental health experts about providing text-based online counseling services to young people, factors that reduce the effectiveness of online support are difficulties with evaluating the system, slow progress of text communication, lack of nonverbal speech signs, and connectivity problems. On the other hand, factors that increase the effectiveness of text-based online support are the strength of the therapist's interpersonal communication skills, the use of response strategies in crisis, working with less complex problems, and facilitating access when more intensive support is needed (2).
Some studies show that people tend to feel that the internet is a more ‘safe space’ than in-person interviews (3).
Some people also feel less shame and worry when they are communicating online. For these people, the lack of obligation to share the same room may increase their ability to be open.
As with traditional in-person therapies, it is important that information about cancelation, rescheduling, payment, session frequency and duration, and the limits of the relationship with the therapist be clarified and agreed to with the client beforehand. As the internet facilitates instant access to each other, it can allow a wider range of possible oversteps of the boundaries of therapy. The main point here lies in creating this framework with the same sensitivity as in-person interventions.
When we come to the second concern, in a serious situation, the online session can be very useful in terms of quick access to analyze the problem, give appropriate guidance, and decide on further steps. Many telephone counseling lines providing first step services and case management are actively used all around the world. Moreover, the intervention that a psychotherapist can do in-person in a very large crisis is already limited: The person's relatives are informed and the person is referred to the hospital quickly for medical support.
On the otherhand, we may occasionally see clients having difficulty adjusting to the appropriate environment for therapy. In such cases, I think it is important to ask questions about whether the client feels comfortable or not intermittently during the session in order not to sabotage the process, and to continue if everything is fine. Although very rare, especially in cases of unforeseen circumstances out of the client’s control, I believe that keeping the option of rescheduling the session also makes clients feel more confident. Since there may be situations where some clients may be uncomfortable with the presence of others with whom they share the home or office, I can say that it may be useful to re-think alternative solutions to bring this issue up while scheduling the session.
References:
(1) Scharff, J. S. (2013). Technology-assisted psychoanalysis. Journal of the American Psychoanalytic Association, 61(3), 491–510.
(2) Navarro P, Sheffield J, Edirippulige S, Bambling M. (2020). Exploring Mental Health Professionals’ Perspectives of Text-Based Online Counseling Effectiveness With Young People: Mixed Methods Pilot Study. JMIR Ment Health;7(1):e15564
(3) Amichai-Hamburger, Y., & Barak, A. (2009). Internet and well-being. In Y. Amichai- Hamburger (Ed.), Technology and well-being (pp. 34–76). Cambridge University Press.
Is online therapy secure and confidential?
Even if the online world does indeed involve risks to a client's privacy, we cannot say that these risks are significantly or greater than similar risks taken in real-world therapy sessions.
In general, privacy, whether online or in-person sessions, can be declassified under certain legal conditions:
Court order: the therapist may have to share some information about the client when forced by legal circumstances; however, even in these circumstances, the therapist tries to keep as much information about the person as possible confidential when responding.
Life threat and harm: when the client's life is in danger or when the client threatens to harm someone else, the client's privacy rights are set aside. Life is more important than a person's right to privacy in this context. The therapist receives outside support in cooperation with the client as much as possible. In many cases of violence against sensitive groups especially under 18, elderly, disabled etc., the therapist has to make a legal notice.
We often hear about some cases that unfortunately privacy can be lost without even realizing it.
For example, many medical staff have access to information about the activities of the clients, even if they do not treat the client directly in many institutional structures such as hospitals, health centers etc. In larger structures, this activity may not be questioned and may not even be noticed by the responsible personnel.
There can be many situations where the right to privacy is breached, from waiting rooms, where you can clearly hear what is being said in the next room, which are not properly isolated or are misplaced, to the staff of the institution talking between each other about the clients, even if they are informed about the importance of privacy.
In fact, privacy can be lost even in cases where the client is seen going to his or her clinic or to a therapist's office.
While these risks are common, many professionals may tend to ignore the daily risks associated with in-person therapy sessions. Still, they are more able to perceive the risks of online interventions.
All these privacy risks, of course, may not be one hundred percent contained; however, understanding the potential risks and informing the client, whether in-person or online, is the first step in taking measures to mitigate these risks. Then, in order to be a little more precise and systematic, it is necessary to apply routine security steps.
All these privacy risks, of course, may not be one hundred percent contained; however, understanding the potential risks and informing the client, whether in-person or online, is the first step in taking measures to mitigate these risks. Then, in order to be a little more precise and systematic, it is necessary to apply routine security steps.
Are there any ethical problems in online therapies?
Until now, researchers have discussed some of the following ethical issues: - Ensuring privacy - Licensing of implementation methods - The validity of data transmitted via digital networks - Identification of client and therapist - Certification - Crisis intervention and risk in clinical situations - Therapist adequacy of the intervention - Possible misuse of software applications - Legal procedures - Issues related to geography, culture, etc. - The therapeutic relationship and therapeutic impact on the development of a relationship.
With these in mind, many researchers have emphasized the importance of creating guidelines for the safest practices.
According to the literature, some recommendations for dealing with the challenges and limitations of cyberspace are: - Seeking informed consent when the limits of privacy and confidentiality in intervention are at risk - Ensuring that the client comes to a physical address by making the first session in-person in order to obtain reliable information - Obtaining written permission from parents for underage clients. However, it may not always be possible to fulfill these conditions in practical life. Moreover, many recommendations are only to document that permission has been obtained. I believe that it is important for the system to be set up in a way that minimizes human mistakes and I think this should not be entirely left to the individual initiative of clinicians.
However, the lack of a comprehensive and well-planned mental health law and a professional law for psychologists makes it difficult to control therapy processes as well as to protect the rights of therapists and clients. At this point, until a systemic step is taken, I have to tell clients that the greatest responsibility for the choice of therapist and therapy is on their shoulders. I also believe that getting information through online channels (personal blog, Instagram, Twitter etc.) about therapists such as the techniques they use, the schools they graduated from, and their specialties, may allow them to make an informed decision on a therapist for a relatively safe start. Also, clients may request a variety of documentation from a therapist regarding their area of expertise.
Can personal information be protected in online therapies?
E-mail-based risks can be almost completely eliminated using current available technologies. If clients are informed about the benefits of encryption and encouraged to use these technologies, the risks can be minimized.
Nowadays, there are actually technical solutions on many issues such as privacy, online threats (spam, identity theft), secure payments etc. It is important that therapists and clients have information about these issues. In my own therapy practice, I have been following the news in the online systems. I can also say that I have obtained and applied a lot of current information through my colleagues and clients.
If problems or violations occur during online therapies, which authorities are involved?