Online Trauma Therapy – Effective Strategies for Counsellors

The following article is taken from our Trauma-Informed Practice course.

As the landscape of therapy continues to evolve with technology, working with trauma online presents unique challenges and opportunities. This article explores the complexities of ensuring client safety online, highlighting fundamental psychological phenomena, and the importance of thorough risk management. By addressing these elements, you can better navigate the intricacies of online trauma therapy and provide effective support to your clients.

Learning Outcomes

• Importance of training: Undertaking a dedicated online and telephone counselling course is essential for understanding the unique psychological and safety aspects of online therapy.
• Disinhibition effect: Online interactions can lead to clients over-disclosing, which might result in regret and disengagement.
• Black-hole effect: Lack of immediate feedback in online communication can lead to client anxiety about message receipt and response.
• Fantasy attachment: Clients may develop unrealistic attachments to therapists without physical presence, complicating the therapeutic relationship.

• Risk management: It is crucial to develop a robust risk-management plan, which includes gathering comprehensive client information and having clear emergency procedures.
• Use of mental health questionnaires: Tools such as PHQ-9, Beck’s Depression Inventory and CORE can help assess client status and inform ethical decision-making.
• Communication and competence: It is vital to maintain ongoing assessment of your ability to manage online therapy safely and effectively; peer discussions and supervision are important in this.

The Psychological Complexities of Online Trauma Therapy

The Disinhibition Effect

The disinhibition effect refers to the phenomenon where clients feel less inhibited in online environments, leading to greater disclosure than they might offer in face-to-face sessions. This over-disclosure can pose challenges for therapists, as clients may later regret sharing more than they intended and disengage from the therapeutic process. Understanding this effect is crucial for managing client expectations and for maintaining therapeutic boundaries.

The Black-Hole Effect

The black-hole effect – another term coined by American psychologist John Suler in the 1990s (Suler, 2023, pp. 70-71) – describes the anxiety often felt by people when their communications appear to vanish into the void without immediate feedback. This can be particularly problematic in online therapy, where delays in responses can exacerbate clients’ anxieties. To mitigate this effect, you need to establish clear communication protocols and backup plans, such as switching to telephone communication if video calls fail.

Fantasy Attachment

In the absence of physical presence, clients may form fantasy attachments to their therapists, imagining them as perfect figures. This can complicate the therapeutic relationship and make the termination of therapy more challenging. You must be aware of this dynamic and address it proactively, helping clients to maintain realistic perspectives.

Developing a Comprehensive Risk-Management Plan

Importance of Training and Competence

Before working online and/or by telephone, you must undergo training in online and telephone counselling so that you understand this medium’s unique risks and requirements. Ethical bodies and practitioners stress the necessity of these skills to ensure safe practice. The training should cover psychological aspects, safety considerations, and the development of a risk-management plan.

Key Components of a Risk-Management Plan

1. Client information: Collect detailed information about the client’s location, emergency contacts and health status so that you can take prompt action if an emergency arises during a session.
2. Emergency procedures: Have clear protocols for emergencies, including how to contact emergency services remotely.
3. Regular reviews: Revisit and update the risk-management plan regularly in order to address any new developments in the client’s condition or circumstances.
4. Documentation: Keep thorough records of all interactions and risk assessments to maintain an audit trail, and to protect both the client and yourself.

Utilising Mental Health Questionnaires

Mental health questionnaires, such as PHQ-9 and Beck’s Depression Inventory, provide valuable insights into a client’s mental state and help identify risks like suicidal ideation. These tools support ethical decision-making and ensure that therapists can make informed choices about their client’s care.

Standardised mental health questionnaires can provide valuable insights into the client’s psychological state and help in ethical decision-making. Counselling Tutor (2024, ‘Using Mental-Health Questionnaires’ section, para. 2) writes:

As well as providing evidence-based information to support your decision-making on whether or not it is safe and ethical to work with a particular client, using a standard tool as part of your assessment for all clients can help reduce the feeling of invasiveness.

Commonly used questionnaires include:

• PHQ-9, which assesses the severity of depression and includes questions on suicidal ideation
• Beck’s Depression Inventory, which measures the depth of depression
• GAD-7, which screens for general anxiety disorder
• CORE, which is designed specifically for therapists, helping to gauge the client’s overall well-being and treatment progress.

These tools are helpful for initial assessments and can also be used throughout the therapeutic process to monitor changes and adjust treatment plans accordingly.

Final Remarks

Working with trauma online demands a heightened awareness of unique psychological effects and the implementation of rigorous safety protocols. By understanding phenomena such as the disinhibition effect and fantasy attachment, and by developing comprehensive risk-management plans, therapists can provide safe and effective online therapy.

Continuing professional development, peer discussions and supervision are essential for maintaining competence and ensuring the best outcomes for clients. As online therapy continues to grow, staying informed and prepared will be vital for successfully navigating its challenges.

While online trauma therapy presents distinct challenges, it also offers significant opportunities for reaching clients in new ways. Therapists can effectively support their clients through their healing journeys by adhering to best practices and by remaining vigilant about safety.

References and Further Reading

Counselling Tutor. (2024). Risk Assessment in Online Therapy [online]. Counselling Tutor. [Viewed 30/5/22]. Available from: https://counsellingtutor.com/managing-risk-in-online-therapy/

Kelly, K. and Lees-Oakes, R. (2021). Online and Telephone Counselling: A Practitioner’s Guide. Warrington: Counsellor Tutor Ltd.

Suler, J. (2023). The Psychology of Cyberspace: The Classic Text [online]. John Suler. [Viewed 9/7/24. Available from: https://www.johnsuler.com/pdfs/psycyber.pdf