Online Therapy Interaction Study

OTIS summary

Depression is mostly diagnosed and treated in primary care. Face-to-face Cognitive Behavioural Therapy (CBT) is effective, but is in short-supply and may not suit all patients. CBT is now being used in real-time text-based online consultations. A previous trial which included interviews with patients (the IPCRESS trial, PI Kessler) found that online CBT was effective in treating primary care patients with depression and was acceptable to patients. But it is unclear how a therapeutic approach designed for face-to-face delivery might be impacted when adapted for use online.

The aim of the Online Therapy Interaction Study (OTIS) was to examine how therapists and clients build a therapeutic relationship during online CBT. The objectives were to: 1) analyse an existing dataset of online CBT session transcripts; 2) use a detailed qualitative approach known as Conversation Analysis to analyse how therapists and clients develop a therapeutic relationship; 3) identify the implications for CBT practice and research. OTIS consisted of two main phases.

In phase one, we examined therapy session transcripts to see how therapists and clients developed and maintained a therapeutic relationship online when they cannot see or hear one another. Using the methods of Conversation Analysis, we focused on how therapists responded to the emotional content of what clients described, finding that therapists’ responses were carefully designed in relation to clients’ preceding descriptions. This shows how in an online context, therapists can display empathy in response to clients’ posts that describe the personal emotional impact of their experiences.   

In phase two, we examined the management of expectations by therapists at the start of therapy, given that CBT may be unfamiliar to clients and they may struggle to know what to expect. Using the methods of Conversation Analysis, we first identified different types of expectation management routinely used by therapists to orient clients as to what therapy will involve. From this qualitative analysis, we anticipated that the use of some form of expectation management might be associated with client retention in therapy. We used our qualitative analysis to generate coding variables that described the different types of expectation management used by therapists. We then applied this coding scheme to a subset of first therapy sessions, established the inter-rater agreement regarding this coding, and then applied this coding scheme to all first and second therapy sessions from the trial. Finally, we conducted a statistical analysis of the relationship between expectation management and retention in therapy. While this analysis suggested that expectation management may effect retention in therapy, a larger study is required to provide more precise evidence of the effectiveness (or lack of effectiveness) of expectation management. 

Overall, OTIS highlights the value of detailed understanding of communication during online psychotherapy. Our findings suggest that communicative practices used by therapists matter, even at the level of individual turns or online posts, as therapists precisely design their empathic responses in relation to what clients have previously described. Our research also gives insight into the sort of basic expectations that therapists need to manage at the beginning of the first session of therapy and the practices that therapists may use to manage those expectations. Through further work of this nature, using the methods of Conversation Analysis, it may be possible to develop a body of systematic knowledge of communicative practices used by therapists and clients during psychotherapy. Of particular value would be the comparison of communicative practices during face to face and online therapy, to elaborate the shared and distinctive practices across these modalities. Such findings will enable the ‘craft’ of good communication to increasingly inform evidence based training, and enhance online and face to face psychotherapy practice


Ali Heawood (PI), Rebecca Barnes, David Kessler, Alice Malpass, Stuart Ekberg


The Bupa Foundation




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