“The future isn’t what it used to be”
Technology in Counselling and Psychotherapy
Derek Richards
Introduction
Change is prefigured in the articulation by Dr Rick Satavas: ‘the future isn’t what it
used to be’. Its sentiment rings true; recently psychotherapy practitioners and
researchers have begun investigating the potential of engaging new technologies,
such as the internet and software programs to deliver psychological interventions
(Ritterband et al, 2003). Quite a bit of work has already been done and this paper
will give an overview. The paper addresses the reasons for innovation and discusses
the more salient advantages and disadvantages of engaging technology.
In
particular the paper will focus on online counselling.
Lastly, the therapeutic
relationship online will be considered.
An overview of what’s been done:
Psychotherapy practitioners can choose from an ever increasing range of technology
to compliment and extend current practice. Technologies such as the World Wide
Web, software programs, mobile phones, multimedia, games and virtual reality; each
have been experimented with in delivering psychological interventions:
- World Wide Web (WWW):
The potential of the Internet has been realised by many in a multitude of different
ways; beneficial and otherwise (Barak, 1999).
Psychological practitioners and
researchers have also considered the WWW as a vehicle for education and mental
health service delivery (Richards & Tangney, 2008; Gross & Anthony, 2005). It’s
certainly wide-ranging and includes online psycho-educational materials (Barak,
1999) such as the virtual pamphlet collection (http://www.dr-bob.org/vpc/). Peer
support has been successfully developed online for groups such as cancer patients,
HIV patients, eating disorder patients and those suffering with depression (Darcy &
Dooley, 2007; Salem et al, 1997). The Internet has also been realised for counselling
online and has been successful (Richards & Tangney, 2008; Gross & Anthony, 2005).
- Self-Directed Software:
Self-directed software packages are computer programs designed as treatment
packages for specific disorders. They are mostly client-led, the user works though
the program and its related exercises in the same way one might use a self-help
book.
Beating the Blues for depression and anxiety is one example (Marks,
Cavanagh & Gega, 2007). It is an eight session program based on a Cognitive
Behaviour Therapy (CBT) protocol. A number of research studies have contributed
to establishing its effectiveness (Marks, Cavanagh & Gega, 2007). As the program is
self-directed; there is minimal therapist contact with those who use it. Arguably,
this has compromised its acceptance and usage; however, it has also been a point of
benefit for users (Gross & Anthony, 2005). Similar CBT based protocols for
depression, anxiety, and PTSD have been developed and effectively delivered over
the Internet to the general population (Lange, 2003; Wagner, 2006; Proudfoot,
2004).
-
Mobile Phones
Mobile phone penetration and usage is high especially for young people. In
counselling and therapy there are some tasks that can be administered using mobile
phones. At its simplest, sending txt messages to make or break appointments.
Another example is the use of a phone to record a mood diary. In this way the
therapist can potentially have a recording of the diary entry and when it was made
(Matthews, 2008).
Other examples of the use of mobile phones are in delivering
motivational messages to clients, or used as a check-in for clients between sessions.
In these ways the phone can be used as an adjunct to therapy and support users’
engagement.
-
Multimedia
Multimedia is the use of a variety of media such as text, sound, animation, and
video. One example is the development of podcasts on relaxation techniques
(http://www.ul.ie/counselling/). A more elaborate example, developed by Clinical
researchers at the Mater Hospital, is the use of hand crafted multimedia storytelling
as an aid in the therapy process. They are currently testing its effectiveness in
group therapy with Adolescents. ‘Transforming Stories’ is essentially a multimedia
toolkit that aid users in building their therapeutic story (Brosnan, Sharry et al,
2006).
-
Gaming
Computer games are interactive and engaging. Researchers at Trinity College Dublin
have developed games for use with Adolescents in therapy. The games are based on
a range of different therapeutic approaches and clinical issues. Examples include:
‘Private Investigator (PI)’ (Coyle, 2005) which is a solution focused approach to
problem solving. In PI a young person can train as a detective, learning skills and
strategies that will help them find solutions to problems. Another example is
‘Temper Quest’, here users visit the temper lab and explore aspects of their temper
and its impact on their lives. ‘Temper Quest’ follows a narrative therapy protocol.
-
Virtual Reality
The potential for the Internet to dramatically alter how we relate in the world is
perceived. Social Networking Sites such as Bebo and Facebook and virtual worlds
such as Second Life are examples of how much of life is now being conducted
through the technology that is so pervasive in people’s lives. In realising the
possibilities of virtual reality for psychological therapy researchers in Italy and Spain
have developed virtual worlds that allow users to address issues such as anxiety and
phobias (Banos, 2007). One example is Emma’s world which is an adaptable virtual
reality that can be used for different problems.
“In Emma’s world … to accomplish therapeutic goals a series of emotional
virtual elements are used and personalised so that they are meaningful to
the user and contain the emotional elements that the user is working
with.” (Banos, 2007)
The above sample will give the reader some notion of what’s already been spawned
in the use of technology in psychological therapies. While it’s in it’s infancy it is
important to recognise that the results from research studies are showing positive
outcomes and resultantly the work is continuing (Rochlen, Zach & Speyer, 2004;
Marks et al, 2007).
Why work in new and Innovative ways?
The question of ‘Why are we doing this?’ needs to be addressed, specifically, why
psychological therapies might need to harness new technologies and innovate in
delivering services.
Therapy services are expensive, there is an evident shortage of trained therapists,
and national resource allocation for mental health can be considered poor. Most
services and therapists are already overburdened and increased demands have not
been met with a commensurate increase in mental health service resources. Also,
and for a variety of reasons, a majority of individuals don‘t seek the help they
require. Large questions also exist about the cost-effectiveness of therapeutic
treatments and a consequent preference for shorter-term solutions.
The result of this situation means that people who need services are being short
changed because of the demands for throughput. Many can never come into contact
with services delivered because of capacity overflow, cost of treatments and stigma
associated with seeking help and service use. Inadequate funding and insufficient
resources compromise the beneficial impact of early intervention and impede
services reaching most needed population groups such as young people and those at
risk. Also shorter treatment modalities, while they may be more established, are not
always the most suitable.
Arising from these concerns and issues researchers, clinicians and services have
turned to consider alternative solutions including the potential of technology to help
attract and meet potential service user’s needs. In addition the pervasiveness of
technology in people’s lives is also a major factor, which would simply be shortsighted to ignore. This is especially so for young people, affectionately known as
‘screenagers’.
- Advantages of Innovation
The advantages of engaging technology are many and include increasing access to
services that for a greater number of people and range of people services can be
delivered. For example, Simpson (2004, 2005), a clinician and researcher, based in
the psychological service in Aberdeen that services the Shetland Islands has
successfully used video conference technology to provide a much needed therapy
service to a remote group for eating disorders.
Widening access does not necessarily mean incurring extra costs. Many of the selfdirected programs have detailed cost-benefits analysis and show reduced costs
because of reduced therapist time, without compromising outcome (Marks et al,
2007).
Extending access includes geographical access, access to people with disabilities, and
access to populations who many never seek needed help because of their condition.
The potential of such accessibility can mean that individuals receive treatment
without incurring the stigma of presenting at a face-to-face service. In addition, the
service being offered is more user-centred, where the user controls the pace of work,
when to work and where to work. These factors have been noted as advantages by
users and in some cases preferential (Gross and Anthony, 2005).
- Disadvantages of innovation
The benefits of extending services to a greater number and range of people, of
reducing costs and relieving already overburdened services are worthwhile benefits
that may contribute to counter-balancing the current inequity of service availability
and access. At the same time there are also potential obstacles.
One issue regards the clinical assessment of individuals using technology-aided
treatments. Often therapists rely on self-reports which can be inaccurate. Therefore,
can accurate assessments be made and consequently correct treatment delivered?
Unless provided by a reputable source it is difficult to monitor the quality of
information or interventions being made available and also to guard against the
potential naivety and vulnerability of users; especially so in the case of younger
users.
Transferring psychological support services online is controversial and raises many
concerns; primary among these are questions about crisis management, anonymity,
ethical and clinical responsibility, user safety, technical security, and retention and
completion of treatments (Rochlen, 2004; Tate, 2004; Marks et al, 2007). Each of
these is a challenge that faces practitioners in this area.
Online counselling
Online counselling can be conducted asynchronously [e-mail], which is time-delayed
between users submission and a counsellors reply or synchronously [chat], which is
live and occurs in real-time. Since 2006 an online counselling (asynchronous) has
been available for student at Trinity College (Richards, 2008). In one year sixty-two
students have used the service. The following features of e-counselling were
positively evaluated:
- Reaching an audience that does not ordinarily use face-to-face services:
Statistical analysis of use of online counselling demonstrates its potential to reach
people who don’t ordinarily use traditional services. E.g.: Science student’s use of
online counselling is 31% whereas their use of face-to-face services is 10%
(Richards, 2008). The literature makes reference to this perceived benefit and
perhaps online counselling helps to lower the impact of stigma in help-seeking.
The analysis also shows how the majority of submissions, 73% [N=45], were outside
of 9-5 office hours and 11% were at weekends [N=7]. This highlights the need for
flexible service provision. It also demonstrates the value for users in accessing
services on time and on demand, which is often outside of traditional service hours.
- Acting as a gateway to other services:
The statistics highlight how 33 [F=23; M=10] students who used the online system
thereafter accessed face-to-face counselling. Given service demands, the lack of
therapists, often there are waiting lists (Marks, 2007), which delays early
intervention (Royal College of Psychiatrists, 2003). Online counselling has the
potential to act as a first step for users. Therefore, it is not seen as a replacement of
traditional services but rather an extension (Proudfoot, 2004).
At the same time, and as referenced earlier, some users may hold a preference for
working online. One user wrote: ‘I couldn't make a confidential appointment with a
counsellor’.
- Inherent effectiveness of online counselling:
Based on users comments one can speculate on the inherent effectiveness of the
intervention - “Counsellor gave me very helpful advice and recommendations”;
another return user wrote: ‘I wrote a message to a counsellor and I received some
great advice’. Such a comment is not extraneous to the bulk of comments received.
In addition, many students [46%] self-reported change as a result of the
intervention and self-selection for change is a good indicator for actual change
(Netemeyer, 1991).
- Presenting issues:
A content analysis of submissions [N=32] reveals how the range of presenting issues
to online counselling is no different to that of face-to-face counselling.
- Anonymity and disinhibition:
Both the self-reported questionnaire and the content analysis of submissions to
online counselling illustrate the characteristic of disinhibition being supported by
anonymity (Suler, 2004). The perceived privacy of the internet seems to help users
overcome stigma associated with service use. This is reflected in the depth and
detail of the submissions, and the apparent ease for users in reporting difficulties
such as suicidal ideation [N=5], loneliness [N=6], and depression [N=7].
- Therapeutic benefit of writing:
Users commented on the benefit of writing out their problems, irrespective of the
response they received. Pennebaker (1987) has long documented the therapeutic
benefits of writing.
- Satisfaction with counselling:
Client satisfaction was measured and Mean satisfaction established [M=57.94 out of
100]. The Mean shows no significant difference with a similar study in online
counselling [M=67.8 out of 100]. When benchmarked with face-to-face studies one
can deduce that clients are reporting satisfaction but less so than in face-to-face
counselling (Leibert et al, 2007).
No major difficulties emerged in the online work and the feedback from users has
been positive. The findings are preliminary and generalizability weakened by small
sample sizes [Self-reported questionnaire N=13; Content analysis N=32; Client
satisfaction N=7]. At the same time the data collected supports the literature in
respect of some of the perceived benefits of online counselling.
The therapeutic relationship online
A central question in online counselling and other technology-led interventions is the
nature of online therapeutic relationship. Psychotherapy research has continually
identified the positive correlation of therapeutic alliance and outcome.
Research has looked at the therapeutic relationship online. Cook and Doyle (2002)
researching a comparison of face-to-face and online counselling using both e-mail
and chat found that working alliance levels demonstrate that participants felt a
collaborative, bonding relationship with therapists. Participants overwhelmingly
indicated that online counselling was a positive experience with advantages over
face-to-face. In a recent and ongoing study of session impact and alliance in online
counselling compared to face-to-face counselling Reynolds (Reynolds et al, 2006)
suggests that session impact and alliance are similar between the two modes of
treatment. Peck’s (2000) meta-analysis found equivalence of outcome between
face-to-face and non-face-to-face counselling delivery methods.
However, the
nature and amount of therapist contact for success with counselling and therapy that
is technology-aided is still unanswered (Marks et al, 2007).
Conclusion
The future certainly will be different. In the context of what Yellowless (1999)
describes as a healthcare revolution and our understanding of the pervasiveness of
technology in peoples lives it’s not to difficult to prefigure a time when technologyled services will not only be appreciated but may in fact be demanded. The range of
applications is varied and will continue as current technology is developed and new
technology discovered. As professionals it’s important that we maintain an interest,
and rather than simply reject we can embrace innovation. In doing so we can
ensure that what is developed is done so within an ethic that is professional and
positive for mental health and well-being.
Biography:
Derek Richards is a psychotherapist and researcher at
Trinity College Dublin.
His research is focused on
the use of technology in mental health service
delivery. He is currently researching client-led and
therapist-led online psychological interventions for
depression. derek.richards@tcd.ie
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