Online therapy provides users access to a variety of therapy services offered by qualified and skilled practitioners from the comfort of their own home. There is no denying technology has impacted nearly every aspect of life and therapy is no exception. Secure platforms have been developed to allow the general public to connect with a licensed therapist through a variety of mediums including chat rooms, phone calls, and video sessions.
Online therapy provides clients in remote and rural areas access to highly trained professionals who may live hours away and specialize in the issue for which the individual is seeking treatment. While this form of therapy has received its share of criticism from the onset of the idea of phone therapy, innovations in technology have greatly improved the efficacy of this approach, and the benefits seem to be outweighing what is missed in a typical, in-person format.
What is Online Therapy?
Online therapy, also referred to as teletherapy and e-therapy, allows individuals struggling with a variety of concerns to receive support and assistance from therapists and counselors who are highly trained and prepared to assist them through their issues. Therapists, at minimum, hold a graduate degree in psychology, counseling, social work, or another related field. Services are similar to those gained from traditional face-to-face therapy and can assist users in attaining relational and mental health goals. While many therapists and clinics offer teletherapy independently, popular platforms like BetterHelp and Talkspace have sprung up to meet the demand for online therapy.
Core Concepts of Online Therapy
Connecting virtually with a therapist can happen in many different ways. The services may be provided synchronously (connecting at the same time, as in video sessions) or asynchronously (connecting through messaging when both parties are not interacting simultaneously).
An important consideration regarding online therapy is that most state regulatory boards and professional ethical codes prevent providers from serving clients who live outside of the state issuing the practitioners license. This means that, when seeking online therapy, one can expect that the professional who they will be connecting with will either be living in the same state or are licensed in the state the client is residing.
There are many considerations to make when seeking therapy services, and online therapy seems to be primarily chosen as a factor of convenience and available resources. When receiving services from online therapists, clients are able to avoid travel to and from an office, may not need childcare for older children, can be in the company of comfort objects and animals, and are able to schedule outside of traditional office hours, as well as other economic and environmental advantages.
What Are the Goals in Online Therapy?
Goals of online therapy are similar to those established through traditional therapy. Users may seek to find self-understanding, decrease behavioral concerns, stabilize mood, or strengthen relationships. The goals for online therapy vary depending on the issues that drove the individual, couple, or family into therapy.
Just as in traditional therapy, it is important the goals of online therapy are a collaboration between the client and therapist. Therapists are advised against creating goals without the voice of the client directing the treatment plan. Similar to traditional therapy, there will likely be no progress if the client does not desire to grow in the ways the therapist may identify as necessary.
What Can Online Therapy Help With?
Online therapy can be effective to help support or treat a variety of mental health concerns. While the research appears to be mixed regarding who can benefit and what online modalities of therapy are most effective for what issues, it is generally accepted that the majority of mood and behavioral disorders can be supported and helped through online therapy.
Mental and Behavioral Disorders
While many individuals may benefit from online therapy, it is important to understand which particular issues are best suited for this modality of treatment and which disorders may benefit from seeking different services.
Depression
Online therapy may be helpful for individuals experiencing symptoms of depression, such as feelings of sadness or irritability, appetite and sleep changes, lack of motivation, and feelings of hopelessness. Working with an online therapist may be most helpful to those individuals who do not want to get out of bed or leave the home due to feelings of depression. Connecting with a trained professional from your bed during times of difficult symptoms is possible through online therapy and may be the motivation needed to regain mental health.
Anxiety
Individuals experiencing anxiety and panic attacks may benefit greatly from accessing online therapy services. Not only do online therapy modalities provide access to individuals in their most comfortable environment, it also allows the provider to be with clients during an anxiety attack. The connection afforded through online therapy allows those with high anxiety to maintain control over the physical environment, which may increase likelihood of follow through with therapy.
Personality Disorders
Often, individuals with personality disorders struggle with relationships. Interacting with a therapist online may provide a solution to some clients who are inclined to develop codependency, struggle with high needs in communication, or require high levels of support. The synchronous and asynchronous functions of online therapy, when used intentionally, may enhance relational understanding and progress in establishing boundaries.
Trauma
Many people in our society today are impacted by traumatic events. With the preventative nature of counseling and the ability to work at their own pace, clients may experience much relief through online therapy services. Clients who have been impacted by trauma could find the direct and behavioral approaches often used in online therapy to be effective and relieving of symptoms.
Bipolar Disorders
Those experiencing difficulty with emotional regulation and intense mood fluctuations may benefit from online therapy. This modality can allow for easy education, mood monitoring, bibliotherapy, workbooks, and other proven forms of treatment for this population.
Couples Issues
Online therapy may be a great resource for couples looking to work on their relationship. Many individuals requiring couples counseling need nontraditional hours due to both partners’ work schedules. Online therapy can accommodate both parties and provide many of the necessary components of successful couples counseling such as assessment of the relational dynamics, education, insight, and communication modeling.
Neurodevelopmental Disorders
Those experiencing neurodevelopmental disorders such as Autism Spectrum Disorder are cautioned in utilizing these services. Those with profound presentations may find it difficult to communicate through technology. In addition, treatment of these disorders often requires a social behavioral component which can be difficult to facilitate in online therapy.
Psychosis/Delusions
Individuals diagnosed with psychotic and delusional disorders are often not advised to participate in online therapy due to the difficulty of facilitating reality testing through this modality.
Common Types of Online Therapy
Online therapy can vary greatly based on client needs. Some may need an independent and unbiased individual to assist in finding solutions while others may require behavioral modification. Still others may be seeking interpersonal psychotherapy in attempts to reach self-actualization. Online therapy is vast and highly accommodating to client needs due to the many modalities available.
Messaging
One modality that can be used with online therapy is asynchronous chat. This form of therapy allows clients to dialogue with a therapist similar to text-messaging or emailing. Also, some platforms are now offering clients the option of sending their therapist a voice message instead of typing out what they want to communicate. Once the therapist logs on and checks the messages, they will respond and dialogue will continue. This form of therapy is not accepted by every state and therapists must be mindful of boundaries and management of crisis services when the communication occurs asynchronously.
Chat Room
Another modality used in online therapy is the chatroom. Chat Rooms allow for synchronous messaging with a therapist. Most often, the client can see when the counselor is typing and vice versa. This form of synchronous messaging allows users to engage in real-time with a therapist but does not rely on voice to convey the message. Some clients who are particularly anxious about social interactions and fear judgement may choose this modality due to the removed connection it provides.
Voice Session
Communicating with a therapist over the phone is one modality that can be accessed through online counseling services. Phone sessions have been around for more than a half-century and the general consensus is that there is an element of communication lost when relying solely on one’s voice instead of incorporating body language as well. While voice sessions facilitated through the internet may be lacking in all helpful components of therapy, they do provide the user an opportunity to talk out problems and communicate more efficiently than through messaging. Voice sessions may be a good starting point for those who are apprehensive about connecting with a therapist online due to social anxiety.
Video Sessions
Oftentimes when someone thinks of online therapy, they envision meeting with a counselor by connecting through video on a computer. This form of online therapy, also known as videoconferencing, is most closely aligned with traditional talk therapy and provides many benefits to the client as well as counselor. Meeting through video connecting services, clients are able to discuss issues, problem-solve solutions, identify patterns, understand communication styles, gain insight into thoughts, feelings, and behaviors, learn new ways of coping, and prevent future issues.
Video sessions provide the client and counselor with several ethical considerations, as well as the idea that something is missed by not sharing the same space. Even in this missing component, video therapy sessions allow the therapist to consider body language, facial expressions, and other visual interaction patterns. This added component of communication may be the most efficient form of online therapy and the one most preferred by clinicians.
Online Therapy Examples
There are several examples of ways these modalities can allow clients to meet their goals. The use of online services depends on the needs of the client and resources available. When clients are able to access online therapy services with specific goals and needs in mind, the approach can be more intentional and the outcome could be more efficient and lasting.
A young woman newly pregnant with her first child who is struggling to find support from family members may want to access several modalities of online therapy to gain support, education, insight, and monitoring through this emotional journey.
A couple struggling with infidelity and wanting to decide if their relationship is worth saving may access video sessions with an online couple and family therapist trained in evaluating and treating issues of unfaithfulness.
A businessman struggling with depression, working 70 hours a week, and juggling an inconsistent and hectic schedule may benefit from asynchronous messaging with a trained mental health counselor to identify coping skills, learn new ways of managing symptoms, and find general support.
Cost of Online Therapy
With providers and the general public decreasing skepticism of online therapy, insurance providers and financial assistance for this modality seems to be improving. Most online platforms do not accept insurance and clients can expect to pay anywhere between $30 to $80 dollars a week for services. While different platforms provide different payment packages and arrangements, it is typical for clients to access four to six 30 to 50-minute video or phone sessions a week with asynchronous messaging between sessions.
Insurance companies seem to be increasing their coverage of online therapy, however, the majority of these insurance companies require the service to be synchronous and provided through a HIPAA-compliant system. When receiving online therapy services that are reimbursed by insurance companies, clients can expect to pay about $20/session or their listed copay. These services are limited to the same time frames and modalities provided by traditional therapy and can be accessed primarily through private practitioners offering this service.
In addition to pay-per-week online therapy platforms and insurance-reimbursed private practice e-therapy, some employee assistance programs (EAPs) are allowing online therapy services. With more and more employers identifying the cost and time savings provided through online therapy, the number of companies accessing online therapy services for their workers is increasing. Some companies are contracting with online platforms while others are working with insurance providers to identify private practitioners who can provide this service.
How to Find an Online Therapist
It is important to find a therapist you trust, whether in-person or online. Be sure to find a therapist who is certified and you know will meet your specific needs.
Who is Able to Offer Online Therapy?
While some states may allow bachelor’s-level trained individuals to perform some forms of therapy under supervision, the vast majority of online therapy services are provided by masters and doctorate level clinicians. Those individuals holding licensure as a professional counselor or social worker seem to be the most likely to provide online therapy services.
There have been some reports of individuals without proper credentials being accepted as providers on some platforms who offer online therapy. While this may be an issue, faking credentials to gain access to these platforms seems to be rare and not unique to online therapy.
Federal licensure standards for mental health providers are lacking and each state is responsible for determining the rules around licensure and service delivery. Some states may not allow some forms of online therapy and others may require special certifications or credentials in order to offer these services. Online therapy is relatively new and many state licensing boards are working to build regulations and rules around the offering and use of online therapy.
Associations such as the American Counseling Association, American Psychology Association, and the National Association of Social Workers are working to build standards and procedures regarding new technology usage in therapy. While these associations work to increase practitioner understanding, clients need to be mindful of their personal goals of therapy and prepared to advocate for their needs.
Key Questions to Ask a Therapist When Considering Online Therapy
- What type of services do you offer through an online format?
- What approach do you take to the particular issue for which I am seeking treatment?
- What training do you have in therapy and online approaches?
- How long does the average individual with similar issues receive services before experiencing relief?
- When are you available to clients and/or how often do you check messages?
- What platforms do you use and how do I connect with you?
- How is my information kept private?
What to Expect at Your First Appointment
When making an appointment for online therapy, one can generally expect the counselor to provide detailed information about how the connection will occur. If the client needs to download an app, sign in to a website, or click a link, this information should be provided at the time the appointment was scheduled. Some platforms are only accessible through certain browsers and permissions to audio/video equipment may need to be set.
During the time of first connection, the client can expect to be “called” by, or enter the same video-conferencing room, as the therapist. Many counselors will check with the client to make sure they can see and hear them sufficiently before starting services. Once the connection is established, one can expect the session to progress as it would with traditional therapy; the counselor will discuss informed consent including limits of confidentiality and what to expect from the services, as well as perform some form of assessment.
Once services are established, the therapeutic relationship may continue to develop as it does in traditional therapy with the client understanding what to expect and what the path forward may be. Online therapy offers a unique function in the ability to connect with a therapist between sessions, depending on messaging features offered by the provider. Before ending the first session with an online therapist, it is important to understand the expectations around scheduling and communicating between sessions.
Is Online Therapy Effective?
As online therapy gains in popularity and use, research on this modality of treatment continues to grow and a favorable outcome seems to be the consensus. Research points to the idea that online individual therapy delivered through video sessions may be a comparable and viable alternative to traditional face-to-face therapy.1 Also, research is showing video sessions for couples and families are being received positively by those accessing these services.2
In addition, providers are finding online therapy through video sessions to be a good alternative to in-person counseling for those diagnosed with Post Traumatic Stress Disorder.3 Generally speaking, available research indicates that online therapy is not inferior to in-person therapy for individuals and groups with a variety of disorders.4
While the American Counseling Association does not currently have competencies for online therapy, the American Psychology Association currently has practice guidelines for telepsychology and there is an intentional push towards increasing the efficacy of this practice. The National Association of Social Workers is also publishing information and guidelines related to technology use in practice. All of the above listed organizations have incorporated online therapy into their ethical standards and seem to be continually working on understanding and bettering this service.
Risks of Online Therapy
There are some concerns regarding the therapeutic alliance cultivated through online therapy. While there may be a difference in the connection virtually, online therapy may be a good supplement to traditional therapy and its usefulness should not be overlooked.5 One of the concerns cited in using technology to connect with others are the typical issues inherent to the use of technology such as failed connection, service interruption, and glitches in the connection.6
Online Therapy vs In-Person Therapy
As noted by the research listed above, in-person therapy and online therapy (when using video sessions) are comparable and findings continually point to the idea that online therapy is a great alternative, particularly for those who cannot access traditional therapy. Online therapy through video sessions may be the resource needed for some people who would not normally be able to connect with a professional specializing in their particular issue.
In addition to online individual therapy, online group therapy has been conducted for years and is gaining in support and availability. Today, many online groups are available to offer support, psychotherapy, or cognitive processing to individuals with social, mental health, or addictive behavioral concerns. Online therapy is similar to traditional group therapy and individuals may find a lot of support for issues through these networks. The National Alliance on Mental Illness provides a list of online support groups available to clients for a myriad of issues.
History of Online Therapy
The use of technology in therapy began early in the profession with the use of phone sessions before the internet became widely available in the 1980s. Skepticism for telephone counseling was noted and well-known. The first public forum was introduced through Cornell University in 1986 and offered a place for individuals to ask questions to a trained therapist. With the increased advancement of technology, video conferencing services have been offered since the 1990s and are gaining traction as new research continues to support this medium.
Currently, online psychotherapy services are offered worldwide and international research continues to support this service. The use of technology in therapy is continuing to grow and new ways of connecting with therapists seem to continually be developed. As these new modalities are developed, major networks and associations work diligently to ensure safety to the general public and training of practitioners. Through these continued efforts, online therapy is likely to continue to grow in momentum and offering.
With the increased innovation around the use of technology to connect with others around the world, online therapy is likely to continue to grow and be accepted by professionals as well as the general public. As research continues to point toward the efficacy of this modality, many individuals may be encouraged to try the service. Those who are comfortable using, technology are likely to experience the most benefit from online therapy and the various ways of connecting are likely to fit any individual’s needs and schedule.
