Online Therapy 
Delivering therapy online

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Delivering therapy online

The following article is written by Kate Dunn, a psychotherapeutic counsellor with a particular interest in online therapy.

In my previous article, I introduced the concept of the ‘digital native’ (those born after 1980) and, by implication, the ‘digital immigrant’, born before this date. The majority of practitioners engaging in the world of online therapy are currently immigrants and this will be the case for some time to come. We find ourselves working in an environment where the language is not our ‘mother tongue’ and the culture may at times feel strange and challenging.

With this in mind, how do we choose the most effective approach to working online? How is the therapy itself affected by the language and medium in which it is delivered? It is tempting to assume that ‘newest is best’ and that every development means progress, but I suggest that this is not necessarily always the case and urge you to take a little time to consider the potential of a variety of approaches.

The number of commercially produced computerised interactive programs designed for the delivery of structured and specific psychological interventions (for example, the Computerised Cognitive Behaviour Therapy – CCBT programs or Apps that target anxiety or deliver daily mindfulness meditations to your phone or tablet computer) grow daily. These can be discovered and explored individually by therapists and clients alike and are often used as self-help applications, although you may choose to incorporate them into therapeutic client work.

My focus here, is on choosing between methods for engaging directly with clients which are facilitated by technology.

Technology - synchronous or asynchronous?

The chosen approach may be:

  • ‘synchronous’: live and immediate, in real time, delivered via Instant Messenger [IM] or video/audio link
  • ‘asynchronous’: the exchange of pre-considered material, usually delivered by email 

It is tempting to assume that each technological development will always improve on and supersede the method that was popular ‘last year’ or even ‘last month’. However, it is essential to take time to think in detail about the more subtle nuances of each available approach, and to consider what impact these might have both on the therapist and the client. How do they influence, for example, the capacity to convey to each other aspects of identity, disturbance and distress and what impact do they have on the development of a therapeutic relationship?


Video/audio-links accessed via software apps seem to present the obvious contemporary first choice for most. But do they always provide the most effective therapeutic platform? However good our hardware and software, we will still sometimes experience problems with the quality of the video, erratic connections and confounding technological ‘glitches’.  The video link can provide a practical solution to a geographical problem but in therapeutic and relational terms some will feel it remains a poor substitute for two people being in the room in person together – a condition it strives to replicate.

Text-based communication (eg Instant Messenger or email)

A number of online therapists use text-based communication approaches (perhaps enhanced by image and sound – the opportunities for creativity and imagination are vast) and I encourage you to consider what happens when counsellor and clients’ faces are unseen and voices are imagined. You may initially predict that this approach will feel ‘clunky’ and slow, and of course, in technological terms, you are right. However, I wonder if you have considered how liberating this may feel for certain clients, especially those who will never cross the therapist’s threshold (or Skype screen for that matter!), perhaps because they are overwhelmed at the idea of the immediacy of the real-time meeting because of shame, social anxiety or stigma. What opportunities and freedom might they discover within a slowed down, unseen communication? Could this be the very chance they have been seeking to help them overcome their inhibitions sufficiently to consider attempting a therapeutic engagement?

The IM meeting can be fascinating. Counsellor and client are both there together in real time… yet either party can stop, think, read, and change the pace before pressing ‘send’. Taking this a step further, the ‘asynchronous’ email exchange, dated though this might already seem to some, offers even greater potential for facilitating both ‘time to think’ and also ‘equality of power’ in ways you may never have imagined. The clients with whom I have worked over a period of years using this approach reflected back to me a sense of empowerment and often described surprising and exciting discoveries of how this approach opened a door to therapy for them that remained previously forever closed. Sometimes an asynchronous online engagement may be simply the starting point and facilitate a subsequent face-to-face contact; a different kind of developmental journey.

Concerns are sometimes raised about the authenticity of the identity that an individual might choose to portray online when there is no physical presence, especially if meeting unseen and asynchronously. Yet, is this so very different from some of your meetings in the therapy room? What identity does your client portray there? Might the online meeting actually present unique and different opportunities for creativity around self-exploration?

Frameworks and boundaries

Of course, the setting of frameworks and boundaries is central to working online, just as it is when meeting in person, and this requires guidance, support and robust planning. You will want to replicate some elements of your face-to-face work but there will be new questions to consider also. The special elements that may arise online, as described above, are tiny examples of new ideas, possibilities and dynamics that you will want to understand better. There are several training programmes that can help prepare you for this work, and in my next article I will write more about what they offer and why I believe they are an essential component if you wish to prepare yourself to work safely, effectively and ethically online.