Evaluating the Controversy of Delivering Therapy Online Using a Postmodern Approach

The increased use of online psychotherapy, particularly following the COVID-19 pandemic, has generated considerable debate regarding whether therapy delivered through technological mediums can preserve the qualities traditionally associated with face-to-face psychotherapy. Central to this debate are concerns regarding the therapeutic relationship, including whether therapeutic alliance and empathy can be adequately established when therapists and clients are not physically present in the same environment. Although these concerns are often discussed in relation to the practical limitations of online therapy, they may also reflect a broader philosophical tension between modern and postmodern worldviews. Specifically, the integration of technology, which has historically been associated with modernist notions of scientific and technological progress, into psychotherapy, which places considerable emphasis on subjective experience and human agency, creates an apparent contradiction. However, this essay argues that the effectiveness of online therapy does not necessarily threaten the humanising foundations of psychotherapy. Rather, it challenges the assumption that humanisation requires physical presence and, consequently, that technological mediation is inherently incompatible with a postmodern approach to psychotherapy.

Despite the range of psychotherapeutic approaches available, the therapeutic relationship has consistently been identified as an important contributor to therapeutic outcomes. Meta-analytic evidence indicates that the quality of the therapeutic alliance is significantly associated with treatment outcomes across different forms of psychotherapy (Flückiger et al., 2018). Therapist empathy has similarly been identified as an important component of the therapeutic relationship. Both therapeutic alliance and empathy involve recognising the client as a psychological individual who possesses thoughts, emotions, intentions, and the capacity to consciously guide their own behaviour (Tarnowska et al., 2015; Waytz et al., 2010). Tarnowska et al. (2015) conceptualise this as the therapist's humanisation of the client, whereby therapists demonstrate interest in clients' beliefs and experiences and recognise their psychological agency. Consequently, psychotherapy is not solely concerned with applying psychological knowledge to clients, but also with understanding their experiences from their own perspectives.

This human-centred orientation is consistent with important aspects of postmodern thought. Rather than conceptualising postmodernism primarily in terms of relativism, as is sometimes done, its relevance to psychotherapy can be more clearly understood through its scepticism towards universal systems of knowledge and explanation. Lyotard (1984), for example, characterised the postmodern condition as an “incredulity toward metanarratives”, referring to scepticism towards overarching narratives that claim to provide universal explanations of knowledge, history, and progress. From this perspective, knowledge cannot simply be understood independently of the systems through which particular accounts of reality become legitimised.

Foucault's (1980) analysis of the relationship between knowledge and power further develops this concern. His work demonstrates how systems of knowledge contribute to determining what is regarded as normal, abnormal, legitimate, or pathological. This is particularly relevant to disciplines concerned with understanding and treating human behaviour, including psychiatry and psychotherapy. Applied to the therapeutic context, such a perspective cautions against allowing professional knowledge to completely displace clients' interpretations of their own experiences. Instead, clients' experiences can be understood as situated within particular personal, social, and cultural contexts. Consistent with this position, Hansen (2002) argues that postmodern approaches to counselling emphasise multiple perspectives and narrative understandings of clients' realities rather than assuming that a single theoretical framework can provide a universal account of human experience. The therapist's humanisation of the client can therefore be understood as compatible with a postmodern orientation because it recognises the client's subjective experience and agency rather than reducing the client to an object of professional knowledge.

This postmodern orientation emerged partly in response to assumptions associated with modernity. The modern period was characterised by substantial developments in industrialisation, capitalism, science, and technology, alongside an emphasis on rationality and progress. Within this worldview, scientific and technological developments became closely associated with the advancement of society. Technology can therefore be understood as reflecting an important component of the modernist belief that scientific knowledge and technological innovation provide mechanisms through which human life can be progressively improved.

However, technological advancement has also generated concerns regarding dehumanisation. Oviatt (2021), for example, argues that technological systems may contribute to dehumanisation when engineering-centred priorities are privileged over human-centred considerations, potentially diminishing users' personal agency. Such concerns become particularly relevant when technology mediates interpersonal interactions, as technologically mediated communication may restrict some of the cues available during face-to-face encounters. Consequently, although technology may facilitate efficiency and accessibility, it may simultaneously be perceived as reducing important dimensions of human interaction.

The introduction of technology into psychotherapy brings these competing orientations into direct contact. Online psychotherapy encompasses the provision of psychological treatment through technologically mediated formats, including videoconferencing and text-based communication. Unlike traditional face-to-face psychotherapy, these formats may restrict therapists' access to aspects of clients' behaviour that would otherwise be observable during physical interactions. Videoconferencing may limit the therapist's ability to observe subtle non-verbal gestures or aspects of body language, while text-based communication removes additional cues such as tone of voice and facial expression. These limitations have raised concerns regarding whether therapists can adequately communicate empathy and establish a strong therapeutic alliance within online environments.

This creates an apparent contradiction. Psychotherapy has traditionally emphasised the therapist's recognition and understanding of the client's subjective experience, whereas technological mediation has frequently been associated with depersonalisation and reduced interpersonal connection. The physical presence of therapists in traditional therapeutic settings may facilitate attention to subtle verbal and non-verbal behaviours and contribute to therapeutic presence, trust, and empathy (Geller et al., 2010). Therefore, when psychotherapy is delivered through a technological medium that potentially restricts these processes, it may appear to threaten the humanising foundations upon which the therapeutic relationship is based.

Nevertheless, empirical findings regarding online psychotherapy complicate this interpretation. Norwood et al. (2018), in a systematic review and meta-analysis comparing videoconferencing psychotherapy with face-to-face psychotherapy, found that symptom reduction through videoconferencing was non-inferior to face-to-face treatment, although equivalence in working alliance was less clearly established. More recently, Hedman-Lagerlöf et al. (2023) examined 31 randomised controlled trials comparing therapist-supported internet-based cognitive behavioural therapy with face-to-face cognitive behavioural therapy across psychiatric and somatic conditions and found similar overall treatment effects between the two modes of delivery. Importantly, evidence that online psychotherapy can be effective does not necessarily imply that therapeutic relationships have become irrelevant. Aafjes-van Doorn et al. (2024) found that therapeutic alliance remained significantly associated with treatment outcomes in teletherapy, while Flückiger et al. (2018) similarly identified significant alliance-outcome associations across different therapeutic modalities.

These findings challenge the assumption that the effectiveness of online therapy necessarily undermines the importance of therapeutic alliance, empathy, or the therapist's humanisation of the client. Instead, they suggest an alternative interpretation: humanisation may not require physical co-presence. Although technology alters the conditions through which therapists and clients interact, it does not necessarily eliminate the therapist's capacity to recognise clients' agency, attend to their subjective experiences, respond empathically, or collaboratively establish therapeutic goals. In this sense, the technological medium through which therapy occurs should be distinguished from the relational processes occurring within that medium.

This distinction is important because physical presence itself does not guarantee humanisation. A therapist conducting therapy face-to-face may nevertheless disregard a client's subjective interpretation, impose rigid explanations upon their experiences, or fail to establish empathy and therapeutic alliance. Conversely, a therapist communicating through an online medium may continue to recognise the client's agency and attempt to understand the client's experiences from their perspective. Thus, although physical presence may facilitate particular forms of interpersonal communication, it should not be treated as synonymous with the humanisation of the client.

The controversy surrounding online therapy therefore reveals a limitation in conceptualising technology and humanisation as necessarily opposing forces. Although technology has historically been associated with modernist narratives of scientific and technological progress, the use of technology does not itself determine the philosophical character of a therapeutic encounter. A technological medium can be used in ways that prioritise standardisation and efficiency, but it can also facilitate therapeutic interactions that remain attentive to subjectivity, agency, and individual experience. Consequently, the relevant distinction may not be between technological and non-technological therapy, but between therapeutic practices that preserve the client's status as a psychological agent and those that do not.

From a postmodern perspective, this interpretation is particularly significant. If postmodernism involves scepticism towards universalising accounts of knowledge and practice, then the assumption that meaningful psychotherapy necessarily requires therapist and client to occupy the same physical environment may itself warrant reconsideration. The traditional face-to-face therapeutic setting represents one means through which humanising therapeutic relationships can be established, but it need not constitute the only legitimate means of doing so. Online therapy therefore does not necessarily represent the displacement of a postmodern therapeutic worldview by modernist technological progress. Rather, it demonstrates that technological advancement and attention to subjective human experience can coexist within the same therapeutic encounter.

In conclusion, the controversy surrounding online therapy reflects an apparent tension between modern and postmodern worldviews. The integration of technology, historically associated with scientific advancement and progress, into a practice that places considerable importance on subjectivity, agency, and interpersonal relationships initially appears to threaten the humanising foundations of psychotherapy. However, evidence regarding the effectiveness of online psychotherapy and the continued relevance of therapeutic alliance suggests that this opposition is insufficient. The effectiveness of online therapy does not demonstrate that humanisation is unnecessary; instead, it suggests that humanisation is not inherently dependent upon physical presence. Physical co-presence may facilitate therapeutic interaction, but it does not itself guarantee that clients will be recognised as psychological agents, just as technological mediation does not necessarily prevent such recognition. The controversy surrounding online therapy therefore requires a distinction between human presence and humanisation. Ultimately, the central question is not whether technology belongs within psychotherapy, but whether psychotherapy can preserve its recognition of clients' subjectivity and agency when delivered through technological mediums. In this respect, online therapy does not necessarily threaten the postmodern foundations of psychotherapy. Rather, it provides an opportunity to reconsider what the humanising foundations of therapy actually require.

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