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Hanley Reynolds 2009
Hanley Reynolds 2009
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Purpose: This paper examines the empirical research concerning counselling psychologists who utilise the
internet in their practice. More specifically, we summarise the quantitative research of online therapeutic
outcomes and alliances reported in text-based therapeutic encounters.
Background: Online therapy creates much debate within the therapeutic world. Many question the validity
of entering into these relatively uncharted waters, while others have begun working productively in this
territory. To date, a small pool of research examining the efficacy of such work has emerged and provides
the focus for this paper.
Method: A review of the literature has been conducted with a two-fold strategy. Initially a review of 16
quantitative outcome studies investigating this area are presented and discussed – these have been selected
from Barak, Hen, Boniel-Nissim and Shapira’s (2008) comprehensive review of the effectiveness of internet-
based psychotherapeutic interventions. Following this, the focus is moved to the concept of the online
therapeutic alliance. A systematic review of the existing literature outlines five pertinent quantitative
studies and these are discussed in relation to key qualitative work in this area.
Conclusions: Conclusions are drawn highlighting that work in this medium shows great promise, with both
successful outcomes and strong alliances being reported online. Such findings, although limited due to the
dearth of the research available, challenge the views of those sceptical of counselling psychologists entering
into virtual arenas.
A growing literature is emerging that specifi- presence. Rochlen, Zack and Speyer (2004)
cally articulates these challenges in online note that it is convenient and increases
communication. This literature also adds access for clients, the client may feel safer
considerable weight to not offering therapy and thus disinhibited by the online environ-
through this medium. ment, e-mail provides a meditative ‘zone of
Therapists who work online have reflection’, writing is therapeutic, individuals
attempted to overcome a number of these report feeling close to others they meet
technical challenges by familiarising them- online (this has been described by Lombard
selves with the nuances of computer-medi- & Ditton [1997] as ‘Telepresence’), and it
ated communication. A number of book provides immediate access to internet-based
chapters have been devoted to outlining resources. Thus, the theoretical retort to
some of the key components of such modes critics of e-therapy has developed substan-
of communication to therapists. Authors tially in recent years. It has shifted from
explain how counsellors can develop innova- examining how the nuances of face-to-face
tive strategies for expressing themselves therapy can be mimicked solely using text, to
solely through text despite the absence of considering how technology can actually
face-to-face cues. Written techniques such as complement and improve service provision.
emoticons (☺), abbreviations (u=you),
acronyms (lol=laughs out loud), and Rationale for the review
emotional bracketing (see Murphy & As outlined above, online therapy is a
Mitchell’s [1998] descriptions of therap- growing field in which interested profes-
e-mail) are all noted to add depth to the rela- sionals have attempted to tackle the chal-
tionships that are created. Stofle (2002) uses lenges posed by the online environment.
the term ‘non-textuals’ to describe ‘every- However, there are still numerous questions
thing other than the words themselves’ of efficacy regarding counselling psycholo-
(p.94) within computer-mediated communi- gists entering into virtual environments.
cation. In such instances, the words and key Consequently, this work aims to investigate
strokes create a mental representation of the two key facets of such practice. First, ‘What
individuals involved and facilitate the evidence suggests that text-based online
creation of relationships of a sufficient depth therapy produces positive outcomes for
to produce positive change (e.g. Anthony, clients?’ Second, ‘What evidence suggests
2000a; Suler, 2004). In addition to the devel- that therapeutic alliances of a sufficient
opment of computer-mediated counselling quality to create positive change can be
skills that are utilised within sessions, indi- created online using text-based media?’
viduals have also paid attention to the ethical
concerns that have been raised (e.g. Review strategy
Anthony & Jamieson, 2005; Bloom, 1998; This paper reviews the literature related to
Childress, 2000; Goss & Anthony, 2004; King the work of counselling psychologists who
& Poulos, 1999; Kraus, 2004; Robson & utilise e-mail or online chat to mediate their
Robson, 2000; Stofle, 1997). These works practice. It specifically examines the quanti-
attempts to highlight the numerous pitfalls tative research that has been conducted
of working in virtual environments such as exploring therapeutic outcomes and the
producing appropriate counselling therapeutic alliance using online text-based
contracts, being mindful of the limits of modes of communication. The review
confidentiality, and protecting any elec- strategy is a two-stage process:
tronic files that are stored. Stage 1: Initially this paper reflects upon Barak
The online environment can provide a et al.’s (2008) comprehensive review of
number of distinct opportunities that may be internet based psychotherapeutic interven-
used to compensate for the lack of physical tions. This review provides a systematic
Cohen (1969), such findings are indicative Each of the studies outlined in Table 2
of moderate effect sizes. supports the notion that good therapeutic
A further consideration with Barak et al.’s alliances can be developed online. Scores
(2008) meta-analysis is that it reflects more within the studies generally indicated that
technical approaches to therapy (e.g. cogni- clients perceived the alliance between them
tive behavioural therapy), rather than those and the counsellor to be moderate or strong
that place more emphasis upon the curative in nature. It is also noteworthy that within
nature of the relationship (e.g. person- three out of the four studies that made
centred therapy). The whole study cate- comparisons to face-to-face equivalents, the
gorises the work that has been collated into online alliance proved higher than the
three main psychotherapeutic approaches: comparison group. Such findings provide
cognitive behavioural therapy, psycho-educa- persuasive evidence supporting online
tional interventions, and behavioural inter- therapy and challenge theoretical assump-
ventions. Only two studies within the analysis tions that relationships of sufficient quality
reflected different approaches to therapy. to create therapeutic change cannot be
They both reflect therapy conducted developed online.
through chat and used an unspecified thera-
peutic approach (Cohen & Kerr, 1998; Effect Discussion
size=0.86) and a client-centred form of moti- Previously, two questions were raised: ‘What
vational interviewing (Woodruff, Edwards, evidence suggests that text-based online
Conway, & Elliott, 2001; Effect Size=0.56). therapy produces positive outcomes for
In summary, this highlights the bias within clients?’ and ‘What evidence suggests that
the present research towards more technical therapeutic alliances of a sufficient quality to
approaches to therapy as opposed to those create positive change can be created online
that are more relational in nature. using text-based media?’ This section will
discuss these questions in relation to the find-
Examining the alliance ings presented above. It will then move on to
Similar to online outcomes, the online ther- briefly consider the limitations of this work
apeutic alliance has received limited atten- and future directions for research in this area.
tion to date. From the on-going review of Within industrialised cultures, the
alliance, five studies have been selected from internet is increasingly being used to seek
the electronic database searches. Table 2 out health care information and services.
outlines the participants involved in the Broadly speaking, the findings from this
studies (both those receiving online therapy review of the quantitative literature support
and those in comparison groups), the type of the notion that individuals who seek out
text-based intervention employed, alliance online mental health services can receive
measure used, and a brief summary of the effective support. Specifically, 16 studies
main conclusions. have reported positive outcomes from such
The five studies had a total of 161 clients encounters. These studies noted effect sizes
who took part in online therapy treatment for e-mail therapy to be 0.51 and therapy
conditions. Of the five studies all but one mediated through chat rooms to be 0.53.
compared their data to face-to-face compar- These findings are comparable to face-to-
ison groups (Prado & Meyer, 2006, face outcomes studies (e.g. Lambert &
compared findings to those of individuals Ogles, 2004), however, the limited number
who dropped out of therapy at earlier of studies in question limit the compara-
stages). In addition, three studies only bility. Although there is growing evidence
utilised asynchronous communication and that online therapy proves effective for some
two utilised a combination of asynchronous individuals, there is still much evaluative
and synchronous communication. work to be undertaken.
Table 2: Table outlining the studies which examine the therapeutic alliance in
text-based therapy.
Authors (date) N= N= Asynchronous/ Alliance Conclusion
Online Comparison Synchronous measure
group group
Cook & N=15 f2f archive Asynchronous Working – Moderate TA scores
Doyle (2002) N=25 & Synchronous Alliance – higher than f2f
Inventory
(WAI)
Knaevelsrud & N=48 Previous f2f Asynchronous Working – High TA scores
Maercker (2006) study with Alliance – higher than f2f
similar Inventory – – no distinction of
client group short form scores for those
N=270 (WAI-S) with different
severity of need
Leiber, Archer, N=52 f2f archive Asynchronous WAI-S – Moderate TA scores
Munson & N=46 & Synchronous – weaker than f2f
York (2006)
Prado & Meyer N=29 Drop out Asynchronous WAI – Moderate to
(2006) N=19 Strong TA scores
– Drop out TA scores
significantly lower
than completion
Reynolds, Stiles N=17 3 Previous Asynchronous Agnew – Similar TA ratings
& Grohol (2006) f2f studies Relationship as f2f
using the Measure –
same short form
measure (ARM-S)
The five studies that investigated the question the view that good quality relation-
online therapeutic alliance in adult therapy ships cannot be fostered in text based rela-
add to our understanding of this phenom- tionships (e.g. Pelling & Reynard, 2000).
enon. They offer clear and compelling Further, it argues against the notion that
insight into the quality of online therapeutic mental health professionals are unprepared
relationships. In particular, each study for technological advances (Alleman, 2002).
reported alliance scores to be of moderate to The qualitative literature on the online
high strength. Thus, it could be suggested therapeutic alliance supports the possibility
that a high percentage of the 161 total of creating good quality relationships online.
participants felt the quality of the relation- For instance, two UK-based studies have
ship to be of a sufficient quality to create consulted small numbers of counsellors
therapeutic change. Similar to the positive about the quality of the relationships that
outcomes reported by those who have they develop with clients in their online
accessed online therapy, this finding chal- practice (Anthony; 2000a; Hanley, 2004b;
lenges those who question the efficacy of this see also Anthony, 2000b). These studies
way of working. More specifically, it calls into suggest participants’ believe that good
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