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Int. J. Environ. Res. Public Health 2021, 18, 10295. https://doi.org/10.3390/ijerph181910295 www.mdpi.com/journal/ijerph
Article
Qualitative Investigation into Therapists’ Experiences of
Online Therapy: Implications for Working Clients
Yasuhiro Kotera
1,
*, Greta Kaluzeviciute
1,2
, Christopher Lloyd
1
, Ann-Marie Edwards
1
and Akihiko Ozaki
3,4
1
College of Health, Psychology and Social Care, University of Derby, Derby DE22 1GB, UK;
g.kaluzeviciute@derby.ac.uk (G.K.); c.lloyd@derby.ac.uk (C.L.); annm.edwards@icloud.com (A.-M.E.)
2
Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge CB2 8AH, UK
3
Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki 972-8322, Japan;
aozaki-tky@umin.ac.jp
4
Medical Governance Research Institute, Tokyo 108-0074, Japan
* Correspondence: y.kotera@derby.ac.uk
Abstract: Online therapy has increasingly been utilised during the COVID-19 pandemic by many,
including working populations. However, few qualitative studies have explored how online ther-
apy is experienced in practice and discussed its implications for those working clients. Semi-struc-
tured interviews attended by nine integrative psychotherapists practising in California, the United
States, were conducted. Thematic analysis of the transcripts identified three themes: i) ‘Positive ex-
periences of online therapy’, ii) ‘Challenges experienced by therapists and clients in online therapy’,
and iii) ‘Preparation and training for online therapy’. Online therapy was assessed as being helpful,
particularly in terms of mitigating against previous geographical and temporal barriers to uptake.
However, due to technological disruptions and potential blurring of professional boundaries, online
therapy may detract from the emotional salience of therapy, negatively impacting the therapeutic
relationship and containment. Considering these positive experiences, participants expected that
the demand for online therapy would continue to increase. Particularly in the occupational context,
online therapy can offer interventions without fostering shame regarding mental health. The find-
ings provide preliminary qualitative evidence that online therapy can be a useful adjunct to tradi-
tional forms of face-to-face therapy. However, therapists require more explicit training in imple-
menting online therapy. Results are discussed in particular regarding the utility of this therapy for
working clients.
Keywords: online therapy; COVID-19; qualitative; therapeutic relationship; thematic analysis;
workplace mental health
1. Introduction
1.1. Emergence of Online Therapy
In 2013, the American Psychological Association published ‘Guidelines for the Prac-
tice of Telepsychology’. Analogous to this, within the UK, the British Association for
Counselling and Psychotherapy (BACP) recently published good practice guidance for
therapeutic working online [1] Both developments underscore the rising interest in online
therapy in the counselling and psychotherapy professions. They have paved the way for
formal recognition of ‘telepsychology’, also known internationally as online therapy, e-
therapy, e-counselling, computerised cognitive behavioural therapy (cCBT) and elec-
tronic cognitive behavioural therapy (eCBT) [2]. The term ‘online therapy’ (online ther-
apy) in this paper predominantly refers to live video therapy. However, we also
acknowledge that this term can include other online and integrative therapeutic support
types, including asynchronous (email) and synchronous (instant messaging) communica-
tion, alongside live video therapy. Additionally, the terms ‘psychological therapist’ and
Citation: Kotera, Y.; Kaluzeviciute,
G.; Lloyd, C.; Edwards, A.-M.;
Ozaki, A. Qualitative Investigation
into Therapists’ Experiences of
Online Therapy: Implications for
Working Clients. Int. J. Environ. Res.
Public Health 2021, 18, 10295. https://
doi.org/10.3390/ijerph181910295
Academic Editor: Els Clays
Received: 17 August 2021
Accepted: 23 September 2021
Published: 29 September 2021
Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional
claims in published maps and insti-
tutional affiliations.
Copyright: © 2021 by the authors. Li-
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con-
ditions of the Creative Commons At-
tribution (CC BY) license (http://crea-
tivecommons.org/licenses/by/4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 10295 2 of 15
‘counsellor’ are used interchangeably and inclusively to refer to a range of trained practi-
tioners who provide talking therapies and psychological intervention to individuals ex-
periencing psychological and emotional distress.
Although online therapy is a relatively recent and emerging means of therapeutic
working, using technology for therapeutic means is not new [3]. As early as the 1970’s,
tape-recorded self-help approaches and computerised programs, which imitated person-
centred therapists, were integrated into therapeutic approaches [4]. More recently, cCBT,
a form of treatment during which clients receive pre-programmed responses based on
CBT, has received significant scholarly attention, and has long been championed within
the National Institute for Health and Care Excellence (NICE) guidelines for good practice,
for both mild to moderate depression, and the treatment of phobias [5]. By contrast, how-
ever, online therapy, such as that provided through video or telephone technology, has
received less attention in the literature, suggesting the need for further evaluation [6,7].
1.2. Strengths and Limitations of Online Therapy
At a broad level, findings from several large-scale meta-analyses have provided
strong support for the adoption of online psychological interventions as legitimate
standalone therapeutic interventions [8]. Indeed, Carlbring et al. [9] found that in-person
versus eCBT were broadly equivalent in outcomes.
On a more idiographic and experiential level, however, the results are more mixed.
Online therapy is generally recognised as having several benefits. One of the most im-
portant arguments in favour of online therapy is that it may assist in meeting a demand
for psychological support that traditional face-to-face therapeutic interventions cannot al-
ways provide [10]. Second, online therapy may also offer individuals increased anonym-
ity and privacy and may be offered at a reduced cost due to lower therapist overheads.
These cost benefits may simultaneously open up access to previously disenfranchised and
minority populations, who may have been excluded from therapeutic support due to eco-
nomic status [11]. Beyond some of these pragmatic benefits, it has been suggested that
online therapies may encourage more emotional expression and self-reflection [12]. How-
ever, the relational impact of these factors is more variable, and there are several challeng-
ing aspects to online therapy, which necessitate further exploration.
First, it is posited that online therapy may make it more challenging for therapists to
identify and repair alliance ruptures [13] or cultivate a therapeutic presence with clients
[14]. Here, one of the most obvious challenges is the lack of non-verbal or behavioural
cues. Prior to the COVID-19 pandemic,[15] identified several important challenges to ther-
apeutic relationships caused by the digital space and social media, including issues of
therapist privacy (clients frequently search for therapist/counsellor personal information
online, which inevitably impacts the therapeutic dynamic), virtual impingements
(through which online discoveries alter the physical therapeutic relationship) and a desire
to internalise digital versions of the therapist or digital communications (e.g., developing
transference through email exchanges). Whilst these are all important aspects, it seems
prudent to explore how therapists themselves have experienced the shift to online therapy
during the COVID-19 pandemic.
1.3. Increased Demand for Online Therapy in Occupational Groups during the COVID-19
Pandemic
Among many populations that have benefitted from online therapy, the working
population has particularly enjoyed greater benefits of online therapy [16]. While these
findings illustrate clients’ experiences receiving online therapy, therapists’ perspective re-
garding online therapy during the COVID-19 pandemic remains to be evaluated. Such an
appraisal will help to inform workforces to better understand how they can benefit from
using online therapy. Accordingly, this study evaluates the perception regarding online
therapy from a qualified therapist’s perspective. Specifically, online therapy allows indi-
viduals and groups to access psychotherapeutic services on demand. This is especially
Int. J. Environ. Res. Public Health 2021, 18, 10295 3 of 15
significant, as research indicates that nearly two-thirds of all people with diagnosable psy-
chological disorders do not seek treatment [17,18]. Likewise, the low rate of help-seeking
is salient among working populations, caused by various factors including shame regard-
ing mental health problems, as identified in various working groups [19–23]. Online ther-
apy is recommended, as a working client can access therapy more privately, bypassing
their mental health shame; however, this has not been discussed in relation to therapists’
perspectives.
1.4. The Present Study
Despite theoretical and anecdotal consideration of the helpful and unhelpful aspects
of online therapy, there is a general lack of in-depth qualitative exploration from the ther-
apist’s perspective. Whilst some qualitative research has used broad surveys to explore
therapists’ attitudes to online therapy during the COVID-19 pandemic [24], this has often
not been carried out in an idiographic and inductive manner. Despite a growing body of
research and the increasing normalisation of online therapies in the last decade, there is
little qualitative research that attempts to explore how psychological therapists experience
and make sense of their online therapeutic work with their clients. Hence, this paper aims
to (a) appraise the perception towards online therapy from the therapist perspective (Aim
1) and offer suggestions for future therapeutic practice (Aim 2) through qualitative inves-
tigation, then (b) discuss how working clients can benefit from online therapy (Aim 3).
Aim 3 was added post hoc, considering the ever-increasing demand of online therapy for
this population, and to inform the readers for this Special Issue.
2. Materials and Methods
In this qualitative study, we sought to assess experiences of conducting online ther-
apy during COVID-19 based on nine licensed and qualified therapists’ work conducted
in California, the United States (US). Participants were recruited via social media through
professional clinical networks. Online individual semi-structured interviews were the
main data collection method, in addition to demographic questions presented to each re-
search participant. Data were analysed using the thematic analysis method [25,26]. GK
and YK held and transcribed the interviews; GK analysed the data and extracted the main
themes emerging from the interviews; and all authors contributed to the discussion of the
findings and further recommendations for online therapy practice. The study adhered to
the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines [27]. All
participants only knew the gender of the interviewers (GK or YK) before the interview.
The details of the study method are explained below.
2.1. Study Design
Ethical approval for this study was granted by the University of Derby Research Eth-
ics Committee 06-15-YK. The study used qualitative semi-structured interviews [28]. This
method consists of a dialogue between the researcher and the participant, guided by a
flexible interview schedule and supplemented by additional follow-up questions and
probes [29]. The semi-structured interview method is appropriate for studies with as few
as 8-12 participants, as it promotes the inclusion of multiple complex datapoints through
iterative interactions between the interviewer and participant (and, as such, the goal is to
qualitatively capture a complex phenomenon within its context rather than to measure an
average parameter across a representative population, as in, for example, statistical stud-
ies) [30]. Experiential accounts of conducting online therapy before and during the
COVID-19 pandemic are scarce. Our study sought to capture the potential strengths, lim-
itations, and unique components of digital therapeutic exchanges (e.g., accessibility due
to a lack of geographical constraints, online containment processes, flexibility with regard
to time, experiencing therapy at one’s home location, and cost-effectiveness), which are
experienced differently by each practising counsellor/therapist.
Int. J. Environ. Res. Public Health 2021, 18, 10295 4 of 15
A pre-designed semi-structured interview schedule (see Appendix A) was devel-
oped and sent to all research participants in advance of the interview to provide some
guidance. Our interview questions were guided by a similar study conducted by [31] on
attitudes toward online therapy among therapist trainees in Turkey, which also used the
semi-structured interview method. In addition to the questions used in Tanrikulu’s study,
we developed additional questions idiographic in nature (e.g., concerned with the mean-
ing of online therapy and its significance for specific patient populations/symptoms). In-
terviews were held online by using the MS Teams software established in the university
system. All interviews were recorded and transcribed verbatim with the consent of the
participants, who later confirmed the accuracy of the transcription. All participants were
required to read the participant information sheet and sign a consent form. Participants
were able to withdraw from the study at any time.
2.2. Recruitment
Purposive and snowball sampling techniques were used to recruit the participants,
who practised in California, US. According to APA data [32], the State of California has
the highest number of licensed psychologists in the country who are trained in various
therapeutic modalities (in CBT, Gestalt, Transpersonal therapy, etc.). Nine licensed thera-
pists/counsellors participated in an online interview. The details of the participants are
reported in the results section.
2.3. Analytic Procedure
The study used thematic analysis to systematically identify and organise meaningful
patterns across a dataset [26]. Since our study seeks to identify unique and/or divergent
idiosyncratic experiences pertaining to online therapy, this method of analysis was
deemed appropriate. Thematic analysis was carried out in the following order to identify
the relevant themes: (i) Familiarisation, (ii) Generating initial codes, (iii) Searching for
themes, (iv) Reviewing themes, and (v) Defining and naming themes [25] (each thematic
analysis process is described below).
2.4. Reflexivity
It is important to acknowledge the role played by researchers’ ideas, thoughts, and
feelings in thematic analysis [25]. Our study approached the research process from a crit-
ical realist standpoint [33]. Although critical realism acknowledges that our world is
largely socially constructed (i.e., we cannot think about the world independently of our
beliefs), it also nurtures the idea of developing realistic and causally meaningful interpre-
tations for complex social phenomena. According to Outhwaite [34], one way to arrive at
a realistic interpretation is immediately acknowledging the researcher’s vehicular social
and epistemic role in the research process (reflexivity). Therefore, tracing how our social
and linguistic practices influence and change research findings and analytic procedures is
part of a critical realist analysis. In our study, a psychotherapy researcher (GK) who held
some of the interviews coded the transcripts and developed master themes; the themes
were then reviewed by a researcher in counselling and an accredited psychotherapist
(YK), who also held some of the interviews, and a researcher and practising chartered
psychologist in counselling psychology (CL), who was not involved in the interview pro-
cess. This enabled a ‘cut and come again’ disposition [35], ensuring that no single causal
account, theme or interpretation was accepted uncritically and that researchers were able
to assess and compare contrasting research findings. All themes and data interpretations
were checked and agreed upon by the researchers.
Int. J. Environ. Res. Public Health 2021, 18, 10295 5 of 15
2.4.1. Familiarisation
Interview data were read repeatedly to formulate initial interpretations, patterns, and
themes [26]. Similarly, audio and video footage of interviews was viewed again to draw
out initial thematic maps [25].
2.4.2. Generating Initial Codes
The coding process in this study was ‘theory-driven’ [25], with a set of research ques-
tions that were identified before the interviews (Table 1) as well as focus areas identified
through the interview schedule (online therapy, therapeutic relationship, the online me-
dium, and client perspective) (Appendix 1). This enabled a more comprehensive coding
process. In total, 78 codes were identified from nine interview transcripts. Some of the
example codes are included in Table 2 below.
Table 1. Generating initial codes—example codes.
Focus Area
Initial Codes
Online
therapy
Having a secure online therapy platform
Willingness to conduct online therapy part-time post COVID-19
The use of online therapy for specific populations
Clients with severe psychopathology are generally not suitable candi-
dates for online therapy
The introduction of online therapy as a way to break historical barriers in
terms of physical distance, access and costs
Therapeutic
relationship
Loss of body language
Clients showing therapists items from their home environment during
online sessions
Frequent distractions from within the home environment (e.g., family
disruptions)
Knowing clients’ location in advance of the session would improve the
online session
Containment as the sacredness of the therapeutic space
The online
medium
‘Way of being’ is lacking online
The ‘goodness of fit’ between client and counsellor is more important
online than face-to-face
Difficulty in establishing a working alliance with a client online
Preference for video communication
Difficulties in picking up micro-emotions through video calls
Client
perspective
Clients do not always have the privacy of a space suitable for online psy-
chotherapy
Online therapy helps with access to care
Clients prefer online therapy due to easy access and temporal flexibility
There remains a difference between client’
s home space and the physical
therapy space; the two do not always overlap
2.4.3. Searching for Themes
The previously identified codes (Table 1) were attached to theme-piles using Braun
and Clarke’s mind map process in order to categorise the data at a broader level of analy-
sis [25,26]. Specifically, codes across all four interview focus areas were compared in terms
of similarity and overlap (code clusters). During this process, we identified the following
themes (Table 2).
Int. J. Environ. Res. Public Health 2021, 18, 10295 6 of 15
Table 2. Themes, corresponding aims, and example comments.
No.
Theme (Corresponding Aim)
Example of Participant Comment
1
Positive therapist and client
experiences of online therapy
(1, 3)
[Online therapy] was not part of my Master’s program or my supervision. It’s
something that I’
ve learnt more about, now that I’m doing it since COVID. … and
it works! And it’s better than I thought it was going to be (Participant 8).
2
Challenges experienced by
therapists and clients in online
therapy (1)
[The fact] that it requires the technology itself, it’s not equally accessible by
everyone who may not
have the bandwidth for the required Internet speed, good
Wi-
Fi, computer, some knowledge of how to set up lighting around the cameras
and some technical aspects that are, you know… it falls on the provider and the
client, as opposed to coming to a room whe
re things are set up and we all kind of
know how it works (Participant 3)
3 Preparation and training for
online therapy (2)
There is something to the idea of clients feeling safe in their environment. So, if
they’re already in a stressful environment and they’re logging in to talk to me,
they’
re still in that same environment so their body might be reacting in the same
way. … so it’s hard to create an experience for clients in their own home
(Participant 1)
Aim 1: Perception towards online therapy. Aim 2: Suggestions for future practice. Aim 3: How employees can benefit from
online therapy.
2.4.4. Reviewing Themes
During this phase of the research, themes were analysed against the coded data as
well as the entire dataset for coherency and relevance (details of which are available in the
‘Results’ section). Specifically, the identified themes (Table 2) were checked in relation to
the study’s research questions [26]. The data were organised in the following manner:
reports of good practice in online therapy, including the suitability of online therapy for
specific clients and, in particular, clients in employment who may have time and/or geo-
graphical limitations which may otherwise pose barriers to receiving psychotherapy (cor-
responding to Theme 1, addressing research aims 1 and 3); challenging and problematic
aspects of online therapy for both therapists and clients (corresponding to Theme 2, ad-
dressing research aim 1); and therapist experiences of training and guidelines for online
therapy, including gaps in available information about online therapy ethics, digital plat-
forms and suggestions for future training (corresponding to Theme 3, addressing research
aim 2).
2.4.5. Defining and Naming Themes
The collated data extracts were refined to ensure that each theme was consistent with
the accompanying narrative [26]. Lastly, during the revision process, sub-themes were
presented to enhance the clarity of our findings. Theme 1: ‘Positive therapist and client
experiences of online therapy’ encompassed T1-1 ‘Beyond expectation’, T1-2 ‘Quality as-
surance’, 1-3 ‘Accessibility’, and 1-4 ‘Control over therapy’. Theme 2: ‘Challenges experi-
enced by therapists and clients in online therapy’ contained T2-1 ‘Technological disrup-
tion’, T2-2 ‘Lack of containment’, T2-3 ‘Disruptive environment’ and T2-4 ‘Severe psycho-
pathology’. Lastly, Theme 3: ‘Preparation and training for online therapy’ included T3-1
‘Lack of training’, T3-2 ‘Lack of guidance’, T3-3 ‘Need for helpful online community’ and
T3-4 ‘Need for evaluation’. Table 3 summarises the themes and sub-themes.
Int. J. Environ. Res. Public Health 2021, 18, 10295 7 of 15
Table 3. Themes and sub-themes.
Themes Sub-Themes
T1 Positive therapist and client experi-
ences of online therapy
T1-1 Beyond expectation
T1-2 Quality assurance
T1-3 Accessibility
T1-4 Control over therapy
T2 Challenges experienced by therapists
and clients in online therapy
T2-1 Technological disruption
T2-2 Lack of containment
T2-3 Disruptive environment
T2-4 Severe psychopathology
T3 Preparation and training for online
therapy
T3-1 Lack of training
T3-2 Lack of guidance
T3-3 Need for helpful online community
T3-4 Need for evaluation
3. Results
The demographic information of the nine participating therapists/counsellors is as
follows: seven females and two males, age M = 44.5, SD = 9.8 years, a high level of experi-
ence in both providing and receiving therapy (M = 14.2, SD = 6.6 years), and complex
theoretical and clinical differences given the variety of therapeutic modalities practised
by each participant (psychodynamic, humanist/existentialist, person-centred, gestalt, ec-
lectic, CBT, attachment, etc.). Further demographic participant information is provided in
Table 4.
Table 4. Participant demographics.
Participant
Gender Age Years of
Experience Therapeutic Orientation
Target Symptoms Target
Population
1 Female 48 20 Psychodynamic Anxiety,
Depression Adults
2 Female 44 7 Humanistic, Existential,
Gestalt, Attachment Anxiety Adults
3 Male 39 11 Eclectic
Trauma, Psychosis, Bipolar
symptoms,
Substance abuse
Adults
4 Female 68 25 Psychodynamic, CBT,
Eclectic
Depression, Anxiety, LGBT
transition, ADHD
Couples,
Adults, LGBT
5 Male 44 22 Existential, Humanistic,
Gestalt
Grief, Anxiety, Anxiety
related to gender identity
Bi-cultural,
Queer youth
6 Female 41 15 Gestalt
Life transitions, Anxiety,
Bereavement, Grief Adults, Women
7 Female 44 9 Gestalt, Non-directive
Play, Art Therapy, CBT
Anxiety, Depression,
Neurosis
Asian-
American
Women,
Adults,
Children
8 Female 32 8 Psychodynamic, CBT
Transitional issues,
Adjustment disorders,
Depression
Women, Teens
9 Female 41 11 Humanistic, Experiential
Stress, Depression, Cultural
issues, Anxiety Adults
Int. J. Environ. Res. Public Health 2021, 18, 10295 8 of 15
3.1. Theme 1: Positive Experiences of Online Therapy
The majority of the participants reported that online therapy worked, or, at the very
least, worked better than expected, leading to favourably shifting attitudes and openness
toward online therapy post-pandemic (T1-1: Beyond expectation).
Participant 8: [Online therapy] was not part of my master’s program or my su-
pervision. It’s something that I’ve learnt more about, now that I’m doing it since
COVID. … and it works! And it’s better than I thought it was going to be.
Participant 7: Until August, I was thinking of online therapy as a poor substitute
for in-person [therapy], and a limitation. … I think that there is a slight decrease in
presence within therapy, and the quality of work I can do in this medium. Lately, in
the last couple of months, I feel as I’ve settled more into the pandemic life in general,
and also because I had some new clients come in and I’ve had some successes with
them [...] I’ve been considering more possibility of just maintaining an online practice
for a couple of years, especially if I move. I notice myself being more open to it.
Participant 5: I see [online therapy] as an adequate substitution. It seems to be
working okay, and in that sense, I feel really grateful that I can keep working.
In addition, some technological benefits were acknowledged for the quality assur-
ance, including supervision as well as the development and sharing of therapeutic
knowledge within therapists’ professional network and training (T1-2: Quality assur-
ance).
Participant 3: I think it offers some additional benefits in terms of the digital tech-
nology, like the ability to record. That can be used for quality purposes, for supervi-
sory purposes, to enhance the experience of the provider, knowledge. Some of the
other technology-related benefits are being able to take notes, share the screen, show
a video on the spot, certain things that we can always do by ourselves, but that can
be a part of the shared space in therapy.
Participating therapists also reported positive aspects of online therapy from the cli-
ent’s perspective, including geographical and temporal flexibility, increased access to
therapy, increased number of providers (as well as the ability to choose a therapist based
on their expertise/suitability rather than geographical proximity) and reduced costs (T1-
3: Accessibility).
Participant 8: I think that online therapy does help with access to care because
some people who, for example, don’t have childcare and they need help, but they
can’t get away from home, they’re more easily able to access services or they’re able
to find low-cost services. There seems to be more opportunity and availability online
because they can be seen by providers from all over California instead of their town.
So, I think there are some good pieces regarding access and equity and fairness.
Participant 3: The biggest benefits, I think, are the obvious ones: the flexibility
that you have, the possibility of doing therapy from your own home, well, from both
ends. It increases flexibility from the provider and the client. [...] It’s shifting the land-
scape of therapy, and it’s coming on the heels of the movement where mental health
is becoming a recognised field and an important aspect for the masses, not just the
traditional psychoanalytic thinking in the Victorian times where patients were from
higher socioeconomics. So, there’s that—the shifting in landscape where therapy is
becoming more mundane, more accessible. Online therapy has accelerated it.
Online therapy is the only option for some clients due to geographical limitations (e.g.,
lack of available counsellors and therapists or time spent travelling) or other circum-
stances (such as illness or caretaking/parenting responsibilities). These aspects are par-
ticularly important for clients in employment who, in the past, did not have time or
lacked geographical proximity to attend face-to-face therapy:
Int. J. Environ. Res. Public Health 2021, 18, 10295 9 of 15
Participant 7: [My patient] was living across the bay from me, and she’s a mom
also, so with traffic and parking and everything, it was taking her between 60 and 80
min to get here. So, for her it was really just like, “I can’t do this for therapy”. I think
if she hasn’t had the online therapy, she would have probably stopped working with
me.
Participants also offered some interesting reflections about having more control over
the therapeutic situation and being less affected by potentially difficult and/or negative
therapeutic experiences with clients (T1-4: Control over therapy).
Participant 7: If somebody’s got a lot of energy, you can shrink the window a
little bit. You can turn down the volume if someone’s voice is very abrasive. And I
actually am somebody who gave up on doing couples therapy, because I find that
my system, my body cannot take the amount of stress and conflict that couples bring
in. Like, I just want to shut down and run away screaming! So, I have actually re-
cently thought about doing it online because I’m not feeling that tension with my
body.
Overall, participating therapists evaluated online therapy more positively than ex-
pected (T1-1), and reported several advantages related to the quality assurance (e.g., use
of recording for supervision; T1-2), increased accessibility from both therapist and client
perspectives (T1-3), and having more control over therapy (e.g., adjustable size of screen
and volume of sounds; T1-4).
3.2. Theme 2: Challenges Experienced by Therapists and Clients in Online Therapy
The most significant limitation of online therapy identified by all participants is lim-
ited physical contact and body language, both of which can be further diminished by tech-
nological disruptions (T2-1) (e.g., bad connection, poor video quality or lack of knowledge
on how to operate a specific software or set up a camera). This was found to have a direct
impact on the development of therapeutic relationships as well as containment processes
(T2-2: Lack of containment).
Participant 1: When there are glitches with technology, it definitely affects the
sense of containment. It is hard to rewind and get back to where a client had been, or
what they had been expressing after a disruption—especially if they were crying.
Participant 3: [The fact] that it requires the technology itself, it’s not equally ac-
cessible by everyone who may not have the bandwidth for the required Internet
speed, good Wi-Fi, computer, some knowledge of how to set up lighting around the
cameras and some technical aspects that are, you know… it falls on the provider and
the client, as opposed to coming to a room where things are set up and we all kind of
know how it works.
Participant 9: I think that clients who have trauma [experiences] struggle more.
They have a hard time to be present. Some people have more [expression] through
their body language, so they need a more solid atmosphere.
Participant 6: [Therapy] feels less of a ritual... How to replace it? … I can’t control
how the client comes into the session, how they’re sitting, their environment, distrac-
tions. For me there’s something sacred around the container and the preparation, and
so I can both prepare and have my surroundings. I obviously have less control over
the client [now]. I notice it a little bit more now and so I think it’s important to do
what I can do from my end to hold that.
Some interesting observations were revealed by the participants about challenges
caused by the blending of the home environment and the digital therapeutic space, which
include disruptions from family members during therapy sessions, other technological
interruptions (phones, laptops, tablets), lack of private space, and client behaviours that
would not ordinarily occur during physical (face-to-face) sessions (T2-3: Disruptive envi-
ronment).
Int. J. Environ. Res. Public Health 2021, 18, 10295 10 of 15
Participant 8: With my teenage clients, I think that they don’t have as much re-
spect for the therapy… [It’s] not the kids, but the parents will come into the room and
say, “are you talking to [participant name]?”, and they’re like “yeah”, and then the
[parents] will say something like, “ok, well, when you’re done, I’ll need you to do the
laundry”, you know. … there’s more interruptions not only from their environment,
their phones and whatever, or their cat or their baby, but also from other people liv-
ing in the household who are reminding them of chores or whatever, so it’s harder
to maintain focus.
Participant 3: I have noticed that clients from lower socioeconomic backgrounds
tend to experience more distraction. I can give you some examples of what I mean:
people who often do therapy in their cars are usually from poorer socioeconomics,
which means less time, and they often quite literally don’t have the private space.
Participant 7: I had a client who… She will drink alcohol, she will have a cocktail
or whatever, during the session… And that would just very rarely happen in your
office. But if they’re home, and their fridge is right there, and it’s a time where they
would kick back anyway, then this seems more natural to have a drink when you’re
talking with a therapist. That was definitely surprising to me, to see that there’s a
blending between someone’s home life and their therapy appointment. [...] In that
sense, the container-ontained relationship is out of control.
Several participants noted that online therapy is not suitable for clients who suffer
from severe psychopathology or mental health distress (e.g., trauma or personality disor-
ders) (T2-4: Severe psychopathology), because they require greater contact and contain-
ment that cannot be facilitated via online mediums:
Participant 8: I feel like right now I have a client who wants to transition to [face-
to-face] psychotherapy because they are too severe, but because there’s this force to
be online, I feel like one of the issues is that not everyone is well-suited for this mode
of therapy.
In sum, the participants reported that technological issues (T2-1) could negatively
impact the containment of the therapy (T2-2). Moreover, they noted that some clients were
not in an ideal environment to engage in therapy (T2-3). Because of these challenges, they
perceived online therapy not suitable to treat severe psychopathology (T2-4).
3.3. Theme 3: Preparation and Training for Online Therapy
All participants reported having only had minimal or no training for online therapy
prior to the pandemic (T3-1: Lack of training).
Participant 2: I received zero training, even though I would have liked to receive
education on online therapy. For example, what about privacy? Containment in the
room?
Some of the issues identified in training for online therapy include a) lack of docu-
ments, surveys and scales for online sessions; b) lack of technological guidance (for both
clients and therapists); and c) lack of guidance on how therapeutic relationships and out-
comes can be addressed in online therapy (T3-2: Lack of guidance).
Participant 8: I’ve had to make certain documents online because they previously
[didn’t exist] […] for example, certain anxiety, depression, relationship, satisfaction,
mood surveys that I would typically do as a check-in just before the session with the
clients to get the baseline of their functioning. The first two weeks of being online I
couldn’t get them because there was no way to administer them. So, tools had to be
developed specifically for online therapy.
Participant 5: I think that it would be really helpful just to understand what is
exactly being expected from you and what are the differences between [online and
face-to-face] therapy.
Int. J. Environ. Res. Public Health 2021, 18, 10295 11 of 15
Participant 3: I still feel like there is a lack of more nuanced aspects that I was
trained about in-person, for example, observing the space, the container of where you
are with the client, the quality of the presence. We didn’t get too much into that when
we did the training, and I think that’s generally very important. […] Similarly, I wish
I have been taught the ground rules more from the beginning to asking about the
address, you know, those tips like: make sure you check with the clients that they’re
in a private space, that they do not have any distractions, even other screens, phones,
things like that. It’s just not natural for people to do and I think they make a big
difference, if you know this from the beginning and set it up. You avoid disruptions
and the general loss of the quality.
In order to mitigate the lack of training and experience in online therapy, some par-
ticipants joined an online community of therapists; however, more support is needed (T3-
3: Need for a helpful online community).
Participant 8: When working online, I found it more difficult to do consults with
other therapists because in real life you’re in an office and you can say, “hey, can I
ask you a question about something?” or “do you have this resource?”. Fortunately,
there are online consult groups that I am a part of, but there is that missing compo-
nent of peer support. It’s more difficult online.
Lastly, some participants highlighted a need for a careful evaluation of online ther-
apy while recognising the potential of this form of therapy (T3-4: Need for evaluation).
Participant 3: Online therapy is shaking up the field. Because a lot of people that
could not access therapy can now access it. The rules of the language of therapy are
changing, and it opens up the field for new interpretations. I do not think we know
yet how digital technologies will change our consciousness, and how we manipulate
it for therapeutic benefits. Much like we do not see how complexity of narrative is
changed over digital technologies.
Taken together, the participants did not feel that they had had enough training (T3-
1), nor that helpful guidance was available (T3-2). Though some of them accessed an
online community of therapists, more support was needed (T3-3). Additionally, a need
for empirical evaluation of online therapy was suggested (T3-4).
4. Discussion
Since the beginning of the COVID-19 pandemic, the use of online therapy has in-
creased rapidly, and working populations have utilised this form of therapy and received
its benefits. However, the existing research primarily focused on clients’ perspectives,
missing an understanding of how therapists perceive and experience online therapy. Ac-
cordingly, we aimed to i) examine the perception towards online therapy, ii) offer sugges-
tions for future practice, and iii) discuss how employees can benefit from online therapy.
Our analysis identified positive experiences (T1), challenges (T2), and preparation and
training (T3) relating to online therapy (Aims 1 and 2). The participating therapists per-
ceived online therapy positively, reporting more utility than expected (T1-1) relating to
factors such as quality assurance (T1-2), accessibility (T1-3), and control over therapy (T1-
4), while noting some challenges, including the technological disruption (T2-1), a lack of
containment (T2-2), disruptive environment (T2-3), and unsuitability for severe mental
illnesses (T2-4). A lack of training and guidance (T3-1, -2) was noted by the participants,
indicating a need for a more helpful online community and the evaluation of online ther-
apy (T3-3, -4) in the future. These findings are discussed below, regarding clients in em-
ployment (Aim 3).
One notable finding of our study is that, although the participating therapists felt that
they had not been trained enough in online therapy (see T3), overall, they found it helpful
and were willing to continue using it (see T1). In addition to their positive experience,
they also reported the advantages of online therapy from the client’s perspective relating
to time, location, and costs. These components contribute to the accessibility of online
Int. J. Environ. Res. Public Health 2021, 18, 10295 12 of 15
therapy, which may be particularly helpful to busy clients. During the pandemic, many
employees were forced to work from home, yet online therapy offered access to treatment
for these clients. Considering the increased rates of mental health problems in the work-
force during the COVID-19 pandemic [36,37], the value of online therapy is high, suggest-
ing a need for more robust education and preparation for this form of therapy. Specifi-
cally, guidance on the digital skills, intake assessments, and how therapeutic relationships
and outcomes can be addressed was raised as an example for educational items. Indeed,
many therapy regulatory bodies have produced information sources to educate their reg-
istered members about online therapy [38]; however, more research-informed guidelines
need to be established.
Moreover, many therapists showed an intention to continue using online therapy,
which can have implications for clients, including employed clients. For example, shame
regarding mental health problems tends to be high in many occupational groups, reduc-
ing help-seeking in this population [5,8,39,40]. Online therapy can offer access to treat-
ment for these shame-sensitive employees, as they can access therapy from home without
any time and costs associated with physically accessing a therapy room. As mental health
shame is strongly associated with poor mental health in many different occupational
groups [21,39], access to therapy without causing shame can be a safer approach to protect
employee mental health. Moreover, as many employees receive therapy, the normalisa-
tion effects may be present, reducing shame in order to facilitate help-seeking in the work-
place [40]. This in turn can result in increased compassion in the organisation [41], which
is linked to numerous advantages, such as collaboration, trust, and loyalty [42]. Longitu-
dinal data are needed to evaluate the impact of online therapy in organisations.
While highlighting the positives of online therapy, challenges were also reported (see
T2). Technological problems, including a lack of digital skills in therapists and/or clients,
are among them. An unstable internet connection can disrupt the flow in a therapy ses-
sion, negatively impacting the therapeutic relationship and outcomes. Moreover, while
many clients can benefit from the flexibility of online therapy, some clients are not
equipped with a good environment at home to focus on therapy (e.g., presence of other
family members, including children). Alternative approaches for this population need to
be considered. Therapeutically, the participating therapists noted the limited view of the
client as a challenge; much information can be received from the physiology (e.g., posture,
how they move their hands and feet, etc.), which is often excluded in online therapy. This
type of information is particularly important when treating a client with severe mental
health problems [43,44], and this is another area of challenge noted by the therapists. How
appropriate online therapy is for severe mental health problems remains to be appraised,
indicating a need for future research.
5. Study Limitations
There are several limitations arising from this research project, which are important
to note. First, as with all small-scale qualitative projects, the data and findings contained
within this project cannot be assumed to be representative of larger therapist groups. In-
deed, this study was conducted in California, US, with a particular social and cultural
representation of what online therapy is (or is not). More diverse and larger samples are
needed in the future studies. Nevertheless, the themes arising from this study will be of
interest to therapists and clients from a broad range of backgrounds and will give insight
into ways of working therapeutically online. Second, as the therapists have been drawn
from a wide and eclectic mix of therapeutic orientations, each with sometimes diverging
conceptualisations of therapy, there is limited sample homogeneity, which has prevented
the in-depth exploration of therapies in depth. Third, due to the nature of study recruit-
ment, the sample was self-selecting: participants who took part likely had stronger views
of online therapy. This has likely impacted the study results. To counter this, further stud-
ies which use a quantitative and larger-scale study design will be useful in exploring in
further depth some of the initial themes generated from this study.
Int. J. Environ. Res. Public Health 2021, 18, 10295 13 of 15
6. Conclusions
The demand for online therapy due to the COVID-19 pandemic is expected to con-
tinue to increase in the coming years. This study reported the first-hand experience of
online therapy from the professional therapist’s perspective, regarding the advantages,
challenges and workplace implications. While noting the small sample size, the findings
will help (i) therapists refine their future practice, and (ii) working clients and workplace
leaders to consider helpful applications of online therapy to improve individual and or-
ganisational mental health outcomes.
Author Contributions: Conceptualization, Y.K.; methodology, G.K.; software, Y.K.; validation,
Y.K.; formal analysis, G.K..; investigation, Y.K., G.K., and C.L.; resources, Y.K., G.K., and C.L.; data
curation, Y.K., G.K., and C.L.; writing—original draft preparation, Y.K., G.K., and C.L.; writing—
review and editing, Y.K., G.K., A.-M.E., and A.O.; visualization, Y.K., and G.K.; supervision, Y.K.;
project administration, Y.K. All authors have read and agreed to the published version of the man-
uscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the University of Derby Research Ethics Committee 06-
15-YK on 11 January 2017.
Informed Consent Statement: All subjects gave their informed consent for inclusion before they
participated in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to ethical restrictions.
Acknowledgments: We are grateful to all the therapists who took part in this study, and Cary
Ann Rosko MFT for her support in this project.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A. Interview Schedule
Focus Area
Interview Questions
Online therapy
1. How has your experience been using online therapy?
2.
Do you think that you received sufficient education/training about online
therapy?
3. As a counsellor trainee/professional counsellor, what types of concerns do you
have about online therapy?
Therapeutic
relationship
4.
What do you think would be necessary to have a good therapeutic rela-
tionship in online therapy to protect the client and ensure safe and ethical treat-
ment?
The online
medium
5.
Do you feel that therapy delivered via the various mediums of online
therapy, such as text, email, or real-time video, is similar or differs signifi-
cantly?
6. Do you think that online therapy can be useful in
providing therapeutic
relief? Is it a form of therapy in its own right or a replacement for face-to-face
therapy?
Client perspective
7.
How do you imagine your clients experience online therapy?
8. What types of concerns do you think clients have (or what concerns do
clients have from your experience) about online therapy?
9. Are there instances where clients might prefer online therapy to face-to-
face therapy?
Int. J. Environ. Res. Public Health 2021, 18, 10295 14 of 15
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