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Article Excerpt
Online counseling is a growing area of clinical work with relatively little empirical evidence about the kind of clients that use the medium, advantages and disadvantages of online counseling, and satisfaction with relationships and treatment service. Sociodemographics were collected on 81 self-selected clients using online counseling, and self-reported therapeutic alliance and satisfaction with online counseling were assessed for comparison to past studies of clients using traditional face-to-face counseling. Online clients were predominantly female, were already regular Internet users, and enjoyed the convenience and anonymity of the service. They were satisfied with their relationships and treatment online but not as satisfied as clients who have undergone traditional face-to-face counseling. The main disadvantage, the loss of nonverbal information, was offset by the advantage of anonymity when sharing shameful personal information. Research limitations and clinical implications of the study are discussed.
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Nearly 580 million people across the globe access the Internet (Nielsen/NetRatings, 2003). Americans are turning to the Internet with increased regularity to gain mental health services (Cook & Doyle, 2002). The practice of online counseling in particular continues to grow, as does the demand for empirical evidence of both the advantages and disadvantages of the medium (Rochlen, Zack, & Speyer, 2004).
Advantages cited for online counseling include the level of convenience (e.g., accessibility from home, without travel or grooming), the privacy or anonymity of the encounter, the ability to reread and edit communication, and the relative inexpensiveness of the service (Cook & Doyle, 2002; Lange, van de Ven, Schrieken, & Emmelkamp, 2001). Researchers have hypothesized that anonymity of the contact is especially appealing for introverted people (Hamburger & Ben-Artzi, 2000); people with anxiety disorders, such as agoraphobia and social phobias (Bouchard et al., 2000); and problems surrounding body image or eating (Rochlen et al., 2004).
The disadvantage levied against online counseling concerns the difficulties with establishing strong therapeutic alliances in the absence of nonverbal information available in traditional face-to-face counseling (Cook & Doyle, 2002; Rochlen et al., 2004). Nonverbal cues are thought to be critical to the development of relationships and intimacy (Altman & Taylor, 1973) and necessary in counseling relationships (Alleman, 2002). In a study involving interviews of 16 experienced HIV/AIDS counselors using the Internet, the absence of visual and verbal cues reportedly interfered with the formation of rapport and a "safe place" for counsel (DeGuzman & Ross, 1999). The question of the adequacy of the therapy relationship is essential because clinical evidence suggests that the relationship is one of the largest and most consistent factors predicting successful outcome of counseling (Lambert & Ogles, 2004; Wampold, 2001). For example, meta-analyses encompassing hundreds of therapist-client relationships have consistently found effect sizes from .25 to .35 (Horvath, 1994; Horvath & Symonds, 1991). Only allegiance to therapy technique (e.g., cognitive-behavioral therapy, interpersonal therapy) and competence of the individual therapist accounted for more variance in outcome than the therapist-client dyad (Wampold). A critical question for researchers to answer is whether effective online relationships can be forged.
To date, a modicum of theory and empirical evidence suggests that effective working alliances are possible through online counseling. Theoretically, Parks and Roberts (1998) cited Thibaut and Kelley's (1959) stranger-on-the-train phenomenon, whereby anonymity facilitated rapid and deep disclosure. Parks and Roberts hypothesized that when anonymity is coupled with time to fashion clear and thoughtful responses, online communication might result in higher levels of self-disclosure than occur during face-to-face communication. They tested the hypothesis by comparing 155 off-line relationships with relationships formed online (i.e., text-based virtual environments). Their results showed that online relationships equaled off-line relationships in depth of relationship (e.g., "I feel I could confide in the person about almost anything") and in breadth of the relationship (e.g., "Once we get started we move easily from one topic to another"). However, off-line relationship development exceeded online relationships in terms of amount of interpersonal influence, sense of knowing who the person was, and commitment to maintaining the relationship.
Other studies of relationship development revealed clearer advantages for online communication (McKenna & Bargh, 2000). Both experimental and descriptive studies all provided evidence that individuals who were lonely, socially anxious, and struggling with forming relationships in person were more likely to develop relationships online. McKenna and Bargh concluded that the Internet provided a setting perceived as more safe and under the client's control by those who are isolated and anxious. The finding accorded well with an effect known as disinhibition, where people reveal themselves more openly and fully in private compared to face-to-face exchanges (Suler, 2001). The finding also supported a previous finding by McKenna and Bargh (1998) that marginalized social groups benefited when anonymous communication shrouded the influence of physical appearance.
Cook and Doyle (2002) evaluated online counseling relationships directly quantitatively and qualitatively. Fifteen online clients completed the Working Alliance Inventory (WAI) after at least one online therapy session. A comparison group was drawn from a validation study of the WAI reported by Horvath and Greenberg (1986). Cook and Doyle's analysis revealed that both the total score for the WAI and its subgroup scores (i.e.,Task, Bond, and Goal) were as strong for online as for face-to-face clients. More impressively, the total score was significantly higher for online therapist-client dyads than for face-to-face therapist-client dyads. Qualitatively, their results complemented these findings. Clients reported experiencing strong alliances with their online therapists and also reported disinhibition effects. Therefore, despite the loss of nonverbal cues available in online counseling, the therapeutic alliances were nevertheless effectively established.
Although research supporting therapeutic alliance formation online is increasing, as pointed out in a recent review of online...
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