Home / Articles / Volume 10 (2013) / Managing the therapeutic relationship in online cognitive behavioural therapy for depression: Therapists' treatment of clients' contributions
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This article examines how therapists and clients manage the therapeutic relationship in online psychotherapy. Our study focuses on early sessions of therapy involving 22 therapist-client pairs participating in online Cognitive Behavioural Therapy (CBT) for depression. Using Conversation Analysis (CA), we describe two practices that therapists can use, at their discretion, following clients’ responses to requests for information. The first, thanking, accepts clients’ responses, orienting to the neutral affective valence of those responses. The second, commiseration, orients to the negative affective valence of clients’ responses. We argue that both practices are a means by which therapists can simultaneously manage developing rapport, while also retaining control of the therapeutic process.


Our contribution to this special issue on computer-mediated discussion of troubles focuses on therapist-client interaction during online Cognitive Behavioural Therapy (CBT). Although conventionally conceived as a ‘talking cure’ (Peräkylä, Antaki, Vehiläinen, & Leudar, 2008a), psychotherapy is now also delivered in text-based online consultations. Originally developed for use by physically co-present (i.e., face-to-face) parties, CBT has been shown to be effective in treating depression when conducted online through a website enabling real time text-based interaction between therapists and clients (Kessler et al., 2009).

Moving beyond an understanding of the effectiveness of online CBT, we seek to examine how participants accomplish the routine business of online psychotherapy. In the research reported here, we examine early sessions of CBT, a context in which therapist and client work together to establish a shared understanding of the client’s troubles. It is important to understand interactional processes that underpin early sessions, as the understanding reached there informs the therapeutic work that clients and therapists subsequently undertake (Antaki, Barnes, & Leudar, 2005). We explore how therapists can elect to orient to the affective valence of clients’ descriptions, treating what the client has written either as troubling and to be commiserated with or neutral and to be treated as mere information. In so doing, our aim is to contribute to the study of online social interaction, specifically the practices used in online psychotherapy that foster rapport while advancing other therapeutic tasks.


Online Cognitive Behavioural Therapy for Depression

Interest in computer-mediated mental health care is increasing worldwide. This interest has been driven by various factors, including the lack of availability of conventional psychotherapy, the need to provide access to geographically isolated clients, and calls to offer therapeutic encounters that suit the particular characteristics and preferences of clients (Hollinghurst, Peters, Kaur, Wiles, Lewis, & Kessler, 2010). In response to such factors, a range of internet-supported therapeutic interventions is now available (cf. Barak, Klein, & Proudfoot, 2009), including online interactions between therapists and clients. Recent research conducted on a sample of primary health care patients in the UK has shown that when conducted online, text-based CBT can be successful at reducing the symptoms of depression (Kessler et al., 2009). Benefits of online CBT include improved access, therapeutic effects of writing feelings down, and the potential for anonymity to enhance disclosure; challenges include a lack of nonverbal cues, delayed responses, and the need for a sufficient level of computer literacy (Beattie, Shaw, Kaur, & Kessler, 2009; Mallen, Vogel, Rochlen, & Day, 2005).

There are also differences between physically co-present and online CBT that have unknown ramifications. Participants in text-based online therapy have been observed to write, on average, around one-third of the words that are spoken during the same time period in co-present therapy (Mallen et al., 2005). As we argue below, this may result in part from the efficiency of the communicative practices that are possible in this online medium. It allows therapists to develop a degree of rapport by responding to what clients have written – troubled or otherwise – while also attending to other therapeutic tasks by enabling the interaction to progress rapidly and efficiently. This is an important accomplishment for psychotherapy, a treatment which requires both the development of rapport and sustained focus on working towards client improvement, a point that we return to below.

There are a range of online media through which people can communicate, each enabling different practices of interaction (e.g., Anderson, Beard, & Walther, 2010; Garcia & Jacobs, 1999). The therapy examined in this article was conducted via instant messaging, a text-based communication system where users privately compose turns of text, or ‘posts,’ before electing to make those posts available for others to read. Instant messaging enables a quasi-synchronous form of interaction, in which transmission of a post is separate from the private process of composing that post (Garcia & Jacobs, 1999). Each client and therapist participated in up to 10 sessions of this online therapy, with each session scheduled to last 55 minutes. Although we have demonstrated through a randomised trial (Kessler et al., 2009) and qualitative interview study (Beattie et al., 2009) that CBT conducted via instant messaging is both effective and acceptable to clients, it remains unclear how clients and therapists work together through this medium to accomplish the activities that constitute this type of psychotherapy.

Our current aim is to understand how clients and therapists manage the potentially delicate task of exploring clients’ troubles in early sessions of online CBT. Our research, involving the first known use of conversation analytic techniques to study online psychotherapy, explores how therapists manage a range of therapeutic tasks, including developing and maintaining a good relationship that enables working towards relieving clients’ mental distress.

Conversation Analysis and the Study of Online Interaction

Conversation Analysis (hereafter ‘CA’) involves the study of how people accomplish particular actions when they come to interact with one another (Liddicoat, 2007; Sidnell, 2010). It does this by investigating specific types of conduct that are produced at particular junctures in social encounters, providing an explanation of the commonsense understandings that the participants involved use to make sense of what is happening (Schegloff, 1995). Although originally devised to study what is described as mundane ‘talk-in-interaction’ (Schegloff, 1987), CA has application to the study of interactions conducted within institutional settings (Heritage & Clayman, 2010), as well as to study online interaction (e.g., Anderson et al., 2010; Garcia & Jacobs, 1999). CA research has identified how people utilise commonsense understandings of how interactions are ordered to understand what is happening on a moment-by-moment basis. However, CA has also demonstrated how interactional order can vary to suit particular contexts, institutional and otherwise. For instance, turn-taking in courtrooms differs substantially to that in mundane talk-in-interaction (Atkinson & Drew, 1979). Similarly, online interaction can exhibit adaptations from the turn-taking practices used in co-present interaction (cf. Garcia & Jacobs, 1999). For instance, whereas overlap tends to be avoided in talk-in-interaction, in both synchronous and quasi-synchronous online interaction participants can successfully manage simultaneous message composition; this accomplishment appears to be systematically enabled by an ongoing record of composed turns to which participants can refer (Anderson et al., 2010; Garcia & Jacobs, 1999).

In our analysis, we build upon previous research which demonstrates that just as people orient to rules of turn-taking (Sacks, Schegloff, & Jefferson, 1974) and sequence organisation (Schegloff, 1968, 2007; Schegloff & Sacks, 1973) in mundane talk-in-interaction, they also orient to adapted versions of these rules in institutionalised forms of online interaction. For instance, in types of text-based online interactions where participants privately compose turns before publicly posting them (such as the data considered here), it can be difficult for recipients to be sure when a contribution will be forthcoming. Participants can deal with this by unilaterally by making a series of posts, not waiting for a response to one before they make another. However, unlike talk-in-interaction, where there is no lasting record of what has passed, participants in text-based online interaction can interpret responses (if and when they are made) with reference to prior posts that are contained in the log record of the conversation (Garcia & Jacobs, 1999; Herring, 1999). Our analysis will build on findings from talk-in-interaction, examining the different ways in which therapists respond to and comment on the descriptions clients make within online psychotherapy.

The Interactional Organisation of Discussing Troubles

The research we present in this article contributes to wider CA studies of how people discuss troubles. Seminal work in this area argues that although conversations about troubles exhibit variation, the parties involved orient to an underlying organisation. One general pattern is the organisation of people into roles of troubles-tellers and troubles-recipients. The role of troubles-tellers is to describe the details of a trouble or troubles. Conversely, troubles-recipients should appropriately align with troubles-tellers’ accounts through displays of affiliation (Jefferson, 1988; Jefferson & Lee, 1981).

Recipients’ responses to new information, including troubles, are constructed in relation to the manner of the information just delivered. Maynard (1997, 2003) has identified three relevant factors: first, whether the information is novel; second, if it is novel, what the valence of the information is (i.e., whether it is good or bad); third, who the information has consequences for (what Maynard refers to as “consequential figures”). Each of these factors is established by participants during interaction. For their part, recipients can elect to treat (or not treat) a prior turn as novel, as information with a particular valence, and with a consequential figure or figures. Therefore, whether some information comes to be discussed as novel, a trouble, and so on is an interactive accomplishment in which recipients play a crucial role. Our interest in this article is in the context and manner in which therapists can, but need not necessarily, orient to the affective valence of clients’ descriptions.

Rapport and Therapeutic Progress

In early sessions of therapy, in addition to finding out about clients’ troubles, therapists must develop rapport with clients while not becoming distracted from managing activities the CBT framework identifies as crucial for therapeutic change (Beck, Rush, Shaw, & Emery, 1979; Beck, 2011). A good working relationship between therapist and client is thought to be a vital precondition for this change to occur (Bordin, 1979; Horvath, 2005; Horvath & Luborsky, 1993; Kozart, 2002). The beneficial elements of the therapeutic relationship are typically studied with reference to the concept of the therapeutic alliance. This alliance is thought to be important in all forms of psychotherapy (Bordin, 1979; Horvath & Luborsky, 1993; Kozart, 2002), including CBT (Beck et al., 1979; Beck, 2011) and online psychotherapy (Cook & Doyle, 2002). It refers to the development and maintenance of a collaborative relationship focused on modifying psychological experiences that are negatively impacting upon the client (Horvath & Luborsky, 1993; Kozart, 2002). Although the precise nature of the therapeutic alliance has never been established, research has generally found that it is a moderate predictor of therapeutic outcome (Horvath, 2005).

Research has also determined that establishing a strong alliance in the early sessions of psychotherapy, in which a good sense of collaboration and trust is established, is crucial to the therapeutic process (Horvath & Luborsky, 1993). However, there is little research on specific actions that therapists can use to develop, let alone maintain, the therapeutic relationship (Horvath & Symonds, 1991; Kozart, 2002), and very little research on this process in online therapy (Mallen et al., 2005). The present study addresses this deficit, examining the interactional practices through which therapists and clients collaborate, moment-by-moment, in the process of online therapy. We focus on early sessions of therapy when clients and therapists are forming their relationship, and explore how both parties respond to therapists’ requests for clients to provide information about their personal circumstances. Specifically, our research identifies how therapists orient to clients’ contributions, while also maintaining focus on working towards client improvement.



Data for this study were collected from 22 client-therapist pairs (comprising 22 clients and 10 therapists) who participated in a qualitative study (Beattie et al., 2009) that ran parallel to a trial of online CBT for primary care patients with depression in the UK (Kessler et al., 2009). Each client interacted with a trained psychologist through an online service ( http://www.psychologyonline.co.uk/ ). Clients could access up to ten sessions of therapy through the trial, each session lasting for up to 55 minutes. Their participation resulted in 149 sessions of therapy that were available for analysis. The mean length of therapeutic treatment was 6.8 sessions (SD = 3.5), with each session containing an average of 47.4 posts (SD = 23.2) and 1,229 words (SD = 431). Participants provided written informed consent for their anonymised session transcripts to be examined for research purposes. The content of therapy sessions was recorded in a log that both therapists and clients could access.

Data incorporated in this article are in the same format as the online logs that were available to the clients and therapists participating in therapy. Speaker labels on the left-hand side of the transcript correspond to the beginning of a post. There are occasions where a single participant has made several contiguous posts. This means that they have posted a turn before electing to continue composing another turn, which they also post before their interlocutor has transmitted a post; a practice that results in disrupted adjacency (Herring, 1999). Fragments from the session logs that are reproduced in this report have only been modified in three ways. First, names have been replaced with pseudonyms, in order to protect participant anonymity. Second, post numbering has been added as a reference point. Third, boldface font, a feature not available to participants, is used to highlight practices that are of particular analytic interest.

Analytic Approach

CA provides an increasingly recognised approach to psychotherapeutic process research (Peräkylä, 2004), and there has been a burgeoning of research in this area in recent years (e.g., Peräkylä, Antaki, Vehiläinen, & Leudar, 2008b). The present study used a standard CA approach in which a corpus of data was qualitatively examined to identify recurrent ways in which people contributed to online psychotherapy. We built collections of different types of interactional practices that were used at the same juncture (in this case, what therapists did following clients’ responses to questions) and studied them to determine what different types of actions were accomplished by these practices. In line with the focus in CA on how people make sense of their social interactions, our analysis is concerned with how participants themselves react to the actions we study (ten Have, 1999). Due to space constraints, we report just a few instances from our data sets to illustrate the analysis we have generated.

As discussed earlier, text-based online interaction is, in many ways, distinct from talk-in-interaction. It does not, for instance, have many of the paralinguistic features of speech, such as intonation, the uses of which are demonstrably relevant for participants involved in co-present psychotherapy (Fitzgerald & Leudar, 2010; Freese & Maynard, 1998; Labov & Fanshel, 1977). These are not, however, analytic constraints, but rather they are systemic constraints for which the participants themselves must find solutions (cf. Schegloff, 1972). Our analytic task is to identify the practices that they use to accomplish this, by focusing on the information that was made publicly available to both participants in an interaction (cf. Garcia & Jacobs, 1999).

The principal constraint on our analysis is that it was not possible to access information about the length of time between the posts that were made by participants (i.e., the silence between posts). This information was available to participants, through their subjective experience of the temporal distribution of posts, but not to us as analysts. This meant we were unable to examine the impact that silence between the posting of turns might have on a progressing interaction, unless participants made this explicitly relevant in their posts. We therefore avoid making analytic claims that rely upon this information.


In the early sessions of psychotherapy that we studied, understandings of the particulars of clients’ experiences were commonly arrived at through successive requests for information. That is, therapists would ask a series of questions and clients usually responded, in turn, to each of these. In responding, clients introduced a range of topics, ranging from descriptions of their inner mental experience to matters that extend beyond themselves (the dynamics of relationships, the external pressures that come from a particular job, etc). Although the basic organisation of sequences of interaction was into adjacency pairs (Schegloff, 1968, 2007; Schegloff & Sacks, 1973), we found that these question-response sequences could be expanded to include a ‘third position object.’ These objects were found to respond to the client’s prior turn in some way, while also nominating a closure of the sequence in order to move to a further matter (Schegloff 1986, 2007; ten Have, 1991). We explain this further shortly.

The focus of our analysis is two different but common third position objects: thanking and commiseration. The latter involves therapists’ orienting to the affective valence of clients’ descriptions, whereas thanking involves no such orientation. In order to demonstrate that therapists need not orient to affective valence, we turn to cases of thanking first.

Not Orienting to Affective Valence: The Practice of Thanking

The first example of thanking comes from an initial session of therapy between a therapist (Stephanie) and her client (Amanda). The data fragment begins partway through the session. Amanda has already described her symptoms as having intensified following the breakdown of an abusive relationship, and immediately prior to the beginning of the fragment, she has described her current challenges in caring for her granddaughter Bianca. Stephanie then seeks information about Amanda’s children.

(01) Online CBT: P54-T4-S1

The focal practice of thanking is highlighted with boldface in post 50. However, in order to appreciate that practice, it is important to consider the sequence of its production. Stephanie has sought information about Amanda’s children at post 45 and, in response, Amanda describes each of her children by name. Once Amanda has finished, Stephanie’s post contains two components. The first, in which she thanks Amanda, is located in ‘third position’ (Peräkylä, 2004, 2010; Schegloff 1992, 2007; ten Have, 1991). This third position object is directly responsive to Amanda’s preceding description, insofar as it acknowledges what Amanda has written, rather than moving to another matter. What is of interest about this particular comment is it treats Amanda’s prior posts as having conveyed information. It does this in two ways. First, Stephanie thanks Amanda for having produced the sort of response that she was seeking. That is, she asked Amanda to tell her about her children and in thanking accepts that Amanda has done what she has been asked. Second, in writing “thank you for all that info” (emphasis added), Stephanie displays her understanding that what Amanda has produced is information. She does not orient to that information as something troublesome by, for instance, commiserating with Amanda’s situation. As we shall observe, treating a turn in this way is different from orienting to the negative personal impact of events described by clients.

It is worth considering why Stephanie responded in this particular way. Although Amanda has described the very complicated lives of her children, her description does not explicitly foreground, at least at this point, the impact of her children on her personally (an exception is the positive personal impact described at the end of post 48 and the beginning of post 49, but this is followed by a return to a more affectively ‘neutral’ description of her children). As mentioned above, Maynard (1997, 2003) has argued that whether information is to be treated as novel, a trouble, and so on is an outcome that is accomplished in interaction. It is not the case, for instance, that the status of information is automatically determined by categorical relationships such as ties of kinship. Amanda’s description is not necessarily something that has positive or negative implications for herself, simply because it is about her children. Her posts merely list information, being generally comprised of short sentences, rather than as a narrative about personal troubles. Although many circumstances she describes are clearly unfortunate, her description does not highlight personal negative consequences. These may exist, but they are not conveyed by Amanda at this point. Her response to Stephanie’s request, therefore, is composed as information-giving rather than as troubles telling, and this is how it comes to be treated by Stephanie. Given that the focus of therapy is Amanda, Stephanie here elects to treat Amanda’s posts as providing information without an affective valence that warrants comment.

Having accepted, in third position, the information that Amanda provided, the second component of Stephanie’s turn is to ask a new question, which initiates a new sequence. Although this new question continues the topic of Amanda’s children, it moves away from the details Amanda provides about them, to seek new information. This is what we routinely identify as a task-focused move, made by the therapist, to advance the therapy in some way. Prefacing this with a third position thanking allows therapists to explicitly acknowledge clients’ contributions, before making this move. Third position thanking therefore functions as a sequence-closing third (Schegloff, 1986, 2007).

A similar practice, more truncated in form, can be observed in the next instance. It comes from a second session of therapy in which the therapist has sought to continue the activity of collecting information about the client’s personal history that was initiated in the first session. Prior to this fragment, the therapist (Mark) and his client (Brenda) discussed one of Brenda’s past relationships. Mark’s assessment at the beginning of post 39 relates to that topic, which he closes down to inquire about Brenda’s physical health and fitness.

(02) Online CBT: P9-T1-S2

Following Brenda’s response to Mark’s request for information, Mark probes an aspect of that response in his next question in post 41. In pursuing the final aspect of Brenda’s preceding post, that this “bad” state of affairs only relates to “the last year,” Mark constructs his further request as specifically building on what Brenda has just posted. It is worth considering why Mark does not use a third position object to preface his question at post 41. As this question is topically connected to the prior sequence, it would be premature for Mark to thank Brenda for her first response; his question is designed to solicit further information that was evidently missing from Brenda’s previous response. In contrast, following Brenda’s response to this follow-up request in post 42 and before moving to ask another question, in post 43 Mark explicitly replies to Brenda’s response by thanking her.

As in fragment 1, but on this occasion with a single lexical sequence-closing third, Mark accepts that Brenda has provided the information he was seeking. Also, as with fragment 1, the thanking casts her response as mere information, not as a description of troubles. Although Brenda describes her health and fitness as “bad,” she does not associate this with negative personal consequences and describes it as temporary (“but this is only the last year,” post 40). Therefore, Mark is not responding to an apparent troubles telling. In contrast with our analysis of fragments 4 and 5 below, the therapists’ treatment of their clients’ contributions as information orients to the relatively neutral affective valence of the descriptions that the clients provided.

Following his thanking, which functions as a sequence-closing third, Mark continues in the same post to initiate a new sequence in which he asks another history-taking question. Although his question maintains discussion about lifestyle, the focus shifts to alcohol consumption specifically (using the colloquial term “drink” that Brenda had already used in post 40). This move is interpolated by thanking, a means by which Mark can accept Brenda’s response, before moving to discuss something different. It is consistent with our observation regarding fragment 1, that thanking is a means by which therapists can accept the prior content of the discussion before moving to another matter.

In the above fragments, thanking was used to move from one question to another, thus progressing the therapist’s agenda. However, as the next fragment illustrates, explicit acceptances of clients’ contributions are not normatively necessary. Therapists can, following clients’ responses to their questions, directly proceed to ask a topically unrelated question. What the following fragment also shows, however, is how thanking can be used by a therapist to move between different phases of the consultation – in this case, the ‘assessment’ and ‘goal-setting’ phases. Fragment 3 begins early in the second session of therapy of a different dyad. The therapist, Holly, seeks to continue the assessment that was postponed by the end of her first session with Mary.

(03) Online CBT: P72-T5-S2

Between posts 17 and 24, Holly makes a series of requests for information, and Mary responds to each in turn. Holly does not provide a third position acceptance of Mary’s responses, however, until post 25. This highlights that the practice we have been considering is discretionary. As Sacks identified, questioners have “a reserved right” (1992: V1: 264) to follow a recipient’s response with another turn. It is a right that is discretionary and need not be exercised. We find that therapists can utilise the third position space to comment on and convey an understanding of clients’ prior conduct. In this sense, and consistent with the related instances in our data set, Holly’s third position thanking at post 25 is an acceptance that Mary’s prior turns have provided the information that was requested. Moreover, that information is treated as mere information or, to put it another way, as having a neutral affective valence.

In studies of talk-in-interaction, thanking has been shown to be co-opted into closing down conversations (Schegloff 2007; Schegloff & Sacks 1973). In instances of online CBT that we have examined, it is often used as a sequence-closing third. In this sense, thanking is also a closing-relevant practice when deployed in this position. As we have seen, thanking is an appropriate way for therapists to treat prior turns as providing information with a relatively neutral affective valence. In the next section, we explore instances where therapists respond to affective valence in clients’ posts and thereby manage orienting to affect, while also remaining focused on the practical tasks of therapy.

Orienting to Affective Valence: Commiserating

In contrast to what was observed above, therapists can, in third position, explicitly orient to a client’s prior post as containing more than just information. They can describe a personal stance taken towards that information, claiming a positive or negative status for clients’ descriptions. Due to space constraints we only examine one type of action here: commiserating. The following fragment contains one such instance. It occurred early in a first session involving a therapist (Stephanie) and her client (Jennifer). The beginning of the fragment follows remarks Jennifer made about her poor short-term memory and taking a natural serotonin supplement. On the basis of this, and presumably in the context of a client seeking treatment for depression, in post 9 Stephanie makes a connection between Jennifer’s expressed poor memory and her apparent low mood.

(04) Online CBT: P53-T4-S1

Having asked Jennifer, in post 9, to describe her situation, Stephanie follows with another post in which she makes multiple requests for information that specifically relate to the history of Jennifer’s depression. In response to these questions, Jennifer provides a range of information. Stephanie then elects, in post 12, to probe two aspects of Jennifer’s response. She first asks whether Jennifer has continually experienced symptoms during her depression. She then asks whether Jennifer’s work situation is ongoing. Although Jennifer replies in post 13 that she is always capable of working, she continues to explain that she has been otherwise socially isolated for the entire seven years. She prefaces this explanation with “but,” marking what follows as an exception to her preceding description. It is at this juncture that Stephanie elects to use the third position slot to comment on Jennifer’s response.

The third position comment Stephanie employs in post 14 is located in the same sequential position as those considered above, following a client’s response in a question-response sequence. What differs, however, is the affective status of the post to which Stephanie’s third position comment responds. In the instances considered above, the descriptions were composed by clients, and treated by therapists, as mere information. Essentially, clients provided, and were accepted as having providing, the information that had been solicited. In this fragment, however, Jennifer’s response describes a deleterious state of affairs and establishes how this impacts her personally. Although she represents herself as someone able to adequately cope professionally, she sets this in contrast to her long-standing social isolation outside of work. Stephanie’s third position remark is made in the context of this description of negative personal consequences.

As with fragments 1 to 3, Jennifer’s response in post 14 contains two separate components. The first responds directly to Jennifer’s preceding talk, while the second initiates a new sequence in which Stephanie pursues her earlier unanswered question about Jennifer’s work situation. The first component, located in third position, differs from the preceding instances in that it does not treat Jennifer’s prior posts as mere information. Although that post did produce novel material, it also portrayed an aspect of Jennifer’s life negatively. Jennifer establishes herself as a ‘consequential figure’ (Maynard 1997, 2003) in her account. In response, Stephanie displays an explicit personal stance towards the information contained in Jennifer’s response by commiserating with her situation. This distinguishes this practice from its counterparts in fragments 1 to 3. Otherwise its function is the same. It is a sequence-closing third that prefaces a task-focused move in which Stephanie asks another question.

The following fragment involves the same practice of commiserating as we observed in fragment 4. It comes partway through a first therapy session involving a therapist Mark and his client Debra. Debra had earlier reported: a bad relationship, experience of child abuse, and a bad relationship between her marriages. Mark eventually, in post 67, comes to ask about Debra’s bad relationship between her marriages.

(05) Online CBT: P8-T1-S1

Mark’s comment on Debra’s response is in a near identical fashion to Stephanie’s response in fragment 4. In post 71, he commiserates with Debra’s situation generically, by using the deictic reference “that” to tie to Debra’s prior posts. This commiseration prefaces Mark’s initiation of a new sequence, in which he asks Debra to provide information that is ostensibly missing from her prior description. Thus, although he remains on topic, Mark’s question seeks a very discrete piece of information which is apparently important for his professional understanding of Debra’s situation. The sequence-closing third practice of commiseration allows Mark to orient to aspects of Debra’s response that are likely to have had considerable impact on her. Moreover, the practice allows Mark to make this orientation in an efficient way, before moving to pursue his own agenda.

The other-attentiveness exhibited by the therapists to the troubles expressed by clients in fragments 4 and 5 has been previously noted to be more characteristic of mundane than institutionalised forms of interaction (Jefferson, 1984; Jefferson & Lee, 1981). What we might be observing here, in an institutional environment where establishing rapport is important, is a practice therapists can use to affiliate with clients before moving therapy in a task-focused direction. There is growing evidence that orientations to the affective valence of clients’ descriptions, when made by therapists in physically co-present psychotherapy, tend to occasion at least minimal responses from clients (Peräkylä, 2010; Ruusuvouri, 2005, 2007; Voutilainen, Peräkylä, & Ruusuvouri, 2010b). However, in this particular type of quasi-synchronous online interaction, participants are able to compose their posts privately before making them available to their interlocutor. This provides space to string together components that would be liable to being responded to as a complete turn in synchronous talk-in-interaction. In quasi-synchronous text-based interactions like the one considered here, recipients tend to withhold responding until after receiving a post (Garcia & Jacobs, 1999). This enables authors to compose the sort of multi-unit posts that we have been examining. We may therefore be observing a practice that is practically suited for use in text-based online interaction.


In this article we have considered two different third position objects found in posts made by therapists in quasi-synchronous text-based online CBT. Both orient to the information clients provide before moving the interaction in a task-focused direction. We have identified how these practices function as sequence-closing thirds, and that therapists can elect to use them to orient to the affective valence in an efficient way. This position represents an opportunity for therapists to develop rapport with clients. Moreover, due to the interactional modality of quasi-synchronous text-based psychotherapy, therapists can also accomplish this without deferring other tasks aimed at contributing to the reduction of clients’ mental distress. This finding supports existing arguments (Jefferson & Lee, 1981; Maynard, 1997; 2003; Terasaki, 2004) that information only tends to be treated as good or bad news, or as a trouble, if it is interactionally established as such. In accomplishing this, both parties can play a role.

Establishing, developing, and maintaining rapport in practitioner-client interactions can pose problems for professionals like psychotherapists. A key occasion when rapport-building is possible – following troubles tellings – is also the point during the interaction where a professional could legitimately make a task-relevant response (Jefferson & Lee, 1981), such as making a request for further information. Although developing rapport is evidently important, task-relevant responses are also crucial, as they function to advance the problem-solving orientation of the consultation as a whole (Ruusuvouri, 2005, 2007). The choice between attending to the affective aspects of clients’ descriptions, and thereby hopefully developing rapport, and making a task-relevant response is potentially problematic, because doing the former involves suspending the latter. Orienting to the affective aspects of clients’ descriptions takes time. We have identified practices that enable therapists to affiliate with clients by orienting to what they have written but without substantially delaying other therapeutic tasks.

Although we can only speculate, explicit orientations to affective valence may be used more frequently in an online medium where other types of orientations are not possible. For instance, research on physically co-present psychotherapy has demonstrated how therapists can use intonation, even in relatively minimal utterances like “mm hm,” to orient to the affective valence of clients’ tellings (Fitzgerald & Leudar, 2010). In text-based psychotherapy, where such paralinguistic expression is not possible, sequence-closing thirds are a practice therapists can use to align with clients’ responses. Future comparative research could confirm whether this practice is more common in text-based online than in co-present psychotherapy.

Although the practices we have examined are differentially designed, both allow therapists to orient to what clients have described while also pursuing other therapeutic tasks. Crucially, therapists in the online data we have studied are able to accomplish both these moves within a single post. Seamlessly accomplishing a response that orients to affective valence before moving the discussion in a task-focused direction is unlikely to succeed in forms of talk-in-interaction like physically co-present psychotherapy. In this context, orienting to the affective valence of a client’s description can make at least a minimal response from the client relevant, which can delay a task-focused move by a practitioner (Peräkylä, 2010; Ruusuvouri, 2005, 2007; Voutilainen et al., 2010b).

As in online psychotherapy, in physically co-present therapy it is also possible that third position orientations to affective valance may help therapists move discussion in a task-focused direction. Our claim, however, is that they are unlikely to be accomplished within a single turn at talk. Ruusuvouri (2007) has shown that in physically co-present healthcare consultations, attending to the affective valence of clients’ talk can function to close down troubles-telling sequences, enabling practitioners to advance the interaction in a task-focused direction. At the same time, her analysis shows how orienting to affective valence occasions a response from clients to confirm practitioners’ contributions. Therefore, even if orientations to affective valence are attempts to promote the closure of troubles tellings, it seems that closing these types of sequences cannot be accomplished as succinctly in co-present CBT as compared to online CBT. The relative efficiency of that practice in online therapy may account in part for the smaller numbers of words typically used in text-based online therapy (cf. Mallen et al., 2005).

Our analysis shows that orientations to the affective valence of clients’ descriptions and the pursuit of other therapeutic tasks need not be mutually exclusive (see also Ruusuvouri, 2005, 2007). In the particular modality of text-based online therapy examined here, therapists can exploit an extended turn space (relative to talk-in-interaction), orienting to clients’ responses before producing a task-focused next action. Although there are differences in the turn space used to make such orientations, there are similarities with other modalities. For instance, as can be the case in physically co-present therapy (Voutilainen, Peräkylä, & Ruusuvouri, 2010a), third position replies in question-response sequences are a reserved right that therapists need not utilise. Our study therefore indicates how online therapy can involve adapted, but not fundamentally different, interactional practices to those used in co-present therapy. This shows that therapists do not need a radically different approach to conduct therapy online but can rather modify their conduct to suit the modality through which they are attempting to facilitate therapeutic change.


This research was funded by a grant from the Bupa Foundation (UK). The authors would like to thank Katie Ekberg and two anonymous reviewers for helpful comments on earlier versions of this work.


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Biographical Notes

Stuart Ekberg [ stuart.ekberg@qut.edu.au ] is a Research Fellow in the Institute of Health and Biomedical Innovation at Queensland University of Technology (Australia). He specialises in conversation analysis, with particular interest in social interaction within health care settings. Until February 2013, he worked at the University of Bristol (UK) on the study reported here.

Rebecca Barnes [ rebecca.barnes@bristol.ac.uk ] is a Research Fellow in primary care in the School of Social and Community Medicine at the University of Bristol, specialising in applied conversation analytic methods with a particular interest in health care communication.

David Kessler [ david.kessler@bristol.ac.uk ] is a Senior Lecturer in primary care in the School of Social and Community Medicine at the University of Bristol. His main research area is depression and anxiety, and he has a special interest in the use of information technology to deliver treatment.

Alice Malpass [ a.malpass@bristol.ac.uk ] is a Research Fellow in the Centre for Academic Primary Care at the School of Social and Community Medicine at the University of Bristol. She has methodological expertise in the use of meta-ethnography for qualitative synthesis and cognitive interviewing. She teaches mindfulness based cognitive therapy (MBCT) to medical students and researches MBCT and its clinical applications.

Ali Heawood (nee Shaw) [ ali.heawood@bristol.ac.uk ] is a Senior Research Fellow in the Centre for Academic Primary Care, School of Social and Community Medicine at the University of Bristol. She is a qualitative health services researcher whose interests include practitioner-patient interactions, patients' experiences of health and illness, synthesis of qualitative research, and the integration of qualitative research within randomised controlled trials.


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