Couns Psychother Res. 2020;00:1–13.
Received: 27 August 2020
Revised: 15 November 2020
Accepted: 16 Nove mber 2020
SPECIAL SECTION ONLINE TECHNOLOGIES
A systematic review of higher education students' experiences
of engaging with online therapy
Terry Hanley | Claire Wyatt
This is an op en access arti cle under the ter ms of the Creative Commons Attribution-NonCommercial Licen se, which permi ts use, distri bution and repr oduction
in any medium, provided the original work is properl y cited an d is not use d for comm ercial purposes.
© 2020 The Authors. Counselling and Psychotherapy Research published by John Wiley & So ns Ltd on behalf of British Associat ion for Counselling and
Contri buting autho r: Terr y Hanley (terr y.hanley @manc heste r.ac.uk )
University of Ma nches ter, Manchester, UK
Claire Wyatt, University of Ma nches ter,
Manche ster, UK
Aim: The prevalence of mental health difficulties and the demand for psychological
support for students in higher education (HE) appear to be increasing. Online therapy
is a widely accessible resource that could provide effective support; however, little
is known about such provision. The aim of this study was therefore to answer the
research question ‘What factors serve to influence higher education students' levels
of engagement with online therapy?’
Method: A systematic review of qualitative scholarly and peer-reviewed literature
was conducted across 10 databases. Six papers met the inclusion criteria, were as-
sessed for quality and were analysed using thematic synthesis.
Findings: Factors that serve to motivate HE students to engage with online therapy
included the perception that it might enhance the quality of the therapeutic relation-
ship, that it would facilitate more autonomy in the work, and that it might enable
them to be anonymous and avoid face-to-face contact. In contrast, demotivating
factors were primarily practical in nature. Fitting therapeutic work into their busy
lives, technological challenges and persisting mental health stigma proved important
Conclusion: This review synthesises the reasons why HE students might engage with
or withdraw from online therapy. It highlights that students appear to view online
therapy positively, but they can be inhibited by both personal and practical issues.
Therapeutic services therefore need to ensure that information about the work they
offer online is clear and transparent and that the platforms they work on are secure
and stable. Finally, the need for further research, to keep abreast of technological
developments, is recommended.
COVID-19, engagement, higher education, online therapy, student
HANLEY ANd W YAT T
1 | INTRODUCTION
The increasing prevalence of mental health difficulties in higher
education students is a growing concern that requires considerable
critical attention (Deasy et al., 2014). In the summary of equality
and diversity data issued by the United Kingdom's (UK) Office for
Students (OfS), reporting of mental health conditions by students
increased from 0.6% in 2010/11 to 3.1% in 2017/18, an inc rease big-
ger than the reporting of any other disability (May, 2019). A recent
briefing paper by Hubble and Bolton (2019, p.3) also draws attention
to 33.9% of students who have experienced a ‘serious psychological
issue for which they felt they needed professional help’.
Students engaging in higher education are a particularly vulnera-
ble population due to the developmental transition they are experi-
encing (Conley et al., 2014). The additional impact of the COVID-19/
coronavirus global pandemic (ECDC, 2020) has been a current and
highly per tine nt con ce rn for th e prov ision of appr op riate, he lp fu l on-
line psychological support during challenging times (Sahu, 2020). As
a consequence, within some countries, all educational institutions
(schools, colleges and universities), and retail and non-essential ser-
vices were instructed by governments to close and populations were
advised to stay home with the exception of essential travel or work.
The implications of measures such as these for well-being and men-
tal health are vast. Arguably, this is further heightened for young
people and HE students whose education, physical–social interac-
tion and support networks have been dramatically curtailed.
Prior to the outbreak of COVID-19, the number of HE students
experiencing mental health difficulties had already appeared to in-
crease, reflected in the rising demand for support. In a survey con-
ducted by the Institute for Public Policy Research (IPPR; 2017), 61%
of higher education institutions reported an increase in demand
for counselling services of more than 25% over a five-year period
(T ho rl ey, 2017). The mounti ng dem an d on ins ti tu ti on s to provide ad-
equate and effective counselling services, combined with limite d re-
sources, has contributed to the development and provision of online
therapy services in addition to traditional support pathways (Inglis
& Cathcar t, 2018). HE students communicate and relate to other
people pervasively via technology online, repor tedly spending more
than 55 hr/week online (Hyperoptic, 2019). Services such as online
support networks (e.g. Big White Wall, SilverCloud), university on-
line therapy services (Kooth Student) and interactive self-help pro-
grammes have been established to tr y to meet this demand. Despite
the increasing demand for, and supply of, online therapy services
for HE students, data from several studies suggest that student en-
gagement in, and completion of, online therapy are consistently low
(Clarke et al., 2014; Musiat et al., 2014; Santucci et al., 2013).
1.1 | HE student well-being
The term ‘h igher educat ion’ in this review ref ers to individ uals who are
18 years or older attending institutions of education such as colleges
and universities. HE students are vulnerable to the development of
mental health problems as they are faced with a spectrum of internal
intrapersonal, interpersonal, educational, financial and cultural pres-
sures (Clear y et al., 2011). Internal risk factors relate to the individual
person and situation. Students transition through a signific ant phase
of intrapersonal growth and development during their time in higher
education (e.g. Chickering, 1969).
Chickering (1969) proposed seven areas that impact upon the
identity development for students. These include developing
competence, managing emotions, moving through autonomy, de-
veloping mature interpersonal relationships, establishing identity,
developing purpose and developing integrity. Chickering's (1969)
theory is supported by research that demonstrates that disruption
of the intrapersonal developmental process may contribute to the
onset of ment al health difficulties (Clear y et al., 2011; Eisenberg
et al., 2007). Most HE students are living away from home, often
for the firs t time, in an unfamiliar town , city or even cou ntr y, away
from an established network of family and friends, and experi-
ence subsequent homesickness and social isolation (Thurber &
Walton, 2012). International students are also confronted with
cultural–transitional factors, such as adapting to a different lan-
gu age , cu l t ure and cus tom s of a new cou ntr y. Fu r t h e r more, HE stu-
de nts mu s t man a ge fi nan c ia l inse cur i t y (Ei sen b erg et al., 20 07) an d
the establishing, developing and maintaining of a social network
Implications for practice
• Higher education institutions might of fer online therapy
as an alternative to face-to-face support. Online therapy
can provide a means of supporting students who might
not ordinarily access therapy, with the convenience, and
in some cases the anonymous nature of the communica-
tion, proving attractive to some individuals.
• Technological problems and personal concerns about
accessing therapeutic services can act as a major de-
terrent to engaging with online services. To limit de-
motivating factors, online therapy ser vices need to be
offered on secure and stable platforms. Further, they
should provide clear and transparent descriptions of the
online therapeutic support that they offer. Such content
will help to manage the expect ations of those accessing
• Currently, there is a very limited body of work explor-
ing online therapy with students in higher education.
Further research is needed to explore new developments
in online therapy with students in higher education.
Implication for policy
• Those involved in developing counselling and psycho-
therapy services in higher education settings should
consider online therapy as a viable way of increasing
engagement with the support they offer.
HANLE Y ANd W YATT
(Vazquez et al., 2011). Of consideration, during the COVID-19
global pandemic, are the stay-at-home policies and the psycho-
logical, emotional and financial pressure of unfolding events
(Sahu, 2020). HE student s have had to return to their homes, and
families all over the world and, in some instances, individuals are
solely reliant on technology to retain contact with educational
services, friends, social networks and support systems.
To support HE students in need of additional support, the re-
sources available vary from institution to institution. In general,
however, they comprise of services such as pastoral services, tele-
phone help lines, face-to-face institutional counselling services,
institutional online self-administered and supported services, work-
shops and online psychoeducation information (Broglia et al., 2017;
Hanley et al., 2020; Mair, 2016).
1.2 | Online therapy
Online therapy is an evolving therapeutic way of working that en-
deavours to provide an alternative pathway to support individuals
experiencing mental health difficulties (Hanley & Reynolds, 2009;
Sweeney et al., 2019). It assists in meeting a demand for psycho-
logical support that traditional face-to-face therapeutic resources
are not always able to meet (Stallman, 2011). For instance, online
services can support younger individuals in accessing services that
they may not ordinarily approach (Ersahin & Hanley, 2017). Online
provision of therapeutic support is recognised and referenced in
the literature by various terms including online therapy, e-therapy,
e-counselling, computerised cognitive behavioural therapy (cCBT)
and electronic cognitive behavioural therapy (eCBT) (Ostrowski &
Collins, 2016). The term ‘online therapy’ in this review refers to all
types of online therapeutic support, including asynchronous (email)
and synchronous (instant messaging) communication, video support
and self-administered Internet-delivered systems (SAID) of support.
The ongoing development of online therapy can be aligned to the
research reflecting upon the help-seeking behaviour of HE students.
This indicates an increasing demand by young people for psychologi-
cal support and help-seeking predominantly via the Internet in the
first instance (Hanley et al., 2019).
1.3 | Engagement with online therapy
The term ‘engagement’ in this review is interpreted as ‘to partici-
pate in, and to complete an agreed number of therapeutic sessions’.
There is considerable literature relating to online therapy, includ-
ing studies on engagement with online therapy. This includes re-
flections on the broad territory of online therapy and also focuses
on specific areas such as cCBT, eCBT, and asynchronous and syn-
chronous approaches, and concerns different presentations and
populations. However, most of the research is currently quantitative
(Musiat et al., 2014; Richards & Timulak, 2012) and focuses upon re-
ported fallout rates, dropout figures, levels of attrition, efficacy and
satisfaction. For instance, in Santucci et al.'s (2013) study evaluat-
ing university-implemented computerised CBT, 88% of participants
(n = 43) did not complete the course of eight sessions. High levels
of attrition, 61.7% of participants (n = 1,141), were also repor ted
in Musiat et al.'s (2014) paper investigating the efficacy for HE stu-
dents of a CBT-informed transdiagnostic online intervention. There
seems to be limited research, however, that considers how students
are engaging and experiencing online therapy or why levels of attri-
tion are consistently high for this medium of therapy.
1.4 | Rationale
Given the increasing prevalence of online therapy for HE students,
alongside the limited understanding of why this group might engage
with such services, this review provides a synthesis of the research
reflecting upon this topic. As such, the following research question
What factors serve to influence higher education stu-
dents' levels of engagement with online therapy?
2 | METHODOLOGY
A systematic review is a rigorous and methodical review of the litera-
ture that, unlike a standard literature review, utilises a ‘pre-specified
protocol to minimise bias’ (Dempster, 2011, p.15) to appraise and
synthesise qualit y research findings (Hanley & Cutts, 2013). In this
paper, a systematic review of the peer-reviewed literature was con-
ducted, investigating HE student s' engagement with online therapy.
2.1 | Search terms and strategy
The search strategy comprised of an initial search of Google Scholar,
PsycINFO and EMBASE to confirm no existing systematic reviews
relating to HE students' experiences of online therapy had been
conducted. A total of 10 dat abases, plus additional sources such as
Google Scholar and reference list s of relevant articles, were used in
the search strategy, including the following: PsycINFO, ERIC , Scopus,
Cochrane Library, American Periodicals, British Periodicals, Humanities
Index, Periodicals Archive Online, SciTech Premium Collection and Social
Science Premium Collection. Following a number of pilot searches,
the following search terms were developed: “higher education” OR
“HE” AND “student*” AND “online therapy” OR “e-therapy ” OR “in-
ternet counselling” OR “online therapy” OR “internet therapy” AND
“engagement” OR “attending” OR “attend” OR “engage” AND “com-
puterised cognitive behaviour therapy” OR “ccbt”. Searches were
limited to scholarly journals and peer-reviewed journal articles for
the time period 20 09–2019 and included only English-language ar-
ticles where full text was available. All searches were completed in
HANLEY ANd W YAT T
2.2 | Eligibility criteria
Studies retrieved from the searches were transferred to Mendeley
to facilitate removal of duplicates and assessment against the inclu-
sion and exclusion criteria (Figure 1).
Studies included a population sample of students aged 18 years
or older, which focused upon those attending higher education and
related explicitly to mental health. Additionally, eligible studies in-
cluded an online therapy intervention via computer, smar tphone or
other computer-mediated devices delivered synchronously (by text
message, chat room, Voice over Internet Protocol [VoIP], instant
messaging or videoconferencing) or asynchronously (by email, online
discussion boards) or via an independent programme or application,
for example cCBT. Qualitative studies reporting on engagement, at-
titudes and experience, access, adherence, repetition, completion,
attrition, dropout, premature termination or non-usage were con-
sidered for inclusion.
The database and Google Scholar searches followed the
Preferred Reporting Items for Systematic Reviews and Meta-
an alys es (PR ISMA) prot o c o l (see Figur e 2 for a PRIS MA flow di a gr am
of search process), generating a total of 1,315 records. Following
a screening by title and removal of duplicates, 181 records were
screened by abstract according to the inclusion and exclusion cri-
teria; of these, 151 records were excluded. The full-text articles
were then read, and of the remaining 30 records, 24 records were
excluded that were either unpublished, did not focus upon mental
health, did not relate explicitly to higher education and where the
population sample was below 18 years old. Thirteen additional re-
cords were identified within the articles as potentially eligible but
were further excluded due to not relating to mental health, not fo-
cusing on engagement or not pertaining to online therapy. The re-
maining six studies were deemed to meet the inclusion criteria for
the review, subject to quality appraisal.
2.3 | Quality appraisal
The final papers identified through the PRISMA process were as-
sessed for methodological qualit y using an adapted version of the
guidelines prepared by the National Institute for Health and Clinical
Excellence (NICE, 2009), devised by Ersahin (2014). The criteria con-
sidered to assess the quality of the papers focused upon (a) the aims
of the research, (b) the study design, (c) the recruitment and data
collection, (d) the data analysis, (e) the findings/interpretation, and
(f) the implications for research.
The overall quality assessment of the papers resulted in four of
six papers being rated as high quality and two of six papers rated
as medium quality (due to lack of clarity regarding ethical consider-
ations of the studies). Due to the limited number of papers involved
in the review, it was decided to include all six in the analysis.
FIGURE 1 Inclusion and Exclusion
Participants: aged between 18yrs
+, in Higher Education, Students,
related to mental health
Participants: under 18yrs, not in
Higher Education, not students
Intervention: Online therapy
o Interventions delivered via
computer / Smart phone / other IT
o Type of interventions:
Synchronous: text message /chat
room / VOIP / Instant messaging /
video conferencing or
Asynchronous: Email / Online
discussion boards or
Independent: Programme /
Application e.g. Computerised
cognitive behavioural therapy
Intervention: Not mental health, not
o Attitudes and experience
o Accessing, adherence, repetition
o Attrition, drop-out, premature
termination or non-usage
Study type: Not a study
Study type: Qualitative
Publication status: Published
Publication status: Unpublished
studies due to possible lower
Country of origin: Worldwide
Language: English Language Language: Not English language
HANLE Y ANd W YATT
2.4 | Data extraction and synthesis
The results/findings sections of the six papers that were identified
were utilised as data for thematic synthesis in this review (Thomas
& Harden, 2008). Thematic synthesis is an example of integrative
synthesis that is often more deductive when concepts in primar y
research are clearly defined (Flemming et al., 2019). There are three
stages to the process of thematic synthesis, including the following:
(a) line-by-line coding, (b) development of descriptive themes, and (c)
generation of analy tical themes. The analysis involved both deduc-
tive analysis of the data and explorator y inductive analysis. Themes
were explicitly looked for that reflected motivating and demotivating
factors related to student engagement with online therapy. Within
these high-level categories, a more explorative inductive analysis
was conduc ted to present the nuances reported in the papers.
2.5 | Ethical considerations
This review was a desk-based study that did not include human
participants. As such, the study was conducted in accordance
with the University of Manchester ethical guidelines, the British
Psychological Society (BPS, 2014) and Health and Care Professions
Council (HCPC, 2012) research guidelines and the National Institute
for Health and Care E xcellence guidelines (NICE, 2012) for under-
taking systematic reviews.
3 | FINDINGS
The systematic search process (Figure 2) identified six peer-reviewed
journal articles for thematic synthesis in this review.
3.1 | Characteristics of Included Studies Table
A summary of the characteristics of the six identified articles was
produced and is reported in Figure 3 below. This included the
author(s) and year of publication, the primary aim and focus of the
article, the sample, the research design and the location of the au-
thor. The referenced numbers within the findings section relate to
the numbered papers on the characteristics table.
All of the papers focus upon therapeutic work with HE stu-
dents aged 18 years or older. As indicated in Figure 3, the primar y
FIGURE 2 PRISMA flow diagram of
the systematic search process
HANLEY ANd W YAT T
aim and focus of the papers varied, but each explicitly focused
upon the experiences of students accessing online therapeutic
3.2 | Summary of findings from data synthesis
The findings from the six papers are presented in three major
strands. Firstly, the motivating and demotivating factors are
presented. Following this, a final strand of unique factors is pre-
sented. This final strand included elements that did not naturally
fit into either of the first strands but related directly to the stu-
dents' experience of accessing online therapy. Sixteen subordinate
themes were identified from the data synthesis that fit into these
three overarching strands. Figure 4 illustrates these subordinate
themes and includes the number of coded references observed in
the papers in parenthesis.
3.3 | Motivating factors
Factors motivating individuals to engage with online therapy were
evident in all six studies and were strongly linked to the client's per-
sonal experiences of, and feelings about, engaging in online therapy.
These motivating factors were categorised into the following nine
subordinate themes: (a) enhancing the therapeutic relationship, (b)
facilitating autonomy, (c) avoiding face-to-face support, (d) providing
additional thinking time, (e) therapy tool, (f) reducing isolation, (g)
the value of the ra peutic wr it in g, (h) ano ny mit y, an d (i ) so ci al sup por t.
3.3.1 | Enhancing the therapeutic relationship
Clients reported greater engagement with online therapy when the
therapy was more personalised, offering support and understand-
ing, ack no wl edgement, a sen se of being heard and cared ab ou t (1–5).
FIGURE 3 Characteristics of included
Primary Aim and
Sample Design Location
2 Fang et al
experiences of online
of text-based online
Perspectives of cyber
Focus: Benefits &
challenges of cyber
4 Walsh &
and engagement with
Helpful and hindering
events in therapist-
delivered vs self-
CBT in college
online CBT in college
HANLE Y ANd W YATT
even when you didn't even read the email yet, you
know that somebody is caring for you.
(Mishna et al., 2013, p.173)
Further, in Dunn's (2012) analysis of semi-structured interviews,
10 former email counselling clients revealed aspects of the therapeu-
tic relationship necessary for positive engagement in therapy. These
included the establishment and maintenance of clear boundaries,
consistent unconditional positive regard and not feeling judged by the
therapist. Clients were seen to be more inclined to engage in face-to-
face therapy after a positive experience of the therapeutic relationship
in online therapy (1).
I felt she honestly cared ab out me and my problems and
I felt better about counsellors in general which made
me feel more comfortable meeting someone in person.
(Dunn, 2012, p.323)
In both Dunn (2012) and Fang et al.'s (2018) studies, the findings
supported the idea that the online environment can offer relational
distance within the therapeutic relationship, and create a sense of se-
curity, and that this is preferred over relational absence (i.e. computer-
ised cognitive behavioural therapy).
email just gives you that little bit of distance that pro-
(Dunn, 2012, p.321)
3.3.2 | Facilitating autonomy
Dunn (2012) linked the client's feelings of disempowerment in face-
to-face therapy to the perceived positions of power between the
therapist and client. In contrast, in online therapy the clients in the
study reported a greater locus of control with the therapy process.
if my issues were made light of or if I was told that
I was overreacting…I could just ignore the advice if
I wanted to and not reply. I guess it has to do with
a feeling of having more control over the counselling
and the directions it would take.
(Dunn, 2012, p.323)
Distinctive advantages of online therapy reported in Fang et al.'s
(2018) study included ‘autonomy and agency in the counselling pro-
cess’ (Fang et al., 2018, p.1781). In their study, clients report having
autonomy over when and how they chose to engage with online ther-
apy as being a factor that maintained engagement in online services.
typing stuf f out in whatever order I feel like, taking
as much time as I need to, directing the conversation
however I want and in whatever order I want…this is
one of the things that drew me to this programme.
(Fang et al., 2018, p.1781)
3.3.3 | Avoiding face-to-face contact
Clients reported experiencing difficulty with direct or face-to-face
contact. This linked with fear and preconceptions of judgement,
criticism and the perception of wasting another person's time
(1– 4) .
I don't like counsellors bec ause I always feel kind of
guilty that I'm wasting someone's time and it's very
intimidating sitting one on one with someone and
chatting about yourself.
(Walsh & Richards, 2017, p.26)
Consequently, for some, engaging in online therapy seemed to be a
safer and less intimidating alternative for seeking support.
FIGURE 4 Themes identified in findings
HANLEY ANd W YAT T
3.3.4 | Providing additional thinking time
In five of the studies (1–5), asynchronous online therapy was offered
to participants either by email, text-based or programme-based for-
mats. Individuals repor ted that thinking time was important to them
(1). Furthermore, convenience for those living at long distance, sup-
por t be ing available 24/7 and flexibilit y wi th lifest yle, espe cially dur-
ing examination and holiday periods, were key motivating factors for
engagement with online therapy (2–4).
you know it's easy, it fits into your lifestyle, it's
(Walsh & Richards, 2017, p.22)
3.3.5 | Therapy tool
Clients report using past online therapy sessions as a ‘therapy tool’
(1–4), notably being able to refer to previous work to gain a sense
of progress and accomplishment, as well as a set of resources
available in the prac tice and acquiring of new skills. Having a re-
cord of the therapeutic work completed appeared to motivate cli-
ents to engage with the therapeutic work as it facilitated change
and acted as a therapy tool for use in the present and future. Fang
et al. (2018) reported the provision of instant resources, such
as online tools and links, also encouraged engagement in online
you can read back over the reply again and again. This
helped me and I did it a lot. I would read them at dif-
ferent points throughout the week and in various dif-
ferent frames of mind.
(Dunn, 2012, p.322)
3.3.6 | Reducing isolation
Findings in four of the papers (1–4) reviewed reported that
clients engage with online therapy due to their experience of
physical and psychological isolation. For instance, findings in
Dunn's (2012) study suggest that difficult y asking for help and
self-doubt can psychologically isolate clients, preventing indi-
viduals from seeking help face-to-face. Engagement in online
therapy for these clients can therefore be within personal levels
of tolerance and reduce psychological pressure and the sense of
I had a problem with asking for help…online therapy
attracted me because I thought it would indicate to
me whether I was worthy of talking to someone and
(Dunn, 2012, p.323)
3.3.7 | Value of therapeutic writing
Mishna et al. (2013) report the value of written communication as
being cathartic, reducing avoidance and feeling more legitimate for
students engaging with cyber counselling. The cathartic quality of
writing was similarly reported in two of the other studies (2,4). Some
students appear to feel greater confidence t yping or writing, rather
than verbalising their feelings and experience (1).
instead of just writing into a journal where no one
would see it, it's like now someone is reading this and
responding in a way that's really good.
(Mishna et al., 2013, p.174)
3.3.8 | Anonymity
There is a level of safety and comfor t reported in the findings of
studies within the review (1,2,4,6). Clients reported being hidden or
concealed in this way of working. In some cases, a desire for ano-
nymity in counselling was repor ted, described in Dunn's (2012) find-
ings as being similar to a confessional. The desire for, and comfort
with, being detached or hidden is connected intrapersonally for cli-
ents with other subthemes of isolation and autonomy.
I was hoping to remain totally anonymous even to
you, my councillor.
(Fang et al., 2018, p.1780)
3.3.9 | Social support
Walsh and Richards' (2017) study repor ted on students engaging in a
programme of online therapy that also offered community support.
Findings in th is stu dy sugges t that stud en ts expe ri en ce d re assuran ce ,
support, validation and a sense of community whilst maintaining a
sense of anonymity. This helped student s to feel less alone and more
motivated to engage with the platform. As only one study offered
this type of suppor t, the significance of this cannot be extended too
far. Further studies exploring the helpfulness of community support
alongside online therapy could therefore be investigated.
it was good to like, know that other people were ac-
cessing it and have a sense of like community and
know that like you weren't alone it.
(Walsh & Richards, 2017, p.25)
3.4 | Demotivating factors
It is clear from synthesis of the findings of the papers that there
are factors that demotivate individuals from engaging with online
HANLE Y ANd W YATT
therapy. Four subordinate themes were identified. These were as
follows: (a) time challenges, (b) technology challenges, (c) experi-
encing stigma, and (d) writing difficulty. It is critical to gain a clear
understanding of the factors demotivating clients from sustained
engagement with online therapy in order to improve services
and meet the demands of students experiencing psychological
3.4.1 | Time challenges
Findings in three of the studies reviewed (2,4,6) suggest that stu-
dents underestimate the commitment of time and effor t required
to engage with online therapy, perhaps mistaking it for a ‘quick
fix’. However, once they engage with the process, those involved
in the studies reported gaining a clearer understanding of what is
involved and what is expected. This process can lead to high rates
of dropout. Conflicts with other priorities such as educational de-
mands and pressure also result in dropping out of the online pro-
cess (4). Findings in two of the studies reported frustration with
the time needed in online therapy, the involvement of a lot of work
and resistance to do the work due to the time commitment re-
It seems to require a lot more effort than a session
(Fang et al., 2018, p.1783)
3.4.2 | Technology challenges
Two out of six studies found technology to be a demotivating factor
relating to engagement in online therapy. The key issues reported
related to the difficulty of navigating support online, administration
issues (such as difficulty logging in or being disconnected), bounda-
ries being interrupted by technology, and confusion and frustration
navigating the nuances of online communication (2,5).
I hit the wrong button and saved a draft instead of
sending out the email! It seems that technical difficul-
ties keep happening to me.
(Fang et al., 2018, p.1782)
3.4.3 | Experiencing stigma
Individuals continue to experience stigma regarding seeking psycho-
logical help and support. Students reported feelings of shame and
fear of judgement for needing counselling and fear of exposure or
wasting the counsellors' time (1,2,4).
I do feel that people generally look shamefully on
people who need counselling, like they can't deal
with their problems on their own. And prior to signing
up..there was an element of shame in myself, for this
(Dunn, 2012, p.322)
3.4.4 | Writing difficulty
One of the studies in the review highlighted that writing may be a
challenge for some individuals and bec ause online therapy is heavily
dependent on the client communicating their feelings and experi-
ences by writing, students may be more inclined to dropout for this
reason. The key challenges reported relating to writing difficulty
were frustration with the difficulty experienced trying to commu-
nicate, a lack of guidance with the writing process, uncertainty and
self-doubt about writing ability and being overwhelmed with the ef-
fort needed to engage by writing (2).
I felt a little frustrated with myself. I think it is difficult
for me within this email format to actually reflect on
what I am saying, even if I revise it.
(Fang et al., 2018, p.1782)
3.5 | Unique factors
During the synthesis process, it was evident that certain factors
were impacting levels of engagement both positively and negatively
that were specific to the individual or the design/t ype of online
therapy. The three subordinate themes identified were programme
content and design, individual beliefs and values, and online suppor t
3.5.1 | Programme content and design
This subtheme comprised 26 of the coding references across three
out of the six papers. It is clear from the data that how individuals ac-
cess, navigate and engage with online therapy programmes, whether
self-administered or facilitated by a therapist, can encourage or de-
motivate clients to maintain their engagement. Factors such as hav-
ing the ability to track achievement , monitor progress and gain new
information and skills (e.g. relaxation techniques) proved important.
Other factors such as difficulty navigating online platforms, an over-
whelming design, being tex t heavy, disengaging content and lack of
identification with programme features (e.g. unrealistic examples
and complicated programme structures) negatively impacted en-
When an item I'd completed was ticked of f of my to
do list, it provided me with a sense of accomplishment
(Walsh & Richards, 2017, p.22)
HANLEY ANd W YAT T
3.5.2 | Individual beliefs and values
Walsh and Richards (2017) reported that successful maintained en-
gagement in online therapy depended upon personal characteristics
such as how self-motivated the individual is. Findings in their study
were supported by Fang et al.'s (2018) study repor ting that individu-
als who are conscientious, goal-driven and self-motivated, with a
high level of self-efficacy, found engaging with online therapy more
comfortable and helpful.
I wanted to use the programme to gain the relevant
skills and strategies to tackle my personal issues.
(Walsh & Richards, 2017, p.25)
3.5.3 | Online support and provision
Differences in the counsellor response method and structure of
therapeutic interventions online can facilitate or interrupt the thera-
peutic relationship and therapeutic process (1). In Dunn's (2012)
findings, individuals reported the importance of consideration of
language and tex t formatting in online therapy. Adapting language,
text format and st yle to meet the needs of clients may help them to
feel heard and understood.
the way [my counsellor] responded to my emails was
perfect. She wrote between my paragraphs, address-
ing each issue as I had raised it, then I could do the
same for my reply. It helped to see clearly as issues
were addressed and clarified.
(Dunn, 2012, p.322)
4 | DISCUSSION
The findings of this study can help to guide services and improve the
effective provision of psychological support to potentially vulnerable
HE students. Within the three main strands highlighted in the analysis
(motivating factors, demotivating factors and unique factors), 16 sub-
ordinate themes were identified offering further insight and provid-
ing answers to the research question, ‘What factor s serve to influence
higher education students’ levels of engagement with online therapy?'
In summary, these highlight that the students in the studies were rela-
tively positive towards online therapy. They found the flexible nature
of the resources being offered helpful and this appeared to increase
the likelihood that they would engage with therapy. In contrast, how-
ever, the nascent development of online services also came through
in the reports from those in the studies. Technological limitations and
personal concerns about engaging with mental health and well-being
services were not always overcome by the mediated services on offer.
Below, we discuss these elements in more det ail.
Six out of the nine subthemes generated under the main theme
‘motivating factors’ relate to the value of humanising the clients'
experience of online therapy. Clients are motivated to engage with
online therapy when their experience is personalised, and they re-
ceive understanding, acknowledgement, caring and support from an-
other human being in addition to clear boundaries, consistency and
non-judgement. Providing online support services that embrace the
value of the therapeutic relationship is therefore critical, particularly
during extended periods of isolation. Equally, the research indicated
that the support of others experiencing psychological difficulties,
shared vi a fo ru ms or online comm unit ies, offered individuals a sense of
reassurance, validation, belonging and greater motivation to maintain
engagement. Such a finding is echoed in studies of students seeking
psychological support through similar means (e.g. Hanley et al., 2019;
Hyperoptic, 2019). The experience of communicating via technology
for HE students is arguably more normalised and comfortable for this
population. Considerable efforts and inroads have been made to cou-
ple this prolific use of technology with the increased demand for psy-
chological support. Stand-alone online therapeutic programmes have
become more prevalent, and in the effor t to expedite these services
swiftly, coupled with finite human resources (before the COVID-19
pandemic), the importance and significance of the human fac tor in the
online therapeutic arena is arguably in jeopardy of being lost. Such a
shift in therapeutic provision would contrast many of the engaging
factors noted in this synthesis. As such, this could have serious impli-
cations for the provision of self-administered online therapy and online
therapy facilitated by an untrained online supporter.
The studies also reflected that online therapy can mitigate initial
difficulties with direct interpersonal contact. For instance, Dunn's
(2012) paper reports that face-to-face therapy can be intimidating,
with some individuals fearing being analysed and judged by the ther-
apist and thus feeling overly self-conscious and finding themselves
unable to form the words to communicate. These findings are con-
sistent with studies such as Hanley et al.'s (2019) study exploring
how young people use online forums for support. Online therapy
therefore has the potential to offer psychological support to HE stu-
dents that is within their locus of control and level of tolerance.
Higher education students can experience greater agency in
online therapy. They can choose how and when they engage, fac-
tors that are often motivated by the perception of privacy and an-
onymity. Further, some students reported utilising online therapy
as a tool for the present and future (notably returning to therapeu-
tic interchanges that had been stored). Bohart and Tallman (2010)
describe client agency as critical in the therapeutic process in con-
tributing towards a successful outcome. Findings in Hanley's (2009,
2012) work examining the quality of the working alliance in online
therapy with young people similarly indicate the impor tance of cli-
ent agency when working therapeutically online. This is concordant
with Chickering's (1969) ‘seven vectors’ theory of identity, particu-
larly managing emotional well-being and moving through autonomy.
Accordingly, the wide provision of an online therapeutic resource
has the potential to offer ongoing suppor t in the psychological de-
velopment of young adults.
Significant factors demotivating HE student's engagement in
online therapy relate to the limited perception, expectation and
HANLE Y ANd W YATT
understanding of the work and time required to engage with the
online therapeutic process. As such, it is arguably the responsibil-
ity of therapists to find ways to inform, educate and raise aware-
ness of the therapeutic process, a factor that is not different with
face-to-face therapy but needs to be tailored to account for the
different media it is offered in. Technolog y removes many of the
physical barriers that traditional therapy can encounter; for in-
stance, it can increase accessibility to support by providing time
and space (Harris & Birnbaum, 2015; Pattison et al., 2015). Where
one bar ri er ma y be rem oved howeve r, pra c ti c al tech nol og ica l cha l-
lenges emerge in their place and can negatively impact upon levels
of engagement. The research informs us that some HE students
disengage from the online therapy process due to individual diffi-
culties and challenges with the process of writing itself. Findings
in King et al.'s (2007) study, focusing upon the motives and ex-
periences of young people who choose Internet instead of face-
to-face counselling, are consistent with this. They highlight the
challenge and concern that feelings may be lost in text or not fully
understood by the therapist.
Counsellors, psychotherapists and psychologists are well posi-
tioned to further develop and communicate standards and policies
for online therapeutic practice to therapists and client s. Similarly, as
stigma continues to be a factor affec ting individuals' engagement
with online therapy, it is arguably the responsibility of professionals
in these fields to continue raising awareness about mental health
and well-being so as to destigmatise the seeking of psychological
help and support. A s such, this review contributes to the idea that
the role of therapists, and thus the training of therapists, stretches
beyond the therapy room itself.
4.1 | Strengths, Limitations and Future Research
This systematic review is the first to bring together the literature
focusing upon how HE students experience engagement with on-
line therapy. The hope is that findings inform future research and
development of online services and better support the increasing
numbers of HE students experiencing psychological difficulty. There
are limitations to this study, however, which must be highlighted and
considered. Firstly, the limited capacity of the paper only permitted
a broad thematic synthesis of the data, which with more time and
resources could be deepened and potentially investigated further. A
thorough search was conducted of the library databases; however,
unpublished and grey literature was not included in the search strat-
egy, which may have limited the final ar ticles selected.
The work highlights numerous gaps in the understanding of on-
line work. For instance, further development of strategies to support
individuals who may find writing more arduous will help increase the
accessibility of online therapy. Similarly, future research and analy-
sis of existing online therapy platforms and programme content and
design may fur ther aid our un der st a nd in g of what str uct ure s, moda l-
ities and content HE students find helpful or unhelpful. Explorations
into these arenas will help inform the shaping of existing platforms
and design of new platforms to better meet the needs of users and
expectantly reduce attrition rates of such services.
In addition to the above, future re search should consider th e les-
sons learnt from the expedited transition of therapeutic face-to-face
services to online during the COVID-19 global pandemic. In particu-
lar, topics such as how services have evolved or been experienced as
helpful, unhelpful or differently to previous online provisions would
further the understanding of how HE students engage with online
5 | CONCLUSION
This paper set out to review the existing literature exploring how
HE students engage with online therapy. Doing so has highlighted a
series of fa ctors that are likely to both motiv ate an d de mo ti vate ind i-
viduals from such engagement. Specifically, students appear to view
online therapy positively, but they can be inhibited by both personal
issues, such as the stigma associated with seeking help for issues
related to their mental health and well-being, and practical issues,
such as technological failures. Therapeutic services therefore need
to ensure that information about the work they offer online is clear
and transparent and that the platforms they work on are secure and
stable. These findings resonate with the findings exploring online
work with other groups, such as younger populations, and highlight
the need for more research focusing upon this growing arena. Online
therapy is moving at such a pace, particularly given the impac t of
changes to modes of delivery during the COVID-19 pandemic, that
research needs to keep abreast of these changes to support the de-
velopment and reflect upon the appropriateness of such changes.
Student populations are ‘digital natives’, and the expectation that
therapeutic support is provided online is only likely to grow.
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How to cite this article: Hanley T, Wyatt C . A systematic
review of higher education students' experiences of engaging
with online therapy. Couns Psychother Res. 2020;00:1–13.