Thesis Amended For Repository

EMAIL COUNSELLING AND THE THERAPEUTIC
RELATIONSHIP: A GROUNDED THEORY ANALYSIS

OF THERAPISTS’ EXPERIENCES.
CAROLE FRANCIS-SMITH
Thesis submitted in partial completion of the requirements of the

award of Professional Doctorate in Counselling Psychology
Department of Psychology
Faculty of Health and Life Sciences
University of the West of England, Bristol
Submitted: December 2014
This copy has been supplied on the understanding that it is

copyright material and that no quotation from the thesis may be
published without proper acknowledgement.
CONTENTS
Contents Page No.
Acknowledgments .......................................................................... 1
Abstract .......................................................................................... 2
Introduction .................................................................................... 4
Literature review .......................................................................6-38
What is online counselling? .................................................... 6
Computer Mediated Communication and Interpersonal
Dynamics ........................................................................... 15
The Therapeutic Relationship ....................................................23
Summary of differences between face-to-face and Email
counselling ............................................................................... 35
Email Counselling and Uncertainty ........................................... 37
Conclusion .............................................................................. 39
Research rationale and aims ....................................................... 40
Methodology and ethical considerations .................................42-61
Design ...................................................................................... 41
Data collection .......................................................................... 49
Participants .............................................................................. 53
Procedure ........................................................................... 54
Reflexivity .................................................................................... 62
Results ....................................................................................66-92
Experiencing Cuelessness ........................................................68
Losing touch ..............................................................................69
Peering through the Looking Glass............................................74
Worrying about risk ...................................................................77
Becoming uncertain ...................................................................80
Experiencing anxiety .................................................................82
Becoming more task orientated .................................................83
Avoiding difficulties ....................................................................86
Overcompensating ....................................................................88
Defending the professional self-concept................................. 90
Discussion ................................................................................... 93
Limitations of research ............................................................... 112
Contents Page No.
Implications for email practitioners and counselling
psychologists ............................................................................. 116
Directions for further research.................................................... 121
Conclusions ............................................................................... 123
References.......................................................................... 124-156
Appendices ......................................................................... 155-202
Figure 1. Email counselling and the therapeutic

relationship: A grounded theory analysis of
therapists’ experiences ................................................................ 67
ACKNOWLEDGMENTS
Firstly, I would like to say thank you to the participants in this study who so
generously offered their time. I hope I have done their experiences justice.
Secondly, I am thankful to the family and friends who have stood by and
supported me through the years, despite my disappearing into the ‘black hole’
of academia now and again.
Finally, I would like to express enormous gratitude to my supervisor, Andrea

Halewood, who steered me through this research journey and championed me
to the end. I would further like to thank supervisors Dr Naomi Moller and Dr Paul
Redford for their contributions to the process.
1
ABSTRACT
ABSTRACT
Provision of online counselling in its many forms has increased dramatically

over the last 10 years, however research findings suggest that many therapists
have concerns about whether a therapeutic relationship can be successfully
engendered online, particularly given the absence of non-verbal communication
cues. To date there is very little research available about the online therapeutic
relationship; email counselling was chosen for the current study as through its
dearth of non-verbal cues it may deemed most different to face-to-face
counselling, and is considered to be the most popularly used mode.
The central aim of this study was to explore the accounts of therapists who
have worked both face to face and by email about how they construct their
experiences of the therapeutic relationship in email counselling. The secondary
aim was to co-construct an explanatory grounded theory of the process.
The study adopted a constructivist grounded theory methodology (Charmaz,

2010); using an initial purposeful sampling strategy, nineteen participants were
recruited to the study and completed an anonymous online qualitative survey;
four also took part in semi-structured interviews. A theoretical sampling was
then adopted to refine the developing theory; two novice email therapists and
four non-email therapists were recruited. Overall there were twenty-five
participants, some of whom engaged using more than one media.
The basic psychological processes that were co-constructed from the data
indicated that many participants found working in the cueless online
environment highly challenging and that the resultant anxiety led to several sets
of behaviours. Participants described how Experiencing cuelessness i.e. the
absence of sensory cues led to an experience of Losing touch in four ways;
Loss of interactive factors with the client, Responding with no sensory steer,
Losing control of the process and Losing control of the context to the client. This
led to a sense of Peering through the looking glass when counselling online;
counsellors felt as though they were Fantasising into a void, and Fearing [client]
disappearing. Participants also described Worrying about risk and expressed
Worrying about Client safety and Fearing exposure due to having a written
2
ABSTRACT
record and any possible legal or professional ramifications. Further

uncertainties were also revealed as participants were led to Questioning
computer reliability and Questioning own competence.
Consequently participants were left Experiencing anxiety. This anxiety

appeared to be managed in a number of ways; participants described Becoming
more task orientated (Relying on skills and theory and Taking control of the
context), Avoiding difficulties (Minimising the role of the computer and
Minimising differences between modalities/ Holding on tight to the known),
Overcompensating (Reflecting and perfecting), and Defending the professional
self-concept (Protecting by defending expertise and Becoming an expert).
The key struggle and therefore core category would seem to lie in participants
attempting to apply relational face-to-face skills to the cueless atmosphere of
email therapy, the anxiety of which materialised in several avoidant behaviours.
The findings from this study provide important insights into therapists’
experience of email counselling and identify a process that could help inform
future online therapists, as well as being useful to the online counselling
profession as a whole. It is suggested that the email counselling process
identified could provide a framework for therapists to reflect on their
experiences. Full implications for practice, supervision, training and the
psychological profession will be further discussed, in addition to directions for
further research.
3
INTRODUCTION
INTRODUCTION
Online counselling is the term used for the provision of mental health
counselling services via the Internet and the first UK professional practice
guidelines appeared in 2001 (BACP). Online therapy has been found to be
efficacious in reducing clients’ presenting problems (Day & Schneider, 2002)
and it has been suggested that some of the advantages for clients of using this
medium is ease of access to the service (Rochlen et al., 2004), access for the
geographically isolated (Robson & Robson, 2000); and online counselling is
considered to provide a gateway to mental health services for the socially
phobic and those for whom face-to-face interactions are difficult for a number of
reasons (Fenichel et al., 2002). Concerns about the online medium include: the
possibility of excluding non-literate clients (Abbot et al., 2008) and relationally,
the lack of non-verbal cues (which it is thought might add to the possibility of
miscommunication (Mallen et al., 2005a) and undermine the quality of the
therapeutic relationship.
Online counselling has been categorised into two types; synchronous real time
therapy, such as instant messaging or web-conferencing (e.g. Skype) and
asynchronous turn-taking therapy not conducted in real time, such as email
based counselling (Mulhauser, 2005), suggested to be the most popular form of
online therapy (Richards & Viganó, 2013; Chester & Glass, 2006). As an
asynchronous therapy email counselling is likely to be qualitatively different to
synchronous forms of online counselling, but as yet does not appear to have its
own distinct place in the online counselling arena, which might be problematic
as it is suggested that certain ethical issues are likely to be specific to the
asynchronous mode through its unique time delay aspects, and different to
synchronous ‘real time’ modes (Rummel & Joyce, 2010).

The term Online counselling will be used throughout to describe generic online
counselling methods and Email counselling this specific form of counselling.
The term Therapist has been adopted to describe the different types of professionals
who conduct therapy, counselling and online counselling.
4
INTRODUCTION
Evans, an online practitioner, supervisor and trainer, predicts that there will be a
dramatic increase in online counselling provision over the coming years (2009).
However the therapeutic world appears to have been slow to catch up with
these developments (Weitz, 2014), and whilst many therapists have moved to
working online it appears that psychologists are more reluctant to engage with
this medium (Shaw & Shaw, 2006). Despite research evidence which suggests
that online counselling can be efficacious for clients, it is suggested that
counselling psychologists appear sceptical about stepping into the online arena
(Hanley & Reynolds, Jr., 2009), possibly through concerns about the viability of
creating the crucial therapeutic relationship needed for effective therapy
(Lambert & Ogles, 2004), given the absence of non-verbal cues (Mallen et al.,
2005a). Counselling psychologists Hanley & Reynolds Jr. suggest that ‘online
therapy appears to violate many of the fundamental principles of the therapeutic
relationship’ (2009. p5); in particular the physical distance between client and
therapist or lack of non-verbal cues, which many impact negatively on the levels
of intimacy achieved.
5
RESEARCH RATIONALE AND AIMS
LITERATURE REVIEW
What is online counselling?

Since its inception online counselling has been given many different titles
(Cohen & Kerr, 1998) such as; e-therapy, cybertherapy (Suler, 2001), e-
counselling, web-therapy, internet counselling (Pollock, 2006) and, in more
recent times, online counselling. Online counselling has recently been
described as ‘the delivery of therapeutic interventions in cyberspace where the
communication between a trained professional counsellor and client is
facilitated using computer mediated communication (CMC) technologies’
(Richards & Viganó, 2012, p698). However, one of the problems with
conducting research into this area is that online counselling has many forms
(Mulhauser, 2005); group chat rooms, web-conferencing, instant messaging
and online self-help packages for specific psychological issues, such as
cognitive behavioural therapy for depression or anxiety (e.g. ‘Beating the blues’
http://www.beatingtheblues.co.uk). These forms are categorised into two types;
synchronous real time therapy such as instant messaging or web-conferencing
(e.g. Skype) and asynchronous turn-taking therapy not conducted in real time
such as e-mail based counselling (Mulhauser, 2005). Synchronicity offers an
immediacy that the asynchronous modality does not provide and as such is
more analogous to face-to-face counselling.
History and development of online counselling

The Internet came into more general use around 1995 (Lawrence & Giles,
1998) but it is suggested therapists were using the medium to conduct therapy
prior to this (Ainsworth, 2001). The earliest known service was ‘Ask Uncle Ezra’,
a free online mental health advice offered to students at Ithica University, New
York in 1986, which still exists today (Available at: http://ezra.cornell.edu/), and
MD Ivan Goldberg has been fielding mental health questions online since 1993
(Ainsworth, 2001). The Samaritans have been offering anonymous email
support to suicidal individuals since 1994 (Ainsworth, 2001). Online counselling
in its present forms was first introduced as a fee-based Internet service in the
US in 1995 (Wardell, 2008), with dissemination as a worldwide service not long
6
after. Whilst there is no specific information regarding its origins in the UK it is

noted that the British Association for Counselling and Psychotherapy (BACP)
published guidance for working online in 2001 in response to a demand from
practitioners already working in the area. Provision of online counselling in its
many forms has increased dramatically over the last 10 years (Barak et al.,
2008) in line with increased Internet access. UK statistics (2014) indicate that
21 million people (84% of population) have Internet access, which is an
increase of 27% since 2006. This would suggest a cultural shift in Internet use;
it is reported that 76% of adults in the UK are using a computer every day (UK
statistics, 2014). Evans anticipates that there will be a dramatic increase in
online provision over the next five years and it has been suggested that
professionals are strongly influenced to move therapy into the online area, not
least in order to keep up with consumer demand (Evans, 2009). This suggestion
and the rapid growth in this area are important rationales for the current study.
It seems important and timely to understand more about this type of therapeutic
intervention and how it may potentially impact the therapeutic relationship if it is
going to be offered more widely.
Email counselling has been cited as the most common form of online
counselling (Chester & Glass, 2006, Richards & Viganó, 2013) but this is
closely followed by synchronous chat based methods (Finn & Barak, 2010)
which may be particularly attractive to young people who have been brought up
using the internet e.g. through Twitter or instant messaging (Vossler & Hanley,
2010).
Online counselling debated

The advantages and disadvantages of online counselling have been debated by
a study group of psychologists and practitioners for the International Society for
Mental Health Online (ISHMO) (Fenichel et al., 2002). This study group
concluded that it was a new type of flexible therapy (Grohol, 2001). Others
consider online counselling as a transposition from face-to-face counselling with
technology mediating therapeutic communication, impacting on the process with
associated limitations and advantages (Castelnuovo, et al., 2003). It has been
noted that online counselling has been criticised by professional and lay people
7
from its inception (Barak et al., 2008) and that many reviews are negative. One
review questions the effectiveness and appropriateness of online counselling,
on the grounds that there is no standard qualification for therapists and that the
email mode is not sufficiently expressive to provide a helping relationship, which
they feel could compromise beneficence (Robson & Robson, 2000).
Advantages of online counselling

Online counselling has been found to be efficacious in reducing clients’
presenting problems (e.g. depression, anxiety, relationship problems) (Cohen &
Kerr 1998, Day & Schneider, 2002); a meta-analysis of 92 research studies
(9,764 clients) using internet based psychotherapeutic interventions and various
types of outcome measures, found online counselling to be as effective as face-
to-face counselling (Barak et al., 2008,); clients have also reported satisfaction
with the working alliance (Murphy et al., 2009). A review of quantitative research
studies in this area also supports this conclusion (Hanley & Reynolds Jr., 2009)
and a recent, critical narrative review of 123 studies found that online
counselling can have a similar impact as face-to-face counselling (Richards &
Viganó, 2013), although the authors suggest a need for more specific and
clearly defined research.
Other advantages suggested include: the flexibility afforded to clients about

what type of online service to choose (Powell, 1998), ease of access to it
especially for those with transport problems, physical ailments, family
obligations or illness (Rochlen et al., 2004; Maples & Han, 2008) and for the
geographically isolated (Robson & Robson, 2000). Online counselling also
offers an alternative for clients facing long waiting lists for face-to-face
counselling (Bailey et al., 2002). In addition online counselling has been found
to be advantageous for the socially phobic (Fenichell et al., 2002) who may find
face-to-face interactions particularly difficult, (Barnett, 2005), and for those to
whom the perceived privacy of using an online service is important (Rochlen et
al., 2004). It has also been suggested that young people may prefer this
medium as it allows them to remain more in control of how much they reveal
about their emotional state (Hanley, 2009). Yager suggests that the lack of
visual cues may level the power differential and that therefore online counselling
8
may be useful as an adjunct to face-to-face therapy for clients with anorexia

nervosa, who might have difficulty attending face-to-face through shame issues
(Yager, 2001). Similarly therapists have suggested that it may be especially
advantageous for clients when working with issues such as trauma and social
marginalization which might have an element of shame that would make it
difficult to work face-to-face (Liebert et al., 2006). Richards suggests that the
disinhibition engendered through the anonymity of online encounters is as a
positive factor as this enables the early disclosure of issues (Richards, 2009),
although this should be viewed with caution as for some clients early disclosure
can be difficult to deal with and cause early cessation of therapy (Suler, 2004a).
For therapists practicing email counselling, additional advantages are

considered to be having more time to consider therapeutic responses (Chester
& Glass, 2006, Dunn 2012) and having a permanent record of therapy that
clients can return to when helpful (Pollock, 2006). Psychotherapist and author of
the online resource ‘Psychology of Cyberspace’ Professor John Suler (2004b)
suggests that the write-wait-revise exercise of waiting to give a reply, can tap
into therapeutic cognitive processes in a more heightened way than in face-to-
face situations, and, for clients, encourage an observing ego, self-reflection,
insight, the ability to work through the issue and a therapeutic construction of a
personal narrative. These cognitive processes can also be encouraged in face-
to-face therapeutic encounters; the current study aimed to explore what might
be different in the absence of a physical therapist.
Disadvantages of online counselling

One disadvantage of online therapy is that it excludes non-literate clients; it is
suggested that reading and writing skills need to be fairly good to access this
service (Abbot et al., 2008; Stofle, 2001). Fenichel et al., (2002) argue that there
is a need to be able to operate on a phonemic process level in order to take part
in online counselling; this relates to the metalinguistic skill of being able to
reflect on the structure of language, which allows for the reading (decoding) and
writing (encoding) of words. On a further practical note a client would need to
have a certain degree of computer literacy as well as appropriate hardware to
utilise online counselling (Evans, 2009), which might exclude older age groups,
9
clients with limited income or education, clients for whom English is a second
language, and clients who live in areas with poor internet access.
Although it is suggested that the importance of non-verbal cues is sometimes

overstated (Kraus, 1981) the lack of cues in the online medium has been
suggested to be problematic for therapists in a number of opinion papers and
reviews (Mallen et al, 2005a; Liess et al., 2008); these cues are deemed to be
particularly relevant for conveying meaning (Mehrabian, 1971), therefore it is
suggested that this lack may add to the possibility of miscommunication
(Rochlen et al., 2004). Other possibly problematic issues are thought to be:
issues with working with the time delay, the skill levels of both client and
counsellor with communication, coping with crisis situations, identity issues,
how comfortable clients might be in expressing themselves via email and
therapeutic sensitivity (Rochlen et al., 2004). Having a written record is also
considered problematic as it could potentially leave practitioners open to
prosecution (Mackay, 2001).
Findings from a randomised trial which surveyed the attitudes of 138 American
psychologists towards four different online counselling methods (email therapy,
Internet-based individual chat, Internet-based group chat, and Internet-based
videoconferencing) suggest that practitioners did not endorse any online
therapeutic method and expressed a number of concerns about email-based
counselling (Mora et al., 2008), including the lack of accessibility to non-verbal
behaviour, difficulties in establishing a working alliance and the lack of
professional and legal guidelines available. A study, which explored differences
between voice and email communication, suggested that email was a ‘socially
blind’ medium; findings suggested that ambiguity was more likely than in voice
communications and bogus first impressions more likely to persevere (Epley &
Kruger, 2005). Other areas of concern cited by therapists are confidentiality,
personal liability and being misinformed by clients (Rochlen et al., 2004; Wells,
et al., 2007). However, the latter research does conclude that it is unclear if the
concerns come from actual experience with email counselling or are based on
uninformed opinion. Others fear the isolated nature of email counselling for
therapists and feel that the impersonal nature should be of concern in therapy
10
(Lago, 2006). A further potential problem with email counselling is that it can be
time-consuming; the extra time taken in reading and formulating a reply in e-
mail counselling can be a great deal more than any face-to-face encounter;
client emails are thought to average at least one third more than a transcribed
online chat session (Day & Schneider, 2002).
Another important disadvantage already alluded to is an ethical one: many

online counsellors are not trained (Chester & Glass, 2006; Caleb, 2000). It has
been suggested that without a high level of skill and competence in using the
online space, email therapy might be reduced to advice giving (Pelling &
Renard, 2000). Furthermore, that competence in face-to-face counselling does
not automatically map on to competence in email counselling, and that training
in the appropriate arena is therefore required (Pelling, 2009). An additional
danger of not having appropriate levels of training and experience in this
medium is that an inappropriate or inadequate response could occur (Hunt,
2002) which is potentially harmful to the client. The BACP strongly advocate
training specifically in the online medium for this reason (BACP, 2009).
Ethical issues in online counselling

Whilst it should be noted that counselling in face-to-face settings does not come
without risk (Childress, 2000) areas that have been identified as ethically
problematic in email counselling are around the online written record produced
which could lead to breaches in confidentiality; the fact that client assessments,
do not have the advantage of visual cues and thus may be less accurate; this is
of particular concern when assessing risk; the risk of possible harm to clients in
the form of emotional injury or re-traumatisation due to the increased potential
of miscommunication in online counselling; risk of harm also through client’s
over-zealous self-disclosure and disinhibition, which is estimated as a particular
issue in the more anonymous context of online counselling; issues of informed
consent/ crisis intervention planning and boundary issues e.g. clients finding
other ways to communicate with therapists online (website, social media etc.).
In addition it has been argued that online counselling may encourage
dysfunctional behaviours in clients and that therapists risk becoming complicit in
internet addiction behaviours and that they may be discouraging physical
11
activity by encouraging clients to become “mouse potatoes” (Pelling, 2009,

p13). Given these disadvantages it has been suggested that providing services
in electronic form can be iatrogenic or harmful to clients and caution when using
this medium is often advised (Caleb, 2000), Pelling (2009, p20) suggests that
therapists keen to use the email medium “drive safely” as the reputation of the
profession, their personal existence and client welfare are all at stake.
Whilst there is a growing body of research into online counselling practitioner

Mulhauser (2005) argues that there has been no fundamentally new ethical
territory generated relating to email therapy, merely new technological territory.
Mulhauser suggests that applying technological guidelines, which require
constant updating, to ethical principles is not helpful for the profession as a
whole as it may encourage practitioners to see practical guidelines as a
substitute for ethical principles. Mulhauser (2005, p17) cautions that;
the preponderance of available guidelines may nonetheless

encourage some online practitioners to accept adherence to
them as a substitute for the technical competence required to
support ethical decision-making and risk assessment in situ.
Although this view is understandable as online technology develops so quickly,

it would seem important to have both in order to provide clear guidance for
online practitioners, or create a clearly stated difference within future ethical
guidelines. Presenting an overview of ethical concerns in online counselling
psychologists Rummell & Joyce (2010) describe the area as an ‘ethical
quagmire’ mainly due to the lack of consensus and concrete guidance currently
available.
Who provides guidelines for online counselling and what do these offer?
Guidelines on the practice, process and ethical implications of online
counselling have been developed by practitioners and researchers from
different therapeutic fields covering areas such as: practical skills in
12
establishing an online presence (Evans, 2009), online listening, attending to the

client and maintaining an open dialogue (Weitz, 2014), as well as professional
considerations such as online assessment/contracting (Mallen et al., 2005b).
Guidance has also been provided on the consideration and handling of ethical
issues (Anthony & Goss, 2009) since online counselling opens a whole new
arena of potential ethical concerns. There are some ethical guidelines from
professional organisations to support online therapists, for example: the
American Psychological Association (APA, 1997), the International Society for
Mental Health Online (ISMHO, 2000), the American Counselling Association
(ACA, 2014) and the British Association for Counselling and Psychotherapy
(BACP, 2009). However, these guidelines have been criticised for appearing to
have been set up as an afterthought (Finn & Barak, 2010), and a review from a
counselling psychology perspective suggests that there appears to be a lack of
consensus amongst therapists about their ethical obligations in the context of
online counselling (Mallen et al., 2005a).
To date the British Psychological Society have only produced ethical guidance
on internet mediated research (BPS, 2013); although interestingly the
professional practice guidelines for the Division of Counselling Psychology
(BPS, 2005) advocate working within the client’s context. The Association of
Counselling and Therapy Online (ACTO), an umbrella organisation for UK
online therapists was established in 2006. Members need to belong to a
recognised professional body and agree to adhere to both their own and the
ACTO (2014) professional code of conduct and ethics, which is very
comprehensive.
Supervision is recommended for practitioners across all ethical guidance and

guidelines available for online supervisors in the BACP (2009), and ACTO
(2014) documents. The APA (2002) have been criticised for subsuming
separate online counselling guidelines under traditional face-to-face ethics from
their earlier version (Rummell & Joyce, 2010); but it is noted the APA have
subsequently re-issued guidelines for ‘the practice of telepsychology’ (APA,
2013); the American Counselling Association (ACA, 2014) offer ethical
guidance under distance counselling relationships and the International Society
13
for Mental Health Online (ISMHO, 2000) offer suggestions for practice issues in
the area, which are described as very extensive (Rummell & Joyce, 2010). A
comprehensive set of professional practice guidelines for online counselling,
and perhaps most relevant to the UK, comes from the third edition of the BACP
(2009) ‘guidelines for online counselling and psychotherapy’; which covers
practitioner competence, client suitability, and contracting, issues specific to
online working, confidentiality and jurisdiction of professional codes and law.
Hanley and Reynolds Jr. suggest that therapist uptake in online counselling
could in some way be due to the increasing provision of guidelines and text
books for practitioners wishing to work online (Hanley & Reynolds Jr., 2009).
In summary, the debate regarding advantages and disadvantages of online

counselling continues in opinion papers and reviews predominantly in the US,
Australia and the UK. Ethical issues are at the heart of therapist concerns and
often emanate from concerns regarding whether a therapeutic relationship can
be developed, and developed safely, with clients in the absence of non-verbal
communication. Mixed research methods utilising mostly self-report data
highlights practical advantages and disadvantages for both client and therapist
in the online medium, and miscommunication appears to be a major area of
concern for therapists. However, outcome research using self-reports with
clients is often positive and includes satisfaction with the working alliance,
although it is also important to note that a number of clients have been found to
be dissatisfied with the therapeutic alliance in the online context (Hufford et al.,
1999). Outcome research in this area is mostly European and quantitative in
nature, and meta-analyses appear positive. However what is problematic about
these findings needs to be considered; there are some inherent difficulties
involved due to the differences between the studies reviewed, the measures
involved, and the problems involved in researching something as intangible as
the therapeutic relationship. The research related to this area is reviewed in the
following section.
14
COMPUTER MEDIATED COMMUNICATION AND INTERPERSONAL

DYNAMICS
Computer mediated communication (CMC) has been defined as any
communication that occurs through the use of two or more electronic devices
(McQuail, 2005), or “a process of human communication via computers,
involving people, situated in particular contexts” (Walther, 2011 p443).
Research in the field of interpersonal dynamics in CMC suggests that it is
involved in the subtle shaping of communication, in almost every relational
context (Walther, 2011). Communication researcher Professor Joseph Walther
(1996) suggests that when examining interpersonal dynamics it is appropriate,
and highly relevant in the digital age, to compare face-to-face or offline methods
with online forms of communication which lack social cues or similar. He further
suggests that research into CMC has historically gone through three stages;
from Impersonal to Interpersonal through to the development of his
Hyperpersonal model (1996), and this section of the review will use these
stages to examine the development of several relevant models, theories and
modes.
IMPERSONAL MODELS
Walther suggests that through the lack of distraction afforded by the absence of
non-verbal cues interactions become more task oriented, and thereby more
impersonal than face-to-face interactions. Although the lack of social cues is
suggested to be advantageous in group situations (e.g. online chat rooms;
social network sites) as it is thought to save time by decreasing ‘irrelevant’
interpersonal influences, and the anonymity afforded can result in more freedom
for members who may feel pressure from high-(social) status members
(Walther, 1996). Impersonal models are sometimes referred to as ‘deficit
models’, relating to their lack of social cues, and several models are presented
in this section; The Cuelessessness Model (Rutter & Stephenson, 1979), Social
Presence Theory (Short, Williams & Christie, 1976), and The Media Richness
Model (Daft & Lengel, 1986).
The Cuelessness Model - This model was developed by academics Rutter and
Stephenson in the 1970s, when working in the area of economics and social
15
research. Whilst not strictly a CMC model it is perhaps a precursor to

investigations of communication regarding social cues and is presented as a
deficit model. Rutter and Stephenson (1979) conducted experiments into social
interaction and explored; lack of visual communication using blind participants,
visual communication using sighted participants via videolink and proximity with
a lack of visual cues between sighted participants. Noting conversational styles
these researchers found that the less social nonverbal and identity marker (e.g.
status) cues available the more the discussion became task oriented,
depersonalized and lacking in spontaneity.
Building on these findings Kemp & Rutter, (1982) assigned participants

randomly to one of three conditions; in the first condition participants were
facing each other, in the second a screen was placed between participants and
in the third participants communicated via a headset. Analysis of conversations
suggested cuelessness reduced spontaneity of style, the discussion became
more task oriented and depersonalised and participants failed to adapt to their
condition over time. However a later experiment involving blind participants
(Kemp & Rutter, 1986) indicated that communication exchanges were more
personal and less task orientated; it was hypothesised that blind participants
had learnt to compensate by asking for information, in contrast to sighted
participants in the study who the researchers suggested, avoided asking for
personal information and focused instead on the task in hand. An earlier study
observing the effect of the medium and group size on debates suggested that
introducing an emotive topic brought in more social cues, and reduced
perceived psychological distance (Rutter et al.,1984).
There is some criticism of the cuelessness model suggesting that these findings
lack a sociopsychological perspective. It has been suggested that this makes it
difficult to apply them to other contexts and that they therefore present a narrow
view (Roger & Bull, 1989). This suggestion is supported by Eadie (2009) who
suggests that cultural differences were disregarded in early CMC research (i.e.
some cultures rely more heavily on non-verbal communications to convey
meaning and respect). However, whilst findings from this research may not
16
completely translate into online counselling, the idea of compensating in a

cueless situation is of relevance to the current research question.
Social Presence Theory - Social presence theory (SPT) (Short, Williams &
Christie, 1976), imported from teleconferencing research, was one of the first
analytic frameworks applied to CMC (Walther, 2011); SPT focuses on the
communicator’s sense of awareness of the presence of an interactive partner.
SPT suggests that the fewer cue systems a teleconferencing system supports,
the less warmth and involvement users experience, which is relevant to the
current research question. According to SPT immediacy is important in
enhancing social presence (Gunawardena & Zittle, 1997) and is felt to occur via
a person’s physical presence. It is further suggested that the internet is not a
functional alternative to face-to-face encounters but rather a specialised
channel. While SPT is now a little outdated due to the development of creative
and synchronous methods which provide more cues (Biocca et al., 2003) it
would seem to have some relevance to the current research question due to the
lack of cues inherent in email counselling. A recent research study with 128
nursing students from the USA and Holland utilised an online survey, which
included a social presence scale (Gunwardena & Zittle, 1997) to measure
satisfaction when taking part in a web based nursing course; participants
reported feeling comfortable and satisfied with this type of interaction (Copley-
Cobb, 2009), however while this may be relevant to online teaching it may not
be as relevant to online counselling which relies on more relational factors.
The Media Richness Model (MRM) - The Media Richness Model was developed
by Daft & Lengel (1986) and originated as an organisational decision making
model, but was later applied to interpersonal situations. Within this model
richness of communication is determined by the ‘bandwidth’ or ability to transmit
multiple cues, ability to give immediate feedback, ability to support the use of
natural or conversational language, and the degree to which a message can be
personalised. In effect this model suggests that the more complex the task the
richer the medium needed. MRM has been criticised (Walther & Parks, 2002)
for its inability to generate hypotheses that are applicable to all forms of CMC;
some forms, for example email communication, might have changeable content
17
which may or may not meet the richness criteria (e.g. natural language &
personalization). A review of digital deception suggests that in MRM
participants are considered less likely to use deception using email than other
CMC methods, such as the telephone, as having a record was clearly not
conducive to deception (Hancock et al., 2004), due to those methods being less
rich in ‘bandwidth’ than face-to-face communication. Critics of the MRM suggest
the model is deterministic in nature and was developed before the widespread
use of the internet, and is therefore unsuitable for capturing all the dimensions
of the medium (Dennis et al., 2008).
INTERPERSONAL MODELS
Walther (2011) suggests that CMC is not always impersonal; that it can also
develop social relationships. Although the absence of non-verbal cues means
that there is less social information exchange in CMC it is suggested that as the
communication time increases so does the exchange of social information.
Anticipating future communications may result in communicators looking for
more information from the other. This mechanism, he suggests, might lead to
similar immediacy, composure, similarity and receptivity as is found in face-to-
face communications. However, since it takes time for CMC to achieve
consensus and if this is time limited the information exchanged will be less,
thereby affecting any social relationships (Walther, 2011). This evolution of
CMC is considered to have developed from being considered cueless to a cues-
filtered-out perspective, and several theories and models that fall in to this
category are presented; The Social Identity Model of Deindividuation Effects
(SIDE)(Lea & Spears, 1991), and Social Information Processing Theory
(SIP)(Walther, 1992).
Social Identity Model of Deindividuation Effects (SIDE) - The SIDE model was
first posited by Lea and Spears (1991). This model applied research findings
regarding crowd behaviour to CMC. Early research in this domain suggested
that, similar to deindividuation theory developed in the 1960’s (Zimbardo,1969)
online communicators were prone to ‘online flaming’ (behaving in a hostile
manner in exchanges online, due to the anonymity afforded by the internet),
and other disinhibited behaviours, possibly due to a reduction in social cues.
18
The SIDE model was developed to account for the contradictory effects of
social cues in online groups, assuming that crowd effects showed some similar
properties to online environments. Presently SIDE is used to explain the effects
of anonymity and social isolation in various contexts, including electronic
relationships and virtual communities. The SIDE model has been developed
over the years and currently specifies two factors that drive online behaviour;
visual anonymity that occurs when sending messages by text in CMC, and
behaviour that is thought to be driven by social identity factors which lead to a
loss of one’s individuality. In turn it is suggested that CMC users then tend
towards an in-group bias of similarity and attraction. Findings from a field
experiment with a church community who were asked to donate money via
email CMC rather than interacting face-to-face (Chan, 2010) suggest that those
who identified less with the group were more likely to respond to email requests
when the salience of social identity was heightened. This finding supports the
hypothesis that the process depersonalised individuals who then became more
sensitive to group norms. However, recent revisions to the SIDE model have
retracted the idea that visually anonymous users cannot relate to each other as
individuals (Postmes et al., 2006), suggesting that relationships can be
developed over time and that communicators are able to identify with the small,
interacting group. Whilst once very popular in research terms the influence of
the SIDE model in CMC research has now decreased (Walther, 2011), although
the focus within the model regarding anonymity effects might be relevant to this
study.
Social Information Processing Theory (SIP) - SIP was suggested by Walther

(1992) as an alternative to the impersonal models and is used to theorise the
differences between text-based CMC and offline communications. Walther
(2011) suggests that, when using CMC people are able to accrue impressions
of, and relationships with, others that are equivalent to offline experiences over
time. He suggests that communicators are motivated to develop interpersonal
impressions and will adapt to whatever cues are available. Regarding text
based CMC the theory predicts that individuals will adapt the encoding and
decoding of social information (i.e. relational messages) into language and the
timing of messages. Support for this theory exists in communication theory
19
research where the group interaction in a synchronous context was analysed;

findings suggest that the presence of anticipated future interaction moderated
participants’ behaviour by encouraging the development of social relationship
factors (Ramirez et al., 2007). The theory was posited as an optimistic
alternative to Impersonal CMC ideas but further research by Walther
disconfirmed some of the aspects regarding relationships developing over time
(Joinson, 2003) , which led to development of Hyperpersonal theory (Walther,
1996). Further to this a study found that whilst SIP might work for people with
high individualistic values it did not necessarily do the same for those with high
collectivist values (Tokunaga, 2009 ).
THE HYPERPERSONAL MODEL

The Hyperpersonal model (Walther, 1996) consists of a set of concurrent
theoretically based processes to explain how CMC may facilitate relationships
and impressions online that exceeds the intimacy that occurs in parallel off-line
interactions. The model outlines four components of the communication
process relating to message construction and reception:
1) Receivers – In the absence of non-verbal communication an individual may

tend to exaggerate perceptions of the message sender, fill in the blanks with
regard to missing information based on initial favourable clues, make
overattributions of similarity when visually anonymous and, if conversational
partners share some salient social identity, communicators may experience
heightened attraction. Research in this aspect often uses the SIDE model to
explain over-attributions, but this is changing to include more individual
stereotypes, such as who the online person reminds you of (Walther, 2011).
2) Senders – Text based CMC facilitates selective presentation, as unless a

person communicates their behaviour, they are more in control of what to
transmit and may choose only desirable characteristics to portray a preferential
image. In this way self-disclosure is suggested to facilitate intimacy and is
thought to be more commonly used online (Walther, 2011);
20
3) Channel – Involves characteristics of the channel; one part focuses on the

mechanics of the CMC interface, suggesting that users exploit the ability to take
time to contemplate and construct messages mindfully. The model further
suggests that CMC users may redirect cognitive resources into enhancing a
message without needing to pay attention to the physical behaviours of self or
others, or be distracted by other aspects of the context;
4) Feedback- This suggests that aspects of all three components, idealisation,

selective representation and channel effects reciprocally influence the response
by reproducing it and enhancing the effects. This is thought to be akin to
‘behavioural confirmation’ (Snyder et al, 1977) whereby interactors effect each
other’s behaviours in a reciprocal manner and is reminiscent of findings in the
social psychology field about reciprocal liking, where individuals tend to like
people who like them.
In effect Hyperpersonal CMC purports there might be advantages over face-to-

face interactions in some situations, and whilst Walther (2011) suggests there is
some evidence for the first three components of Hyperpersonal CMC (Walther,
1996), he believes that the construct of ‘Feedback’ has not yet been fully
explored. Whilst not a CMC model, findings of research into sensory deprivation
have been included in this section as this aspect would seem relevant when
considering the impact of cuelessness on social interaction.
Sensory deprivation - Research with blind participants suggests a degree of

compensatory plasticity in the brain which allows for other auditory senses to
compensate in social situations (Rauschecker, 2002). Rauschecker (2002) also
proposes that there may be a degree of tactile compensation which allows for
the brain to visualise an image. A research study with deaf participants used a
map reading task to look at communication dialogue variables in face-to-face
and the online videoconferencing medium (Gournaris & Leigh, 2004), with
findings suggesting a similar understanding of the task across both modes. A
comparison study with deaf participants suffering depression, which conducted
psycho-educational therapy both in written form and using an online medium
(Wilson & Wells, 2009), reported efficacy similar in both modes and suggested
21
‘Telehealth’ a viable option for the deaf population suffering depression. In a

perceptual deprivation research study (Lloyd et al., 2012) participants were
seated in a room devoid of visual stimulation where they listened to white noise.
Findings from this study indicated that the brain may impose meaning on the
environment even when no cues were given. Further to this a research study
with students into total sensory deprivation suggested some auditory and visual
perceptual disturbances may occur (Mason & Brady, 2009). These studies
would tend to indicate some sort of compensatory process occurs in a relatively
cueless situation.
In summary, the models included in the impersonal and interpersonal stages

are often criticised for being unsuitable for exploring later versions of CMC and
the cuelessness models have been criticised as even a situation high in
cuelessness, it is suggested, can still be deemed psychologically close through
CMC avenues (Thurlow et al., 2004). This is supported by the Hyperpersonal
proposition that in some situations CMC might be advantageous in
interpersonal interactions (Walther, 2011).
However, whilst the research and theorising in this area consider interpersonal
dynamics through CMC, this is largely from a social psychology perspective;
qualities of personal relationships and how these might relate to the crucial
forming of a therapeutic relationship is not clear. Findings from the field of
neuroscience indicate that the brain is capable of compensating in cueless
situations of sensory deprivation (Rauschecker, 2002), although research would
seem to be a little speculative. The therapeutic relationship from a
psychotherapeutic perspective will be examined within the following section
THE THERAPEUTIC RELATIONSHIP
The therapeutic relationship in face-to-face encounters
Decades of empirical research indicate that the quality of the therapeutic

relationship is strongly linked to positive client outcome (Lambert & Barley,
2001; Norcross, 2011) and a critical factor in successful therapy outcome
(Lambert & Ogles, 2004). Indeed 30% of outcome variance has been predicted
22
by the therapeutic relationship (Lambert & Barley, 2001) and a review of over
2000 process-outcome studies (Orlinsky et al., 1994) suggests that several
therapist variables have a positive impact including empathic understanding,
affirmation of the client and the ability to engage with the client. Cooper (2008)
suggests that the therapeutic alliance and empathy are strong predictors of
outcome. However, a major criticism of research in this field is around the lack
of specificity about which constituent of the therapeutic relationship is under
investigation. Horvath suggests (Horvath, 2005.p5).
The significant overlap evident among these elements, and a

lack of a conceptual model knitting these elements into a
cohesive framework, indicates that there is a need to make
some clarifications and distinctions… critical relational factors
might be affected by different therapeutic contexts.
The importance of the therapeutic relationship was first noted by Freud (1913),
who suggested that patients attached themselves to their therapists. From
these observations about the intensity of these attachments Freud developed
the concept of transference. Freud (1940 pp.202-203) suggests:
The patient is not satisfied with regarding the analyst in the

light of reality as a helper and adviser who, moreover, is
remunerated for the trouble he takes and who would himself
be content with some such role as that of a guide on a difficult
mountain climb. On the contrary, the patient sees in him the
return, the reincarnation, of some important figure out of his
childhood or past, and consequently transfers on to him
feelings and reactions which undoubtedly applied to this
prototype.
Transference is believed to be the ‘transference’ of past feelings, conflicts, and

attitudes into present relationships, situations, and circumstances, and is
thought to be revealed within the therapeutic situation (Jacobs, 2010);
practitioners of various perspectives hold different ideas about how to work with
23
this. Psychoanalytic practitioners believe strongly that therapy happens within

the relationship (Sandler & Sandler, 1997) and would lean very strongly towards
the transference/countertransference relationship; countertransference is
defined here as the therapist’s emotional reaction towards the client (Lemma,
2003). With reference to email counselling cyberpsychologist and
psychoanalyst Suler (1998) suggests that it is also possible to have a
transference reaction to the computer in response to an unconscious
relationship template. Suler refers to a double transference effect both through
and with the computer in email therapy, and suggests (Suler, 1998 para. 36):
Because we experience online others THROUGH the

computer, it's also possible that the transference reactions
to them may interact with the transference reactions to the
computer.
Suler further suggests that one might ‘know’ transference was at work through
having exaggerated or inappropriately strong feelings towards the computer.
The key to being able to use the space therapeutically as an online counsellor is
by realising when transference is at play, which can often be tricky to negotiate
he suggests; ‘’Healthy online relationships are those in which we realize that our
perceptions are not always accurate’’ (Suler, 1998 para.37).
The therapeutic process is common to different forms of counselling and

therapy, and is thought to take place in the interchange between therapist and
client. It concerns a therapist’s capacity to be self-aware of; thoughts and
feelings, possibilities and limitations, and personal and professional boundaries
in psychological counselling. The relationship between therapist and client has
taken a prominent role in theories of therapeutic process (Gelso & Carter,
1994); Gelso and Carter (1994) postulate that most models of the therapeutic
relationship emanate from Greenson’s (1967) analytic relationship model,
where the three core aspects are: the working alliance, the
transference/countertransference relationship and the real relationship. The
working alliance described the patient's and the therapist's conscious
determination and ability to work together on the troublesome aspects of the
24
patient's internal world, his relationships with others and or other aspects of his
life (Molnos, 1998), it has been suggested that no successful therapy can take
place without a good working alliance (Clarkson, 2003). The working alliance is
most often linked with short term therapy such as Cognitive Behavioural
Therapy (CBT), first developed by Aaron Beck (1975); this alliance has been
deemed necessary but not sufficient for therapeutic change by cognitive
psychotherapist Wills (2008).
The ‘real relationship’ is often spoken about as being open and genuine as well
as being most linked with person-centred/humanistic/existential orientations.
Carl Rogers (1967) the founder of person- centred therapy suggested that the
core conditions are necessary and sufficient for therapy. In particular that the
therapist needs to be congruent and to experience unconditional positive regard
towards the client and empathic understanding of the client’s internal frame of
reference and importantly, convey both to the client. Whilst the working alliance,
transference and real relationships can be discussed separately it is also
suggested that they exist in all therapies (Clarkson, 2003; Gelso, 2011).
In addition to these three core aspects the therapeutic relationship has also
been conceptualised as having two parts; the technical aspect - relating to
therapist technique and the relational aspect -relating to the psychological
connection of therapist and client based on feelings and attitudes held by both
(Gelso & Hayes, 1998). Eleven relationship factors as potential contributors to
therapeutic efficacy have been identified via an empirical review: alliance,
cohesion, empathy, goal consensus and collaboration, positive regard,
congruence, feedback, repair of alliance ruptures, self-disclosure, management
of counter transference and relational interpretation (Norcross, 2011). This
highlights many of the research areas therapists are interested in.
One clear area of interest is in the communication between client and therapist,
which requires technical and relationship skills such as listening, attending and
attunement. Attunement is deemed to foster a sense of rapport and can have
several functions, such as respect and safety, which are seen as crucial to the
therapeutic relationship (Erskine et al., 1999). A recent study exploring how
25
practitioners conceptualise their online counselling work used a mixed method

study to analyse 83 single session transcripts; findings from this study indicate
that therapists appear to concentrate more on rapport building than on other
aspects of therapeutic work or tasks (Williams et al., 2009). Other factors such
as power, intimacy, confidentiality and trust are deemed to be crucial factors in
building and maintaining a good therapeutic relationship (Clarkson, 2003); it is
also suggested that repairing relationship ruptures has a positive therapeutic
effect (Bordin, 1980).
Non-verbal communication and the therapeutic relationship

Argyle (1983) argues that the majority of communication is via body language
and it is suggested that 93% of a message is communicated non-verbally and is
therefore out of conscious awareness of the sender and receiver (McKay et al.,
1983). Baxter (2013), a physiologist and author on non-verbal communication,
argues that body language communication takes one of the following forms:
Haptics – communicating via touch; Proxemics – communication via the use of
personal space; Physiognomy – reading of facial ‘micro-expressions’; and
Paralinguistics –how the voice is used, all of which are relevant to the
therapeutic relationship. Findings from a study exploring the clients’
perspectives on which counsellor behaviours positively impacted on the
therapeutic relationship suggest that greeting the client with a smile was
considered to be important (Duff & Bedi, 2010). The pattern of communication is
also important with dialogue needing to be both receptive and expressive as
well as being at the client’s pace (Cooper & McLeod, 2011).
Also of interest is therapeutic presence in the therapeutic relationship which has

been defined by mindfulness practitioners as being fully in the moment with a
client on a multitude of levels with the therapist being mindful of their own
process but being in the service of the clients healing process (Geller,
Greenberg & Watson, 2010); client awareness of therapist presence is mostly
measured through self-report instruments, such as the Therapeutic Presence
Inventory (TPI) (Geller et al., 2010). While conceptualisations of therapeutic
presence differ according to theoretical orientation it has been suggested that
this is key to therapeutic efficacy (Webster, 1998). Kahn (2001) argues that both
26
client and therapist need to be ‘actively’ present, in a two-person relationship, in

order for the work to be possible. Other psychotherapeutic theorists highlight
the need for openness to all aspects of the clients experience, one’s own
experience and the capacity to respond from this place as a therapist (Bugental,
1989). However, although there are different descriptions of therapeutic
presence these would seem to refer more to the openness of the relationship
and skills of the therapist than physical presence. Psychotherapist Dr Jeri Fink
(1999) describes telepresence as the feeling of being close to others and in
another’s presence in an environment mediated by the communications
medium; if a ‘safe’ clinical environment can be engendered he suggests that
this may be considered a clinical tool (Fink, 1999).
However researchers in the field of neuropsychology (Schore, 2013) stress the

importance of gaze and facial movements in the formation of relationships,
particularly early relationships, as these help to create an internal concept of
relationship, which is crucial in forming attachments later in life. Schore (2013)
suggests that the ‘gaze’ of the therapist helps to create or recreate the
conditions of the client’s early relationships allowing for a more positive internal
construct to develop, thereby making it possible for clients to bond or develop
healthy attachments in the future. As Schore (1996, p. 59) explains:
Experiences in the therapeutic relationship are encoded as

implicit memory, often effecting change with the synaptic
connections of that memory system with regard to bonding
and attachment. Attention to this relationship with some clients
will help transform negative implicit memories of relationships
by creating a new encoding of a positive experience of
attachment.
Neuropsychological findings have been gaining prominence in the therapeutic

world in recent years; linking ideas about psychology, biology and
psychoanalysis, particularly when considering theories of affect, has shed new
light on that which was previously considered unconscious (Schore, 1997) and
27
added credence to many of Freud’s findings and those of relational theorists

and researchers.
Perhaps the most relevant neuropsychological findings to the field of non-verbal

communication are those concerning mirror neurons. Mirror neurons are a set
of neurons that are activated when performing or witnessing an action; and
have historically been researched using monkeys (see Iacoboni, 2009) and with
brain damaged humans often in relation to empathy (see Eslinger, 1998).
Contemporary findings from the field of neuroscience suggest that mirror
neurons are important regarding empathy as these appear to affect the
reception and interpretation of facial expressions; this is supported by
neuroscientific experiments which suggest that the better the individual is at
interpreting facial expressions the more active their mirror neuron system
(Enticott et al., 2008). Empathy is viewed as a critical manifestation of human
experience and relatedness the desired end state.
In addition Schore suggests that a therapist’s brain may need the capacity to
create a holding environment in order to tolerate the ambiguity, uncertainty and
lack of differentiation involved when ‘wondering’ with a client (Schore, 2013), by
which he is referring to the important task of client containment. The ability to
act as a holding container for a client’s affective energy it is suggested may
involve dual modes of existence (Schore, 2013); the therapist attending to their
own self-regulatory functioning whilst simultaneously attending to their clients’
needs (Holmes, 1998). Schore (2013) suggests that the brain has capacity to
shift between these two modes; turning inwards to look for relationship patterns
and looking outwards to connect empathically with others. In this sense as
Wallerstein (1998) suggests, psychoanalysis is a two person psychology
involving as it does two minds. One-person psychology has become unpopular
in current, relational, therapeutic theorising (Wachtel, 2010), as it implies a
solipistic view that the self is the only reality and has often been sidelined in
favour of the two-person psychological view that relationships are a co-creation;
others take the view that both can exist in theories of therapeutic relationship
(Lewis, 1990).
28
Of interest to the current study is what happens within the therapeutic

relationship when ‘gaze’ is not possible as in email counselling. If, as Schore
suggests, the eyes are the window to the therapeutic soul, how might this affect
the process of the therapeutic relationship when counselling by email?
Research findings from the field of attachment theory are also helpful in
considering interpersonal dynamics and the therapeutic relationship. (Waters et
al., 2005). Contemporary ideas in attachment theory suggest that the empathic
therapists’ capacity to regulate the clients’ arousal state within the affectively
charged non conscious transference-countertransference relationship is critical
to clinical effectiveness (Schore, 2013). The therapeutic relationship is thought
to act as a secure base to a client with insecure attachment issues, from where
they can explore difficult issues and it has been suggested that attachment is
impacted by emotional proximity (Holmes, 2001).
The intersubjective space

In psychology intersubjectivity is a key term used to conceptualize the
psychological relational space between people and often used in contrast to
solipsistic individual experience, as it emphasises social existence. It has been
argued that the symbols and signs of language make it deeply subjective and
self-reflection entails intersubjectivity (Gillespie & Cornish, 2009). Evidence is
provided in mirror neuron research (Rizzolatti & Arbib, 1998) for this aspect of
human psychology, which include research on empathy, and the idea of a
theory of mind (the ability to attribute mental states to oneself and others and to
understand that others have beliefs, desires, and intentions that are different
from one's own). Contemporary psychoanalytic literature suggests that
intersubjectivity is a key factor in the therapeutic relationship and that emotional
experience takes form in the intersubjective space (Stolorow et al., 2002);
indeed it has been argued that self-expression through this medium is
representative of a constructed aspect of self, unfettered by some transferential
aspects and therefore a more visible, concrete and objective format than
speech and useful in its own right in therapy (Suler, 2003).
The therapeutic relationship and telephone counselling
29
Telephone counselling is often included in research into the differences

between face-to-face and online counselling methods (Mallen et al., 2005a) due
to its lack of non-verbal social cues. Telephone counselling has been in
existence since the 1950’s when the Samaritans helpline was developed and
has been a growing trend since then in the therapeutic world (Barnett &
Scheetz, 2003). Centore and Milacci (2008) surveyed 854 Christian counsellors
online regarding their use, and perception, of the distance counselling
modalities of; telephone, email, text chat and video conferencing. Overall
participants described a decrease in social stigma aspects signifying an
advantage, and a decrease in the counsellor’s ability to build rapport, fulfill
ethical duties and treat mental disorders signifying several disadvantages.
However, a study by counsellors Rees et al., (2002) of 186 participants who
took part in a free telephone counselling service for various mental health
complaints found no difference in the amount of therapeutic bonding or social
influence between telephone and face-to-face counselling; although the ‘more
poorly’ participants preferred face-to-face interactions. In a study of 569
psychologists who answered a survey about using the telephone for clinical
work it was found that 98% reported using telephone counselling (Vanden bos
& Williams, 2000), but the Centore and Milacci (2008) research reported a drop
in therapists’ use of telephone counselling to 74%, which may perhaps indicate
a shift towards other distance counselling methods, such as online counselling
in its different forms. The Vanden bos & Williams (2000) claim that 98% of
psychologists using telephone counselling would seem very high, and it should
perhaps be considered what is meant by clinical work; psychologists could
perhaps have been reporting telephone contact.
The therapeutic relationship and online counselling
Research into online counselling and the therapeutic relationship is limited

(Richards & Viganó, 2013); part of the rationale for the current study is to
attempt to add to the research base by exploring therapists experiences of the
therapeutic relationship when working with the email medium. Attempts have
been made to measure the therapeutic alliance in online counselling using
quantitative self-report surveys such as the; Working Alliance Inventory (WAI),
30
Therapeutic Alliance Quality Scale (TAQS) and Client Satisfaction Inventory

(CSI), (Murphy, et.al, 2009; Barak & Bloch, 2006; Hanley, 2009; King et al.,
2006; Reynolds et al., 2006; Prado & Meyer, 2004). Mixed method research has
also been used to assess the online therapeutic relationship, with the quality of
the online working alliance judged medium to high by three quarters of
participants in a review of sixteen quantitative outcome studies (Hanley &
Reynolds Jr., 2009). A smaller study into 16 mostly female participants found a
strong therapeutic alliance, with disinhibition suggested to be a positive factor in
creation of this alliance (Cook & Doyle, 2002).
Research into the working alliance in cognitive behavioural therapy online

indicates that it is possible to establish a stable and positive relationship when
working online; however, the study results also indicate that the therapeutic
relationship was not thought to be a contributory factor to positive outcome,
unlike face-to-face therapy approaches (Knaevelsrud & Maercker, 2006).
However, it has been suggested that what is problematic about the current
research literature into online counselling is that it attempts to translate theory
about the therapeutic relationship developed from face-to-face counselling into
the online medium (Laslow et al., 1999; Hunt, 2002), and a review of research
in the area suggests the future of online counselling might benefit from a new
framework for this clearly different mode of counselling (Richards & Viganó,
2013).
The current edition of BACP guidelines (2009) for online counselling and
psychotherapy remain ‘optimistic’ but neutral on the position of online
counselling, they suggest (BACP, 2009 p4):
It remains unwise ……to definitively claim that written

communication over the Internet should, or should not, be
considered equivalent to face-to-face provision
Other authors are sceptical suggesting that therapeutic conversation online can
be shallow and superficial (Barak & Bloch, 2006). It has been suggested that
31
sufficient intimacy cannot be reached online due to working via the computer
(Robson & Robson, 1998); Robson & Robson (1998, p.40) argue that:
The creation of the relationship that is necessary in client

centred counselling could not be facilitated in its wholeness
through computer communication…..the uniqueness of
humanity will always be limited by transmission through the
wires
Quantitative research regarding email counselling and the therapeutic

relationship often confounds email counselling with other online counselling
media and whilst it could perhaps be assumed some of these findings may
relate to email counselling (anonymity effects etc.) it would be difficult to
confidently assert this. Qualitative studies in this field are rare; an Interpretive
Phenomenological Analysis (IPA) study exploring six therapists’ views on the
online therapeutic alliance suggested that trust in the therapeutic relationship
was viewed similarly whether online or face-to-face and that the online medium
impacted both positively and negatively on trust (Fletcher-Tomenious &
Vossler, 2009). Three key findings surrounding trust emerged from this study:
 The role of anonymity was thought to act as a positive factor as this

facilitated the speed with which the online relationship progressed;
clients brought issues they may not have been able to bring to face-to-
face, and therapist anonymity was viewed positively as clients felt less
judged but raised concerns over the issue of therapist accountability.
These researchers suggest that therapists might need to start the
therapeutic process with a ‘leap of faith’ if they did not feel fully informed
about the client, and trust their mental picture of a client.
 The second theme was that of trust which impacted both positively and
negatively; clients were thought to have more control of the process than
in face-to-face encounters and consequently the power balance was
perceived to be more equal. The process of typing was deemed to effect
32
the relationship formed as the typist was engaged with their thoughts and
it was generally believed the ability to re-read was beneficial for clients.
The lack of cues in the online context made understanding the client
more difficult but participants also describes alternative ways and
techniques to help establish the relationship (e.g. emoticons).
 Thirdly, participants viewed trust in their online relationships similarly to

their face-to-face relationships.
Psychotherapist, Dr Kate Anthony (2000), explored whether or not a ‘real’

(person-to-person) relationship can be established via online counselling and
suggested that a therapeutic relationship was possible via text-based, medium
led forms of counselling. Six practitioners and one client were interviewed and
asked three main questions regarding the relationship in text based counselling.
Results were qualitatively analysed from what was referred to as the
relationship (person-to-person) point of view which generated six categories
emerging as essential to the online relationship; Rapport (via clients mental
construct), Presence (perception of the session being non-computer mediated),
Openness online (bypassing defences), Quality of written communication,
Fantasy (client & counsellor) and Anonymity (as opportunity), suggesting a ‘real’
therapeutic relationship was possible via text-based, medium led forms of
counselling. Studies that specifically relate to online counselling via email are
rare (Stummer, 2009); however a recent IPA study (Dunn, 2012) used email
interviews with ten clients and six counsellors to explore their experiences of
email therapy. Four areas of focus were presented; the importance of the
structure and processes involved, their impact on thinking and feeling, their
impact on self and relationships, and changes that followed email counselling.
What emerged was the importance of clients and therapists having ‘time to
think’ and of email offering clients choice and control over how to engage. A
further suggestion was that the unique aspects of time and disinhibition in email
therapy might afford clients an opportunity to test out the idea of relationship,
possibly making them more confident about trying this in a face-to-face context.
These studies focus on experiences of participants whereas this study focuses
on the processes involved in email therapy.
33
In summary, research into the therapeutic relationship in online counselling is in

its infancy (Richards & Viganó, 2013) and somewhat complicated by the
differences between synchronous and asynchronous methods which are often
reviewed together, and the difficulties in what aspect of the therapeutic
relationship is being researched (Horvath, 2005; Norcross, 2011). There are
strong arguments that non-verbal communication is an important aspect of
communication and relationship and that therapist presence is important in the
therapeutic relationship. Findings from the field of neuropsychology further
suggest the importance of non-verbal communications, including gaze, in
relationship building and attachment. Research into the quality of therapeutic
relationships in online counselling have tended so far to rely on quantitative self-
reports; findings from these studies suggest that a working alliance is possible,
but this is qualified by clients reports of dissatisfaction with the therapeutic
alliance in online contexts (Hufford et al., 1999), and reports that even though a
stable online therapeutic relationship may be established it is a less reliable
predictor of outcome than in face-to-face contexts (Knaevvelsrud & Maercker,
2006). Mixed methods and qualitative research is rarer but mostly positive;
findings indicate many similarities between face-to-face and online therapeutic
relationships, with a recent study into email counselling indicating positive
factors such as client choice, control and client and time to think before
responding. However what are yet to be considered is email therapists
experiences of the therapeutic relationship and what type of processes might
exist when using this medium.
It has been suggested that the reason that many counselling psychologists do
not foray into the online counselling field is that “online therapy appears to
violate many of the fundamental principles of the therapeutic relationship”
(Hanley & Reynolds Jr., 2009, p5.). Research into the therapeutic relationship
in face to face counselling indicates that this relationship is affected by body
language, therapeutic presence and empathy; to date what is qualitatively
different about these factors in the online counselling field has not been
considered.
34
SUMMARY OF DIFFERENCES BETWEEN FACE-TO-FACE AND EMAIL

COUNSELLING
One key difference between face-to-face and email counselling is the lack of
cues available when counselling online; this has been described as
disorientating and difficult to adapt to; Mallen et al. report (2005a, p800):
It would seem that text based synchronous chat and

asynchronous e-mail would be the most disorientating for
counselling psychologists to adapt to because non-verbal
cues are not present.
Of particular relevance to the current research are the attempts that have been
made by online therapists to address the lack of physical and verbal cues by
developing methods to convey emotional valence visually. One such attempt
has been using emoticons, which is a combination of the words emotion and
icon, often used in image form to describe emotions via text based therapies
(e.g. smiley or sad face) (Wolf, 2000); however this ‘solution’ has been criticised
as potentially unappealing to some generations and open to further
misinterpretation (Derks et al., 2004). Another attempt is the ongoing
development of a technique of text-based counselling trademarked as therp-e-
mail (Murphy & Mitchell, 2009) which advocates several ways to counteract the
lack of cues by incorporating verbal descriptions of emotions in brackets to
convey issues of immediacy (e.g. when I read X I was feeling Y), and other
emotional aspects. Counselling psychologists and co-founders of
www.therapyonline.ca Murphy and Mitchell (1998) suggest that these
techniques may help to provide a richer level of relationship by including
therapist contextual feedback.
Researchers working in the field of neurolinguistic programming suggest that

individuals become 100% connected to the actual words on the page
(Addlington, 2009), and that rapport is developed by entering a client’s mental
constructs via the written word (Anthony, 2000). Cyberpsychologist John Suler,
further suggests that the ambiguity created by a lack of visual and verbal cues
35
can stir up fantasy and enhances the tendency to project expectations, wishes,
and anxieties onto the unknown figure at the other end of the internet exchange
(Suler, 2007). Suler suggests there is a heightened possibility of transference
and therapist countertransference that is often unconscious, and needs to be
accounted for in order to safely work in the medium; although he acknowledges
there are often cues available in the text to aid relationship forming (Suler,
2007). Intertextuality was coined by Kristeva (1986) to explain how meaning is
mediated through ‘codes’ in texts rather than transferring directly from writer to
reader. The link between intertextuality and hypertextuality, or text on the
internet, is made and indeed the world wide web it has been suggested is a
unique realm of reciprocal intertextuality (Mitra, 1999), but this relates more to
communities involved in reading off the web and is not necessarily descriptive
of email counselling.
Relevant to the context is the actual process of writing and reading; recursive
writing is deemed to be the reflective process of reading the words as they are
written, and in this in itself is seen to be efficacious (Murphy & Mitchell, 1998).
Writing has also been explained as useful in externalising difficult issues and
the process of putting thoughts and feelings into words is thought to be healing
in itself (Pennebaker & Chung, 2007), however the possibility of translating
therapeutic writing into online practice, it is suggested, is not yet confirmed by
research (Gray, 1999). A review of the possible advantages in writing for clients
in particular towards the therapeutic relationship, have been suggested as:
Being able to write when in crisis and express feelings immediately (Esterling et
al., 1999), having a high degree of freedom in which to define experience (Collie
et al., 2000), privacy, as shame is an inhibiting factor and the anonymity
afforded may help overcome aspects of this (Lange, 1994), being active by re-
authoring their life story through writing (White & Epson, 1990), producing a
permanent record and boosting successes by re-reading (Adams, 1990). It is
further suggested that asynchronous email therapy can provide both client and
counsellor with an opportunity for greater reflection and clarity in the
communication (Murphy & Mitchell, 1998). Where email therapy is perhaps
different to most styles of expressive writing is that it has a conversational or
turn-taking element, which requires different skills; how this may or may not
36
impact on the therapeutic relationship is an area of interest in the current

research.
In summary, one of the biggest differences between face-to-face and email

counselling it would seem is the socially cueless context of working online; there
are some suggestions that therapists aim to compensate by being inventive
about relaying empathy (e.g. therp-e-mail). Due to the lack of cues inherent with
the medium there is a suggestion email counselling offers a new type of
intersubjective space to work with and this has yet to be explored. Other
contextual issues to be explored are the role of therapeutic writing which could
clearly be facilitated by using the computer but it is perhaps less clear what role
it plays in therapy. These ideas of how email therapy might differ from other
forms of therapy suggest it might represent something unique in the therapy
world.
EMAIL COUNSELLING AND UNCERTAINTY
Working therapeutically comes with a degree of uncertainty, often regarding

ethical dilemmas such as; whether a therapists skills are matched to the client,
and what type of intervention would be useful for a client (Kamhi, 2011; Dryden
1985); it seems important therefore to consider how working asynchronously via
the internet might further impact on therapeutic uncertainty. Smithson (2008)
suggests a psychological view of uncertainty whereby three elements lead to
uncertain feelings; Probability/ randomness which are often treated as having
the same meaning as uncertainty; human judgments are often assessed
according to probability theory. The second construct is delay, and how it
impacts on consequences or outcomes of acts; generally, Smithson suggests,
humans behave as if the consequential magnitude of an outcome is larger if it
happens sooner rather than later; The third uncertainty construct is absence or
lack of clarity in information, which Smithson argues, is sometimes perceived as
ambiguity but can also include different kinds of ignorance, e.g. conscious
(knowing what we do not know), or meta-ignorance (not knowing that we do not
know). To some degree all three of these constructs could be seen to be
present in email therapy. There might conceivably be a perceived degree of
37
probability involved in decision making based on text based communication

which lack social cues and the random nature of when and if a response will
occur. The clear time delay inherent in email counselling may also have an
impact; delay is believed to exert the same kind of influences as uncertainty.
The third uncertainty construct of absence/ lack of clarity can be found in the
absence of social cues in email therapy which may impact the therapeutic
relationship.
Balancing uncertainty and certainty in clinical practice is difficult, according to

Kamhi (2011), and requires an appropriate balance of scepticism and openness
to developing evidence based practice. Practitioners, he suggests, have no
external self-correction mechanism and tend to err on the side of certainty,
staying with what is known to be safe. Evidence based practice, he argues,
does not allow for clinician qualities, such as interpersonal skills and attitudes. It
could be that email counselling is likely to feel even more uncertain due to
factors of delay inherent in the system and lack of clarity in working without
social cues (Smithson, 2008).
CONCLUSION
In conclusion, research into the therapeutic relationship in online counselling in

still in its infancy and there is very little information as yet regarding email
counselling, despite it being reported as the most popular online method
(Richards & Viganó, 2013). Debates in the online field do not seem to be
helping clarify issues for therapists and research in this field sometimes
conflates email counselling with other synchronous methods and does not
specify what aspect of the therapeutic relationship is being considered, making
it difficult to extrapolate and isolate results. The limited amount of research
there is specifically in the email area makes it difficult to draw any conclusions
and there is very little from the therapist’s perspective. It is further suggested
that research into the area is confounded by trying to impose face-to-face
theory onto online methods (Laslow et al.,1999) and that perhaps the future of
online counselling could benefit from research into a new framework for the
mode (Richards & Viganó, 2013). Given that very few counselling
psychologists foray into online counselling and express concerns about aspects
38
of the therapeutic relationship in this medium (Hanley & Reynolds Jr., 2009), it
is hoped that the current research will help to identify the processes involved in
email counselling and the therapeutic relationship.
RESEARCH RATIONALE
The upsurge in online access suggests that the provision of online counselling
will continue to increase, and yet little is known about the therapeutic
relationship within this medium. Whilst email counselling is described as the
most often used online mode it appears to have the least amount of research
dedicated to it, and for these reasons it would seem important to explore how
therapists experience the therapeutic relationship in the email counselling
arena.
A qualitative research method was deemed appropriate as it has the ability to

story tell from the participant’s perspective (Wynn & Money, 2009) and
grounded theory was chosen specifically for its focus on processes and actions
in the data (Charmaz,2006). The relationship between researcher and research
participant in grounded theory is especially significant as it mirrors debates
surrounding therapeutic relationships between therapist and client (McLeod,
2003), and is highly relevant to this study bearing in mind the differing modes of
contact with participants mirrors some of the different modes of contact within
online counselling.
The research is thought to be particularly timely as it is suggested that

therapists and counselling psychologists are being encouraged to work online
(Evans, 2009) but although there is some evidence about its efficacy, the limited
and generic nature of the research base seems to be making some therapists
nervous (Wells et al 2007). This enquiry was stimulated by the researcher’s
experience of working with experienced counsellors who were undertaking
email counselling training, the subsequent realisation that this style of operating
was not popular in the counselling psychology world and the researchers own
decision to train this medium.
39
RESEARCH AIMS
The primary research aim and therefore central research question is to explore
therapists constructions of their experiences of the therapeutic relationship in
email counselling. The secondary aim is to co-construct an explanatory
grounded theory of this process.
40
METHODOLOGY
METHODOLOGY
DESIGN
Traditionally psychological research has positioned itself within the positivist

paradigm which generally utilises experimental testing to produce valid
knowledge (McLeod, 2003); an alternative is offered with qualitative research as
the variety of methods available have the flexibility to adequately explore the
complexity and depth of the human experience (Morrow & Smith, 2000).
Qualitative research has been gaining credence in the counselling psychology
world (Ponterotto, 2001) and it is suggested that counselling psychologists may
be drawn to this method as the inquiry is more congruent with the narrative
perspectives of their therapeutic work (Morrow, 2007). Constructivist grounded
theory is considered appropriate for the current research study as it has an
underlying assumption that social events and processes have an objective
reality and that ultimately the grounded theory studied ‘world’ is a product of
human participation and transaction, creating a dynamic domain. This current
enquiry is a qualitative study using a variety of data collection methods
(responses to an anonymous online survey, semi-structured interviews in
person and via video conferencing, plus email interviews) and a constructivist
grounded theory methodology (Charmaz, 2010).
Rationale for qualitative research
Unlike quantitative research which often deals with the question ‘why’ (Creswell,
2009) qualitative methods are ideal for looking at the ‘how’ or what’ of the
enquiry (Morrow, 2007) and can be very effective in examining
psychotherapeutic processes in depth (Hill, 2005). This is deemed particularly
helpful for this enquiry as the psychotherapeutic process examined is the
therapeutic relationship, which is considered crucial for successful therapy
outcomes (Lambert & Ogles, 2004). One of the strengths qualitative research is
deemed to possess is its ability to story tell from participants’ perspectives,
provide rich detail and put this into a human context (Wynn & Money, 2009).
Qualitative research evolved from a post-positivist ontology that reality is

thought to exist but can only be known imperfectly through the researcher’s
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METHODOLOGY
human limitations, a position referred to as ‘critical realism’ (Maxwell, 2012). It is

suggested that researchers discover ‘reality’ within a certain realm of probability
and cannot ‘prove’ a theory but can make a stronger case by eliminating
alternative explanations (Mertens, 2009). As opposed to post positivist objective
reality qualitative researchers believe in a relativist ontology that there are as
many realities as there are participants, plus the researcher (Morrow, 2007),
and that meanings are often co-constructions of participants and researcher.
The primary aim of qualitative research is to develop an understanding of how
the world is constructed (McLeod, 2001), and can be utilised to adequately
explore the depth and complexity of the human experience (Gelso, 1979).
There have been many attempts at an overall description of qualitative research

and a simple, functional description is offered by Nkwi et al. (2001) who state
that qualitative research involves ‘any research that uses data that do not
indicate ordinal values’. More precisely, qualitative research is summarised as
being;
1. Grounded in a broadly ‘interpretivist’ philosophical position in the sense

that it is concerned with how the social world is interpreted, understood,
experienced, produced or constituted.
2. Based on data generation methods, which are both flexible and sensitive
to the social context they are produced within.
3. Based on methods of analysis, explanation and argument building
involving understanding of detail, complexity and context. It aims to
produce rounded, contextual understandings on the basis of rich,
detailed and nuanced data.
4. Concerned to emphasise ‘holistic’ forms of analysis explanation in this
sense, than on charting trends, surface patterns and correlations.
(Mason, 2002)
The general paradigm in qualitative research is interpretivism which assumes

that researchers’ values exist and are embraced (Guba & Lincoln, 1994).
Phenomenology can be considered a subset of interpretivism-constructivism
and is a design often utilised by counselling psychologists (Wertz, 2005).
Qualitative researchers are interested in understanding the meanings that
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METHODOLOGY
individuals construct, as well as how people make sense of their world and the
experiences they have in the world (Merriam, 2009). This involves delving into
complex processes and illustrating the multi-faceted nature of human
phenomena (Morrow, 2007).
Whatever qualitative research may be it is has grown out of a wide range of

intellectual and disciplinary traditions and is strongly felt it is certainly not a
unified set of philosophies or techniques (Mason, 2002).It is worth noting that
there are various qualitative research methodologies under the umbrella
heading and description, each one of them taking on a different facet of the
research task (Mcleod, 2001). This often leads to debates as to which method is
best or appropriate within the qualitative research field (Denzin & Lincoln,
2011).
Grounded theory
Grounded theory was conceived in the 1960’s by sociologists Glaser and

Strauss (1967) as an alternative to reductionist research methods and was
considered revolutionary in its time (Urquhart, 2013). It is currently considered
the ‘market leader’ in qualitative research (McLeod, 2001) and can be described
as the systematic generation of theory from systematic research (Glaser &
Strauss, 1967). It does not begin with a hypothesis, rather being a method of
qualitative research that focuses on creating conceptual frameworks or theories
through building inductive analysis from the data (Charmaz, 2006). Hence the
description ‘grounded’, as this is where the analytic categories in the data
emerge from (McLeod, 2003). The goal of a grounded theory approach is to
generate a theory explaining how an aspect of the social world works (Creswell,
2009).
A divergence in opinions occurred in later years between Glaser and Strauss

(Dey, 1999) causing two distinctive schools of grounded theory to emerge,
Objectivist and constructivist. Objectivist grounded theory has positivist origins
and constructivist is part of the interpretive movement.
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METHODOLOGY
Objectivist grounded theory
The objectivist grounded theory approach assumes an objective stance

whereby the researcher is deemed to be passive in the process (Onions, 2006);
the data already exists in the world and is found by the researcher who then
discovers the theory (Glaser & Strauss, 1967). The discovery of categories was
thought to be inherent in the data and observed in the external world by a
neutral observer (Charmaz, 2000) who held no preconceived ideas (Glaser &
Strauss, 1967). This rather implies minimal impact by the researcher on any
emerging theory and disciplined restraint applied (Jones & Alony, 2011) to
minimise ‘researcher bias’, of which Glaser (2002) strongly disapproved.
However Charmaz (2006) suggests that the neutrality claimed actually assumes
a value position.
Epistemology
Epistemology can be defined as the theory of knowledge and what justifies/

evaluates knowledge gleaned from research (Carter & Little, 2007). In this
respect it is important to position oneself epistemologically, as differing
qualitative research methods have varied paradigms, which are crucial in
underpinning the style of research, and therefore require specifying.
Symbolic Interactionism
Grounded theory has been described as ‘fully compatible’ (Charmaz, 2010) with
symbolic interactionism (Glaser & Strauss, 1965, 1967). Blumer (1969)
described the three basic premises of symbolic interactionism as: Humans
acting toward things on the basis of the meanings they ascribe to them; the
meaning of such things is derived from, or arises out of, the social interaction
one has with others and society and these meanings are handled with, and
modified through, an interpretive process used by the person in dealing with the
things encountered. This perspective focuses on dynamic relationships between
meaning and actions as well as addressing the active processes that people
create and mediate meaning through (Charmaz, 2010). A further assumption
describes society as a linguistic or symbolic construct which arises out of the
social process, and which consists of individuals interacting (Herman &
44
METHODOLOGY
Reynolds, 1994). Symbolic interactionism has been said to require an analytic

vehicle such as grounded theory to realise its potential (Pascale, 2011).
Social constructionism and constructivist grounded theory
Within the interpretive tradition it is argued that the objectivist stance is no

longer tenable (Denzin & Lincoln, 2011) and Charmaz (2006) offers
constructivist grounded theory as an emergent process that occurs through
interaction. Constructivism thus challenges the belief that there is an objective
truth that can be measured or captured through research enquiry (Crotty 1998).
Charmaz (2006) claims the terms social constructionism and constructivism

have become interchangeable in contemporary literature, especially in relation
to grounded theory, but others argue differently. Social psychologist Jonathon
Raskin (2002) suggests that although constructivist and constructionist versions
of psychology can be viewed as similar through their focus on the process of
meaning making, they can also be viewed as competing orientations.
Historically constructivism has focused on the internal, cognitive process of
individuals, whereas social constructionism focuses on the social activities or
discourse that transpire between people (Raskin & Bridges, 2004). McNamee
(2004) proposes that both constructionism and constructivism have common
threads in meaning making, and operate through a relational interaction. It
would seem useful at this stage to outline my epistemological position: as a
counseling psychologist I am interested in what goes on in the individual mind
and in personal meaning making and cognitive processes; in this is sense I am
constructivist. However, I position myself as a social constructionist in that I
believe that realities and meanings are co-constructed in the social world; my
interest is in the relational and the social, rather than purely in the intrapsychic
and the individual. This position is synchronous with counselling psychology
values i.e. the focus on subjectivity, intersubjectivity and on the importance of
social context (BPS, 2005). As an epistemological stance constructivism asserts
that individuals construct reality as they assign meaning to the world around
them (Appleton & King 2002). From a constructivism perspective, meaning does
not lie dormant within objects waiting to be discovered, but rather is created as
individuals interact with and interpret these objects (Crotty 1998).
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METHODOLOGY
Constructivist grounded theory is viewed as a set of principles and practices,

rather than methodological rules, recipes, and requirements (Charmaz, 2006).
Charmaz’s model has a constructivism paradigm with the underlying
assumptions of this method being: that social events and processes have an
objective reality in that they can be observed and documented because they
take place irrespective of the researcher – this suggests a realist ontology; it
also assumes that social realities are negotiated by human players and that
participants’ interpretations of events shape their consequence (Willig, 2001).
Ultimately the grounded theory studied ‘world’ is a product of human
participation and transaction, which creates a dynamic domain. Grounded
theory attempts to be sensitive to these dynamic properties by focussing on
‘processes and actions’.
In order to adhere to a constructivist grounded theory method it is important to

highlight the role, and epistemological position, of the researcher as it is
recognized and accepted that no two researchers’ data analysis will produce
the same theory (Glaser & Strauss, 1967; Rennie, 1994). This is congruous with
the qualitative research epistemology in general where there is an assumption
that there is no correct version of reality, and where there is a prizing of each
individual involved in the researcher’s unique perspective, enriching the
understanding of the explored phenomena. Credibility of the grounded theory
research therefore relies on; a) accurate and complete data, b) interpretations
that capture participants’ meanings as well as minimising researcher bias, c)
emerging categories fitting with the phenomena under study, d) the theory being
transferable (making sense to the reader and able to be applied to different
people/settings) (Miles & Huberman, 1994), as well as consistent application of
grounded theory methods and documentation of the steps (Dey, 1993).
Charmaz (2010) encourages researchers to embrace the interpretive tradition
by theorizing on both overt processes and implicit meanings. With the
researcher’s view and influence being recognized and prized in this way a
visible reflexive stance is important for credibility of the work.
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METHODOLOGY
Rationale for grounded theory
A qualitative research method was deemed most fitting at an early stage, due to
the explorative and experiential nature of the enquiry. Owing to the plethora of
different types and underlying philosophies in qualitative research methods very
careful consideration needs to be applied in choosing which one is the most
appropriate fit, at the earliest opportunity (Willig, 2013). The current research
enquiry focuses on actions and processes (Glaser, 2002) making it better suited
to grounded theory than other methods.
This constructivist approach aligns with the researchers’ beliefs and the current
enquiry, most notably for the following reasons: It adopts a relativist position in
recognising there are multiple realities in the world; with individuals having more
than one main concern; Charmaz’s approach involves the researcher co-
constructing the data with the participant bringing with that the recognition of the
subjectivity that influences their lives; the approach has the flexibility to
adequately allow for the idiosyncrasies of this type of research; it is particularly
useful in advocating the importance of the storytelling or narrative perspective of
therapeutic work (Morrow, 2007), and helps yield rich data. What is particularly
relevant for the current study is that it allows for deep exploration of implicit
meanings and experiences derived from participants’ stories, which are told via
different mediums.
Grounded theory values the language of informants and aims to interpret this
through the voice of the researcher and the voice of the participant (McLeod,
2001). The relationship between researcher and research participant is
especially significant as it mirrors debates surrounding therapeutic relationships
between therapist and client, as most therapy researchers are also practitioners
(McLeod, 2003). Stern (1995) postulated that the strongest case for using
grounded theory is in investigations of relatively unchartered water which is one
of the reasons it has been chosen for this research study as there are very few
studies solely focussing on email style counselling specifically as an
asynchronous method. On a pragmatic level grounded theory offers a clear
practical process for analysis (Charmaz, 2010). Like many other methodologies
47
METHODOLOGY
grounded theory has its limitations, which will be discussed further in the
discussion section
DATA COLLECTION
The aim of this research was to explore how therapists (with practice
experience of face-to-face and email therapy) experienced the therapeutic
relationship. In order to achieve this it was important to find a data collection
method that would reflect what was being explored and enable the narrative of
the participants be heard as well as illuminating researcher and participant
interaction. It was hoped that this would then produce a thick description of both
meaning and experience for analysis. In order to reflect the nature of what was
being explored it was decided to start data collection via an anonymous online
survey with several open-ended questions and to offer follow up face-to-face or
Skype webmail semi-structured interviews with an option for further interview
via email. Four main open-ended questions were developed in line with
Charmaz’s guidelines (2010) in order to allow for participants relatively
unsolicited responses via the online survey. Further semi-structured interviews
using open-ended questioning allowed for more detailed explanations to be
elicited as required (Charmaz, 2010).
The anonymous online survey
It was considered that using an anonymous online survey might afford

participants a safer arena in which to share their responses than that provided
by face-to-face interactions. In addition it is considered that social desirability
pressures on participants to produce only positive responses are reduced in
anonymous data collection methods (Braun & Clarke, 2012). This in turn can
provide an opportunity to gather data from larger groups of participants (Braun
& Clarke, 2012). The online survey method mirrored the online phenomena
being researched and was seen as a good fit with the research aims.
Disadvantages with anonymous surveys can be in possible abuse by users as

well as varying quality/quantity of reply. There is also an argument that the self-
selection bias makes it difficult to relate findings to the general population
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METHODOLOGY
(Wright, 2005) but this was not considered relevant as generalisability was not
the aim of this study. More obvious advantages are in the minimal cost, time to
set up the survey and ability to access the population targeted. Research
indicates that online surveys are equal or better than traditional mail based
methods in the number of participants (Thompson et al., 2003) and that there
can be a relatively fast reply (Mehta & Suvadas, 1995).
The survey was set up online using the University of the West of England
psychology department licensed software site ‘Qualtrics’, as this complies with
confidentiality and security policies as well as being in line with British
Psychological Society’s guidelines in the area (BPS, 2007). An invitation was
issued via the survey for participants to become further involved via semi-
structured interviews in person, via webcam or email. This allowed for
participant preference (Cooper & McLeod, 2011) and different opportunities to
become involved in the data, in the hope that what was presented would be a
rich and unique view on the subject area
The open-ended questions designed for the survey were:
1. How do you experience the therapeutic relationship in e-mail style

counselling?
2. Can you tell me something about differences, if any, you experience

between face-to-face and e-mail counselling work?
3. Can you tell me something about similarities, if any, you experience

between face-to-face and e-mail counselling work?
4. How do you experience the computer, if at all, in the therapeutic

relationship?
5. Is there anything else you would like to add about your experience of
taking part in this survey via an online medium?
In accordance with the grounded theory method as the analysis developed

further a theoretical sampling strategy was adopted in order to refine emerging
categories. Following the line of enquiry from the first survey, a second
anonymous online survey was launched aimed at those new to email
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METHODOLOGY
counselling as it was thought that their experiences would enable further theory
development by means of the constant comparison method. The following
open-end questions were asked:
1. How do you experience the computer, if at all, in the therapeutic

relationship?
2. How do you experience the therapeutic relationship in email counselling?
3. Can you tell me something about the differences or similarities, if any,

you experience between face to face and email counselling work?
4. How do you feel about safety when working online as compared to face
to face?
5. How do you experience the relative anonymity of online counselling?
6. Is there anything else you would like to add?
In order to expand on and provide richer data for comparison it was decided, at
the outset, to offer follow up interviews to participants. Participants who
expressed an interest in being interviewed following the survey were offered the
opportunity to take part via email, Skype webcam or face-to-face, according to
preference. Questions were along the lines of those in the surveys and also
followed up lines of enquiry that had arisen from the data. Further interviewing
afforded the researcher and participants a different experience of getting
involved with the research, and subscribed to the ‘all is data’ premise (Glaser,
2002). Glaser describes the premise (Glaser, 2002. p.145):
It means exactly what is going on in the research scene is the

data, whatever the source, whether interview, observations,
documents, in whatever combination. It is not only what is
being told, how it is being told and the conditions of its being
told, but also all the data surrounding what is being told. It
means what is going on must be figured out exactly what it is
to be used for, that is conceptualization, not for accurate
description. Data is always as good as far as it goes, and
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METHODOLOGY
there is always more data to keep correcting the categories

with more relevant properties.
The Skype interview
The Skype interview is gaining in popularity as a flexible, synchronous research

method, which provides geographical convenience and a neutral location for
participants (Hanna, 2012). As well as these practical advantages it is thought
to be ethically equivocal to face-to-face interviewing through the capacity to
follow facial cues, and the ability to obtain informed consent (Janghorban et al.,
2014).
Certain considerations to be made before embarking on research via

technological online methods (Hanley, 2011) and whilst the researcher had a
degree of competence in all methodologies utilised, the reality is that
interviewing online came with a different set of issues such as; feeling
competent in computer mediated communication and negotiating technical
issues/ breakdown, which could possibly influence data collection.
The research interview
The semi-structured interview is deemed to have flexibility as opposed to a

structured interview, which can be viewed as unnatural and restrictive and can
impose the researcher’s frame on the researched. An advantage of this type of
intensive interviewing to the grounded theory process is the immediacy involved
in following up analytic lines of enquiry but in order to conduct this well an
interviewer needs to have skills in this type of interviewing (Kvale, 1996).
Successful interviewing is thought to be self-reflective and requires sensitisation
to personal biases (Rubin & Rubin, 2005). It seemed important to consider the
fact that several of the interviews were conducted by Skype webmail which
whilst being a synchronous method was likely to have some differences to
being in physically in the room (Hanley, 2011), although it afforded the
participant and the researcher an opportunity to experience a synchronous
online method of relating.
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PARTICIPANTS
Sampling considerations
A purposeful (targeting possible participants) sampling strategy was developed

for the anonymous online survey. This first purposeful sample was composed of
nineteen accredited face-to-face therapists who were also conducting email
therapy. Four participants from the purposeful sampling cohort were further
interviewed (one face-to-face, three by Skype), and three follow up interviews
were conducted (one by Skype interview, two by email). Theoretical sampling is
a qualitative research strategy that involves seeking pertinent data to elaborate
on and refine developing theory or concepts, using the constant comparison
method (Charmaz, 2006). This strategy drew two responses from accredited
face-to-face therapists who were new to email counselling and who completed
the survey and four accredited face-to-face therapists who were not conducting
email therapy, two of whom were interviewed face to face and two by email.
The rationale for recruiting new to email therapists and non-email therapists
was to provide a comparison of experiences in order to refine/develop the
categories. Overall twenty-five participants were recruited generating twenty-
one survey responses, three face-to-face interviews, three Skype interviews
and two email interviews.
Inclusion criteria
Inclusion criteria for the first purposeful sample were: being an accredited
therapist, and having experience of working with clients in both face-to-face and
email therapy. The first theoretical sample criteria asked for accredited
therapists new to email therapy. The second theoretical sample inclusion
criteria asked for accredited therapists who did not have experience of working
with clients via email therapy. There were no explicit exclusion criteria.
Participant information
There were some gaps in demographic information where online survey

participants chose not to give full details. Of the data available; twenty four
participants identified as white Caucasian, two identified as male and twenty
three female, the age range was between thirty two and eighty one, the range of
52
METHODOLOGY
experience in face-to-face counselling was between two and thirty two years,
the range of experience in email counselling (excluding non-practising email
therapists) was under one to eleven years. Qualification and theoretical
orientation demographic information has been shortened to ensure anonymity
of participants (Appendix A).
PROCEDURE
Ethical considerations
It is possible that asking therapists to reflect on their clinical practice and

experiences of the therapeutic relationship might elicit some difficult feelings,
especially regarding relational issues and practitioner competence (Kamhi,
2011). It was thought possible that this type of enquiry could bring into
consciousness what may have been out of awareness. With this in mind each
participant was shown or given a debrief sheet after finishing the survey/
interview with helpful information on how to access support, should they suffer
any distress (Appendix, B). Contact information for the research team was also
provided in case participants wished to discuss anything arising from taking
part.
Ethical approval
Full ethical approval was granted by the University of the West of England’s
research committee (Ethical approval certificate at Appendix C).
Informed consent process
After following an online link to the anonymous survey participants were taken
to an information page (Appendix D), which outlined what was involved with the
research; participants were not able to move on to the survey unless they
agreed with the conditions of consent by clicking on the agreement button. The
research complied with British Psychological Society research guidelines (BPS,
2007) and there was no deception involved. Interview participants were asked
to view the information sheet either via email or in person prior to interview,
given space to ask any questions and only interviewed after the consent form
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METHODOLOGY
(Appendix E) was signed. Demographic information was asked for with all
participants on a voluntary basis.
Right to withdraw
It was made explicit to participants that they had a right to withdraw from the
research project at any time without giving a reason and this was both clearly
stated in the information given and reiterated by the researcher prior to
interview. In order to facilitate data withdrawal in the anonymous survey and
other methods participants were asked to provide a self-identifying code.
Confidentiality
Participants were asked to provide a self-identifying code in order to facilitate

the withdrawal of data should this have been required. In addition to this
participants were asked if they may be contacted for further interview via e-mail
exchange or in person.
Recruitment
Participants for the online survey were invited to take part via an online link
which was advertised widely through the following professional networks and
bodies: The Division of Counselling Psychology (DCoP) newsletter, DCoP
Facebook page, The BACP research section, Online Therapy Institute (OTI)
Linkedin group, OTI Facebook page, OTI developers’ twitter account.
Participants who advertised as email therapists and who published their email
addresses (either via organisations such as BACP, ACTO or a search engine
enquiry) were invited to take part in the research by email. The second survey
advertising for new to email therapists further advertised through the Online
Counselling Services and Training (OCST) and Online Training for Counsellors
Ltd (OLT). Participants had an option at the end of the surveys to leave an
email address through which they were contacted to arrange further interview.
Initial contact for participants taking part in the theoretical sampling stage was
by email. All interview participants had access to the information sheet, had
time to ask questions prior to the interview and fully consented to take part.
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METHODOLOGY
Interview process
Interviews took place at the participants’ convenience either at their home or via
Skype webmail. Interviews lasted approximately 60 minutes and were audio
recorded either by recording machine or computer software.
Email interview process
Email interview questions were sent and returned via email, at the participants’
convenience.
Transcription
Grounded theory calls for employment of a more denaturalised style of

transcribing (Charmaz, 2000), which suggests accuracy concerns the substance
of the interview shared during conversation. As with the naturalized method a
denaturalized approach to transcription also attempts a verbatim depiction of
speech but has less to do with depicting involuntary vocalization or accents and
more to do with co-creations of meaning and perceptions (Oliver et.al, 2005).
Denaturalised styles of transcription also work to avoid a priori assumptions,
which are a criticism of naturalised transcription (Schegloff, 1997). Reflection in
transcribing posits that it positions the author in relation to the field (Haggerty,
2003) which fits with grounded theory methodology and Counselling Psychology
traditions of being mindful of the context.
Each interview was transcribed line by line following a denaturalised style and
attempting to stay close to the substance of the interview. A short transcription
key is provided in the appendices (Appendix L). Data was either already on
software on the computer or transferred on to it and data security and
confidentiality guidelines were upheld by password protection and deleting the
original recording after data transferral from the recording technology.
Data protection
Any identifying information was removed at the point of transcription. Identifiable

information was kept securely on a password-protected computer or secure
filing cabinet. Only anonymised information was shared with the research team
or utilised in the written document.
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Data Analysis
Charmaz (2006) argues that it is possible to use the basic grounded theory
method with contemporary methodological assumptions and approaches.
Charmaz (2006) identifies a number of steps within the method to be utilized in
constructing grounded theory. Data collection takes place concurrently with
analysis. Interviews are fully transcribed and data analysed line by line.
Coding constitutes the most basic and the most fundamental process in
grounded theory (Willig, 2001). The initial coding process requires the
researcher to ask questions of the data such as ‘what is being suggested’ and
‘from whose point of view?’ (Charmaz, 2006). Initial coding sticks closely to the
data and looks for the actions indicated rather than applying any pre-existing
ideas; researchers are seen as active in the coding process, which is an
interactive process (Charmaz, 2010). The initial coding stage allowed for
generation of a large number of meanings and conceptualisations of the
material (McLeod, 2003).
Coding using the gerund is thought to help discover processes and aids staying
close to the data by focusing on actions (Glaser, 1978). The gerund is the form
of the verb that functions as a noun and Charmaz (2010) following Glaser
(1978) advocates the use of the gerund as it aids building actions into the data
which enables the identification of processes.
The next analytic stage is focused coding; focused codes are more selective,
directed and conceptual than line-by-line coding (Glaser, 1978) and are utilised
to synthesise and explain larger sections of data (Charmaz, 2010). Charmaz
considers that when the researcher starts thinking analytically about the data in
the focused coding stage they are beginning to use it rather than just relate it to
an audience. The coding process is not a discrete stage as it is in some
research methodologies but rather a continuous aspect of the grounded theory
method.
Using constant comparison methods categories started emerging from the data
and at this stage relationships between concepts were examined to see
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METHODOLOGY
whether they belonged to one category or required separating into others

(McLeod, 2003). Constant comparative methods continued to be utilised
throughout the analytic process, which involves comparing newer data with
previously collected data to generate further theoretical ideas.
Developing ‘theoretical sensitivity’ (Glaser, 2004) as a researcher is crucial in

order to allow generation of concepts and being able to relate them to general
models of theory. Charmaz (2010) suggests theorising means stopping
pondering, and rethinking anew, and that because theorising guides your
direction you may not be able to see the endpoint. To gain theoretical sensitivity
it is suggested researchers look at life studies from multiple vantage points,
make comparisons, follow leads, and build on ideas (Charmaz, 2010).
Tentative hypotheses can begin to emerge at this stage of the analysis about
what appears to be important (McLeod, 2003). It became apparent that
therapists who participated in the research appeared to be attempting to
manage the heightened anxiety of working by email in several ways;
‘Intellectualising’, ‘Avoidance’, ‘Overcompensating’ and ‘Defending the
professional self’. These hypotheses were tentatively examined for how they
emerged and had progressed.
Memo writing is seen as crucial to the process as it prompts the researcher to

stop and analyse any and every idea that occurs to them in the moment
(Charmaz, 2010). It is the link between data collection and writing up.
Throughout the whole process of data collection, note taking and coding memo
writing took place to help to show transparency in how hypotheses, categories
and potential relationships between these concepts progressed.
Theoretical sampling was adopted after categories started to emerge and four
accredited face to face therapists who were not practicing by email were
recruited and interviewed; two face to face and two by email. As categories
started to be constructed a process of selective coding was utilised, which
refers to the process of selecting the main category, and then selectively coding
only the data that relates to the core category.
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METHODOLOGY
The next step is when theoretical saturation of categories is reached, which is

described by Charmaz (2010 p113) as the moment when ‘fresh data does not
spark any new theoretical insights or reveal any new properties on the core
theoretical categories’. It has been also been labelled theoretical sufficiency
(Dey, 1999) denoting the fact that it does not mean the exhaustion of data
sources but development of a category. The data collection stopped at this point
and sorting of memoing materials began. Memos that had been created
throughout the analytic process were collected, reviewed, then integrated into a
core category and related categories and their properties.
The grounded theorist’s aim is to identify a core category that brings all the data
together and builds up a descriptive narrative about the central phenomena
(McLeod, 2003). A core category is deemed to have analytic power in that it
pulls the other categories together forming an explanatory whole. Further
analytic efforts are based on these categorical findings and the core category
may potentially be a number of theoretical codes including; a consequence,
condition or process (Glaser, 2004).
Diagramming can be viewed as advantageous in grounded theory as it allows a

visual representation in order to tease out categories and relationships to help
with sorting and integration (Charmaz, 2010). Diagramming is a useful tool in
assisting the researcher to formulate ideas, refine conceptualisations in the
process of theory building and in communicating ideas to others. From this, an
initial theoretical outline was developed from generation of the emergent
grounded theory through an integrated set of hypotheses (Glaser, 2004).
There are continuing debates in the grounded theory world regarding early
literature review (Dunne, 2011) and generally researchers conducting research
such as this are discouraged from doing so prior to data collection (McLeod,
2003). However an alternate view is that early review of the literature can be
helpful in identifying gaps in understanding and identify under researched areas
(McGhee et al., 2007). Along with constructivist ideology is the notion that
researchers bring with them prior learning, assumptions and biases and this is
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METHODOLOGY
acknowledged (Cutcliffe, 2000). Doctoral research of this nature requires

identifying paucity in a research area and is thought to be essential for
academic honesty as well as showing how the study contributes to and builds
on existing knowledge in the area (Stern, 2004). A middle ground is suggested
by utilising high reflexivity for transparency and to ameliorate the possible
ingoing effects (Heath, 2006). A general literature review was conducted with a
respectful yet critical view and an understanding that any relevant extant
literature would have to earn its way into the research narrative (Charmaz,
2006). Relevant literature was only integrated after categories were
constructed. The literature review was drafted as a useful tool in order to draw
comparisons and aid analysis for the developing grounded theory. The intention
was to weave existing theory into the analysis in order to clarify where the ideas
align with or extend relevant literatures, and begin further discussion (Charmaz,
2010).
The sorting was rendered into a first draft of the research project write up.
Refinement of the completed sort translated into the final grounded theory
research project write up.
Methods to ensure rigour
Rigour is often related to ideas of reliability and validity across research

modes (Seale & Silverman, 1997) and is crucial to the idea of producing
credible qualitative research. Recognising quality in grounded theory studies
is sometimes seen as being down to rigorously following the guidelines (as
listed in this study) and whilst there is no ‘best’ practice consensus (Elliot &
Lazenbatt, 2004), Chiovitti & Piran (2003) suggest criteria for trustworthiness
in grounded theory research as credibility, auditability and fittingness, as
follows:
 Ensuring credibility involves allowing participants to guide the process

of inquiry which in this case utilised open-ended questions via an
anonymous survey, other methods of interviewing, using participants
own words and checking theoretical constructions generated against
participants own words. Also articulating the researchers’ personal
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METHODOLOGY
insights and views of the phenomenon explored by utilising field notes,

a reflexive journal and monitoring how the literature was used.
 Auditability involves specifying how and why participants were selected

and being clear about the criteria built into the researchers thinking.
 Fittingness can be achieved by outlining the scope of the research in

terms of the sample setting and level of theory generated, whilst also
describing how the literature relates to each category (Chiovitti & Piran,
2003). In this current study trustworthiness was ensured by following
these guidelines for rigour.
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REFLEXIVITY
REFLEXIVITY
Reflexivity as a researcher is constrained by the capacity to acknowledge one’s

own experiences and contexts as well as their fluid/changing nature
(Etherington, 2004). It is argued this goes further than self-reflection and
acknowledges a moral dimension as well as inviting consideration of the
process co-constructed through the text (McLeod, 2003). It is noted that in
qualitative designs the researcher plays an important role in the research
(Charmaz, 2010); addressing the issue of reflexivity enables the researcher to
reflect upon possible biases and assumptions (McLeod, 2001).
There has been debate regarding the place of reflexivity in grounded theory
research (McLeod, 2003) and an argument that reflexivity and relationality,
attending to the power and trust in researcher-participant interactions, should be
incorporated into the methodology to ensure rigour (Hall & Callery, 2001). Many
researchers work in their field of study and reflexivity has been positioned as
important to prevent prior knowledge distorting the researcher’s perception of
the data (McGhee et al., 2007). Social constructivist grounded theory
researchers encourage open scrutiny of the research journey, to enable the
reader to assess how and to what extent the researcher has influenced the
enquiry (Charmaz, 2006), this places the reflexive stance as pivotal to the
credibility of the research. The role of the reflexive researcher is clearly
important as it recognises and accounts for the fact that the researcher will be
bringing their own interpretations of meanings and experiences (McLeod 2001).
Whilst it is suggested that reflexivity holds a firm place in the qualitative
research agenda it is also recognised that it can feel like a perilous journey, full
of intersubjective reflection (Finlay, 2002). Critics believe that attending to the
dynamics of the research method can disguise relevant meaning by sometimes
overriding participant accounts (Potter & Wetherell, 1995), but as a necessary
evil this researcher would agree with the idea of transforming subjectivity from
problem to opportunity (Finlay, 2002).
My interest in this research area started early in the training process; my

position at the time was as a counselling psychologist in training who was quite
61
REFLEXIVITY
new to the counselling field as a whole. When encountering experienced

counselling colleagues in a work setting who were embarking on an email
counselling training I became fascinated by the dilemmas and concerns
expressed. I subsequently noticed that despite its wide use there was no input
regarding online counselling on my counselling psychology course and in order
to undertake the research and understand the area more fully I took further
training and obtained a certificate in online counselling skills. However, despite
being qualified to work in the online counselling area I made a decision to
suspend this until completion of my doctorate in order to maintain as central a
position as possible.
It has been suggested that it is important to identify the researcher’s relationship

with the area of enquiry; this has been described in three ways; Outsider – no
relationship with area, Hybrid – part relationship, Insider – working in the same
area (McGhee et al., 2007). In this respect my relationship with the research
area could be positioned as hybrid in that I have a qualification in online
counselling but no experience of operating independently as an email therapist,
and it was important to bear this in mind during the research process. However,
it has further been suggested that relationships with research are complex, and
not usually just insider or outsider in nature (Hayfield & Huxley, 2014), and in
this respect it could be that I hold different positions by nature of being a trainee
counselling psychologist who has trained in online counselling.
A reflexive journal is a tool that allows the reader to assess the researchers
positioning, assumptions and interests on the inquiry (Charmaz, 2010). A
journal was kept throughout my research journey from beginnings to final write
up in order to show transparency by documenting the decisions and
interpretation I made that shaped the research and which were influential in
constructing my grounded theory. Despite having a foot in both camps it would
be fair to say at times it has been difficult to maintain the middle ground as
although being trained in online methods was very useful in one respect it also
tipped me into a ‘knowing’ position in relation to the subject area, and some
participants overtly asked my position in relation to the subject. Despite this I
made sure that participants were not aware of my position prior to interview in
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REFLEXIVITY
an attempt not to unduly influence the process, and in addition to field notes
after each interview I noted the struggle and difficulties involved within my
reflexive journal. That said I am also mindful that there may be unconscious
influences at play and that the researcher plays such a pivotal role in the
creation of codes there is the potential to miss relevant information in favour of
their own bias. This is also where supervision was useful in bringing things into
awareness and having another view.
During the research process I felt that my position as a trainee counselling

psychologist with no experience of email counselling quite strongly and at times
noted feeling disempowered, deskilled and treated with suspicion. I immersed
myself in the field to gain a better insight into the area, access practitioners’
views and to listen to discourses in the profession by attending the OCTIA
(online counselling) conference, joining ACTO and following debates in the
area. I acknowledge that whilst this helped my understanding of the subject
area it may at times have added to the deskilled conscious/ incompetence
feeling and it took great reflexive efforts to keep operating in the perceived
middle ground.
Although I have conducted qualitative research previously I found adhering to

the grounded theory process both nerve-wracking and thought provoking at
times but fought to maintain integrity in order to produce a credible piece of
research. Mcleod & Balamoutsous (1996) note the influence of unconscious
processes in choosing a qualitative research method which I find heartening as
a trainee counselling psychologist interested in human processes, as it
indicates that trusting my instincts led me to find an appropriate match of
research to researcher. Ultimately the grounded theory studied ‘world’ is a
product of human participation and transaction, which creates a dynamic
domain, and it is recognized and accepted that no two researcher’s data
analysis will produce precisely the same theory (Glaser & Strauss, 1967;
Rennie, 1994). This is congruous with qualitative research epistemology in
general where there is an assumption that there is no correct version of reality
and a prizing of each individual involved in the researcher’s unique perspective,
enriching the understanding of the explored phenomena.
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REFLEXIVITY
I believe that being drawn to a research subject might indicate researcher bias
or assumptions and although I was mindful of this in the process, there is a
possibility this may have influenced the research. Deciding to further train in
online therapy techniques was in part to fill the knowledge gap missing from my
own training, and to help in being respectful to participants who might expect a
level of knowledge from a researcher in their area; However, the training may
have put me in a position of ‘knowing’ that could have acted as a bias, albeit
ameliorated by deciding to hold off experiencing working as an online therapist.
Also, I had naively assumed that recruiting email therapists through an
anonymous survey would result in more responses than actually occurred and
had not anticipated the defensive behaviour I occasionally encountered.
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RESULTS
RESULTS
This section presents a grounded theory developed from the analysis of

interview and survey data using Charmaz’s grounded theory methodology
(Charmaz, 2006). The purpose of the research was to explore therapists’
experiences of the therapeutic relationship in email counselling and to formulate
a grounded theory of this process. The basic social psychological process
constructed highlights how participants experience the process of conducting
therapy via email and the therapeutic relationship in this medium.
Participants described how Experiencing cuelessness i.e. the absence of

sensory cues led to an experience of Losing touch in four ways; Loss of
interactive factors with the client, Responding with no sensory steer, Losing
control of the process and Losing control of the context to the client. This led to
a sense of Peering through the looking glass when counselling online;
counsellors felt as though they were Fantasising into a void, and Fearing [client]
disappearing. Participants also described Worrying about risk and expressed
Worrying about Client safety and Fearing exposure due to having a written
record and any possible legal or professional ramifications. Further
uncertainties were also revealed as participants were led to Questioning
Consequently participants were left Experiencing anxiety. This anxiety

appeared to be managed in a number of ways; participants described Becoming
more task orientated (Relying on skills and theory and Taking control of the
context), Avoiding difficulties (Minimising the role of the computer and
Minimising differences between modalities/ Holding on tight to the known),
Overcompensating (Reflecting and perfecting), and Defending the professional
self-concept (Protecting by defending expertise and Becoming an expert). The
key struggle and therefore core category would seem to lie in participants
attempting to apply relational face-to-face skills to the cueless atmosphere of
email therapy, the anxiety of which materialised in several avoidant behaviours.
The process identified here is illustrated in, figure 1:
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RESULTS
Figure 1: Email counselling and the therapeutic relationship: A grounded theory analysis of therapists’ experiences
Experiencing cuelessness
Losing touch
 Loss of interactive factors

 Responding with no sensory steer
 Losing control of the process
 Losing control of the context, to the client

Becoming uncertain Peering through the looking glass Worrying about risk
 Questioning computer reliability  Fantasising into the void  Worrying about client safety
 Questioning own competence  Fearing disappearing  Fearing exposure
EXPERIENCING ANXIETY
DEFENDING THE
BECOMING MORE TASK PROFESSIONAL SELF
AVOIDING DIFFICULTIES OVERCOMPENSATING
ORIENTATED CONCEPT
 Relying on skills and theory  Minimising the role of the computer  Reflecting and
 Protecting by defending
 Taking control of the context  Minimising the differences between perfecting
expertise 66
modalities/Holding on tight to the  Becoming an expert
known
RESULTS
EXPERIENCING CUELESSNESS
Cuelessness, a term coined by Rutter and Stephenson (1979) describes

communication which lacks all non-verbal and social cues. The impact of
cuelessness on the therapeutic relationship was described by one participant
as; ‘Challenging …… there are less visual or verbal cues as to the benefits of
the responses made, which is the main difference’ (P11, F, 1 yrs exp., survey)’
and another participant believed having non-verbal cues in face-to-face
interactions made the work 'smoother' (P12, F, 2yrs exp., survey).
One client described what was missing from the interaction; ‘Whereas in face to
face, I mean you’ve got a face that you can read, a voice that you can read and
all those things I s’pose (sic) are missing in email’ (P4, F, 10yrs exp., Skype),
and what was missed by them: ‘I really miss not being able to follow face to face
'cues'. Noticing when someone looks away...noticing different body language
and tones of voice. (P4, F, 10yrs exp., Skype).
It would also seem participants worried about miscommunication with the lack
of cues in email; ‘not having the voice and facial expressions to rely on for
communication can mean that I may not understand something the way the
client would like me to (initially)...’(P15, F, 1yrs exp., survey), and described
skills they used to try and decipher client meaning ‘ you’ve just got things like
the frequency, uh, of their emails and the language that they use and the length
of the email, you’ve got all those sorts of things but they’re not as revealing as
face to face’ (P4, F, 10yrs exp., Skype).
The lack of social cues was also noted:
Another major difference is being aware that you cannot verify details such as
age and gender.’(P19, F, 11yrs exp., survey),
Participants were also concerned about clients experiencing this lack of sensory
feedback, and appeared to attempt to compensate for this in order to build the
therapeutic relationship as this example indicates:
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RESULTS
‘you might say um, I’m, as I read your email um, I noticed I was sighing a lot or
I, um my shoulders felt very tense or whatever it might be. You have to actually
put that in.’ (P19, F, 11yrs exp., survey).
This aspect of email counselling was notably different to face-to-face working:
Very different in terms of conveying core conditions - i.e. there's no way of

expressing myself physically (body language) or easily conveying my verbal
tone.’ (P7, F, 4yrs exp., survey).
LOSING TOUCH
Consequently being ‘cueless’ lead to participants developing a sense of Losing

touch in four distinct ways; the lack of cues lead to a Loss of interactive factors
and to participants Responding with no sensory steer; the focus here was on
what was missing relationally. However participants also described Losing
control of the process particularly regarding loss of control over the therapeutic
space, and Losing control of the context which mostly pertained to a sense that
the client was perceived as having more power, and be being more in control of
context.
Loss of interactive factors
In this category attention was drawn to the fact that many client interaction
feedback aspects were lacking, such as; speech, non-verbal communication,
touch, smell and identity markers as well as what was described as the more
nebulous intersubjective facets like the shared energy field. It seemed as
though participants struggled with ‘knowing’ a therapeutic connection had been
made; this was thought to be dependent on empathic reciprocation. Sometimes
it was very difficult to read anything from the text:
‘it can be more difficult to ascertain how the client is feeling at the time of
writing their email if they haven’t been very explicit in written words to describe
their feelings’ (P18, F, 9yrs exp., survey).
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RESULTS
Losing the immediate confirming response that might happen in face to face
work also seemed difficult for participants to negotiate and this lack of
reciprocation led to participants Responding with no sensory steer.
Responding with no sensory steer
Participants outlined the difficulties of responding without receiving a confirming

or disconfirming response from their clients:
‘….. because of the nature of the communication medium, I find I am 'saying'

(writing) in larger chunks (of text) without any feedback, confirmation or
challenge from my client.’ (P1, F, 11yrs exp., survey)
‘I am writing a response as one big chunk, without the client there to offer
"course correction" as I write’ (P5, M, 1yr exp., survey).
This caused a number of concerns for non email practicing participants:
‘If a therapist got the wrong end of the stick (so to speak) and spent an hour
following a wrong lead in an email it would be a total waste and they would not
know until the client corrected them’ (P24, F, 0yrs, email)
‘I guess the bit that I think would be difficult is I think a lot of the times our clients
are looking for how we react to kind of material and things, as a kind of model of
what the rest of the world kind of like think will help,’ (P22, F, 0yrs, face-to-face).
As well as the more experienced email practitioners:
‘The lack of immediate response can be quite disconcerting - for example when
a challenge has been made, and it may be some time before the response
comes back’, (P5, M, 1yr exp., survey), ‘……this can sometimes mean I
continue with my understanding of an issue in the hope that I haven't held up
with the counselling process for the client by a misunderstanding which can only
be rectified in my next email’. (P1, F, 11yrs exp., survey).
Not being able to ‘pass the tissues’ (P25, F, Oyrs, email), in a physical sense, in
order to console a client was of concern: I can't reach out to them or offer them
a tissue and I have to trust that my interpretation of their distress is correct and
they will respond to my last email’ (P1, F, 11yrs exp., survey).
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Participants described ‘knowing’ a therapeutic relationship was formed if

empathy was acknowledged by a client ‘when clients respond and confirm
empathy, it can feel just as rewarding as face to face counselling.’(P5, M, 1yr
exp., survey).
The loss of immediacy through the loss of cues and interactive factors, or
working in the moment with the relationship, appeared to be exacerbated by
asynchronous working:
‘The relationship feels less immediate than in f2f counselling with distance
created by additional filters related to the medium of e-mail (technology and
written language)’ (P3, no demographic data, survey),
‘I think what I miss most and again I go back to the sort of five senses, is not
having and immediacy, so not having the instant because we don’t work um,
instantly’, (P13, F, 4yrs exp., Skype).
Described as a more nebulous factor and brought into conversation more

tentatively was losing the ‘shared energy field’, which was felt to happen when
two people are in the same physical space:
‘um I think in face to face you do get vibes from the other person, whether
that’s to do with um both of your electromagnetic fields being compatible..’ (P4,
F, 10yrs exp., Skype).
Whilst it was generally felt that a therapeutic relationship could be achieved

albeit in a different way:
‘The therapeutic relationship is established in a different way (absence of 'felt

sense', transpersonal (sic), immediacy, takes longer to establish) and has a
different quality’ (P3, no demographic data, survey).
Losing control of the process
This sub category encompasses the idea of client containment, which in

therapeutic working is generally the responsibility of the therapist, and of course
supervisor. Containment is a concept developed by psychoanalyst Wilfred Bion
(1967) which explains the process by which the therapist manages the client’s
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RESULTS
unmanageable emotions and experiences by taking these in, reflecting on them,

and returning them to the client in a more manageable form. It is suggested that
creating a safe (contained) place for clients to emotionally unload involves the
therapist setting therapeutic boundaries, and being able to tolerate the impact of
the client’s unmanageable experiences and feelings (Gravell, 2010).
Participants expressed concerns about how clients were managing the therapy
process because the ‘travelling time’ was instant and some participants worried
that this immediacy might not allow the client (or the therapist) suitable
processing time:
‘something I have noticed which both groups need to be aware of is giving time
to themselves for the counselling, processing and tasks. I think online perhaps
take longer to realise it’s not just a case of "fitting it in" Travelling to and from f2f
gives some processing time.’(P10, F, 2yrs exp., survey).
In an attempt to provide containment as part of their duty of care participants

made suggestions to clients on how to best to pace the therapy:
’….. a client can read(sic) my responses much faster than our dialogue would
be in the room so I advise them maybe reading my replies in mangeable (sic)
chunks so that they do not go into emotional overload.’(P6, F, 10yrs exp.,
survey).
Losing control of the process appeared to be exacerbated by the online

disinhibition effect (Suler, 2003); a phenomenon where, due to the relative
anonymity and lack of face-to-face interactions involved in working online,
people feel less inhibited by social conventions and are more likely to do and
say things they wouldn’t normally. In email therapy this often transpires as
clients self-disclosing at a faster pace than would happen in face-to-face
working and in this study participants frequently described clients going deeper,
quicker in therapeutic terms. In some ways, mainly around speed of disclosure,
this phenomenon was viewed positively:
‘I believe you can develop really good relationships with the client. Because
they perceive anonymity you seem to get the client to open up right from the
first couple of sessions, which in turn helps you to establish a better
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RESULTS
relationship.’ (P9, F, 8yrs, survey), including the idea that clients disclose at an
accelerated rate: ‘the disinhibition (sic) effect really works, people will share
sensitive information sooner than f2f.’ (P17, F, 4yrs exp., survey).
The positive view was seemingly extended to an idea that the relative
anonymity allowed for a more creative space for clients, where they didn’t need
to conform to the social constraints of face-to-face interactions: ‘Easier to ask
clients to free associate (in writing) whereas in f2f there's a sense that clients
feel they need to 'make sense'’ (P7, F, 4yrs exp., survey).
However, disinhibition also raised concerns for some participants regarding the
speed of going to a deeper level: ‘They (the clients) usually find that the
relationship can go deeper quicker, which may suprise (sic) them and can even
be a bit scary’. (P6, F, 10yrs exp., survey), some expressed concerns that the
process might cause a bypassing of the conscious: ‘it’s almost as if the
unconscious is going straight from the unconscious onto the screen, and it’s not
going through the conscious’ (P6, F, 10yrs exp., face-to-face).
Losing control of the context, to the client
A further loss of control was that regarding context; participants voiced some
concerns that the client was more in control in online counselling than they
would be in face-to-face counselling; one reason for this is that clients can email
the therapist whenever they choose to, although the therapist can choose not to
respond:
‘People appreciate it that they can email me when it suits them and not the
other way around.’(P17, F, 4yrs exp., survey), and strongly suggesting clients
use that control ‘And, um, I think, uh, in email, um counselling, um the client is
more in control, um, and uses that control.’(P4, F, 10yrs exp., Skype), implying
a client might be aware of their power in the process,
This was considered to be a difference and an advantage for the client in having
more control of the therapeutic encounter: ‘Perhaps the difference is, and the
advantage in some respects, that the room doesn't become any more/less
emotionally laden than the client wishes.’ (P20, F, <1yr exp., survey).
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And a suggestion that getting the boundaries right was important through the
24/7 nature of the internet: ‘Email counselling effectively leaves the counsellors'
door open 24/7, so there are also boundary considerations to take into account
- for example managing the incidence of additional emails in between the main
counselling emails (depending on what has been contracted).’ (P5, M, 1yr exp.,
survey), and perhaps harder to get right.
This seemed especially important for the therapist: ‘the boundaries are slightly
harder to get into place... also my response therefore has to be boundaried in
terms of TIME that I use...’ (P15, F, 1yrs exp., survey).
As well as time, there were also boundary concerns in terms of context i.e. the
place and method of responding:
‘ I do often wonder what the client is writing their email to me on (i.e. are they on
a phone in a park or at school or in their bedroom at 4am...).’(P15, F, 1yr exp.,
survey).
PEERING THROUGH THE LOOKING GLASS
Experiencing cuelessness, the resulting loss of interactive factors and loss of

control left participants with a sense of unreality as they related via their
computer ‘looking glass’ screen. As with Lewis Carroll’s classic novel ‘Through
the Looking Glass’ (Carroll, 1872) where objects on the other side of the glass
are not what they seem and where time can be distorted, participants’ gave
accounts of email counselling via the computer screen which appear to have a
distorting, magnifying and/or intensifying effect, sometimes producing
something paradoxical. The analogy also describes the mirror effect of
communicating via the computer screen and seeing yourself reflected at the
same time. Two sub-categories were constructed within this category;
Fantasising into the void and Fearing disappearing.
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Fantasising into the void
Participants seemed to compensate for the absence of sensory cues and the
consequent loss of interactive factors by using an element of fantasy, or
imagination to ‘create’ their clients:
‘There is a heightened sense of objectivity and greater tendency to fantasy and

projection.’ (P3, no demographic data, survey),
‘Sometimes it feels strange because I have this picture of a client in my head

that I know may be completely different to how they are’ (P5, M, 1yr exp.,
survey),
Well, I suppose (pause) in the main, um, you’ve got this sort of um, imaginary
figure at the other end (P4, F, 10yrs exp., Skype).
One participant described what happened after receiving a request for help
within a service for young people:
‘ as soon as I get that there is a relationship happening from my side so I feel

invested with them, and there is some attachment that I put into that person, I
imagine from what they’ve said I imagine their life and what’s going on for them,
um, and then when I get their reply it’s like there’s a relationship forms’ (P13, F,
4yrs exp., Skype).
In the absence of sensory cues participants appeared to be relying more on a

sense of what was described as intuition:
‘I have to use my intuitive sense more as the visual clues are absent’ (P2, F,
10yrs exp., survey),
‘I suppose that even though I am working online...I still rely on my 'gut instinct'
when working.’ (P13, F, 4yrs exp., survey)
Conversely, as result of the use of fantasy, intuition and instinct, participants

appeared to trust their judgment less, doubting that they had enough
information to form an accurate perception:
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‘So it’s like, um, there’s some, some Arab proverb I think which is something
like, uh, ‘trust something but tie your camel to, or you know tie your camel to the
post as well as trusting your camel’ (P13, F, 4yrs exp., Skype).
This is a somewhat paradoxical position it would seem; an Oxford dictionary

definition describes intuition as ‘the ability to understand something
immediately, without the need for conscious reasoning’ but ‘gut feelings’ (as
they were also described) are thought to be based in experience and NVC’s
such as micro-expressions or physiognomy (Baxter, 2013). It would seem the
mistrust of previously relied on intuition created incongruence in participants,
and lacking trust in the internal could explain participants being less likely to
follow through with an ‘intuitive’ feeling. Consequently participants reported
becoming more tentative with their responses:
‘When using e-mail I have to be more tentative in the responses I give’ (P2, F,
10yrs exp., survey).
However participants were aware of the need to consider their own projections
and transferences in this process:
‘so I very much own what I might be imagining (hmm). Yeah, that kind of thing.
It’s not making any assumptions at all and that’s even more important, I mean I
think that’s important face to face but I think that’s even more important online,
because you can’t, you can’t start saying something and then you see a
person’s facial reaction and think woah, woah, woah, I’ve got that wrong, sorry’
(P13, F, 4yrs exp., Skype).
The role of supervision was felt to be crucial in ensuring that fantasy didn’t
distort the therapeutic relationship, ‘Emotions / transference can be more
powerful online - there can be more of a need for restorative supervision.’ (P14,
F, 3yrs exp., survey),
‘I still encounter transference and projection online. However it can be harder to

get to grips with at first - and may take discussion through supervision to
understand what is going on.’ (P15, F, 1yr exp., survey).
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Participants also described their concerns about the client disappearing; their
fantasies about what might be going on when they did are outlined in the
subcategory ‘fearing disappearing’:
Fearing disappearing
The black hole effect (Suler, 1997) describes the phenomenon of sending an
email message into the internet space (or void) and perhaps being sucked into
an uncertain wondering of whether a response will be returned, and if so what
will it entail. Participants, it would seem, felt these effects quite strongly in the
first instance as to whether a client would disappear by not responding:
‘Sometimes clients will disappear during the process (as with face to face). This
can lead to a different set of questions from face to face - such as thoughts
about whether the technology has failed or the client has been unable to access
the required technology (P5, M, 1yr exp., survey)
‘but I think in clients minds they can just disappear if they choose to’ (P19, F,
11yrs exp., Skype).
Disappearing during ruptures in the therapeutic exchange was thought to be

more likely early in the process:
‘when enough trust has built up I do feel ruptures are addressed and have
been addressed with our clients... and if a rupture occurs very early on… the
client tends to simply 'disappear'.’ (P14, F, 3yrs exp., email).
One client had to face the reality that disappearing might indicate the worst
having worked with a client who disappeared after a natural disaster struck ‘So,
I’m left wondering forever, uh, whether, um, she perished in that event, you
know’ (P4, F, 10yrs exp., Skype).
WORRYING ABOUT RISK
Experiencing Cuelessness and Losing touch and losing control of both process
and context lead to participants worrying about risk; this took two main forms;
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the risk to the client Worrying about client safety and the risk to the therapist
Fearing exposure.
Worrying about client safety
Participants experienced concern about client safety as their clients’ identities

could not be confidently assumed:
‘I will only be working with clients whom can proove (sic) their identifaction (sic),
as there are issues around someone else logging in to the clients profile as an
imposter or even an under aged person.’ (P21, F, 1yr exp., survey).
Assessment was perceived to be difficult:
‘uh, I spose, when they’re face to face things may feel a little bit more solid and
when it’s online and anonymous, um, that, that, that sense feels less solid
(uhu), um, in assessing risk maybe, I think that’s it, maybe a little bit harder’
(P13, F, 4yrs exp., Skype),
‘I feel that the therapeutic effect might be quicker in online working however, it is
more difficult to make an accurate assessment of a client online than face to
face’ (P14, F, 3yrs exp., survey).
This was of particular concern if the client was deemed to be at risk:
‘Online, if someone is suicidal, since you haven't had the benefits of face to
face contact, you might miss clues that they were intending to act on suicide
ideation or go misuse a substance or harm someone else. The risk factor goes
up dramatically.’ (P20, F, <1 exp., survey)
Those participants newer to email counselling reported feeling safer in face to

face working:
‘I feel 'safer' in f2f work and as though I can get a clearer picture quicker than
online’ (P12, F, 2yrs exp., survey).
Fearing exposure
Whilst participants felt that it may be beneficial for clients to have a written
record of the email therapy, to reread and maybe feel connected with the
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RESULTS
therapist ‘they’re carrying that medium and the therapist around with them in
their pocket’ (P13, F, 4yrs exp., Skype).
Participants raised concerns about the ‘worst case scenario’ of the written
record being published:
‘I mean, clients keep the record and they can do with what they want,
according to the contract, but you don’t know what they’re going to do with it,
you don’t even know if they’ve taken in that bit of the contract’ (P6, F, 10yrs
exp., Skype).
Despite contracting to keep things confidential there was a perception that there
was very little control over a client publishing an account:
‘ I’m very aware for the client that if they wanted to show anybody, if they
wanted to post it up on their blog they could, so I could be left very exposed
‘(P13, F, 4yrs exp., Skype)
The threat of being taken to court for a written record was very real for
participants:
‘the thought that someone, you know, what I’m writing now could actually
worst case scenario be used in court’ (P23, M, 0, skype)
‘I mean Tim Bond always used to say you know, don’t say anything that you
couldn’t stand up in court and actually defend’, (P6, F, 10yrs exp., Skype),
Participants described how the fear of exposure might influence the process by
ensuring caution before writing anything: ‘Um, huh because it’s there on their
shoulder as they are writing, the fear about if I say this and it goes online sort of
um, what is everybody going to think, what will BACP make of it etc’ (P19, F,
11yrs exp., Skype), as well as not being overly confident of what their
professional bodies would make of it.
Mostly fear of exposure was expressed by newly online trained and non-email
practicing participants, fears around being taken out of context and facing a
legal scenario appeared to lessen with experience:
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RESULTS
‘at the beginning I think when I started I was probably a little bit afraid of what
might happen to the sessions, or, um, I may be felt a bit vulnerable to the fact
that my sessions could be out there, um, and then as I’ve grown in confidence I
kind of feel, um, I stand, I stand by my session’ (P13, F, 4yrs exp., Skype).
BECOMING UNCERTAIN
Facing the above factors participants appeared to become more uncertain and
questioning about their work. In particular these uncertainties led to Questioning
Questioning computer reliability
The importance of computer reliability was recognised in forming a therapeutic

relationship:
‘I see the computer as an essential tool for my work and subsequently make
sure it is always running efficiently and is well maintained etc.’ (P18, F, 9yrs
exp., survey).
The fact that this was the only means of contact with clients seemed to
heighten the importance of the computer, especially when a client was in crisis:
‘it is also my only means of communication with a client who may be in crisis
and that has felt very hard.’ (P1, F, 11yrs exp., survey).
Technology failing was naturally of concern: If the computer runs slow, or

crashes, this can be an issue’. (P5, M, 1yr exp., survey), and prompted
participants to have a fall back plan:
‘I can get frustrated if technology fails - so the need for back-up systems
agreed in the contract with the client.’(P19, F, 11yrs exp., survey)
‘I have a more basic laptop as a stand-by in case state-of-the-art doesn't

produce the goods one day (heaven forbid!)’ (P4, F, 10yrs exp., survey),
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Questioning own competence
Many of the uncertainties outlined above caused participants to question their

own competence and understanding; while this questioning appeared to be
ameliorated by the level of training and experience they had acquired, most
participants described professional insecurities that seemed to be caused by
working solely by text and by the time delay:
‘I expect there’s a tendency amongst, um counsellors to think, um, you know,

um, am I good enough, am I not doing what the clients wants me to help them
with and all these sorts of things’ (P4, F, 10yrs exp., Skype).
Participants’ sense of competence appeared to be eroded through the

requirement to decipher client distress and needs entirely through the written
word:
‘You have no idea if the person is crying or if something you've said has
resonated or upset them unless they choose to tell you’ (P20, F, <1 survey),
‘sometimes difficult to interpret what the tone of the email message is - and so
one has to be careful about ones response’ (P15, F, 1yr exp., survey),
And seemed to suggest that this could be worse the more heightened the
emotion:
‘One client became so angry that she used capital letters throughout her email
and no punctuation at all. It was difficult to unravel what she was writing about’
(P1, F, 11yrs, survey).
The time delay appeared to afford participants more time to doubt their abilities,
particularly those newly trained in email therapy; as participants became more
experienced and confident in the mode a ‘feeling the fear and doing it anyway’
type of therapeutic robustness was identified:
‘I can wonder (mm) between differences but you are taking an awful lot of
information, um, on trust and have to hope that it bears out.’ (P19, F, 11yrs
exp., Skype), especially in relation to the idea of internet exposure.
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On top of this participants felt the importance of conveying oneself via the
written word ‘it could be a barrier [the computer] but I like writing so it's ok for
me’ (P11, F, 1yr exp., survey).
Conversely a non email practicing participant questioned whether this was

possible:
‘It's also hard to convey ones inner most feelings and experiences with the
written word - unless you have an exceedingly long time and the skills of Byron
or Austen.’ (P24, F, 0, email).
The questioning of competence in separating a participants own issues from

those of the client appeared to stimulate the need to maintain a heightened
sense of congruence:
‘it’s just keeping that internal supervisor going, ah, and listening to it’ (P6, F,
10yrs exp., face-to-face).
Experiencing cuelessness, Losing touch with interactive factors and Losing

control of both the process and context led to understandable feelings of anxiety
amongst participants. These feelings were exacerbated by the distortions and
fantasies caused by Peering through the looking glass and losing a sense of
certainty. Email therapists experienced Worrying about risk and Becoming
uncertain and these processes fed into Experiencing of anxiety which was
seemingly managed by several psychological processes; Becoming more task
orientated, Avoiding difficulties, Overcompensating and Defending the
professional self concept.
The level of anxiety experienced was revealed by participants as being on a

continuum and perceived to be ameliorated by greater levels of training and
experience in therapy, email training and familiarity with the Internet and
computer. Certain aspects of email counselling caused anxiety for all
participants, with the only difference being in how it was conceptualised. Mostly
participants talked in terms of relational factors being different to face-to-face
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RESULTS
working, not better or worse, and the need to adapt existing skills. Participants
new to email practice spoke more about experiencing anxiety about the
process, about their clients, their email counselling abilities and negotiating the
computer, whereas experienced counsellors (who were often engaged in
training and supervising others in online counselling) used a generally more
professional discourse and were less likely to overtly convey anxiety unless it
was retrospective, relating to client’s abilities or the anxieties of newly training
online counsellors. It was as though anxiety was better managed with time.
BECOMING MORE TASK ORIENTATED
With the loss of interactive factors and the ensuing lack of sensory steer
participants appeared to concentrate more on the text relationship and the task
in hand:
‘Not distracted by the client's physical presence and vice versa, so a lot easier
to really focus on the words and feelings expressed’ (P7, F, 4yrs exp., survey).
Participants felt that over time it was possible to build a therapeutic relationship
by utilising the nuances of the written text:
‘The relationship between me and my client builds in the same way as it does
in the room - i.e. gradually and with increasing trust as we get to know each
other and each other's written style, use of language and presentation (choice
of font, whether or not they are using emoticons, etc.)’ (P1, F, 11yrs exp.,
survey).
However, whilst ‘cues’ from the text helped participants feel they had some
steer ‘Online, I’m in a therapeutic space in connection with them but in a
different way and I’m picking up all those clues from, the colour they use, if they
change the font, from the words they use’ (P6, F, 10yrs exp., face-to-face)
As a way of managing anxiety participants appeared to focus more on

conscious factors, cognition rather than intuition seemed to come to the fore, a
process which was described by an experienced participant as being ‘up in the
head’ (P6,F, 10yrs exp., Skype) when using the medium of email counselling.
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There were two positions adopted: Relying on skills and theory and Taking
control of the context.
Relying on skills and theory
As well as having the time to reflect on and perfect responses participants

appeared to be working more consciously by overtly relying on skills and theory.
This was felt to particularly happen in initial contacts where more effort was put
into being explicit in exchanges:
‘so therefore online you have to initially work harder but I want to say work
differently to um, to compensate for that to bring that in, um, so that you are
much more explicit,’ (P19,F, 11yrs exp., Skype),
Regarding applying face-to-face techniques:
‘I apply my counselling theory in the same way and will use tasks that I may
have used in the room e.g. gestalt empty chair work can translate into 3 emails
between the client and their significant other with me acting as a cyber
postman,’ (P13, F, 4yrs exp., survey),
‘ It feels like the core conditions of my model (Person Centred) do work via e-
mail. Two people are in psychological contact whether it is by email or face to
face, and one of these is incongruent, the other being the counsellor. Empathy
is offered and received (or not!)’ (Pf, M, 1yr exp., survey),
One participant strongly advocated the benefits of discourse analysis but felt
that this was missing from both f2f and email modes ‘A really good background
in discourse analysis of the written word is required in email counselling. Just as
discourse analysis is a necessary part of f2f counselling, BUT, as far as I know,
is Not (sic) taught on any counselling courses’ (P4, F, 10yrs exp., survey).
Becoming more task orientated in some cases appeared to come with a loss of
relationality ‘No requirement to remember anything after the session, as it’s all
available in textual form’ (P7, F, 4yrs exp., survey).
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Taking control of the context
Looking after the technology was akin to taking care of the therapy room it
seemed, and in this way participants seemed to be taking more control of the
context in an attempt to manage their anxieties about risk:
‘It needs looking after as does the room you use in f2f’ (P6, F, 10yrs exp.,
survey).
Another participant who felt very strongly about online safety ensured this by
having appropriate encryption:
‘Yeah, I do think encryption is imperative. Um, what they what the client does at
their end, whether they tell their partner what they’re, um, password is and all
that, I mean that’s their business, but, I make sure that um, from my end, um, I
uh I teach them that particular bit.’ (P4, F, 10yrs exp., Skype),
Much like the counselling space participants took their work computers very
seriously:
‘My computer feels like a 'solid colleague'...some'one' that I can reply on. I only
use my laptop for work purposes...so when I see my laptop and when I use my
laptop, I know I am 'at work' and using it for a specific task’ (P13, F, 4yrs exp.,
survey), even suggesting there might be difference in computers for work and
computers for play ‘I wouldnt (sic) use my ipad ever as it feels to frivolous (P10,
F, 2yrs exp., survey).
Treating the computer seriously was felt to be akin to looking after a face-to-
face therapy room ‘And let’s face it, um, you wouldn’t do your face to face, um,
counselling in a grotty old garden shed, would you?’ (P4, F, 10yrs exp., Skype),
and the idea of having back-ups for client safety was suggested ‘I do, um, have
um, a spare, uh, laptop just in case this one, um, plays up on the day so I have
got another one rather than having to, um, phone the, um, client to say sorry but
my um, computers uh not operating we’ll have to reschedule, I don’t think that’s
really a good thing’ (P4, F, 10yrs exp., Skype).
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AVOIDING DIFFICULTIES
Avoidance is one way of dealing with anxiety although it is often not thought of
as a healthy option for the long term as the initial issue still remains and is
thought to keep a person in a cycle of anxiety. Avoidant behaviours were
demonstrated by participants by what appeared to be the use of certain
defensive manoeuvres; Minimising the role of the computer and minimising
differences between modalities/Holding on tight to the known.
Minimising the role of the computer
Participants appeared to minimise the role of the computer; which was often
dismissed as a ‘tool’:
‘My personal response to the computer is to think of it as tool to enhance my

work’ (P1, F, 11yrs exp., survey), ‘It is the tool that allows me to speak’ (P2, F,
10yrs exp., survey) ‘I really don't think about it’ (P7, F, 4yrs exp., survey), ‘I
experience the computer as my tool! i haven't really thought of it as much more
than that’ (P15, F, 1yr exp., survey).
Interestingly the computer only came ‘alive’ when it was misbehaving and this
minimisation was no longer possible:
‘It’s sort of, it’s almost like it’s an extension of me (mm) um, other than when
the blooming thing goes wrong’ (P19, F, 11yrs exp., Skype),
‘The computer seems to effectively vanish - except when it decides to cause

problems’ (P5, M, 1yr exp., survey)
in which case it could cause an outpouring of negative emotion:
‘when the connection is poor it becomes and object which hold all my rage’
(P10, F, 2yrs exp., survey).
The therapeutic gold standard of relationship appeared to be in seeing through

the computer to the person:
‘Initially during training the computer is very much there, as time goes on I see
beyond the computer to the client’ (P6, F, 10yrs exp., survey). In this sense
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participants seemed to demonstrate a need to minimise the differences

between email and face-to-face counselling.
Minimising differences between modalities/Holding on tight to the known
This seemed to represent another way of managing anxieties with participants

appearing anxious to hold on to what was familiar about face-to-face work:
‘When I am focusing on a client's words I am completely unaware of anything

else around me - this is similar to the intensity felt in the counselling room.’ (P1,
F, 11yrs exp., survey), and was often described as being developed in the
‘same way’ (P2, F, 10yrs exp., survey) as face-to-face skills:
‘I use the same basic counselling skills of warmth, genuineness, UPR

(sic)(Unconditional Positive Regard) and empathy, as I do in face to face work
and to that extent the relationships feel very similar’ (P1, F. 11yrs exp., survey)
Sometimes trying to minimise differences entailed a protracted explanation: ‘I

suppose then my hope is that in my session in my response I’m very here and
now and when the young person or the, you know, the client does their
response they’re very here and now with their reply or their session, it’s just htat
(sic) we’re not here nad (sic) now together, that’s the only difference’ (P13, F,
4yrs exp., survey).
Despite clear differences between face-to-face and email therapy similarities

appeared to be focused on by participants when describing the therapeutic
relationship:
‘The relationship in email counselling can be as powerful as face to face

counselling’ (P14, F, 3yrs exp., survey),
‘Um, so I think there is a sense of holding going on in both ways, the therapist
holding the client and the client holding the therapist in mind, I think that is quite
similar too.’ (P13, F, 4yrs exp., Skype).
As well as minimising the differences in terms of the therapeutic relationship,

participants appeared to want to minimise contextual differences:
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RESULTS
‘I always say my screen is always open. Well of course it’s not open 24 hours a
day but, (hmm) it’s a bit like counsellors saying, face to face counsellors saying
my door is always open.’ (P4, F, 10yrs exp., Skype).
It was as if participants were struggling with the idea that there might be
differences in boundaries between face-to-face and online therapeutic
interactions.
OVERCOMPENSATING
The time delay involved in email counselling and doubts about

miscommunication appeared to push participants into an overcompensatory
position, whereby the time to reflect and lack of cues gave extra time to
contemplate perfecting responses, indicating a degree of anxiety.
Overcompensating is described as a negative psychological defense where a
person might strive to overcome what is lacking in a process. This is best
demonstrated in the subcategory Reflecting and Perfecting.
Reflecting and perfecting
Notably having time to respond forced participants into a reflect and perfect
position where they felt the draw to keep polishing responses to ‘get it right’ (P7,
F, 4yrs, survey) for clients:
‘I appreciate the time to reflect before I respond and the opportunity to make
my response as good as I can’ (P1, F, 11yrs exp., survey)
‘..as the process allows as much time as I need to craft my responses in a way
which feels appropriate for each individual client in terms of mirroring their
'style', 'tone', etc.’(P7, F, 4yrs exp., survey).
The urge to perfect is further described by an experienced participant:
‘I got drawn into responding to that bit there but actually there was that as well,
so you might go back and add something, um, adjust something slightly’ (P6, F,
10yrs exp., face-to-face).
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RESULTS
And often needed resisting:
‘I think there could ,(sic) yeah, I think there could be an urge to tinker, um, but I
resist that urge (laughs),’ (P13, F, 4yrs exp., Skype).
The experience of delayed responding in email is described as leading to

further doubts; participants had only clues from the text and were forced to rely
on their own frame of reference:
‘With email counselling I feel a greater need to pause for reflection, to ask
clients questions to check meaning, to take care that I am not going off at a
tangent or drifiting (sic) into my own frame of reference ..’ (P5, M, 1yrs exp.,
survey)
In addition participants described a need to check in with the client to make sure
they were getting it right:
‘When the response is delayed, this can lead to doubts and a desire to check in
with the client.’ (P5, M, 1yr exp., survey);
‘I do a lot of checking out in emails um, both in terms of, of something I’ve said,
I’ve check out whether I’ve got it right’ (P19, F, 11yrs exp., Skype).
It is perhaps most evident with participants’ frequent plea of the importance of

choosing words carefully:
‘there's no way of expressing myself physically (body language) or easily

conveying my verbal tone, so every single word I write matters enormously,
whereas in f2f, words can be changed/adjusted/retracted as we go along’ (P7,
F, 4yrs exp., survey),
‘Language, always important in therapeutic work, has to be carefully selected

because any misunderstandings take another email exchange to clarify, OR
may never be clarified.’ (P4, F, 10yrs exp., survey),
And an awareness at times that participants were overanalysing the text:
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RESULTS
‘I think where it can be unhelpful is, um, in overanalysing what’s been written,
probably more on the part of the counsellor, uh, both going back and
overanalysing’ (P19, F, 11yrs, Skype).
DEFENDING THE PROFESSIONAL SELF-CONCEPT
Online counselling is a relatively new occupation and participants showed signs

of fighting for professional recognition. Although participants already had face to
face experience defending their professional self-concept in this new domain
was illustrated by participants’ protective behaviours.
Protecting by defending expertise
Possibly partly due to the anxieties and professional insecurities evoked by

email counselling, and the fact that this is a relatively new profession
participants appeared to be engaged in the search for professional recognition:
‘I think the online counselling profession should get more recognition, more
training and be a bigger part of the system. My clients have all benefitted from
this type of counselling - hugely.’ (P15, F, 1yr exp., survey)
Many participants held the belief that experience and further training were
necessary to work therapeutically via email, as the field required an
understanding of the nuances involved:
‘Thank you for doing research into this medium. Many people don't understand
the huge benefits nor (sic) the need for training’ (P9, F, 8yrs exp., survey) as
well as the high level of congruence and support required in working so
differently:
‘Good supervision is essential always and for a space to be able to discuss

how to handle such situations as safely as possible.’ (P3, no demographic info,
survey).
Training was presented in participant accounts as important:
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RESULTS
‘I enjoy the flexibility of this medium - but also appreciate the importance of
suitable training and experience before working in this way’ (P14, F, 3yrs exp.,
survey), and there was a sense that you were either in the know (trained) or not,
a view summed up by several participants:
‘Essential, and with tutors who demonstrate in their correspondence the best
techniques’ (P6, F, 10yrs exp., email), ‘so, um, to do a specific training your
eyes will be opened to things that you didn’t know you didn’t know and um,
(hmm) I think it just can keep everybody a little safer’ (P13, F, 4yrs exp., Skype).
This was a phenomenon the researcher had experienced whilst becoming

trained and when trying to recruit for the study, and had been asked her
‘position’ in relation to email therapy during the research process:
‘Well I do think you need training, and you must know yourself that it’s not until
you do the training that you realise, yes you do need it.’ (P4, F, 10yrs exp.,
Skype).
There was a degree of relief expressed by one participant that their professional
body was beginning to recognise the importance of training in the area:
‘I’m really glad that BACP are beginning to say that, that, um, it is a different
medium and therefore training is vital’ (P19, F, 11yrs exp., Skype).
Becoming an expert
Possibly as a result of the challenges outlined above, many participants

seemed attracted to an expert position; the importance of having a degree of
experience in face-to-face working before embarking on email therapy was
stressed:
‘personally I feel you need to have your face to face training first and then there
has to be specific online training to work online, because it throws up so many
different issues and you need to think about’ (P13, F, 4yrs exp., Skype).
Participants were also keen to stress the importance of completing an

appropriate training in online therapy:
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RESULTS
‘I might say that in my experience um, when people have gone into training
they have understood that it it’s almost um, that it is a necessity because
they’ve seen round the edges of working that way.’(P19, F, 11yrs exp., Skype).
Finally participants stressed the importance of competence in working with

computers on the Internet:
‘The counsellor needs to be TOTALLY familiar with all aspects of the

technology being used’ (P4, F, 10yrs exp., survey),
‘It has the capacity to make me feel deskilled when the connection drops or it
reboots half way through an email’ (P9, F, 8yrs exp., survey).
Professionalisation also involves training and participants emphasised this as

being crucial, with three levels of expertise to negotiate before being able to join
the group; experience in face-to-face, specific training and competence in
working with computers. There was also a further expert progression that was
borne out of the new profession where participants could be a practitioner in
face-to-face and online therapy, a supervisor and a training provider, as
described by this experienced participant:
‘I am very used to working online as a counsellor, supervisor and trainer,’(P5,

M, 1yr exp., survey).
Member checking resulted in an email response regarding the idea of sending a

message into the void, which demonstrated an expert position:
‘To me it is not a void, they are very much there for me. If it feels like a void
then I am not engaging with them and their issues sufficiently. I suspect the
counsellor/s who raised this may not be as well trained or experienced [and
maybe in f2f too] online as others.’ (P6, F, 10yrs exp., email).
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DISCUSSION
DISCUSSION
The grounded theory presented above outlines the basic social psychological
processes involved in email counselling and the therapeutic relationship. The
theory was influenced by the researcher’s social constructionist position, by
psychoanalytic theorising on anxiety and organisational processes, and by the
researcher’s insider position as a trainee counselling psychologist and hybrid
position (McGhee et al., 2007) as a non-practicing online therapist. This study
aimed to address identified gaps in the research literature in this substantive
area. In brief, the grounded theory constructed is as follows:
Participants described how providing counselling via email led to them

Experiencing Cuelessness and how this absence of sensory cues led to an
experience of Losing touch in several ways; Loss of interactive factors with the
client Responding with no sensory steer i.e. having no immediate feedback to
guide their responses: Losing control of the process whereby participants
struggled with issues of therapeutic containment, and Losing control of the
context, to the client which included a sense that clients were more in control,
participants were more accessible and boundaries were harder to establish.
Cuelessness and Losing touch led to a sense of Peering through the looking
glass when counselling online; counsellors felt as if they were Fantasising into
the void, both in terms of who clients were and having to rely more on internal
factors like intuition to make therapeutic judgements, and Fearing (client)
disappearing through the ‘black hole’ effect of sending a message and
wondering, often anxiously, about the response. Participants also described
Worrying about risk; this took two forms Worrying about Client safety, but also
fears about their own; participants described Fearing exposure due to there
being a written record of the therapy which led to concerns about possible legal
or professional ramifications. Becoming uncertain related to further uncertainties
through therapists Questioning computer reliability and Questioning own
competence. As a result participants were left Experiencing anxiety. This
anxiety appeared to be managed in a number of ways; participants described;
Becoming more task orientated which involved participants adopting a more
rational position of relying on professional learning and taking control of the
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DISCUSSION
technological context; participants described Avoiding difficulties i.e. coping with

anxiety by minimising some of the clear differences between face-to-face and
email counselling and holding on tightly to what felt familiar. Overcompensating
describes another mechanism participants appeared to use to manage their
anxieties; participants described being drawn to reflect and perfect their
responses in the time delay. Additionally participants seemed drawn to
Defending the professional self-concept; i.e. protecting their expertise in the
online counselling occupation and highlighting a drive for recognition as
professionals.
It is generally accepted that working with clients face to face in mental health
settings induces anxiety and creates dilemmas (Kahmi, 2011; Dryden, 1985;
Childress, 2000); this also appeared to be the case for therapists practising
email counselling. The findings outlined above suggest that aspects of email
therapy were difficult for therapists when working to establish a therapeutic
connection. However, rather than fully acknowledging what was difficult and
different, it appeared as though therapists were attempting to adapt their face-
to-face skills to this new medium and minimising what was difficult, although
important aspects that had been relied upon in face-to-face connections were
clearly absent. This process will be discussed in three sections: 1) Factors
feeding into uncertainty, 2) Uncertainty and Anxiety, and 3) Managing Anxiety.
FACTORS FEEDING INTO UNCERTAINTY
Experiencing Cuelessness
The lack of non-verbal, visual, verbal and social cues was described by
participants as the biggest difference between email and face-to-face
interactions; the difference was described as a loss, which made developing the
therapeutic relationship challenging and difficult for the participant. This
appeared true both in understanding a client’s communication and conveying
relational aspects through email. Concerns regarding the lack of cues and
possible impact on the therapeutic relationship are one of the main concerns in
practitioner guidance papers (e.g. Mallen et al, 2005a) and reviews (e.g. Pelling,
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DISCUSSION
2009), so it is perhaps not surprising to find participants focusing on this aspect

in particular, even though participants had been invited to describe both
similarities and differences by the researcher.
These findings support those of the Cuelessness model (Rutter & Stephenson,
1979) which suggests the less social cues the more impersonal the interaction,
and Social Presence Theory (Short, Williams & Christie, 1976) which suggests
that the fewer cues a communication method has the less warmth and
involvement users experience. It is perhaps not surprising that this lack would
be difficult to deal with as a therapist. Later adaptations to the cuelessness
model suggest that people can adapt to cueless situations (Kemp & Rutter,
1986), especially with a more emotive subject matter (Rutter et al., 1984), and
interpersonal aspects of Social Information Processing theory (Walther, 1992)
suggest that the communicator’s motivation is key to adapting to what cues are
available, albeit taking a longer period of time. The grounded theory presented
here outlines the process by which participants adapted to the lack of cues, and
suggests that this adaptation came at some cost. The Media Richness Model
(Daft & Lengel, 1986) which sits within the impersonal literature in CMC,
suggests that email may provide more opportunity for social cues in its ability to
use natural language and personalisations, however this finding was not
supported by the current study; participants clearly struggled with the lack of
cues, while making attempts to adapt. The Hyperpersonal model (Walther,
1996) suggests there might be advantages to working in a cueless situation but
this was also not supported with current study findings; participants found the
communication method challenging and as ‘receivers’ participants were not
inclined to fill in the blanks when dealing with such important messages.
Losing touch - responding with no sensory steer

Working by email caused participants to lose the immediate conversational
aspects involved in face-to-face settings as working in this medium necessitated
writing in larger chunks of text leading to the experience of responding with no
confirming steer from their clients. The loss of immediacy in the asynchronous
communication method appeared to be felt deeply by participants, who referred
to their inability to do things such as ‘pass(ing) the tissues’, or having the
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DISCUSSION
proverbial ‘shoulder to cry on’ (Baxter, 2013). Yet, even whilst these differences
were described, it was as though the impact of loss was not fully acknowledged
or processed. Participants may have been exposed to messages regarding
non-verbal communication in their core training; such as 93% of a message
being communicated non-verbally (Argyle, 1983) and the importance of
therapeutic presence in the relationship (Kahn, 2001), which might have made it
quite difficult to sit with ideas of immediacy. Participant’s views are supported by
ideas in enhancing social presence which it is suggested can only be achieved
in another’s physical presence (Gunawardena & Zittle, 1997); perhaps
suggesting this was not a skill that participants felt could be adapted. The
concerns outlined in the current study support concerns outlined in the literature
regarding this method of communication (Fenichel et al, 2002). Therapeutic
presence has been deemed key to therapeutic efficacy (Webster, 1998) and
whilst other literatures do not rule out the possibility this can be engendered in
an online environment (Fink, 1999; Geller et al, 2010) it seemed difficult for
participants in this study to feel reassured they were ensuring a client’s
emotional safety without sensory cues.
Participants described being reliant on having their empathic response

confirmed via email exchange to signify that a therapeutic connection was being
made and this is supported by ideas from the person centred perspective,
whereby empathic understanding is conceptualised as central to the therapeutic
relationship process (Rogers, 1967); contemporary literature in the
psychotherapy field from a number of therapeutic perspectives further supports
this assertion (Gelso, 2011). Empathy is thought to have a positive impact on a
therapist’s ability to engage with a client (Orlinsky et al., 1994; Cooper, 2008)
and was clearly important for participants in this study, but due to the time delay
they had to tolerate waiting for written confirmation of their empathic
responding. These findings would tend to contradict ideas in the interpersonal
model of Social Information Processing theory (Walther, 1992) regarding being
able to adapt to a cueless situation over time, and may represent something
participants felt was different in the process. While emotional responses can be
suggested visually via text by the use of emoticons (Wolf, 2000) and writing
emotions in brackets (Murphy, 2009) it would seem that participants in this
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DISCUSSION
study struggled to feel they were adequate to convey immediacy and

therapeutic presence.
Losing touch - losing control of the process
One of the key areas participants seemed concerned with was therapeutic
containment; their ability to hold the client’s emotional distress in the therapy
process (Gravell, 2010). Findings from the current study suggest that
participants took the therapeutic process very seriously but that working within
the email medium led to concerns about where, how or when a client might read
a response, or where they may respond from. Findings also suggested that
participants had mixed feelings about the online disinhibition effect that often
impacted on the process through clients self-disclosing at an accelerated rate
than in face-to-face contexts. Another concern seemed to be about the speed
with which a written response could be read.
These findings regarding the difficulty participants experienced when attempting

to establish therapeutic containment via the cueless atmosphere of email to
some degree support research into the role of mirror neurons in
neuropsychology (Schore, 2013), which suggests that the ‘gaze’ of the therapist
is crucial in creating a safe space for the client to explore relationship issues
(Holmes, 2001). Attachment in this sense is conceptualised as a form of affect
regulation that occurs in relationships and relates to how individuals deal with
emotions, which could be considered highly relevant in the formation of the
therapeutic relationship (Holmes, 2001). Research regarding the role of mirror
neurons in empathic responding would seem to call into question whether a
safe attachment space can be engendered in a cueless context, and it is further
suggested that the non-conscious transference-countertransference relationship
thought to be critical to clinical effectiveness is reliant on this safe space
(Schore, 2013).
Findings that clients might self-disclose at a faster rate would seem to have
given participants a dilemma in that whilst it was described as helpful to the
process it was also of concern that it might overload clients, due to the lack of
control participants had in how fast the message was read. The fact it seemed
to be happening supports the findings outlined by the Hyperpersonal model
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DISCUSSION
(Walther, 1996) in CMC whereby the ‘sender’ (client) is more in control of the
message and more inclined to self-disclose. While some argue that early self-
disclosure may be a positive factor in online counselling (Richards, 2009), and
that it can be useful for clients (Fletcher-Tomenious & Vossler, 2009)
participants in the current study expressed concerns about this process and felt
drawn to ‘teach’ clients to use the process more safely.
Losing touch - losing control of the context, to the client
Linked to this section are findings that participants felt the client was more in
control of the context, if not the process, in email counselling through being able
to respond when they wished. Participants appeared to be struggling with the
notion they were ‘keeping the door open 24/7’ and this led to a sense of being
unboundaried. This finding supports the idea that cyberspace creates a flexible
temporal space which can feel unboundaried for clients and therapists (Suler,
2007). It also supports the Hyperpersonal model (Walther, 1996) in that the
client as a ‘sender’ has more control and research suggesting the advantages
for the client in emailing at a convenient time (Powell, 1998); however the
therapist as the ‘sender’ does not seem supported in this situation as
participants reported having to be firmer with boundaries. The client being more
in control expands on research into young people having more control of the
emotional content in online counselling (Hanley, 2009). However, the sense of
being permanently ‘plugged in’ for participants seemed to lead to a feeling of
over responsibility, which aligns with the supposition that client containment is
necessarily an asymmetric process being the responsibility of the therapist
(Aron, 1996), although in email counselling it seems a much greater
responsibility. Paradoxically while participants expressed concerns about the
client having more control, they were also concerned about the client having
less control about the pace of the therapy, and that email counselling might not
be at the pace of the client (Cooper & McLeod, 2011), participants worried that
clients might be reading too quickly to safely process what is written.
Peering through the looking glass
This Lewis Carol analogy helps illustrate some of the processes involved in
email counselling; adopting the psychoanalytic constructs of fantasy and
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DISCUSSION
projection helps to explain some of the processes involved in ‘imagining’ a client

in order to conduct email counselling, seemingly a necessary part of the
process. Participants indicated being both aware the possibility of, and nervous
about, these processes and how they might impact on the work. Whilst
imagining was deemed useful in ‘getting the conversation going’ to help form a
therapeutic relationship it is also totally reliant on cues from the text or
intertextuality (Kristeva, 1986), and at times participants found it difficult to
decipher these meanings. With very little in the way of cues to inform them
participants seemed to be creating the client from their own internal constructs.
This finding supports Suler’s (2007) theorising about solipsistic introjection in
email counselling; whereby through consciously or unconsciously assigning an
image or voice for example. A person can feel like the person on the other end
of the email exchange has been introjected into one’s psyche, as Suler says
(2007 p34):
The online companion now becomes a character within our intrapsychic

world, a character that is shaped partly by how the person actually
presents him or herself via text communication, but also by our
expectations, wishes, and needs
Psychoanalytic practitioners argue that transference and countertransference

reactions are key in developing the therapeutic relationship (Sandler & Sandler,
1997) and participants consciously fantasising about clients in this way seemed
a necessary part of the process, albeit perhaps in a less informed way than in
face-to-face counselling due to the lack of cues. Lemma (2003) suggests that
therapists need to composite a reasonable hypothetical imagination of a client
in their physical absence, and that this would rely on a degree of therapeutic
experience. Neuropsychology might also support the idea that therapist’s dual
role of existence (Schore, 2013) in acting as a safe holding container for a client
means simultaneously needing to attend to their own self-regulatory function,
and where there is a need to work more with the fantasy one holds of client it
could perhaps be suggested this could be difficult for a therapist to negotiate.
Relying on an internal construct in this way also expands on Anthony’s findings
which suggest that rapport is built via the therapists’ mental construct (Anthony,
2000), and that therapists have to trust their mental picture (Fletcher-Tomenious
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DISCUSSION
& Vossler (2009) to form a therapeutic relationship. Studies into sensory

deprivation may throw a worrying light on relying on imagination in these
instances, as in order for the brain to compensate for the lack of cues it has the
capacity to create something out of nothing (Mason & Brachy, 2009), perhaps
suggesting overcompensation. The Hyperpersonal CMC model (Walther, 1996)
also suggests that a ‘receiver’ of information may fill in the blanks. While
theories about transference and countertransference would suggest that much
of how we perceive others is confused by our own internal templates, it is
suggested that this confusion may be greater in email therapy.
Participants also described missing the ‘shared energy field’ thought to be

present in face-to-face work and absent from email counselling, and described
as the psychological relational space between two people interacting.
Contemporary psychoanalytic theorising suggests that intersubjectivity is a key
factor in the therapeutic relationship and it is believed that emotional experience
takes form in the intersubjective space (Stolorow et al., 2002). It has been
argued that participant and client self-reflecting entails intersubjectivity,
emphasising our social existence (Gillespie & Cornish, 2009); some support for
these claims is provided in mirror neuron research into empathy (Rizzolatti &
Arbib, 1998). In theory there is no reason to believe an intersubjective space
does not exist when working online, although this might be problematic if
relationship formation is partly reliant on ‘gaze’ (Schore, 2013). The findings of
the current study would suggest that this nebulous experience was missed by
participants implying it was somehow difficult to experience the space between,
when dealing more with their own fantasy.
Fearing disappearing
In addition participants expressed fears regarding early ruptures in the

relationship which might cause clients to disappear, and this supports Social
Information Processing Theory (Walther, 2002), which suggests that time is
needed to develop relationships when using CMC. Paradoxically it seemed
there was perhaps more likelihood of clients disappearing through early self-
disclosure, from the effects of online disinhibition as suggested by Suler (2003).
Of course it is important to bear in mind that CMC research is not necessarily
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DISCUSSION
talking about therapeutic communication but it has been further argued that self-
expression through this medium is representative of a constructed aspect of self
and therefore a more visible, concrete and objective format than speech and
useful in its own right in therapy (Suler, 2003). In any event participants
struggled and looked for balance in this tricky negotiation with self by looking to
the external supervisor, but as most supervision is conducted online one has to
wonder if the possibility of a further parallel process (Weitz, 2014) is always
helpful.
UNCERTAINTY, WORRY AND ANXIETY
Worrying about risk
Participants expressed a number of concerns about client safety as the client’s

identity could not be confidently assumed. These concerns constellated around
assessment and ‘at risk’ clients. These concerns are often cited in reviews
about online counselling (Wells et al., 2007; Rochlen et al., 2004). Findings from
this study indicate that participants found the lack of cues disorientating (Mallen
et al., 2005a; Liess et al., 2008). Participants described feeling safer in face-to-
face interaction when dealing with risk and assessment. This supports the
Media Richness Model (Daft & Lengel, 1986) in CMC which asserts that the
greater the complexity of the message the more media outlet channels are
needed to convey it; participants’ accounts indicated that the email medium did
not seem to have enough media outlets to feel confident about what was
communicated. Findings indicated that participants were concerned about
possible deception by clients when working online, which is supported by other
therapists when reviewed about concerns (Wells, et al., 2007). Research
suggested deception was more likely in email as it is a ‘socially blind’ medium
(Epley & Kruger, 2005), this is rather contradicted by research using the Media
Richness Model (Daft & Lengel, 1986) that asserts that deception is less likely
when using email than other synchronous communication methods, through the
evidence trail of leaving a record (Hancock et al., 2004). From a
neuropsychological attachment perspective if physical ‘gaze’ (Schore, 2013)
holds the key to a sense of safety in healthy adults it might also in some way
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DISCUSSION
explain how participants struggled in dealing with risk and erosion in self-
confidence.
Findings also suggest that practitioners feared exposure through the creation of
a written record of therapy that could be posted online by a client. The
perceived risk of what was referred to as the ‘worst case scenario’ had not
actually been experienced by any participants but these concerns are often
voiced in ethical reviews (Caleb, 2000), where it is suggested that the records
produced leave online therapists open to prosecution (Mackay, 2001). The
feeling of uncertainty may also be explained in the construct of randomness
described by Smithson (2008), through the lack of control of the clients’ actions
and unknown element of the Internet, which has potential to expose therapeutic
interactions to the world. Findings would seem to suggest that participants were
concerned about exposure to their professional bodies and/or being taken to
court which might be more indicative of the interpersonal CMC Social Identity
Deindividuation Effects model (Lea & Spear, 1991) which suggests that social
identity factors are heightened and people become more sensitive to group
norms when communicating solely by text; Whilst participants in this study tried
to counteract the perceived fear by specific contracting, as per guidelines in
online counselling (BACP, 2009) it would seem this was often not enough to
allay their concerns.
Becoming uncertain
Findings from the current study suggest that participants became uncertain
about their own competence in being able to decipher client meaning through
the text and this seemed to be exacerbated through the time delay. It also
impacted on a questioning of the computer’s reliability in being the only means
of contact.
There is a great deal of concern in the therapeutic world regarding the lack of
cues in email therapy possibly impacting the therapeutic relationship and the
possibility of misinterpreting a client’s message (Rochlen, et al., 2004; Mora et
al., 2008); and findings indicate this was an area of worry for participants, and
one which appeared to erode their sense of therapeutic competence. One of the
therapist’s primary roles is to empathically decipher a client’s distress,
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DISCUSSION
(Norcross, 2011) and it seems that anxieties around caused a number of

concerns for email therapists. Social Presence Theory (Short et al., 1976)
suggests that the lack of cues are worrying and that immediacy found in
physical proximity is crucial to understanding a message and the findings of this
study would appear to support this hypothesis and contradict the finding that
suggests that the lack of cues can be adapted to over time, as hypothesised in
Social Information Processing Theory (Walther, 1992).
Participants’ concerns also seemed to be exacerbated by the time delay and

this supports Smithson’s suggestion that delay (Smithson, 2008) can create the
conditions for uncertainty, or perhaps adds to it in this case through the need to
work therapeutically via the medium. In addition findings suggest participants
felt ‘drawn in’ to wanting to respond during the void created by the time delay
and were left wondering about the client during this time, a phenomenon
described as ‘the black hole effect’ (Suler, 1997). Those participants newer to
email seemed to find these factors most difficult to negotiate and to some
degree this might be explained by the inexperience that comes with using a new
skill, or perhaps a conscious incompetence feeling. As participants became
more experienced and more confident in the email medium they seemed to
build up a degree of robustness, but a ‘feeling the fear and doing it anyway’
attitude remained, which expands on research findings that online therapists
need to take a ‘leap of faith’ (Fletcher-Tomenious & Vossler, 2009) to negotiate
the information missing through the lack of cues in working in email therapy.
Whilst it has been suggested that the time delay context of email therapy could
be a positive factor in that it gives both therapists and clients’ time to reflect
(Dunn, 2012; Chester & Glass, 2006) this was rather contradicted by the
findings of this study. Conversely the time delay appeared to cause
consternation for some participants in this study and the anxieties induced by
waiting for a response appeared difficult to tolerate. This contradicts the
suggestion of the Hyperpersonal CMC model, which suggests that having time
to contemplate a message is a positive factor; whilst this may be true of some
clients many participants did not feel it.
102
DISCUSSION
Whilst anxiety is believed to be an inevitable outcome of relatedness (Spinelli,

2007) the finding of the current study suggest that a lack of relatedness in email
counselling can also lead to anxiety, and supports Lemma’s suggestion that too
much can perhaps feel disabling (Lemma, 2003). In addition the current
research findings suggest that the lack of containment experienced when
working online can exacerbate anxiety. A study of staff working in medical and
psychiatric institutions by psychoanalysts Hinshelwood and Skotsgad suggests
that there can be severe consequences for therapists who lack a containing
structure (Hinshelwood and Skotsgad, 2010). These researchers noted that the
resultant defenses against anxiety tended to undermine personal contact and
relationships by causing the worker to become detached in order to cope with
the anxiety. In addition these researchers suggested that fears could lead to
negative unconscious fantasies. Participants in the current study seemed
affected by the loss of containment of the process afforded by the email context
and alarmed by the possibility of being exposed to the world (wide web). It is
believed that it can be costly to ignore stress in working situations as this can
lead to ‘burnout’ (Haslam, 2004) when the therapist is no longer able to cope
with the working conditions. Kamhi suggests that practitioners tend to err on
the side of certainty when faced with balancing clinical decisions due to
concerns over harming clients (Kamhi, 2011), however findings from the current
study would appear to suggest that certainty can be difficult to attain when
working online and that this would appear to be a source of anxiety.
The anxiety experienced by participants appeared to be fed by the higher

degree of uncertainty and worry involved in working with the email medium due
to its lack of sensory cues, time delay and anonymity effects. The anxiety
expressed did not always appear to be fully processed or acknowledged and
sometimes emerged in interview situations with one participant realising how
much face-to-face cues were missed and resolving to change part of her
practice to incorporate a face-to-face element, and another participant feeling
‘meeting’ the researcher via Skype interview had made the relationship more
concrete and wondering whether to offer this facility to email clients. This
highlights the possibility that different contexts might offer different opportunities
103
DISCUSSION
for self-reflection. The lack of social cues involved with email therapy fits with
the third uncertainty construct of absence of, or clarity about, information that
Smithson (2008) argues can include different types of ignorance; conscious
(knowing what we do not know) and meta-ignorance (not knowing what we do
not know). This seems important in relation to what might be conscious or
unconscious to participants in the process, and whilst both these aspects are
thought to exist in human beings an important facet of the therapeutic
relationship is in being congruent (Norcross, 2011) as a therapist, keeping as
much as possible in awareness. This leads into the next category - managing
anxiety.
MANAGING ANXIETY
The anxiety that ensued from working with the therapeutic relationship in the
relatively cueless email counselling context appeared to be managed by several
processes; Becoming more task orientated, Avoiding difficulties,
Overcompensating and Defending the professional self-concept. Defense
mechanisms, in psychodynamic thinking, are suggested as unconscious tools to
protect the ego from anxiety and guilt, and further protecting the individual from
unacceptable impulses or perceived external threats (Vaillant, 1992), as
opposed to coping strategies which are described as conscious mechanisms
(Kramer, 2009) . Defense mechanism concepts are utilised here in helping to
make sense of participants’ actions and processes within the categories
presented.
Becoming more task orientated
As predicted by the cuelessness model, participants demonstrated more of a

focus on the task of therapy; this was suggested by participants’ reliance on
skills and theory. These actions could also be explained by the psychodynamic
construct of intellectualisation whereby the use of reason lessens anxiety
caused by emotional stress. Defense mechanisms can move between the
healthy or adaptive to more disturbed processes and the same one can be
useful in one situation but unhelpful in another (Lemma, 2003). Participants
104
DISCUSSION
appeared to be drawing on their existing face-to-face skills and theory as they

focused more on the task; this supports Rutter and Stephenson’s claim that
face-to-face conversations with social cues were more personal and
relationship building whereby cueless conversations become task driven and
impersonal (Rutter and Stephenson, 1979). These findings also offer some
support to the suggestion that the therapeutic relationship as a whole can be
considered to have two parts; functional and relational (Gelso & Hayes, 1998);
participants in this study seemed to be protecting themselves from the anxieties
evoked in the work by drawing on skills and theory - the cognitive, functional
aspect of the therapeutic relationship. The findings of the current study also
offer some tentative support for Hinshelwood & Skotsgad’s (2010) observations
about how mental health workers can become detached from their feelings
through anxiety defenses.
Roth and Cohen (1986) suggest there are two ways of dealing with stress, one
being; approaching, obsessing, being vigilant, which seems relevant to the
finding that participants demonstrated their task orientation by taking control of
the computer and having backups and encryption for safety; there appeared to
be a certain vigilance about what was contextually controllable in the process,
i.e. the computer. The second way of dealing with stress is thought to be
avoiding, repressing or forgetting (Roth and Cohen, 1986) and is further
described in the next category.
Avoiding difficulties
Participants also appeared to manage anxiety through minimising, both the role
of the computer and the differences between the modalities, often by holding on
tight to the known as outlined in the previous category. Roth and Cohen (1986),
suggest that the other way of dealing with stress is by avoiding, repressing,
forgetting or escaping a situation as it becomes too emotionally difficult to
handle. Participants described feeling as if they had no power over parts of the
therapeutic process, and appeared to be minimising this difficulty in order to
cope with the situation. Psychoanalytic researchers Miceli & Castelfranchi
(2005) suggest uncertainty through lack of perceived power in a situation might
lead to the defense of displacement which refers to transferring the threat from
105
DISCUSSION
an anxiety inducing situation to a less dangerous one, and that this results in
minimising the issue in order to cope.
Minimising in the current study appeared to protect participants from

considering what might be particularly difficult about email counselling.
Participants tended to focus on the similarities between face-to-face and email
counselling modes even while outlining, albeit indirectly, that they were clearly
quite different. Findings suggest that a degree of holding on to what was known
in face-to-face working was found which is supported by suggestions that
dealing with uncertainty in clinical practice is difficult, and practitioners have no
external self-correction mechanism which often causes them to err on the side
of safety (Kamhi, 2011).
Minimising also occurred in response to a question asking about the computer’s

possible role, where quite often it was referred to as a ‘tool’ and in some cases
participants expressed they did not think about it at all. These actions seem to
hint at the defense of denial, which can be described as refusal to accept
external reality because it seems too threatening by stating it does not exist, in
order to reduce anxiety. However, while the role of the computer was
minimised, participants expressed strong feelings towards the computer when it
‘misbehaved’; indicating perhaps, a transference reaction to the computer
(Suler, 2003). Suler further suggests the possibility that therapists may
experience transference both with and through the computer, but despite
evidence of it being ‘alive’ in the relationship participants did not seem to wish to
acknowledge it, which is unsurprising given the need to focus on similarities
with face-to-face counselling rather than differences. It seemed to be difficult to
acknowledge the place of the computer in the therapeutic relationship bearing in
mind the importance of aspects such as non-verbal communication
(Argyle,1983) and empathy (Mallen, et al., 2005a; Schore, 2013), yet
participants appeared to be suggesting that the goal, with experience, is to see
through the computer to the client, perhaps indicating an earlier struggle which
was hard to acknowledge.
106
DISCUSSION
Overcompensating
Findings suggest participants were drawn to counteract the uncertainty of

conducting a therapeutic relationship by email by overanalysing text, and trying
to perfect responses in the time delay. Findings indicated that the extra time
participants were afforded in email therapy drew them into a position of trying to
‘perfect’ responses, and caused them more doubt in the process. Being ‘drawn
in’ is reminiscent of ‘the black hole effect’ which Suler (1997) describes as being
sucked into an uncertain wondering of whether the email will be responded to,
and in this category seemed to also reflect participants’ fears about
miscommunication which seemed to lead to overcompensatory behaviour. This
reflect and perfect behaviour could be supported by the neuro linguistic
programming hypothesis that individuals become 100% connected to the words
on the page in email therapy, being the only source of communication
information (Addlington, 2009). This behaviour also supports the Hyperpersonal
model in CMC (Walther, 1996) with the ‘feedback’ aspect, suggesting a
reproducing and enhancing of all other three aspects of the model (Receivers,
Senders, Channel) in order to form a relationship; the suggestion being that the
enhancing element might act similarly to an overcompensatory process. Whilst
the reflect and perfect finding demonstrates that participants were highly
motivated to communicate clearly as in the interpersonal Social information
Processing CMC model (Walther, 1992) it also indicates that the time delay can
sometimes cause more self-reflection in participants, who may further doubt
their abilities. At times participants were aware of the urge to keep enhancing
messages, and the Hyperpersonal CMC model (Walther, 1992) ‘channel’ aspect
suggests users may redirect cognitive resources into enhancing a message,
which might tend to support this mindful finding.
Defending the professional self-concept
Findings indicated participants were engaged in defending their occupational

status in several ways; stressing the occupation should get more recognition;
stressing the importance of specific training in online therapy, strongly
advocating an expert route into becoming an online therapist, and
demonstrating an expert position. These protective behaviors would seem to
107
DISCUSSION
reflect the newness of the online counselling occupation and participants

demonstrated feeling very strongly about them.
Participants appeared to be engaged in fighting for professional recognition of

online counselling within the therapeutic world and this was indicated by
attempts to justify the importance of online counselling, especially in regard to
additional training in online counselling for practitioners. Participants seemed
keen to stress an expert route; one which incorporated a transition through
training to become an online counsellor, and ultimately reaching the position of
expert. Social identity theory is a concept developed by Tajfel and Turner
(1979) and suggests that a person’s sense of who they are is based on their
group membership(s). One reason people identify with groups is to reduce
subjective uncertainty in the situation (Hogg & Vaughan, 2002) and social
identity is that part of the self-concept derived from group membership,
considered separate to personal identity which is derived from personality traits
and relationships with others (Turner, 1982). Identification with the group is
thought to blur the distinction between self-concept (Smith & Henry, 1996), and
can lead to identification with the minimal group to reduce subjective uncertainty
(Hogg & Vaughan, 2002). Much as counselling psychology can be seen as a
sub-group of psychology, online counselling can be seen as a subgroup within
therapeutic circles: in effect both represent a collection of individuals who have
trained in a field and are now led to seek a social identity for safety and
protection.
Participants in this study often overtly suggested that the online counselling
profession should get more recognition and expressed gratitude that research
was being conducted in the area; indicating perhaps that participants did not
feel that online counselling had been accepted in to the counselling profession.
The need to train specifically in the online area was strongly supported;
participants appeared to be engaging in a discourse around ‘in or out’ positions
dependent on whether or not a specific online training had been completed.
This would seem to suggest that participants had developed a social identity,
perhaps to reduce the subjective uncertainty they felt (Hogg & Vaughan, 2002),
108
DISCUSSION
that group membership may have led to an identifying with the minimal group
creating an ingroup bias (Turner, 1982).
Belonging to an organisation such as the BPS/ BACP and/or a sub-group is

indicative of professionalisation; whereby members of a profession subscribe to
the values and beliefs nurtured by the professional group. It involves
modification of attitudes during the training phase and conformity to group
standards, as well as an acceptance of specific obligations to colleagues,
clients and the public (McKenna, 2012). The rise of ethical guidelines in online
counselling (BACP, 2009; APA, 2013; ISMHO, 2000; ACA, 2104) and
development of organisations such as ACTO, and other training text books in
the area (Evans, 2009; Weitz, 2014;) would also support the notion that the
online occupation were looking to professionalise.
The discourse was quite defensive at times which is understandable given that
new professions often feel under threat. Support for this is found with research
into health organisations, and it has been argued that social systems are a
defense against anxiety (Menzies Lyth, 1960), A thematic analysis into
professional identity in community mental health nursing (Crawford, Brown &
Majori, 2008) found that constant changes in the health service caused
uncertainty and that professionals were drawn to further their training to escape
their situation; this professional identity paradoxically became burdensome as
the pursuit of recognition made achieving professional status more difficult. For
the participants in the current study while professionalisation may be sought
with the best of intentions, it may also have the effect of creating a closed shop
situation and MacDonald (2004) suggests that occupational closure, or
professional demarcation, whereby an occupation transforms itself into a
profession by closing off entry to all but the suitably qualified may have the
negative effect of becoming over-defended and can therefore prevent important
messages being heard. Findings from the current study support the idea of
professional demarcation in advocating only the suitably qualified should enter
the field and whilst participants were very generous with their messages in this
study the fact that the survey was not overly responded to might indicate an
over-defended position.
109
DISCUSSION
Debates regarding the advantages and disadvantages (Mulhauser, 2005;

Fenichel et al., 2002) of online counselling may suggest it has not reached a
legitimate place in the therapeutic world, and George (2013) suggests that
cultural legitimacy is required before professionalisation can occur. Threat is
often felt in new professions who are striving for recognition supported by
Timmons (2010), an academic at a school of nursing, who suggests sub-sectors
of the NHS often feel under threat and push for professionalisation and
recognition for its members. Also a thematic analysis into professional identity in
community mental health nursing (Crawford et al., 2008) found that constant
changes in the health service caused uncertainty and professionals were drawn
to further their training to escape their situation. it is interesting to note that
online counselling has been around for the same amount of time as counselling
psychology as a profession, and possibly shares many of the same concerns.
110
LIMITATIONS OF RESEARCH
Although this research has provided a useful theoretical account of therapists’

experiences of email counselling and the therapeutic relationship it is
acknowledged that there are a number of limitations that require consideration:
 All participants in the research were Caucasian meaning that the

sample is not necessarily representative of culturally diverse
experiences and views. Counselling as a profession is often considered
a Western notion and perhaps over-represented by Caucasian women;
members of non-Western cultures might have given a different view.
 Whilst care was taken to attend to the nuances of the different face-to-
face and online research methods used in the study (Hanley, 2011)
there is a possibility that researcher inexperience in semi-structured
interviewing, competence in Skype, and occasional, unavoidable
technology breakdowns such as internet connection problems
influenced the process, thereby affecting the findings.
 Self-selection bias is an issue when using survey data as it may produce
a voluntary-response bias, where the resulting sample can be over-
representative of those who have strong opinions and thus may not be a
true representation of the general opinion. However, in qualitative
research some of these issues are unavoidable due to the need to
recruit from a relatively homogenous group (Collier & Mahoney, 1996).
 The researcher acknowledges that the grounded theory presented is her
construction and her framework will have influenced that this. In
addition, participants’ accounts are likely to have been influenced by the
researcher’s position as a trainee counselling psychologist who had
additionally trained in online counselling. Given the uncertainties
outlined above and need to protect the profession participants may well
have been unsure about the researcher’s position on online counselling
and they may have felt the need to defend both themselves and the
profession. This may have impacted on more critical voices being heard.
Critics suggest a number of limitations with the grounded theory method and
although utilizing the constructivist style of grounded theory provided a
111
substantial degree of rich data on therapists’ experiences of the email

phenomenon, it is acknowledged there are a number of potential
methodological issues to be considered. A critique of grounded theory is
provided by Thomas & James (2006); these writers criticise grounded theory for
oversimplifying complex meanings and interrelationships in the data,
constraining analysis by putting procedure before interpretation and depending
on inappropriate models of induction from which claims about explanation and
prediction are made. Thomas and James (2006) argue that grounded theory
promises too much, and rejects simple understanding through researcher
interpretation. Much of this critique can be disputed, on the basis that
constructivist grounded theory has clear epistemological assumptions that
include the researcher’s perspective, the methods are flexible enough to access
the unanticipated and facilitate creative and open coding, but avoid imposing a
forced framework on the codes (Charmaz, 2006).
In summary grounded theory is criticised for trying to claim it is something it is

not and that the focus on method misses simple understandings and meaning
from participant accounts. It has further been criticised for being overly labour
intensive and being difficult to report succinctly (Fassinger, 2005). Whilst the
development of a constructivist grounded theory (Charmaz, 2010) has gone
some way to overcome some of the criticisms of traditional grounded theory by
rejecting objectivity claims and its positivist nature, Charmaz is still challenged
for calling the method ‘grounded theory’, suggesting that it is more about
enabling interpretation and insight than a theory (Thomas & James, 2006).
Ensuring methodological rigour

Methodological rigour is a way of assuring quality and validity in qualitative
research and is assessed on both the basis of the paradigmatic underpinnings,
and the standards of the discipline (Morrow, 2005). When ensuring
methodological rigour in qualitative research the most well known qualitative
evaluative criteria are those of Lincoln and Guba (1985) who believe
trustworthiness consists of;
 Credibility – Having confidence in the ‘truth’ of the findings by
prolonged engagement with participants. In this study care was
112
taken to ensure anonymous and open-ended questioning allowed

participants to guide the enquiry as well as checking back (where
appropriate) with emerging theory and using participants’ own
words. In addition the researcher kept a reflexive journal articulating
her personal views and the directions taken whilst exploring the
phenomenon.
 Transferability – The researcher needs to show that their findings
have applicability in other contexts by providing thick description, a
concept described as the detailed account of field experiences in
which the researcher makes explicit the patterns of cultural and
social relationships and puts them in context (Holloway, 1997). To
ensure visibility in complying with aspects of transferability examples
of survey material, interview transcripts, and email responses are
included in the appendices of the report (Appendices G, H & I).
 Dependability and Confirmability – These rely to some degree on
external supervisors (in this researcher’s case) who checked on-
going data analysis and analytical developments to ensure that the
researchers own biases were not unduly influencing the process and
that the analysis was grounded in the data; although in constructivist
grounded theory the emphasis is less about trying to bracket
assumptions and biases, and more about acknowledging what these
are and that they will have an impact. All of the supervisors of this
project were experienced researchers and the main supervisor was
experienced and skilled in grounded theory analysis methods. The
researchers’ reflexive diary, contact with supervisors throughout the
research process, and research notes were all useful to this
evaluation.
Grounded theory offers a number of strengths: It safeguards against inherent

rigidity through explanation grounded in empirical data (Munhall & Oiler, 1986),
through constant comparison a modifiable theory is developed (Glaser, 1999). It
is further argued that strictly adhering to the process and methods of grounded
theory will ensure rigour (Seale & Silverman, 1997).
113
Chiovitti & Piran (2003) suggest that rigour can be ensured in grounded theory
by using the following criteria for trustworthiness in grounded theory research;
credibility, auditability and fittingness. Credibility was ensured by allowing
participants to guide the process of inquiry, which in this case utilised open-
ended questions via an anonymous survey, and interviewing, using
participant’s own words and checking theoretical constructions by member
checking. Also articulating the researcher’s personal insights and views of the
phenomenon explored by utilising field notes, a reflexive journal and
monitoring how the literature was used. Auditability involved specifying how
and why participants were selected and being clear about the criteria built into
the researcher’s thinking, these are clearly stated within this study; Fittingness
was achieved by outlining the scope of the research in terms of the sample
setting and level of theory generated, whilst also describing how the literature
relates to each category (Chiovitti & Piran, 2003). By following the
trustworthiness criteria in this grounded theory research it is believed
methodological rigour can be ensured.
114
IMPLICATIONS FOR EMAIL PRACTITIONERS AND COUNSELLING PSYCHOLOGISTS
IMPLICATIONS FOR EMAIL PRACTITIONERS AND COUNSELLING

PSYCHOLOGISTS
The findings outlined in this current study offer an understanding of the

processes involved in conducting email counselling, especially in relation to the
therapeutic relationship. What has been identified is that participants
considered it was possible to foster a therapeutic relationship with clients via the
computer mediated context of email therapy; however the process was clearly
quite different and challenging in ways which weren’t always fully acknowledged
by participants. There was a tendency to adapt face-to-face skills when working
in the email counselling context but this did not always seem to fit onto some of
the more unique aspects of the medium, causing anxiety for practitioners.
Importantly some of this anxiety was managed by minimising what might be
difficult and holding on tight to what was known from face-to-face experiences.
Additional ways of managing anxiety such as protecting by defending expertise
and looking to professionalise the online therapy occupation indicated that email
counsellors might be struggling with their sense of professional identity. These
findings suggest there might be a different process occurring for therapists
conducting email counselling that has not previously been considered,
suggesting a different way of working in this mode. The significance of these
findings are important and are likely to have implications for the practice,
supervision, training, and in particular the profession of email counselling.
These aspects are discussed as follows.
Practice issues
There are several issues arising from this research study that would seem
relevant to therapists, supervisors and trainers working in the area of email
counselling. Although in face-to-face work therapeutic containment is generally
the responsibility of the therapist (who may rely on supervision for their own
containment), this process seems more problematic in email counselling
through the difficulties outlined above. This loss of control of the process and
the context in email therapy leads to a number of anxieties and this can impact
on therapists in many ways as they attempt to manage them. Implications for
therapists are that perhaps there is a drive to work harder to engender the
115
therapeutic relationship, and more concern over client safety in email

counselling due to the lack of confirming physical ‘evidence’ that therapists in
face-to-face working have come to rely on. Client safety cannot be assumed in
the same way as in face-to-face and the responsibility for ensuring a safe
emotionally containing space in cyberspace would appear to be an extra burden
for email therapists.
It would seem important to recognise that for client and therapist developing a
therapeutic relationship via email counselling is mostly built on an internal
construct of relationship, and a certain degree of fantasy is necessary to
facilitate this. Participants described concerns about recognising their own
process i.e. what was their own imagination and how much they could act on it,
and had to do this while working in the relative uncertainty of the intersubjective
‘space’ afforded by only working with cues in the text. Some of the
understandable anxiety transpired in more avoidant defensive behaviours,
indicating there might be aspects of working in this way that were more difficult
to express than in face-to-face encounters. It is important to note that as well as
checking ‘externally’ with supervision, email therapists it would seem developed
a degree of therapeutic robustness over time, in order to tolerate working with
the heightened internal processes and other inherent uncertainties. The
‘robustness’ would also seem to be linked to levels of training and experience in
the email counselling field.
Participants in this study appeared to be facing additional difficulties regarding

their professional identity. As professionals in a relatively new profession they
appeared to be particularly concerned about professional recognition despite
evidence that the service was being widely used and accepted by clients
(Hanley & Reynolds Jr., 2009; Fenichell et al., 2002; Richards & Viganó, 2013).
Where they felt less accepted perhaps was within the professional therapeutic
community perhaps due to the ‘quagmire’ (Rummell & Joyce, 2010) of differing
ethical and practice guidelines. It has been suggested there is an alarming
degree of non-compliance with the online counselling guidelines currently in
existence (Richards & Viganó, 2013), which would imply that larger professional
bodies are not supporting online counselling in general by dealing with bad
practice. This has implications for therapists feeling safe within their own
116
practice and the possibility that this lack of safety might lead to defensive
practices, which would have implications for professional practice and the
therapeutic relationship.
Recommendations for practice
Recommendations for practitioners - Although it is important to be able to

respond to client preferences (Cooper & McLeod, 2011) practitioners also need
to consider whether they feel able to weather the uncertainties involved in email
counselling, both personally and professionally. This would involve making
themselves aware of these issues and ensuring that they had enough training to
help deliver a safe and effective service. Practitioners may need to consider the
isolated nature of working one end of a looking glass screen and perhaps join
professional groups for support. There is also the perceived issue that the
therapeutic ‘door’ might be open 24/7 and that a therapist might perhaps need
to be more boundaried; a suggestion from a presentation at the ACTO 2014
conference is that therapists need to become ‘unplugged’ from work for a while
to ensure self-care. Crucially, it is recommended to retain a supervisor
experienced in email counselling (or whatever style of online counselling
practised) and consider interacting in different ways (webchat, telephone, email,
instant message, face-to-face) in order to provide different contextual insights of
therapist process. It would seem important for practitioners to have
opportunities to express any natural anxieties, conscious or unconscious, in
order to avoid ‘burnout’ (Haslem, 2004); Menzies Lyth (1960) suggests that
unexpressed anxieties negatively affected nurses.
Recommendations for training – The grounded theory presented illustrates

some of the unique issues and processes involved in online counselling and
add support to the suggestion that there should be a separation between
asynchronous and synchronous methods within the trainings (Rummell &
Joyce, 2010). Current UK guidelines (BACP, 2009) suggest online counselling
requires a competency level of its own, which includes a level of therapeutic
experience. The BACP strongly advocates additional training. Despite online
and email therapy in particular being so prolific there is currently no provision in
core therapy trainings to consider the difference between online and face-to-
117
face methods (Anthony, 2014). Bearing in mind that practitioners are likely to be
strongly influenced to move in to the online area (Evans, 2009) a
recommendation is that training in online counselling should be offered on all
core trainings in order that practitioners can consider what is involved in working
in the area. There are a growing number of reputable training organisations for
online counselling but it is suggested perhaps not enough provision (Richards &
Viganó, 2013) for novice therapists and this is an area that needs to be
addressed.
Recommendations for supervision – It is hoped that the processes outlined in

the grounded theory presented will be of interest and use to supervisors, both
those experienced in online practice and those who are unfamiliar with the
processes involved in online work. Training for online supervision is as yet
limited, although the BACP have been working on necessary competencies;
however there is still debate as to whether online supervision should be an
actual requirement (BACP, 2009). Findings from the current study indicate that
the containment provided by supervision is essential and that supervisors need
to be aware that practitioners working online need support to work in an area
that has so much inherent uncertainty. Whilst still debated it is currently
suggested as useful to provide online supervision to online therapists, as the
parallel process involved may throw light on the process (Weitz, 2014), and for
convenience. However, findings in this study indicate that it might be
advantageous to consider different modes of communication (e.g. webchat,
telephone, face-to-face) as whilst emulating a parallel process might be useful,
other contexts might also be useful in providing other insights and add
additional social cues to work with.
Practice guidelines– Practice and ethical guidelines do not seem to be giving a

consistent message about whether online counselling is a legitimate sub-
profession, and this could be undermining email therapists’ confidence in
conducting the therapy. This is indicated by the high level of anxiety revealed
and what appears to be protective discourse and protective practices. It would
seem that the inconsistent message could be muddying the waters and that
email therapists are not sure that their professional bodies will safely support
118
them. This needs to be addressed, especially in light of how prevalent the

practice is and several suggestions are offered:
1) Professional bodies should perhaps come to an accord regarding online

counselling and produce a coherent set of guidelines and ensure
adherence to these. It is hoped that this would help to protect the client,
support email therapists to feel safer practising and add legitimacy to the
profession.
2) Psychologists are underrepresented in the online therapy area (Shaw &

Shaw, 2006) and the BPS have not recognised working online as a
separate entity or issued guidelines for psychologists wishing to move
into the area. There are advice papers for psychologists who wish to do
so but these do not specify what is involved with online working in
psychology training, and with an absence of support from the
professional body it might be difficult to make an informed decision about
whether to train to become an online practitioner. Additionally, it is
suggested there is a problem in not enough counselling psychologists
operating online currently, which will be likely to impact on the provision
of online supervision by counselling psychologists for the future (Mallen
et al., 2005a). There is a danger that the psychology profession will be
left behind (Rummell & Joyce, 2010)
119
DIRECTIONS FOR FURTHER RESEARCH
Findings from the current study indicate that email therapists struggle with
aspects of developing a therapeutic relationship due to the lack of non-verbal
cues and working through a computer, which may in part be due to the fact that
research in this area tends to translate theory from face-to-face counselling into
the online medium (Laslow et al., 1999; Hunt, 2002). Research regarding the
therapeutic relationship within online counselling has also been criticised for a
lack of clarity about which elements of the relationship are being explored
(Horvath, 2005, Norcross 2011) and what medium within online counselling it
relates to (Rummell & Joyce, 2010). Future qualitative research could involve
the important therapeutic relationship factor of empathy and how this is
conveyed and received (if it is), through the relatively cueless email therapy
mode. This could be achieved through mixed research methods of client and
therapist of the same therapeutic encounter; measuring the working alliance
and/ or and adapted empathy measure, and qualitatively exploring the
experience of empathy. This concurs with a counselling psychology review
(Mallen et al., 2005a) regarding empathy as an important facet of the
therapeutic relationship and further supports the idea of more defined research
in the area (Richards & Viganó, 2013).
Findings in this research highlight a particular difficulty participants had in

acknowledging the computer, sometimes denying its existence in the process.
This is a fascinating finding and could be indicative of an imposition of face-to-
face values on the very different processes identified in this research. Further
qualitative research into the perceived role of the computer in the therapeutic
relationship, within email counselling, from both practitioner and client
perspectives might throw some light on how the computer is experienced in
therapy.
Future research might also include extending and testing the process identified
in this research, and furthering the suggestion that the creation of a new
theoretical framework for email therapy would be useful to prospective online
practitioners (Barnett, 2005). One way this could be achieved is in further
investigating a therapist’s overreliance on their intuitive sense in the absence of
120
non-verbal cues/ external evidence using qualitative research. Also researching

whether the process identified by participants would be useful, as in is it similar
or different for clients, by utilising qualitative research methods.
CONCLUSIONS
The grounded theory outlined above describes the unique set of challenges
involved in email counselling and how these impact on the therapeutic
relationship. These challenges involve a loss of control of the process and
context, fears around client safety issues and professional exposure,
uncertainties regarding computer and professional competence. Additional
challenges involved with working in a time delay and with the anonymity of
cyberspace that led to fantasy and solipsistic introjection. There was a tendency
to adapt face-to-face skills to try to fit the email therapy context, which did not
always overlap, and at times this led to uncertainty. The challenges involved in
working with the uncertainty inherent in email therapy appeared to cause
anxiety in practitioners, which was not always acknowledged, processed or
expressed but which became apparent through the protective behaviours that
participants engaged in.
The most unexpected finding was the amount of anxiety within the discourse
regarding email counselling’s position within the therapy profession. The unique
factors of conducting email therapy through CMC required a high degree of skill,
competence and robustness but the ‘quagmire’ (Rummell & Joyce, 2010) in
different guidelines and professional bodies seemed to undermine email
counselling’s status. Email counsellors were drawn to professionalise for safety
it would seem, not helped by stark warnings to would be email therapists to
‘drive safely’ as the reputation of the profession, their personal existence and
client welfare are at stake (Pelling, 2009). Perhaps the message is rather black
and white in suggesting an ‘in’ or ‘out’ position when the therapy profession as a
whole would be better served by looking to be more inclusive, explorative and
welcoming of a mode of counselling that clients find helpful. This in turn might
allow for open conversations about what is difficult and different in the dynamic
world of therapy in cyberspace.
121
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APPENDIX SECTION
A Table of available participant demographic information
B Debrief sheet
C Ethical approval certificate
D Information sheet
E Consent form
F Information regarding journal considered for future submission
G Section of coded survey data
H Extracts from two transcribed and coded interviews
I Example of coded email interview
J Examples of diagramming process
K Example of memoing process
L Transcription key
155
Appendix A- Table of available participant demographic information
PARTICIPANT AGE SEX ETHNICITY FACE-TO- EMAIL QUALIFICATIONS THEORETICAL MODE of

FACE EXPERIENCE ORIENTATION Interview
EXPERIENCE
1 68 F White 17 11 Advanced certificate in Integrative Survey
British counselling
2 F British 15 10 Advanced certificate in on-line TA integrative Survey
counselling
3 Survey
4 81 F British 32 10 Certificate in counselling Integrative Survey.
Skype
interview
5 42 M White 2 1 Postgraduate Diploma in Person Centred Survey
British Counselling & Psychotherapy
6 62 F White 19 10 Diploma in counselling Integrative Survey
British online counselling cert F2F
interview
Member
checking
Email
7 F White 2 4 Diploma in Therapeutic Integrative Survey

British Counselling. Additional training
in Online counselling .
8 46 F British 8 2 Diploma in both Integrative Survey
9 F British 8 Certificate in counselling Person centred and CBT Survey
Advanced certificate in online
156
counselling
10 46 F White 8 2 Diploma in both Integrative Survey
British
11 F White 8 1 MSc Degree in Counselling Person centred Survey
European
12 F White 8 2 Online - Cert in Online therapy Integretative - Mostly Survey
British PC and CBT
13 37 F White 9 4 Certificate in Online Therapy Mainly Gestalt...and Survey.
British Integrative Skype
interview.
Follow up
Email.
Member
checking
Skype int.
14 49 F White 3 3 Certificate in counselling Person - centred and Survey
British Integrative
15 F White 4 1 Diploma in counselling Integrative Survey

British Work based training in online
16 50 M White 12 2 Post-graduate Diploma in Person centred Survey
Counselling
Online Counselling certificate
17 45 F White 2 4 Diploma in counselling diploma Person centred Survey
in online counselling
18 F White 16 9 MA in counselling Humanistic Survey
British Diploma in online counselling
19 67 F White 28 11 Diploma and MSc in counselling. Humanistic Survey
157
British Cert and Dip in Online Skype
counselling interview
SURVEY 2
New to email
20 59 F White 4 <1 Diploma and MSc in counselling. CBT Survey
Online counselling briefly
covered within other course.
21 F British 16 <1 Diploma in counselling, BSc hons Integrative Survey

white Integrative counselling. Specialist
certificate in online therapy
Interviews of
Non email
practicing
22 32 F White 6 0 Professional doctorate in Pluralistic F2F
British counselling psychology interview
23 45 M White 15 0 MA Psychotherapy Relational F2F
British Diploma in counselling psychotherapy interview
24 38 F White 7 0 Professional doctorate in Relational integrative Email
British counselling psychology
25 40 F White 7 0 Intermediate certificate in Integrative Email
British counselling skills
Advanced cert in counselling
skills
158
Appendix B – Debrief
Debrief
Title of study: Email counselling and the therapeutic relationship
Thank you for taking part in this study; if you have any questions about the study or would like
to say anything about your experience of participating then please feel free to discuss this with
me.
Please remember that you have the right to withdraw the information collected about you at
any time during or after the study. All you have to do is email me giving your ID number
(which can be found at the top of your Participant Information Sheet) and your data will be
removed from the study.
It is possible that you may have experienced some distress as a result of talking about your
experiences of Email counselling. If this is the case, then I am providing details of the
following agencies for your convenience:
For a list of accredited therapists, refer to the following:
www.bps.org.uk (T: 0116 254 9568)
www.bacp.co.uk (T: 01455 883316)
Assistance can also be accessed via your GP
If you have any comments or concerns about the study, please email me at:
[email protected] or my Director of Studies
[email protected]
Thank you once again for participating in this study.
159
Appendix C – Ethical approval certificate
University of the West of England,

Bristol
Faculty of Health & Life Sciences
Research Governance
Project Certificate
HLS10-2341 APPROVED
Project Details Overall approval status for is
Therapists' experiences of the therapeutic relationship i

Project Title:
Project Area/Level: Psychology Doctorate

/
Proposed Start/End Dates: 01-06-2012 28-04-2014

/
Chief Investigator: Mrs Carole Francis-Sm
Ms Andrea Halew ood
Supervisor/Manager: Review Complete

<-Approval Lock
should be checked
Section Status: Approved
160
Ethics Ethics Not Required? or Previous Approval?
Supervisor/Manager Status/Approval: Review Complete
Ethics Scrutineer Status/Approval: Review Complete
Ethics Chair Status/Approval: Not Review ed
UWE Ethics Comm Status/Approval: Not Review ed
Ethics Section Status: Approved
Health & Safety Low Risk? or Previous Approval?
H+S Scrutineer Status/Approval: Review Complete
H+S Chair Status/Approval: Not Review ed
H+S Section Status: Approved
Genetic Modification No use of GM Organisms?:
161
GM RA Lead Worker Status/Approval: Not Review ed
GM Chair Status/Approval: Not Review ed
GM Section Status: Approved
Animal Care & Husbandry No Involvement of Animals?:
Animal Care Chair Status/Approval: Not Review ed
Animal Care Section Status: Approved
162
Appendix D- Information sheet (slightly altered according to mode of
contact)
ID no.
Participant Information Sheet
Title of study: E-mail counselling and the therapeutic relationship: A grounded

theory analysis of therapists’ experiences.
Please take the time to read the following information carefully; if there is
anything that is not clear or that you would like more information about then
please do ask.
What is the purpose of the research?

To explore therapist’s experiences of offering e-mail counselling, and their view
of the therapeutic relationship within this medium.
Who is carrying out the research?

I am trainee counselling psychologist and I am undertaking this research as a
part of my Professional Doctorate in Counselling Psychology. My project is
being supervised by Andrea Halewood and Dr Naomi Moller, Principal Lecturer
in Psychology at UWE.
Why have you been invited to take part?

You have been invited to take part because you have trained to at least diploma
level as a counsellor and have three years post qualification experience of face-
to-face counselling, prior to becoming an online counsellor. I would be
interested in hearing about your experience of online counselling and in
particular the style of online counselling I am focusing on is non-synchronous,
e-mail type.
What will happen if you decide to take part?

If you decide to take part in the study you will be asked to confirm that you have
read this information sheet and to sign a consent form. You will be invited to
take part in an online survey. You may be asked to become further involved and
will have the choice of being interviewed at a pre-arranged time at a suitable
location or interviewed by e-mail. Your interview will then be transcribed as
necessary and analysed. Please be assured that any identifying material will be
removed at the point of transcription.
What happens if you decide at any point that you do not want to carry on
with the study?
You may withdraw from the study at any time without giving a reason and any
data collected from you will be destroyed.
163
What are the benefits/risks of taking part?
There is no physical harm inherent in the project but it is possible that the
experience of talking about your work in the area of online counselling may
evoke some distress. In terms of benefits, you may find that the opportunity to
talk about and reflect on your experiences to be beneficial. Additionally, the
study results have the potential to contribute to an under-researched area.
Will my participation in the study be kept confidential?

All information collected for the study will remain confidential; data stored on
paper will be held in locked filing cabinets and data stored on computers will be
password protected. All potentially identifying information will be removed from
transcripts and only anonymised data will be shared with study supervisors or
written up.
What happens at the end of the research study?

Interview data will be analysed and the findings will be written-up and submitted
as part of my Doctoral thesis. Papers for publication in academic journals may
also be written based upon the findings in which case all identifying features will
be removed in order to maintain anonymity.
What if there is a problem?

If you have concerns about any aspect of the study you can contact me by e-
mail: [email protected]. If you would like to contact one of
my supervisors then you can do so by e-mailing [email protected]
or [email protected]
Thank you for taking the time to read this document
164
Appendix E – Consent form
ID no.
Consent Form
Title of study: E-mail counselling and the therapeutic relationship: A grounded

theory analysis of therapists’ experiences.
I confirm that I have read and understood the Participant Information Sheet
for the study entitled “E-mail counselling and the therapeutic relationship: A
grounded theory analysis of therapists’ experiences.”
Please tick the following boxes to indicate you agree to the following:-
I have had the opportunity to consider the information, ask questions

if I so wish and have them answered satisfactorily.
I also understand that I am free to withdraw from the study at any time.
I consent to take part in this study
I agree to the face-to-face/Skype interview being audio recorded
I agree to the use of anonymised quotes being used in publications
By signing below you are indicating that you consent to take part in the study.
____________________ ______________ ______________________________

Signature Date Print name
____________________ ______________ ______________________________

Researchers signature Date Print name
165
Appendix F – Journal considered for article submission
Psychology and Psychotherapy: Theory, Research and Practice. Published by

the British Psychological Society.
Psychology and Psychotherapy: Theory, Research and Practice (formerly the

British Journal of Medical Psychology) is an international scientific journal with a
focus on the psychological aspects of mental health difficulties and well-being;
and psychological problems and their psychological treatments.
Journal publication guidelines:
The word limit for qualitative papers is 6,000. The word limit does not include
the abstract, reference list, figures and tables. Appendices however are
included in the word limit.
Contributions must be typed in double spacing with wide margins. All sheets
must be numbered.
Manuscripts should be preceded by a title page which includes a full list of
authors and their affiliations, as well as the corresponding author's contact
details.
Tables should be typed in double spacing, each on a separate page with a self-
explanatory title. Tables should be comprehensible without reference to the text.
They should be placed at the end of the manuscript with their approximate
locations indicated in the text.
Figures can be included at the end of the document or attached as separate
files, carefully labelled in initial capital/lower case lettering with symbols in a
form consistent with text use. Unnecessary background patterns, lines and
shading should be avoided. Captions should be listed on a separate sheet. The
resolution of digital images must be at least 300 dpi.
All Articles must include Practitioner Points – these are 2-4 bullet points, in
addition to the abstract, with the heading ‘Practitioner Points’. These should
briefly and clearly outline the relevance of your research to professional
practice.
For articles containing original scientific research, a structured abstract of up to
250 words should be included with the headings: Objectives, Design, Methods,
Results and Conclusions.
For reference citations, please use APA style. Particular care should be taken to
ensure that references are accurate and complete. Give all journal titles in full.
Authors are requested to avoid the use of sexist language.
Authors are responsible for acquiring written permission to publish lengthy
quotations, illustrations, etc. for which they do not own copyright.
This journal was chosen as it is likely to be read by the target audience of
Counselling Psychologists and therapists alike.
166
Appendix G – Examples of coded anonymous survey data
P1 There are differences between the email and a face to face relationship of Acknowledging differences Waiting for a
course. The email relationship works in a different way - there is no 'to-ing between relationship response.
and fro-ing' of interchanges. If I have a question or need to check for modalities.
understanding, for example, I have to write my query down and wait for the Working differently through Checking and
client's next email for a reply. Meanwhile, I continue to respond to the delayed interchange. waiting,
current email without an answer. This can sometimes mean I continue with Responding in the void.
my understanding of an issue in the hope that I haven't held up with the Worrying about Responding in the
counselling process for the client by a misunderstanding which can only be void.
misunderstanding
rectified in my next email. I find that working online by email can be a very
Noting similarity in intensity.
intense experience. When I am focusing on a client's words I am completely Worrying about lack
Focussing on clients words. of confirmation
unaware of anything else around me - this is similar to the intensity felt in
the counselling room. The relationship between me and my client builds in Being absorbed in clients (needing to get it
the same way as it does in the room - i.e. gradually and with increasing words. right).
trust as we get to know each other and each other's written style, use of Building a relationship the
language and presentation (choice of font, whether or not they are using same.
emoticons, etc.). I use the same basic counselling skills of warmth, Building increasing trust
genuineness, UPR and empathy, as I do in face to face work and to that gradually.
extent the relationships feel very similar. However, because of the nature of Getting to know each other’s
the communication medium, I find I am 'saying' (writing) in larger chunks (of style. Building a
text) without any feedback, confirmation or challenge from my client. That Using same basic counselling relationship via
feels very different from a face to face setting and at first I found it a difficult skills writing style.
aspect of working like this. I have been doing email counselling for 11 years Feeling very similar in terms
now, and it feels a lot less difficult now. I appreciate the time to reflect of skill usage.
before I respond and the opportunity to make my response as good as I Saying ‘more’ without
can. I find that because I can re-read what the client has written, I can feedback Saying ‘more’
formulate my reply very carefully. I could probably write more about the without feedback
Feeling a lot less difficult
therapeutic relationship but I'll continue with the other questions now,
over time
assuming my further thoughts will come out in later responses.#
I think the most significant difference for me is the quantity of text which I Appreciating time to reflect Formulating a
write without any input from the client. Some people might find this a before responding. careful response (as
distancing feature but my experience is that I have the same degree of Formulating more carefully. good as I can)
167
'closeness' with my clients as I would in the room. Where clients have Stressing quantity of text
become distressed I have noticed this from their 'presentation' (their most significant difference. Difficulty in
sentence structure becomes disjointed and they may jump from topic to Enthusiasm to talk further deciphering writing
topic without finishing a sentence. Their spelling shows they are typing the about therapeutic style of client when
words as they come into their head without reading or correcting spelling relationship. distressed ,
mistakes. One client became so angry that she used capital letters Feeling same degree of ‘vomiting’ or angry.
throughout her email and no punctuation at all. It was difficult to unravel closeness.
what she was writing about. Another client who felt misunderstood and Considering others might
unheard was also very angry and she wrote using ... instead of structuring
see as distancing.
her thoughts into separate sentences. All her thoughts joined into one long
sentence, and the dots became like pauses for breath. She needed to get a Noting client distress from Translating f2f skills,
lot of things off her chest like some people come a 'vomit' out their feelings quality of presentation. tasks & theories to
in the room. I'm not sure if what I've described are similarities or differences Struggling to unravel angry online.
between email and face to face work. response. Acting as
I think I've mentioned these in my previous answer. I use the same basic cyberpostman.
skills, I apply my counselling theory in the same way and will use tasks that Acknowledging similarity in
I may have used in the room e.g. gestalt empty chair work can translate into clients ‘vomiting’ out
3 emails between the client and their significant other with me acting as a feelings.
cyber postman, other writing tasks I use would also be ones I might use Using same basic skills.
face to face.The session boundaries are similar, too, as I now schedule Applying counselling theory
each email session into my diary and invite clients to send me emails same way.
between 'sessions' - the session then becomes the time I spend reading Adapting skills to email.
their email and replying to it. Other boundaries are similar, too, I do not Acting as cyber postman.
expect to have out of session contact with my clients and I do not contact Keeping similar session
them after we have ended a contract. Payment is made before a session boundaries.
begins.
Expecting payment in
My personal response to the computer is to think of it as tool to enhance my
advance. Keeping similar
work (my handwriting is atrocious, so seeing my words neatly printed gives
me personal satisfaction). However, it is also my only means of Viewing computer as boundaries.
communication with a client who may be in crisis and that has felt very enhancement tool.
hard. I have spent perhaps more time worrying about online clients in crisis Personally satisfying seeing
than I have worried about face to face ones and I think that might have neatly typed/written
something to do with my feeling helpless to do more at such times. message.
168
P2 I have to use my intuitive sense more as the visual clues are absent. Using intuitive sense to Working intuitively
make up for absent visual in visual clue void.
It takes time for me to adjust to the difference between face to face and on- cues.
line work. Taking time to adjust Taking time to adjust
between f2f and online. between modalities.
Face to face I have the ability to check out more and dialogue. Having ability to check out
more and use dialogue with
When using e-mail I have to be more tentative in the responses I give. Tentatively
f2f.
approaching via
Having to use more tentative
I build a working relationship in the same way; contract, sessional goals email.
and reviews. approach with email.
Building working relationship
It is the tool that allows me to speak.Much like my voice tone within a face in same way. Keeping similar
to face session. Using contracting, goals and boundaries.
reviews in same way.
I have come to accept that this is the medium that alot of people now use Computer tool facilitating Computer is a tool
and therefore it is one I consider speech. facilitating speech.
Similarity between text
online and voice tone. Accepting medium is
Accepting over time online more prevalent so
medium is more prevalent need to consider as
and therefore consider using therapist.
it.
P5 There are differences between this and face to face counselling, sometimes Acknowledging difference
I experience more doubt as to whether I am really in the client's frame of between different Doubting whether in
reference, because I am writing a response as one big chunk, without the modalities. clients frame of
client there to offer "course correction" as I write. At the same time, the Experiencing more doubt reference.
medium offers me the chance to pause and reflect to wonder whether a about whether in client’s
reflection is really appropriate. Sometimes it feels strange because I have frame of reference. Responding with no
this picture of a client in my head that I know may be completely different to Responding in big chunk with ‘course direction’.
how they are. Knitting the therapeutic relationship together can consist of no ‘course direction’.
169
several different strands - sometimes the experience can be amazing, in Delay offering opportunity to Opportunity to ‘get it
how much can be picked up from a few paragraphs, other times it is hard to get response as appropriate right’ enhanced by
tease out client meaning because there are no other clues. as poss. delay.
Feeling strange sometimes Fantasising about
as client ID may differ from client identity.
fantasy.
Differing strands knitting to Knitting the
therapeutic
form therapeutic
relationship together
relationship.
Sometimes it can be frustrating when clients, for whatever reason, do not can be amazing or
reply at a scheduled time, this can lead to doubt, but at the same time when Picking up cues from text. hard to tease out.
clients respond and confirm empathy, it can feel just as rewarding as face Experiencing as both
to face counselling. amazing and hard through
lack of cues.
Worrying and doubting Worrying and
The asynchronous nature of e-mail counselling make it difficult to check when no scheduled doubting when no
meaning reflection by reflection. With email counselling I feel a greater response. scheduled response.
need to pause for reflection, to ask clients questions to check meaning, to Feeling as rewarding as f2f
take care that I am not going off at a tangent or drifiting into my own frame when empathy confirmed.
of reference because the client is not there to correct me or nudge me back Checking meaning difficult Feeling relief &
into the right direction. The lack of immediate response can be quite when time delay. reward when
disconcerting - for example when a challenge has been made, and it may Taking care not going off on empathy confirmed.
be some time before the response comes back. When the response is tangent or drifting into own
delayed, this can lead to doubts and a desire to check in with the client. frame of reference. Disconcerting if no
immediate response
Feeling greater need to stop
after challenge made
& reflect, ask q’s to check
meaning.
Feeling congruence of own Congruently feeling
process vital, in absence of own process vital in
correction. absence of
Disconcerting when lack of correction.
One thing I have noticed is that the drop out rate at pre-therapy stage is immediate response.
170
much higher with email clients - many clients only get as far as starting the Especially when challenge Desiring to check-in
contracting process and then disappear. Sometimes clients will disappear has been made. in the void.
during the process (as with face to face). This can lead to a different set of Desiring to check-in when
questions from face to face - such as thoughts about whether the response delayed. Dropping out higher
technology has failed or the client has been unable to access the required Noticing pre-therapy pre-therapy.
technology. Contracting needs to account for very different things (such as dropout higher in email. Contracting
the technology above), and there is not always the "safety net" of being Disappearing after accounting for
able to refer on to appropriate support. Quite often, people who would not technology.
contracting.
access face to face counselling due to location (such as another country)
Disappearance leading to
get in touch, and there are complicated ethical considerations about
working with someone from another country, for example. Email counselling different set of questions Extra boundary
effectively leaves the counsellors' door open 24/7, so there are also from f2f. considerations.
boundary considerations to take into account - for example managing the Accounting for technology in
incidence of additional emails in between the main counselling emails contract.
(depending on what has been contracted). Disappearing causing unsafe
It feels like the core conditions of my model (Person Centred) do work via feeling as unable to refer. Black Hole
e-mail. Two people are in psychological contact whether it is by email or No ‘safety net’. Disappearing with
face to face, and one of these is incongruent, the other being the Ethical & legal & time no ‘safety net’.
counsellor. Empathy is offered and received (or not!), challenges may be management issues if
made, and congruence voiced. I have experienced very similar changes in abroad. The computer seems
clients via either medium. Managing uncontracted to effectively vanish
emails. - except when it
Acknowledging model fits decides to cause
The computer seems to effectively vanish - except when it decides to cause mode. problems!
problems! If the computer runs slow, or crashes, this can be an issue. Experiencing similarity with
There is an awareness that drafts need to be saved, so one eye needs to
person centred model in
be kept on protecting the email content that has been drafted. If there are
both modes.
connection problems etc, the technology can lead to some frustrations!
171
P7 It's hard to generalise, but I find it relatively easy to build a therapeutic Finding it relatively easy to As much time as I
relationship in e-mail counselling, as the process allows as much time as I build therapeutic need to get it right.
need to craft my responses in a way which feels appropriate for each relationship.
individual client in terms of mirroring their 'style', 'tone', etc. Allowing time to craft
1) Much less stressful in terms of immediacy - i.e. because the work is response in process.
asychronous, I don't feel the same pressure as in face to face when making Responding appropriately to
interventions... I can take my time and consider each one very carefully. 2) individual client,
No requirement to remember anything after the session, as it's all available Generally relieved as
eg.mirroring.
in textual form. 3) Very different in terms of conveying core conditions - i.e. less pressure.
Finding immediacy less
there's no way of expressing myself physically (body language) or easily
conveying my verbal tone, so every single word I write matters enormously, stressful. Lacking Every single word I
whereas in f2f, words can be changed/adjusted/retracted as we go along. requirement to remember write matters
4) Not distracted by the client's physical presence and vice versa, so a lot anything after session a enormously.
easier to really focus on the words and feelings expressed. 5) Easier to ask relief.
clients to free associate (in writing) whereas in f2f there's a sense that Greatly different in Both feeling less
clients feel they need to 'make sense'. 6) Much easier to focus on the conveying core conditions pressure to ‘perform’
client's vocabulary and notice patterns (lots of use of words like 'control', through lack of contact through less
'perfect', 'scared' etc. which is really useful and easy to draw clients Feeling every word written distractions.
attention to this too, so we can wonder about patterns and what they might matters enormously.
mean etc. Focussing on words and Easier to focus on
feelings easier through lack patterns in writing.
of client distraction.
Finding it easier to identify Freer to free
patterns in text. associate
1) Same sense of new-ness with each new client (who is this person, what Freer for clients to free
will our work involve, will I feel able to help, will they engage in the
associate.
process). 2) Same counselling skills are involved and same requirement to Similarities in
Using clients words to curiosity, skills, care
convey the core conditions. 3) Same feelings of care for client and their
welfare and happiness. 4) Same priorities in terms of professional conduct. explore issue feeling less and conduct.
pressure on therapist.
Acknowledging similarity in
I really don't think about it. same sense of newness with
I appreciate the convenience of online communication - so easy to client. Tending not to think
172
complete a survey online compared to having to physically complete a form Using same counselling skills. about computer.
or post it off. Conveying core conditions.
Priorities in professional
conduct same. Convenience of
Tending not to think about online survey.
computer.
Completing survey online
convenient.
Posting physically not
required.
173
Appendix H – Extracts from two transcribed and coded interviews
Skype (Brief description of how the interview is going to be conducted)

interview
Are you ready to begin?
P19
Yes, yes, absolutely (laughs)
So, I’ve got my little podium here, so I’m looking over to the left
(yeah – ok) or the right to you, then that’s what I’m looking at. So my
first question was, um, how do you experience the therapeutic
relationship in email counselling?
Yeah (quizzically) I wasn’t entirely sure what you meant by the

question (laughing)(hmm hmm) I mean I, experience it in that uh I
establish a relationship with the, with the clients, um, with majority of
clients, it’s a, a good strong relationship, um, with the odd client it’s Unsure on meaning of
not, um, as in face to face, um (hmm) as I say I wasn’t quite sure question.
what you were (yeah) you were asking there.
Feeling a good, strong
Yeah, yeah, I can see that, by a little bit by what you’ve written there, relationship is established
so, um, with, with that in mind I was wondering whether perhaps a with most clients.
better question might be ‘how do you know you’re experiencing it?’
Um, online
Uh, ok,
174
Or in email in particular
Yes, um, I think in two ways, um, probably more than two ways, but,
um, by the responses of the client, whether they are um, not so
Writing becoming
much engaging with the work because that sometimes is difficult for more intimate.
them, um, but engaging with me, sort of responding to me as a, Responses from clients show
another human being if you like rather than, um, responding to uh, a if relationship there.
robot at the end of computer or whatever. Um, and also by the
Engaging in the work Risking more as
change in the way that, uh, they might write or I might write to them, relationship
sort of, um, if I say how it becomes more casual, casual’s not really sometimes difficult for
develops.
client.
the right word, um, more intimate, more able to, um, risk them, them
risking saying things to me and me risking, um, saying something to Responding to me as a
them etc. So, that sort of change in how we write to each other, um, I human being an indicator.
think is, sort of, is quite a good indicator and also I ask them (laughs)
um, you know, I do a lot of checking out in emails um, both in terms Responding to a robot at the Asking overtly about
of, of something I’ve said, I’ve check out whether I’ve got it right, um, end of the computer. the process.
whether I’ve understood something, um, and I’ll ask them how it’s Feedback can be in
Changes in writing,
going, how they think the process is going regularly, um, what we’re the saying or not
becoming more intimate.
getting right, what we need to change (uhu) and that, if you feedback saying.
on the relationship (uhu) I mean either because they’re saying, um, Risking saying things to each
what I find helpful is the way you, you interact with me, you relate to other. Asking both ‘how
am I’ and’ how are
me or they don’t mention anything at all about the relationship and
Checking out more in email. we’ doing?
that can be an indicator it’s not going so well (uhu) if they totally
avoid commenting on it (mmm). Does that kind of make sense?
Um, yeah, I think so. If I could just ask you a couple of things (uhu)
about what you’ve just said? Um, one of them, I think you were
175
saying is that you, um, you ask about the relationship (hmm) is that Asking how the process is Asking about
what you were saying? That you ask about the relationship to see going. ‘relationship’ in
how the relationship is going, or? feedback.
Naming what we’re getting
Oh, uh, not so, I won’t say ‘how is the relationship going?’ but I’ll say right and what needs
what am I, what, what am I doing, what are we doing? Two separate changing.
questions, that is helping you? What are we doing, what am I doing
Feedback on the relationship
that maybe isn’t helpful, that you want me to do more of, what do we
need to do less of and that usually is about how we’re working Saying or not mentioning can
together and gives me an indication of the relationship. And I show what is happening in
wouldn’t ever, I don’t think I’ve ever said I think ‘how is our the relationship building.
relationship?’ (Said in a preposterous way) (Brief laugh)(yeah)
sking indirectly how the
Although in feedback, um, you know this is at the end of working as
relationship is going.
a client I might ask them to do an evaluation or a feedback, um,
form, um, then, there I would ask about the relationship, sort of Separating two question – is
directly, specifically (uhu uhu). How do you experience our that helping? What are we
relationship? doing?
Mmm, ok, brilliant. And the sort of process of email, um, therapy is Finding question from
obviously sort of writing something then waiting for a response, um, interviewer foolish.
do you, how do you experience that, um, or what are your thoughts
on the sort of process that’s going on in that gap, or that space? Asking more directly after.
For me or for the client or both?
Well both if you have any..
Right. Um, I think for, for me, um, it’s, it’s giving me time to reflect on
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both what they said in their last emails I’ve responded to and what
I’ve said and, um, thinking about sort of … what I might expect,
Reflecting in the
hope, that was going to come back in the next email, uh, um, it
void.
doesn’t always follow that that’s what’s going to happen, um, I, with
a lot of clients I think they do the same thing, they will go back and
reread their own emails, they’ll reread my emails in the gap in
Anticipating next
between, I always, with, with, my clients, uh, and supervisees for Given time to reflect in the response.
that matter, um, I always ask clients that they will acknowledge they gap.
have received my email and I will do the same for them, even if
they’re not, I’m not doing a full response at that point or I’m not Thinking time.
expecting them to do the full response. Um, but I think there’s
Forming expectation next
something about lessening anxiety on both sides about whether the
response.
emails been received, um, which I think’s important (uhu) Um,
Acknowledging early
actually something came up last night at the talk I was giving, um, Rereading own emails
lessens anxiety both
about what happens if I receive, um an email, suppose I receive an inbetween. sides.
email today but my day that we contracted to reply is, um, what day
are we? Is Friday, but within the client email there is, they’re
obviously very distressed and somebody asked how I dealt with that, Acknowledging email Treating distressed
so I guess that fits in with the time in between, um, I would probably received lessens anxiety on client more
in my, I received your email safely, email, I would probably actually both sides. therapeutically,
do something slightly more therapeutic than I would normally and initially.
say that I noticed that, um, you’re having a really difficult time and, Responding fuller at
um, for example, um, I’m aware that you in the past have used blah appropriate time.
as a support, or, um, I hope that you’re really be able to, um, carry
Feeling strongly immediate
out the self-care thing – whatever feels most appropriate. I wouldn’t
acknowledgment important.
do more than that (uhu) but I might, um, cos normally the sort of
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acknowledgement is absolutely non-therapeutic, it is purely an
acknowledgement of an email, but I might do something slightly in
that, that, that gap between, um, emails. Umm, you know.
Dealing with email from very
Hmm, ok, thank you.
distressed client in more
It’s rare but it happens (small laugh). therapeutic way.
So, I’ll just have a little scan through what you, what you wrote, um, Bringing in clients own
under this to see if there’s anything sort of different (yeah, yeah) um, support strategies.
(small pause), mm, you’ve put that often the therapeutic relationship
Acknowledgment usually
has formed very quickly (mm) possibly more so than face to face, I non-therapeutic.
wonder if you could elaborate a little on that please?
Um, I think clients often jump into, I know in face to face this can ‘jumping in’
happen as well but they jump into, um, working really hard, really
engaging in the process and therefore I think it’s, um, there’s less of
the sussing process going on, what I would call the sniffing, sniffing ‘sniffing the
the therapist out. Um, possible because there’s been a more ‘Jumping in’ to work therapist out’
prolonged contracting period, because they’ve approached me, um, happens in pre-
happens more in email.
therapy exchanges.
I’ve said yes I’ve got or no, whatever the case (laughs) I’ve said yes
I’ve got space to take you, um, I’ve sent them perhaps the contract Working hard.
and guidelines then they have perhaps queried or clarified Engaging in process.
something, so there’s been non therapeutic exchanges going Knowing more about
therapist from
backwards and forwards, they also probably know more about me, ‘Sniffing the therapist out’
internet.
um, if they’ve looked on the website or, or, or whatever, um, so I happens less.
think for that reason it’s often quicker, uh, forming the relationship
Contracting period longer,
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actually in the therapeutic work. (small pause) Um, I suspect it’s also could account for jumping in.
something to do, I can’t prove this, but I suspect it’s something to do
Exchanges of non-
with the medium as well. (uhu) but actually the, um, for whatever
therapeutic nature.
reason, perhaps it’s almost disinhibition but not in the true sense of
disinhibition but um, preparedness tooo, to trust, to get in there, um, Knowing more about
not to trust but to get in there, um, perhaps also because the therapist from website and
counsellor probably has to show more of themselves, um, if you’re in exchange. Preparedness to
a room with somebody, they can see you, they can see you’re engage.
nodding, they can see that and they sort of will pick up, will pick that Forming the relationship
up whereas you have to be much more specific, much more direct prior to work.
in, um, in saying those things so you perhaps, I don’t know, perhaps Suspecting the medium adds Showing more of
put more of yourself into, uh, initial emails than a client would to disinhibition. yourself as online
experience of you specifically face to face (mm mm ) yeah. therapist.
Preparedness to engage.
Mmm (start talking over the top of each other) Sorry, what were you Putting more of
going to say? Showing more of yourself as yourself in the email.
counsellor because you’re
I was going to say, I’m sort of really thinking that through, I’d, I, I, I’ve not in the room.
certainly experienced relationships being formed quickly, possibly in
some cases, um, more quickly than face to face, I was just trying to Putting more of yourself into
think if I put more, how a client possibly experiences me in the initial email than f2f.
different, um, in the different ways (thinking). So I’m aware that Having experienced
actually my online counselling has influenced the way that I work as relationships formed
an uh, a face to face counsellor not that I do very much of that, in Experienced relationships quicker online.
fact none at all now, um, but I think I was, um, there was more of formed quicker than f2f.
myself in the face to face counselling room as I worked online than
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there had been previously. Influenced as
therapist through
Hmm (yep) ok, thank you. And, the, you’ve mentioned disinhibition Working online has online learnings.
(yeah) in what we were just talking about, and had a, had an idea influenced how therapist
about, um, partly what was happening, I wondered if you other ideas works f2f.
on, um disinhibition or perhaps the anonymity effect uh.
Putting more of self in f2f
Oh I think that’s for many clients that’s um, being anonymous, um, counselling room now.
gives them the, the opportunity to say things that would take much
longer to say face to face, and also I do think it’s easier in the clients
mind for them to, they know that they can actually just stop Taking less time to say things
counselling (uhu uhu) and somehow, I know they can face to face in anonymity.
theoretically, not turn up for a session, not respond to your phone Taking less time to
call or not saying you haven’t come are you alright? Um, it’s, I think
Perceiving it is easier as get to point, through
client. anonymity.
it’s easier for the clients to believe that they can just stop so
therefore they’re willing to give you more. Um, I think disinhibition is Knowing they can just stop,
both helpful and unhelpful, um, I think sometimes the fact that therefore willing to give
they’re able to say a lot to start with does enable the process to Perceiving control
more.
over ending breeds
happen, um, quite speedily, uh, you into, to, to a lot of depth but it
Feeling disinhibition both willingness to give
can be opposite, that um, clients reread what they’ve written and
positive and negative. more.
think eeegodslittlefishes I didn’t really mean to say all that, so they
will then back off, um, for a bit, I mean they may still be emailing with Saying a lot at start enables
you but they will say much less for, for a while. So I think it’s both speedy, indepth process.
positive and negative. (mm mm) positive and unhelpful, not negative
(laughs). Rereading early emails can
cause anxiety and lead to
And how do you feel about the, uh, uh ability to reread, for both the
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counsellor and the, the client? backing off.
On the whole it’s, I think it’s helpful. I think it’s particularly helpful for Re-reading can
the client but I think the way in which it is helpful for the client is that cause client anxiety.
they can, um, they can hear their thoughts again. It’s a bit like having Hearing their
a tape of face to face session, they can, and decide whether that is Rereading helpful, on the thoughts again,
what they think, what they believe, what they feel or, or not, because whole. helpful.
sometimes we say things and then we hear what we’ve said and
think actually no, that’s not, that’s not right. It’s just something I’ve Hearing their thoughts again,
said forever and it’s not what I any longer believe or think or feel, I helpful.
Seeing old patterns,
think that can be, seeing that can be really useful. I think clients can Likening to having tape of f2f in text.
feel very affirmed by our responses, um, and that when they’re in session.
low patches can be very helpful for them to go back and read that
(mm). Uh, um they can mark progress cos they can see what they Reflecting on own words.
Affirmation via
wrote, what I wrote, um, in email 1, um and see where we’ve got to therapist.
Seeing old patterns can be
so I think that, that’s helpful. Um, ditto for the counsellor. I think
useful.
where it can be unhelpful is, um, in overanalysing what’s been
written, probably more on the part of the counsellor, uh, both going Affirmation via therapist Written words
back and overanalysing did I, um, what was that about, um, you responses. marking progress.
know should I pick that up, uh blahdiblahdiblah, or, um, gosh that
Marking progress by what’s
was an unhelpful remark that I made or, or, or whatever and I think
written.
you can do that too much and it sort of stops, it stops the Rereading
spontaneity, it stops you being there. Clients, mm, obviously can do Rereading as counsellor can (therapist) can lead
that but I think they do that less than couns, well I don’t know, my lead to overanalysing. to overanalysing and
sense is that they do it less than counsellors in a critical sort of stunting
analytic way (hmm hmm) Yeah, but on the whole I think it’s useful. I spontaneity.
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think it’s really useful in terms of supervision as well, to actually be
able to, to consult client’s material (hmm) and your own material.
Stopping the spontaneity or Consulting material
… ‘being there’. useful in
supervision.
(CONNECTION DROPPED OUT FOR A FEW MINUTES)
(Brief conversation about being reconnected)
I left just as you were beginning to talk about a cooking metaphor. Likening to whisking egg –
Likening extension
whisk is extension of arm.
Yeah, um, I I think, what I was going to say was if I’m whisking egg to whisking eggs.
whites, it’s almost like the, the whisk is an extension of my arm, I, it’s
sort of , I used to in my distant past teach home economics, that’s
why I’m using a cooking metaphor (laughs) um, um you it sort of was
just part of, part of what I’ve been doing, um, so the computer in that
sense although I’m, I know it’s a separate entity it, it just feel much
Knowing is separate entity Knowing separate
more like an extension (hmm) from me (laughs quietly) (ok) a tool.
but feeling like extension of but feeling like part
Yeah.
self. of self.
Thank you, um, under this section, um, you’ve, you say that if you
are working synchronously you use emoticons and text expression
(mm) and you use them in emails but much more sparingly.
Yeah, I, I can immediately check out with a client if I’m working Checking out use of Attuning to clients
synchronously whether they like the use of uh, emoticons or, or emoticons with client. text expressions.
whatever, um, with a a email client I will either tend to wait until
they’ve used them um, or whether they’ve used what I call texting
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expressions, you know, abbreviations etc. um, and then use them Using if they’ve used them.
because they’ve used them, I, I don’t mean in a sort of reflective way
Using texting expressions.
I mean using different ones possibly, um, but being aware that they
like using them. If they don’t use them and I really want to use Attuning to client.
something because I feel it’s appropriate I’ll do that but then I will
actually put in brackets um, ‘I don’t know whether you like uh
emoticons or find them irritating do let me know’ (uhu) and now
they’ll say yeah, I use them all the time, I haven’t liked to in emails,
or no I hate them or whatever it might be (mm). But I think, uh, um,
what I don’t want to do I suppose is um, do something that the client
might be, might find irritating but, um, doesn’t think that they should
tell me (mm mm), um, yeah.
And, do you, do you feel like you experience that, um, that idea that,
do you feel that happens, that you might do something but a client
wouldn’t tell in an email, or they more or less likely perhaps? In face
to face to email?
Face to face whether it be like this or whether it be in a room you,

you can pick up perhaps from the body language, you can’t do that
in an email and while you do ask what has been helpful and what
has been unhelpful they might, I think they’re more likely, they more
oftenly talk about what you’ve said or not said, um, and how you’ve
said it rather than, um, the specifics of, of things like emoticons that,
that, um, almost needs a more specific ‘how do you find this?’.
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P23 Um, it was how do you imagine it might, the therapeutic relationship Dialogue process might be Wondering if
slower. dialogue process
How do I ,yes, ok. So, in a way it’s a bit similar, there’s a sort of slower.
dialogue process but it’s a slower process, um, it feels potentially
more open to um, you know, stuff could be interpreted there’s quite a
lot more room for interpretation of, because you’re just trying to work,
you know, cos you’ve got less data to go on, uh, um, to some degree Using similar skills
I imagine there would be some, as a therapist you’d be wanting to do
some similar things like, some of the sort of skills you might use in
verbal, um, interactions like mirroring, I imagine, you know, if
someone’s using certain types of language you mirror that kind of
language, so building up a sense of we’re on the same page here Moving relational a bit
(mm). Um, you know, (short pause) I, I, I imagine that the relational further into the background Moving relational
bit, in some ways would move, move a little bit further into the into background.
background, that you would be a bit more task focused that would
come more into the foreground and your sort of, would be, I imagine
then you would be more, um, working towards..so, so in a lot of
therapeutic interaction there’s, there’s sort of mirroring so, you know,
you might say, you know, ‘it sounds like you’re feeling angry about
that’, I imagine you wouldn’t do that in email, I imagine you, there
wouldn’t be that mirroring process, although that might be included in Mirroring process not the Mirroring process
it but there would, there would be, so you might, I imagine you might same. different.
say, ‘I imagine you’re feeling angry and reading through the
difficulties’ so you might be in a bit more of an expert position,
perhaps, I don’t know, wanting to, um, so it’d be less sort of purely Positioning self as expert Positioning self as
humanistic I imagine, you’d be, uh, you might be more, yes, a bit more perhaps expert possibly
184
more expert if you like, um, offering your views on things um, and
suggesting techniques and things that they can practice so I, I
imagine it might be a bit more practical (uhu) um in its focus, um, you
you you’re not working, so in psychotherapy for instance which I do Creating a space for Creating
mostly you’ll you’re sort of thinking in terms of unconscious process, unconscious process to unconscious
you’re allowing, you’re allowing, creating a space for unconscious emerge- less likely. space less likely,
process to emerge into, I imagine there’s, you’re not doing a lot of postulated.
that, I imagine, um, you’re more working with the conscious, I’d have
thought (mm), you’re working with the clients conscious I think, I don’t Feeling there would be less
(uhu), um, just cos, uh, although stuff might , I imagine stuff could space for unconscious.
bubble up but there’s probably less of a space for that, it’s a bit more,
I imagine it to be more practically focused. I know I’m aware I’m
coming a bit off the point there, um, um, a bit away from the actual
Working with conscious. Working with
therapeutic relationship, I suppose I’m just wanting to imagine um,
how it might be different (mm) what a different feel might be. conscious.
Mmm mm, and that sort of leads into my next question which is, you
know, do you imagine what differences there might be, I know you’ve
eluded to some of them but, um Interacting in a much
slowed down way in email.
Interacting slower.
Um, well one of the differences is the, the rapidity of the interaction,
Feeling like there’s a screen
um, so it’s like, it’ll be like a much slowed down, you know, it will be
between you.
like, it will be like, you know, like there’s a screen between you and
there was a sort of, you know you could ima, there’s less Conversational quality but
conversation. Although it would I’m sure have a conversational quality slower. Having a screen
because there would be an ongoing flow but it would be a much between you
slower, I imagine, a much slower flow, because presumably this could
185
happen on different days and stuff, you know, one email could come
one day and another the next day
Mmm mm, and quite often there’s a week in between
(Talking over top in surprised tone) or even a week? (yeah) right ok,
Having a whole raft of stuff
um, so, so it’s less, I imagine it’ll be less dialogic you’d have a whole
from one side, then the
raft of stuff from one side and then a whole raft of stuff from the other Taking turns in big
other.
side (mm) I imagine. Um, if there’s a bit of quality of conversation chunks of data.
about that it’s very different; it’s a bit like one person talking for ages Taking turns in big chunks of
and another person talking for ages. Um, the main difference it seems data.
to be that, would be that the data is much reduced, that it’s just, just
words and so of course words, words are already one step removed
from the thing, you know, because they’re just a symbolisation aren’t Postulating words are one Being one step
they of an experience, so, so when you get to um, so when you’re step removed – symbolizing removed by using
talking to a person they’re talking about being angry for instance the experience. words.
you’ve got the words and, but there’s also the, you know, you’ve um,
they’re experiencing the feeling and you’re in their energy field so
you’re experiencing it (mm), you’ve got all that kind of stuff, um,
Experiencing the energy Experiencing the
whereas you haven’t in this case but you have got words that will field between you in f2f. shared energy
potentially, or words that written will potentially point towards
field.
something because we, you know, our language, our language allows
us to um to point towards certain states but it’s a bit one step
Translating words.
removed, isn’t it, you’ve got, you know, you’re translating, so they’ve
translated, it’s a bit like they’re translating something into Punjabi and Translating something into
you’re translating Punjabi back into English or something, you know, Punjabi and you’re
there’s a sort of translation process there, that’s, that’s taking place in
186
an email situation, which, less of which is required in a face to face translating back into Translating from
situation because you’ve got all the other bits of, bits of data. (mm) English. one language to
Um, I, I can imagine that it would be particularly helpful for some another.
people like, might call themselves socially anxious for instance, (uhu)
that may be, um, that actually the idea of actually going to see
someone face to face is just too distressing, um and so I can see that
for some, for someone who might put themselves in that category it Imagining email being
could be, certainly a start to to therapy and maybe even enough. It’s a helpful when f2f might be Using email when
bit like, it’s a bit like the agony aunt thing in a way, um, it seems to me too distressing. f2f too distressing.
(uhu), you know, or I, or I wonder if it’s a bit like that like you write a
letter and someone writes a letter and says why don’t you try this that
and the other, or this is my view (mm). Um so, so that might be Likening to agony
another, um, might be another thing that might be a bit different, you aunt thing
Wondering if email is like
might offer more of your view than you might, perhaps, well there
the agony aunt thing?
again it depends from what framework you come from but from the
framework I would be coming from I think I might offer more fee, I
might more frequently offer my view on things than I would do in the
face to face thing, in the face to face thing I might more work to Offering more of
facilitate them to get to their view (uhu) if you like, I imagine I might Offering more of your view your view perhaps.
just put in my view more (uhu) frequently. perhaps.
And what, what, I don’t know if I can word this very well but what
makes you think that you might do that? What would draw you to…
The thing that would draw me to do that would be um, because the
process of facilitating someone to come to their own answers is, is
usually quite a sort of mirroring, you know, s, you know, so I mirror
187
back ‘sounds like you’re angry’ ‘yeah, yeah I’m angry about..’ blah Drawn to offer own view
blah blah, ok so you’re angry about blah blah blah (hm) and they’re more as immediate
gradually descending into a thing which is, in a way there’s quite a mirroring not possible. Being drawn to
rapidity of that (mm) in that interaction (mm) whereas in this case offer more of own
there isn’t that. If I just send an email back saying ‘it sounds like view.
you’re angry’ (mm), you know, I guess you could do it that way but I
imagine it could be an incredibly long winded process so I might
because of the limited amounts of interaction, therefore I might put a
lot more, I might put it sounds like you’re angry and, you know, when
I’ve been in situations like that I’ve felt blah blah blah and you know,
you, it might even be, it might even be a bit more advice oriented, I Imagining mirroring by
dunno, it could be I imagine (uhu), um, or there could be advice in the email longwinded.
mix more, I don’t really know what the rules are about whether that
ceases to be counselling then (mumbles something).
Mmm, ok, thank you. Um, how, the idea of ruptures in therapy (mm)
um, I’m, I’m guessing most people have heard of that word, (mm),
you know, the rupture and repair (yeah) process can be a good thing
(yeah yeah) in the therapeutic relationship, or relationships in general
um, do you have any sort of views on what that might, um, how that
might operate in email therapy?
Yeahhh, sooo, (short pause) I’m imagining cos absolutely I’m with Vanishing more
you about the thing of, the centrality of rupture and repair and how, or Rupture & repair easier to
likely.
what a, if that can be worked through, the rupture can be worked collapse in email.
through what a powerful building thing that is for therapeutic
relationships. I’m imagining in an email situation um, uh, in an email
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situation (talking to self) I imagine it could be easier for the thing to Attacking each other in
collapse because, um, (short pause) I don’t know, they’re, it’s like anonymous spaces, then
people attack each other on twitter a lot easier than they do on the vanishing more likely.
street (mm), you know, so, when there’s an anonymity it’s a lot easier
for someone to say oh fuck that, they’re off (hmm) and vanish,
whereas when there’s a sort of face to face relationship there’s more, Bonding occurs more often
more bonding to, that occurs I would imagine, so, relatively speaking in f2f, less likely to do the
Bonding more
there would be more likely for the person do the off. Um, I, I imagine off.
likely in f2f.
in the situation of the repair would in some ways would be quite
similar to, to what would happen in face to face, except for again a
much slower process, so, so I imagine I’m not, I can imagine myself
writing you know, it sounds like I really, I really got that wrong (hmm) I
really misheard you when I said that and, you know and I feel sorry Repair might be similar, but
Repairing might be
even that I, or whatever (mm mm), it sounds like actually what you slower.
slower
were trying to let me know was blah blah blah and you know, and I,
and I’m wondering how you’re left feeling that I misunderstood you
etc. So all the, all of those sort of things are the sorts of things that
might occur in a, in a face to face situation but I’d be, I’d be um writing
Writing words slower and
them in, writing them in words so in some ways, some of the same Viewing negatively
imagine less chance of
sort of processes would take place except much slower and with, to likelihood of
success.
some degree I would imagine a bit less chance of success. Although success in rupture/
probably more, I could imagine more email relationships would break Breaking down at the point repair.
down at the point of rupture than face to face, on average, that would of rupture more likely in
be my hunch. email, is a hunch.
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Appendix I – Example of coded email interview
Email 1. Can you tell me something of how you experience the therapeutic Describing therapy Describing therapy
Interview relationship in face to face counselling (this is sometimes difficult experience as sensual. experience as
P25 to relay so another helpful way to look at this seems to be 'how do Moving within ‘sensual’.
you know you are experiencing the therapeutic relationship)' ‘indescribable’ element. Achieving
Transpersonal. therapeutic
Mutually acknowledging relationship when
I describe the 'experience' of therapy as a sensual one. The r/ship mutual
moves within what is being said/not said, felt/not felt with the transpersonal factors
acknowledgment of
'indescribable' element ,the transpersonal relationship. (Clarkson, P achieves therapeutic
transpersonal
2003) For me, the therapeutic relationship is achieved when there is relationship.
factors.
mutual acknowledgement of these factors.
2. How do you imagine the therapeutic relationship might work, or

not, in email counselling?
Imagining sense of freedom
in email.
I imagine a sense of freedom in therapy in this form. In the absence
Liberating sense may happen Liberating sense
of non verbal cues , the client may feel a sense of liberation to freely may happen with
in absence of nvc.
'speak'. In contrast, the meaning of the written word can often be nvc absence.
Misinterpreting written word
misinterpreted and clarification of meaning can either work in favour may happen.
or against the flow of the work. I image e-mail counselling can help Clarifying can work for or Postulating meaning
through the process of writing itself and to help focus the client and against flow of work. of the written word
the therapist. Writing as a process can needs interpreting.
The absence of the transpersonal element , in my view will offer a help. Focussing client &
different flavour of therapy. therapist via writing
Focussing client and
process possible.
therapist.
3. Can you tell me something about any differences or similarities Offering a different ‘flavour’
you might imagine between email and face to face therapy? Offering ‘different
of therapy. flavour’.
190
Differences- Differently experiencing Experiencing feeling
 the experience of feelings and the delay in which they are feeling via delay , differently with
conveyed and validated. conveyance of message & email.
 the comfort of being with a compassionate human being lack of validation.
 someone to pass the tissues Deriving comfort from being Deriving comfort
from others physical
 time/accessibility boundaries with other missing.
Passing the tissues. presence missing.

Similarities-
 the comfort in knowing someone is there for them Knowing someone is there
Knowing someone
 having an opportunity to share your problems for you is similar. there is comforting.
 receiving support from a professional helper Sharing problems. Making life easier via
 a method which makes life easier not harder Receiving support from pro mode.
helper.
Making life easier by email.
4. Can you say something about how you might imagine the
computer impacts, or not, in the email therapy relationship?
Offering anonymous vehicle Offering anonymous
 the pc is a vehicle for those who can not/prefer not to attend vehicle.
for those preferring not to
or be identified through face to face counselling attend.
 it may draw out attachment issues Drawing out attachment
 it may evoke questions around 'the faceless therapist'. issues. Drawing out
 the pc may raise questions around trust due Delayed Evoking question about attachment issues.
responses, different intonations in the text, length of ‘faceless therapist’
response in the absence of non verbal clues. Raising questions around
Raising trust issues
trust through delayed through time & text
response, differing text differences.
intonations & length of
5. Is there anything else you would like to add?no written response.
191
APPENDIX J – THREE EXAMPLES ILLUSTRATING DIAGRAMING PROCESS
1) Email counselling and the therapeutic relationship: A GT of therapist’s experiences November 8 th (MK3)
MISTRUST OF PROCESS (of relationship?)

Feeling mistrustful of the whole process – Risking exposure/ computer/ responding into the void/
self – leading to anxiety and overcompensatory behaviour.
 ‘Trust something but tie your camel to a post’

 Difficult to follow ‘gut instinct’ (as is usually backed up by NVC’s)
 ‘Holding’ a client takes on a whole new meaning. (Feeling relationship is 1-sided and drawn
to worry about additional issues ‘for’ the person – safety/encryption/speed of relationship
forming/leading to more careful handling concerns and additional ‘instructing’ of how to
work online to clients.
 Subconscious to subconscious – bypassing safety channels?
 Not getting immediate feedback feeds into uncertainty and ensuing feelings/behaviours
RISKING EXPOSURE
FANTASISING/ ONLINE DISINHIBITION
 Personally
 Responding into the void
 Professionally
 1-sided relationship requires imagined
 Legally
relationship initially
 to researcher
 Sixth sense?
 to therapeutic community
 Attachment issues can make it difficult to
 to online world
work in this way for therapist and client
 SI theory/ Group ID/Similar in CP world?
 Exacerbated in void/time lapse
 Struggling to be accepted 192
WORKING HARDER/ NEEDING TO GET IT RIGHT BEING HIDDEN/ DISAPPEARING
 Overcompensation?  Pro’s – therapist can operate if unwell. Both

 Email paradox – less time pressure leading to can work at own convenience.
more time to worry about answer  Perceived power of client to ‘choose’ when &
 Perhaps invoking perfectionist attachment how to have therapy or if to disappear.
issues for the therapist? Therapist may ‘notice’ their own power in
 Taking on client worries in the void. these instances?
 Con’s – Therapist working harder to be ‘seen’,
polite society means f2f less likely to
disappear, sobriety can be unknown.
RELATING TO COMPUTER  Ultimate fear that disappearance means death
– causing understandable anxiety.
 Relegating/dismissing presence
 Coming ‘alive’ when misbehaving
(attachment?)
 Memory process (Research digest)
 Computer expert anxiety ATTITUDES
 Allocating computers for work & play  Online counselling ‘needs more
 Object relations? recognition’
 ‘inbetween’ client and therapist  Training is ‘essential’
 Disappearing when relationship formed.  Online is ‘better than nothing’
 Survey answered in succinct maybe
exaggerated way – is this like email?
193
DIFFERENCE
TRAINING
 Can write when crisis is ‘live’
 Exacerbated conscious incompetence
 Written account of therapy created
through lack of intraining programs &
(exposure?).
exposure worries
 Email maybe more exaggerated/ succinct?
 Old counselling lags have harder time
 Writing does not disobey ‘silencing’ rules.
training (exposure?)
E.g. alcoholic parent situations.
 Johari window advice – ‘you don’t know
 Chemical interaction missing.
what you don’t know’
 Typing speed affecting therapeutic
 Advanced skills in ‘congruence’ essential.
relationship.
 Anxiety high initially but abates with
 Specific skills helpful in email – pacing,
experience.
‘saying’ more in bigger chunks, deciphering
written extreme emotion
UNDERLYING PROCESSES SIMILARITY
 Power?  Many skills transferable

 Psychodynamic defences/ (& other perspectives)  Computer space like therapy room
 Attachment – conflict  Using clients own language
 Same types of issues brought
 Personality (Adler, compensation)
 Same boundaries and contracting can be
 Psychological uncertainty (Smithson, 08) applied.
 Social construct of uncertainty
 Redress balance for client in Autonomy/trust
194
2) Email counselling and the therapeutic relationship (MK 12)
INTELLECTUALISING Focusing more on WORKING OUT OF RELATIONAL CONTEXT LOSING CONTACT

the conscious? Becoming more reliant
on cognition rather than intuition  Relating into the void (Responding with no steer, using fantasy/  Loss of interaction and connection with
delayed responding) client (lack of sensory feedback/visual
 Reflecting and perfecting before  Loss of non-verbal communication and verbal cues, electromagnetic
responding – polishing responses
connection, loss of immediacy, lack of
(losing the relational ‘mess’ of f2f)  Fantasising into a void – relying more on ‘intuition’. Creating a fantasy
confirming response)
client.
 Working more consciously i.e. taking
 With self ( own intuition/ability to
time to think but less unconscious  Not needing to hold the client in mind (on the page)
express self non verbally)
communication – thinking more
/Choosing words more carefully
 Focusing on skills and theory rather

than relationship?
 Having to put things into words EXPERIENCING ANXIETY BECOMING MORE DOUBTFUL
Feeling more helpless and uncertain  Questioning understanding (own and

clients)
Worrying more about client safety
 Questioning competence
Experiencing threat to professional self-concept/feeling less
competent  Questioning reliability of computer
195
MANAGING ANXIETY through PROTECTIVE BEHAVIOURS
DEFENDING THE PROFESSIONAL SELF CONCEPT

MINIMISING/ INTELLECTUALISING
 Working harder/overcompensating
DIFFICULTIES /DIFFERENCE
 Projecting feelings of incompetence onto others
 Minimising the role of the computer  Focusing on training and gaining advanced skills
 Minimising differences between
modalities
 Focusing on the positive
 Holding on tight to the known
MOVING TO PROFESSIONALIZE
 Establishing rules
 Creating organizations
 Closing ranks
 Focusing on training
 Becoming an expert
196
3) Email counselling and the therapeutic relationship: A grounded theory analysis of therapists experiences
WORKING OUT OF RELATIONAL CONTEXT
Through the looking glass effects Losing touch Writing and Responding
 Fantasising into the void (other senses  Loss of interactive factors  Having to consider ‘worst case legal
heightened?)  Loss of connection with self scenario’ BEFORE writing.
 Intuition  Losing control of the therapy room  Using text
 Unconscious to unconscious? (containment).  Writing in big chunks
 Anonymity effects (disappearing,  Delayed responding (Feeling drawn to
disinhibition, ‘safety’) respond)
 Computer on continuum of –  Responding with no steer
‘Alive’………’Tool’ depending on its
behaviour (attachment).
 Feeling more helpless and uncertain/ questioning understanding & computer reliability
 Worrying more about client safety/ questioning client understanding
 Experiencing threat to professional self-concept/questioning competence
 Anxiety ameliorated by degree of training & experience in email therapy AND experience with computer.
197
MANAGING ANXIETY through PROTECTIVE BEHAVIOURS
INTELLECTUALISING AVOIDING THE VOID DEFENDING THE PROFESSIONAL SELF CONCEPT
Focusing more on the conscious?  Minimising the role of the computer  Working harder/overcompensating
Becoming more reliant on cognition  Minimising differences between  Protecting by defending expertize
rather than intuition modalities  Focusing on training and gaining advanced skills
 Focusing on the positive
 Reflecting and perfecting before
 Holding on tight to the known
responding – polishing responses.
 Feeling the risk and doing it anyway.
 Working more consciously i.e.
taking time to think but less
unconscious communication –
thinking more /Choosing words
MOVING TO PROFESSIONALIZE
more carefully
 Establishing rules
 Relying on skills and theory initially,
to nurture relationship.  Creating organizations
 Closing ranks
 Having to put things into words.
 Focusing on training
Translating from one language to
another and back. One step  Becoming an expert
removed. Words as symbols
APPENDIX K – Example from memoing process
198
MEMOING
Therapists wanting to get it right – somehow more time exacerbates possible perfectionist traits.
Clients in crisis seem to make distance feel greater & lack of touch harder.
Exciting that a client can write whilst ‘live’ in the issue – although there is a delay in response.
Lack of distractions linked with quicker and deeper therapeutic relationship forming – although this sometimes causes
consternation.
Computer seen as a tool when working well and invoking its own relational feelings when not (anger, frustration towards it).
Transference?
Computers for work and computers for play.
Therapist needing additional ‘computer expert’ abilities.
Computer space like therapy room.
Every word mattering (getting it right)
Using clients own language key in empathy.
Are their differences in how men & women answer the survey?
Possibility therapist can go ‘off track’ in the void with no ‘steer’. Advanced skills in congruence perhaps necessary?
Perhaps survey text is more succinct than interview?
Bypassing the conscious straight into text
199
Online dis – myth/misjudgement by client that they can keep their distance online
Finding therapists saying computer is only a tool but having ‘warm feelings’ towards a favourite computer when asked?
Responses different from new & experienced therapists.
Anxiety triggered in therps – urge to hear, responding in void, worrying more, feelings of helplessness, getting it right, every word
matters, disappearing.
Online disinhibition – bypassing conscious, fantasising, deeper quickiner, powervully experiencing, urge to hear in void, perceived
anonymity help & hindrance.
Survey answered in succinct maybe exaggerated way – is this like email?
Training – initially anxiety getting in way, typing speed affects TR,
Do you need different set of personal values to work online?
Computers for work & play, only come ‘alive’ when misbehaving, seeing beyond to client.
Extra skills needed.
Writing a letter to themselves – therapist affirmation.
‘how’ & ‘what’ important in email
Personality showing through - introvert? So, with online dis only act to personality?
Worrying about working from own frame of reference.
200
Client in control (timing) – power levelling.
Fears for client in disappearance – needing to be able to tolerate.
Both subconsciousnesses in play – different things triggered in email.
E – less likely to follow up ‘instinctive’ feelings
Power of suggestion feeling greater/ more exaggerated
Electromagnetic fields ‘vibes’ in f2f compatibility
Is the ‘doing it right’ feeling linked to being ‘exposed’ by written word.
Carrying the therapist around with you on your phone in email? – Transitional object?
 Online counselling relatively new to therapeutic world and could be feeling they need to justify the method?
 CP also new and could be similar justifications going on.
 CP training ‘relational’ – may be bias towards against online counselling?
 Consider defensiveness in interviews and accounts of work.
 Anxieties?
 Being mistrustful – leading to compensatory processes – Defensiveness? – Anxiety?
 Power?
 Is a different set of personal values needed to work this way?
201
APPENDIX L – TRANSCRIPTION KEY
… - denotes missing words
(sic) - denotes participant spelling of words
CAPS – words written in capital letters denotes shouting in online etiquette
202

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EMAIL COUNSELLING AND THE THERAPEUTIC

RELATIONSHIP: A GROUNDED THEORY ANALYSIS

Thesis submitted in partial completion of the requirements of the

Submitted: December 2014

This copy has been supplied on the understanding that it is

Figure 1. Email counselling and the therapeutic

Finally, I would like to express enormous gratitude to my supervisor, Andrea

Provision of online counselling in its many forms has increased dramatically

The study adopted a constructivist grounded theory methodology (Charmaz,

record and any possible legal or professional ramifications. Further

Consequently participants were left Experiencing anxiety. This anxiety

What is online counselling?

History and development of online counselling

after. Whilst there is no specific information regarding its origins in the UK it is

Online counselling debated

Advantages of online counselling

Other advantages suggested include: the flexibility afforded to clients about

may be useful as an adjunct to face-to-face therapy for clients with anorexia

For therapists practicing email counselling, additional advantages are

Disadvantages of online counselling

Although it is suggested that the importance of non-verbal cues is sometimes

Another important disadvantage already alluded to is an ethical one: many

Ethical issues in online counselling

activity by encouraging clients to become “mouse potatoes” (Pelling, 2009,

Whilst there is a growing body of research into online counselling practitioner

the preponderance of available guidelines may nonetheless

Although this view is understandable as online technology develops so quickly,

establishing an online presence (Evans, 2009), online listening, attending to the

Supervision is recommended for practitioners across all ethical guidance and

In summary, the debate regarding advantages and disadvantages of online

COMPUTER MEDIATED COMMUNICATION AND INTERPERSONAL

research. Whilst not strictly a CMC model it is perhaps a precursor to

Building on these findings Kemp & Rutter, (1982) assigned participants

completely translate into online counselling, the idea of compensating in a

Social Information Processing Theory (SIP) - SIP was suggested by Walther

research where the group interaction in a synchronous context was analysed;

THE HYPERPERSONAL MODEL

1) Receivers – In the absence of non-verbal communication an individual may

2) Senders – Text based CMC facilitates selective presentation, as unless a

3) Channel – Involves characteristics of the channel; one part focuses on the

4) Feedback- This suggests that aspects of all three components, idealisation,

In effect Hyperpersonal CMC purports there might be advantages over face-to-

Sensory deprivation - Research with blind participants suggests a degree of

‘Telehealth’ a viable option for the deaf population suffering depression. In a

In summary, the models included in the impersonal and interpersonal stages

THE THERAPEUTIC RELATIONSHIP

The therapeutic relationship in face-to-face encounters

Decades of empirical research indicate that the quality of the therapeutic

The significant overlap evident among these elements, and a

The patient is not satisfied with regarding the analyst in the

Transference is believed to be the ‘transference’ of past feelings, conflicts, and

this. Psychoanalytic practitioners believe strongly that therapy happens within

Because we experience online others THROUGH the

The therapeutic process is common to different forms of counselling and

practitioners conceptualise their online counselling work used a mixed method

Non-verbal communication and the therapeutic relationship

Also of interest is therapeutic presence in the therapeutic relationship which has

client and therapist need to be ‘actively’ present, in a two-person relationship, in

However researchers in the field of neuropsychology (Schore, 2013) stress the