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Online Therapy: The Next Generation
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Online Therapy: The Next Generation


Chat 2 Recovery is a unique online addiction treatment program for individuals age 21 and over. Nick Lessa, founder of Chat 2 Recovery, provided this presentation at the The 45th Annual Addictions …

Chat 2 Recovery is a unique online addiction treatment program for individuals age 21 and over. Nick Lessa, founder of Chat 2 Recovery, provided this presentation at the The 45th Annual Addictions Institute Conference, held in NYC June of 2013

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  • 1. Presented by: Nick Lessa, LCSW, MA, CASAC
  • 2. “Online therapy is not just an idea for the future. Its time has come.” Casey Truffo, MFT CEO and Founder of the Therapist Leadership Institute
  • 3.  E-Therapy  Online Therapy  Online Counseling  Cyber-Therapy  Distance Counseling  Telementalhealth Counseling  Telecounseling  Internet Psychotherapy  Web-counseling
  • 4. E-therapy is the use of electronic media and information technologies to provide services for participants in different locations. It is used by skilled and knowledgeable professionals (e.g. counselors, therapists) to address a variety of individual, familial, and social issues. E-therapy can (1) include a range of services, including screening, assessment, primary treatment, and after care; (2) provide accessible modes of treatment than the traditional ones to those who actively use the recent development of technology (i.e. adolescents and young adults); (3) help people access treatment services who traditionally would not seek services because of barriers related to geography, shame and guilt, stigma, or other issues; and (4) be provided as a sole treatment modality, or in combination with other treatment modalities, like traditional or existing programs. (SAMHSA, 2009)
  • 5. “18.6 million Americans needed treatment for a serious alcohol problem, and 7.7 million people needed treatment for a diagnosable drug problem. Fewer than 3 million obtained treatment in 2002.” (Stofle, 2004).
  • 6.  Convenient and flexible  Not confined to a specific location  Available 24 hrs. a day  Accessible w/o regard to normal business hrs., set apt. times; or waiting lists  The immediacy of online services can capitalize on fluctuating motivation to seek treatment  May result in feeling less dependent on the therapist  Allows client time to reflect without pressure to think quickly  Anonymity eases discomfort and potentially embarrassing and stigmatizing disclosure of behavior and thoughts  Adults and children have disclosed higher levels of personal information sooner on a computer than FtF. (Alleman, 2002).  “clients of online counseling have reported they feel less self- conscious, less inhibited, and better able to express themselves than they would sitting in someone‟s therapy room, and therapists have reported they feel more focused and that their responses are more powerful when they have time to reflect before responding to a client‟s input (Alleman, 2002)
  • 7.  Security and privacy concerns  Legal concerns (jurisdiction, adequate care)  Misunderstanding due to lack of non-verbal cues or misunderstanding of written response  Inappropriate training may affect clinical competence  Inappropriate online relationships through social media sites (Facebook, Twitter, LinkedIn, etc.)***
  • 8.  Asynchronous Communication: E- mail, Forums, Listservs  Synchronous Communication: Audio Conferencing, Videoconferencing; chat, IM  Many who sought online therapy later used ftf counseling  90% felt online therapy helped them  Many felt they would not have initially sought ftf therapy (Alleman, 2002) (SAMSHA, 2009)
  • 9. “Thus far, research findings indicate that online counseling may be beneficial for clients who do not have easy access to traditional FtF therapy.” (Mallen & Vogel, 2005)
  • 10.  CBT to change drinking behavior as effective when delivered online (Copeland and Martin, 2004) (SAMHSA, 2005)  Alcohol interventions conducted over the internet showed promising results (Copeland and Martin, 2004)  “There is good evidence that computer- delivered interventions for mental health and behavioral problems can be effective.” (Copeland & Martin)
  • 11.  Does the person possess the written language skills and able to express emotion through text?  How might the person‟s computer skills, knowledge, platform and Internet access affect the therapy?  How knowledgeable is the person about online communication and relationships?  How well suited is the person for the reading and writing involved in text communication?  How might physical and medical factors affect the online therapy?  Assessing a Person‟s Suitability for Online Therapy at: t.asp.
  • 12.  Can one express empathy online?  Can one express Presence online?  The Disinhibition Effect – the perceived safety of the distance between clients and therapist makes them much more willing to admit the uncomfortable thoughts  Issues of Fantasy online
  • 13.  Determining what methods of Internet delivery is best suited for client and therapist  Adequate typing skills, comfort with downloading programs, using various platforms & software, basic computer skills, ease of use with web links, ability to protect communication of clients including use of encryption, expressive writing skills, comfort in text-only environment, skill at clarifying online communication, desire to be online, experience w/ online relationships, belief that online relationships can be meaningful, able to handle computer glitches, able to handle various methods of delivery (Fenichel, 2000)
  • 14.  Attending and Acknowledging – “Jane, I did receive your email today and will respond by tomorrow. Take care.”  Probing – “Can you clarify for me what you meant when you said…?”  Supporting – shows warmth. Physicality through emotional bracketing [take my hand], expressing emotion [smiling], emoticons, hugs ((((Jane))))  Checking Perceptions – “What I hear you saying is…”
  • 15.  See “Ethical Framework for the Use of Technology in Mental Health”***  Informed Consent – should have a page on website dedicated to this.  Practitioner Competence – experience, training, supervision, computer skills, verification of qualifications  Clear Client Exclusionary Criteria – age, severity of illness, computer savvy, location
  • 16.  Privacy and Security Protections – encryption, back-up, use of passwords, firewalls, virus protection, etc.  Initial Intake and Screening Process
  • 17.  Should begin at first client contact  Screening form/questionnaire  Screen for client‟s technology skills  Screen for client‟s language skills  Presenting problem (Why seeking therapy online?)  Client identity verification  Clinical screening  See example questionnaire***
  • 18.  The process (what to expect, misunderstandings that may occur, turnaround time, safeguards)  About the practitioner(s) (credentials, contact info, training)  Potential risks and benefits  Alternative treatment services  Emergency procedures  Should be acknowledged as read and understood
  • 19.  Always obtain demographic info. (name, address, contact info, emergency contact info)  If located in a different geographic location, look up community emergency and safety resources (hospitals, SOs, clinicians, police)  If you don‟t know exact location of client in an emergency, contact local police dept.
  • 20.  Jurisdiction Issues  Confidentiality and privacy protections (Hushmail, Office 365)  Determine what constitutes the clinical record (chat transcripts, video recordings, email exchanges, etc.) and who owns it  Important to have an attorney review your website, forms, procedures
  • 21.  Issue of Jurisdiction (lack of inter-state reciprocity)  How can we be assured that we are not violating laws around jurisdiction? Answer – “Damn near impossible” (Jason S. Zack)  To date, no known lawsuits brought up in any states which address online therapy specifically
  • 22. “Consistent with the Model Act, the Technology Standards admonish social workers to „abide by all regulations of their professional practice with the understanding that their practice may be subject to regulation in both the jurisdiction in which the client receives services as well as the jurisdiction in which the social worker provides services.‟ (NASW &ASWB, 2005).
  • 23.  “This highlights the requirement that social work practices that operate in more than one state must review and interpret the laws and regulations for social work practice in each state and determine how the practice should be structured to avoid conflicting requirements and afford clients the greatest level of protection from unregulated practice.”
  • 24.  Know the laws of your state  Know the laws of your client‟s state  Check out the National Telehealth Policy Resource Center (provides state-by-state laws)  Understand the scope of practice related to your license, certification, education and law  Determine whether your insurance carrier will cover an out-of-state claim  Seek legal consultation for your practice  If your website indicates that you consider services rendered to be at your location, seek legal advice
  • 25.  Specific Online Training is strongly recommended in most Guidelines  Distance Credentialed Counselor (DCC) Training Program and Credential at A 2-day (15-hr.) program. $595.  Online Therapy Specialist Certification at 60-hour, online modules. $2,000.
  • 26.  The Importance of a Website (important to speak to the client‟s need) 6 Characteristics that top therapist websites share (Truffo, 2007): 1. Speaks about services that client can appreciate 2. Has a clear „call to action‟ & contacting therapist is easy 3. Offers something for free 4. Reflects personality and picture of therapist 5. Geared towards the ideal client 6. Simple and to the point, presented in caring manner
  • 27.  Crisis Intervention Information  Contact Information  Practitioner Education, Licensure, Certification Information  Terms of Use and Privacy Policy  Explanation of security/privacy (personal info)  An Initial Screening form/questionnaire  An Informed Consent  Costs of treatment and payment info.
  • 28. Consider using MedForward ( website design for healthcare professionals and HIPAA compliant online forms
  • 29.  Deciding Whether to Join an E-Clinic or Private Practice  Joining Online Therapist Directories (e.g., Psychology Today, Find-a, Nat. Directory of Online Counselors)  Blogs  Pay-Per-Click Advertising  Ask questions on home page  Offer free information  Use audio  Write articles  Create a Podcast  Join social networks  Write a Press Release
  • 30.  E-Mail  Videoconferencing  Chat Rooms and Instant Messaging  Cell/Mobile Phone SMS (text messaging)  Audio Conferencing
  • 31.  Use emoticons – the creative use of keyboard characters to indicate to the other person what is happening at your end of the conversation (e.g., the wink when you‟re not wholly serious). Should be led by client.  Learn acronyms and abbreviations  Enhancing Text – makes it more „alive‟ (e.g., use of capitalization, underlining, bolding, exclamation marks, emotional bracketing, and parenthetical use
  • 32.  Signature files (not used in therapeutic emails)  CCing, BCCing and address books (never to be used)  Greeting and sign-offs (less formal as time goes on)  Subject lines  Paragraphing (many shorter paragraphs)
  • 33.  Enormous benefit for those with mobility problems (elderly, rural, military, agoraphobia)  Majority of studies: little difference in outcome  Excellent and inexpensive applications: WebEx, Go-To-Meeting (HIPAA compliant)  Use of headphones with microphone  Held in private area - important  Initial set-up and training required  Great feeling of “Presence”  Clients seem to love it (feel safer, comfortable)
  • 34.  Involves a level of honesty about substance use  Decision on recording sessions  Suggested maximum size of group – 6  Do all members see each other?  Work assignments in between sessions (e.g., Wellness Self-Management Plus)  Sign-in Sheet (days C &S, distress level, self- help, self-efficacy, completion of assignments)  Join 15 min. prior to group
  • 35.  Chat rooms usually “open” rooms  IM usually a private dialogue  Common use of abbreviated words & emoticons. Follow client‟s lead.  How do we know we are speaking to client?  Clients reports getting to their root issues more quickly that ftf.  Use secure chat service providers (HIPAA compliant). Encrypted & proper storage.
  • 36.  Proficient typing recommended  Understand the reason why someone may be choosing this modality  Best served by adolescents and young adults  Eliminating ftf presence reduces anxiety  Useful in couples therapy  Useful for those who lack a private area in home to speak
  • 37.  Preparing to begin services for over a year  Start-up began in January, 2013  OASAS would not consider endorsing product  No insurance accepted  6-week program (twice weekly groups, 3 individual sessions, weekly educational assignments, access to counselor by phone/email)  Cost - $899 
  • 38.  Alleman, J.R. (2002) Online Counseling. Psychotherapy:Theory/Research/Practice/Trainin g, vol. 39, No. 2, 199-209.  Anthony, K. and Nagel, D. (2010) Therapy Online: A Practical Guide  Anthony, K., Nagel, D. and Goss, S. (2010) The Use of Technology in Mental Health: Applications, Ethics and Practice  Copeland, J. & Martin, G. (2004) Web-based interventions for substance use disorders: A qualitative review. J. of Sub. Abuse Treatment, 26, 109-116.
  • 39.  Hsiung, Robert C. (2002) e-Therapy: Case Studies, Guiding Principles, and the Clinical Potential of the Internet  Kraus, R., Zack, J. and Stricker, G. (2004) Online Counseling: A Handbook for Mental Health Professionals  Mallen, M.J. & Vogel, D.L. (2005) Counseling Psychology and Online Counseling. The Counseling Psychologist, Vol. 33 No.6, Nov., 761-775.  Substance Abuse and Mental Health Services Administration (2009) Considerations for the Provision of E-Therapy.  Stofle, G.S. (2004) Addiction Treatment Online. Behavioral Health Management, March/April, 53-55.