Qualitative Investigation into Therapists’ Experiences of Online Therapy: Implications for Working Clients
1.1. Emergence of Online Therapy
1.2. Strengths and Limitations of Online Therapy
1.3. Increased Demand for Online Therapy in Occupational Groups during the COVID-19 Pandemic
1.4. The Present Study
2. Materials and Methods
2.1. Study Design
2.3. Analytic Procedure
2.4.2. Generating Initial Codes
2.4.3. Searching for Themes
2.4.4. Reviewing Themes
2.4.5. Defining and Naming Themes
3.1. Theme 1: Positive Experiences of Online Therapy
Participant 8: [Online therapy] was not part of my master’s program or my supervision. It’s something that I’ve learnt more about, now that I’m doing it since COVID. … and it works! And it’s better than I thought it was going to be.
Participant 7: Until August, I was thinking of online therapy as a poor substitute for in-person [therapy], and a limitation. … I think that there is a slight decrease in presence within therapy, and the quality of work I can do in this medium. Lately, in the last couple of months, I feel as I’ve settled more into the pandemic life in general, and also because I had some new clients come in and I’ve had some successes with them […] I’ve been considering more possibility of just maintaining an online practice for a couple of years, especially if I move. I notice myself being more open to it.
Participant 5: I see [online therapy] as an adequate substitution. It seems to be working okay, and in that sense, I feel really grateful that I can keep working.
Participant 3: I think it offers some additional benefits in terms of the digital technology, like the ability to record. That can be used for quality purposes, for supervisory purposes, to enhance the experience of the provider, knowledge. Some of the other technology-related benefits are being able to take notes, share the screen, show a video on the spot, certain things that we can always do by ourselves, but that can be a part of the shared space in therapy.
Participant 8: I think that online therapy does help with access to care because some people who, for example, don’t have childcare and they need help, but they can’t get away from home, they’re more easily able to access services or they’re able to find low-cost services. There seems to be more opportunity and availability online because they can be seen by providers from all over California instead of their town. So, I think there are some good pieces regarding access and equity and fairness.
Participant 3: The biggest benefits, I think, are the obvious ones: the flexibility that you have, the possibility of doing therapy from your own home, well, from both ends. It increases flexibility from the provider and the client. […] It’s shifting the landscape of therapy, and it’s coming on the heels of the movement where mental health is becoming a recognised field and an important aspect for the masses, not just the traditional psychoanalytic thinking in the Victorian times where patients were from higher socioeconomics. So, there’s that—the shifting in landscape where therapy is becoming more mundane, more accessible. Online therapy has accelerated it.
Participant 7: [My patient] was living across the bay from me, and she’s a mom also, so with traffic and parking and everything, it was taking her between 60 and 80 min to get here. So, for her it was really just like, “I can’t do this for therapy”. I think if she hasn’t had the online therapy, she would have probably stopped working with me.
Participant 7: If somebody’s got a lot of energy, you can shrink the window a little bit. You can turn down the volume if someone’s voice is very abrasive. And I actually am somebody who gave up on doing couples therapy, because I find that my system, my body cannot take the amount of stress and conflict that couples bring in. Like, I just want to shut down and run away screaming! So, I have actually recently thought about doing it online because I’m not feeling that tension with my body.
3.2. Theme 2: Challenges Experienced by Therapists and Clients in Online Therapy
Participant 1: When there are glitches with technology, it definitely affects the sense of containment. It is hard to rewind and get back to where a client had been, or what they had been expressing after a disruption—especially if they were crying.
Participant 3: [The fact] that it requires the technology itself, it’s not equally accessible by everyone who may not have the bandwidth for the required Internet speed, good Wi-Fi, computer, some knowledge of how to set up lighting around the cameras and some technical aspects that are, you know… it falls on the provider and the client, as opposed to coming to a room where things are set up and we all kind of know how it works.
Participant 9: I think that clients who have trauma [experiences] struggle more. They have a hard time to be present. Some people have more [expression] through their body language, so they need a more solid atmosphere.
Participant 6: [Therapy] feels less of a ritual… How to replace it? … I can’t control how the client comes into the session, how they’re sitting, their environment, distractions. For me there’s something sacred around the container and the preparation, and so I can both prepare and have my surroundings. I obviously have less control over the client [now]. I notice it a little bit more now and so I think it’s important to do what I can do from my end to hold that.
Participant 8: With my teenage clients, I think that they don’t have as much respect for the therapy… [It’s] not the kids, but the parents will come into the room and say, “are you talking to [participant name]?”, and they’re like “yeah”, and then the [parents] will say something like, “ok, well, when you’re done, I’ll need you to do the laundry”, you know. … there’s more interruptions not only from their environment, their phones and whatever, or their cat or their baby, but also from other people living in the household who are reminding them of chores or whatever, so it’s harder to maintain focus.
Participant 3: I have noticed that clients from lower socioeconomic backgrounds tend to experience more distraction. I can give you some examples of what I mean: people who often do therapy in their cars are usually from poorer socioeconomics, which means less time, and they often quite literally don’t have the private space.
Participant 7: I had a client who… She will drink alcohol, she will have a cocktail or whatever, during the session… And that would just very rarely happen in your office. But if they’re home, and their fridge is right there, and it’s a time where they would kick back anyway, then this seems more natural to have a drink when you’re talking with a therapist. That was definitely surprising to me, to see that there’s a blending between someone’s home life and their therapy appointment. […] In that sense, the container-ontained relationship is out of control.
Participant 8: I feel like right now I have a client who wants to transition to [face-to-face] psychotherapy because they are too severe, but because there’s this force to be online, I feel like one of the issues is that not everyone is well-suited for this mode of therapy.
3.3. Theme 3: Preparation and Training for Online Therapy
Participant 2: I received zero training, even though I would have liked to receive education on online therapy. For example, what about privacy? Containment in the room?
Participant 8: I’ve had to make certain documents online because they previously [didn’t exist] […] for example, certain anxiety, depression, relationship, satisfaction, mood surveys that I would typically do as a check-in just before the session with the clients to get the baseline of their functioning. The first two weeks of being online I couldn’t get them because there was no way to administer them. So, tools had to be developed specifically for online therapy.
Participant 5: I think that it would be really helpful just to understand what is exactly being expected from you and what are the differences between [online and face-to-face] therapy.
Participant 3: I still feel like there is a lack of more nuanced aspects that I was trained about in-person, for example, observing the space, the container of where you are with the client, the quality of the presence. We didn’t get too much into that when we did the training, and I think that’s generally very important. […] Similarly, I wish I have been taught the ground rules more from the beginning to asking about the address, you know, those tips like: make sure you check with the clients that they’re in a private space, that they do not have any distractions, even other screens, phones, things like that. It’s just not natural for people to do and I think they make a big difference, if you know this from the beginning and set it up. You avoid disruptions and the general loss of the quality.
Participant 8: When working online, I found it more difficult to do consults with other therapists because in real life you’re in an office and you can say, “hey, can I ask you a question about something?” or “do you have this resource?”. Fortunately, there are online consult groups that I am a part of, but there is that missing component of peer support. It’s more difficult online.
Participant 3: Online therapy is shaking up the field. Because a lot of people that could not access therapy can now access it. The rules of the language of therapy are changing, and it opens up the field for new interpretations. I do not think we know yet how digital technologies will change our consciousness, and how we manipulate it for therapeutic benefits. Much like we do not see how complexity of narrative is changed over digital technologies.
5. Study Limitations
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. Interview Schedule
|Focus Area||Interview Questions|
|The online medium|
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|Focus Area||Initial Codes|
|Online therapy||Having a secure online therapy platform|
Willingness to conduct online therapy part-time post COVID-19
The use of online therapy for specific populations
Clients with severe psychopathology are generally not suitable candidates for online therapy
The introduction of online therapy as a way to break historical barriers in terms of physical distance, access and costs
|Therapeutic relationship||Loss of body language|
Clients showing therapists items from their home environment during online sessions
Frequent distractions from within the home environment (e.g., family disruptions)
Knowing clients’ location in advance of the session would improve the online session
Containment as the sacredness of the therapeutic space
|The online medium||‘Way of being’ is lacking online|
The ‘goodness of fit’ between client and counsellor is more important online than face-to-face
Difficulty in establishing a working alliance with a client online
Preference for video communication
Difficulties in picking up micro-emotions through video calls
|Client perspective||Clients do not always have the privacy of a space suitable for online psychotherapy|
Online therapy helps with access to care
Clients prefer online therapy due to easy access and temporal flexibility
There remains a difference between client’s home space and the physical therapy space; the two do not always overlap
|No.||Theme (Corresponding Aim)||Example of Participant Comment|
|1||Positive therapist and client experiences of online therapy (1, 3)||[Online therapy] was not part of my Master’s program or my supervision. It’s something that I’ve learnt more about, now that I’m doing it since COVID. … and it works! And it’s better than I thought it was going to be (Participant 8).|
|2||Challenges experienced by therapists and clients in online therapy (1)||[The fact] that it requires the technology itself, it’s not equally accessible by everyone who may not have the bandwidth for the required Internet speed, good Wi-Fi, computer, some knowledge of how to set up lighting around the cameras and some technical aspects that are, you know… it falls on the provider and the client, as opposed to coming to a room where things are set up and we all kind of know how it works (Participant 3)|
|3||Preparation and training for online therapy (2)||There is something to the idea of clients feeling safe in their environment. So, if they’re already in a stressful environment and they’re logging in to talk to me, they’re still in that same environment so their body might be reacting in the same way. … so it’s hard to create an experience for clients in their own home (Participant 1)|
|T1 Positive therapist and client experiences of online therapy||T1-1 Beyond expectation|
|T1-2 Quality assurance|
|T1-4 Control over therapy|
|T2 Challenges experienced by therapists and clients in online therapy||T2-1 Technological disruption|
|T2-2 Lack of containment|
|T2-3 Disruptive environment|
|T2-4 Severe psychopathology|
|T3 Preparation and training for online therapy||T3-1 Lack of training|
|T3-2 Lack of guidance|
|T3-3 Need for helpful online community|
|T3-4 Need for evaluation|
|Participant||Gender||Age||Years of Experience||Therapeutic Orientation||Target Symptoms||Target Population|
|2||Female||44||7||Humanistic, Existential, Gestalt, Attachment||Anxiety||Adults|
|3||Male||39||11||Eclectic||Trauma, Psychosis, Bipolar symptoms,|
|4||Female||68||25||Psychodynamic, CBT, Eclectic||Depression, Anxiety, LGBT transition, ADHD||Couples, Adults, LGBT|
|5||Male||44||22||Existential, Humanistic, Gestalt||Grief, Anxiety, Anxiety related to gender identity||Bi-cultural, Queer youth|
|6||Female||41||15||Gestalt||Life transitions, Anxiety, Bereavement, Grief||Adults, Women|
|7||Female||44||9||Gestalt, Non-directive Play, Art Therapy, CBT||Anxiety, Depression, Neurosis||Asian-American Women, Adults, Children|
|8||Female||32||8||Psychodynamic, CBT||Transitional issues, Adjustment disorders, Depression||Women, Teens|
|9||Female||41||11||Humanistic, Experiential||Stress, Depression, Cultural issues, Anxiety||Adults|
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Kotera, Y.; Kaluzeviciute, G.; Lloyd, C.; Edwards, A.-M.; Ozaki, A. Qualitative Investigation into Therapists’ Experiences of Online Therapy: Implications for Working Clients. Int. J. Environ. Res. Public Health 2021, 18, 10295. https://doi.org/10.3390/ijerph181910295
Kotera Y, Kaluzeviciute G, Lloyd C, Edwards A-M, Ozaki A. Qualitative Investigation into Therapists’ Experiences of Online Therapy: Implications for Working Clients. International Journal of Environmental Research and Public Health. 2021; 18(19):10295. https://doi.org/10.3390/ijerph181910295Chicago/Turabian Style
Kotera, Yasuhiro, Greta Kaluzeviciute, Christopher Lloyd, Ann-Marie Edwards, and Akihiko Ozaki. 2021. "Qualitative Investigation into Therapists’ Experiences of Online Therapy: Implications for Working Clients" International Journal of Environmental Research and Public Health 18, no. 19: 10295. https://doi.org/10.3390/ijerph181910295