The Limitations of Virtual Online Therapy in an African setting.
Firstly , increased accessibility is no panacea in African settings; such easy access involves some risk. One may note that the expanded base of potential clients made possible through online counselling raises the question of its clinical limitations. A question becomes who can be effectively treated online? As in many settings, web-based intake procedures have been designed expressly to screen out candidates who would be better served offline. Unarguably the initial online assessments are designed to triage issues involving violence, domestic or otherwise, active suicidal ideation, serious substance abuse, or an immediate and urgent crisis. Clients in these categories may still be “seen” online en route to more appropriate resources, and they may well view the online contact as a crucial transition, or a buffer zone to relieve desperation. Yet it is generally agreed that these clients are not ideal for service that takes place entirely online as posed by (Suler et al, 2001; Stofle, 2001). Furthermore, new technology does not justify the eradication of necessary boundaries inherent in cultures and social systems. Ease of access may be secondary if a client’s needs are compromised by conflicts of interest or misunderstandings of which already exist within the African setting.
In addition, in virtual therapy, especially in Africa, deficits can be advantageous. Research has reviewed that there are a number of challenges faced by online counsellors. For instance, the ‘virtual’ connection is open to a host of projections and seems to be the perfect template for transference and countertransference (Gwinnell, 2003). In addition the network problem in Africa tends to affect the connectedness. However, in the tradition of good counselling, one may find that the counsellor and the client are able to positively reframe many of the problems. The transparency of online relationships can provide opportunities to explore the client's irrational beliefs and distorted perceptions in the face of little nonverbal input. Be that as it may, one cannot ‘cut to the chase’ of the client’s thought processes, revealed in writing as visible ‘self-talk.’ As Suler (2002) states, “There is a special type of interpersonal empathy that is unique to text relationships. In some cases, text-only communication connects you more directly to a person's psyche than distracted, superficial aspects of their existence. However, this remains inconclusive and needs to be researched within the African context as the African belief system values connection, which fosters openness and communication.
Worth noting is that in African virtual therapy a synchronicity allows reflection, but can also breed misunderstandings. The absence of spontaneous clarification is a drawback of online counselling. Despite the loss of visual and auditory cues, clients may not be self-validating enough to compensate. When counsellors lack training in text-based communication, vital information about clients may remain "between the lines" and the real issues may go unnoticed. Even with the requisite skills on both sides, there are those who would find the middle ground of cyberspace more of a void than a healing sanctuary. The counsellor may make provisional hypotheses based on the client's responses, but there is room for error in assessment. The therapeutic priority remains expressing warmth, authenticity, and empathy.
In addition the counselor and client must also be reasonably good writers and typists to utilize virtual online therapy in Africa. It must be indicated that clients must be comfortable with what is essentially a letter-writing process and be able to express their thoughts and feelings clearly, and to interpret messages carefully, with a willingness to ‘give the benefit of the doubt’ when humour or the intended meanings miss the mark. Be that as it may, it may be justified to pose that online counselling is best suited to those who are capable of sustained introspection, value written self-expression, and have the creative independence it takes to hold up their end of the written dialogue.
More so , another limitation of virtual online counselling in Africa is the interjection of clients and counselors. It is thus possible that the experience of using online therapy in Africa especially during the pandemic might have a similarly positive impact on therapists’ concerns and attitudes toward online therapy. At the same time, mandatory versus voluntary use of technological innovations has been found to moderate the relationship between predicting factors and users’ attitudes (Venkatesh et al., 2003), and thus the involuntary nature of the transition to online therapy might have a negative impact on therapists’ attitudes on using online therapy. Moreover, the challenges of the abrupt transition, as well as the general stress associated with the global crisis situation might make more Africans resistant to online therapy. Online therapy which was used during the pandemic tended to be a distressing experience for many therapists, from which they were unlikely to gain positive experiences or develop more positive views on online therapy as posed by (Messina and Loffler-Stastka, 2021).
In addition Africa is characterised by a number of aged people and age has been theorized to also have an impact on attitudes toward technology use (Venkatesh et al., 2012), and younger age is often associated with being more technology savvy which proves to be a limitation for virtual therapy. . In the context of online psychotherapy, pre-pandemic studies found no relationship between age and attitudes toward online therapy (Liu et al., 2015; Hennemann et al., 2017); however, therapists of all ages’ sudden and en masse transition to online therapy might have posed specific challenges to therapists based on their age and experience. That is, even though younger generations might have had more preliminary experience with video conferencing, which they might have used more for personal communication purposes, older, clinically more experienced therapists might have had the advantage of having developed more solid and transferable therapy skills that could be more easily adapted to the new online platform.
Another limitation of virtual therapy in Africa is the increase in unlicensed practitioners online, with new licensing issues emerging in recent years. It should be noted that it is always important for a patient looking for a therapist or counsellor to verify the therapist's licensing. It must be stated that the patient has the right to learn whether the therapist has ever been disciplined by the licensing board or had any law suits filed against him, particularly if he lost that suit. This is important whether the therapist is online or in person. This type of information is available to the public in the state where the therapist is licensed. However, with regard to online therapy, which state is the therapist licensed in becomes a problem. Because online therapy can cross state and even international borders, it is critical to know whether the therapist is licensed in the state where the patient resides (Chen & Bonnano, 2020). There is now a long list of states in which an online therapist cannot practice psychotherapy in any state other than the one in which he is licensed. It is entirely possible for therapists to be licensed in more than one state, but it is never safe to assume that they are licensed in the state in which you live. This is important in order to protect the patient from unethical therapists who may not even be therapists at all (Topocco et al, 2017)
So what do we realise in summary: Firstly; acknowledging and addressing challenges regarding feeling and expressing empathy, feeling connected, and reading patients’ emotions in online sessions should now be a central part of therapist training, supervision, and continued education especially in Africa. Moreover, with a number of research results supporting the notion that first-hand experience with online therapy reduces negative attitudes toward online therapy and its efficacy in Africa. It is imperative to note that even under the stressful circumstances and the involuntary transition to online therapy instead of in person, experiencing the ability to overcome initial challenges and personally learning what it is like to provide online therapy led to more positive attitudes toward online therapy and its efficacy. Although at this point even the short-term future of online therapy is uncertain, an important implication of these results is to expose psychology trainees to the online therapy format early enough so that they can learn skills of how to manage challenges related to online therapy, and to experience its benefits. Training of junior therapists appears to be especially important in this regard, given that in our study, younger and less experienced therapists appeared to be more challenged by the switch to online therapy compared to their older and more clinically experienced counterparts.
Rushwaya T (RMHAF CEO). Forensic Psychologist
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