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Counselling Psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy

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Purpose: This paper examines the empirical research concerning counselling psychologists who utilise the internet in their practice. More specifically, we summarise the quantitative research of online therapeutic outcomes and alliances reported in text-based therapeutic encounters. Background: Online therapy creates much debate within the therapeutic world. Many question the validity of entering into these relatively uncharted waters, while others have begun working productively in this territory. To date, a small pool of research examining the efficacy of such work has emerged and provides the focus for this paper. Method: A review of the literature has been conducted with a two-fold strategy. Initially a review of 16 quantitative outcome studies investigating this area are presented and discussed – these have been selected from Barak, Hen, Boniel-Nissim and Shapira’s (2008) comprehensive review of the effectiveness of Internet based psychotherapeutic interventions. Following this, the focus is moved to the concept of the online therapeutic alliance. A systematic review of the existing literature outlines five pertinent quantitative studies and these are discussed in relation to key qualitative work in this area. Conclusions: Conclusions are drawn highlighting that work in this medium shows great promise, with both successful outcomes and strong alliances being reported online. Such findings, although limited due to the dearth of the research available, challenge the views of those sceptical of counselling psychologists entering into virtual arenas.
Technology and Therapy: A brief history
LTHOUGH online therapy is a relative
newcomer to the therapeutic world,
using technology is not. Tape-
recorded self-help approaches and
computer programs which mimic person-
centred therapists were experimented with
during the 1970s (Lang, Melamed & Hart,
1970; Weizenbaum, 1976). More recently,
computerised cognitive behavioural therapy
(CCBT) has received considerable attention
from researchers (Kaltenthaler, Parry &
Beverley, 2004; Marks, Cavanagh & Gega,
2007) and has been included within the
National Institute for Clinical Excellence
(NICE) guidelines for good practice for
both mild to moderate depression and the
treatment of phobias (NICE, 2006). In
contrast, less systematic research has focused
upon the influence of human-to-human
therapeutic interventions mediated through
technology. This is the focus of our paper.
Prior to discussing mediated therapy
directly, we provide some statistics to contex-
tualise changing health seeking behaviours
within industrialised societies such as the
UK. First, in 2007, 61 per cent of households
within the UK had access to the internet
from home (National Statistics, 2007). This
is a dramatic increase from previous decades
and has an inevitable impact upon online
mental health services. Probably the most
relevant and striking statistics available are
those collected by the Samaritans’ e-mail
4Counselling Psychology Review, Vol. 24, No. 2, June 2009
© The British Psychological Society – ISSN 0269-6975
Counselling Psychology and the internet:
A review of the quantitative research into
online outcomes and alliances within
text-based therapy
Terry Hanley & D’Arcy J. Reynolds, Jr.
Purpose: This paper examines the empirical research concerning counselling psychologists who utilise the
internet in their practice. More specifically, we summarise the quantitative research of online therapeutic
outcomes and alliances reported in text-based therapeutic encounters.
Background: Online therapy creates much debate within the therapeutic world. Many question the validity
of entering into these relatively uncharted waters, while others have begun working productively in this
territory. To date, a small pool of research examining the efficacy of such work has emerged and provides
the focus for this paper.
Method: A review of the literature has been conducted with a two-fold strategy. Initially a review of 16
quantitative outcome studies investigating this area are presented and discussed – these have been selected
from Barak, Hen, Boniel-Nissim and Shapira’s (2008) comprehensive review of the effectiveness of internet-
based psychotherapeutic interventions. Following this, the focus is moved to the concept of the online
therapeutic alliance. A systematic review of the existing literature outlines five pertinent quantitative
studies and these are discussed in relation to key qualitative work in this area.
Conclusions: Conclusions are drawn highlighting that work in this medium shows great promise, with both
successful outcomes and strong alliances being reported online. Such findings, although limited due to the
dearth of the research available, challenge the views of those sceptical of counselling psychologists entering
into virtual arenas.
Keywords: online therapy, counselling psychology, outcomes, therapeutic alliance.
A
support service. It received and responded
to 36,500 e-mails in the year 2000, this
increased to 72,000 during 2002, and more
recently in 2006 they received 184,000
(Samaritans, 2004, 2007). This phenomenal
increase reflects changing attitudes to the
internet as a resource, a concept that is also
supported by a recent MORI poll finding
(2001) that 60 per cent of internet users
would seek help for mental health problems
online. However, many individuals still
remain wary and appropriately question how
prepared the mental health profession is for
such developments (e.g. Alleman, 2002).
Counselling Psychology and the internet
Despite concerns regarding the develop-
ment of online mental health care, thera-
peutic provision in this medium has become
a burgeoning profession. The first recorded
individual to pay for online therapy occurred
in 1995 (Anthony, 2003). Presently there is
no record of the number of online coun-
selling sessions being offered. However, the
increase in therapeutic services offered in
this medium suggests a public demand for
online access to therapists (Grover et al.,
2002). This demand is also reflected in the
increasing number of text books that
include substantial reference to online prac-
tices (Fink, 1999; Goss & Anthony, 2003; Riva
& Galimberti, 2001; Sanders, 2007; Wootton,
Yellowlees & McLaren, 2003) or that have
been solely written for counselling practi-
tioners who wish to offer their services over
the internet (Bloom & Walz, 2000; Bloom &
Walz, 2004; Derrig-Palumbo & Zeine, 2005;
Evans, 2009; Hsiung, 2002; Jones & Stokes,
2009; Kraus, Zack & Stricker, 2004).
There are numerous ways of offering
online therapy (e.g. e-mail, chat rooms, and
videoconferencing) with e-mail the most
prevalent (Chester & Glass, 2006; Heinlen,
Welfel, Richmond, & Rak, 2003; Stofle,
2001). Such findings are not surprising given
the ease of access and the perceived privacy
of online services not typically available face-
to-face (e.g. Rochlen, Zack & Speyer, 2004).
Provision of online therapeutic services is,
therefore, developing at a reasonable pace
and individuals seeking support are not
pushing for more sophisticated modes of
computer-mediated communication.
Online therapy appears to violate many
of the fundamental principles of the thera-
peutic relationship. In particular, the
physical distance between the counsellor
and client is a point of great contention.
Lago (1996) expresses this contention in the
form of the following paradox:
‘I have connected deeply with you
psychologically and emotionally on my
computer, yet still remain isolated from
you in every physical sense (no vision, no
sound, no touch). It is very personal and
not personal at all’ (p.288).
Critics challenge online practice because
they believe relationships cannot reach suffi-
cient levels of intimacy. For instance, Robson
and Robson (1998) state that ‘[u]sing
computer communication runs the risk that
the ‘space between the two parties’ becomes
filled with hardware’ (p.40) and Pelling and
Renard (2000) note that without a high level
of skill ‘therapeutic interactions may be
reduced to mere advice giving when face-to-
face interactions are translated to the elec-
tronic medium’ (p.68). Although these
critical voices have subsided slightly in recent
years, online therapy is still in its infancy and
there has been little systematic focus upon
the quality of the online therapeutic
alliance.
In applying therapeutic skills online,
counsellors need to be mindful of the tech-
nical challenges that they can expect to
encounter. Briefly summarised from the
work of Rochlen, Zack and Speyer (2004)
these include the missing non-verbal
communication, the increased opportunity
for miscommunication, the time delay
present when using e-mail, the computer
skill deficiency of either the counsellor or
client, the inability to intervene when there
is a crisis, the cultural clashes that may occur,
the question of identity (‘Is this really who
they say they are?’), and the vulnerability of
sending sensitive material over the internet.
Counselling Psychology Review, Vol. 24, No. 2, June 2009 5
The quantitative research into online outcomes and alliances
A growing literature is emerging that specifi-
cally articulates these challenges in online
communication. This literature also adds
considerable weight to not offering therapy
through this medium.
Therapists who work online have
attempted to overcome a number of these
technical challenges by familiarising them-
selves with the nuances of computer-medi-
ated communication. A number of book
chapters have been devoted to outlining
some of the key components of such modes
of communication to therapists. Authors
explain how counsellors can develop innova-
tive strategies for expressing themselves
solely through text despite the absence of
face-to-face cues. Written techniques such as
emoticons (), abbreviations (u=you),
acronyms (lol=laughs out loud), and
emotional bracketing (see Murphy &
Mitchell’s [1998] descriptions of therap-
e-mail) are all noted to add depth to the rela-
tionships that are created. Stofle (2002) uses
the term ‘non-textuals’ to describe ‘every-
thing other than the words themselves’
(p.94) within computer-mediated communi-
cation. In such instances, the words and key
strokes create a mental representation of the
individuals involved and facilitate the
creation of relationships of a sufficient depth
to produce positive change (e.g. Anthony,
2000a; Suler, 2004). In addition to the devel-
opment of computer-mediated counselling
skills that are utilised within sessions, indi-
viduals have also paid attention to the ethical
concerns that have been raised (e.g.
Anthony & Jamieson, 2005; Bloom, 1998;
Childress, 2000; Goss & Anthony, 2004; King
& Poulos, 1999; Kraus, 2004; Robson &
Robson, 2000; Stofle, 1997). These works
attempts to highlight the numerous pitfalls
of working in virtual environments such as
producing appropriate counselling
contracts, being mindful of the limits of
confidentiality, and protecting any elec-
tronic files that are stored.
The online environment can provide a
number of distinct opportunities that may be
used to compensate for the lack of physical
presence. Rochlen, Zack and Speyer (2004)
note that it is convenient and increases
access for clients, the client may feel safer
and thus disinhibited by the online environ-
ment, e-mail provides a meditative ‘zone of
reflection’, writing is therapeutic, individuals
report feeling close to others they meet
online (this has been described by Lombard
& Ditton [1997] as ‘Telepresence’), and it
provides immediate access to internet-based
resources. Thus, the theoretical retort to
critics of e-therapy has developed substan-
tially in recent years. It has shifted from
examining how the nuances of face-to-face
therapy can be mimicked solely using text, to
considering how technology can actually
complement and improve service provision.
Rationale for the review
As outlined above, online therapy is a
growing field in which interested profes-
sionals have attempted to tackle the chal-
lenges posed by the online environment.
However, there are still numerous questions
of efficacy regarding counselling psycholo-
gists entering into virtual environments.
Consequently, this work aims to investigate
two key facets of such practice. First, ‘What
evidence suggests that text-based online
therapy produces positive outcomes for
clients?’ Second, ‘What evidence suggests
that therapeutic alliances of a sufficient
quality to create positive change can be
created online using text-based media?’
Review strategy
This paper reviews the literature related to
the work of counselling psychologists who
utilise e-mail or online chat to mediate their
practice. It specifically examines the quanti-
tative research that has been conducted
exploring therapeutic outcomes and the
therapeutic alliance using online text-based
modes of communication. The review
strategy is a two-stage process:
Stage 1: Initially this paper reflects upon Barak
et al.’s (2008) comprehensive review of
internet based psychotherapeutic interven-
tions. This review provides a systematic
6Counselling Psychology Review, Vol. 24, No. 2, June 2009
Terry Hanley & D’Arcy J. Reynolds, Jr.
overview up until March, 2006, of outcome
studies related to various online interventions.
For the purposes of this paper, only human-to-
human computer-mediated contact studies
are extracted from the review and discussed.
The effect size of the intervention calculated
for each mode of communication is reported
and Cohen’s (1969) rule of thumb is used to
interpret the data: 0.2 is a small effect, 0.5 a
medium effect (‘visible to the naked eye’
[p.23]), and 0.8 a large effect size (‘grossly
perceptible’ [p.23]).
Stage 2: The second stage of the review
involves reporting on part of an ongoing
systematic review examining online thera-
peutic alliance (Reynolds & Hanley, in
preparation). The analysis of the literature
cited within several major electronic data-
bases (PsycINFO, Medline, Scopus, and
Google.Scholar) up until March, 2008, has
been conducted. Although the work
reported focuses solely on text-based
communication, interested readers can also
investigate the videoconference therapeutic
work (e.g. Wade et al., 2005), the impact of
using online technologies as an adjunct to
face-to-face work (e.g. Murdoch & Connor-
Greene, 2000), and as an adjunct to self-help
materials (Klein, Richards & Austin, 2006).
The major quantitative studies presented
reflecting work conducted primarily with an
adult population and reported in the
English language. For work with younger
populations, see Hanley (in press) and King
et al. (2006).
Findings
Examining outcomes
The Barak et al. (2008) study evaluates the
effectiveness of internet-based psychothera-
peutic interventions and provides a compre-
hensive summary of 92 studies involving
9764 clients. The review generally concludes
that online work is moderately effective, with
an overall mean weighted effect size of 0.53.
Barak and his colleagues remind the reader
that this effect size is ‘quite similar to the
average effect size of traditional, face-to-face
therapy’ (p.109). This finding is compelling
evidence for those interested in the efficacy
of online practice as it reflects a growing
body of evidence indicating that online
therapy can be of use to some clients.
When limiting the work examined to
only the effectiveness of one-on-one therapy,
only 27 of the studies in question represent
work conducted synchronously or asynchro-
nously with a therapist. See Table 1 for a
breakdown of the modalities utilised and the
respective effect sizes.
Upon further reflection, it is also evident
that some of the interventions that reflect
more sensory rich environments (notably
audio and webcam) and those interventions
through forums do not reflect one-to-one
therapy. Excluding these findings leaves a
total of 16 relevant studies for this review and
cumulatively involve 614 clients. More specif-
ically, they reflect effect sizes for text-based
interventions using e-mail (Effect size=0.51)
and chat (Effect size=0.53). According to
Counselling Psychology Review, Vol. 24, No. 2, June 2009 7
The quantitative research into online outcomes and alliances
Table 1: Effect size of online counselling by communication modality (27 studies).
Communication Effect Size Number of studies Number of clients
Modality involved
Audio 0.91 1 54
Chat 0.53 9 231
Webcam 0.31 2 208
E-mail 0.51 7 383
Forum 0.34 8 523
(Summary from Barak et al., 2008)
Cohen (1969), such findings are indicative
of moderate effect sizes.
A further consideration with Barak et al.’s
(2008) meta-analysis is that it reflects more
technical approaches to therapy (e.g. cogni-
tive behavioural therapy), rather than those
that place more emphasis upon the curative
nature of the relationship (e.g. person-
centred therapy). The whole study cate-
gorises the work that has been collated into
three main psychotherapeutic approaches:
cognitive behavioural therapy, psycho-educa-
tional interventions, and behavioural inter-
ventions. Only two studies within the analysis
reflected different approaches to therapy.
They both reflect therapy conducted
through chat and used an unspecified thera-
peutic approach (Cohen & Kerr, 1998; Effect
size=0.86) and a client-centred form of moti-
vational interviewing (Woodruff, Edwards,
Conway, & Elliott, 2001; Effect Size=0.56).
In summary, this highlights the bias within
the present research towards more technical
approaches to therapy as opposed to those
that are more relational in nature.
Examining the alliance
Similar to online outcomes, the online ther-
apeutic alliance has received limited atten-
tion to date. From the on-going review of
alliance, five studies have been selected from
the electronic database searches. Table 2
outlines the participants involved in the
studies (both those receiving online therapy
and those in comparison groups), the type of
text-based intervention employed, alliance
measure used, and a brief summary of the
main conclusions.
The five studies had a total of 161 clients
who took part in online therapy treatment
conditions. Of the five studies all but one
compared their data to face-to-face compar-
ison groups (Prado & Meyer, 2006,
compared findings to those of individuals
who dropped out of therapy at earlier
stages). In addition, three studies only
utilised asynchronous communication and
two utilised a combination of asynchronous
and synchronous communication.
Each of the studies outlined in Table 2
supports the notion that good therapeutic
alliances can be developed online. Scores
within the studies generally indicated that
clients perceived the alliance between them
and the counsellor to be moderate or strong
in nature. It is also noteworthy that within
three out of the four studies that made
comparisons to face-to-face equivalents, the
online alliance proved higher than the
comparison group. Such findings provide
persuasive evidence supporting online
therapy and challenge theoretical assump-
tions that relationships of sufficient quality
to create therapeutic change cannot be
developed online.
Discussion
Previously, two questions were raised: ‘What
evidence suggests that text-based online
therapy produces positive outcomes for
clients?’ and ‘What evidence suggests that
therapeutic alliances of a sufficient quality to
create positive change can be created online
using text-based media?’ This section will
discuss these questions in relation to the find-
ings presented above. It will then move on to
briefly consider the limitations of this work
and future directions for research in this area.
Within industrialised cultures, the
internet is increasingly being used to seek
out health care information and services.
Broadly speaking, the findings from this
review of the quantitative literature support
the notion that individuals who seek out
online mental health services can receive
effective support. Specifically, 16 studies
have reported positive outcomes from such
encounters. These studies noted effect sizes
for e-mail therapy to be 0.51 and therapy
mediated through chat rooms to be 0.53.
These findings are comparable to face-to-
face outcomes studies (e.g. Lambert &
Ogles, 2004), however, the limited number
of studies in question limit the compara-
bility. Although there is growing evidence
that online therapy proves effective for some
individuals, there is still much evaluative
work to be undertaken.
8Counselling Psychology Review, Vol. 24, No. 2, June 2009
Terry Hanley & D’Arcy J. Reynolds, Jr.
Counselling Psychology Review, Vol. 24, No. 2, June 2009 9
The quantitative research into online outcomes and alliances
Table 2: Table outlining the studies which examine the therapeutic alliance in
text-based therapy.
Authors (date)
N
=
N
= Asynchronous/ Alliance Conclusion
Online Comparison Synchronous measure
group group
Cook & N=15 f2f archive Asynchronous Working – Moderate TA scores
Doyle (2002) N=25 & Synchronous Alliance – higher than f2f
Inventory
(WAI)
Knaevelsrud & N=48 Previous f2f Asynchronous Working – High TA scores
Maercker (2006) study with Alliance – higher than f2f
similar Inventory – – no distinction of
client group short form scores for those
N=270 (WAI-S) with different
severity of need
Leiber, Archer, N=52 f2f archive Asynchronous WAI-S – Moderate TA scores
Munson & N=46 & Synchronous – weaker than f2f
York (2006)
Prado & Meyer N=29 Drop out Asynchronous WAI – Moderate to
(2006) N=19 Strong TA scores
– Drop out TA scores
significantly lower
than completion
Reynolds, Stiles N=17 3 Previous Asynchronous Agnew – Similar TA ratings
& Grohol (2006) f2f studies Relationship as f2f
using the Measure –
same short form
measure (ARM-S)
Key: f2f = face-to-face; TA = therapeutic alliance.
The five studies that investigated the
online therapeutic alliance in adult therapy
add to our understanding of this phenom-
enon. They offer clear and compelling
insight into the quality of online therapeutic
relationships. In particular, each study
reported alliance scores to be of moderate to
high strength. Thus, it could be suggested
that a high percentage of the 161 total
participants felt the quality of the relation-
ship to be of a sufficient quality to create
therapeutic change. Similar to the positive
outcomes reported by those who have
accessed online therapy, this finding chal-
lenges those who question the efficacy of this
way of working. More specifically, it calls into
question the view that good quality relation-
ships cannot be fostered in text based rela-
tionships (e.g. Pelling & Reynard, 2000).
Further, it argues against the notion that
mental health professionals are unprepared
for technological advances (Alleman, 2002).
The qualitative literature on the online
therapeutic alliance supports the possibility
of creating good quality relationships online.
For instance, two UK-based studies have
consulted small numbers of counsellors
about the quality of the relationships that
they develop with clients in their online
practice (Anthony; 2000a; Hanley, 2004b;
see also Anthony, 2000b). These studies
suggest participants’ believe that good
quality relationships can be developed
online. There are fewer studies which reflect
the views of clients, although these are not
completely absent. In most of these reports,
the focus is on practical concerns such as
utilising the medium for therapy rather than
the nature of the relationship itself (e.g.
Haberstroh et al., 2007; Young, 2005). More
sustained reports are emerging including
researchers consulting with adolescents’
about their views of forming relationships
with therapists online (Hanley, in press) and,
on rare occasions, client reports of their
experiences (e.g. Ainsworth, 2002). When
reflecting upon the experience of receiving
her first e-mail response from a therapist,
Ainsworth captures the potential of online
therapeutic relationships:
‘It was a connection. Physically, we were
separated by five states; but psychically we
were more connected than if we had
been in the same room’ (Ainsworth,
2002, p.198).
Finally, we return to the view that mental
health professionals are not prepared for
working in such environments (Alleman,
2002). As is evident above, the studies
presented here suggest that the therapists in
question are adequately prepared for such
work. One possible explanation for thera-
pists’ preparation is the growth of the online
therapy literature. Theoretical developments
have evolved at a similar pace to the practice
of online therapy. As noted earlier,
numerous text books have been written and
specific bodies of literature have emerged
supporting practitioners in developing their
skills base. Therefore, it may be this height-
ened interest in the nuances of computer-
medicated communication that has led to
appropriately skilled therapists working in
these studies.
Limitations and future directions
A major limitation to this review is the dearth
of studies which it brings together. The study
of outcomes and alliances within online
therapy is an area still very much in its
infancy and one that will undoubtedly be
strengthened as time goes on. It is tempting
to contrast this body of work to the large
meta analyses of face-to-face equivalents (e.g.
Lambert & Ogles, 2004, when contemplating
outcome studies, and Horvath & Bedi, 2002,
when contemplating alliance studies).
Within these bodies of work there is a rich-
ness that is impossible to duplicate from the
limited work examined here. For instance, it
is not yet possible to examine specific
nuances such as the use of different meas-
ures, variety of people completing the ques-
tionnaires, and variable times of
questionnaire implementation. Such a
problem goes to the core of this paper.
Although trends that can be generalised
from one group to another may not be iden-
tifiable, it is possible to say for certain that
some individuals have benefited from online
therapeutic support. Thus, the cumulative
body of work strengthens the arguments in
favour of online therapy. It does not claim to
offer a cheap alternative for those who want
face-to-face therapy, but it does suggest that
online work can play an important part in
supporting the psychological well-being of
those seeking out such support.
There is much need for continued
research into the exploration of online ther-
apeutic outcomes and alliances. For
example, an important issue is the influence
of online as opposed to face-to-face data
collection of online therapy data (e.g.
Reynolds & Stiles, 2007). The research that is
presented here just scratches the surface but
acts as a useful starting point for those
entering into this area. As is mentioned
above, studies which help to add to the rich-
ness of our understanding of online thera-
peutic work will provide more fodder for
quantitative analysis. In addition, explana-
tory qualitative studies and theoretical devel-
opments have played an important part in
the evolution of this work. With this in mind,
it is difficult to identify specific research
priorities. However, the continuation of such
work feels essential for this growing area of
the counselling psychology profession.
10 Counselling Psychology Review, Vol. 24, No. 2, June 2009
Terry Hanley & D’Arcy J. Reynolds, Jr.
The Authors
Terry Hanley
Lecturer in Counselling at the
University of Manchester.
D’Arcy J. Reynolds, Jr.
Doctoral Student in the Department of
Psychology at Miami University.
Correspondence
Terry Hanley
Lecturer in Counselling,
Educational Support & Inclusion,
Ellen Wilkinson Building,
The University of Manchester,
Oxford Road,
Manchester M13 9PL.
Tel +44(0)161 275 3307
E-mail: terry.hanley@manchester.ac.uk
Counselling Psychology Review, Vol. 24, No. 2, June 2009 11
The quantitative research into online outcomes and alliances
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... In the same vein, web-counselling is advantageous because it improves the efficiency of counselling, increases the rate of delivery with greater efficiency with less repetition especially in group counselling, increases flexibility and independence and furthermore, breaks the barriers of time, distance, and space as it can be conduct despite where the client is located and even outside the normal working time frame (Paterson et al., 2019). The effectiveness of web-counselling is almost the same like that of the traditional face-to-face counselling which is a compelling evidence that online counselling is paying some dividend (Terry, 2009). Web-counselling is promising exponentially and has registered great successes and efficiency both in terms of outcomes and building strong alliance among online clienteles (Terry, 2009). ...
... The effectiveness of web-counselling is almost the same like that of the traditional face-to-face counselling which is a compelling evidence that online counselling is paying some dividend (Terry, 2009). Web-counselling is promising exponentially and has registered great successes and efficiency both in terms of outcomes and building strong alliance among online clienteles (Terry, 2009). Web-therapy has been found to be efficient in treating a number of psychological problems including panic disorder, tinnitus disorder, depression, posttraumatic stress disorder, and body image concerns (Abbott et al., 2008). ...
... However, in a complete virtual relationship sometimes, it is with difficulties that one feels the presence of other and leave alone adequately understanding what s/he is grappling with and as well be literally part of it while never carried away as a professional as encapsulated: although e-counselling is suitable for all types of counselling, therapists must be extremely careful during group counselling as invisibility can make it complicated and less effective (Barak et al., 2009). Online counselling for a number of reasons such as the physical distance between the counsellor and counselee and inability for parties to be connected psychologically and emotionally has violated some fundamental principle of the therapeutic relationships (Terry, 2009). In spite of the fact that cyber counselling involves the use of gargets such as computers and the internet, still it has the same capacity like the traditional face-to-face counselling in building strong alliance between counsellor and counselee (Terry, 2009). ...
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Daily, in almost every part of the world, series of maltreatment are meted on the children. Because of their vulnerability, the time has come to take serious actions and unreserved measures to end this inhumane treatment and support the victims and their communities. Children are innocent beings and are the last hope of every community and nation and deserve a decent and safe environment to grow to the fullest. This is a fundamental human right as capsulated in the United Nations Convention on the Rights of the Child (UNCRC), an international legal instrument of universal significance. A systematic review of the works of literature using information collected from different sources was actuated. Google search engine, google scholar, web of science, and Scopus database were used to search for these articles. During the search, combinations of words and phrases were used to ensure articles reflected the most current knowledge and scholarly works. The systematic searches beget varied and voluminous articles that had to be sieved not only to meet the inclusion and exclusion criteria but also to ensure the fundamental objectives of the study are wrangled. In summary, the potentials of web-counseling include but are not restricted to unlimited access and improved seeking behavior, affordability, convenience, limited pressure, permanent record availability, anonymity, independence and autonomy, empowerment, geographical barriers elimination, less feeling shy, freedom of expression, confidentiality, and privacy, efficiency and effectiveness improvement, all-time access to multiple therapists, resources with no transport cost and hassle, and client-driven therapy sessions
... There is consistent evidence that a good therapeutic alliance can be developed in therapistsupported internet-based therapy (Hadjistavropoulos et al., 2017), and studies comparing this to face-to-face therapy have often found higher ratings of alliance in internet-based treatment (Hanley & Reynolds, 2009;Pihlaja et al., 2017). Though individual studies report variable findings, metaanalyses of the research on internet-based interventions for adults have found a positive correlation between therapeutic alliance and treatment outcome, similar to that seen in face-to-face therapy (Flückiger et al., 2018;Probst et al., 2019). ...
... No cases showed a pattern of consistently low alliance, or a deteriorating trajectory, and overall, the alliance ratings were generally high. This is consistent with other studies that have found high client ratings of alliance in therapist-supported internet-based therapy (Hadjistavropoulos et al., 2017;Hanley & Reynolds, 2009;Pihlaja et al., 2017). ...
Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three 'values' that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.
... The development of a strong client-therapist alliance has been recognized as a key factor in the success of a variety of psychotherapy paradigms (Genova et al., 2020;Ring & Gysin-Maliart, 2020;Sprenkle et al., 2009). Although research is currently limited, academic literature is beginning to acknowledge that strong working alliances between therapists and clients can be developed over online therapy platforms, such as through video, phone, and even via textbased therapy (Hanley, 2012;Hanley & Reynolds, 2009). While this kind of relationship has great clinical value, the primary role of an ethically practicing MHI-MFT is more likely to resemble that of a psychoeducator than a personal therapist. ...
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The increase in social media usage contributes to a greater number of Marriage and Family Therapists (MFTs) using social media to grow their professional outreach and to increase awareness about mental health by engaging with online audiences. Although existing literature has discussed how MFTs can make ethical use of personal social media in and around their therapeutic role, no literature at this time has explored the potential ethical issues faced by MFTs seeking to build public presence on social media as a “mental health influencer.” The present paper intends to provide a definition of mental health influencers (MHIs) and reviews ethical concerns relevant to MFTs acting as MHIs. Particular consideration is given to ethical dilemmas and conflicts-of-interest which may emerge via parasocial relationships developed through social media influencing, as well as how the boundaries and the limitations of an MFT’s professional scope can be tested when presenting as a personable, public figure over digital platforms. A framework for conceptualizing ethical issues for MHI-MFTs is offered, with a selection of prescient issues being examined within the scope of existing ethical standards set forth by the American Association of Marriage and Family Therapy’s (AAMFT) Code of Ethics. Reflections are offered about what questions and guidelines should be observed by MFTs in order to avoid unethical use of social media as an MHI, followed by a brief discussion about future considerations which should be considered by MHIs.
... These concerns seem to have been gradually dispelled as available research suggests that a therapeutic alliance is indeed possible to an equal depth as FtF and in some studies this has been cited to be superior with an accelerated rate of self-disclosure and sense of safety within the therapeutic process (Reynolds et al., 2006). For instance, in their review Hanley & Reynolds (2009) considered 5 quantitative studies with cumulative data from 161 participants who used the Working Alliance Inventory (WAI) and showed similar ratings in text-based therapy to face-to-face studies (Dunn, 2018) These findings point to the unique possibilities of empowerment, flexibility and choice (such as not fixed time appointments of a certain duration). On this basis, it may be said that while the therapeutic alliance via email has comparable outcome effects to FtF, the processes and factors involved in it seem to be different (similar to instant chat interventions). ...
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Online therapy has been increasingly utilised during the COVID-19 pandemic by many including working populations. However, few qualitative studies have explored how online therapy is ex-perienced in practice, and discussed its implications for those working clients. Semi-structured interviews attended by nine integrative psychotherapists practising in California, United States, were conducted. Thematic analysis of the transcripts identified three themes: i) ‘Positive experi-ences of online therapy’, ii) ‘Challenges experienced by therapists and clients in online therapy’, and iii) ‘Preparation and training for online therapy’. Online therapy was experienced as helpful, particularly in terms of mitigating against previous geographical and temporal barriers to up-take. However, due to technological disruptions and potential blurring of professional bounda-ries, online therapy may detract from the emotional salience of therapy, negatively impacting the therapeutic relationship and containment. Considering the positive experiences, participants ex-pected the demand for online therapy would continue to increase. Particularly in the occupational context, online therapy can offer intervention without jeopardising mental health shame. The findings provide preliminary qualitative evidence that online therapy can be a useful adjunct to traditional forms of face-to-face therapy. However, therapists require more explicit training in implementing online therapy. Results are discussed in particular regarding the utility of this therapy for working clients.
... Tuttavia, nonostante queste credenze e pregiudizi siano diffusi, talvolta anche nei clinici, la letteratura documenta (Hanley & Reynolds, 2009;Beatty & Binnion, 2016;Wind, Rijkeboer, Andersson, & Riper, 2020;Hubley, Lynch, Schneck, Thomas, & Shore, 2016;Kramer, Mishkind, Luxton, & Shore, 2013) come la psicoterapia online sembra essere utilizzata efficacemente da anni, innanzitutto per rispondere ad un problema di accessibilità e "democraticità" della cura, ovvero raggiungere gli "irraggiungibili" geograficamente o per altri ostacoli di varia natura (Mancuso, 2019), ma anche con plurime prove in sostegno della non inferiorità (Yuen, Goetter, Herbert, & Forman, 2012;Berger, 2017;Berryhill et al., 2019;Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018;Hoffmann et al., 2019) anche durante il periodo di emergenza da COVID-19 Bouchard et al., 2020;Liu et al., 2020;Chherawala & Gill, 2020;Simon, 2020;Chiauzzi, Clayton, & Huh-Yoo, 2020;Waller et al., 2020;Yu et al., 2020) dimostrandone l'efficacia in termini di intervento, sostegno e riduzione del sintomo. In particolare, nello studio di Bouchard e colleghi (2020) condotto su 71 partecipanti adulti con disturbo di panico e agorafobia, divisi in due sottogruppi, entrambi in trattamento CBT, il primo (n=40) trattato mediante setting online e il secondo (n=31) tramite setting standard (face-to-face), ha evidenziato un significativo miglioramento della sintomatologia da panico, agorafobica assieme ad una riduzione dei timori legati alle sensazioni fisiche e ad un miglioramento del tono dell'umore: tali risultati sono stati riscontrati anche a 12 mesi di follow-up in entrambi i gruppi. ...
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Risultati: Dal confronto operato tra il campione totale dei Tp e dei Pz su un set di variabili indagate (qualità dell’interazione/comunicazione, condivisione, percezione del setting, COVID self-disclosure, autoefficacia percepita, impotenza, frustrazione, ottimismo, disponibilità a continuare in modalità online) emerge che il gruppo dei Tp mostra punteggi più elevati, rispetto al gruppo di Pz, su tutte le variabili indagate, mantenendo un atteggiamento ottimistico e una disponibilità a continuare la psicoterapia con modalità online anche a seguito della quarantena. Dall’analisi di confronto tra Tp con expertise e senza, emerge minore impotenza nei primi rispetto ai secondi senza esperienza pregressa nel setting online. Infine, emergono interessanti correlazioni significative fra il pregiudizio negativo dei Pz, l’andamento della terapia, i vissuti emotivi negativi del paziente e la percezione del terapeuta durante la terapia in modalità online. Conclusioni: Questo studio mette in luce interessanti risultati, evidenziando il punto di vista di psicoterapeuti e Pz sulla psicoterapia online. A riguardo, emergono alcune difficoltà riscontrate sia nei Tp che nei Pz. Vale a dire le preoccupazioni dei Tp riguardo all’autoefficacia percepita rispetto all’intervento, alla qualità della comunicazione con i propri Pz, maggiori nei Tp senza esperienza di terapia online pregressa. Inoltre, si osserva nei Tp un maggiore ricorso ad interventi di self-disclosure rispetto al tema del COVID-19 e in risposta alle difficoltà percepite. Inoltre, il pregiudizio e le credenze al negativo dei Pz sembrano avere un’influenza sulla percezione della qualità della terapia. Lo studio evidenzia i vantaggi del setting online come funzionale alla gestione dell’emergenza e come possibile alternativa al setting standard. Fornisce spunti di riflessione riguardo la gestione del setting online sottolineando come le difficoltà riscontrate non siano solo dei Pz ma anche relative al vissuto dei Tp, entrambi costretti dall’emergenza COVID-19 ad adattarsi al cambiamento di setting. ONLINE PSYCHOTHERAPY: LIMITS AND ADVANTAGES. THE POINT OF VIEW OF THERAPIST AND PATIENTS Abstract Objective: The aim of this work is to explore the issue of online psychotherapy as a means of intervention which has become necessary due to the COVID-19 emergency. Research was conducted with the aim of investigating, from the point of view of therapists and patients, the quality, self-efficacy and difficulties related to the online setting, highlighting their limitations and advantages. Method: Two macro-samples, a first composed by therapists (Tp) (n=364) and a second by patients (Pz) (n = 226) filled out a questionnaire built ad hoc, sent with a remote link that investigated different areas. Exploratory and parametric analyses were carried out on the two samples (Tp and Pz) obtaining different comparisons and correlations. Results: From the comparison made between the total sample of therapists and patients on a set of investigated variables (quality of interaction/communication, sharing, perception of setting, COVID self- disclosure, perceived self-efficacy, impotence, frustration, optimism, willingness to continue online) it emerges that the group of therapists shows higher scores, with respect to the group of patients, on all the variables investigated, maintaining an optimistic attitude and a willingness to continue psychotherapy with online modality also following the quarantine. The comparison analysis between therapists with expertise and without, shows less impotence in the former than in the latter without previous experience in the online setting. Finally, interesting meaningful correlations emerge between the negative prejudice of the patients, the course of the therapy, the negative emotional experiences of the patient and the perception of the therapist during the therapy in online mode. Conclusions: This study highlights interesting results, highlighting the point of view of psychotherapists and patients on online psychotherapy. In this regard, there are some difficulties found in both therapists and patients. However, it highlights the difficulties encountered most in both therapists and patients. That is to say, the therapists’ concerns about the perceived self-efficacy of the intervention, the quality of communication with their patients, greater in therapists without previous experience of online therapy. In addition, therapists see greater use of self-disclosure interventions than the COVID-19 issue and in response to perceived difficulties. Furthermore, the prejudice and negative beliefs of patients seem to have an influence on the perception of the quality of therapy. The study highlights the advantages of the online psychotherapy as functional to emergency management and as a possible alternative to the standard setting. It provides food for thought regarding the management of this type of setting emphasizing how the difficulties encountered are not only patients-experience-related but also therapists-experience-related, both forced by the emergency COVID-19 to adapt to this change of setting.
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Tele-mental health, or the provision of remote counseling services, has been available for decades. This qualitative study uses the framework of affordances, derived from Gibson, to examine what social work practitioners working on direct to consumer tele-mental health (DTCTMH) platforms are discovering about the features, benefits, and constraints of virtual therapy. An interpretive phenomenological approach was employed to document the lived experiences of social workers who practice in this manner. According to the practitioners interviewed, for a subset of individuals seeking treatment, DTCTMH can offer meaningful interpersonal interaction that confers benefit. Key affordances include accessibility, anonymity, meaningful work, autonomy, lifelong learning, and access by new populations. Practitioners simultaneously acknowledge the ethical complexities and structural challenges of DTCTMH practice. The article concludes with suggestions for future research, policy, and practice.
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The study provides insight into counsellors’ experiences of counselling clients online. The foci include (a) counsellors’ experience of negotiating the therapeutic relationship online, (b) their experiences of utilising and adapting their clinical skills to assess clients in an online capacity, and (c) ethical issues associated with practicing online. Open-ended interviews were conducted with 3 counsellors located in Canada and 1 in the United States. Narrative analysis revealed eight major themes: convenience, therapeutic alliance, online counselling skills, assessing client suitability, reaching diverse clients, assessing client satisfaction, legal and ethical concerns, and personal and professional goals.
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Background: Clinical assessments for children and young people entering a mental health service help to identify the prevalence of need within that population, support intervention recommendations, and enable service evaluation. Evidence related to the use of standardised measures in an ever-expanding online environment, for the purpose of identifying need, is limited. Methods: This study explores the reliability of using a standardised measure to detect clinical need in an online therapeutic environment, and the measures assessed are as follows: Strengths and Difficulties Questionnaire (SDQ), Young Person's CORE (YP-CORE) and the Short Warwick and Edinburgh Wellbeing Scale (SWEMWBS). A deep-dive approach is used to inform practitioner assessment of young people, followed by a Weighted Cohen's Kappa (Κw) to measure the interrater reliability between this and the individuals' self-rated outcome. Composite case studies represent the complexities of presentation among the sample population. Results: The interrater reliability between self-rated and practitioner rated assessment varied between Κw = .222 and Κw = 0.446 depending on the measure. High levels of need and low levels of well-being were found among the sample (YP-CORE Avg. = 26.9, SDQ Avg. = 19.56, SWEMWBS Avg. = 18.1). Conclusions: The findings demonstrate a fair to moderate reliability when assessing concordance between service users and practitioners, which suggests standardised measures are a reliable indicator of need. Higher levels of need were present than those seen previously in general or face-to-face clinical populations, which suggests using such measures in an online therapeutic environment influences the way in which assessments are responded to.
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Online counseling is a growing area of clinical work with relatively little empirical evidence about the kind of clients that use the medium, advantages and disadvantages of online counseling, and satisfaction with relationships and treatment service. Sociodemographics were collected on 81 self-selected clients using online counseling, and self-reported therapeutic alliance and satisfaction with online counseling were assessed for comparison to past studies of clients using traditional face-to-face counseling. Online clients were predominantly female, were already regular Internet users, and enjoyed the convenience and anonymity of the service. They were satisfied with their relationships and treatment online but not as satisfied as clients who have undergone traditional face-to-face counseling. The main disadvantage, the loss of nonverbal information, was offset by the advantage of anonymity when sharing shameful personal information. Research limitations and clinical implications of the study are discussed.
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The Brazilian Federal Council of Psychology has not approved Internet Therapy yet, therefore, research is recommended. The technical possibility of offering such a service and the possibility of developing a working alliance were investigated. A system of registration and brief psychotherapy, which was asynchronously carried out, was created using free software. The therapeutic relationship was analyzed by using the Working Alliance Inventory (WAI). Clients enrolled (373) were predominantly female, with median age around 28, graduate and experienced Internet users. In the 53 therapies carried out there were significant differences in the WAI results between clients who abandoned the therapy (19) and clients who finished it (29). It was possible to conduct Internet therapy, and tht therapeutic relationship presented characteristics similar to those described in the specialized bibliography about the inventory.
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Hands-on Help is a narrative review of the mushrooming field of computer-aided psychotherapy for mental health problems as a whole, from the time it began in the 1960's through to the present day. The many types of computer-aided psychotherapy and how each might be accessed are detailed together with the pros and cons of such help and the functions it can serve. The authors review prevention as well as treatment. The book describes and summarizes 97 computer-aided self-help systems in 175 studies according to the types of problem they aim to alleviate. These include phobic, panic, obsessive-compulsive and post-traumatic disorders, depression, anxiety, eating disorders, sexual problems, smoking, alcohol and drug misuse, schizophrenia, insomnia, pain and tinnitus distress, and childhood problems such as encopresis, autism and asthma. Within each type of problem the systems are described according to whether they are used on the internet, CD-ROM, phone, handheld or other device. The final chapter shows how internet self-help systems with phone or email support allow clinics to become more virtual than physical. It also discusses methods of screening suitability and of supporting users, constraints to delivery, uptake and completion, cost-effectiveness, and the place of computer-aided self-help in healthcare provision. This informative book will be essential reading for psychiatrists, psychologists and all other mental health professionals interested in broadening their understanding of computer-aided psychotherapy.
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A new form of therapy termed therap-e-mail, developed by the authors for use in their Internet-based counselling service Therapy Online, is explained. Two major challenges that have been brought up by other professionals concerning on-line therapy are addressed, and solutions to these challenges are proposed. Five significant advantages of therap-e-mail are discussed. The need for research, and the implications for guidance and counselling, are addressed.