TILT Magazine Issue 17

volume 4, Issue two WINTER 2014

Aromatherapy Goes Digital PAGE 26

PAGE 13

From Snail Mail to Email to Private Conversation PAGE 49

How Online Health & Wellness Got Its Silver Lining PLUS...

Cybersupervision, Marketing Toolbox, Student Spotlight and much, much more!

TILT - Therapeutic Innovations in Light of Technology TILT is the magazine of the Online Therapy Institute, a publication published four times a year online at www.onlinetherapymagazine.com.

ISSN 2156-5619 Volume 4, Issue 2, winter 2014 TILT Magazine Staff Managing Editors Kate Anthony & DeeAnna Merz Nagel Magazine Distribution Coordinator Sophia Zollman Magazine Design and Layout Delaine Ulmer Associate Editor for Research Stephen Goss Associate Editor for Innovations Jay Ostrowski Associate Editor for Supervision Anne Stokes Associate Editor for Marketing and Practice Building Sarah Lawton Resident cartoonist Christine Korol

Advertising Policy The views expressed in TILT do not necessarily reflect those of the Online Therapy Institute, nor does TILT endorse any specific technology, company or device unless Verified by the Online Therapy Institute.

If you are interested in advertising in TILT please, review our advertising specs and fees at www.onlinetherapymagazine.com Writer’s Guidelines If you have information or an idea for one of our regular columns, please email editor@onlinetherapymagazine.com with the name of the column in the subject line (e.g. Reel Culture).

If you are interested in submitting an article for publication please visit our writer’s guidelines at www.onlinetherapymagazine.com.

TILT is about envisioning therapeutic interventions in a new way. While Kate was visiting DeeAnna on the Jersey Shore, they took a late afternoon boat ride and a display of sail boats tilting against the sunset came within view. It reminded them how, as helping professionals, we should always be willing to tilt our heads a bit to be able to envision which innovations – however seemingly unconventional – may fit our clients’ needs.

Our clients are experiencing issues in new ways in light of the presence of technology in their lives. As helping professionals, so are we. TILT and the Online Therapy Institute is about embracing the changes technology brings to the profession, keeping you informed and aware of those developments, and entertaining you along the way.

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Features 13 From Snail Mail to Email to Private Conversation Could Online Counselling Become Clients' Preference?

26 Aromotherapy Goes Digi-

tal: Why Nature Now Needs Technology The Creation of LabAroma

49 How Online Health & Wellness Got Its Silver Lining The SilverCloud Health Story

Issue in every

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News from the CyberStreet

10 Research Review 12 Research Call 24 Wired to Worry 34 Views From the Front Line 41 Student Spotlight 60 CyberSupervision 64 New Innovations 68 Marketing Toolbox

72 For the Love of Books

A Note from the Managing Editors…

A happy 2014 to all our readers, and welcome (or welcome back!) to Therapeutic Innovations in Light of Technology.

kate anthony

& deeanna merz nagel with the

online therapy institute in second life

We are very pleased to be continually re-examining the world of technology and the possibility of therapeutic applications within it. In this issue, we bring you new columnists, news of developments in the global approach to online work, ways of complimenting your practice and exciting events to consider attending – offline and online.

Our colleagues in Canada, Dan Mitchell and Lawrence Murphy, discuss how they blended the theories of Narrative Therapy with technology to develop PrivacEmail –and the concept of layered written communication which comprises “Private Conversations”, software for clients and therapists to securely communicate with one another. In particular, they acknowledge how in-person counselling has always informed developments in online counselling, but also consider whether online counselling may someday be the preferred way to access counselling for a majority of clients.

Ken Cahill of SilverCloud Health gives us the story of the development of their online service, and also shares with us the SIPS model, their approach of therapeutic work via technology being Supportive, Interactive, Personal and Social. Ken’s colleagues at SilverCloud also offer us industry perspectives from a UK and USA perspective, with an overview of the future of technology in mental health from Professor Derek Richards.

DeeAnna and Kate have been looking at the application of technology to the complementary and alternative medicine field, and our article on the creation of LabAroma by Colleen Harte is very relevant to this. Aromatherapy is such a central part of so many practitioners’ personal lives and professional work, and to see the development of smartphone apps to help in this work is very exciting.

We are pleased to introduce Sarah Lawton to you as our new Marketing Toolbox columnist, and we have taken the liberty of taking over our Student Spotlight column to tell you – including the words of our Kosovan graduates – about a recent visit to Kosova by the Institute, and to describe the important concept of how online work can thrive and develop in a postwar country, with dedicated international parties working together to help benefit the mental health of a community still working to re-build after deep inter-communal conflict and doing so through intelligent application of the opportunities that online care provides.

We wish everyone a happy and prosperous 2014!

Managing Editors

TILT MAGAZINE WINTER 2014

NEWS CyberStreet TILT – Therapeutic Innovations in Light of Technology

from the

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Practitioner (CIP) credentials we are pleased to offer: Certified Essential Oils Consultant Be sure to check out the details here: http://onlinetherapyinstitute.com/certifiedessential-oils-consultant/

News from the Training Room!

Certified Cyber Facilitator We now offer a Certified Cyber Facilitator (CCF) Credential (choosing 1 of the 5 concentration areas as your focus).

• • • • •

Online Therapy Online Coaching Online Supervision Avatar Identities Complementary & Alternative Medicine

MSc in Cyberculture Five concentration areas of our CCF credential form the entry criteria to a second year of study toward a Master’s degree with Metanoia Institute to commence October 2015.

Be sure to sign up for details about the MSc in Cyberculture. We send out emails as details emerge: http://onlinetherapyinstitute.com/earnmasters-degree/

MORE Training NEWS! In addition to our Certified Professional Coach (CPC) and Certified Intuitive

Where are we facilitating workshops live?

DeeAnna is facilitating a number of live workshops from small group intensives to full Distance Credentialed Counselor (DCC) trainings. Be sure to check out her full training schedule here: http://www.mentalhealthonthewebblog.com/ workshops-training/ DeeAnna is also facilitating a workshop at the 2014 Psychotherapy Networker Symposium in March. The topic of her presentation is Therapy’s Digital Future.

For more information on the symposium: http://www.psychotherapynetworker.org/ symposium/2014/welcome/at-a-glance/ BACP Practitioner’s Conference Friday 28 February 2014 Holiday Inn, London – Bloomsbury Saturday 8 March 2014 Weetwood Hall, Hotel & Conference Centre - Leeds BACP will be in London and Leeds for the first BACP Practitioner’s Conference. These innovative and ground-breaking conferences are hosted

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TILT – Therapeutic Innovations in Light of Technology

jointly by four of BACP's specialist divisions and will be one of their biggest events to date with four guest lectures, 27 sessions and an exhibition to choose from.

Kate Anthony will be presenting “Online Coaching: What you need to know” at both venues and will be hosting a booth with Dr Stephen Goss in the exhibition hall for those interested in discussing training in online methods and/ or academic projects with a view to gaining a doctorate in Professional Studies with Metanoia Institute.

The day's programme is divided into nine streams, four of which will reflect the interests of members of the specialist divisions, four that will be more generic, focusing on the ‘Mind and Body,' the role and influence of ‘Technology' in counselling today, new perspectives on working with 'Trauma' and lastly exploring issues around ‘Inclusivity' and one wholly dedicated to the 'Counselling MindEd Project.'

Come and collect your 10% discount card on all courses!!

generally chat over coffee breaks and lunch, then come and join us in Bristol. You can enjoy the comfort of a well-appointed conference centre. Become part of a group of like-minded professionals, all of whom are enthusiastic about working online, with varying levels of experience.

If your online service is still at the planning stage (whether sole practitioner or agency service), why not use this conference to make contacts and find out how other people work?

Attend online or in-room! More information at http://octia.org.uk/

Join our community Find out all the ways to join our community by checking out our community page!

In other INDUSTRY news...

OCTIA 2014 April 5th 2014 Joining OCTIA 2014 In Bristol: If you want to make new contacts through networking; look at the latest books and meet the authors; discuss computer hardware and

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Our Linkedin group is growing with over 2500 members! http://onlinetherapyinstitute.com/community/

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Research BONU

Aromather it’s nothing

O

nline Therapy Institute now offers a variety of courses that are not solely focused on the delivery of online counseling or coaching services.

We have increased our catalog of courses with specialisms in a broad area of Complementary and Alternative Medicine (CAM). CAM is a popular approach to healing across the globe with CAM healing modalities recognized by many governments.

This issue of TILT includes a feature article about a technology aromatherapy application. Online Therapy Institute offers a Certified Essential Oils Consultant (CEOC) credential and, as with all our courses even when the primary content does not focus on online delivery of services, we do incorporate our knowledge of technology and cyberculture into the course curriculum. Our CEOC credential is no different. Within TILT we will be

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bringing additional articles that focus on the integration of technology and CAM. To complement LabAroma’s contribution to the field of aromatherapy, we are offering additional aromatherapy research resources.

Let’s start with Gattefosse’s Aromatherapy: The First Book on Aromatherapy. While there are many books on the market about essential oils and aromatherapy, this is the quintessential guide and the first true book published about aromatherapy. Gattefosse is to aromatherapy what Freud is to psychology.

The first edition came out in 1937 written by René-Maurice Gattefossé, a french chemist.

His father, Louis Gattefossé founded the company Gattefossé in France in 1880.

The company specializes in the creation, development, manufacture, and marketing of specialty ingredients and innovative

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US!

f rom the edito rs o f TILT

rapy: Research shows g to sneeze at! formulation solutions for the Health and Beauty industries worldwide.

The GattefossĂŠ Foundation conducts aromatherapy research and for those of us who are becoming more and more intrigued by the intersection of essential oils and health, their research is very important.

REFERENCES The research to date includes clinical trials conducted in hospitals so aromatherapy is nothing to sneeze at. n Please send reports of research studies, planned, in progress or completed, to the TILT Editor at info@onlinetherapyinstitute.com

Additional resources to keep up-to-date on aromatherapy research and information National Association for Holistic Aromatherapy Essential Oils and Research E-Booklet Association for the International Research of Aromatic Science and Education Alliance of International Aromatherapists List of Professional Journals The International Federation of Aromatherapists Reference Guide for Essential Oils by Connie and Alan Higley Offers an extensive bibliography Hospitals Across the U.S. Use Young Living Essential Oils Online Aromatherapy Institute

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Research Call Do you, or have you ever worked from home? Would you like to share your experience?

If interested in participating in the Home Sweet Home?: Therapists' Perspectives on Conducting Therapy Out of Home, (Masters study) please respond by choosing one of the following two options: OPTION 1: Online Questionnaire This option takes approximately 20-25 minutes to complete. Full instructions can be found on the questionnaire but please do not hesitate to contact me should any questions or concerns arise during completion of the questionnaire.

To choose this option, click on the link below to access the Questionnaire: Interested in doing a PhD in psychology at Stockholm University, Sweden?

It is a 4 year commitment that includes reading advanced courses and doing empirical studies together with the research group. The salary is around 2500 Euros (or 3500 USD) a month. There are three positions open: 1. Mobile phone application targeting social phobia/panic disorder.

https://guelphfran.eu.qualtrics.com/ SE/?SID=SV_brcplzaKePLz9Bj OPTION 2: INTERVIEW The interview will be conducted via Skype and take forty-five minutes to one hour.

To choose this option, email Reba to Request Interview: rfleury@uoguelph.ca

2. Prevention of gambling problems (brief intervention on the internet and/or smartphone).

3. Whatever you wish (competition is higher than for position 1 & 2).

If interested, please contact: Per Carlbring, Professor at the Dept of Psychology at per@carlbring.se http://www.carlbring.se/en/wantbecome-phd-candidate/

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Jeanette Hennigan is currently investigating how Counsellors and Therapists in UK Secondary Schools are using technology (or not) in their work with young people aged 11-18 years. If you are a school counsellor/psychotherapist you are invited to complete a very quick (5 minute) questionnaire at: https://w w w.sur veymonkey.com/ s/5TYCQM3

Could Online Counselling Become Clients' Preference?

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From Snail Mail to Email to Private Conversations Dan L. Mitchell and Lawrence J. Murphy

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I

n 1994, while working in an addictions outpatient clinic, we - Dan Mitchell and Lawrence Murphy - came up with the idea of using email to provide therapy.

At the time, Michael White and David Epston were travelling the world talking about their new form of Narrative Therapy. Between sessions they would write clients letters that reflected on the session and underscored key therapeutic moments. Research was demonstrating that these letters were shaving one to several sessions off the total needed for change (White & Epston, 1990).

Not only that, the letters themselves were being treated as prized possessions by the clients who received them.

At the same time, a clinic in British Columbia, Canada, where we worked had provided all of us clinicians with computers, Internet access and email. Our idea was to marry the therapeutic benefit of Narrative Therapy letter writing and

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the technology of email. If we could develop appropriate ethics; text-based therapeutic techniques to compensate for missing non-verbal cues; and appropriate clinical processes, we could provide services to anyone anywhere in the world.

So in 1994 we founded our online clinical practice called Therapy Online. At the time, we were using a community based electronic bulletin board system. In order to access the bulletin board, one would need to dial their modem directly into the bulletin board server. A 2400 baud modem was top-of-the-line, colour monitors were all the rage, and graphical display was sparse to say the least.

To everyone online it was all cutting edge.

A clear need right from the start was some form of email that was secure. We were accustomed to locking paper files away at night in our offices and so we protected our files with passwords on our computers. But what of the email whilst in transmission? By 1998, we had discovered Hushmail. Hushmail, of course, provides fully encrypted email. The problem for us using Hushmail for e-mail counselling was that we could not register clients online. We believed then, and have always believed, that counsellors need their clients’ contact information if there is a client emergency, at least to inform emergency services local to the client so that appropriate action may be taken. Without a client’s name, telephone number, and address information, this is challenging to say the least. So we began our first software development project intent on moving from our tiny community bulletin board to the World Wide Web. We called the new software PrivacEmail (pronounced privacy-mail).

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Even the name of the software was important.

We wanted clients to be able to visit our website and somehow hide the fact that the website pertained to counselling, thus protecting client confidentiality. We knew that, if computers are shared amongst family members, one person's web history could be looked up by another family member. So the domain name had to be cryptic.

concerns clearly, identify problem severity and longevity and, in the tradition of Solution Focused Therapy, helped them become aware of the ways they had coped thus far. From there, the client would reply to their counsellor and the counselling process would be underway.

From the client’s point of view, registration had to be simple. ...

The simple registration form collected very basic information and then led them to set up a Hushmail account.

From the client’s point of view, registration had to be simple. The individual would go to the website and read about counselling by e-mail, including procedural information (such as the fact that they would receive e-mail contact from a counselor within 72 hours). If they chose to become involved, they would simply click to register at PrivacEmail.com. The simple registration form collected very basic information and then led them to set up a Hushmail account.

This would trigger a notification to let us know of the registration. Within 24 hours, the client would receive a secure e-mail from their counsellor that warmly welcomed them, informed them of clinical procedures and obtained their consent.

As well, the client received a set of questions we called the “Virtually Solve It” worksheet.

These questions led the client to describe their

Not a bad system really, until we started to expand Therapy Online beyond just online counselling provision.

When we partnered with the University of Toronto to offer training for online counsellors, we soon realized that other clinicians needed a secure solution too.

But there was no way for PrivacEmail to segregate Therapy Online’s clients from other agencies’ or counsellors’ clients.

It was evident that we needed to upgrade: PrivacEmail 2.0. By now we knew some of the features we needed to add to the original PrivacEmail. This time, we wanted to have a way to screen clients. We wanted to inform them better, in advance of registration, which kinds of concerns would be better served in a face-toface setting. As well, if someone were reaching out to us in crisis, we could redirect him or her to appropriate crisis intervention services before they even attempted to register.

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So PrivacEmail 2.0 had its own pre-registration screening information. If clients felt they would be well served online, they could register with their basic demographic information as before.

In PrivacEmail 2.0 clients could now consent to counselling as a part of their registration process. As well, they could describe their concerns immediately. Many agencies who were to use PrivacEmail 2.0, including Therapy Online, also integrated custom questionnaires into the system; after clients described their concerns, they would fill out a self-assessment.

Upon registration and setup of their Hushmail account, clients would await their counsellor’s Welcome Message, which, in Therapy Online’s case, would be received via secure email within 24 hours as per our internal standards.

The system worked well. Many individuals, institutions and agencies licensed the product and began providing online clinical services.

One of the insights we had was that client change would be enhanced to the degree that they experienced the presence of the counsellor.

Presence is an experience of close proximity to another person, irrespective of temporal and geographic distance, even when text is the only mode of communication. Presence is achieved by focused attunement on valuing the client’s experience and humanness, whose essence may be represented only in text. Our purpose was and is to establish and maintain a strong therapeutic alliance. For a more comprehensive exploration of the concept of presence, see Lombard & Ditton, 1997.

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We worked towards this in several ways. We refined and expanded a set of therapeutic techniques to compensate for the absence of tone of voice and non-verbals in text and to increase the sense of presence. Emotional Bracketing is probably the most common and fundamental presence techniques. Perhaps if the counsellor has just written something potentially confrontational, he may express some thoughts and feelings within square brackets, such as, “[feeling a little concerned right now because I am not sure about your reaction.]” Descriptive Immediacy uses descriptive language that provides the client with information about the counsellor’s present experience of the therapeutic relationship. This includes the counsellor’s thoughts and feelings toward the client, descriptions of the counsellor’s non-verbal behaviour, or other relevant relational information that could be observed by any person in the presence of the therapist. For example: If you were here with me right now Tina you would see that I am smiling, my eyes are wide, and the look on my face says “Wow! You showed real courage in the game today”. If you were here I’d shake your hand and simply say “congratulations”.

We also engaged in a process of inserting our replies to clients in the body of their emails. Instead of hitting reply and typing our observations, empathic replies, questions and so forth in a new message above the client’s, we created a dialogue that looked much like a script for a play or movie.

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“

Online counselling helps to clarify my own thought process. I can rethink and rewrite my comments. I couldn’t do that in face-toface counselling. I can reread [my counsellor’s] comments, many of which are profound and moving. I can respond whenever and however I wish. I can even print out the sessions to reflect on.

In the past, when I left an in-person session with a therapist, I often felt better, but I couldn’t always recall exactly what we talked about.

In looking back at some previous sessions with [my counsellor], I realize how often I don’t answer her questions in subsequent sessions. I do consider responses to her questions, but I don’t feel that I have to answer them, nor does she pester me for answers. In this way, I feel that I have more control over what we discuss, and I like that. This process has allowed me to have more responsibility for my healing. [My counsellor] has always responded to my questions or requests for more information. It has been delightful to receive e-mails from her that simply list web sites she thinks might interest me. That makes me feel like she really cares.

“

I find online counselling to be more helpful than face-to-face. It can happen anytime, any place. I encourage other counsellors to consider it.

(SHELL, 2010)

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This technique went some distance toward accomplishing our goal of enhancing presence.

And it did several other things as well. First, it provided clients with a context for the questions we asked and the comments we made. Second, it brought clients back, to some extent at least, to the emotional place they were when they wrote their initial message.

Taking this approach also highlighted a popular sentiment in the clinical world. We often say that if someone were to peer through a window at a therapy session it would appear like a simple conversation between two people. But walk into the room and listen to the communication and it becomes clear that this is no normal conversation.

In the same way, the clinical process that we engage in through text may sound from the outside like two people emailing each other. But review of the transcripts makes plain that this is no normal email conversation.

Using email had its drawbacks.

At some point, with multiple replies, the length of the email becomes problematic.

Following which person is saying what was dealt with by inserting initials prior to comments, but at a certain point even this becomes challenging due to the multiple indentations and comments.

Counsellors would use their clinical judgement in deciding when to move to a new email, which thematic threads to follow, which elements of previous interactions to include and other similar challenges. Still, multiple replies in email created

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a level of complexity that we wanted somehow to avoid.

This led us to begin working on new ideas. What if we could design a user interface that integrated the clinical need to create an interactive yet asynchronous process with the practical need of being able to limit the size of the transcript as it grows with every session? Inserting responses within the client’s transcript was a must. And the result had to create an experience of being in the presence of another human engaged in deep conversation.

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this screenshot shows the first two levels of a private conversation. the initial message from the client dan mitchell is overlaid with responses from the counsellor lawrence murphy. on the left is a list of all reply levels from each participant. any level can be accessed with a single click.

Nothing existed that met all of these requirements.

Chat bubbles found on smartphones were appealing and familiar, but would not allow insertion of text anywhere. It was becoming apparent that we would need to create something new.

Besides our desire to create a new format for asynchronous work, there was a natural pull towards synchronous means of communication as well. Chat was an obvious extension in the textonly realm. With Skype being the dominant means of international family communication, we were

pulled into the demand for video. Counsellors, at least, as well as human resource managers, seemed convinced that video would be the only sensible way to do online counselling. Interestingly, our impressions were, and still are, that many clients prefer the anonymity afforded by text-only approaches. It allows them to focus entirely on the issues at hand without giving any attention to their appearance or their surroundings.

The English-only language capability of PrivacEmail 2.0 started to be a significant limitation. This was especially true in Canada, where French and English are official languages. We were unable to serve French-speaking clients in our own nation!

This multi-lingual need was consistent with our original vision back in 1994 to provide counselling services to anyone anywhere in the world. The time had come to start over again and rebuild PrivacEmail into a multi-lingual platform. So began the development of PrivacEmail 3.0.

The core of the new platform was Private Conversations, the name we gave to a new way of staying in conversation asynchronously. The interface looks a lot like chat bubbles, with one person’s bubbles pointing the left and the other person’s pointing to the right. The first message (the client’s narrative description of their concerns) looks like a single body of text within a bubble.

The counsellor can then click anywhere within that body of text to insert his contribution to the conversation which itself appears as a bubble. The counsellor can insert in multiple places creating both the visual representation of a conversation and the flow of a truly therapeutic experience.

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After the counsellor has finished creating a therapeutic conversation, he presses Send. The client then receives a notification in her regular email inbox and clicks the link to View the secure message awaiting her. She supplies her username and password in order to view the message, which now displays as a series of conversational bubbles.

The client can now insert anywhere within the counsellor’s text as well, thus creating a series of nested conversational bubbles. Visible to the client at this point are her original description of her concerns, now interspersed with the counsellor’s comments, and a third “layer” of her own insertions. From this point on, three layers of the conversation remain visible at all times, regardless of which person is viewing the conversation.

Being such a novel way of engaging in conversation, we felt the need to carefully explain to clients how to use Private Conversations.

Instructions with screenshots are provided to clients in a resource page within PrivacEmail 3.0.

We also provide clients a demonstration Private Conversations Privées YouTube video, intended to be as language-neutral as possible, while showing clients a short “how to.”

Our objective was to create an interface that was therapeutic, intuitive and practical. One of the most rewarding aspects of the system to date is the absence of questions about how it works. Even though Private Conversations presents human communication in a novel display, apparently the interface is user friendly. Clients are able to use Private Conversations without assistance or guidance.

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The counselling experience, from a client perspective now goes like this: When clients first decide to register, they see a description of the secure and confidential nature of what they are about to embark on, with the limits to that confidentiality stated in brief. Clients then begin responding to queries about their computer and Internet configuration, such as their preference for asynchronous communication or chat/video. As questions progress, depending on their answers, they may be presented with recommendations. Some questions may guide them to take immediate action – for example, calling for an ambulance if imminently suicidal.

Therapy Online includes a brief anxiety and depression scale, and an opportunity to record any prescribed medications.

All of this happens before the client is registered. Based on their responses to the initial questionnaire, some clients are redirected to other, more appropriate services before they go

any further. But the majority of clients continue with the registration process, where they create a username and password, provide their name and contact information, read and agree to the client consent form, and describe their concerns. After they complete this process, clients are provided information about what to expect next.

that others in the client’s vicinity may overhear the session). If this person lived in an urban setting, we would have options such as recommending in-person counselling (if easily accessible).

Sometimes what is not available for the client weighs strongly in the balance of accepting a client for online service.

Once Intake determines that a client is best served online, the client is assigned to a counsellor.

At this point, an intake counsellor carefully examines the client’s questionnaire results and considers the narrative of their concerns. In some cases, an outreach phone call must be made – particularly if there is a need to assess possible risks of harm to self or others. Clinical judgments are made regarding the client’s level of risk and the most appropriate course of action for the client.

If clients have indicated a preference for Private Conversations, they are welcomed by their counsellor within 24 hours and receive their full asynchronous session within 72 hours. If clients have chosen chat or video, again they receive a welcome message via Private Conversations, but their counsellor will also phone them to arrange a mutually convenient meeting time. Once counselling is underway, clients and counsellors can decide whether to use other modalities or the one they began with.

Looking to the future, we online counsellors need only look at the present state of technological development to see that, by and large, we have a lot of catching up to do.

At times a difficult decision must be made considering the balance of ethics. For example, a client contemplating suicide and living in a remote area may have little access to face-to-face resources of any kind. And even if the client were to access what scarce resources may be available, often it is not possible to keep such visits confidential within their small community. Text-based online counselling affords an unmatched level of confidentiality in this all-too-common situation (this is less true with video, since there is a chance

Some clients continue to engage with their counsellor until an end point is reached by mutual agreement. Many times, though, as in face-to-face counselling, clients drop out of online counselling without explanation. When this happens, Therapy Online’s counsellors make a polite effort to reengage the client, at least to permit the client to explain whether he or she feels satisfied or

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unsatisfied with the service received and to offer further support if desired. The re-engagement effort is simply a brief Private Conversation message, which then triggers a “You have a secure message: View” notification to land in the client’s regular email inbox.

Looking to the future, we online counsellors need only look at the present state of technological development to see that, by and large, we have a lot of catching up to do. Changes in online technologies, and more profoundly, mobile technologies are accelerating. As is typical with technological advancements, professional ethics and laws lag behind. It behooves us, as a counselling profession, to continue to keep up with the latest technological advances. We need to know what new communication tools are being created and consider the implications of using those tools for counselling.

This requires a proactive attitude, not just a reluctant acknowledgment that such and such advancement seems to be here to stay, “so we’d better deal with it.” On the contrary, ethics committees should include members who proactively notice the latest new communication trends, and bring them to the committee to wrestle REFERENCES Lombard, M. and Ditton, T. (1997), At the Heart of It All: The Concept of Presence. Journal of Computer-Mediated Communication, 3: 0. doi: 10.1111/j.1083-6101.1997. tb00072.x Schell, D. (2010). Being there. Crosscurrents: The Journal of Addiction and Mental Health, 13 (2), 16-17.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W.W. Norton and Company.

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with. Our profession requires solid leadership so that clients are both protected from harm and positively helped whenever new advancements in technologically mediated human communication could improve client satisfaction and benefit.

Twenty years ago, Narrative Therapy introduced letter writing to enhance the in-person counselling experience. For us, moving the therapeutic letter writing concept to the online realm, and expanding it to create a complete online counselling experience, seemed to be an obvious extension. In-person counselling will always be the traditional approach. In-person counselling has always informed developments in online counselling. But we have to admit – at times we wonder whether online counselling may some day be the preferred way to access counselling for a majority of clients. n

About the authorS Dan L. Mitchell, currently living in North Vancouver, Canada, earned his Masters degree in Counselling Psychology from the University of British Columbia in 1989. He is a Canadian Certified Counsellor with the Canadian Counselling and Psychotherapy Association.

Dan has extensive experience in the field of addiction counselling having maintained a role in BC Mental Health & Addictions from 1990. Dan is the Clinical Supervisor for Therapy Online’s team of Counsellors.

Contact Dan Mitchell dmitchell@therapyonline.ca Lawrence J. Murphy, currently living in Guelph, Canada, obtained his Masters degree in Counselling Psychology from the University of British Columbia in 1995. Lawrence has travelled extensively giving presentations at international conferences and workshops on the topic of online counselling. Lawrence is the Dean for Therapy Online’s courses.

Contact Laurence Murphy research@sympatico.ca

The Use of Technology in Mental Health Applications, Ethics and Practice Edited by

Kate Anthony, MSc, FBACP

Online Therapy Institute

DeeAnna Merz Nagel, LPC, DCC

Online Therapy Institute

Stephen Goss, PH.D., MBACP

Independent Consultant in Counselling, Research, Supervision and Technology in Mental Health 2010, 354 pp., 7 x 10, 6 il., 5 tables • (hard) ISBN 978-0-398-07953-6 • (paper) ISBN 978-0-398-07954-3 • (eBook) ISBN 978-0-398-08447-9

Technology is revolutionizing the delivery of mental health services. In this book, the reader is introduced to the broadest possible sampling of technologies used by mental health professionals today. It contains 30 chapters on different aspects of technological innovation in mental health care from 43 expert contributors from all over the globe, appropriate for a subject that holds such promise for a worldwide clientele and that applies to professionals in every country.

A wide range of styles is offered, from the individual practitioner exploring a new technology and writing anecdotally about their personal experience, to some of the world’s most experienced practitioners writing a thorough overview of a technology and its uses in the profession.

In each chapter, you will find introductions to the technology and discussion of its application to the therapeutic intervention being discussed, in each case brought to life through vivid case material that shows its use in practice. Each chapter also contains an examination of the ethical implications – and cautions – of the possibilities these technologies offer, now and in the future. Technological terms are explained in each chapter for those not already familiar with the field, while the content should stimulate even the most seasoned and technologically minded practitioner.

Psychotherapists, counsellors, psychiatrists, life coaches, social workers, nurses – in fact, every professional in the field of mental health care – can make use of the exciting opportunities technology presents. Whether you have been a therapist for a long time, are a student or are simply new to the field, The Use of Technology in Mental Health will be an important tool for better understanding the psychological struggles of your clients and the impact that technology will have on your practice.

Further information on ethics, training and practical exploration of online therapy can be found at: www.onlinetherapyinstitute.com, whose work extends and deepens the resources made available in this volume.

Order Online at:

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TILT – Therapeutic Innovations in Light of Technology

WIRED TO WORRY

Left To My Own Devices I love gadgets. I also love tracking data. You would think that I would be over the moon about all the cool personal fitness trackers on the market. Surprisingly, I am underwhelmed and I have spent some time reflecting on my lack of unreserved enthusiasm.

Christine Korol

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As a cognitive behavioural therapist, I frequently ask my clients to track their sleep, exercise, caffeine, thoughts, mood, diet and more. Even though research shows that tracking improves outcomes, it is still a hassle and compliance is often an issue. Letting clients know that some data is better than no data does help, but an easier way to collect that information would be a relief.

That brings us to the early adopters in the Quantified Self Movement who have started to develop some impressive technical solutions to the collection of behavioural data. If you are not already familiar with the term, Quantified Self refers to using technology (often using wearable sensors) to track behavioural data. Some examples of the devices that are making their way into the mainstream are Nike’s Fuelband, the Fitbit, and the Jawbone UP. These devices make data collection easy and can track sleep, steps taken, and even stairs climbed (in models that have an altimeter).

So, what’s my problem?

I have decided that it boils down to the fact that

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many people see these devices as a solution to their motivation problems when, in fact, they simply assist you in tracking your progress. Activity trackers might simplify life for avid exercisers already tracking their progress with more complex systems.

However, for someone who is ambivalent or precontemplative about making healthy behavioural changes, buying a personal activity monitor is unlikely to be enough to achieve their personal health goals. At the end of the day, that

Fitbit or Fuelband doesn’t make the workout less painful or force you to keep running when you feel like packing it in.

The technology is wonderful and I look forward to future quantified self developments. The danger in misunderstanding that data alone does not equal behavioural change is the discouragement and mistaken belief that the individual has failed. As therapists, we can mitigate some of this damage by teaching our clients some

of the many strategies that increase motivation, encourage persistence and help us cope with the inevitable failures on the road to better health.

ABOUT THE AUTHOR/ ILLUSTRATOR: Christine Korol, Ph.D. is a cartoonist, psychologist in private practice in Calgary, Canada and the host/ producer of a podcast on WiredToWorry.com that provides free online anxiety and stress reduction education videos.

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Colleen Harte

Why Nature NOW Need Technology The Creation of LabAroma

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‘There has to be an easier way!” this was my crying plea when I was in the early stages of developing the core essential oil formulas for my luxury organic aromatherapy-based beauty and lifestyle brand, ‘Lucy Annabella’.

I needed to find a solution to accurately deal with the time-consuming, complex mathematical process of essential oil formulations.

However this thought was only second to the reality that as a start-up company with verylittle-to-no cash, I could not afford for my formulas to fail the pharmaceutical testing which I was preparing them for. I had little option but to convince a dear friend to code a basic software program to tackle these chemistry calculations with accuracy and speed, while also providing me with the breakdown of the calculated chemistry for each formula.

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Four months later and all my aromatherapy product submissions for Lucy Annabella passed pharmaceutical testing on the first try! I was delighted as this meant I would launch my labor of love ‘Lucy Annabella Organics’ but it was also the day I realized that I needed to share LabAroma with the world of aromatherapy. (Figure 1) The two companies are so closely connected that we named LabAroma after Lucy Annabella. The ‘Lab’ in LabAroma stands for Lucy AnnaBella and ‘Aroma’ meaning that we blend aromas with the software. A further twenty months and after an

inconceivable amount of technical development and vast in-depth exploration of the world of essential oil chemistry LabAroma was born!

From the beginning Since we launched LabAroma our team regularly hear, ‘who is Colleen Harte? We have never heard of her.’ So let me take this opportunity to explain who I am and how I come to create an aromatherapy based luxury retail brand and an aromatherapy focused software tool.

I started my aromatherapy

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figure 1

career 12 years ago in a quiet little area of north Belfast where I was taught the spiritual elements of aromatherapy from a very interesting exnun. However my clinic work directed me to specialise in Complementary Therapy and Clinical Aromatherapy. In 2005 while working in the sector of cancer care with therapy I stumbled across a weekend course with Rhiannon Lewis - that weekend was the beginning of everything I have become now. For the next 8

years I spend all my training time in Rhiannon’s care where she took me and her adored students through the complex but vitally important aspects of clinical aromatherapy and essential oil chemistry while always relating theses lessons back to the practicalities of aromatherapy in the field.

I ran my private practice from 2002 until the launch of Lucy Annabella in 2012 when I decided to close my appointment book to focus

on my life ambition – to get aromatherapy into the hands of the wider world. However my other realization at this time was that the more the chemistry of essential oils seeped into my blood the more I felt there needed to be a better understanding of the science behind our precious plants. Our world is becoming so digitally dependent and technologically driven, it made sense to me to bring this knowledge to the aromatherapy world in a practical tool via technology

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which we can use every day to better our work as aromatherapists. I am committed to the education and development of essential oil knowledge.

Using Technology to Enhance Aromatherapy The aim of LabAroma is to enhance aromatherapists' formulating skills while creating better blends. This software is a chemistry based, clinical aromatherapy focused software tool. It was created to add reliability and accurateness to formulating essential oil blends and to make producing essential oil blends more productive and precise. I believe it is so important that aromatherapists understand the chemistry behind the essential oils we use. If this knowledge is part of our dayto-day interaction with essential oils we will be better equipped to use the integrity of nature’s plants to treat our clients and create beautiful formulas that can be therapeutically effective.

Understanding the chemical profile of each essential oil is

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figure 2 the key to this knowledge.

LabAroma applies technology to the formulation of essential oil blending and helps focus the formulator on both clinical and chemical components of a blend.

You can start formulating blends as soon as you’ve subscribed to your favourite package, LabAroma or LabAroma+. You can choose from 198 essential oils to blend. You are given a full profile of each essential oil, its country of origin, Italian

name, botanical family, aroma, and a short profile description from therapists within our aromatherapy community so you can identify the exact details of each plant oil stored within LabAroma. We even have an added feature whereby you can input your own bespoke essential oil GC data so that your formulation will be 100% reflective of the oils you use, own or distill.

To create a blend, click and drag the oils over to “Your Blend”.

Select the percentage of the oils you’d like to use, and click

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“calculate”. LabAroma gives you a complete chemical component breakdown of essential oils. LabAroma+ has the added feature of giving you a warning if the blend you just created breaks any legal pharmaceutical restrictions in the EU, US, Japan or Australia. This LabAroma+ feature which highlights which chemical components in your blend has breached international pharmaceutical laws is fascinating to me, as this tool ensures you are accurately guided when formulating if you are creating products to be sold internationally. (Figure 2) The effect your blend has on the physical body is also highlighted. The effect of your

blend is broken down into 10 body systems by level of the most affected, ensuring that if you are blending for a specific physical condition you can be confident that you are successfully blending for that condition (as LabAroma will indicate which part of the body will be most affected). For example, image 3 shows the body system results for my repetitive strain blend. This is my favorite feature within LabAroma: as an aromatherapist it is so important for me to know that my blend is successfully targeting the body system I am working on. LabAroma will also allow you to print or save your blend. (Figure 3) We support the software with

the LabAroma site which offers blogs with great blend recipes for lots of conditions and detailed oil profiles to help drive your learning experience.

More updates will come in time, but for now we are happy with all the functions and features.

The future options are endless and we love hearing from our growing aromatherapy community on what they want to see added to LabAroma in the future.

‘Why does nature ‘NOW’ need technology?’

I’ve explained the story of LabAroma’s creation, its uses and how I created a career in aromatherapy, but the question

figure 3

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we are looking to answer here is ‘Why does nature ‘NOW’ need technology?’ I believe this answer is very simple, we are a rapidly evolving digital generation and the next generations of genius aromatherapists are set to be so much more digitally dependent.

We are in a digital revolution that is more powerful than radio or TV ever had the ability to be. It took less than 12 months for facebook to signup 200 million people compared to the 13 years it took TV to reach just 50 million people.

Another staggering fact about facebook is that in terms of size, if it where a country it would be the 3rd largest just behind China and India. These social media statistics are

fascinating but this rate of growth is also reflected in how we use technology today. The US department of educators states that online students are out performing those receiving face-to-face instruction! This alone explains why technology is so important in todays world, especially todays professional and learning worlds. The future aromatherapists who are sitting in lecture rooms or more likely taking a webinar in aromatherapy and essential oil chemistry today demand technology, because they understand the speed, accuracy and beneficial necessity of it.

As an industry we are lacking this level of professionalism and digital growth. I believe that technology is essential for growth and development, and LabAroma is a bridge to this gap in the aromatherapy industry.

Not only do our next generations expect technology but we, the aromatherapists of today need it in order to stay ahead in our industry, to be the best we can and to do justice to natures gifts, our essential oils.

We can embrace our ipads and tablets as well as our bunches of lavender and patchouli - we need the two to survive in this rapidly changing world.

ABOUT THE AUTHOR Colleen Harte is the founder and director of Lucy Annabella and LabAroma. She is proud to be the Irish ambassador of Botanica 2014 International conference on plant therapeutics and clinical aromatherapy.

Learn more about LabAroma, sign up for a subscription, and follow them on their social media sites!

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Views From The

FRONT LINE An industry perspective

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Aislinn Enright and Mark Wallin represent SilverCloud Health in the UK and US respectively.

As leaders in their field, producing and promoting engaging online health and wellness solutions, their roles require them to stay abreast of industry relevant matters. However, their geographic localities each present different issues and priorities, and occasionally divergent perspectives.

A View from the US Mark Wallin, SVP, SilverCloud Health Inc. Mark has U.S. and international experience with corporate healthcare and eHealth organizations, such as Aetna, WebMD and ICW AG. Driven by a passion for quality health outcomes, Mark has successfully operated or engaged in multiple entrepreneurial start-up and turnaround opportunities in healthcare technology.

Behavioural health in the US In the United States, the burden of the cost of behavioural health care has traditionally fallen primarily to the patient and their families. Over the past twenty years, that has slowly begun to change, and more recently, in November 2013, ‘The Mental Health Parity and Addiction Equity Act of 2008’ (MHPAEA) legislation received the approval of Final Rules. [1] The MHPAEA represents substantive change in coverage and reimbursement requirements.

However, amid the evolving healthcare landscape in the U.S., the impact of this legislation may not be fully known until real-world tested, fully implemented and perhaps litigated.

Progress through technology Progress is being made however! Behavioral health care in the US is beginning to more thoughtfully address matters of stigma, access and cost. Additionally, delivery of appropriate, timely, efficient and effective behavioral health care is being addressed through adaptive innovation and advances in the unique application of technologies.

For the last 15-20 years, online therapies have delivered basic levels of support with mixed results. More recently, highly creative strategies that engage the user and the therapist in an online therapeutic space have evolved. This blended approach provides care and support, combining human engagement with technology. These innovations can be used to extend

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clinical services, rather than attempt to replace them and offer clients with broader, easy-toaccess options.

Such a breakthrough is well timed for the US healthcare market as it tackles the issues of cost and quality. In addition to providing low barrier access and quality outcomes on par with traditional therapeutic methods, these guided online health and wellness solutions are set to support and help stabilize the expanding behavioral health costs of health care in the United States.

References United States Department of Labor, Employee Benefits Security Administration, http://www.dol.gov/ebsa/mentalhealthparity/

A view from the UK Aislinn Enright, UK Director, SilverCloud Health Aislinn worked within the NHS for 13 years as both a clinician and project manager, and more recently she has worked in private and nonprofit organisations, within the mental health and primary care field. She has vast experience developing and implementing talking therapy services, primary care and long-term condition motivational services.

Mental health care in the UK In health care, never have the concepts of effectiveness, efficiency and value for money been so important.

Apparently in response to the Quality, Innovation, and Prevention (QIPP) program’s aim to save £20bn by 2013/14, the UK government is now demonstrating commitment to telemedicine.

Telemedicine (or telepsychiatry as it is known in mental health) provides maximum benefit in terms of patient access, value for money and efficient use of resources. The 2011 Department of Health (DH) report; ‘Whole Systems Demonstrator Programme: Headline Findings’, suggested that 3 million people could benefit from telemedicine/telecare over five years.

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Improving Access to Psychological Therapies In the UK, the Department of Health developed an initiative called the Improving Access to Psychological Therapies (IAPT), now known as Talking Therapies, for adults aged 18-65 years with common mental illness such as depression and anxiety. IAPT offers patients fast access to a choice of psychological therapies in addition to ‘care as usual’. The service is provided in a step care approach, as recommended by the National Institute of Clinical Excellence (NICE) guidelines for depression and anxiety (DH 2004, amended 2007).

While the option for paid services is always available, anyone entering the IAPT service will receive free care through the National Health Service (NHS), depending on their need. However, many of these NHS Trust services are struggling to cope with capacity, often ending up with long waiting lists. Telehealth offers clinicians a solution that is both cost effective and resource-friendly and clients with an effective and easily accessible health and wellness solution.

A Clinical & Technological view Derek Richards, Clinical Research Director Derek Richards was responsible for pioneering the first online mental health community for students in conjunction with the Centre for Research in IT in Education (CRITE). Now, as Director of Clinical Research & Innovation at SilverCloud Health, Derek is very interested in the development, implementation and clinical research of technology delivered interventions for mental health problems. In particular interventions for high prevalence disorders such as depression and anxiety.

The future of technology evolves In the last 15 years or so, the use of technology as a solution to meeting the needs of health and mental healthcare organisations has grown exponentially. It is a real privilege to be part of that history, and I continue to enjoy being witness to this blossoming field.

Cognitive Behavior Therapy protocols for the treatment of various mental health difficulties have predominated, especially in the delivery of interventions online. However, I recently came across some new research that uses psychodynamic psychotherapy for the treatment of depression and anxiety. This work originates from a highly reputable group in Sweden;

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Andersson, Carlbring, Johansson and their colleagues, from whom we are becoming used to seeing great things. This current work is based on a particular model of psychodynamic psychotherapy called ‘affect-focused’.

Affect-focused psychodynamic psychotherapy presents to clients a psychodynamic understanding of depression. The treatment seeks to help uncover unconscious patterns that contribute to emotional difficulties that may be interfering with different areas of one’s life, such as work and personal relationships. Once a client comes to understand these unhelpful patterns, they can learn to break them. The treatment includes provision of tools to prevent relapse.

The Swedish group has published three randomized trials of the treatment and has reported significant outcomes for participants (see reading list).

In my opinion this work, that began 15-20 years ago, was only a beginning. From the firmly grounded foundations of this valuable learning, inspiration comes from the significant technological advances that continue today… stimulating ideas for creative ventures of the future.

Watch this space!

The question of engagement Technology has certainly advanced!

Treatments for various mental health problems are being delivered online and, for the most part, their clinical utility need not be questioned as the content is based on well-established behavioural and cognitive interventions. Also, if these interventions are supported, to allow something of the therapeutic alliance to feature in the treatment, outcomes improve.

Nothing surprising or new there … But what about the problem of dropout? Or, to turn it on its head; the question of engagement?

I think we can improve on the clinical utility of current technology to enable better client management, meet the needs of non-responders and ultimately improve outcomes.

We have the technological capability to include, as part of any platform, several ways of monitoring clients. This can be done simply, through the analysis of psychometrics collected routinely, or by flagging risk factors for any given client. For example, if client x has had a previous episode of depression. Monitoring can also involve tracking and comparing clients’ use of programme elements from week to week.

The automated tracking and easy reporting of simple online acts has enormous implications for understanding engagement and facilitating more accurate and timely support. The result38

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ing feedback loop enables mapping of the clinical path most suitable for individual clients, including the possibility of removing the client from the programme and offering a more suitable solution if necessary.

Client monitoring has always been a central feature of the therapeutic endeavor. Not least for informing the appropriate clinical path for a client. It should not be lost when delivering interventions online and modern technology can, and should, promote this goal.

References: Johansson, R., Bjรถrklund, M., Hornborg, C., Karlsson, S., Hesser, H., Ljรณtsson, B., . . . Andersson, G. (2013). Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial. PeerJ, 1, e102. doi: 10.7717/peerj.102 Johansson, R., Ekbladh, S., Hebert, A., Lindstrรถm, M., Mรถller, S., Petitt, E., . . . Andersson, G. (2012).

Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial. PLoS ONE, 7(5), e38021. doi: 10.1371/journal.pone.0038021 Johansson, R., Nyblom, A., Carlbring, P., Cuijpers, P., & Andersson, G. (2013). Choosing between Internet-based psychodynamic versus cognitive behavioral therapy for depression: a pilot preference study. BMC Psychiatry, 13(1), 268.

Online Counselling Software

Secure and encrypted email, chat, and video!

Used by individuals, agencies, and institutions around the world For a demo or more information: Lawrence Murphy: lmurphy@privacemail.com

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STUDENT Spotlight 40

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Foundation Together Kosovo Introduction from Kate Anthony One of the opportunities that the Institute has been honoured to take from 2012 onwards has been working with Foundation Together Kosovo (FTK) in the development and progression of their online reach-out programme Nuk je Vet! (You Are Not Alone!).

Nuk je Vet! is an online forum where young members of the Kosovan community can talk openly to volunteer health professionals and each other about the problems they face.

Post-war Kosovo is a young country with a young Mental Health profession (and Internet connection!), relying on outside sources for funding of this valuable new way of reaching the population.

Created by Vera Remškar and Aliriza Arenliu , and supported mainly by the Norwegian Government, FTK is a strong team of over 30 people both in administration and clinical work. Taking the concept of training seriously, we were invited to provide this online through our Certified Cyber Facilitator

(CCF) credential for an initial five members of the team (two more have subsequently joined us), and also through live webinars to the wider group. In September of 2013, Kate Anthony and Stephen Goss flew to Kosovo to be the guests of FTK both at the first Kosovan Conference on Online Counselling and then subsequently for a three day intensive training in the beautiful Sharr mountains of the country. While there, Kate was delighted to be able to give the CCF live oral examination in person to two of the trainees – Valdet Plakolli and Adelina Nura.

Valdet and Adelina are now taking our Clinical Supervision Series to add another level of expertise to the service.

None of the team have English as their first language, of course, making the training even more of a challenge for them. Here are Valdet and Adelina’s thoughts in their own words, and more on the conference itself from Stephen Goss.

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Adelina Nura Hello!

I would like briefly to announce to my experience in counseling and preparing my professional online [work] through OTI Team.

Being a psychologist who lives in a country where prejudice for psychologists are still in a high level, the desire to be close to the people and to provide psychological assistance pushed to become part of advisory website for young nukjevet.net, even though the technology and its use was something very new and not widely applied in Kosovo. In that time I was fulfilled with motivation and willingness to help people and not to causing damage but cannot say that I knew so much about the online counseling as I know now.

Contributions and volunteer work enabled me to gain professional training by OTI Team which The Foundation Together Kosova provides for its workers. Training received by my side qualifies as one of the most useful training I've take during my professional experience with content more useful and valuable.

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This training has been an extremely great influence on my work in nukjevet , during and after training I felt more open minded about online counseling. I was more aware about the processes that occur during this work, for responsibility and ethics as well as removed more dilemmas , prejudices and worldviews other related to technology , communication and online counseling .

As a certified psychologist for the first time in Kosovo by OTI Team for Online Counseling I am feeling very proud, strong, motivated, confident and ready to contribute more in this area of online counseling. I can say that I feel very privileged to have had the opportunity to be part of this training.

Foundation Together Kosova with OTI team can say that they are the first professional road in establishing online communications professionals in Kosovo and co deserve merit gratitude. Finally I would like to thank my trainer Kate Anthony more for which I feel very proud that I've met that I had the chance to be teach by her.

Cheers!

Clock wise fro m top left: Th e full FTK stude Kate Anthony p nt group at Ho resents to the te tel Sharri; am; Kate with O Valdet, Ilir and TI CCF students Adelina; Steph Lirie, en Goss and Ve Norwegian Am ra Remškar cha bassador Jan B t to the raathu

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Valdet Plakolli When my colleagues and I talk to create a website for online counseling for the youth in Kosovo, it was more a desire and enthusiasm of a group of colleagues. The goal was to do something good for the youth of our country.

Although our experience in this field was limited, we had a clear goal and were willing to using all our knowledge to our goal. We began and like any beginning, this was not easy. Given the fact that online counseling was something very new for us we felt the need to take additional classes in order to increase our knowledge in this field.

To view more of my colleagues that the decision of the FTK staff, that five of us start a professional course for online counseling, was one of the most important decisions for website work. Tracking online training was something new to us and we each had our hesitations. I would need written some pages to describe my experiences in the course that I attended and the events which have been in collaboration with Online Therapy Institute. Below I will try to briefly present my impressions during that time.

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The way I was received warmly by coaches Kate Anthony & DeeAnna Nagel, their willingness to provide necessary explanations, regular meetings that were organized in webinars, access to literature, numerous articles, books that I have taken, access to forums, feedbacks that I take for each assignments… that makes me feel very good and gladly take participate in this course. I can easily say that this time may qualify as among the most valuable in my professional setting. It makes me feel good.

When I think how valuable that experience was and how well it has influenced my work in FTK, pleasure is even greater. All that I was teaching the course had made that: • I have clarified many issues which I doubt, • I feel more confident in the work which I do, • I feel more competent, • I increased my and website credibility,

• I can share knowledge and experiences with colleagues from the website and wider, • Now this knowledge I have the opportunity to convey to the youth of my country, in the lectures which FTK organize in secondary schools in Kosovo.

A further special event which cannot leave without mentioning here is the organization of the first Conference for Online Counseling in Kosovo. For the first time in Kosovo, in an event, are gathered in one place, more than 100 professionals in the field of psychology, medicine, sociology, to discuss opportunities for online counseling. Even more special this event related to their participation two recognized experts from the UK, Kate Anthony and Stephen Goss.

Their precious presentations now had the opportunity to directly follow all conference participants. I had the opportunity and responsibilities along to the conference with my colleague Adelina Nura introduce the topic: “The benefits of online counseling

training - international certification for online counseling."

After the conference, that from local professionals and the media considered very successful (to meet all these activities), the FTK had organized a three days workshop.

In a picturesque location in the beautiful mountains of Sharr, I and colleagues from the web page (http://www.nukjevet.net), in a friendly and professional atmosphere had the opportunity to discuss specifically with experts Kate and Stephen on matters of interest to us. Discussions, experiences, knowledge that is brought to us by UK experts were and remain very precious in our daily work. Adelina and I will remember this event always, because we both during this time graduate of the Certified Facilitators Cyber Credential.

With special thanks to the staff of OTI, I close this brief writing of my impressions during our cooperation.

Conclusion from Stephen Goss Prior to three days of intensive training for the team of volunteers who work on the front line of responding to enquiries from young people across the country, a special one day event, Sfidat Dhe Prëparësitë E Këshillimit Online (the First Conference on Online Counselling in Kosovo) conference was the first of its kind in Kosovo, a country that is itself younger than the study and practice of online counselling. This was a landmark event in the growth of the online mental health care profession that is still sometimes called young, despite having been in development since at least the 1960s and 70s.

It is a measure of the strong commitment to developing online mental health services that the conference was attended by three government ministers and was opened by the Norwegian Ambassador himself. Such support from such high levels not only indicates the strength of the potential the field now commands. This is especially the case where need is acute. If infrastructure is poor or there are barriers to accessing f2f services for cultural, geographical or financial reasons – all of which are true in parts of

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Kosovo - online services can be vital.

The Norwegian Ambassador, Jan Braathu, spoke of the need to ensure that in a country that is not only young as a nation but in which a remarkable 70% of population is under 35 (ECIKS, 2011), where the legacy of inter-communal violence is still fresh and the need to build a strong, cohesive social fabric is so great it is imperative to invest in the resilience and social and emotional wellbeing of the individuals who will, together, create the country’s future. This is not just mental health care for the benefit of a minority of disadvantaged individuals. It is also about creating the conditions in which the bitter legacy of war does not fester in a generation who have few places to turn for guidance and from whom another, even more widespread conflict could re-emerge. Quality services now, and the funding they need to operate, is nothing to do with coddling the ‘worried well’. It is about preventing another Balkan conflict in 10 or 20 years’ time. In the more immediate future, it is about helping young people to deal with the problems faced by young people everywhere, each

step being another building block towards the country that is – visibly as well as metaphorically – re-creating itself as the new Kosovo.

The founders of FoundacionTogether Kosova, Aliriza Arenliu and Vera Remškar, were also present at the day’s conference and it was very clear that the intent of Nuk je vet! is very much about creating sufficient social cohesion to support the healing of social wounds, through helping individual young people from all communities in the country.

The message that ‘you are not alone’ would be welcome and powerful for young people in many countries and, perhaps, a socially desirable one too. In Kosovo it is one that cannot be neglected. Rebuilding a country requires that the communities and people work together. For them to do so requires that they are able to find the social and emotional supports they need and that is what Nuk je vet! Seeks to provide.

Working together online has few of the social and geographic boundaries that hamper f2f services which are necessarily limited in

their range. A dramatic demonstration of the extended reach of online working across communities was offered by the contribution to the conference of Audrey Jung, on the challenges of cross-border counselling provision, live from her offices in Arizona and beamed into the conference room complete with Q and A from the audience, translated live – as was the entire event – at the venue in Prishtina.

The conference also held presentations on the history and future of online mental health care, the challenges that it brings and accounts of the experience of providing support through both synchronous and asynchronous means including contributions from Adelina and Valdet, and from Professor Dashamir Berxylli, of the University of Prishtina, and Arta Hyseni and Ardita Bahtiri among others. Young people from a school in Prishtina in which Foundacion Together Kosovo attended in the afternoon and spoke to the audience of professionals, bringing us right back to the point of the work of the Foundation. continued next page

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Article Reference ECIKS (Economic Initiative for Kosovo) (2011) Investing in Kosovo. PrishtinĂŤ: IPAK.

The following two days comprised a highly intensive workshop in a mountain retreat for the volunteers who work at the front line of the work of Nuk je vet! responding to enquiries from the young people the service is targeted at. Long days of intense discussion were interspersed with fine Albanian cuisine and music and fortified by the distinctive, and strong, Kosovan coffee. The OTI offices themselves were temporarily transferred to this beautiful setting, including the final examinations of Adelina and Valdet mentioned above.

A new, young country brings fresh opportunities as well as challenges and, together, we worked with the issues faced by the team of enthusiastic and highly committed volunteers. Adapting one’s communication style to online work is a process that any quality training for online work will attend to and to do so across languages and cultures increases the importance of tackling the often thorny problems brought by clients with care. Language and cultural barriers are not, ultimately, barriers to success, however. We ended this phase of our involvement with FTK (which is ongoing online) with a deepened

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respect for the work of the volunteers and their managers and an appreciation for a culture that sits part way between West and East and must be sensitively responsive to both for the work of Nuk je vet! to be successful (read the contributions from Adelina and Valdet above in an accent part way between a smoothly flowing Russian and a passionately expressive Italian and you will hear the lilt and tone quite clearly).

There are similarities between any places where inter-communal conflict is entrenched and recent and I was reminded of my crosscommunity work in Northern Ireland in the 1990s. One of those consistent themes is that the place and the people must work hard not to be defined by that conflict. One part of building the escape from its legacy is working with individuals, and young people especially, so that they are enabled to build secure relationships and to be happy and well enough in themselves to contribute to a happy and secure future for their country. Support for troubled youth was never so needed and we are glad to have been able to make a contribution through our work with FTK.

How Online Health & Wellness Got Its Silver Lining The SilverCloud Health Story With an expanding international client base in the US, Ireland and the UK, SilverCloud Health is reshaping the delivery of online therapeutic services. CEO, Ken Cahill, outlines the ideas and process that brought the company to life, and how its products benefit clients.

by Ken Cahill

TILT – Therapeutic Innovations in Light of Technology

Extreme Social Need

Academic Beginnings SilverCloud Health is a spin out from the Technology Enhanced Therapy (TET) project, a three year joint translational research project undertaken jointly by the National Digital Research Centre (NDRC), Trinity College Dublin and Parents Plus, Mater University Hospital in Ireland. Prior to this, the project underwent seven years of direct academic and clinical research at Trinity College Dublin and Mater University Hospital.

When I first met Dr Gavin Dhoerty, Dr John Sharry, Dr David Coyle and Dr Mark Matthews, the four founding scientists of the TET project, I was hugely impressed that they were bringing over 120 years of academic and clinical expertise. They coupled this experience with refreshingly positive and forward thinking attitudes towards mental health and positive behaviour change.

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Mental illness is extremely common with estimates of almost 1 in 4 of the global population suffering from a mental illness in any given year[1,2]. In addition, anywhere up to 50% of those with chronic or long-term illness such as diabetes or cardiovascular disease, will also suffer a mental health issue, disorder or condition at the same time[3,4,5,6]. The extreme social need for these products, interventions and supports really helped to form the project’s founding aim, which was simply to help people first.

Helping People First While we use computers to inform ourselves in many different ways and they are easy-to-access tools, previous attempts at online therapy solutions had produced extremely poor clinical results as a result of high dropout rates due to poor engagement.

SilverCloud is an innovative solution to the problem that is clinically proven and really helps people – a lot!

In my opinion, there is

'Help people first’ is the SilverCloud Health mantra. something very powerful in actually helping people in a fundamental way. Rather than shifting boxes or selling telephone minutes, by working with the full SilverCloud team, we actually get to improve peoples’ lives in many, many different ways. From improving work/life balance and relationships between husbands and wives, to helping individuals understand negative thoughts more clearly and enabling them to identify, understand and address those issues so they can live happier and mentally healthier lives, that is what drives the team and I forward every day.

At SilverCloud Health, not only do we tackle the underlying issues but we also tackle mental wellness for those suffering from chronic and long-term disease.

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Our current product base is firmly rooted in rigorous academic and clinical research.

Moving From Instructional To Constructionist Ideas Traditionally, computerised mental wellness solutions applied an instructional approach, delivering multimedia versions of standard self-help and psychoeducational material to teach basic concepts and structured knowledge. An alternative, constructionist approach, aims to enhance engagement.

In 1991, Jonassen noted that, by offering the client the opportunity to experiment and construct personally meaningful artefacts, the constructionist approach has the potential to increase collaborative learning and improve learning outcomes[7].

The TET project recognised that the constructionist approach is well suited to advanced knowledge acquisition within ill-structured knowledge domains such as the mental health care (MHC).

Relationships In Effective Interventions In 1999, Assay et al. concluded that, achieving positive change across all interventions models relies on four main factors[8].

They estimated the relative contribution of each factor: • 40% Client Factors - Client and environment strengths and resources.

• 30% Quality of Therapeutic Alliance or Relationship.

• 15% Therapeutic Model and Technique.

• 15% Expectance, Hope and Placebo factors.

These results demonstrate the central importance of client factors to effective interventions and the importance of building, and maintaining, a strong therapeutic relationship between the therapist and client.

Combining Human/ Computer Interaction & Mental Health Care In 2007, the potential of enhanced engagement through computer assisted mental health interventions

remained unexplored, most likely because those working within this area came from a clinical, rather than a technical background.

By combining the specialist know-how of both human/ computer interaction (HCI) experts and mental health care (MHC) professionals, the TET project was able to identify several significant factors effecting design and evaluation of computer-mediated intervention models and develop a broad set of design guidelines to aid technological development[9].

Issues identified included ethical requirements and the challenge posed by the sensitivity and stigma associated with mental illness.

Tackling Attrition Rates Evidence suggested that online solutions delivering cognitive behavioural therapy (CBT), with its well-structured protocol and clearly delineated activities and homework exercises, could be as effective as face-to-face delivery for depression[10].

However, attrition rates remained a challenge.

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Over a typical 8-10 week intervention period people were dropping out early during weeks 2,3 and 4 which means that the clinical improvement is never achieved. The platforms available were simply not engaging enough.

Engagement is critical to building client-therapist relationships and improving client self-efficacy.

At that time, those delivering computer-based therapy programmes were mistakenly delivering their platforms to those with mental health issues in a very basic way. Content was very flat, condescending and static, employing a ‘clickthe-next-button’ type delivery.

While perhaps appropriate for those with very severe mental illness, in the vast majority of cases this approach is, at best, off-putting and,

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Engagement is critical to building clienttherapist relationships and improving client selfefficacy. at worst, insulting. Using these programmes was not natural, dynamic, interactive or exploratory, and people simply did not like it.

“People are neither interested in a dull but useful tool, nor in a

fancy but utterly useless toy. The challenge for HCI research is to systematically address hedonic (non-utilitarian) requirements and combine them with goal orientated requirements.” Monk, Hassenzahl, Blythe, & Reed, 2002[11] For those with mental health disabilities, content should be delivered in the same way it would be to any other individual via modern online platforms such as Facebook, Google, and commercially driven websites. Good content should attract attention, engage, inform and entertain, to retain the readers’ interest all the way through to the end.

Designing SilverCloud When we approached the SilverCloud platform, we thought of news websites such

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as CNN, Forbes or the BBC. News sites in particular set out to grab attention quickly and allow quick, easy digestion of lots of different information.

Implemented as an online application, users access the SilverCloud system through a web browser. Where possible, the design draws on familiar features from social networking and other web 2.0 applications.

Evidence-based Content Development of the platform proceeded in parallel with the development of the clinical content, with tight integration of both processes.

The platform delivers a broad range of engaging evidencebased clinical content, programmes and support in the areas of mental health and chronic/long-term illness.

We have access to publishers with great content and interesting areas of coverage in both the mental health and chronic illness care spheres.

We also provide access to additional resources for organisations through our extensive professional and academic network.

“By working with SilverCloud Health we can combine our expertise in providing therapy support to our patients with their expertise in technology.

The outcome should be of real benefit to our patients, increasing their choice of treatments and helping their recovery.” Judith Chapman, Clinical Director of Talking Therapies (IAPT) at Berkshire Healthcare NHS Foundation Trust

The Coyle and Doherty ‘SIPS’ Model Bringing together previous clinical evidence and TET project outcomes, the SilverCloud approach employs four main engagement strategies, in what is now referred to as the Coyle and Doherty ‘SIPS’ model: • Supportive - each client has an assigned therapist,

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who provides weekly reviews of their progress on the program.

• Interactive – technological content delivery is aimed at engaging clients and immediate feedback offered wherever possible.

• Personal – tailored online experiences help establish a sense of ownership, and provide useful information for the therapist, allowing them to provide more personal feedback.

• Social - to reassure clients that they are not alone in experiencing difficulties and that many other people have experienced similar problems and overcome them, users can respond to content by indicating that they “like” it, and can see how many other people liked it. This helps to reduce the sense of isolation. More detailed shared content (such as tips and ideas) is subject to therapist moderation.

A key innovative of the SilverCloud system is the way in which the SIPS strategies combine within the overall design. For example, the

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interactive features of the program generate content which can be shared with the therapist (enhancing the quality of feedback which can be provided), and in some cases with peers (further enhancing the experience of other users).

have been developed to date: • MindBalance Depression: A cognitive behavioural therapy (CBT) based programme for individuals suffering from low mood and depression

Programme Development

• MindBalance Anxiety: A CBT based programme with tools for tracking, managing and challenging fears and worry

Using this approach pictured above, several programmes

• LifeBalance: A pro-active and practical programme

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which empowers individuals dealing with stress • SeeMySelf: A preventive programme for eating disorders, with tools for promoting positive body image and greater self-esteem - created in conjunction with BodyWhys, a national eating disorder association of Ireland (http://www. bodywhys.ie/ ), a positive body image programme The accompanying case study demonstrates how the effectiveness of the MindBalance programme was assessed and how effective it has been shown to be.

Why People Choose Online Solutions [13] Studies show that, in addition to a basic novelty factor, people sign up for online therapy programs because they offer immediate, easy access.

“It seemed like something that would help me without interfering too much with my schedule or activities, something I could participate in from home.”

“I was initially drawn to the fact it was online and easily accessible.”

Clients often find it easier to disclose sensitive information to a computer.

“I felt I would be more comfortable in doing an online programme than face-to-face counselling.”

“They didn't know me, and therefore were not in a position to judge me.”

Support and the feeling of safety in sharing is also important. Simply knowing that someone is there is significant.

SilverCloud solutions can be delivered at one thirtieth of the cost of face-to-face services.

“It is nice to know someone is monitoring and taking an interest in your progress and that there is someone who will answer any questions you have.”

“I felt no longer alone. I felt that I had someone to go to. It was comforting. The ability of linking in with a specific therapist was very attractive as it felt more personal.”

“I wanted as much feedback as I could get on what I was going through.”

Do More For Less From the perspective of a clinician or healthcare organisation, SilverCloud programmes ‘do more for less’.

All healthcare organisations are overstretched and clinicians have to do their utmost with the resources they have.

Services are already more in demand than ever before and yet there remains a massive unmet need among an increasing population suffering from stress, anxiety, depression and eating disorders.

From a clinician’s perspective, computer-based mental health solutions can help increase continued on page 58

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Case Study: Assessing t Participants Participants were recruited by self-sign-up and direct face-to-face referral as the program was rolled out, in parallel with the usual practice of the counselling service.

Mind Balance is a 7-module online CBT-based intervention for depression. The structure and content of the program modules follow evidence-based principles of a traditional CBT program, incorporating ideas from mindfulness.

Each module is structured in an identical way and incorporates introductory quizzes, videos, informational content, interactive activities, as well as homework suggestions and summaries. In addition, personal stories and accounts from other clients are incorporated into the presentation of the material.

Baseline evidence To assess the effectiveness of the MindBalance programme, a practice-based evaluation was carried out within a University Counselling Service.

The service had previously used a commercially available CBT system but experienced significant attrition, as measured by an internal trial (n=43) in which 74% of users dropped out by session 8 [ ]. This trial provided useful baseline data for the service and a concrete target for improved engagement. Our trial followed a similar protocol and was as close as possible to how the service would actually deploy such a technology in practice.

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Participants were 80 registered students, all supported by the student counselling service, who identified themselves as having an existing difficulty with low mood. Mean age 23.29 years (SD 4.84), 69% female.

Inclusion criteria were: (1) at least 18 years of age, (2) having at least self-reported mild symptoms of depression with a Beck Depression Inventory-II (BDIII) score ≼14, and (3) have received no face-to-face therapy since program commencement.

Measures The online system collected anonymised descriptive information relating to engagement and usage. Data collected included the number of sessions completed, mean time spent on the program, average number of sessions per client, and average length of a session.

Dropout was analysed in terms of the last time a participant used the system.

Delivery Following initial sign-up, clients were assigned a therapist who would support them online. While the program suggested that clients complete one module per week, clients were free to dictate the pace and order of their work. Therapists were asked to provide seven weekly reviews of each client’s work.

Results Refer to Figure 2 and Figure 3. The outcome data are encouraging, with a significant reduction in depressive symptomatology following program completion, with a pre-post effect size estimate of d=1.17.

A high level of engagement was observed compared to the baseline study, along with extensive use of a

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the Effectiveness of MindBalance [12]

Figure 2. Dropout of clients over time

Figure 3. Client usage of program features

range of program features. A statistically significant (P<.001) decrease in self-reported depressive symptomatology from preintervention (mean BDI-II 25.47) to postintervention (mean BDI-II 15.53) with a large effect size (d=1.17) was also observed.

engagement strategies intended to improve the user experience. Findings suggest that a low level of asynchronous online therapist support is a promising avenue for the development of online interventions, when appropriately integrated into program delivery.

Conclusion

“It was great to know that a therapist was reviewing my work and reading my journal entries and offering feedback.

It meant I could get the support I needed each week without having to meet face to face with the therapist.” ~SilverCloud Health Patient User

Recruitment for the study illustrates the appeal that online interventions may have for some clients. All students are eligible for free face-to-face treatment, but the offer of online treatment led many people with clinically significant symptoms of depression to make contact with the service for the first time. This suggests that therapist-supported online interventions may attract people who are reluctant to engage with face-to-face treatment; hence, improving access to psychological interventions for those in need of them.

“I think the programme is set up wonderfully for people experiencing depression, to have help but be able to work through activities and programmes independently.” ~SilverCloud Health Patient User The MindBalance system also illustrates how online support can be tightly integrated with interactive online programs by using a range of design and

Most importantly, this study demonstrates a three-fold increase in client engagement rate when compared with rival products that exist within the marketplace.

The MindBalance programme demonstrated a total of >65% retention rate of people going through the full eight week programme compared with the previous rates of around 23% enjoyed by competitor products.

It also demonstrates results which are clinically effective, efficacious and on par with face-to-face services. In other words; it works!

Another set of randomised control studies will begin again in January 2014. A huge wealth of work is also being carried out across a wide area of study in this area.

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visibility, increase service capacity and reduce waiting lists, increase reach into the community, help de-stigmatise mental health issues and make recovery a more positive experience. Online programs offer an additional, highly cost-effective tool in the counselling toolbox and have been shown to improve client outcomes. SilverCloud solutions, for example, can be delivered at one thirtieth of the cost of face-to-face services.

“There is quite a wide range of ways to apply the SilverCloud platform effectively. It can be utilised as reinforcement therapy. Clients can go home and do homework to underpin what they have learned through face-to-face contact. It can be

utilised in relapse care, or used as an adjunct to face-to-face services.

“SilverCloud Health has helped many of my clients make positive changes and is based on a platform that allows me to easily monitor and support them.

We have used online support tools for several years, and SilverCloud Health has by far been the most successful from both client and therapist perspectives.” Chuck Rashleigh, Psychologist

How Can YOU Get Hold Of SilverCloud?

One of the largest health insurance providers in the United States and several NHS Trusts already have access to SilverCloud Health. To find out more about your nearest provider, contact SilverCloud Health directly.n

ABOUT THE AUTHOR Ken Cahill is the CEO and one of the founding partners of SilverCloud Health, tasked to bring the company global. Previous to SilverCloud Health he was employed by the NDRC, where in his role as an entrepreneur in residence he guided multiple start-up companies through the early phases of growth.

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Wilkinson, G. (2001). Depressive disorders in Europe: prevalence figures from the ODIN study. British Journal of Psychiatry, 179(4), 308-316. doi: 10.1192/bjp.179.4.308 Copeland, J. R., Beekman, A. T., Braam, A. W., Dewey, M. E., Delespaul, P., Fuhrer, R., . . . Wilson, K. C. (2004). Depression among older people in Europe: the EURODEP studies. World Psychiatry, 3(1), 4549.

Gotlib, I. H., & Hammen, C. L. (Eds.). (2002). Handbook of depression. New York: The Guilford Press Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., . . . Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51(1), 8-19 Angst, J., Gamma, A., Rossler, W., Ajdacic, V., & Klien, D. N. (2009). Long-term depression versus episodic major depression: Results from the prospective Zurich study of a community sample.

Journal of Affective Disorders, 115(1), 112-121. doi: 10.1016/j.jad.2008.09.023 Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., Daniels, M., . . . Ware, J. (1989). The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA, 262(7), 914-919. doi: 10.1001/jama.262.7.914 Jonassen, D. (1991). Objectivism vs. Constructivism. Educational Technology Research and Development, 39(3), 5-14 Assay, T. P., & Lambert, M. J. (1999). The Empirical Case for Common Factors in Therapy: Quantitative Findings. In B. L. Duncan, M. L. Hubble & S. D. Miller (Eds.), The Heart and Soul of Change (pp. 23-55).

Washington, DC: American Psychological Association.

D. Coyle, G. Doherty, J. Sharry and M.Matthews, Computers in Talk-based mental health interventions, Interacting with Computers, 19(4), pp.545-562, 2007 Spek V, Cuijpers P, NyklĂ­cek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med 2007 Mar;37(3):319-328 Monk, A., Hassenzahl, M., Blythe, M., & Reed, D. (2002). Funology: designing enjoyment. Proceedings of ACM CHIâ&#x20AC;&#x2122;02 Conference on Human Factors in Computing Systems, April 20-25 2002, Minneapolis, Minnesota *G. Doherty, R. Davidson, O. McLoughlin and J. Sharry, A Service-Based Evaluation of a TherapistSupported Online Cognitive Behavioral Therapy Program for Depression, J Med Internet Res 2013;15(6):e121 *G. Doherty, D. Coyle and J. Sharry, Engagement with Online Mental Health Interventions: An Exploratory Clinical Study of a Treatment for Depression, ACM CHI 2012 Conference on Human Factors in Computing Systems, Austin, TX, ACM, 2012.

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Cyber Supervision Anne Stokes

The Dilemma!

Your online supervisee, Jo, works from home, but is employed to provide online counselling and support for employees of a large organisation.

A supervision issue has emerged concerning pressure on counsellors providing this service to be available to monitor and support employees in the chat room at the same time as being available for drop in sessions with online clients.

The organisation’s stance is that often there are no drop-in clients, so it makes sense for the counsellor on duty to be also responsible for the chat room at this time. You both agree that there are both practical and ethical issues involved here. What suggestions do you have for the supervisor and the supervisee to take this forward? You are an external supervisor, paid for

by Jo. Is there anything that with hindsight might have been done in the past to help now?

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In the last edition this column was concerned with online workplace supervision, and at the end I posed a dilemma and asked for your thoughts. I have amalgamated the responses under several headings.

What are the issues?

A key response was that Jo and the supervisor needed to go back to basics and consider the Ethical Principles in the BACP’s Framework. Even if the organisation was not a member, it was assumed that Jo and her* supervisor were.

There were no responses from online practitioners working to other Frameworks, but the same guideline would apply here – what would your

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Responses to a

Dilemma in Online Workplace Supervision professional organisation’s stance be?

The principle which came up most was Non-maleficence – the basic commitment to avoiding harm to the client. If a counsellor was expected to work with a drop-in client at the same time as monitoring the chat room, there was a likelihood that neither setting had the counsellor’s full attention, and so there was a danger of inadvertently failing the online employees. This was reinforced by the consideration of Justice, where several people stressed that this practice did not constitute fair treatment or the provision of an adequate service.

So there was no disagreement that something had to be done! But what and how?

Contracts First of all, what is Jo’s contract with the organisation? Is she fully employed by them, or is it part of her independent practice? A number of responses examined the difference that this might make in determining Jo’s options. If this is her sole employment, she is likely to have closer ties with management and other counsellors in the organisation.

There would hopefully be a platform for raising issues informally, and this was seen to be the best starting place.

There were different responses if Jo was in independent practice. It was felt that she might have more difficulty in raising the matter - as she worked from home, she may have little contact with

others in the organisation. On the other hand, one person thought that this actually gave her a stronger position from which to challenge the practice, having less to lose - presumably having other clients / contracts - so as a last resort, she could walk away.

Second, what is the supervisor’s contract with the organisation? Indeed, is there one? A couple of people pointed out that in their experience working online, the organisations for which their supervisees worked, had no formal contract with them as supervisors. Indeed, they did not know if the organisations knew who they were. Again, one person said that they felt this was a difference between their practice f2f and online. In f2f practice they would always

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CyberSUPERVISION make sure they were known to the organisation, which was usually a local one, whereas online, the workplace felt more remote and this hadn’t happened.

What has Jo done so far?

All respondents said that this needed to be clarified before they could go much further as supervisors. What does ‘pressure is being put on counsellors’ actually mean?

Is Jo someone who wants to please and therefore finds it difficult to express concerns until it is almost too late? Or is this genuinely management being heavy handed?

It was hoped that Jo had brought this issue to supervision more than once, and wasn’t just bringing it when a crisis had been reached. One person said

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that he noticed a difference between synchronous and asynchronous online supervision in terms of what he knew about how his supervisees’ workplaces operated in general terms – management styles, awareness of counselling issues in general etc. Where the supervision was synchronous, he thought he had a better global sense of the organisation.

The important questions for Jo were around whether she had already raised the matter with her manager informally (or formally) and if so, what the response had been. It might also be useful to sound out other counsellors working for that organisation, if there are any. Putting her concerns in writing was seen as important, and that this is an advantage of working online, as this is likely to be the medium through

which Jo had contact with her manager. It was stressed that an email needed to be written in non-emotive language, and simply state the facts as Jo saw them, including reference to ethics and professional bodies.

Running an email by the supervisor was suggested as a support for Jo.

Going forward If Jo has already tried raising the matter and got nowhere, what should she do next?

She might take the matter to a higher management level.

If she could think of ways in which the situation could be managed so that there was a win-win, rather than an impasse, that could be beneficial. One suggestion was to acknowledge that there are rarely drop-ins, but that perhaps a second counsellor could be ‘on-call’ and paid a small retainer to be at home with their computer on, ready to pick up a drop-in client if one did appear. Another was to limit the times when the dropin service was available and have a second counsellor on duty then. It was wondered if a

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ABOUT THE AUTHOR

trainee online counsellor might be responsible for the chat room (thereby not incurring cost for the workplace!), while the online counsellor simply took the drop-ins, and was also available at beginning and end of sessions to support the trainee.

There were people for and against the supervisor taking a pro-active role and contacting the organisation herself to express her concern. This might feel supportive to her supervisee and add weight to the seriousness of the practice; however it might also undermine the supervisee, and make the organisational position more entrenched. It probably comes down to what the relationship is between both the supervisor and supervisee, and also between the supervisor and the organisation.

It was recognised that in the final instance, if the matter was not resolved, both supervisor and supervisee could end their relationship with the organisation, but this was seen as a last resort, and not very productive.

Anne Stokes is based in Hampshire, UK, and is a well-known online therapist, supervisor and trainer and Director of Online Training ltd.

She can be contacted at anne.stokes4@btinternet.com.

That wonderful thing, hindsight!

So what could have been different? The importance of contracts was again underlined.

Have the terms of Joâ&#x20AC;&#x2122;s work with the employees been spelled out clearly, and was this a departure from those terms?

It would be helpful to have outlined the steps to be taken in case of a dilemma. Again a plus point of working online is that so much takes place through the written word, therefore these things can be agreed at the contracting stage, to refer back to later. In most cases, it was suggested that the supervisor should, as a minimum, be known by name and email address to the organisation, and better still, to have an agreement in place that outlines the relationship and contact points between her and the organisation.

A final point was made that as in f2f supervision, the supervisor needs to have as clear an overall sense of the

organisation as possible. That is partly down to her to research, and partly down to the dialogue between supervisor and supervisee about the organisation, not solely about individual employee clients.

I havenâ&#x20AC;&#x2122;t been able to include all the points made in response to the dilemma, and I am very grateful to those who contacted me. It is obvious that there are no absolutes in terms of rights and wrongs in seeking ways forward, but that it makes the situation slightly less overwhelming if both supervisor and supervisee have thought about some of the implications of working as an online workplace counsellor at the start of the contract. * Interestingly, everyone assumed that both Jo and the supervisor were female, though Jo could have been Joseph, Jonathan, or Jonah, just as easily as Joanne or Josephine! I wonder if the responses would have been different in any way if either party had been male.

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Ne wInnovations

Unlock Cou Jay Ostrowski

Counselors can be really creative when helping clients brainstorm solutions to problems. Weâ&#x20AC;&#x2122;re great at helping others see from a new point of view and identifying new options. With the threat of significant changes in the healthcare industry, perhaps it is time to use those same skills to create new helping paradigms with our clients.

Much of our current way of working in the counseling industry is the not the result of research or best practices, but of the allowable parameters imposed by the health insurance industry decades ago. Savvy therapists who see clients on a cash basis are now using technology in creative ways to offer more clientcentric services that break with the insurance tradition.

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Therapists are also weaving online counseling into face-toface services for the growing number of clients whose insurance now pays for online therapy.

Technology is changing a lot of things in society, and therapy is clearly one of them.

We now have lots of HIPAA/ HITECH compliant software to deliver services online. To

date there are over a hundred software platforms used for online therapy and over 300 dedicated Apps for mental health care. With the revision of mental health laws allowing online therapy, counselors and psychologists are re-thinking how they provide services.

Twenty states now mandate the same reimbursement for face-to-face and HIPAA compliant video therapy

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unseling Options (see http://ow.ly/pSBGT) and more clients are seeking these services and more therapists are providing them.

If therapists begin thinking outside the one-hour therapy box, it opens up opportunities to serve clients in new ways.

HIPAA compliant video and email now make it practical to provide creative options for scheduling challenges and clients who travel. For instance, instead of traveling to the therapy office once per week, clients can have shorter appointments 2-3 times per week (for a cash client) or visit through video for the full hour at the same reimbursed rate, for some insurances. Short

sessions could help focus the client on behavioral objectives and increase the momentum for change.

Ever have an adolescent no-show due to transportation problems?

The phone session for that client is not reimbursable by third-party insurance,

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About the Author but video will be in at least 20 states. Getting parental consent in your first session will open up the option to see the adolescent via video in their own home.

For those who would benefit, group counseling could also be done via video, overcoming the common transportation issues.

Most clients (and therapists) don’t know that these options are available and like all new things, they may need time to consider the option. It usually takes a series of promotions for clients to take notice, or a taste test to find that distance counseling would work for them. Consider making your online services known to clients in your lobby and refer to the option when planning future treatment with them.

While the option of multiple sessions per week doesn’t work for all therapy needs, it does allow new opportunities for some insurance clients, self-pay clients and those who are homebound or frequently travel. For those filing insurance, you may encounter some resistance at

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first.

A few therapists report that when they get a denial for online services, they fax in the law and are miraculously paid.

We are plowing new

Jay Ostrowski is a Telemental health and marketing innovator with www.

BehavioralHealthInnovation. com. BHI created www. telementalhealthcomparisons. com to help professionals choose technology. He lives in Charlotte, NC, USA.

ground here, so, in some cases it will take a little work to get going.

However, the result will be more counseling options for clients with differing needs and more clinical sessions to fill your schedule.

Starting out in online counseling can feel daunting. There are ways to practice legally and ethically online. Training and coaching through companies like the Online Therapy Institute and Behavioral Health Innovation can help you get started. Once you learn the basics, you’ll be able to reinvent your counseling practice. n

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Marketing Toolbox

Sarah Lawton

Continued push for quality content; with Google and other search engines continually improving their search algorithms in favour of relevance and quality, the SEO and marketing benefits of superior, custom content will remain high on the agenda across the long term.

Mobile marketing; mobile is becoming an increasingly important platform for marketers. However, the growing variety of devices will make all-inclusive strategies unachievable. Define clear expectations around what you can achieve and balance flexibility with confidentiality and privacy requirements.

Video marketing; now video can be shared across mobile devices and Facebook has enhanced their mobile ads platform to accommodate; the savvy online marketer will get acquainted with apps like Instagram, Snapchat and Vine. Visual content is a must in any 2014 campaign!

Social Media diversification; Facebook, Twitter and LinkedIn are joined by new networks like Google+, Pinterest, Vine and Instagram.

Techno paranoia will grow in 2014; better awareness among individuals is increasing concerns regarding privacy invasion. As a result, marketers should expect people to opt-out from most data collection when given the opportunity.

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ONLINE MARKETING TRENDS 2014 Trounce techno paranoia with TACT Facing the challenge of online privacy Marketers are predicting that one of the most challenging trends we will face throughout 2014 will be a rise in public awareness regarding online privacy invasion. As a result, data collection may become increasingly difficult, with individuals preferring to opt out wherever possible. To combat this trend, online marketers must manage consumer loyalty, working harder to gain confidence, provide a sense of security to pave the way to comfortable sharing.

The value of data If you handle personal information about individuals, you have both legal and ethical obligations to protect that information[1].

Consumer data is an invaluable asset, providing us with the ability to personalise the customer journey and quantify marketing success.

Unfortunately, well publicised data breaches and black-hat marketing have undermined public confidence.

Data values The EU is overhauling data legislation to reflect changes in technology, social media and cloud computing. Due in 2012, the legislative proposals will focus on four central principles: The right to be forgotten, data transparency, privacy by default, and universal data protection.

In the meantime, marketers cannot afford to wait for public and private policy to catch up to technology and the marketplace. It remains down to businesses themselves to ensure they operate within an ethical framework around the collection, use and protection of consumer data.

To counter this trend towards techno paranoia, Aimia, a global leader in loyalty management, has developed a useful new set of â&#x20AC;&#x2DC;data valuesâ&#x20AC;&#x2122;[2] to guide us on how to protect the data assets in our care.

TACT: transparency, added value, control and trust Designed to inform our approach to how we handle personal data to help drive better products, services, value-added offers, rewards

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Transparency: Inform customers on the specific data being collected, how it is being collected and how it will be used. Be clear and make the information easily accessible.

Trust: Build consumer confidence in data security. Use personal data only in the manner in which you promise it will be used.

Share it only with named partners. Collect only data you need. Use data collected to build consumer value.

Added Value: Compensate customers for providing personal data. Apply explicit value exchange by leveraging loyalty programme rewards, partner benefits, exclusive experiences, or other exclusive information.

"Privacy by Design" is another term that marketers may want to learn. By embedding privacy into the design of business practices, privacy and data protection compliance is designed into systems holding information right from the start.

and recognition. The four core principles of TACT are:

Control: Give customers control over the data they have provided. Tell them with whom the data is being shared and provide easy to access opt out facilities at every step.

References 1. International Privacy Laws: http:// www.informationshield.com/ intprivacylaws.html 2. New Data Values Whitepaper, 2012, Aimia Institute, http://www. aimia.com/files/doc_downloads/ WhitepaperUKDataValuesFINAL.pdf

Understanding EU Cookie Law [1] Cookies enable websites to gather data about visitors and users. The cookie law requires EU businesses to inform consumers of what is being gathered, and enables them to choose to participate in this or not. The intent behind the cookie law is to increase the options available for consumers to protect their data privacy.

Cookie laws apply across the EU, although are implemented differently in each country. A US

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website with UK visitors ought to be asking for consent from those UK visitors according to the UK legislation. Any business whose website is exclusively targeted to non-EU audiences will not have to comply.

widely debated, you may wish to use one of the main free online services[2,3] to create a Cookie Control Widget that asks readers to proactively click to agree consent.

Any EU website not compliant is open to enforcement action from the regulators.

While most country regulators take a measured approach to enforcement, there are mechanisms for registering complaints and investigating them. The safest approach is to take action now to become compliant.

References

This need not be a difficult process.

1. The Cookie Collective website; http:// www.cookielaw.org/ 2. CookieAssistant.com website; http:// cookieassistant.com/ 3. Cookie-Script.com website; http:// www.cookie-script.com/

Steps to compliance 1. Carry out a free cookie audit of your site at The Cookie Collective website[1] 2. Generate a Cookie Policy that informs users: a. that you're using cookies b. on what cookies you're using (and why) c. about how to disable cookies 3. Obtain informed consent from visitors by displaying your policy text prominently but not distractingly on your site. Consent is defined in the cookie law as "any freely given specific and informed indication of his wishes". While the need to do so is

Protect your own privacy Personal.com creates data lockers that let users control how much of their information is accessible to companies.

The Respect Network is a personal cloud network that allows people to 'safely store and share personal data with other people and businesses.

Best Advice for 2014

Keep It Simple!

ABOUT THE AUTHOR Sarah Lawton is a UK based content marketer and social media expert. With a passion for communication, new technologies and top quality content, Sarah encourages SMEs to make the best use of both traditional and online solutions. For further information or advice, please contact: sarah@for-content.com and see www.for-content.com

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Love For the

Books of

v an m u h s i “Where as k a e w o nature s ?” e r o t s k o in the bo echer

ard Be enry W

~H

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s

Psychotherapy 2.0: Where Psychotherapy and Technology Meet Editor : Philippa Weitz The digital age is both exciting and challenging for psychotherapy, opening the apters Features four ch door to clients groups previously not able utors! from TILT contrib to access psychological help, whilst also eeAnna Nagel, Kate Anthony, D providing the challenges caused by social nne Stokes, Stephen Goss, A media and internet abuse and how these & Aaron Balick impact on the consulting room.

v

Psychotherapy 2.0 blows open the consulting BUY NOW room doors and shows successful pathways for attracting new clients to gain access to psychological help, as well as demonstrating that despite initial scepticism, working online as a psychotherapist or counsellor can be as effective as 'face2face' work: the therapeutic relationship may be different but it remains the centrally important feature for successful psychotherapy. It follows therefore that all psychotherapists and counsellors need to be fully informed about the impact of the digital age on their clinical practice.

From Gutenberg to Zuckerberg: What You Really Need to Know About the Internet John Naughton Our society has gone through a weird, unremarked transition: once a novelty, the Net is now something that we take for granted, like mains electricity or running water. In the process we’ve been surprisingly incurious about its significance or cultural implications. How has our society become dependent on a utility that it doesn’t really understand?

John Naughton has distilled the noisy chatter surrounding the internet’s relentless evolution into nine clear-sighted areas of understanding. In doing so he affords everyone the requisite knowledge to make better use of the technologies and networks around us, as well as highlighting some of their more disturbing implications.

BUY NOW

Visit the Online Therapy Institute’s Book Store to purchase featured books and more! http://www.onlinetherapyinstitute.com/bookstore/

Online Therapy Institute, Inc. P.O. Box 392 Highlands, NJ 07732 877.773 5591 www.OnlineTherapyMagazine.com Magazine Designed by www.StudioUltimateDesign.com

Stay tuned next issue for...

99 More great articles about online coaching, online therapy and related topics!

99 As always, we will feature our regular columns about ethics, research, law, film, marketing and technology!

99 If you are interested in submitting an article, review our author guidelines at www.onlinetherapymagazine.com 99 If you are interested in advertising in TILT magazine, please visit http://onlinetherapyinstitute.com/advertising-options/