British Journal of Guidance & Counselling

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/cbjg20

Online therapy: lessons learned from the COVID-19

health crisis

Gina G. Barker & Edgar E. Barker

To cite this article: Gina G. Barker & Edgar E. Barker (2021): Online therapy: lessons
learned from the COVID-19 health crisis, British Journal of Guidance & Counselling, DOI:
10.1080/03069885.2021.1889462

To link to this article: https://doi.org/10.1080/03069885.2021.1889462

Published online: 19 May 2021.

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BRITISH JOURNAL OF GUIDANCE & COUNSELLING
https://doi.org/10.1080/03069885.2021.1889462

Online therapy: lessons learned from the COVID-19 health crisis

Gina G. Barker and Edgar E. Barker
School of Behavioral Sciences, Liberty University, Lynchburg, VA, USA

ABSTRACT ARTICLE HISTORY

This study explored counsellors’ experiences with online therapy during Received 24 October 2020
the COVID-19 crisis, which presented an opportunity to examine how Revised 23 December 2020
counsellors evaluated the drawbacks, benefits, and appropriateness of Accepted 6 February 2021
online therapy. Data collected through surveys from 114 professional
KEYWORDS
counsellors, school counsellors, addiction counsellors, clinical social COVID-19; online therapy;
workers, and marriage and family therapists in the United States were counselling online;
analysed. Results indicated the level of preparation for online therapy telehealth; best practices
varied. The process was heavily impacted by technical functionality and
perceived as more effective face-to-face. Counsellors found clients
disengaged and distracted rather than comfortable and open. The
effectiveness of online therapy was more strongly associated with client
characteristics and treatment approaches than with diagnoses and
treatment goals. Interpretations, clinical implications, and further
research recommendations are provided.

The ongoing COVID-19 coronavirus pandemic would, by most definitions, be considered a ‘crisis’. While crises can
be overwhelming, and often expose vulnerabilities and gaps in our preparedness, they can also be seen as oppor-
tunities to quickly adapt, innovate and learn. (‘crisis’McFarlane et al., 2020, p. 1)

When it became evident that the COVID-19 virus was causing a pandemic with far-reaching impli-
cations, the necessity of providing psychological services online became clear as well (Duan &
Zhu, 2020; Jiang et al., 2020; Li et al., 2020; McGuire, 2020; Zhou et al., 2020). Service providers
were unexpectedly faced with questions on how to adapt to an unfamiliar crisis situation while
immersed in the crisis themselves (Gunn, 2020; Yalom, 2020). Following the lead of the Centers for
Medicare and Medicaid Services (CMS, 2020), many insurance companies announced they would
pay for telehealth services on a temporary basis during the health crisis, which provided opportu-
nities for professional counsellors and clinical social workers all over the United States to shift their
sessions to be conducted online. With universities, colleges, and schools closed, college and
school counsellors also shifted to serving their students remotely.
Some counsellors were already set up with an Internet platform; others had to quickly transition to
continue to serve their clients online. Drawing on pre-crisis best practices, professional organisations
provided guidance for members on selecting video applications that met legal and ethical require-
ments for privacy and confidentiality; ensuring malpractice insurance coverage; optimising electronic
client forms; educating clients and marketing online therapy; obtaining informed consent; receiving
payments; identifying local emergency services for clients in crisis; and creating contingencies for
technical failures. The American Counseling Association offered free training, for which over 7,000
counsellors signed up within the first 24 h (Yep, 2020).

CONTACT Gina G. Barker gbarker@liberty.edu School of Behavioral Sciences, Liberty University, 1971 University Boulevard,
Lynchburg, VA 24515, USA
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 G. G. BARKER AND E. E. BARKER

The COVID-19 health crisis also created new needs among existing and prospective clients. The
National Domestic Violence Hotline received over 2000 COVID-19 related calls between mid-March
and early April, 2020. The most common calls were from healthcare workers or other essential
employees who were prevented from going to work by abusers who claimed the callers were purpo-
sely trying to infect them with the virus by going to work or abusers who saw an opportunity to gain
financial control by causing the callers to lose their jobs (Sandler, 2020). Many quarantined couples
and families were confronted with the realities of their fractured relationships and dysfunctional
home life (Mulqueen, 2020). Due to the healthcare system being overtaxed, a shortage of psychiatric
emergency services for vulnerable populations such as veterans was noted (McFarlane et al., 2020).
Health care workers experienced elevated levels of stress from overtime and viral exposure (The
Department of Veterans Affairs, 2020). Counsellors were encouraged to prepare to offer crisis inter-
vention to clients experiencing fear exacerbated by uncertainty; distress associated with social iso-
lation; grief counselling to those who lost a loved one due to the coronavirus; and career
counselling to those who lost employment because of the shut-down and economic downturn
(Forte, 2020). The need for crisis intervention was also predicted from a review of previous pandemics
by Shah et al. (2020). School counsellors were encouraged to identify and reach out to at-risk students
and their families and to resource them (Texas Counseling Association, 2020). Major news sources
offered self-help to reduce fear and anxiety. For people in crisis looking for professional help, a
WebMd blogger offered timely advice to prospective clients on what to expect from online
therapy and how to choose a reputable counsellor (Gillihan, 2020) and a Healthline article educated
clients on how to make the most of online therapy (Finch, 2020).
Drawing on counsellors’ experiences during the COVID-19 health crisis, this study examined per-
ceptions of the effectiveness, drawbacks, benefits, and appropriateness of online therapy, thereby
adding a fresh and unique perspective to the existing body of knowledge and responding to the
American Counseling Association’s call for a discussion on lessons learned (Yep, 2020). The term
counsellor is used herein inclusive of professional counsellors, school counsellors, addiction counsel-
lors, clinical social workers, and marriage and family therapists. The terms counsellor, clinician, thera-
pist, and practitioner are used interchangeably. Online therapy is defined in this study as real-time
video and audio interaction between a counsellor and his or her client(s) using computers, tablets,
or smartphones. Other terms used in the literature include distance/remote/virtual counselling/
therapy, online/cyber/web counselling, video therapy, teletherapy, telehealth, etherapy, and itherapy.
Audio-only communication is differentiated as telephone counselling and traditional counselling as
face-to-face.

Review of literature
The use of technology in counselling is not a new phenomenon. Internet-based therapeutic services
became available with the expansion of broadband and are effective to reduce barriers to help-
seeking related to stigma, cost, mobility, or availability of services in rural or underserved areas (Cipol-
letta & Mocellin, 2018; Cuijpers et al., 2009; Reger & Gahm, 2009; Richards & Vigano, 2013; Simpson &
Reid, 2014; Sloan et al., 2011; Weiss et al., 2018). Online therapy is also efficient in terms of scheduling.
For example, Guzman et al. (2020) reported that telehealth shortened the time between inquiry and
intake and enhanced access to palliative counselling services for cancer patients. Therapy can also be
enhanced using video along with mobile applications, advanced graphics, or virtual reality. For
example, Yu et al. (2017) explored utilising Second Life in counselling with university students. The
level of clinician involvement varies from essentially self-help solutions or mutual-support to
regular or synchronous contact with a clinician (Berger, 2017; Dowling & Rickwood, 2013; Mallen
et al., 2005; Orengo-Aguayo et al., 2018; Paul et al., 2012; Pipoly, 2013; Reamer, 2015; Reger &
Gahm, 2009).
As background to this study, research highlighting the relative effectiveness and unique benefits
of online therapy were reviewed and therapeutic best practices from counsellors’ recent experiences,
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 3

from the professional literature, and from the research literature were examined. Research on coun-
selling services provided via telephone, email, and other text/audio-only communication means
received a cursory review. Practice-oriented, policy, and legal issues associated with online therapy
were beyond the scope of this study.

Effectiveness and unique benefits of online therapy

Counsellors have generally viewed counselling online as less effective than meeting clients face-to-
face in terms of establishing a therapeutic alliance and empathically guiding them to achieve healing
and wellness. Evidence emerging from a reasonably large body of comparison studies suggest this is
not necessarily the case (Berger, 2017), although findings on the effectiveness of online therapy
across different client groups vary. Simpson and Reid’s (2014) systematic literature review generated
23 studies published since 1990 that measured the therapeutic alliance in therapy conducted via a
videoconferencing application. In general, their review confirmed that clients consistently rate the
therapeutic alliance online as moderate to high across diagnostic groups and interventions and
roughly equivalent to face-to-face in studies with a comparison group. Horvath et al.’s (2011)
meta-analysis of 201 studies indicated that therapeutic alliance in face-to-face counselling accounts
for about 8% of the total variance in therapeutic outcomes across treatment models and that the cor-
relation between therapeutic alliance and treatment outcomes tends to increase over time. Thera-
peutic alliance encompasses counsellor-client agreement on treatment goals, therapeutic tasks
collaboration, and attachment. Berger (2017) reasoned that while clients report perceiving the coun-
sellor as empathically and socially present with them online and becoming immersed in the thera-
peutic process without being distracted by the technology, they may not have the same
expectations of forming an affective bond and connection to the counsellor that they would have
in face-to-face counselling.
In terms of treatment outcomes, Sloan et al.’s (2011) meta-analysis of 13 studies that compared the
effectiveness of telehealth-delivered cognitive–behavioral therapy (CBT) to treat posttraumatic stress
disorder (PTSD) and related symptoms with face-to-face counselling showed telehealth as equally
effective to reduce depression, less effective to reduce PTSD, but more effective than no treatment.
Treatment modalities in these studies included synchronous video or telephone counselling, clini-
cian-assisted protocols, or self-guided online exercises. Relatedly, Cuijpers et al.’s (2009) meta-analysis
of 23 studies comparing the treatment of anxiety disorders, phobias, panic disorder, PTSD, and obses-
sive–compulsive disorder via computer-aided psychotherapy compared to face-to-face counselling
revealed compatible outcome across all disorders. Not all delivery formats included synchronous
online interaction with a counsellor, but the outcomes did not differ across various types of delivery
systems. Similarly, Reger and Gahm’s (2009) meta-analysis examined the outcomes of 19 studies invol-
ving online and computer-based approaches that automatically delivered CBT training to reduce
depression, anxiety, general distress, and dysfunctional thinking and to increase functioning/quality
of life in clients diagnosed with anxiety disorders. Most treatment protocols required minimal inter-
action with a clinician. Control groups included participants who received face-to-face counselling
in a few studies and no treatment in most studies. Online and computer-based treatment was
found effective overall and clinician contact was not associated with greater outcome effects.
Studies of online therapy often involve clients who live remotely, have limited mobility, or face
other barriers to participating in face-to-face counselling. Sloan et al. (2011) noted,
A distinct advantage of telehealth interventions is that they can be accessed by individuals who might not other-
wise seek psychotherapy treatment for a variety of reasons (e.g. access to providers). Consequently, there may be
limited value to compare telehealth interventions with face-to-face interventions if the only available option for
individuals is telehealth interventions. (p. 121)

Online therapy has disadvantages as well as advantages (Cantore & Milacci, 2008). The disadvantages
associated with the counsellor not being physically present with the client are fairly obvious. It has
4 G. G. BARKER AND E. E. BARKER

been suggested that online therapy may be unsuitable for clients with paranoid, rigid, and avoidant
traits; clients with a history of childhood abuse; and clients with symptoms of emotional dysregula-
tion and dissociation (Simpson & Reid, 2014).
Conversely, there is evidence suggesting that online therapy is advantageous for clients with high
levels of body shame and self-consciousness. For example, Simpson and Slowey’s (2011) case
involved a client treated for an atypical eating disorder, body image disturbance, depression, and
low self-esteem. Although she had trouble engaging in the therapeutic interventions at first, the
online format reduced her body shame and allowed her to comfortably open up, resulting in signifi-
cant symptom reduction. Clients with a bulimic disorder have reported feeling less intimidated and
less pressured online compared to face-to-face (Simpson et al., 2005). Given the shame linked to
eating disorders, Simpson and Reid (2014) suggested that online therapy may facilitate a degree
of distance or space necessary for safe engagement. Glasheen et al. (2016) found that students
prefer online therapy for guidance on highly personal concerns, such as sexuality. This phenomenon,
known as disinhibition, has been highlighted as an important feature of online therapy (Cipolletta &
Mocellin, 2018; Richards & Vigano, 2013; Suler, 2004). It may be inferred that for sexual abuse and
assault victims whose shame, self-blame, and fear of re-traumatization keep them from coming to
a counsellor’s office, online therapy may represent a cautious first step toward help-seeking.
While online therapy does not offer the anonymity of crisis hotlines, Callahan and Inckle (2012)
suggested that the physical distance and use of technology provide the clients with more authority
and control over the session. This may be particularly important for victims of abuse, clients who
experience low levels of internal control in their day-to-day lives and relationships, and people
who have a strong need for control in general (Simpson & Reid, 2014). Counsellors have also
suggested that online therapy is empowering for clients who experience social stigma (Cantore &
Milacci, 2008; Nagarajan & Yuvaraj, 2019).
Another benefit identified in the research literature is that client investment and participation
increase in online therapy, as they take greater responsibility for effectively communicating than
they might do face-to-face (Berger, 2017; Bischoff et al., 2004). Additionally, the reduced distance
between an online counselling session and the client’s home environment may also be advantageous
in terms of transferring skills learned in-session to between-session homework practice and appli-
cation (Simpson & Reid, 2014).
Online therapy may appeal to a category of clients who are qualitatively different. Finn and
Barak (2010) reported that nearly half of the online counsellors they surveyed had only had one
session with each client. The authors reasoned that online clients may be looking for instant
help; dealing with short-term issues; or seeking advice rather than longer-term counselling. This
was echoed in Radovancevic’s (2013) study, in which counsellors reported typically seeing
clients with mild to moderate psychopathology for time-limited online therapy or in conjunction
with face-to-face therapy, and not for processing deep issues. Several authors have also suggested
that online therapy is more appealing and appropriate for children, adolescents and young adults,
who are comfortable using online technology (Callahan & Inckle, 2012; Nagarajan & Yuvaraj, 2019;
Orengo-Aguayo et al., 2018).

Best practices for online therapy

A wealth of best practices information became available in the spring of 2020 as counsellors shared their
experiences with online therapy to educate peers who were new to online therapy and trying to get up
to speed. The American Counseling Association (2020) cautioned practitioners to secure a private home
office space, but also to visually convey privacy by avoiding having an open door in the background or
conducting sessions in an open-air setting. To convey professionalism, attention to lighting, camera
angle, and stabilizing the device on a table or tripod was stressed as well. A Psychotherapy.net
blogger (Federico, 2020) emphasised the importance for counsellors to get comfortable with the tech-
nology and to be enthusiastic, rather than apologetic, when connecting with clients online.
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 5

Educating clients on how to interact with the counsellor using a video application and giving
ample time for questions emerged as another best practice. Establishing a deeply-attuned relation-
ship is considered more difficult to accomplish remotely (EMDRIA, 2020). Eckel (2020) explained how
the lack of nonverbal synchronisation and inability to detect micro-expressions leave the clients more
guarded. The American School Counselor Association (2020) recommended developing methods for
preventing or else minimising misunderstandings that occur when unable to fully interpret visual
cues, verbal statements, and body language. Although adolescents grew up with social media
(Gallo et al., 2017), they often prefer texting over talking, and counsellors also discovered that
many young clients were self-conscious about the video transfer and seeing themselves on the
screen. Online therapy sometimes feels more intimate because the video frame is close up; therefore,
counsellors were recommended to check with their clients more frequently how they experienced
the session (ACA, 2020).
Federico (2020) shared that the virtual connection allows some clients to open up, express
emotions, and disclose difficult experiences more readily. Despite counsellors’ best efforts to
create a sense of safety for the client in their offices and in the therapeutic relationship, she had
found that some clients are more comfortable in their own homes and more able to access
private aspects of their inner selves.
It should not be assumed, however, that all clients are physically and emotionally safe in their
homes. The need for a thorough safety assessment was emphasised, along with the importance of
informing clients about the limits of confidentiality when participating in counselling from home.
School counsellors were instructed to mitigate the inherent confidentiality limits when connecting
with students online (ASCA, 2020). Clients may need to be instructed to find a place in their home
where they can focus only on their session and avoid distractions (ACA, 2020). Clients participating
in counselling from home also provides opportunities. Federico (2020) noted that counsellors can
learn more about clients’ home environments and get virtual tours, which can be very helpful. She
also suggested that guiding clients in practicing skills can generate better results when done on-
site compared to in a counsellor’s office.
When resources normally available in their offices were no longer available to clients, counsellors
had to get creative using supplies and toys available in the clients’ homes for art and play therapy; the
clients’ own pillows, blankets, and other objects of comfort for somatic techniques; and clients’ pets
for animal-assisted therapy. Clients were directed to arrange their furniture for empty-chair interven-
tions, to access worksheets online for CBT exercises, and to download applications for EMDR proces-
sing and other specialised techniques (Abundance Practice Building, 2020; Federico, 2020).
The pandemic disrupted some people’s lives more than others, and treatment approaches for
special populations such as clients on the spectrum, clients with mental health or physical disabilities,
older clients, substance abuse clients, etc. needed to be adapted for online therapy. The National
Association of Social Workers (2020) stressed that many clients needed education, assistance, advo-
cacy, and support identifying and securing federal, state, and local resources.
When transitioning to online therapy, counsellors were also well served by the standards and
guidelines for using technology in online practice that had already been developed and adopted
by their professional organisations. These policy documents generally address legal and ethical com-
pliance, technical requirements, obtaining informed consent regarding risks and benefits, contingen-
cies for technical disruptions, screening and assessing clients, and managing crisis situations.
(American Association of Marriage and Family Therapy, 2017; American Psychiatric Association &
American Telemedicine Association, 2018; National Association of Social Workers et al., 2017).
The research literature on best practices for online therapy confirms much of this anecdotal infor-
mation and professional documents. Many authors have focused on identifying and mitigating the
inherent limitations of video technology, such as audio delays; lack of eye contact; frozen images;
and limited view of gestures, postures, and body movements, resulting in greater incidences of con-
fusion and counsellor-client conflict (Mallen et al., 2003). To compensate, counsellors tend to rely
more on tone-of-voice; be more deliberately overt, exaggerate their non-verbal cues; provide
6 G. G. BARKER AND E. E. BARKER

more verbal affirmations; give more elaborate verbal feedback; and ask more clarifying questions
(Berger, 2017; Bischoff et al., 2004; Richards & Vigano, 2013; Simpson & Reid, 2014).
McCord et al. (2015) suggested that in order to establish a therapeutic alliance, the counsellor
must first assess the client’s prior experience using a video application. If limited, the counsellor
needs to normalise the nature of online communication, explaining that when the counsellor is
looking at the client on the screen, it may seem as if he or she is looking down, depending on the
location of the camera. While the picture-in-picture setting is recommended for the counsellor, so
to keep track of what the client sees, it is best if this feature is turned off on the client side to
avoid being distracted by looking at him- or herself. However, if the counsellor is not be able to
control the client’s settings, he or she can only make a recommendation. The counsellor needs to
also decide whether a close framing of his or her face – which creates the appearance of leaning
in – is more advantageous than a wider frame that allows the client to see the counsellor’s body
movements and hand gestures. Johnson (2014) used the term telepresence to describe online thera-
peutic communication that is warm, smooth, emotionally engaging, supportive, empathic, nonjudg-
mental, reassuring, unfractured, and credible.
Campos-Castillo’s (2012) review of research on co-presence in online environments revealed that
the subjective perception of being present with another online predicts the degree to which social pro-
cesses unfold in the interaction. They also found that light colours and textures on walls are linked to
greater intimacy with the other and that well-lit virtual environments are perceived as more appealing
than darker environments. Henry et al.’s (2017) review of telehealth research also confirmed the impor-
tance of visually providing the privacy and professionalism of an office environment.
Most of the online therapy protocols rely heavily on CBT (Johnson, 2014), which raises the ques-
tion if online therapy is more effective when cognitively-based treatment approaches are used, as
opposed to emotion-focused, experiential, and somatic approaches. The EMDRIA (2020) survey
cited earlier revealed that over half of the respondents had already conducted EMDR therapy
online before the COVID-19 pandemic. Tuerk et al. (2010) reported that therapists had developed
clinical flexibility and creativity to effectively treat adults with PTSD using prolonged exposure
therapy online. Hassija and Gray (2011) also reported effective use of prolonged exposure for treat-
ment of PTSD online. The treatment protocol in Simpson and Slowey’s (2011) case study included
schema therapy, guided imagery, and empty chair interventions. Weiss et al. (2018) described a treat-
ment protocol for female victims of military sexual trauma that included psychoeducation and skills
training in self-care, self-soothing, self-compassion, and relational communication. It should be noted
that most approaches addressed in the literature are individual, as opposed to couple, family, or
group approaches.
Lastly, a best practice emerging from the research literature is ascertaining at the beginning of an
online session that the clients are safe in their environment and with the people who are with them,
particularly when intimate partner violence or child abuse is part of the presentation. Safety also
needs to be provided by establishing a secondary venue – typically by telephone – for continuing
the session should the video application malfunction (Hassija & Gray, 2011; Johnson, 2014).

Rationale and research question

The online therapy literature has generally stressed the benefit of technology in providing access to
counselling services for clients who live in remote areas and who otherwise do not have the mobility,
opportunity, and/or means to travel to counselling appointments. Outcome studies that compare
online and face-to-face counselling have mostly recruited participants through online discussion
forums and websites (Berger, 2017), suggesting a possible selection bias and a need to conduct
more studies in mainstream clinical settings. Research that sheds light on why some counsellors
prefer online over face-to-face counselling is lacking (Pipoly, 2013). Interestingly, although online
counselling is a rapidly growing field, skills needed for online therapy are only marginally included
in professional counselling curricula (McCord et al., 2015).
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 7

The COVID-19 health crisis presented a unique opportunity for research in that virtually all coun-
sellors and clients worldwide were limited to online therapy, which meant that both groups gained
experience with online therapy that they otherwise may not have had. In order to move the research
forward, Cuijpers et al. (2009) recommended that future explorations seek to unpack “the actively
therapeutic components” of online therapy and examine both the content and the delivery of coun-
sellor-provided support (p. 79). In the same vein, Dunn (2012) argued that online therapy should be
evaluated for unique therapeutic opportunities, rather than as a delivery system compatible to face-
to-face counselling. Accordingly, this investigation was conducted with the perspective that it may be
more fruitful to view online therapy as a unique therapeutic approach that is suitable for certain
clients with certain characteristics and highly effective to achieve specific treatment goals. rather
than treating it as simply conducting counselling with clients remotely using a video application.
With this approach in mind, this study aimed to examine experiences by counsellors who had not
previously specialised in online therapy. The following two research questions were developed to
guide the research:
(RQ1) What were counsellors’ experiences regarding the effectiveness, drawbacks, and benefits of online therapy
during the COVID-19 health crisis?

(RQ2) How did counsellors evaluate the appropriateness of online therapy for various clients, presentations, and
treatment goals.

Method
In order to obtain a broad and timely response, a short online survey was created, drawing upon the
literature reviewed above, and a quantitative research method was chosen. The ethical aspects of the
study were examined by the Institutional Review Board at the researchers’ home institution, and the
study was conducted in compliance with its recommendations.
A convenience/snowball sample of respondents in the United States was recruited from the
researchers’ personal networks, online communities, and the respective professional associations’
member forums. Participants completed an online survey on SurveyMonkey April 8–May 11, 2020.
The survey invitation and introduction specified that the intended study participants were practicing
professional counsellors, clinical social workers, addiction counsellors, school counsellors, or marriage
and family therapists who were fully licensed or working under supervision and who were conduct-
ing half or more of their counselling sessions online via a video conference application at some point
during the COVID-19 health crisis. The demographic data obtained included age, gender, and
credentials.
Participants were asked to indicate what percentage of their counselling sessions were conducted
via telephone or online prior to the COVID-19 health crisis and how prepared they or their employers
were to offer counselling online when COVID-19 restrictions limited or prevented face-to-face ses-
sions. They were also asked to gauge the extent to which the functionality and reliability of the
video application and the internet connection impacted the perception of their ability to provide
competent counselling services to clients online.
Participants responded on a five-point Likert scale ranging from “strongly agree” (5) to “strongly
disagree” (1) to nine survey items such as “Despite maximizing the opportunities that online/video
applications provide, the counseling process is always more effective when meeting clients face-
to-face” and “I have found that some clients are more comfortable and open when I counsel them
online using a video application compared to when meeting face-to-face”. Survey items were
designed to gauge perceived advantages and disadvantages of online therapy. Three items were
designed to explore whether counsellors evaluated the relative effectiveness of online therapy
based on client characteristics, clients’ presenting problems/diagnosis and treatment goals, or the
treatment approach/techniques used, respectively.
8 G. G. BARKER AND E. E. BARKER

Results
From the initial sample of 117, three surveys from counsellors primarily practicing online prior to the
COVID-19 crisis were omitted, leaving 114 respondents with 50% or more of their clients having been
seen face-to-face. Of those, 85% indicated they are female, 4% that they are male, and 11% did not
indicate either gender. As for age, 11% identified as 18–30 years old; 35% as 31–45; 41% as 46–60;
11% as 61 years or older; and 2% did not disclose their age. Several respondents reported holding
two credentials. The sample included 72 (63%) school counsellors, 45 (39%) professional counsellors,
nine (8%) clinical social workers, seven (6%) addiction counsellors, and two (2%) marriage and family
therapists. Fifty-eight percent of the respondents indicated they had not conducted any counselling
online or via telephone prior to the crisis, and the pre-crisis mean proportion of online/telephone
counselling was 3%.
Table 1 provides an overview of the analysis of the Likert scale items, including Pearson’s r stat-
istics, means, and standard deviations. The first research question guiding this study gauged coun-
sellors’ experiences regarding the effectiveness, drawbacks, and benefits of online therapy during
the COVID-19 health crisis. Meeting restrictions quickly implemented in mid-March 2020 left counsel-
lors with little choice but to move their counselling practice to an online platform. The statement, “I/
my employer was well prepared to offer counseling online when COVID-19 restrictions limited or pre-
vented face-to-face counseling” generated diverse responses slightly weighted toward disagree-
ment. As displayed in Table 1, the overall mean score was 2.78 (SD = 1.33). The analysis yielded a
significant difference between school counsellors (n=59) and counsellors with another credential
(n=55) in that school counsellors perceived their employer as being less prepared (t(104) = −3.22,
p < .01). School counsellors produced a mean score of 2.41 (SD = 1.15), while other counsellors pro-
duced a mean score of 3.18 (SD = 1.40). The effect size (d = .60) was medium, as determined by
Cohen’s (1988) guideline, suggesting that counsellors’ experiences varied based on professional
context.
Respondents indicated strong agreement with the statement, “Despite maximizing the opportu-
nities that online/video applications provide, the counseling process is always more effective when
meeting clients face-to-face,” with a mean score of 4.08 (SD = 1.10). Again, the analysis yielded a sig-
nificant difference between school counsellors and other counsellors in that school counsellors rated
face-to-face counselling as more effective (t(95) = −4.66, p < .001). School counsellors produced a
mean score of 4.51 (SD = .82), while other counsellors produced a mean score of 3.62 (SD = 1.18).
The effect size (d = .88) was large (Cohen, 1988). As shown in Table 1, perception of preparation
was negatively correlated with a preference for face-to-face counselling (r = -.279, p < .01);
however, the effect size (R2 = .08) was small.
The mode response to the statement, “I have found that some clients are more comfortable and
open when I counsel them online using a video application compared to when meeting face-to-face”
was “unsure/neutral.” This variable had a moderately strong (R2 = .20) negative correlation with
viewing face-to-face counselling as more effective (r = -.452, p < .001).
Respondents reported broad agreement with the statement, “I have found that some clients have
a harder time connecting with me and engaging in the counselling process because of distractions,
lack of privacy, or discomfort with the online technology compared to when meeting face-to-face.”
The overall mean score was 3.94 (SD = 1.00). There was a significant difference between school coun-
sellors and counsellors with another credential in that school counsellors reported that their clients
were more disengaged and distracted (t(99) = −2.40, p = .02). School counsellors produced a mean
score of 4.15 (SD = .83), while other counsellors produced a mean score of 3.71 (SD = 1.12). The
effect size (d = .45) was small (Cohen, 1988).
Over 40% of the sample indicated an unsure or neutral stance to the statement, “When clients par-
ticipate in counseling while in their home environment, they are more able to connect and apply
what they learn to their daily lives than when they receive counseling at a counselor’s office.” This
variable was positively correlated with the perception that some clients are more comfortable and
Table 1. Pearson’s r, Means, and Standard Deviations.
1 2 3 4 5 6 7 8 9
Well Prepared (1) 1 -.279** .146 -.331** .081 .110 -.052 .048 -.181
Face-to-Face More Effective (2) 1 -.452** .303** -.388** -.244** -.056 -.183 .173
Comfortable & Open (3) 1 -.259** .352** .295** .145 .223* .034
Disengaged & Distracted (4) 1 -.222* -.206* -.040 -.111 .178
Home & Daily Life Connection (5) 1 .136 .189* .228* -.078
Client Characteristics (6) 1 .320** .213* .080
Presentation & Treatment Goals (7) 1 .502** .056
Approach & Techniques (8) 1 .096
Technical Functionality (9) 1
Mean 2.78 4.08 2.75 3.94 2.76 3.42 3.18 3.39 4.11
SD 1.33 1.10 .85 1.00 .74 .82 .82 .82 .94
Scale 1–5 1–5 1–5 1–5 1–5 1–5 1–5 1–5 1–5
*Correlation is significant at the .05 level (2-tailed).
**Correlation is significant at the .01 level (2-tailed).
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
9
10 G. G. BARKER AND E. E. BARKER

open online (r = .352, p < .001) and negatively correlated with the view that face-to-face counselling is
always more effective (r = -.388, p < .001). Effect sizes were small (R2 = .12 and R2 = .15, respectively).
The highest mean score of 4.11 (SD = .94) in the study was generated by widespread agreement
with the statement, “My ability to provide competent counseling services to clients online is heavily
impacted by the functionality and reliability of the video application/internet connection.” This vari-
able was not significantly correlated with any other variable in the study and responses did not differ
based on professional context.
The second research question guiding this study explored how counsellors evaluated the appro-
priateness of online therapy for various clients, presentations, and treatment goals. The analysis indi-
cated agreement with the statement, “The effectiveness of online/video counseling sessions is
directly related to client characteristics.” This variable was positively correlated with the perception
that some clients are more comfortable and open when participating in counselling online (r
= .295, p = .001). The effect size was medium (R2 = .09).
Responses to the statement, “The effectiveness of online/video counseling sessions is directly
related to clients’ presenting problems/diagnosis and the treatment goals” generated a near-
perfect bell curve that was slightly negatively skewed toward agreement. Lastly, respondents
reported definite agreement with the statement, “The effectiveness of online/video counselling ses-
sions is directly related to the treatment approach/techniques used.” This variable had a moderately
strong correlation with the view that online therapy effectiveness is linked to client presentations and
treatment goals (r = .502, p < .001). The effect size was large (R2 = .25).

Discussion
Drawing on counsellors’ early experiences with online sessions during the COVID-19 health crisis, this
exploratory study examined lessons learned and discoveries made about the benefits and drawbacks
of online therapy, thereby adding a fresh and unique perspective to the existing body of knowledge
and understanding. Although the results indicated that the level of preparation for online therapy
varied among respondents, most had only been counselling face-to-face prior to the crisis. Online
therapy provided an opportunity to offer counselling services when interpersonal contact was
restricted. Previous research identified that one of the chief benefits of online therapy is serving
clients who are facing geographic, physical, or other barriers to receiving counseling face-to-face.
Sloan et al. (2011) noted that when online therapy is the only viable option, comparisons between
online and face-to-face interventions are less meaningful. Thus, the present research adhered to
Berger’s (2017) and Dunn’s (2012) recommendations to view online therapy as a unique therapeutic
approach rather than merely as an alternative delivery system, and it responded to Cuijpers et al.’s
(2009) suggestion to unpack “the actively therapeutic components” of online therapy (p. 79).

Conclusions
Prior research indicated that online therapy can be as effective as face-to-face therapy (Berger, 2017;
Cuijpers et al., 2009; Reger & Gahm, 2009). The participants of the current study, however, decidedly
rated face-to-face therapy as more effective. It should be noted that counsellors’ perceptions of effec-
tiveness do not necessarily measure client treatment outcomes. This was particularly the case with
school counsellors, who also found their student clients less able to connect with them online and
more disengaged, distracted, and uncomfortable with the online technology than counsellors with
other credentials did. Respondents also appeared to struggle with a lack of control over the technical
functionality of the video applications and the reliability of the Internet connections with their clients.
Understandably, video conferencing and Internet providers were heavily taxed by the unexpected
demand created by COVID-19. The results suggest that counsellors who prefer counselling face-to-
face may be reluctant to increase their own comfort with video conferencing technology and com-
petency in using treatment approaches that are uniquely tailored to online therapy. They may also
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 11

have difficulty assessing which clients are more effectively served with online therapy than face-to-
face interventions due to a lack of training and experience.
Prior research suggests that clients who seek online therapy may be qualitatively different from
clients who prefer face-to-face therapy (Finn & Barak, 2010; Orengo-Aguayo et al., 2018; Radovance-
vic, 2013). The findings lend support to this notion. Clients’ age, computer literacy, and living situation
are key characteristics to consider. Clients’ may not have the space and privacy at home to engage in
the counselling process without distractions and interruptions, especially with spouses being off work
and children being out of school. School counsellors may have found themselves treating clients who
were largely unmotivated. Although professional counsellors, clinical social workers, and addiction
counsellors work with children and adolescents as well as adults, school counsellors’ clientele is
mostly made up of minors and their parents or legal guardians. In the U.S., their training emphasises
development and education to a greater degree; however, online education and counselling has not
been given a lot of attention.
The counsellors who participated in this study did not recommend online therapy based on client
characteristics or presentations, but rather out of necessity. While geographic distance or restrictions
for interpersonal contact alone might suggest a client is a good candidate for online therapy, his or
her presenting problem or diagnosis may suggest otherwise. Certain treatment goals may be easier
to achieve with online therapy than others. The literature suggests that online therapy is advan-
tageous for clients with low self-esteem, shame, body image disturbances, and sexual disfunction
(Cipolletta & Mocellin, 2018; Glasheen et al., 2016; Richards & Vigano, 2013; Simpson & Slowey,
2011). Simpson and Reid (2014) said, “Clearly, individuals respond differently to the presence of tech-
nology, with some feeling safer to communicate openly, and others feeling more guarded and sus-
picious” (p. 291). Although some respondents did report clients being more comfortable and open
online, most were unsure or disagreed with this notion. The findings suggest that counsellors with
a preference for face-to-face and limited experience online may be poorly prepared for assessing
clients’ suitability for online therapy.
The results indicate that counsellors perceive online therapy to be more suitable for certain treat-
ment approaches than others. In previous online counselling research, CBT has been the predomi-
nant approach (Johnson, 2014). Counselling techniques have to be adapted or altered to work
well in an online environment. Prior research indicates that being able to interact with clients in
their own home or another key environment is one of the chief benefits of online therapy (Federico,
2020; Simpson & Reid, 2014), whether utilised to enhance assessment, gain insight, practice new
skills, guide in-vivo exposure, or engage family members in the therapeutic process. However, the
participants in the current study did not appear able to take advantage of these opportunities but,
rather, regretted not being face-to-face with their clients. It is possible that their clients’ particular
home environments hindered the pursuit of already established treatment goals more than they
helped. It is also possible that the counsellors’ lacked the training or flexibility needed to successfully
adapt to online therapy and maximise its benefits.

Clinical implications
Several best practices are supported by the current research. They centre on counsellors’ ethical obli-
gations of beneficence, nonmaleficence, and fidelity. An important prerequisite is that counsellors are
comfortable with video applications and able to provide a caring and congruent online represen-
tation of themselves in a space that visually and audibly conveys attunement, as well as actual
and perceived privacy. A discussion on legal issues in online therapy is beyond the scope of this
research, but they must also be attended to prior to conducting online therapy.
First, counsellors must screen clients for online therapy. It is not for everyone. Whether at first
contact, intake, or while obtaining informed consent for online therapy, clients must first be screened
for safety. If they are severely unstable, psychotic, hallucinating, dissociating, suicidal, in the presence
of an intimate partner violence perpetrator, intoxicated, inattentive/hyperactive/manic, or in need of
12 G. G. BARKER AND E. E. BARKER

immediate medical attention, they need to be referred to local emergency care. Also, clients’ video
application literacy, comfort, and quality must be assessed. When clients lack access to reliable high-
speed Internet service or are notably anxious about and unfamiliar with using a video application,
there is a good chance the therapy will be ineffective. In addition, clients’ motives for choosing
online over face-to-face therapy must be assessed in terms of their reasons for seeking counselling,
geographic location, physical mobility, and expectations. Counsellors need to be confident that
online therapy is advantageous. To ensure this, they must enhance their competency through edu-
cation, training, skills development, and mentoring.
Second, an important aspect of obtaining informed consent for online therapy is taking time in the
first session to help clients adapt to the technology and the differences in verbal and nonverbal com-
munication, and to explain how confidentiality is ensured. Counsellors need to normalise the experi-
ence for clients. They need to disclose that the session may be disrupted by technical failures and
instruct clients what to do should this occur. Rather than acting as if meeting face-to-face or apolo-
gising for not meeting face-to-face, counsellors must be comfortable and enthusiastic about connect-
ing with their clients. If the counsellors think the online delivery format is inferior to face-to-face
counselling, this attitude influences the clients and hinders the development of a therapeutic alliance.
Also, counsellors need to use short and succinct phrases and minimise paralanguage to reduce noise
and reliance on nonverbal communication.
Third, counsellors should capitalise on the fact that their clients are in their own space and tailor
the treatment approach accordingly. They must assess how the space is experienced by the clients,
the level of safety, comfort, and engagement they feel, and who else is present. For some clients, this
may mean disclosing deeply personal thoughts and feelings that are accessible because they are less
self-conscious and less inhibited by shame than they would be in a counsellor’s office. Other clients
may be able to involve family members in the session who would be unwilling or unable to accom-
pany the client to a face-to-face session. Clients may be able to gain new insights and apply new
learning to their daily lives because they can more easily make the connection. For example,
instead of trying to implement instructions for how to ground themselves when experiencing dis-
tress, counsellors are able to guide the clients step-by-step. Additionally, clients conduct in-vivo
exposure exercises going to a feared place or engaging in an avoided situation while accompanied
by their virtually present counsellor.

Limitations and directions for further research

The opportunity to generalise the results of this exploratory study was limited by the sampling
method, sample size, and instrumentation. To increase the statistical validity in future studies,
measures with high historic and recent reliability and internal consistency should be used. The
data were gleaned from counsellors’ self-reports and do not provide information about clients’ per-
ceptions or treatment outcomes. Counsellors tend to rate the therapeutic alliance and effectiveness
of online therapy lower than clients do (Berger, 2017; Simpson & Reid, 2014). Despite these limit-
ations, as an early study on lessons learned about online therapy during the COVID-19 health
crisis, it nevertheless offered insights into the benefits of and best practices for online therapy and
provided directions for further research.
During the COVID-19 health crisis, online therapy was the only viable option for most counselling
clients. For many, online therapy remains the only option or the preferred option, for a variety of
reasons addressed in this article. Future studies should focus less on making a case for the validity
and legitimacy of online therapy and more on evaluating its effectiveness based on client character-
istics, presentations, diagnoses, and treatment goals, thus “matching client characteristics, such as
presenting problems, personality type and level of comfort with technology, to different modes of
treatment delivery” (Simpson & Reid, 2014, p. 294). Specifically, clients’ difficulty engaging online
needs to be examined in regards to distractions, lack of privacy, and discomfort with technology,
respectively. Along with examinations of client preferences for online therapy, further research is
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 13

needed on counsellor preferences and how these may change across the career span or vary depend-
ing on counsellor experience and contexts. The compatibility of various treatment approaches with
online therapy must also be evaluated further and guidelines and protocols for conducting online
therapy ethically, appropriately, and efficiently to achieve intended outcomes need to be developed.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Disclosure of interest
The authors report no conflict of interest.

Notes on contributors
Gina G. Barker is an Online Instructor at Liberty University in Lynchburg, Virginia, USA, and a Licensed Professional
Counselor Associate in Myrtle Beach, South Carolina, USA. She earned a Doctor of Philosophy degree in Communication
at Regent University in 2004 and a Doctor of Education degree in Community Care and Counseling at Liberty University in
2018. She served as a full-time faculty member in the Department of Communication at Liberty University 2004–2011
and as a full-time faculty member in the Department of Communication, Languages and Cultures at Coastal Carolina
University 2011–2015. Her research focuses on intercultural adaptation and acculturation processes, intercultural
marriage and family communication, cultural influences on news and advertising, third-culture individuals, crisis com-
munication and intervention, and burnout. Her work in these areas has been published in the International Journal of
Intercultural Relations, Journal of International and Intercultural Communication, Journal of Intercultural Communication
Research, Southern Communication Journal, Western Journal of Communication, International Communication Gazette,
the International Journal of Cross Cultural Management, the International Encyclopedia of Intercultural Communication
and in several book chapters.
Edgar E. Barker is a Licensed School Counselor in Virginia, USA and a Professor of Counseling at Liberty University in
Lynchburg, Virginia, USA, where he has served as a full-time faculty member since 2003. He earned a Doctor of Philos-
ophy degree in Education at the University of Iowa in 1990 and a Doctor of Ministry degree in Pastoral Counseling at
Liberty University in 2015. He holds graduate degrees from Oxford University and Ft. Hays State University. He has
served as a High School Counselor, College Counselor, Director of Counseling, Dean of Students, Director of two
master’s level programs, Doctoral Program Director, Department Chair, ESL Instructor, and teacher at the Middle
School, High School, Community College, Undergraduate, Graduate, and Doctoral levels in a number of areas and insti-
tutions. His primary areas of research are in crisis and trauma. His publications include articles on School Counseling,
Pedophilia, and Forgiveness in The Popular Encyclopedia of Christian Counseling.

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