Imagine me, sitting in a cozy armchair, my little cockapoo, Peanut, at my side, as I sip a warm, soothing tea and write this. Now, picture yourself coming and sitting beside me, getting cozy and – perhaps – warping your hands around your own warm cup of tea. We smile at one another, say a warm hello, and settle in to discuss whether eCounselling is an effective method for delivering eating disorder treatment.
I am excited to share this information with you; and, I can absolutely understand and respect that you may have your reservations [thinking back to the first time I considered the idea of eCounselling, remembering how sceptical I felt]. I hope you take the information in, think about it, and weigh the details for yourself so that you feel you’ve made your own, informed decision about eCounselling, its benefits, and it’s limitations.
Did the paragraphs above seem different to you at all? The way they were written? Was this a unique way to see a blog introduced? If no, I suggest you take note of that.
This style of communication is a little of what you might expect from therapeutic communication in a digital format. The writing format modelled in these first two paragraphs is intended to convey presence, to build relationship when visual cues aren’t present. Did it help? I feel more connected to you even writing it [feeling hopeful, even vulnerable as I picture you reflecting on how you feel].
Pause. Really. Consider how it felt to read those first two paragraphs above….
I do hope you’ll consider how paragraphs such as that might resonate with you… or not!... and take that experience with you as you read on to what’s next.
So… let’s get into the details, shall we?
There is a growing body of research exploring the efficacy of eCounselling (Richards, & Viganó, 2013). While most researchers agree that there is a need for even more study, so far the results of such studies are starting to show consistent trends.
But wait… before we get into it, I should probably define what I mean by eCounselling – right? This in itself is a big topic of discussion (Kotsopoulou, Melisb, Koutsompou, & Karasarlidou, 2015). In general, when I am speaking about eCounselling, I mean any therapeutic method delivered remotely through digital means. This could be synchronous (i.e., therapist and client communicating at the same exact time such as in video conferencing, telephone counselling, or live chat) or asynchronous (i.e., therapist and client communicating at different points in time, such as via text message, email, or similar forms of – mainly written – communication). So, broadly speaking, I am talking about ANY of these options.
1. eCounselling Does Seem to be Effective, In General
First and foremost, yes, eCounselling does consistently show significant efficacy rates and outcomes in research (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Cavanagh, & Millings, 2013; Dowling, & Rickwood, 2013; Mallen, Jenkins, Vogel, & Day, 2011; Mishna, Bogo, & Sawyer, 2015; Murphy, & Mitchell, 1998; Richards, & Viganó, 2013; Robinson, & Serfaty, 2003). In general, research tends to show a “moderate” treatment outcome for eCounselling – which is comparable to any broad study of counselling in general (Barak et al., 2008). Furthermore, research has shown that eCounselling can deliver effective results on a number of treatment outcomes and for a number of presenting problems – especially when the client is interested in eCounselling as a format (Barak et al., 2008; Dowling, & Rickwood, 2013; Richards, & Viganó, 2013; Robinson, & Serfaty, 2003).
2. eCounselling Does Appear to be As Effective as Face-to-Face (if not MORE effective, in Some Circumstances)
Even though eCounselling on it’s own IS effective, the next question becomes whether it’s AS effective as traditional, face-to-face counselling (or whether people should stick to hauling themselves out to the therapist office to physically sit there for the full session). Turns out, eCounselling IS as effective as face-to-face counselling (Barak et al., 2008; Richards, & Viganó, 2013). And, in fact, especially for clients where anonymity is important, eCounselling can be even more effective because people are more likely to access eCounselling and stick to it when their anonymity and autonomy are preserved through the format (Barak et al., 2008; Dowling, & Rickwood, 2013; Richards, & Viganó, 2013; Robinson, & Serfaty, 2003).
3. eCounselling In Shown to be Effective for Eating Disorder Treatment, Specifically
For me (and many of my clients) the next question becomes, yes, but is eCounselling effective for EATING DISORDER treatment? There are, indeed unique challenges (i.e., having to find creating ways to conduct collaborative weighing – for example); however, research has shown that eCounselling has been effective for a wide variety of eating disorder treatments (Robinson, & Serfaty, 2003). Furthermore, because eating disorders are so treatment resistant, this is an area where clients definitely benefit from the anonymity that eCounselling provides.
4. There are Unique Risks and Challenges to eCounselling
As you might have guessed, yes, there are unique challenges in eCounselling environments. Some of the main challenges include the following (Barak et al., 2008; Cavanagh, & Millings, 2013; Kotsopoulou et al., 2015; Mishna, et. al., 2015; Richards, & Viganó, 2013):
Privacy and Security – online tools have their own unique security and privacy issues. As with any sensitive online content (like online banking, online health records, etc.) there is concern about the security of information and who may be able to hack into session information. This is a real, and important issue – both online and offline, realistically.
Ethics – the security issues also point to broader, ethical concerns. For one, what if an eCounselling client is experiencing suicidal or homicidal ideation? How is that assessed and how is safety of the person or people involved reinforced? This gets particularly complicated if the client lives in a jurisdiction where the clinician is unfamiliar with its particular emergency resources, laws, or other cultural indicators.
Therapeutic Relationship – many people worry that the therapeutic relationship and alliance is affected when client and counsellor cannot see each other or, at least, can’t see each other in person. In many cases, the therapeutic relationship is considered the most significant factor in therapeutic change, so this is no small issue. However, most research shows it also doesn’t tend to be a real factor and that therapeutic alliance is often still felt in a meaningful way online.
Communication Challenges (i.e., Distraction, Conveying tone, etc.) – anyone who has participated in remote meetings or virtual learning sessions knows that there is also a unique tendency to “tune out” when engaging in online communication. However, research has shown that clients who are motivated and want the help don’t tend to experience this, especially when the potential for such distraction is addressed up front.
Technical difficulties – another practical challenge is the strength of one’s internet connection, the capabilities of their technology, and what to do if/when technical issues arise (especially at critical points in the therapeutic conversation). Ensuring that technology will support access to counselling is an important first-step and clients without reasonable technical access may want to (re)consider whether eCounselling will be the best fit for them.
Clinician skilfulness and tech savvy – on the other hand, there is also some onus on the clinician to help clients with technical issues and to navigate the tools being used for accessing eCounselling. If a clinician doesn’t have this skill or know-how; the clinician should be ethically considering whether eCounselling is the best method of delivery for them and clients should be considering whether the counsellor is a “fit” for the method of therapy delivery they would like, as well as their therapeutic progress overall. Furthermore, I believe that even though online delivery may be compelling for a clinicians lifestyle, all clinicians have an ethical obligation to consider whether eCounselling is something that they are technically equipped to deliver and deliver well. If not, more training and supervision is available and strongly recommended before attempting to deliver treatment through this medium.
5. Challenges Can be Overcome with Skill and Training
What IS interesting, is that despite the challenges listed above, counsellors who are committed to the development of eCounselling options have also identified specific ways to confront and manage these difficulties. Examples of coping mechanisms for these unique challenges include (Barak et al., 2008; Cavanagh, & Millings, 2013; Dowling, & Rickwood, 2013; Kotsopoulou et al., 2015; Mallen, et. al., 2011; Mishna, et. al., 2015; Richards, & Viganó, 2013):
Using Presence Techniques - remember those opening paragraphs? Those were presence techniques. They are meant to help build and support therapeutic alliance and bridge the non-visual cues that would otherwise exist in face-to-face settings. Developing skill and technique in these presence-building practices online is part of what eCounselling training is built to do and can make the difference between a skilled eCounselling provider, and one that may be… well, less effective (depending on the medium). Furthermore, offering a variety of online options can help with this. For example, video conference sessions reap many of the benefits of other eCounselling techniques but also most closely mimic face-to-face settings and may be an option for many more counsellors than, say, email counselling might be.
Meeting Clients Where They’re At – having scalable options is also one way that clinicians might meet clients “where they are at”. Some clients may not be ready to step into full treatment, but are interested in seeing what they can do to reduce harm and make small improvements, for example. In such cases, email support and online self-help might be more beneficial than video conferencing sessions, and eCounselling offers the opportunity to give these scalable options to clients. It also helps overcome communication challenges that might be more motivational (i.e., not ready or willing to accept challenges through synchronous format) by giving clients more “space” and time to process, as needed, and requiring a different level of reflection when responding to questions from the therapist.
Limiting Jurisdiction – to tackle some of the ethical and security concerns, it is recommended that therapists practice within a defined jurisdiction for which they are qualified to deliver counselling. This jurisdiction should be defined by where the CLIENT resides. And so, clients, you may way tot try and make sure you find an eCounsellor in your own province (or state), or at least in your own country, when/if possible.
More Secure Technologies – clinicians and clients should also be aware of/consider the level of privacy and security afforded by the delivery method being offered. For example, Skype might not be the most secure video conference format, so if a counsellor is offering sessions through Skype you will want to consider that. Those delivering live chat and/or email counselling should also be offering this through a secure system (and ideally one developed for eCounselling, specifically)
Clear Digital-Specific Informed Consent + Policies or Procedures – a strong eCounselling practitioner should also have informed consent forms that outline the unique risks and benefits to eCounselling, specifically. Clients, you’ll want to look out for this when accessing eCounselling as well.
Therapist training in eCounselling – finally, strong eCounselling providers often have specific eCounselling or cybercounselling training. For clinicians interested, I did my cybercounselling training through Therapy Online – which offers a strong variety of training, and tools for practice. Clients, those who have been through this training are more likely to be better skilled at asking questions online, building presence online, more technically savvy, and are more likely to know about eCounselling-specific ethical issues and have managed the security options that arise from such concerns.
6. There are Unique Benefits to eCounselling
Finally, despite its challenges there are also a number of unique benefits to eCounselling that make it worthwhile. These tend to include the following (Barak et al., 2008; Cavanagh, & Millings, 2013; Dowling, & Rickwood, 2013; Kotsopoulou et al., 2015; Mallen, et. al., 2011; Mishna, et. al., 2015; Richards, & Viganó, 2013):
Accessibility – digital counselling is often much more accessible for many people. This may be for geographic reasons, this may be because you need a counselling with specific training, which is not otherwise available near you, or it might be because you have mobility or time limitations and this is the only way you can “get to” counselling. Furthermore, it can be a format that is more comfortable for a lot of people. And, it might offer some people more affordable options for access (i.e., especially email counsellor or live-chat, etc.). This is the reason that I am so passionate about eCounselling. There is such demand for skilled eating disorder counselling in Ontario, and yet so many people live in locations where it is hard to access treatment. I really believe that today’s technologies can help overcome these barriers so that ANYONE can get the help they need to recovery from an eating disorder.
Anonymity – the other benefit is that a lot of people really value the anonymity that eCounselling provides. For a lot of people, they aren’t ready to tell anyone about their eating disorder or other mental health issues. Online, they can create a profile that protects their identity, while allowing them to access some help. For many, this can be the first step to getting help, and allows so many people to access care that they may otherwise avoid.
Scalability – online options are also highly scalable, again providing many ways for people to start their path to recovery. For example, some people may only feel ready to start meal logging and get some meaningful, email guidance once a week or so at first. From there, they may be more willing to add a bit of online live chat when necessary and when in need of something a little more real-time or intensive. Finally, this might open the door to them realizing they could benefit from more regular, full sessions and treatment. For others, it might be all they need to prevent an ED or another condition from getting out of hand and allows them to turn things around without ever needing to access treatment and before symptoms fully develop.
Unique Opportunities for Reflection and “Space” for Processing – last, but not least, online environments offer unique opportunities for reflection and space that is spread out throughout one’s week. In face-to-face therapy, everything happens quickly and the clients are left to reflect and process outcomes on their own. So, treatment is really condensed to what comes up at the specific date and time therapy is accessed. Online, this can be spread out. For example, someone might get feedback on meal logs that starts them thinking about a particular idea, then this is further explored through questions and assignments in emails later n the week, and then they access a live chat or video conference session and can fully hash out ideas that the client has had some space and time to reflect and consider over multiple days and within multiple contexts. Often, this provides even more meaningful learning and can benefit some personalities quite well.
So… what do you think? Really, consider that question – what. do. YOU. think? Intrigued? Curious? Know it’s not for you? Doesn’t Seem Reasonable? Whatever you’re thinking and feeling, I’d really love you to take…. some… time…. Breathe… And consider how you might respond to the following question (or consider ACTUALLY responding in the comments): do you think eCounselling is a beneficial method of delivering treatment for eating disorders?
Now… I must go. It is New Year’s Eve as I write this, and I’m excited to get out into the snow for a bit of fresh air, and to reflect on how it has felt to put these ideas and feelings out there for you to read [realizing I am feeling vulnerable, hopeful, curious… and even a little nervous about how these ideas may be received and debated; but excited for the conversation, and open to however it ends up going, I genuinely want others’ feedback].
Happy 2019 everyone, and thanks for listening along with me. Picture me smiling at you with hope for the year that lies ahead for you.
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Cavanagh, K., & Millings, A. (2013). (Inter)personal computing: The role of the therapeutic relationship in e-mental health. Journal of Contemporary Psychotherapy, 43, 197-206. DOI: DOI 10.1007/s10879-013-9242-z
Dowling, M., & Rickwood, D. (2013). Online counseling and therapy for mental health problems: A systematic review of individual synchronous interventions using chat. Journal of Technology in Human Services, 31, 1-21. DOI: 10.1080/15228835.2012.728508
Kotsopoulou, A., Melisb, A., Koutsompou, V., & Karasarlidou, C. (2015). E-therapy: the ethics behind the process. Procedia Computer Science, 65, 492-499. DOI: 10.1016/j.procs.2015.09.120
Mallen, M. J., Jenkins, I. M., Vogel, D. L., & Day, S. X. (2011). Online counselling: An initial examination of the process in a synchronous chat environment. Counselling and Psychotherapy Research, 11(3), 220-227. DOI: 10.1080/14733145.2010.486865
Mishna, F., Bogo, M., & Sawyer, J. (2015). Cyber counseling: Illuminating benefits and challenges. Clinical Social Work Journal, 43, 169-178. DOI: 10.1007/s10615-013-0470-1
Murphy, L. J., & Mitchell, D. L. (1998). When writing helps to heal: E-mail as therapy. British Journal of Guidance & Counselling, 26(1), 21 — 32. DOI: 10.1080/03069889808253835
Richards, D., & Viganó, N. (2013). Online counseling: A narrative and critical review of the literature. Journal of Clinical Psychology, 69(9), 994-1011. DOI: 10.1002/jclp.21974
Robinson, P., & Serfaty, M. (2003). Computers, e-mail and therapy in eating disorders. European Eating Disorders Review, 11(3), 210-221. DOI: 10.1002/erv.516