In 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.
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