Implications

6.5.1. Implications for Training

Various actions by therapists help to overcome the challenges of online

communication through use of language and establishing presence, and thus facilitate the formation of an effective therapeutic relationship. A conclusion that could be

drawn from this is that it is important for therapists to undergo specialist training to develop the necessary skills before they offer therapy online; the importance of training for managing the relationship was also voiced by most of the participants.

It was interesting to note that participants who had not received specialist training in online therapy contributed much more vociferously to the category entitled “obstacles to developing a relationship online” whereas those who had taken part in specialist online therapy training were less likely to express downsides of establishing

therapeutic relationships online, and it was noticeable that they had more faith in it.

However, those without training did contribute to the category “mastering online communication”, showing that they were able to overcome those obstacles, although those participants who had undergone training provided richer data. This anecdotally suggests that untrained therapists were able to develop skills as they adapted to the medium, learning “on the job”, perhaps instinctively finding strategies to facilitate communication, which they were then able to explicate in the interviews. However it also seems that training programs enhance a therapist’s explicit understanding of online communication. Overall these observations indicate that good quality training is a significant factor in being able to establish a therapeutic relationship online.

It has been widely recognised that adapting to the different nature of the online environment requires specific training (Childress, 2000; Goss & Anthony, 2009;

Haberstroh, Parr, Bradley, Morgan-Fleming, & Gee, 2008; Hanley, 2006, Hanley, 2012).

There are several practitioner textbooks for online therapy available (for example Anthony & Nagel, 2010; Evans, 2009; Jones & Stokes, 2009) and professional training for online therapy has been available since 2000 (Goss & Anthony, 2009).

There is clearly a need for the content of training programs to prepare therapists for the use of technology in their work for example learning how to interpret and use emoticons and how to utilise the technology to manage the flow of conversation. It is important that training programs offer knowledge and practical skills that will help therapists to understand and manage the relational challenges of the different media that they will use; video based, email and synchronous chat. Training content about the relational implications of holding sessions online should be given as much

attention as the ethical, legal and practical aspects. Training should also be designed to help therapists to adapt to the uncertainties that are a part of communicating online;

how to deal with the uneasiness of not always knowing the client’s immediate circumstances or emotional state.

A number of different organisations currently offer training programs in the UK as well as internationally. However, worryingly a large proportion of online practitioners appear to set up without any counselling training at all (Chester & Glass, 2006) and as evidenced within the small sample in this study, some face-to-face counselling services have developed an online facility in parallel to their face-to-face service without

offering additional training to their practitioners.

Some possible recommendations arising out of this are as follows: Organisations offering online counselling should ensure that practitioners have specialist post-qualification training in working online. Also, professional and regulatory bodies could encourage members offering an online service to have undertaken training. The BACP, a professional body for counsellors and psychotherapists, leads the way in this respect and strongly recommends that practitioners undergo further specialist training in text-based online therapy (Anthony & Goss, 2009). Current BPS guidelines for delivering psychological services over the internet state that “the practitioner must maintain an informed stance”, (British Psychological Society, 2009, p. 8); this could go further and recommend that practitioners acquire formal training for their online work.

Additionally, the BPS could offer workshops providing the necessary skills for working effectively online as part of their programme of continuing professional development.

As online counselling becomes more mainstream and relevant to both public and private practice then awareness of its implications will become more important.

Ongoing evaluation and research will be valuable as the number of online services grows, and this should continue to shape best practice and practitioner training programs. Even for practitioners who are not communicating exclusively online with clients, perhaps some occasional contact happens by email or text, and it might be useful to have an awareness of some of the issues of non-face-to-face communication and the potential impact on the therapeutic relationship. Also, an awareness of the

organisational implications is important for counselling psychologists; who may be involved in developing and managing online services as well as delivering therapy themselves. Colbow (2013) recommended that training in working online be integrated into mainstream psychology programs, with the proposed curriculum including topics on relationship development and management. Colbow argues that future

psychologists in the United States are lacking in education in what he terms

“Telemental Health Therapy”, and that concepts like projection, transference, countertransference and self-disclosure, all become more complicated through the electronic medium. A similar argument could be made in the UK and an introduction to this topic could usefully be included in counselling psychology training.

6.5.2. Implications for Supervision

In the same way that this study argues for the importance of proper training for practitioners, it follows that supervisors of online work need to have sufficient training in online supervision. There is a need for supervision to attend sufficiently to some of the particular challenges of online therapy, including managing uncertainty and any difficulties that there may be with emotional expression. Online therapists may find it supportive and appropriate to also have their supervision online. As one of the

participants explained, it is helpful to have supervision in the same medium as the therapeutic work, and with someone who has a similar understanding of what happens in an online relationship. It is worth noting that many important aspects of how a therapeutic relationship works online, as described in this study, would also apply to how the supervisory relationship functions online.

6.5.3. Implications for Services and Systems

The therapeutic relationship online is facilitated by therapists’ skills with the written word and that therapists’ belief in online therapy and enthusiasm for learning these new skills was an important factor in their ability to make it work. Therefore, when services develop an online provision, it would make sense for individuals’ skills with the written word as well as their own preferences to be taken into account. It is counterproductive if delivering therapy online becomes a mandatory requirement for practitioners within an existing service.

The use of colour, emoticons and the sharing of pictures and other resources are helpful ways of supplementing text-based communication, allowing for richness of expression. This facilitates the communication of emotion and improves the sense of connectedness between client and therapist. This has implications for the features of instant messaging systems chosen for online therapy, and suggests there would be benefits of a set-up that integrates emoticons, pictures and attachments, so that these features are easy to employ. Systems that have a built-in indication that the other person is typing also help with managing the flow of conversation.

6.5.4. Implications for Counselling Psychologists

The potential for online therapy to offer help to marginalised groups is particularly significant for counselling psychologists. There may be a moral case for the profession to support the introduction of online therapy as a way of responding to the diverse needs of potential clients in a way that reflects counselling psychology’s commitment to inclusivity and deliberate negotiation with diversity (McAteer, 2010). Furthermore, the potential for online therapy to give clients a better sense of control and

empowerment is firmly in keeping with counselling psychology values. Likewise, it is fitting for counselling psychologists to find multiple ways of working with clients and meeting them on their own terms. Of course, online therapy will not be the best choice for everyone, and it is also important to be aware that the most marginalised populations might not have access to a computer (Charura, 2014). There are some further arguments in favour of counselling psychologists engaging with working through online media. Psychologists and other mental health professionals have been slow to adopt online ways of working (Lovejoy, Demireva, Grayson, & McNamara, 2009). As Griffiths (2001) warned, if psychologists shun working with new technology, it is possible that less ethical or less able practitioners will come to fill the gap. Also, Lovejoy et al argued that “A more widespread use of online therapy can enrich the field of psychology and make it competitive in a market.” (p. 123).

6.5.5. Implications for Contracting

The challenges to the therapeutic frame have been discussed and one implication is that online practitioners need to develop an appropriate therapy contract that covers

their use of online media. The use of online methods as an adjunct to face-to-face therapy is also something for practitioners to be aware of, and should be given proper consideration rather than used in an unplanned way. The nature of the relationship might change if the contact switches from face-to-face to online or vice versa. The contract is important to ensure that online therapy is treated with appropriate

seriousness and with firmly agreed boundaries ensuring confidentiality and the privacy of both parties. The procedure for what to do in the case of a technical problem, such as a lost connection, needs to be set out clearly so that there is a defined plan and perhaps an alternative way of making contact. This will help to build some reliability into what is an inherently less dependable frame. Clients need to ensure they have a private space without interruption for their session. Such advice could be built into the therapy contract. Some detailed recommendations for contracting have been made by Weitz (2014).

Both online and face-to-face practitioners need to be aware of online culture and their own digital footprint. They might choose to limit the personal information that is available to be found, or they might want to put policies in place that would specify what is deemed appropriate online contact outside of sessions. They could also have a policy on their response to say, a friend request or casual use of email.