A Brief History of Online Therapy
Providing mental health services and support online is known as online therapy, often referred to as e-therapy, e-counselling, teletherapy, or cyber-counselling. Services may be delivered via email, text message, web chat, video conferencing, or internet phone.
Online therapy can take place in a time-delayed style, like through email communications, or in real-time, like during phone calls and text messages. Although this kind of treatment can have its drawbacks, a rising number of people are finding it to be a valuable and effective resource.
The history begins much earlier if phone therapy is included as a part of online therapy. Confidentiality prevents psychotherapists from keeping a record of their initial private conversation with a client. Yet it is evident that phone calls were being made to offer mental health care as early as the 1960s.
Online therapy began in 1986 founded by Dr Uncle Ezra, a Cornell University question and answer forum where people frequently discussed mental health issues.
The first Internet therapist to offer ongoing communication and a confidential therapeutic connection was Dr David Sommers. Online treatment steadily gained popularity and spread throughout the 2000s.
The online therapy platform was launched in 2012 by Oren and Roni. Clients could send unlimited text, video, and voice communications to each other in the same space by using the software on their mobile phones. The online counselling scene in the 2010s was largely characterised by talk space, and other similar companies have since emerged.
The Benefits of Choosing Online Therapy
Convenience and Accessibility
You can get therapy online from any location if you have a good and reliable internet connection. You don't have to deal with traffic or public transportation, parking, waiting in a waiting area, paying for child care, taking time off of work etc. The convenience of online therapy eliminates many of the barriers that keep people from seeking in-person therapy.
Comfort and Privacy
It can frequently be beneficial to open up, be more vulnerable, and improve your ability to handle challenging emotions that may surface during a therapy session if you see an online therapist from the privacy and safety of your own home. Online therapy may be a good option if you struggle to leave the house due to physical constraints, autoimmune or inflammatory conditions, a chronic disease, or a condition like agoraphobia or social anxiety struggles.
Increased choice of therapists
No matter where you live, the larger number of professionals online increases your chances of finding a therapist who has dealt with problems similar to yours in the past. Another significant advantage of online therapy is that it enables you to find a therapist that is the best fit for your needs.
Privacy and Confidentiality
In my opinion, it is simpler to undergo treatment anonymously online than it is to see a therapist in person. When you connect online, you never have to worry about running into a familiar face, as might happen in the waiting area or parking lot of your therapist for example.
According to research, online therapy is just as successful as traditional in-person therapy. In one study, researchers discovered that online CBT paired with clinical care could successfully ease emotional distress brought on by sickness as well as depression and anxiety. Analysis of 17 trials shows that online CBT is better than in-person CBT for easing the severity of depressive symptoms.
While online talking therapy has some difficulties, many people who have used online mental health treatments have supported it. According to a review of research in the World Journal of Psychiatry, patients getting video conferencing-based mental health treatment expressed "excellent levels of satisfaction."
Things to consider when having an online therapy
Good and reliable internet connection
Make sure your internet connection is fast enough and reliable. If your therapy sessions are interrupted due to connection issues, your therapy experience will suffer.
Be prepared to put in the work
A therapist could assign you “homework” between sessions or ask you to practise strategies in actual life circumstances. Be ready to invest the time and effort necessary to benefit the most from the experience. And if you frequently miss therapy sessions, consider why, and talk to your therapist about it.
Limit distractions at home
It's quite handy to speak with a professional in the privacy of your own home, but you won't benefit as much from therapy if your sessions are interrupted by other people. Pick a peaceful time of day for therapy, ask your family members not to bother you, turn off your phone, and muffle any other apps.
Pros
Online therapy may be a more effective option for those who are housebound. For those with physical limitations, travelling to and from appointments might be difficult. For such clients, online therapy may be more accessible.
The comfort of your own home provides convenience. Additionally, compared to in-person sessions, you might be able to be more flexible with your appointment time with online sessions.
Online therapy can provide people with access to talking therapy services they might not otherwise have if they live in a remote place with few nearby physical or mental health facilities.
Your therapist will be able to continue working with you via online sessions if you are travelling for business or education while in another location. There won't be any breaks or delays in your treatment this way.
Cons
Online therapy may or may not be covered by your health benefits if you have private health insurance. However, there are differences between each health insurance provider.
Many online therapy services will not provide services outside of their locality (country). This is due to different regulations and licenses in different countries. Therefore, I suggest looking for someone in your country of residence or ensuring your therapist has appropriate registration and insurance.
As you may know, anything spoken during an in-person therapy session is intended to be kept private. Online, however, adds a level of complexity. Hacks and privacy leaks can be of increased concern, but as long as secure platforms (end-to-end encrypted) are used for a therapy session, this should not be an issue. Ask your therapist if the platform they are using is end-to-end encrypted and secure. I normally say it is as safe as using online banking to manage your finances.
While online therapy can be beneficial, for some it might be more difficult to emotionally connect if you and the therapist are not in the same room. It's possible to miss some body language cues when speaking on camera. For instance, the therapist might not notice your tapping leg under the table, or you could find it more difficult to sense their compassion and care. A study conducted to systematically review the therapeutic relationship found that online therapy is almost equivalent to in-person therapy in relationship building. I struggled with my online therapy to begin with, once it moved online during the pandemic time. I quickly realised that once I overcame the mental block and bias I had towards online therapy it helped tremendously to open up and connect with my therapist. It completely transformed my view of online therapy and helped me to become a more confident and potent online therapist.
Things to Consider
Online therapy may be a viable option, according to research, but not everyone is a suitable candidate for it. Personally, I would not recommend online therapy for people with very complex issues or major psychiatric conditions requiring strict supervision and direct care. Such as serious substance use disorders and serious psychiatric problems such as active suicidal ideation, and active psychotic episodes such as hallucinations, paranoia or delusions.
It is always good to ask your doctor if online therapy is appropriate for you or if you should simply use it as a supplement to more conventional treatment approaches. If you believe that online therapy would be a good fit for you, investigate some of the websites and applications that are offered to find the one that best suits your requirements. An initial consultation with a potential therapist is a good opportunity to explore whether online therapy is viable for you and ask any questions you might have.
Rules and Ethics of Online Therapy
A therapist providing online therapy should:
Have a decent knowledge of technology. This covers how to use the tools necessary to provide psychotherapy online and guarantees that client information is protected and kept private.
Work inside their field of specialisation. Only the services that therapists are qualified to deliver should be offered. As a result, rather than attempting to handle a problem that you disclose to your therapist, they should refer you to another therapist.
Undertake continuous professional development in the form of training, information, and supervision. Most professional bodies have a mandate that therapists keep up to date on the most recent research and industry best practices to deliver the best service possible. I would also advise having clinical supervision online for the continuity of the process.
Obey all applicable laws and rules. Your therapist is responsible for being aware of and abiding by any regional laws and regulations. For instance, in the United States, only people who have completed the necessary training and have been granted a licence are legally permitted to use the title ‘psychologist’ or ‘psychotherapist’. In the UK, always check if the therapist is registered with the major professional regulatory bodies such as UKCP, BACP and others.
Risk Assessment in Online Therapy for Therapists
One of the difficulties with online therapy is that the therapist may not receive as a complete picture of the client as one would if meeting in person. Understanding risk assessment for online therapy implies we must operate within our competency. Clients from specific groups may behave in ways or circumstances that significantly increase the risk of serious harm to themselves or others.
In my practice, I follow these guidelines and typically avoid taking on clients for online therapy:
Severe eating disorders. Working online with a client who has an eating disorder should be carefully considered unless you are a seasoned therapist.
Complex personality disorders. Working with persons who have complex personality disorders can be difficult, especially if they frequently cancel appointments, arrive late, or don't return calls.
Suicidal ideation or risky behaviours. Risks like self-harm, active suicidal ideation, or risky behaviour might be difficult to detect because cut marks may not be visible physically (on the client's arms for example), thus we must rely on their reporting. A deeper trust may result from this, but it may also cause risk signals to go unnoticed. Consequently, I am more orally explicit and direct when working online.
Domestic violence. Domestic violence is an issue that requires careful evaluation of risk. Take into consideration what may occur if the abuser discovers your contact information on the victim's mobile device or overhears the victim of domestic violence talking with you.
Serious addictions. Clients with addiction problems are frequently viewed as unfit for online therapy. As with self-harming behaviours, it can be extremely difficult because we are once again dependent on self-reporting; for example, we are unable to smell alcohol, and closely observe the client's pupils as such.
Serious medical conditions. Some clients might have health issues that could suddenly manifest as a very serious sickness (e.g., diabetes or epilepsy).
It is our duty as therapists to carefully consider risk management, with assistance, as necessary, from our professional supervisors.
My Tips for The Therapists
As a therapist, I can support clients who might be in danger, by using a risk-management strategy, often known as an "intake form," which enables me to detect any hazards in advance.
Questions I always ask clients include:
1. Current medications.
2. Underlying medical problems.
3. Participation in other mental health treatments.
4. Suicidal ideas, plans, or intentions.
It is crucial to handle these inquiries properly, paying attention to your tone, and reminding the client of confidentiality and its boundaries because they may feel highly invasive. In my opinion, it is important to be aware of possible side effects of the medication client is taking. Being aware of conditions such as epilepsy or diabetes to be able to take appropriate action in an emergency and so on.
Utilising common questionnaires (PHQ-9, GAD-7 and COFRE-10) for mental health can be very beneficial in general. I would strongly recommend using them when working with online clients. Using a consistent tool as part of your assessment for all clients can assist or lessen the impression of intrusiveness. This also gives evidence-based information to support your choice on whether or not it is safe and ethical to work with a particular client.
