Building engagement difficulties.

Building engagement in online sessions is challenging because if the sessions are using message/chat or phone calls, psychologists are only focusing on the story, voice, and tone, and are unable to see the facial expression of the clients.

“In the process of building rapport, it is much more difficult, especially in the form of a phone call that cannot be observed, it means we only focus on the voice, story, and intonation, which means that understanding people’s information is much more difficult than I met them in person.” (P1)

Even when using video conference which allows psychologists to see client’s facial expressions, reading emotion still needs more effort from a psychologist because of face position, or the other details such as gestures, hand activity, and the other important gestures.

“The observations are only the face, no hands, no legs, and nobody posture. Because it’s just his face. If we are offline, we can know, for example, if there is an indication of anxiety, the hand must be doing something. His hands were either clutching the table or the pillow, or the shirt. We can’t observe that. We don’t know whether his legs are moving. Or squeezing for people who are holding back the story, their hands are really clenched into fists. Squeezing his clothes for example” (P5)

Similar to difficulties in reading emotions, delivering or expressing empathy to the client’s also challenging for the psychologist. It is because psychologists only can express their feelings with words. Thus, more verbal strategies are involved in expressing empathy to the clients.

“The other obstacle is less effective in comforting her. Usually, I can show gestures that show empathy, so she’s more comfortable, for example, if a woman, I can hold her hand, I can pat her, that’s usually comforting for the client. But if you’re online, you can’t do things like that. It’s just voice and it’s also limited for comforting them” (P4)

Based on these difficulties to read and expressing emotions to each other, feeling connected also becomes the challenge of the online sessions because psychologists cannot see the expressions and details of the clients. In addition, due to limited time, psychologists do not have time to really into building rapport and build a connection with the clients but focus directly on the problem of the clients

“When analyzing the problem, we can’t help but generalize the client’s problems, it should be personalized, but because of this short rapport building we don’t really explore the client’s character, in the end, we just focus on the problem, and how to solve it. The building rapport is just left as it is” (P3)

These themes were identified and then categorized into three organized themes which are: (1) difficult to read client’s emotion; (2) difficult to express feelings/empathy; (3) difficult to feel engaged/connected with the client. These three themes then being part of the building engagement challenge.

Risk of getting distracted.

Online mental health services which always involve technology in the process, cannot be separated from interned and technical problems. One of these internet problems is freezing in the middle of the session, thus the conversation cannot be heard completely. The other internet problems are internet disconnection which makes the clients out in the middle of the sessions, a bad connection which causes lagging, and the application are stop working in the middle of the sessions. These problems are challenging because psychologists need to repeat and make sure both clients and their statements also start again if something makes the session disrupted.

“Because this is online there is latency, yes connection problems, but this internet problem is still a pretty important problem. Inevitably it will affect how the session goes and it feels comfortable for the client because there is a lot of feedback from the client, some say there was a connection problem earlier so there are some things I have to make sure again I have to ask the psychologist again, or they say the psychologist video is a bit lagging. It’s really disturbing because the emotions are already established, the client is open, suddenly it’s “deg” (stop) like that, and sometimes the client is thrown off from the platform because of the connection. When he got the right moment, he was able to release his emotions, he was also in the phase to start a discussion, suddenly he is out when he came back the moment was gone, it was very distracting” (P2)

Online mental health services which do not require a meeting between psychologists and the clients can be accessed from many places. In contrast to the accessibility, improper place for the sessions can also be distracting the sessions. An example is uncontrol conditions around the clients which can distract the sessions such as doing the session in the café which has live music. It can be distracting the psychologist’s concentration.

“There are some people who take place in the cafe, it’s automatically noisy right, I’m disturbed too, right, I’m still focused, I need to take care of their feelings, I try to be careful with my sentences while the noise is really annoying. We can only remind them” (P1)

In several cases, both the clients and the psychologist are sometimes also surrounded by people which can distract them from the sessions like family members are coming into their room.

“I used to give her relaxation because she really needed it but suddenly her mom came in and she opened her eyes "Wait a minute, Mom! Close again!” even though it was a very deep session. That’s very annoying” (P5)

These challenges psychologist faces can be categorized into three organizing themes which are: (1) internet problem and technical problem; (2) risk of me getting distracted; and (3) risk of the clients getting distracted. These challenges are included the risk of getting distracted challenge while providing online services.

Maintaining professional boundaries during the sessions.

Online sessions involving technology could not be separated from a technical problem mentioned above. Therefore, psychologists need to deal with the possibility of any technical problems which happen during the sessions. In some cases, psychologists need to be patient while facing this technical problem even though it is exhausting for them.

“Honestly, for me personally online is more tiring, maybe one of them because before starting an online session, there was a concern about internet problems, either on my internet or the client’s internet. It means that if the session is online, there are clients from remote areas as well, whose internet stability is not good. And we can’t say sorry, Ms. the network is having problems, even though we are the ones who are upset that the network is bad. So sometimes being patient with technical things is tiring” (P1)

Psychologists as human beings need to regulate their emotions in online sessions to keep them professional. Therefore, because sometimes they are not able to control situations such as improper places of clients such as doing the sessions in the café which has noise from the activities around the clients, doing the sessions on the road, people pass by, psychologists need to deal with their own emotions regarding this condition. In addition, these conditions also indicate the difficulties of the clients to find a conducive place to do online sessions. This makes the sessions cannot be professional as expected

“It sometimes happens in the beginning, counseling in a public place. And I need to control my emotions because we are still focused and there are noisy people which are very annoying. While I input information and I have to verbalize it again and I need concentration to organize it” (P6)

These personal space issues also happen to the psychologist as the professional. Sometimes their place is not supportive for an online session, for example, no internet connection or the internet connection is bad because of raining hard.

Besides the challenge to keep professional boundaries and finding personal space for the sessions, commitment scheduling is also quite challenging for the online sessions. Before the sessions started, clients are given informed consent which includes information on what they should do or what they should prepare for the sessions. Therefore, many clients do not do what is written on the informed consent such as doing the session while lying down on the bed.

“We always remind that counseling sessions must be followed properly, some clients are counseling while lying down, rolling around, smoking cigarettes, and some are eating and holding a spoon. There is a client who does the counseling while in the kitchen peeling onions. There is someone lying on the bed, her cellphone is lifted, and the camera is moving here and there. This distracts me, the session also becomes ineffective because looking at the screen rotates things, it’s making me dizzy. Difficult to condition. And when I remind her, she sat but lay down again. Sometimes their clothes are not proper, it’s too revealing. It’s indeed at home but that doesn’t mean you wear clothes for sleeping. I’m thinking can this session be serious for discussing the problem” (P2)

In addition, clients which choose to do the sessions with chat sometimes are not staying on the sessions as scheduled. In some cases, after telling their condition to the psychologist and getting a reply, these clients do not give any reply anymore until the sessions are finished.

“Usually, the client using chat is a bit hectic because the time is limited to one hour, one and a half, or two hours. Well, usually someone typed a long story straight away, so the psychologist needs to understand, right, read it first, digest it first, and complaints from the long story sometimes when we finish and give a response the client doesn’t respond anymore, doesn’t reply” (P7)

These challenges identified are categorized into four organized themes, which are: (1) difficult to keep professional boundaries; (2) difficult for the client to find a suitable space for the online session; (3) difficult for me to find a suitable space for the online session; (4) scheduling is difficult. These challenges can be categorized as maintaining professional boundaries during the sessions.

Keeping personal information and confidentiality of the sessions.

The next challenge, keeping confidentiality and personal information during psychological sessions is an important thing to be concerned about. Psychologists as professionals, in this case, understand how to keep the information given to them, but there are some conditions which out of psychologist controls. An example is clients who live with their families and do the sessions at home. Their family maybe can hear the things that happen during the sessions.

“If it’s me, I’ll take good care of the data, but if he’s talking about his mother during the session and his mother can hear it, I don’t know, I can’t control it either. It’s more conditioned if it’s offline” (P8)

In addition, sometimes online sessions are involving people which have responsibilities to handle technical problems such as IT staff. Therefore, involving more people which not aware of keeping the confidentiality of the sessions such as IT staff is quite risky.

“Application for video conferencing we used Zoom. Sometimes if there’s something wrong, the admin staff has to be on standby, so there are 3 people involved, right. So, if there’s anything and the admin is not on standby, it will be stuck. And the psychologist doesn’t have the client’s numbers because it will be handled by the office, so there is really a third party. If one day there is a system error, we have to contact the IT person as the admin. Well, like it or not, the IT person will know about client data. So, in the clinical setting, many people are involved and those are not psychological people. So much riskier.” (P5)

While providing online services, a psychologist is using their full name, personal accounts in their application, or personal social media. In offline settings, psychologists always say their full names but the clients usually just remember the nicknames. In contrast, in online settings this full name can easily be remembered by the clients because it is written, then in several chances, these clients are trying to see more personal information about their psychologist which means the personal information is more accessible during online sessions.

“If we go online, our names will be listed on Zoom. Well, one day I saw on my “linked in that my profile was seen by my client. So, it’s more accessible, right? If you’re in the room, just your full name and nickname, but what they remember is just your nickname. But yes, some people from online session saw my linked-in, my Instagram” (P5)

This challenge identified can be categorized into two organized themes which are: (1) confidentiality of the online sessions; and (2) difficulty to keep my and clients’ personal information. These two organized themes then being categorized into keeping the personal information and confidentiality of the sessions challenging.

Perceived efficacy.

Online mental health services provided during this pandemic in Indonesia might be a good choice in response to this pandemic condition. However, psychologists find it difficult to use the online services if it is coming for moderate or severe psychological problems which makes the clients could not use their cognitive processing, and clients with an emergency conditions such as suicidal thoughts. The psychologist also finds it difficult to work with young clients. A case example is children which have autism or Asperger’s.

“Adolescents with diagnoses such as autism, and Asperger’s. It’s a bit difficult to connect. When I’m asking, the answer is just confused and confusing. If you are offline, you can overcome it with tools such as drawing, they are usually okay, but if you are online, they don’t want to” (P2)

Related to these difficulties, online sessions also means psychologist have limited working facilities to help the clients. This challenge exists in the assessment and intervention process. In the intervention process, media limitations for drawing or another activity that they can do together are not available. In the assessment process, psychologists only can rely on self-assessment and have difficulties using projective tests.

“Giving intervention that needs media is quite challenging. Like using a jam board but there is an internet connection problem or drawing. It’s difficult because it should be on the application or clients don’t want to do it because it looks weird, A big enough challenge might be an assessment, a formal assessment using a test kit was a problem yesterday, because, for some of these disorders, we will be greatly helped by test kits, such as personality assessments. So, it’s not just a self-reported inventory, but a projective one. For example, TAT, Thematic Apperception Test. Because TAT in a face-to-face setting also takes a long time. It will help the client to be more open with his story, and more aware of his condition. It helps in mapping clients’ needs that have not been met so that conditions like this arise, what their needs are, and how to cope with the problem. Those are the tendencies. Now for online, it’s very difficult for us to use projective tests, or personality tests, so it’s only limited to self-assessment.” (P2)

These difficulties then being categorized into three organizing themes which are: (1) difficult to work on moderate or severe psychological problems; (2) difficult to work on young clients; and (3) limited working facilities. These challenges and then can be categorized into perceived efficacy challenges.

Attitudes towards online sessions.

The success of online mental health services needs cooperation between the psychologist and the clients. Online mental health services which consider new services in Indonesia make some psychologists are not really believed or have confidence enough that the sessions will work well for the clients because they do not have enough information and training to provide these sessions.

“At the beginning of the pandemic, I didn’t want to do online counseling because I realized that my capacity was still lacking in experience because when I was in college I never got special lessons to do online counseling” (P1)

Online mental health services also have to deal with clients’ cooperation. In some cases, usually for clients which use messenger, are in a hurry because of time limitations. Thus, they are just asking for a solution to their problems quickly and do not want to share more information with the psychologist.

“If it’s counseling, the decision-making goes back to the client. We’re trying to give him an idea of your condition like this, you know now, we’re giving you risk factors, protective factors. But still, the decision-making will go back to him. I don’t know why, but so far, more people are online, they want to tell a little story, and get a lot of advice, and the advice is purely from us, they are the ones who carry it out. Maybe it’s because they think online is more concise, you can go anywhere, don’t meet up, don’t go out. Maybe it’s because of that, I don’t know why. So, when probing it still doesn’t tell much. That’s all I can tell you, then what should I do, just give me feedback now. It was many times and made uncomfortably. If it’s offline in an hour, I can dig deeper, so I can get more information” (P3)

In some cases, psychologists also find that using online services is more comfortable and accessible. On the other hand, this easiness makes the clients get used to online sessions and do not want to do in-person sessions even though they need it as the advanced treatment from online sessions before.

“I’m afraid that the client is already used to online sessions because it’s easy to access. Just in case he needs something offline one day, but because he’s used to doing online, it’s a bit of effort. For example, he experienced a traumatic event that has occurred in moderate conditions and requires offline intervention, but he is used to doing an online session. Well he might be thinking how come his problem can’t be handled” (P5)

These challenges can be organized into three themes which are: (1) doubting whether the session will work; (2) depending on the client’s cooperation; and (3) dependency on online services. These themes then are categorized into challenges related to attitudes towards online sessions which need to be concerned in providing online sessions.

COVID-19 pandemic situation is one of the main factors of mental health services’ transformation into online services. Community’s need for online mental health services in the middle of pandemic conditions and the limitation of in-person services encourage the development of online mental health services in Indonesia. On the other hand, this change presents many challenges for online mental health providers. This research purpose is to map out the challenges that psychologist faces in providing online services.

Results of data analysis in this research have produced six major challenges faced by a psychologist who provides online mental health services in Indonesia. These challenges are: (1) building engagement difficulties (difficult to read client’s emotion, difficult to express feelings/empathy, difficult to engaged/connected with the client); (2) risk of getting distracted (internet and technical problems, risk of me getting distracted, risk of the client getting distracted during session); (3) maintain professional boundaries during the session (difficult to keep professional boundaries, difficult for the client to find a suitable space for online session, difficult for me to find a suitable space for the online session, scheduling); (4) keep the personal information and confidentiality of the sessions (confidentiality of the session, keep personal information); (5) perceived efficacy (difficult to work with moderate or severe psychological problems, difficult to work with young clients, emergency condition, limited working facility); (6) attitudes towards online sessions (doubting whether the session will works, depend on client’s cooperation, dependency with online services).

Interview questions for this research are developed from research by Békés et al. (2021) which maps out the challenges faced by a psychotherapist in providing online services through statistical research. According to this research, challenges faced by a psychotherapist is an emotional connection (feeling connected with patients, reading emotions, expressing or feeling empathy), distraction during sessions (therapist or patient), patients’ privacy (private space, confidentiality), and therapists’ boundaries (professional space, boundary setting) [6]. Similar to the results shown by that study, some of the challenges are also founded in this research.

Difficulties in building engagement challenges are related to reading clients’ emotions, expressing empathy, and being connected with the clients. Reading clients’ emotion is difficult because the psychologist only can hear the voice and even the client’s face is shown on the screen, no details like hands move are available. On the psychologist’s side, it is challenging to express empathy only through verbal. This is because some clients are using messenger for their sessions. The difficulties to read and express emotions then are leading to difficulties to be engaged or connected with the clients. These conditions are related to disengagement theory which says that online communication brings a negative effect on psychological well-being because it is time-consuming. Thus, online communication is considered a poor “virtual substitute” for in-person communication [13]. Therefore, an online session is a good option for providing mental health services during pandemic situations. If these difficulties in building a connection between psychologists and clients can be overcome, forming this therapeutic connection can predict a good outcome of the session [14].

The risk of getting distracted challenge is involving distraction from internet/technical problems and distraction because of surrounding conditions. Online sessions usually were held at home, both for the psychologist and the clients. Psychologist as professionals usually prepare a workroom that is conducive for an online session, but clients sometimes do not have private space and people around them has the possibility to distract the sessions. The transitions from in-person sessions into online sessions might cause more distractions because of some factors, such as popped-up notifications on the device, self-view in video conferencing, or fatigue because of the long online hours [15, 16].

Another challenge in providing online mental health services is the difficulties to maintain professional boundaries which are needed to keep professional even though there are problems like connection obstacles or improper conditions during the sessions. This maintaining professional boundaries challenge is related to the commitment to scheduling the sessions which involve the challenge to make the clients read the consent and stay at the sessions. Afterward, confidentiality and keeping personal information are other challenges faced by a psychologist in providing online sessions. This issue becomes a challenge because psychologists cannot control if there are other people around the clients. Sometimes online session also involves a staff responsible for the meeting, and difficult to handle the amount of online personal information shared between the therapist and clients.

Despite the four challenges mentioned before, there are perceived efficacy and attitudes towards online session challenges. Perceived efficacy is including challenges to working with moderate or severe psychological problems, working with young clients, and limited working facilities. Working together with children or adolescents are quite challenging because children/adolescent may think they do not need counselling or psychotherapy unlike their parents, children/adolescents may come with a completely different problem compared to the problems which have been noticed by their parents, and children/adolescent may do not notice what happened with them, even though they are realized about their problem they might not report their symptoms [17]. In this condition, psychologists need to find multiple sources for the assessment and treatment management which might be limited in the online sessions. Observations are limited, psychological tests are limited, and media to assess and work together are also limited. Overcoming this problem might be improving the use of online service sessions in the future.

The other challenges faced by a psychologist is an attitude toward online services which includes a belief that online services are working well with the clients and challenges related to the client’s cooperation in the sessions. Due to emergency conditions because of COVID-19 mental health services are going through a rapid change from in-person services to online sessions. As a result of these changes, some psychologists are having difficulties believing whether these online sessions are going to work well with the patients. In this condition, psychologist belief and attitudes are needed, because these beliefs will play a role to produce better changes in psychotherapy sessions. Trust between the psychologist and the clients will form a working alliance that ensures that the session will be successful [18, 19].