Online psychotherapy has benefits that are hard to ignore. Clients who lack transportation, or those who live in underserved areas can access treatments that were not previously available. During disasters and public crises, such as the COVID-19 pandemic, treatment can be continued with minimal interruption.
There’s more good news: Research seems to show that online therapy works for a broad range of problems and interventions. In many cases, internet-based treatments have outcomes comparable to in-person therapy.
Although phone, chat, and email therapy have each found support, we have chosen to focus on video-based online therapy because of its prevalence, and its many similarities to in-person therapy. Because treatment is ultimately the same whether practiced online or in-person, we will focus on what’s different.Note: The mental health community has not settled on a definitive winner when it comes to terminology. You might hear “telehealth”, “teletherapy”, “internet-based counseling”, and many other variations of these. In this article, we will use the terms “online therapy” and “in-person therapy”.
Laws and Ethics
There are many laws that limit how and when online therapy can be practiced. For example, if you live in the United States, you may not be permitted to provide services to a person who is in a different state. You might also find that popular video conferencing services such as Skype and FaceTime are not compliant with medical privacy laws, such as HIPAA.
Because laws are location- and situation-specific, it is important to understand how they relate to your own unique situation. If you have any questions about legal or ethical issues related to online counseling, reach out to your local licensure board or an attorney who specializes in the area.
During the COVID-19 pandemic, many of the usual legal requirements related to online therapy are being loosened, allowing for care to continue throughout the crisis. See the resources below for more information.
Legal and Ethical Resources
- APA Telepsychology Resources - Database of telepsychology articles, continuing education, and more.
- Licensure Related Matters and COVID-19 - Database of information about local licensure boards’ COVID-19 related changes.
- Practicing Distance Therapy, Legally and Ethically - Brief article by the APA about ethical and legal guidelines for online therapy.
- The COVID-19 Telehealth Waiver - Summary of laws and regulations that are being loosened during COVID-19 for Medicare patients.
Some critics fear that it might be difficult, or even impossible, to create an effective therapeutic relationship through the internet. They argue that limited nonverbal cues, differences in setting such as timezones or weather, and even the loss of other senses, such as smell, could have a negative impact on treatment.
Although there are some unique challenges to building a working alliance online, research indicates that these relationships can be just as powerful. This can be especially beneficial for clients who have anxiety about travel, crowds, or in-person meetings, by reducing the barriers to starting a therapeutic relationship.
To help build relationships online, some experts recommend having initial sessions in-person, whenever possible. If this isn’t possible, they suggest doing so early in the relationship. However, this is not always necessary to form an effective relationship.
When it comes down to it, building a relationship online works much like offline. Many of the standard helping skills in a therapist’s toolbox, such as reflections, empathy, and active listening, are powerful whether or not you are behind a screen.
Maintaining Focus and Commitment
Getting dressed, driving to an office, and sitting face-to-face with another person helps to create a sense of commitment and convey the importance of each therapy session. It can be difficult to build a similar feeling of commitment through a device that’s more often used for social media, Netflix, and chatting with friends.
Many people—clients and clinicians alike—will find that they unintentionally de-prioritize online therapy sessions. While parents might find a babysitter for in-person therapy sessions, it might not feel necessary during online therapy. Pets will beg for attention, laundry machines will rumble in the background, and phone notifications will become more difficult to ignore.
To combat the mindset that online therapy requires less commitment, and to minimize distractions, set clear expectations about attention and boundaries during online therapy sessions.
First and foremost, this means setting a good example. Ask yourself: Would this behavior be acceptable during in-person therapy? Dress as if you were in the office, silence your phone, place children with a caretaker, and fully commit to the therapy session.
Similarly, encourage your clients to close other computer programs, close their door, and commit fully to the session. If there are distractions on your client’s side, again, ask the question: Would this be appropriate during in-person therapy? If not, it might be a good candidate for exploration.
During in-person therapy, steps are taken by the therapist to ensure privacy. Typically, therapy offices are far from prying friends and family. During online therapy, while you are responsible for using secure technology to maintain privacy, your clients must take steps to create a sense of privacy in their chosen therapy location.
If your clients fear that a family member might hear them through the door, or try to snoop on their session, they might be less likely to self-disclose. Encourage your clients to find a private location for each session. If they live with others, suggest closing the door, and using something to create noise (e.g. white noise audio found online, a loud fan).
For clients who live in a smaller home, you may need to get creative. Do they have an outdoor location that’s private? Can sessions be scheduled for times when other family members will be out of the house? Can your client come to an agreement with housemates to be out of the house during the scheduled session time?
If the expectation of privacy is regularly violated, it may indicate an issue related to boundaries or assertiveness. These issues can be further explored in therapy.
Therapy Office Setup
Whether you’re working from home or an office, create a designated therapy area that is neat and uncluttered, with a simple background. Test out the lighting to ensure the area doesn’t get too dark at night or too bright during the day. Make sure the area is quiet, with minimal background noise. To create consistency for your clients, use this same area for every session.
Ensure the equipment you’re using is conducive to a good therapeutic experience. This means having a computer, microphone, and camera that allow you and your client to see and hear each other clearly. Built-in laptop webcams and microphones are often low quality, making your image blurry, and your voice distorted. This can greatly affect the ability to read non-verbal cues. Try testing with a friend or colleague to see how your image and sound come out on the other end.
Take some time to figure out how you want to appear in front of the camera. How much of your body do you want visible to your clients? By sitting close to the camera, as is typical with a webcam, your face will be visible with great detail. This may allow for better reading of facial expressions. However, by sitting far from the camera, you will allow your clients to see more body language, such as crossed arms or a tapping foot. There is no “right” way to go about this, as both options have different advantages.Tip: If you are distracted by your self-portrait in the corner of the screen, feel free to cover it!
It’s reasonable to have concerns about how to handle a crisis during online therapy. However, if the situation arises, you will take the same general steps, and use the same skills, as you would during a crisis that happens in-person.
Conduct an initial assessment with each client before beginning online therapy. Be mindful that clients who are suicidal, or who have other significant risks, may need more intensive treatment than can be provided by online therapy.
Before each session, make sure you know the client’s current location (e.g. their home address), along with their local emergency phone numbers. You may want to obtain information about personal emergency contacts, such as friends or family, along with a signed release for these contacts. Make sure your client has access to their local emergency numbers at all times.
Technology Backup Plan
Inevitably, your internet will go down. Video software will crash. Someone’s computer will break. Something will go wrong.
Create a technology backup plan with your client. Have phone numbers, email addresses, or other modes of communication handy. If you and your client are in the middle of a difficult session and the connection goes bad, you’ll both be happy that a plan is in place.Note: Complete any necessary consent forms not only for your primary online therapy tool, but also for your backups.
Check out our resources for coping during this time of uncertainty:
1. American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues (2017). Clinical update: telepsychiatry with children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 56(10), 875-893.
2. Amichai-Hamburger, Y., Klomek, A. B., Friedman, D., Zuckerman, O., & Shani-Sherman, T. (2014). The future of online therapy. Computers in Human Behavior, 41, 288-294.
3. Barak A, Hen L, Boniel-Nissim M, Shapira N. A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions. Journal of Technology in Human Services 2008; 26(2-4): 109-160.
4. Cook, J. E., & Doyle, C. (2002). Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. CyberPsychology & Behavior, 5(2), 95-105.
5. DeAngelis, T. (2012). Practicing distance therapy, legally and ethically. Monitor on Psychology, 43(3), 52.
6. Fletcher, T. L., Hogan, J. B., Keegan, F., Davis, M. L., Wassef, M., Day, S., & Lindsay, J. A. (2018). Recent advances in delivering mental health treatment via video to home. Current psychiatry reports, 20(8), 56.
7. Hanley, T. (2009). The working alliance in online therapy with young people: Preliminary findings. British Journal of Guidance & Counselling, 37(3), 257-269.
8. Hertlein, K. M., Blumer, M. L., & Mihaloliakos, J. H. (2015). Marriage and family counselors’ perceived ethical issues related to online therapy. The Family Journal, 23(1), 5-12.
9. Weinberg, H., & Rolnick, A. (2020). Theory and practice of online therapy. Routledge.
10. Yuen, E. K., Herbert, J. D., Forman, E. M., Goetter, E. M., Juarascio, A. S., Rabin, S., ... & Bouchard, S. (2013). Acceptance based behavior therapy for social anxiety disorder through videoconferencing. Journal of Anxiety Disorders, 27(4), 389-397.