3 June 2020

Therapy and Online Platforms: Important Questions from Aristotle

In recent times, numerous clients and supervisees have been keen to discuss their experience of providing therapy or attending meetings through online platforms. The overwhelming consensus is that “it’s exhausting”. Various explanations are put forward — the attention to a small screen, the need to appear attentive; the need not to be seen as having divided attention; the focus on extra cues to compensate for the lack of non-verbal feedback and physical presence, and so on. While it is acknowledged that some clients and practitioners seem to prefer “screen work” to “in-person encounters”, the vast majority seem to say that “in-person engagement” is preferable, and that “screen work” feels exhausting.

Some supervisees have expressed alarm at the tentative suggestions made by their agencies, or agencies that refer clients to them for Employee Assistance Programs, that “given the outrageous success of our online counselling, we might move to this format permanently, even post COVID-19”. Practitioners who are keen to return to “in-person therapy” are horrified at this prospect.

The measures made necessary by the COVID-19 crisis have allowed many industries to re-imagine their models of delivery — and therapy has been part of that re-imagining. And it needs to be acknowledged that it might be valuable to continue some of these measures in a post-COVID-19 world. It would seem that “when things get back to normal” doesn’t describe the prospective reality anymore — a new normal is somewhere in the future.

It is a positive result if online therapy allows people who have faced issues of access with engaging more fully in the therapeutic process such as people in the rural sectors, people with specific syndromes or anxieties, and people who cannot make the journey to the therapist rooms. And, it is a big bonus if the online platform allows more agencies to meet the needs of isolated, vulnerable clients in a more “user-friendly” manner. Let’s not forget the traditional phone counselling services that have operated for decades and have offered invaluable services.

However, these issues are quite different from the argument that conducting therapy online is “more efficient”. This begs the question “more efficient for who?”. Do these arguments suggest that online therapy could be used to save agencies rental costs for therapy offices, that attempts to provide “face-to-face” therapy to rural areas can now be abandoned, or that private practitioners can save the overhead costs of conducting a “face-to-face” practice?

When the Jungian iconoclast, James Hillman, considered Kinds of Power1 (1995), he reviewed the matter of “efficiency” with his characteristic fearsomeness and invoked Aristotle’s thinking:

“Aristotle divided the answer to the question ‘why?’ into four kinds of causes: formal, the idea or archetypal principle that governs an event; final, the purpose, or that for the sake of which the event is intended; material, the substance that is worked upon and changed; and efficient, that which initiates a motion and is the immediate instigator of change.” (p. 37).

Analysing the “why” of psychotherapy and answering it through a consideration of all four causes has been the subject of hundreds of books and theses. Each cause could be debated at great length. The material could be the client’s story/complaint/distress and/or it could be the therapeutic relationship that is worked on, or all these elements and more. The efficient could be the format: the interviews, the location, the rooms, the online format, and anything else that initiates the therapy.

Hillman (1995) warns against becoming so enamoured with the efficient that we lose sight of the formal, final and material. He notes:

“The efficient cause makes things happen. When it is singled out as the only cause, then it does not matter what happens, to what or whom it happens and for what purpose it happens.” (p. 38).

He states further:

“I am arguing here that the idea of efficiency per se does not provide sufficient reason for human action. It must always be attached to its partners, the other three causes, and serve within a complex tension of reasons” ( p. 40).

Concerning the provision of psychotherapy online, one would hope that any enthusiasm for the format would not be driven solely by fantasies of efficiency. It is essential to consider the other causes that give rise to crucial questions such as:

  • What are the images that form and drive psychotherapy?
  • What is its actual purpose or purposes?
  • How do we know that these are being actualised?
  • How does the practitioner contribute to the context of these purposes?
  • What is the material of psychotherapy?
  • The complaint, the distress, the mental health issues, the problem solving, the attachment, the therapeutic relationship and/or something else?

One would hope that all questions of this nature would be given serious consideration before a practitioner, agency or organisation signs up to an “online-only” format. What is striking in any consideration of this issue is the exhaustion that practitioners complain of when engaging online; perhaps it is because they are feeling an absence of the consequences, complexity and consideration of those other three causes.

Paul B. Gibney Ph.D.

1 Hillman, J. 1995. Kinds of Power: A Guide to its Intelligent Uses. New York: Currency Doubleday