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

Abstract

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.

Full text

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
References
Ainsworth, M. (2002). My life as an e-patient.
In R. Hsiung (Ed.), E-Therapy: Case studies, guiding
principles, and the clinical potential of the internet
(pp.194–215). New York: W.W. Norton & Co.
Alleman, J. (2002). Online Counselling: The internet
and metal health treatment. Psychotherapy, 39,
199–209.
Anthony, K. (2003). The use and role of technology
in counselling and psychotherapy. In S. Goss &
K. Anthony (Eds.), Technology in counselling and
psychotherapy: A practitioner’s guide (pp.13–34).
London: Palgrave.
Anthony, K. (2000a). Counselling in cyberspace.
Counselling Journal, 11(10), 625–627,
Anthony, K. (2000b). The nature of the therapeutic
relationship within online counselling. Unpublished
Dissertation, University of Greenwich, London
Anthony, K. & Jamieson, A. (2005). Guidelines for
online counselling and psychotherapy (2nd ed.).
Rugby: BACP.
Barak, A., Hen, L. Boniel-Nissim, M. & Shapira, N.
(2008). A comprehensive review and a meta-
analysis of the effectiveness of internet-based
psychotherapeutic interventions. Journal of
Technology in Human Services, 26(2/3/4), 109–160.
Bloom, J. (1998). The ethical practice of
webcounselling. British Journal of Guidance and
Counselling, 26, 53–60.
Bloom, J. & Walz, G. (Eds.)(2004). Cybercounselling
and cyberlearning: Strategies and resources for the
millennium. Alexandria, VA: American
Counseling Association.
Bloom, J. & Walz, G. (Eds.)(2000). Cybercounselling
and cyberlearning: An encore. Alexandria, VA:
American Counseling Association.
Chester, A. & Glass, C. (2006). Online counselling:
A descriptive analysis of therapy services on the
internet. British Journal of Guidance & Counselling,
34(2), 145–160.
Childress, C. (2000). Ethical issues in providing
online psychotherapeutic interventions. Journal
of Medical Internet Research, 2(1). Retrieved
21 December, 2007, from:
www.pubmedcentral.nih.gov/
articlerender.fcgi?artid=1761841
Cohen, G. & Kerr, B. (1998). Computer-mediated
counselling: An empirical study of a new mental
health treatment. Computers in Human Services,
15, 13–26.
Cohen, J. (1969). Statistical power analysis for the
behavioural sciences. New York: Academic Press.
Cook, J. & Doyle, C. (2002). Working alliance in
online therapy as compared to face-to-face
therapy: Preliminary results. CyberPsychology &
Behaviour, 5, 95–105.
Derrig-Palumbo, K. Zeine, F. (2005). Online therapy:
A therapist’s guide to expanding your practice.
New York: W.W. Norton & Co.
Evans, J. (2009). Online counselling and guidance skills:
A practical resource for trainees and practitioners.
London: Sage.
Fink, J. (Ed.) (1999). How to use computers and
cyberspace in the clinical practice of psychotherapy.
New York: Jason Aronson Inc.
Goss, S. & Anthony, K. (2004). Ethical and practical
dimensions of online writing cures. In G. Bolton,
S. Howlett, C. Lago & J. Wright (Eds.), Writing
cures. East Sussex: Brunner-Routledge.
Goss, S. & Anthony, K. (Eds.) (2003). Technology in
counselling and psychotherapy. London: Palgrave.
Grover, F., Jr., Wu, H.D., Blanford, C., Holcomb, S. &
Tidler, D. (2002). Computer-using patients want
internet services from family physicians. Journal of
Family Practice, 51, 570–572.
Haberstroh, S., Duffey, T., Evans, M. & Trepal, H.
(2007). The experience of online counselling.
Journal of Mental Health Counseling, 29(3),
269–282.

12 Counselling Psychology Review, Vol. 24, No. 2, June 2009
Terry Hanley & D’Arcy J. Reynolds, Jr.
Hanley, T. (in press). The Working Alliance in
Online Therapy with Young People: Preliminary
findings. British Journal of Guidance and
Counselling.
Hanley, T. (2004). Online counselling: A heuristic study
examining the relational depth of computer-mediated
relationships. Unpublished Dissertation,
University of Manchester, Manchester.
Heinlen, K., Welfel, E., Richmond, E. & Rak, C.
(2003). The scope of web counselling: A survey
of services and compliance with NBCC standards
for the ethical practice of web counselling.
Journal of Counselling and Development, 18, 61–70
Horvath, A. & Bedi, R. (2002). The alliance.
In J. Norcross (Ed.), Psychotherapy relationships that
work: Therapist contributions responsive-ness to
patients. New York: Oxford University Press
Hsiung, R. (Ed.) (2002). E-Therapy: Case studies,
guiding principles, and the clinical potential of the
internet. New York: W.W. Norton & Co.
Jones, G. & Stokes, A. (2009). Online Counselling:
A handbook for practitioners. London: Palgrave.
Kaltenthaler, E. Parry, G. & Beverley, C. (2004).
Computerized cognitive behaviour therapy:
A systematic review. Behavioural and Cognitive
Psychotherapy, 32, 31–55.
King, R., Bambling, M., Reid, W. & Thomas, I.
(2006). Telephone and online counselling for
young people: A naturalistic comparison of
session outcome, session impact and therapeutic
alliance. Counselling and Psychotherapy Research,
6(3), 175–181.
King, S. & Poulos, S. (1999). Ethical guidelines for
online therapy. In J. Fink, How to use computers and
cyberspace in the clinical practice of psychotherapy
(pp.121–132). New York: Aronson Inc.
Klein, B., Richards, J. & Austin, D. (2006). Efficacy of
internet therapy for panic disorder. Journal of
Behaviour Therapy and Experimental Psychiatry,
37(3), 213–238.
Knaevelsrud, C. & Maercker, A. (2006). Does the
quality of the working alliance predict treatment
outcome in online psychotherapy for
traumatized patients? Journal of Medical Internet
Research, 8(4). Retrieved 21 December, 2007,
from:
www.pubmedcentral.nih.gov/
articlerender.fcgi?artid=1794007
Kraus, R. (2004). Ethical and legal considerations for
providers of mental health services online.
In R. Kraus, J. Zack & G. Stricker (Eds.), Online
counselling: A handbook for mental health
professionals (pp.123–143). London: Elsevier
Academic Press.
Kraus, R., Zack, J. & Stricker, G. (Eds.) (2004). Online
counselling: A handbook for mental health
professionals. London: Elsevier Academic Press
Lago, C. (1996). Computer therapeutics. The Journal
of the British Association for Counselling, 7(4),
287–289.
Lambert, M. & Ogles, B. (2004). The efficacy and
effectiveness of psychotherapy. In M. Lambert
(Ed.), Bergin and Garfield’s handbook of
psychotherapy and behaviour change (5th ed.,
pp.139–193). New York: John Wiley.
Lang, P., Melamed, B. & Hart, J. (1970).
A psychophysiological analysis of fear modifica-
tion using an automated desensitization
procedure. Journal of Abnormal Psychology, 76,
220–234.
Leibert, T., Archer, J. Jr., Munson, J. & York, G.
(2006). An exploratory study of client
perceptions of internet counselling and the
therapeutic alliance. Journal of Mental Health
Counselling, 28, 69–83.
Lombard, M. & Ditton, T. (1997). At the heart of it
all: The concept of presence. Journal of Computer
Mediated Communication, 3(2). Retrieved
21 December, 2007, from:
http://jcmc.indiana.edu/vol3/issue2/
lombard.html
Marks, I., Cavanagh, K. & Gega, L. (2007). Hands-on
help: Computer-aided psychotherapy. East Sussex:
Psychology Press.
MORI. (2001). Nearly three out of five internet users
would seek help for mental health problems on the net.
Retrieved 21 December, 2007, from:
www.mori.com/polls/2001/zeus.shtml
Murdoch J. & Connor-Greene, P. (2000). Enhancing
therapeutic impact and therapeutic alliance
through electronic mail homework assignments.
Journal of Psychotherapy Practice & Research, 9,
232–237.
Murphy, L. & Mitchell, D. (1998). When writing
helps to heal: E-mail as therapy. British Journal of
Guidance and Counselling, 26(1), 21–32.
National Statistics (2007). First release: Internet access:
households and individuals. London: National
Statistics.
NICE (2006). Computerised cognitive behaviour therapy
(CCBT) for the treatment of depression and anxiety.
Technology Appraisal no. 97. London: NICE.
Pelling, N. & Renard, D. (2000). Counselling via the
internet. Can it be done well? The Psychotherapy
Review, 2(2), 68–72.
Prado, O. & Meyer, S. (2006). Evaluation of
therapeutic relations in asynchronous therapy via
Internet through working alliance inventory
[English translation retrieved 7 January, 2008,
from: www.psico.net/arquivos/]. Psicologia em
Estudo, 11(2), 247–257.
Reynolds, D. & Hanley, T. (in preparation). Reaching
out across the virtual divide: an empirical review of
text-based therapeutic relationships. Personal
Correspondence, 20 April, 2008.

Counselling Psychology Review, Vol. 24, No. 2, June 2009 13
The quantitative research into online outcomes and alliances
Reynolds, D.J., Jr., & Stiles, W.B. (2007). Online data
collection for psychotherapy process research.
CyberPsychology & Behaviour, 10, 92–99.
Reynolds, D., Stiles, W. & Grohol, J. (2006). An
investigation of session impact and alliance in
internet-based psychotherapy: Preliminary
results. Counselling and Psychotherapy Research,
6(3), 164–168.
Riva, G. & Galmiberti, C. (2005). Towards
CyberPsychology: Mind, cognition and society in the
internet age. Amsterdam: IOS Press.
Robson, D. & Robson M. (2000). Ethical issues in
internet counselling. Counselling Psychology
Quarterly, 13(3), 249–257.
Robson, D. & Robson, M. (1998). Intimacy and
computer communication. British Journal of
Guidance and Counselling, 26(1), 33–42.
Rochlen, A., Zack, J. & Speyer, C. (2004). Online
therapy: Review of relevant definitions, debates,
and current empirical support. Journal of Clinical
Psychology, 60(3), 269–283.
Sanders, P. (2007). Using counselling skills on the
telephone and in computer-mediated communication.
Ross-on-Wye: PCCS Books.
Samaritans (2007). Facts and figures. Retrieved
21 December, 2007, from:
www.samaritans.org/about_samaritans/
facts_and_figures.aspx
Samaritans (2004). Personal correspondence.
14 February, 2004.
Stofle, G. (2002). Chat room therapy. In R. Hsiung
(Ed.), E-Therapy: Case studies, guiding principles,
and the clinical potential of the internet (pp.92–135).
New York: W.W. Norton & Co.
Stofle, G. (2001). Choosing an online therapist.
Harrisburg, PA: White Hat Communications.
Stofle, G. (1997). Thoughts about online psychotherapy:
Ethical and practical considerations. Retrieved
21 December, 2007, from:
http://members.aol.com/stofle/
onlinepsych.htm
Suler, J. (2004). The psychology of text relationships.
In R. Kraus, J. Zack & G. Stricker (Eds.), Online
counselling: A handbook for mental health
professionals (pp.19–50). London: Elsevier
Academic Press.
Wade, S.L., Wolfe, C., Brown, T.M. & Pestian, J.P.
(2005). Putting the pieces together: Preliminary
efficacy of a web-based family intervention for
children with traumatic brain injury. Journal of
Pediatric Psychology, 30(5), 437–442.
Weizenbaum, J. (1976). Computer power and human
reason. London: W.H. Freeman.
Woodruff, S., Edwards, C., Conway, T. & Elliott, S.
(2001). Pilot test of an internet virtual chat room
for rural teen smokers. Journal of Adolescent
Health, 29, 239–243.
Wootton, R., Yellowlees, P. & McLaren, P. (Eds.)
(2003). Telepsychiatry and e-mental health.
New York: RSM Press.
Young, K. (2005). An empirical examination of client
attitudes towards online counselling.
CyberPsychology and Behaviour, 8(2), 172–177.