I have been an online counselor for psychological and relationship problems since 2010, having worked by chat or phone with more than 1000 clients from the U.S. and over forty other countries. Although counseling/therapy in an office setting is still by far the standard practice in the mental health professions, that is changing, and research indicates online aid is as effective as the traditional approach
My experience highlights several distinct advantages of online help. First, only about 15-20 percent of my clients have had a debilitating psychiatric disorder. For slightly more than 50 percent, there is instead a crisis with a lover, spouse, child, parent, sibling, co-worker or boss. This might make them confused, anxious or depressed, but these emotions are situation-specific. They are unlikely, often quite correctly, to pursue psychotherapy for such problems, but have no one they can confide in for advice. Moreover, as they occasionally have to make a rapid decision, clients benefit from immediate assistance when an office session, even a few days later, may be too late.
In addition, just over 30 percent of my clients have major long-standing psychological or interpersonal challenges, but indicate an aversion to discuss them without the anonymity that online counseling can provide. For example, I had two clients who self-diagnosed, correctly as it happens, as psychopaths. Both were respected members of their communities, one a health professional. They swore they never would harm anyone, but wanted to discuss their total lack of empathy for other human beings and how to manage that in their thoughts and actions. Yet another client, from a small town where everyone knew each other, was struggling with the realization she was in love with her fraternal twin sister.
Most common in requiring anonymity are clients with sexual issues, e.g., a fetish, such as cross-dressing or infantilism; concerns about their sexual orientation or whether they are transgender; fears about sex addiction; or, sexual desires, such as pedophilia, which could put others and themselves in danger, and want to cope with their sexuality responsibly and safely..
A small number of clients are also from societies or communities where their lifestyles, values and aspirations, while accepted elsewhere, cannot be freely expressed. I have counseled gays in Nigeria, Saudi Arabian females depressed about rigid gender roles which oppress them, and Americans disaffected from religious beliefs they are presumed to embrace.
Finally, not everyone who might prefer face-to-face therapy or counseling lives in a community where it is available, affordable or whose other commitments make it easy to take time off for an office visit. The home-bound and uninsured are also greatly under-served.
Critics of online counseling observe that not being able to actually view the person being helped can often limit one's assessment of certain issues. This can be true, but I have found, when anonymous and not visible, clients can be brutally candid about their perceived appearance if they believe it plays a role in their problems. Only with a possible body dysmorphia diagnosis might a problem exist, but, asking a client if others invariably perceive the disturbing imperfections they are obsessed with can help in assessing whether they suffer from this disorder.
As for reading body language, and sometimes noting a discrepancy between a client's self-report and what professional gamblers call "tells" (the sub-conscious facial expressions and bodily tics which give their true feelings away), online counseling is at a disadvantage. However, once again, anonymity and not being physically present produces more candor, as many clients have told me.
One possible unanticipated consequence of online counseling exclusively done by phone or chat, is what I call the Wizard of Oz Effect. The Wizard was god-like when no one could see him and reacted only to his voice. Once the curtain was drawn back he was exposed as a mere mortal. Perhaps when clients only hear a voice or read text it might appear to be unusually authoritative and less distracting than when also observing a live therapist and office decor. There is, of course, a downside to this, because knowledge regarding human psychology and behavior is continually being revised. An online counselor should try to offset this possible drawback by trying especially hard to walk the fine line between offering no assessment or advice and expressing certainty about both.
While it's risky to draw generalizations, even from the large number and diverse kinds of clients I have worked with, I do find certain issues arise with great frequency. Among these are fears romantic partners are having affairs, often based on "discoveries" of their social media activity; largely unfounded beliefs that one is a sex addict, rooted in their visiting websites that are more moralistic than scientific, and, "social anxiety" among young adults, which is both a cause and effect of the increasing reliance on texts as a substitute for face-to-face interaction, and, paradoxically, the growth of online counseling.
Online counseling is not appropriate for everyone. Those who are suicidal are better served by calling dedicated hotlines available 24/7 in many countries. Ironically, this widely lauded life-saving service also does not involve face-to-face contact, though calling local police or going to an emergency room might be the best option when the stakes are so high.
In addition, people suffering from severe psychiatric disorders, e.g., bi-polar disorder, schizophrenia and related conditions, major depression, and crippling anxiety, require medication a psychiatrist can provide. Pharmaceuticals can stabilize, but don't provide coping skills. An online counselor can be readily available to handle the ongoing and unexpected problems of daily life for these individuals once their symptoms are controlled, such as helping address ruptures in social relationships frequently caused by the onset of the underlying disorder.
Choosing the right counselor, online or in person, obviously makes a difference. While rapport is essential, professional credentials must be verifiable and the counselor's knowledge and methods based on current scientific research. The ability to "audition" multiple candidates -- asking questions and having a brief session -- is a unique advantage of online counseling.