Helpful and unhelpful elements of synchronous text- based therapy: A thematic analysis

Within the UK, there has been a growth of services delivering online therapy to young people. This study identifies the factors that young people find helpful and unhelpful in synchronous text- based therapy (STBT), and the processes by which these factors may be of value. Thirteen young people, aged between 14 and 18, were interviewed synchronously online. All participants had had a minimum of four sessions of STBT. Data were analysed thematically. Four main domains of helpful and unhelpful factors were identified: 1) anonymity, 2) access, 3) communication, and 4) control. Control was a particularly important element for young people and was an underlying aspect across all themes. Young people not only valued several aspects of STBT but also recognised its limitations. Further research should explore the contexts in which online counselling may be helpful or not.


| INTRODUC TI ON
A high level of mental health difficulties is reported in adolescence and young adulthood (Sadler et al., 2018). However, research suggests that young people continue to have difficulty accessing or remaining engaged with psychological services and show high dropout rates (Block & Greeno, 2011;Owen et al., 2002;Rickwood et al., 2005). Reasons for this may include practical issues such as time, cost and location (Owens et al., 2002), or be because services are unable to offer appropriate support for the distinctive developmental and cultural needs of this client group (McGorry et al., 2013).
Given the barriers to accessing services for this high-need social group, research understanding young people's experiences of therapy is crucial. Research focusing on young people's experiences of therapy has found that young people want (a) services to be flexible with the timings and location of support, (b) to know what to expect from services, (c) to feel in control of their care, (d) a strong therapeutic relationship, and (e) privacy in relation to their parents (Gibson et at., 2016;Plaistow et al., 2014).
In order to bridge these gaps between service demands and young people's needs, the use of online platforms has been proposed (Burns & Birrell, 2014;Department of Health & Department of Education, 2017).
Synchronous text-based therapy (STBT) is a therapeutic medium in which therapists and clients send messages and respond instantly: that is, it is in 'real time'. A systematic review concluded that, despite a rise in STBT provisions for young people, research into this medium remains in its infancy (Ersahin & Hanley, 2017). However, qualitative and quantitative research exploring young people's and/or therapists' perceptions of STBT commonly cites anonymity as a helpful factor (Bambling et al., 2008;Callahan & Inckle, 2012;Dowling & Rickwood, 2014;Frith, 2017;Hanley, 2008Hanley, , 2009King et al., 2006). Other helpful factors include the privacy and confidentiality that the online medium offers in terms of not having to inform parents of access (King et al., 2006), the absence of non-verbal cues from counsellors (Callahan & Inckle, 2012;King et al., 2006), accessibility of counselling from a home environment (Hanley, 2008(Hanley, , 2009Sobowale et al., 2016) and feeling more in control of the relationship (Bambling et al., 2008;Callahan & Inkle, 2012;Dowling & Rickwood, 2014;Frith, 2017;Hanley, 2008Hanley, , 2009).
Unhelpful factors of STBT for young people include misinterpretation due to typing (Bambling et al., 2008;King et al., 2006), waiting times for sessions (Hanley, 2008;King et al., 2006), the time taken to type a message which results in being less articulate within a given time frame (Dowling & Rickwood, 2014) and difficulties in expressing one's self through text (Frith, 2017;King et al., 2006).
Given the growth in Internet use and the demands on youth mental health services, the present study aimed to provide insights into the experiences of STBT for young people, and to understand the ways in which this therapeutic medium is considered to be helpful or unhelpful. Although, as indicated above, previous research has been conducted in this area, it is limited, particularly in the UK.
Much of it was also carried out almost a decade ago (e.g. Callahan & Inckle, 2012;Hanley, 2008Hanley, , 2009King et al., 2006), and there have been substantive technological developments since that time.
Much research has also tended to use small sample sizes and quantitative methods, and not focus on how or why particular factors may be helpful or unhelpful (Callahan & Inckle, 2012;Frith, 2017;Hanley, 2008Hanley, , 2009). However, there has been some growing evidence collected around the evidence base of STBT indicating significant and sustained improvements in mental health outcomes equivalent to face-to-face settings (Hoermann et al., 2017).

| Design
This study adopted an online qualitative interview design with thematic analysis of data.

| Participants
An online counselling service for young people was used to recruit participants. The service offers online counselling to 11-to 25-year-olds living within the United Kingdom. Young people register by creating a username and providing their gender, ethnicity and year of birth. Young people access the service anonymously.
The online counselling service is delivered by practitioners who offer a range of therapeutic modalities but work within humanistic, integrative, cognitive and pluralistic frameworks. To access online therapy, the young person registers anonymously and then enters a virtual waiting room where they wait to be allocated to a practitioner. In the first online session, their needs are assessed by the practitioner and they are informed of the confidentiality and safeguarding processes. Subsequently, they are either offered weekly appointments with this practitioner or to use the service as and when they feel they wish to access it. Each session lasts up to 1 hr.
A sample of 13 participants was recruited. The inclusion criteria for participants were that they had to be aged 14 to 18, and to have received a minimum of four STBT sessions in the past year. The participants were nine females and four males with a mean age of 16.3 years (SD = 1.4). Nine of the participants identified as White British, two identified as White and Asian, and one identified as any other mixed.
The total number of online counselling hours ranged from 7.2 to 176.7 hr, with 45.7 hr being the average. Three young people wished to participate but were unable to do so as they did not meet the inclusion criteria. Two of the young people who participated were accessing face-to-face therapy from an external organisation alongside the STBT.

| Materials
A semi-structured interview was adopted, based on Elliott et al.'s (2001) Change Interview. This is a standardised interview protocol that explores, with participants, changes in their therapy and how they believe those changes occurred. The main questions asked were as follows: 1. Has there been anything that you have found helpful about the online counselling?

Implications of Findings for Policy and Practice
• Online therapy platforms should inform potential users about the strengths and limitations of this media, so that young people can make informed choices about whether to participate or not.
• Online therapy platforms for young people should include capacities for drawing and use of colour, as well as document upload functions.
• Given the lack of non-verbal cues in STBT, practitioners should raise the potential for misinterpretation during contracting and in early sessions.
• Policymakers and funders should consider STBT as a viable treatment option for young people.
2. In what ways did you find that to be helpful for you? 3. Has there been anything about the online counselling which you have found unhelpful or negative?
4. In what ways did you find this to be unhelpful for you? Each interview was conducted by the first author, synchronously online for up to an hour, to mirror the platform that the young people were using for their therapy.

| Procedure
Recruitment was undertaken by uploading an advert for the study onto the therapy service's online platform. This provided an overview of the aims of the project, the inclusion criteria and a means for contact. The young person was then contacted by the researcher who sent them an information sheet that provided a more comprehensive account of the research. If consent was received, an interview time was arranged. Braun and Clarke's (2006) six-step approach to thematic analysis was used to develop themes. The first researcher was aware of themes identified in previous research. Consequently, two additional qualitative researchers coded initial transcripts as a means of increasing credibility and of gaining alternative perspectives of the data. Codes were generated from all the transcripts and then grouped into the main themes.

| Analysis
Extracts from the interviews with the young people have been included as they were written by the young people. As a result, there may be grammatical errors within the extracts, which have been left to represent the young person's own narrative. Participants were allocated pseudonyms to preserve their anonymity and confidentiality.

| Reflexivity
The first author is a counselling psychologist who works within an integrative approach following a relational framework. Consequently, she believes that clients are the best narrators for their experiences.
Within this research, her notion is that young people participating will voice their individual experiences of helpful and unhelpful factors of STBT and therefore identify a variety of factors.
The second author works as the chief research officer for an online organisation that provides STBT, and therefore may have been biased to emphasise helpful elements and downplay the unhelpful elements.
The third author is a principal lecturer and programme leader in counselling psychology. He advocates a pluralistic relational stance, but works primarily within a psychodynamic framework. His assumptions about the topic were that despite the potential or perceived benefits for young people, online interventions should be regarded as an adjunct rather than replacement for in-person therapy and relating.
The fourth author is a senior lecturer in Counselling Psychology and a trainer and practitioner of person-centred, relational and creative practices. As such, her biases would be towards seeing these processes as helpful.
The last author is a professor in the counselling psychology field and an advocate of a pluralistic approach to therapy. As such, his assumption is that a range of different client and counsellor factors, associated with a range of different therapeutic orientations, may be experienced as helpful and unhelpful by the clients.

| RE SULTS
Four main themes identified from the analysis were as follows: 1) anonymity, 2) access, 3) communication, and 4) control. Each of these themes consisted of subthemes, which identified the ways in which young people found these elements of STBT helpful and/or unhelpful (see Table 1).

| Anonymity
Central to this theme was the disinhibition effect, which online anonymity encouraged. This refers to the young people's sense of being able to express themselves more openly due to being anonymous.

Increased disinhibition due to a sense of disconnection
For some young people, anonymity created a sense of interpersonal distance between them and the online therapist. By being unknown to the online therapist, the young person felt this created a situation where, 'it feels more detached and so it can be easier to talk about more difficult things' (Ali). However, for some young people there was ambivalence about this disconnection with the therapist. Some young people spoke about how there was some need for connection by 'having that one person' (Bella) to talk to 'every week without getting too personally known to them' (Celine). This paradoxical interaction between the young person and online therapist sees the young person connecting with the therapist therapeutically whilst maintaining a boundary of emotional distance between them. This created a sense of being able to express themselves more freely.

Perception of increased confidentiality
As the young people were anonymous online, many of them spoke about confidentiality being more reliable than in face-to-face therapy. By being anonymous to the online therapist, there was a sense that they could be more open about certain issues as they felt more confident that confidentiality could not be as easily broken online compared to face-to-face therapy. It was also recognised that this led to feeling empowered to make decisions about one's own care and made accessing help more appealing.

| Access
Most of the young people spoke about helpful and unhelpful factors relating to access. This theme captured how flexible STBT was, how STBT increases access to other resources and technological issues with access.

Flexibility of access to platform
Several of the young people identified the access to STBT as a helpful factor. They found it helpful that they were able to access it on any chosen device, such as a laptop or mobile phone.
Furthermore, being able to use portable devices was recognised as helpful as they could be used in any location. Ali wrote, 'You can also be more mobile. I've seen a few people use their phones so they can do it on their way home from school and it takes up less time'. It was also helpful to be able to access it from home, making it 'readily available' (Heidi). This was spoken about in the context of, 'you don't have to drive anywhere to get counselling' (Heidi).
Here, the time saved from not having to travel to therapy sessions was helpful.
Some young people appreciated this flexibility because it meant that they could have therapy in 'the comfort of my own home' (George), which was experienced as a safe and familiar place compared with receiving therapy in a formal therapy setting.
The opportunity that STBT offered in being able to access therapy away from a formal setting meant the environment in which the young people found themselves in seemed to offer them a 'safe' (Esha) place, whereby 'you feel you can prepare, calm yourself down before speaking about your issues and you don't stress yourself out' (Heidi).
Additionally, the familiarity of home resulted in less anxiety for some young people. This flexibility of access linked back to the disinhibition phenomenon, as accessing therapy in a familiar environment made the young person feel they could be more open with the online therapist.
Finally, the increased accessibility from any location was perceived as helpful when the young person needed immediate support.
As the young person was able to engage with STBT from anywhere, they were able to resolve any issues they had in a more timely and immediate manner as they could 'message the team, instead of having to deal with it until you next see a counsellor' (Esha).

Ability to utilise additional resources
A number of young people spoke about being able to use various resources that they found helpful alongside STBT. This included using the Internet during their sessions to supplement what was being discussed and having access to discussion forums. Interestingly, some young people spoke about accessing face-to-face therapy alongside STBT. Esha explained, 'I have a mixture of face to face and online counselling, and when I was only getting face to face, I found it harder to cope during the week before my next appointment'. Here, the impact of being able to utilise both face-to-face therapy and STBT consecutively meant that there was a reduction in distress for the young person across the week due to receiving more support. There was a sense that knowing there was access to face-to-face therapy and STBT provided the young person with a stronger sense of being supported.
The young people also found it helpful to be able to use the Internet to search for topics being discussed in STBT to further aid their understanding. George wrote, 'it did give me the opportunities to looks up different things we were talking about at the time, so I think that's a positive'. Despite the potential disruption to the session as their attention was diverted away from the online therapy session, the access to the Internet was considered to be helpful as they felt it increased their insight into their difficulties as they were able to take a proactive role in understanding it.

Technological issues
Some of the young people identified technological issues as an unhelpful factor. They identified issues with the counselling website whereby the server would crash. They also identified issues with their own Internet connection, involving the Wi-Fi disconnecting or the young person running out of data on their device. This could lead to feelings of frustration and was unhelpful as sessions became disjointed.

| Communication
In STBT, communication relies on typing words and submitting these to the other person. The focus of this theme was how young people spoke about the helpfulness and unhelpfulness of relying on typing to communicate. The theme also captures the way in which communication between the online therapist and young person occurs remotely and therefore creates a physical distance between them.

Typing allows time for reflection and freer expression
Some of the young people summarised the value of typing to communicate as 'it gives you time to think' (Ali). Having the space to think whilst typing and submitting their response appeared to slow down the process of communication compared with face to face. This slowing down allowed the young person to be able to consider how to express their thoughts and feelings, which allowed them to feel that they were able to be more articulate to the therapist.

Communication is done remotely
Communication between the online therapist and young person is done remotely in STBT. This means there is a physical distance between the therapist and young person. For some young people, this meant that they did not feel 'judged' (Katy) by the therapist. Katy wrote, 'its alot easier to express myself more online, as you know you arent ever going to meet these people, whereas face to face they are physically sat with you which makes it alot more intimidating and a bit pressured'. As a consequence of not feeling judged, the young people described not filtering what they expressed. Hence, they were able to be more open as it gave them 'confidence to share difficult things' (Celine). Ike wrote, 'you cant see ones reaction n you feel like your not being silently judged'.
Some of the young people also spoke about how this physical remoteness allowed them to conceal their emotional and physical state. For some, they felt there was value in being able to hide heightened emotions such as anxiety and physical behaviours such as crying. Showing these experiences to a therapist created a fear of embarrassment, being judged and increased anxiety. As a result, being physically distant alleviated anxiety and pressure felt by the young person as the online therapist is unaware of body language, which makes it 'a lot more calming' (Fay).

Text-only communication is time-consuming
Whilst typing was recognised to be a helpful factor for some, it also created 'a little bit less flow' (Ali) and was more time-consuming than talking, which could result in sessions feeling rushed. Consequently, it could feel that more could be said by talking compared with typing.
This resulted in a sense that 'it might take longer for my problems to get sorted' (Katy). This time constraint placed on STBT due to typing was considered unhelpful as it meant some young people felt issues were not dealt with in a timely manner.

Reliance on typing to communicate
Typing to communicate was also described as unhelpful as 'it can make you hold back. Because you're typing instead of just speaking, it gives you a chance to write it and then take it away' (Celine).
There was an appreciation that the only way to get support from the therapist was by saying something, but the capacity to type and then delete the message could lead the young person to withhold information. This 'self-sabotaging' could then lead to feelings of frustration and not getting the desired help.

Nuances of face-to-face communication lost
Several young people wrote about the nuances of face-to-face communication that were lost through typing. This included the inability to communicate through tone of voice and to see the therapist's facial reactions.
The lack of facial expression and tone of voice made it difficult for the young person to identify how the therapist was currently feeling towards them, which the young people used to assess how engaged the counsellors might be. An example of this was described as, 'sometimes i feel like its easy to mistake whats being said because we dont hear the tone that its being said in, so i will automatically think something said is a negative thing' (Fay). There was a reliance on the therapist's text to gauge their emotional state.
Such potential misinterpretations of the therapist resulted in some young people becoming upset due to broken feelings of trust.
This, then, led to them ceasing use of STBT for a short time.
Some young people also wrote about the therapist misinterpreting them through text. This could result in feelings of frustration and annoyance, as there was a 'disconnect' between the therapist and themselves. Katy wrote, 'It was bit annoying as I had to keep explaining something that was clearly upsetting me'. Some of the young people felt that they had to repeatedly clarify what they meant.
For the young person, the lack of non-verbal cues also meant that therapists were unaware of any changes in their emotional states throughout the sessions. Ali stated, 'if you get into the "wrong" frame of mine, a face-to-face counsellor can snap you out of it more easily as they can se you go into and say something to you'.
In such instances, the absence of non-verbal cues was a hindrance as the young person felt the responsibility was on them to support themself during periods of difficulty. Ali explained, 'they can't say "why don't we do this," you have to decide to do something else while you wait and if you aren't feeling to good, you might not think about that'.
A final impact of the lack of non-verbal cues and physical presence was that some young people felt increased loneliness and a reduced feeling that someone cared for, and was available to, them.
Ali wrote, 'also there is no one in front of you so it can sometimes feel like you are still alone… It also means that I feel like no one cares'.
Additionally, some young people felt that when they were upset and crying there was no one to comfort them. Esha said, 'with online counselling, I usually say if I'm going to/am crying, but there's no one else there in the room with me. I can sometimes feel more alone because of this'.

| Control
Many of the young people's responses were coded under the theme of control.

Control of session content
For some young people, accessing STBT felt like they had more control in directing the session and its content, as there was greater distance between them and their therapists. There was a sense that the power dynamics shifted in STBT where the young person felt they had more power to control the session. This was described as

| D ISCUSS I ON
Findings from this study on what young people found helpful and unhelpful in STBT triangulate well with previous evidence. This is despite increased technology use by young people and the growth and development of online therapy services across the years.
Though control was just one of the themes, it seemed apparent in much of what the young people spoke about in other areas.
The sense of control young people had was brought up across all themes, which suggested this was a particularly helpful aspect of STBT. The online nature of STBT provided them with a sense of control in how to use and access the therapy. Consequently, it appeared that feeling in control provided young people with the opportunity to engage with STBT, which resulted in them being able to express themselves more openly. Young people often described how they felt able to lead the online session in the way they wished compared with face-to-face therapy. This seemed to reflect a change in the perception of power between themselves and the online therapist. Suler (2004) writes that the authority of the therapist is reduced online, as factors such as the way they dress and behave that would usually exhibit their power are not so present.
The helpfulness of anonymity can also be understood in terms of control. Young people found that the anonymity of online counselling allowed them to express themselves more freely. There was a perception that, because they were anonymous, the content of their sessions was more likely to remain confidential compared with faceto-face therapy. Anonymity seemed to give the young people the freedom to control what they said, which in turn allowed them to feel freer to discuss what they wanted. This is reflected in findings around telephone counselling (Davidson & Harrison, 2020) where similar links between control and anonymity are identified.
Access also seemed to link to the theme of control. Here, young people described how they valued being able to access STBT wherever and whenever they liked. The underlying control of being able to access STBT from any location was considered important as they were able to choose locations they felt comfortable and safe in (such as their homes), or places that were convenient to them (such as on the bus returning from school). This key theme of accessibility is identifiable as a key selection factor for young people in STBT (Navarro et al., 2020) and more generally in e-clinic settings (Ospinna-Pinnilos et al., 2018).
Finally, control was implicit in communication too. In being able to type their responses, for instance, young people had time to think before responding, which allowed them to convey their message clearly; and it allowed them to control what they put across by typing and deleting the message. In these respects, they valued being able to control the pace and content of sessions (Suler, 2000).
Our finding that young people experienced the anonymity of the online therapy platform as helpful is highly consistent with previous literature on STBT (e.g. Bambling et al., 2008;Hanley, 2008Hanley, , 2009King et al., 2006). Young people described a sense of detachment in the relationship that permitted them to be more open. Many of the young people also felt it was helpful to be able to conceal their emotions and physical behaviours from the therapist. In these situations, they felt it reduced embarrassment and shame. The emotional distance in the relationship with the online therapist, then, permitted some young people to express themselves and feel more secure in the relationship. To some extent, this challenges traditional notions of the working alliance and the centrality of the therapeutic relationship to change (Horvath & Lubarsky, 1993). The young people placed less emphasis on the value of connecting emotionally.
An interesting paradox here, however, is that whilst the young people valued the emotional detachment, they had also come to the therapist for a relationship to help them through their difficulties. This is explored closely in recent work defining the 'theory of change' for STBT, using data from the same service as this case study (Hanley et al., 2021). In this, a key mechanism of change is identified as providing a 'temporary support system', that is a relationship that a young person can engage with, then autonomously end before it becomes emotionally involved. A similar tension was found in the physical distance of remote therapy. On the one hand, a majority of the young people felt the ease of access and availability of STBT was helpful. However, half of the young people also felt this was a hindrance, particularly during times of distress. These young people felt they wanted the online therapist to be physically present to help alleviate distress, but the remoteness of the platform denied this.
Such tensions highlight that the same helpful aspects of STBT can also be a hindrance depending on the situation and the style and preference of the young person. All these tensions point to the complex nature of STBT, and how, as with face-to-face counselling, it is not suited to all.

| Limitations
As with all qualitative research, the findings represent the subjective perceptions of participants and may not reflect the 'actual' factors that might facilitate, or inhibit, STBT.
The research recruited young people from just one STBT service. This same service has served as a site for previous research (e.g. Hanley, 2006;Hanley, 2009;Hanley, 2012). Hence, findings may not be representative of STBT more broadly. Recruitment was done via an advert uploaded onto the STBT website. It is possible that this type of recruitment attracted those with more positive experiences of STBT, and therefore, results may not fully capture unhelpful aspects of this medium.
The study recruited just four males out of 13 participants, and no participants of non-traditional gender identities. As a result, the data may not be representative of young people's experiences across genders. However, it could be argued this mirrors research which suggests that online counselling is predominantly accessed by females (Callahan & Inckle, 2012;Frith, 2017;Fukkink & Hermanns, 2009).
A final limitation of the study was that it used the online platform to deliver the research interview. Given that the young people indicated that this type of communication could lead to misunderstandings, this might also have happened in the present study.

| Implications for practice
The findings from this study suggest that STBT can serve as a positive therapeutic medium for young people and should be considered by service providers and stakeholders as an appropriate form of intervention.
Young people valued the anonymity, perception of control, and increased access this platform provided compared with face-to-face therapy. A summary of the findings from this study and similar research could be posted on STBT platforms to help young people make more informed decisions of whether they wish to access STBT or not. As young people feel they can be more open through this platform, online therapists should recommend they access STBT in a safe environment. Accessing resources alongside STBT was also helpful, and therefore, STBT services could provide young people with a list of online resources to minimise harm from accessing mis-

| Further research
Quantitative studies should be used to establish, more rigorously, whether the effects of STBT identified are present across a wider and more representative population of young people. Randomised trials comparing STBT to face-to-face therapy, as well as across various forms of online therapy, could also be used to examine the causal impact of these different modes of service delivery. Qualitative research could also be conducted to gain perspectives from those young people who are simultaneously accessing STBT and face-toface therapy. Further research could also play an important role in identifying the types of young people for whom STBT, as well as other forms of online therapy, is most effective and appropriate.

ACK N OWLED G EM ENTS
We would like to thank Kooth for their time and effort in delivering researcher training and assisting with setting up the online platform to deliver interviews.
Meera Dhesi is a counselling psychologist who completed her doctorate at the University of Roehampton. She has a special interest in young people's therapy and the ways in which psychological difficulties present themselves within the South Asian community.
Aaron Sefi is a chief research and insights officer at Kooth Plc.
Kooth is an innovator and leading platform for digital mental health. Aaron is responsible for developing the evidence base and building research priorities to ensure the approach to service provision is robust and of the highest quality. Aaron is driven by aligning user needs and wants with an evidence base to ensure meaningful and valuable research and data are shared, understood and implemented.
Mark Donati is a counselling psychologist, head of doctoral training, convener of the PsychD counselling psychology programme and principal teaching fellow at the University of Roehampton.
He has a long-standing interest in personal and professional development and doctoral research that seeks to make original contributions to practice.
Jacqueline Hayes is a senior lecturer in counselling psychology at the University of Roehampton. Jac is a researcher/practitioner specialising in qualitative methodologies, with a special interest in hearing voices in bereavement with non-bereavement voices. Jac's additional specialisms and passions include the following: experi-