05 Apr Online counseling: psychotherapy from your own couch
There are estimated over 600 000 mental health providers (including psychologists, counselors, clinical social workers, psychiatrists, and psychiatric nurse practitioners) in the US, and an estimated 12 percent of them provide some form of online counseling.
Though the techniques have evolved over time, the format of traditional counseling has not significantly changed from what Breuer, Freud, and the other early psychotherapists developed in the 19th century: you meet your therapist in an office and talk. The most significant change was the shift from lying on a couch facing away from the therapist to sitting and directly interacting with him or her. (I will save for another post the topic of “encounter groups”, which were experimental offshoots of psychotherapy in the 1970s with very different formats but questionable therapeutic value.)
As communication technology developed, therapists experimented with adjusting the format to the phone and later the internet. Online counseling (also known as teletherapy and remote counseling) has been conducted through IRC and instant messengers, via virtual avatar, over video and voice over internet calls, and even bots, but it had relatively limited appeal until recently. Now online counseling is growing in popularity due to improving broadband and cellular internet access and the ubiquity of mobile devices with high quality cameras.
Though my training was in traditional face-to-face psychotherapy, I’m drawn to exploring innovations in psychotherapy techniques and formats, so it was a natural fit to focus my private practice on delivering online counseling. I’ve been practicing online psychotherapy for over 5 years and now I exclusively see my clients online. I have discovered a number of benefits to online counseling compared to traditional counseling. There are also several things to keep in mind if you are considering online counseling to ensure you have a positive experience.
Why Choose Online Counseling
| Availability | 24/7 via video or phone |
| Flexibility | Video conferencing, phone, email, text, IM |
| Privacy | Encrypted video conferencing, HIPAA compliant |
| Convenience | Your own space, on your schedule, no travelling required |
Benefits
1. Efficient
Online counseling is a convenient format for a lot of people but it is not an appropriate fit for every person or therapeutic goal. If you lack a private space from which to have sessions or you need a greater level of support than regular talk therapy (such as concurrent medical issues or risk of harming yourself), then in-person counseling may be more appropriate. But for those seeking to fit counseling into their busy schedules, online counseling can be more efficient because it helps the formation of a therapeutic relationship between you and your therapist. The quality and trust of your relationship with your therapist is one of the factors that best predicts the chances of meeting your therapy goals.
Counseling can demand honestly reflecting on yourself and disclosing them to a relative stranger. But while out in the world people feel cultural pressures to filter what we say—even in a therapist’s office, despite our best attempts at interior decorating to make it a comfortable space. Research also shows that being in a medical setting raises our heart rate and increases anxiety, a context that may interfere with your thinking and memory. This discomfort tends to decrease with time and familiarity but it can interfere particularly in earlier sessions. In contrast, when are you in your own space—at home or in your own office—you feel more comfortable discussing personal information. The usual cultural and personal precepts against self-disclosure are reduced so I find that clients are able to work on core issues more quickly.
2. Effective
One of the challenges to counseling is generalizing what you learn in counseling. We all wish we could be our vacation selves every day: less stressed, more sociable, and so on. It is easier to be this version when you do not have the daily stressors affecting you while on vacation, but harder to bring this more relaxed version of yourself back home. Therapy offices create a similar compartmentalization effect: for an hour you are cut off from the outside world and this buffer can help you come to important realizations. But as soon as you leave the office and turn your phone’s ringer back on, the rest of the world floods back and and those realizations you made or skills you learned seem harder to access. Whereas with online counseling, the gap between the counseling environment and your daily life is smaller. Though that may pose distractions to a session, it also makes it easier to generalize what you learn in counseling to your daily life.
3. Convenient
There are many potential barriers to making positive changes in your life, like regularly seeing your therapist. Online counseling means you can see a therapist whenever and wherever it is convenient for you so you do not have to deal with traffic, cancel sessions because of travel, or take time off from work to get to a session during office hours. The internet also provides access to therapists outside your immediate area, which is particularly relevant for those living in rural communities—where the closest therapist might be hours away or you might already be on a first name basis with—and expats who may be more comfortable speaking with their therapist in their first language.
Areas of Expertise
| LGBTQ+ | Everyone deserves accepting nonjudgemental counseling but LGBTQ+ friendly counseling is not equally available everywhere. Counseling from providers specializing in LGBTQ+ issues wherever you are. |
| Expats | Adjusting to living or travelling in another country pose unique challenges, and finding a local counselor may be unrealistic. Online counseling lets you keep your counselor throughout your journey. |
| Rural Residents | People living in rural communities or healthcare deserts often lack access to mental health providers. As high-speed internet access becomes more ubiquitous it's easier to reach more people who need service. |
| Travelling Professionals | With the pace of work it can be challenging enough to find time to eat or exercise let alone see your counselor. Online counseling lets you fit a session into your busy schedule. |
What to keep in mind
Your privacy is paramount for any clinician. When it comes to online counseling there are two factors to consider for keeping your information private: online security and physical privacy.
Online security
It is important to guard the information you transmit over the internet. What you discuss in counseling can be some of the most sensitive information, but if you are careful online psychotherapy sessions can be as private as face-to-face sessions.
For video sessions I only use encrypted peer-to-peer video conferencing software. Most people think of online counseling as “Skype counseling” but Skype is actually a poor choice for two reasons: A. Though Skype calls are encrypted, the software uses a proprietary encryption so that it is impossible for anyone outside Microsoft to evaluate how secure it is, and B. Calls pass through Microsoft servers, which potentially allows third parties at Microsoft to save and access these communications. When you see a therapist, make sure they use video conferencing software whose calls are both decentralized, use open-source encryption, and are not recorded by some third-party, such as VSee. This ensures communication is not intercepted between you and your therapist.
To prevent someone from accessing your data or listening in on your calls, practice good security habits on your devices: update your operating system regularly to receive security updates that close vulnerabilities, and install and regularly run antivirus software. (There’s also FlexiKiller, which can be run on PCs and Macs to detect and deactivate one popular spyware tool, FlexiSpy).
If you’re at risk of government surveillance, there’s no guarantee these methods will be enough to thwart that—though neither would seeing a face-to-face counselor—but it should keep the average person’s information private.
Privacy
With online counseling you have to control the environment from which you have your sessions. The flip side to the above benefit of convenience is that you need to manage your own physical privacy. I recommend people find a quiet room with decent sound insulation and no distractions, but not everyone has access to that and may prefer therapist’s office as providing a needed escape. Some of my clients see me from their offices during a break or after work; others find a quiet room behind a closed door; while I have seen some parents use a headset to keep the conversation private but stay in the common room to keep an eye on their kids. It is up to you to find a space that is appropriately private for you, though I discourage any actually public spaces.
Online technology has the potential to increase the effectiveness and decrease the barriers to accessing counseling, which I hope helps more people live a more satisfying life. Feel free to reach out if you have any questions about online counseling about or if you are curious and would like to try a free consult.