Therapy, Coaching & Distant Healing via Technology

We offer articles from TILT Magazine and information related to online therapy, online coaching, online complementary and alternative modalities and cyberpsychology.

TILT Magazine Issue 18

September 16th, 2014   •   no comments   
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Meandering through models of supervision and coaching!

September 13th, 2014   •   no comments   
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cybersupervisionThe starting point of this issue’s column was an exchange I had with an online supervisee. She isn’t a counsellor, but uses counselling skills in her role as team leader of family supporters within a charity. Let’s call her Liz. She was planning a short training on interpersonal skills for her team, and we were discussing possible inputs and models. Looking at what she had planned, I said that it reminded me of Egan’s ‘The Skilled Helper’. Liz did not know the model, so I briefly and perhaps simplistically mentioned ‘explore/ understand/ act’.

The response from Liz was: ‘Yes- that is exactly what’s needed. The team manage most of the time to help the clients explore and understand their issues, but then they don’t know how to act in the clients’ best interests’.

Dilemma – do I explore with Liz how to help the assistants to ‘know how to act’ or do I explain that actually it’s about what actions the client is going to take? In this supervision, I stayed with Liz’s agenda, which was enabling her team, who are not counsellors, and part of whose job is to take action – enable links between various agencies in particular. I did later email a paper about Egan’s model.

However, it started a train of thought about the use of Egan’s model as an online supervision tool. This was pushed forward by a presentation which one of the participants on the Diploma in Online Therapeutic Supervision gave recently. This was around the C.L.E.A.R. model developed by Peter Hawkins in the 80s (Contract, Listen, Explore, Action, Review). Those middle three stages are so reminiscent of Egan.

Hawkins produced this as a coaching model, which led me to consider online coaching and supervision. What do they have in common? I looked up various definitions of coaching, finding a number where if the words coach was replaced with supervisor, they would still make sense to me.

Coaching is unlocking a person’s potential to maximise their own performance. It is helping them learn rather than teaching them’ (Whitmore, 2004).

Coaching is a process that enables learning and development to take place and thus performance to improve. To be successful, a coach requires a knowledge and understanding of the process as well as a variety of style, skills and techniques that are appropriate to the context in which coaching is taking place’ (Parsloe, 1999).

I then explored various models of coaching as they might well be able to inform and expand my online supervision practice. Many of them have that same similarity to Egan. I am in no way implying that they are all borrowing from Egan; simply musing about the fundamentals of coaching and supervision. Three of the models were:

GROW – Goal, Reality, Options, Way forward /Wrap up
TGROW – Topic, Goal, Reality, Options, Way forward
OSKAR – Outcome, Scaling, Know how, Affirm and Action (so should it really be OSKAAR?) and Review

If I wanted to integrate any of these coaching models, what might be the constraints in online supervision? One is the apparent emphasis on outcomes. Sometimes supervisees (and supervisors) need time to go away from an online session and muse before taking any action. That’s where email supervision can really come into its own, as it builds in this time naturally. Perhaps I also shy away from the term ‘performance’ in the definitions. That may be disingenuous of me as there is a sense in which any role, even as an online counsellor, has a degree of performance in it.

A possible downside might be another emphasis, this time on identifying the goal of supervision. I do believe this is necessary if the supervision is not to be wishy-washy and aimless, though I might prefer to use the term ‘focus’. My niggling concern is that online, we sometimes are so quick to get down to work in both synchronous text and email supervision that we miss some of what I would call ‘walking around’ the focus. However, conversely, the inclusion in all the models of Know How, Options, Ways Forward avoids another pitfall in online supervision, of ‘talking’ around the issue, but never looking at its implication for practice.

I think that is why I feel drawn toward TGROW, as the initial T stage is about clarification of the reasons the Topic is important to the coachee/supervisee at this moment in time, and what impact it may have on the longer term vision (coaching expression) or process (supervision expression). It may uncover issues and a focus which is different from whatever the supervisee/ coachee thought they wish to bring to that online exchange.

Rereading the above paragraph, I realise I had in mind synchronous supervision, so another constraint may be the application to asynchronous exchanges. In email supervision the clarification may only be possible in a more general sense, as there is no immediate interaction.

The positive that I take from looking at OSKAR in particular is the inclusion of Review, which sits well with the Cyclical Model (Page and Wosket, 2002). This seems such a necessary part of supervision and again can be missing from email supervision simply because it is not synchronous. Yes, we carry out reviews of how the online supervision is going from time to time, but often miss the review of individual exchanges.

So where have my meanderings taken me? They have reminded me of the value in staying open to considering ideas and models from other similar fields, of weighing them up and taking from them aspects that may inform or improve my own online supervision practice. Not a bad day’s work.

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the Meandering through models of supervision and coaching article.

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.

REFERENCES

Downey, M. (2003). Effective Coaching: Lessons from the Coach’s Coach Knutsford Texere Publishing (TGROW)
Hawkins, P. & Smith, N. (2006) Coaching, Mentoring and Organizational Consultancy: Supervision and Development. Maidenhead OU Press ( C.L.E.A.R.)
Jackson, P. & McKergow, M. (2006) The Solutions Focus: Making Coaching and Change SIMPLE 2nd edition London Nicholas Brealey Publishing (OSKAR)
Page, S. & Wosket, V. (2002) Supervising the counsellor: a cyclical model 2nd edition London Sage
Whitmore, J. (2002) Coaching for performance 4th edition London Nicholas Brealey Publishing (GROW)

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

Check out the Fall 2014 Issue of TILT Magazine!

September 12th, 2014   •   1 comment   
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It’s been a nail-bitingly exciting time here at TILT Towers between issues!  Your Managing Editors decided to reach out to you, our readers, to help us keep the magazine going for the foreseeable future, and we held a Kickstarter campaign to achieve that.  Our goal of $5000 within three months was well met, including a generous contribution by Hushmail. We tell you the story of TILT’s creation, process and future in this issue, and we are also pleased to welcome Lyn Kelley to our Innovations column to talk you through the options available to start a crowd funding campaign of your own. The gratitude we feel to have received such support from colleagues, friends and strangers in supporting us really cannot be put into words. It was a great creative boost, and we hope that is evident in this latest issue.

Also in this issue, Darlene Ouimet tells us the exciting story of how her recovery from dissociative issues and chronic depression led to her sharing her journey via a website and subsequently a blog – and how this led to being contacted by award winning producer Robin Jay, with an invitation to be in her next self-help movie “The Secrets of the Keys” which is a prequel to her first movie “The Keeper of the Keys”.  Darlene writes of how she never imagined that her passion for reaching the world with her message of hope and healing would land her a movie deal! Her four and a half year journey, via “Emerging from Broken”, is an inspiration to us all.

Susie Mullens and Teresa Warner tell us of their work in the ongoing support of people in recovery via their innovative app A-CHESS.  A-CHESS is comprised of many features to help those in recovery and is currently being vetted as an evidence-based practice, theoretically based in Self Determination Theory (SDT) which focuses on how social and cultural factors facilitate or undermine people’s sense of volition and initiative, in addition to their well-being and the quality of their performance. A-CHESS has been well received by its users as part of their recovery programmes, enhancing the client’s treatment experience and improving client engagement.

Elsewhere we have all our usual regular columnists to keep you abreast of developments and work in the field, including CyberSupervision, Research, Views from the Frontline and of course our resident cartoonist!  Our Student Spotlight column features Thomas Tsakounis, who recently completed the Online Therapy Institute’s Reiki training, and who exemplifies the Institute’s mission to bring innovative ideas and practice to traditional ways of working to those with an open mind and a passion for delivering their services in a dynamic and sophisticated way.

Best wishes to all our readers for the autumn!

Kate and DeeAnna

 

Subscribe to read these feature articles:

 

Crowdfunding How Communities Pull Together

From Starting A Blog To Landing A Movie Deal…All On The WWW

“Tech Support” Using Technology To Support Ongoing Recovery

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

 

Go to TILT Magazine Archives!

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Therapy Workshops Online – a new bonus for all Online Therapy Institute students!

September 10th, 2014   •   no comments   
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Over the years, we have collaborated in many ways with our colleagues over at OnlinEvents!  Not only do we get together at face-to-face conferences whenever possible (easier for Kate than DeeAnna of course), we also meet at online conferences such as CESL (Counselor Education in Second Life) and even shared an island in Second Life for awhile.  John has filmed our Open Office hours, and Chat-Queen Sandra facilitated the live events for us.  John has also contributed chapters in two of our edited textbooks. Wherever possible, we share resources and put our heads together to work out how we can best serve our respective audiences in the therapy/coaching field and its related professions.

onlinevents-website-logo1

For example, the free-to-attend online interviews that John and Sandra so generously make available to practitioners worldwide are a staple of Online Therapy Institute (OTI) courses – whether as part of the fields of online therapy and coaching (such as Phillipa Weitz talking about the online therapeutic relationship) or more general issues in psychotherapy (such as Mick Cooper being interviewed about systematic outcome and process feedback).  Our students get alerted well in advance to these free events through their private closed Therapist Community on Facebook, and can use them in writing up their course assignments.

We were pleased to see the new development of Therapy Workshops from our colleagues – these low-cost online events have more of a workshop feel than an interview, while retaining all the learning philosophy that John and Sandra are rightly proud of – watch the video below to hear more about that philosophy.

One of the obvious bonuses of recording online interviews and workshops is that they are available online for evermore – and we have teamed up with OnlinEvents to ensure that our students now get FREE access to the back catalogue!  That’s over 200 educational CPD videos that our students can take advantage of, and the list grows every week!

If you’re already one of our students, you can sign up for your student membership here!  If you’re not, remember us when you are researching your training needs – remember, as well as free access to the OnlinEvents library, you also get a free subscription to TILT Magazine!

Thanks again to John and Sandra for their ongoing collaboration with us to meet the needs of those interested in our field – we look forward to many more years of it!

Cyberwork: The Irony of Attending Conferences to Discuss Virtual Work!

August 27th, 2014   •   no comments   
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Kate continues with her regular column for the quarterly Journal of the BACP Workplace Division – this issue focuses on attending conferences.

The bringing together of professional minds at conferences is one of the joys of our work.  Conferences offer us learning opportunities, a networking event, and usually an element of socialising. Counselling can sometimes be a solitary way of working, and conferences allow us to diminish that somewhat and spread our wings a little.

However, at almost every conference I present at, someone points out the irony in travelling hundreds of miles to discuss being present virtually! This was certainly the case at the recent Practitioner’s Conferences in Leeds and London, at which I presented on taking services online and what you need to know about doing that.

Both were thoroughly enjoyable and successful events, and ones that also gave me pause for thought on how we can blend technologies to attend conferences as well as we can use technology to offer services to clients.  One of the more recent initiatives that BACP have taken is to explore further the concept of conferences being available both “in-room” and virtually – the annual Online Counselling and Therapy in Action (OCTIA) is a good example of this, with delegates at the venue in (usually) Bristol and also in attendance from (usually) their homes to watch a live stream of presentations and interviews over the Internet while holding discussions live in a chat room next to the video stream.

At a previous OCTIA conference in Manchester, I was able to present to a room of delegates at the venue, with my laptop in front of me.  Broadcast behind me on a screen was the view from my laptop perspective into the virtual environment of Second Life, where I was joined by colleagues from all over the world represented as avatars, who had their own chat facility with me via my laptop, plus the delegates in the room who were also in Second Life as avatars from their own laptops.  On another screen on the wall on my right was where I was shown live from the perspective of one of the other delegates in the room in Second Life, with the official OCTIA chat room being scrolled to the right of the video, where I was also taking part via audio and my laptop via text.

If that description sounds confusing, the point is that I was present in five different realities simultaneously, presenting worldwide.  This groundbreaking event reached four continents – Europe, the USA/Canada, South America and Australia – bringing them together to discuss the use of virtual and mixed realities in counselling and psychotherapy experientially.  Just attempting to explain that experience to you is messing with my head – actually designing it and doing it live was truly extraordinary, and an achievement I am immensely proud of, as are my colleagues at OnlinEvents.co.uk who managed the technological side of it all.

OCTIA 2010 (Virtual Environments)

So, in your professional capacity, are you and your workplace taking advantage of technology for your continuing professional development in addition to the expense of travel to live conferences?  Organisations are increasingly offering live streaming and chat as an alternative way of attending with the cost only being your time and your internet connection; or offering them at least at a discount at the full conference price.  Attending remotely is certainly a different experience than being there in person (and conversely much more exhausting somehow), but blended attendance at conferences is increasingly becoming the norm.

Online conferencing is something my students get introduced to at an early stage of their course, to enable them to take full advantage of what is on offer for their learning from the comfort of their sofa.  I also encourage students to attend live conferences where possible, as I believe that professional human interaction taking place both online and offline is what makes us rounded practitioners as the internet plays a bigger and bigger part in our lives and work.

I loved being in Leeds and London to meet, talk and learn with my colleagues, just as I love being online in a chat room as part of a computer mediated event.  Both ways of attending conferences are nourishing to us as practitioners, and each has its own nuances on how interaction with each other and the speakers takes place – neither better than the other. In fact, I think the main difference in having a experience of good quality is that the lunch tends to be better if physically present at the venue!

Download the .pdf! BC168_CAW Summer 2014_AW2_Final to Press_Cyberwork (1)

Left to My Own Devices

July 11th, 2014   •   no comments   
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Wired to Worry 17 cartoonI 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.

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 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.

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the Left to My Own Devices article.

Christine Korol, PhD, 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.

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

Views from the Front Line: An Industry Perspective

July 6th, 2014   •   no comments   
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Views from the front line USAislinn 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 clinical services, rather than attempt to replace them and offer clients with broader, easy-to-access 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:
1. 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 non-profit 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.

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 and 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; 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 resulting 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., Björklund, M., Hornborg, C., Karlsson, S., Hesser, H., Ljótsson, 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., Lindström, M., Möller, 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.

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the Views from the Front Line: An Industry Perspective article.

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

How Online Health and Wellness got its Silver Lining

June 29th, 2014   •   no comments   
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silvercloudWith 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.

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.

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the How Online Health and Wellness got its Silver Lining article.

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.

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

From Snail Mail to Email to Private Conversations: Could online counselling become clients’ preference?

June 22nd, 2014   •   no comments   
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privacemail1In 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 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).

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.

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 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.

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-to-face 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.

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.

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.

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 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.

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 text-only 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.

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.

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.

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.

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 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.

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.

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 re-engage the client, at least to permit the client to explain whether he or she feels satisfied or 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 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.

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.

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the From Snail Mail to Email to Private Conversations: Could online counselling become clients’ preference article.

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.

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.

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

Online Marketing Trends 2014

June 15th, 2014   •   no comments   
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marketing toolboxContinued 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.

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 ‘data values’ [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 and recognition. The four core principles of TACT are:

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.

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.

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.

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.

“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.

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 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.

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.

This need not be a difficult process.

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 display 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 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.

References

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

Protect your own privacy

Personal.com (https://www.personal.com creates data lockers that let users control how much of their information is accessible to companies.

The Respect Network (https://www.respectnetwork.com) 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!”

This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.

Click here to read the entire PDF version of the Online Marketing Trends 2014 article.

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

Access TILT Magazine archives: http://issuu.com/onlinetherapyinstitute/docs

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