Online Therapy

Establishing Therapeutic Relationship in Online Therapy – The ‘connection’ that is more than the Internet connection

This article was originally written for a professional therapists’ magazine. But it can also be helpful for clients if you are considering an online therapy. 


Prior to this time that online therapy has become the new norm, I was skeptical whether online therapy would be as effective as a face-to-face sessions. There were a few factors that I was concerned about online therapy. These include difficulty to establish trust, the lack of human and emotional connection because of imperceivable body language, as well as environmental and confidential concerns. However, since online therapy became necessary when the pandemic started in 2020, I was practising completely online during the pandemic. I have found that online therapy including the use of psychotherapy and hypnotherapy can be very effective. However, there are some differences from a face-to-face session that I find helpful to keep in mind, which I would like to share to you from my experiences.

Establishing Trust  In my view, trust is one of the most important parts in a therapeutic relationship and is the foundation of the therapeutic relationship. I believe that trust can be established from confidence that a client has in the therapist. This confidence can be developed from many factors such as respect of the therapist’s skills and knowledge, perceived confidentiality, positive regards, congruence and genuineness. Some of these aspects may take time to develop; some others can be established from the first impression. In the online setting, we do not have a physical location that we can present a trustworthy environment and create a first impression to clients as they arrive. These normally may include a well-organised treatment room, an enclosed space that ensures confidentiality, a comfortable seat and drinks to provide comfort. Without all these, the first impression in the online setting will rely mainly on the information we provide online like websites or therapist directories we are on. The way we communicate with clients via e-mail or phone as well as being on time for every call can show our congruence. I believe that a clear and prompt communication plays an important part for clients to perceive that a therapist is reliable and trustworthy. As we have learnt that communication is the key in therapy, it is even more importantly in online therapy.

In addition, for a hypnotherapy session, to ensure that a client is in control at all times, Ideomotor response can help very well in establishing trust. This is when we ask clients to response with a movement after the hypnosis induction if their subconscious mind is ready to continue with the process. The agreeing movements can be, for example, head nodding, moving both hands to come together, or dropping hands by their sides. This helps to enhance trust for the process since the client will be aware that it is completely their decision to continue and they are completely in control. 

Human and emotional connection – I was slightly apprehensive before starting to practise online of how the communication of empathy, positive regards, and genuineness would be. I trust that if we are genuine and our words and body language are expressed according to any emotions being discussed, as well as show sincere empathy for clients, these can help to establish and enhance the therapeutic relationship. I felt that being together in the same room with clients would be easier to communicate and convey these. However, it is actually very much doable in an online setting too, only slightly different from when we are communicating face-to-face. I have learnt that our expression needs to be rather more obvious. I present my expression more verbally in video calls, and of course, totally verbally if it is a phone session. I can use body language and facial expression a lot more in a face-to-face session like keeping eye contact, leaning towards the client, nodding, presenting empathetic facial expression. But, sometimes these actions do not appear clearly in video calls, especially when the quality of the video is low. Therefore, verbal sentences like “I understand” “I hear you say…” “I can see that you are feeling…” are useful to be included more along the way in an online consultation to convey my understanding and empathy to the client. The tone of voice we use is always highly important and influence how the client perceive our empathy. With some adjustment, emotional connection can still occur strongly even through the screens.

Environmental and confidential concerns  In an online setting, clients are not physically in our treatment room, where we normally can ensure safety and a good environment for therapy. In this circumstance, I have learnt that a brief description regarding my setting, comfortable environment, and confidentiality can help to assure the clients that these aspects are always paramount. I believe that clear communication regarding important points like these also helps to enhance the therapeutic relationship, as clients feel more assured and confident about the online therapy process. If using hypnosis, I normally include a brief suggestion into the induction part to ensure that clients will be able to come out of trance safely by themselves if there is any issue with the internet/phone connection and I cannot reconnect with them because of any reasons. For example: 

“In the case that you cannot hear me for more than 5 minutes, it might be because of the lost of connection. You are always in control. So, you can gradually come out of this deep relaxation state naturally by yourself. Perhaps you can count one up to five and open your eyes, feeling fine and refreshed.”

Disinhibition Effect  Disinhibition effect occurs in the online circumstance. By being online, people say and do things that they would not ordinarily say or do in the face-to-face world. According to Suler (2004), disinhibition effect can be either in a constructive or destructive way. For example, one may reveal more of their emotions, feelings, wishes and kindness. Or one may present more aggression like rude language, harsh criticisms, anger and hatred. From my experience, online therapy can facilitate clients to be more honest with their feelings and emotions. This can be due to disinhibition, in particular, the feeling of invisibility. Since we use a voice or video call application as a mediator for communication in an online setting, it can create a feeling of invisibility for clients. Although it is still a direct communication between a client and therapist, the fact that clients are not in the same room with another person (i.e. a therapist) in an unfamiliar environment (i.e. a treatment room) seems to make it easier for clients to express and talk about their thoughts and feelings. I have noticed that clients feel more comfortable than in a face-to-face session to talk about deeper aspects of their thoughts and their actions. The persona (i.e. how one presents themselves to others to make a definite impression according to Carl Jung’s personality theory) seems to be bypassed much quicker. This can be helpful for the online therapeutic relationship and process, since the openness can occur quite promptly. 

I believe these are some of the most important aspects to be mindful of when delivering or engaging in therapy sessions virtually. With some additional awareness, good therapeutic relationship can certainly be established and strengthen in online therapy. I trust that we can bring the best outcome for clients regardless of not being together with them in the same room.