1. An overview of KHL email counselling

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The Process of Counselling via Email:
Ongoing Email Counselling with a Client
Disclosing Sexual Abuse
Author and presenter: Jean
Topic: Kids Help Line counselling process and
procedures for Email: Ongoing email counselling
with a client disclosing sexual abuse.
This discussion will be in three parts
1. An overview of KHL email counselling
2. Strengths and limitations of e-mail counselling
including the use of literary techniques to increase
clarity of communication
3. A Case Study of ongoing e-mail counselling including
the application of Duty of Care principles
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1. An overview of KHL email counselling
Kids Helpline is the only free, confidential and anonymous national
telephone and email and web counselling service for young people
aged 5 to 25 years. It is free, anonymous and confidential.
Kids Helpline began e-mail counselling in 1999 and web counselling in
2000.The move towards providing on-line counselling services was
driven by:
•Responding to the young people who requested online options
for seeking help
•Our BoysTown values of being innovate and resourceful and
using the latest technology to meet the urgent needs of young
people.
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2. Strengths and limitations of e-mail counselling
includes the use of literary techniques to increase
clarity of communication
Advantages of on-line counselling includes reaching a wide
audience, integration of delivery with existing services and
improved access – particularly for certain disadvantaged
groups including those who are socially isolated.
The Kids Helpline website provides young people with access
to counsellors via web-counselling and e-mail. It also has
information on a variety of subjects relevant to young people
(e.g. mental health, homelessness, bullying) and has a data
base of other helping services around Australia.
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Overview of KHL Online Counselling 2007
During 2007 Kids Helpline counsellors engaged in 53,168
counselling session: 40,890 telephone and 12,278 web
and e-mail sessions.
While less contacts are made on-line than by telephone,
the issues discussed online are more complex and severe
than those dealt with on the telephone.
General feedback from young people indicates that online counselling enables them to feel safer, more
anonymous and more in control of their emotions and
find sensitive, difficult and deeply personal issues easier
to write about than talk about. (Kids Help Line Case
Study: Delivering services and support)
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Increase in ongoing counselling and intensive
support
Ongoing counselling was provided at almost double the rate though
our online services (21%) compared with telephone counselling (11%
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Age, gender and background of clients
Online clients tend to be older, with 15-25 yr-olds involved in threequarters of online counselling sessions (compared with two-thirds of
telephone sessions).
Boys and young men continue to prefer contacting by telephone
(compared with one in ten via the on-line service).
Kids Helpline provides strong support to children and young people
living in regional and remote areas. These young people tend to have
less access and choice in support services. E-mail contacts increased
by 71% in 2007 with the service receiving 941 e-mail contacts from
rural and remote area compared with 550 in 2006.
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Concerns of Australian children and young people
Main concerns – highlights and trends: Online vs.
telephone counselling
During 2007, online counselling continued to be accessed for different
concerns to telephone counselling.
In the eight years KHL has offered web and e-mail counselling, greater
proportions of young people have consistently sought help online for some of
the more severe concerns.
Deliberate self injury, emotional and/or behavioural management, mental
health issues, self-image, and eating and weight issues were presented online
at almost double the rate of telephone counselling during 2007.
Conversely, more children and young people were likely to engage in
telephone counselling rather than ongoing services when needing to discuss
concerns surrounding drugs and alcohol, bullying, pregnancy and
homelessness.
The top 15 concerns about which young people contacted KHL online are
shown in here (*INSERT FIGURE 3: MAIN ONLINE PROBLEM TYPES 2007
FROM 2007 REPORT) Telephone counselling figures are also given in order to
provide a comparison.
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Emotional/behavioural management
This was the top concern for online counselling, frequently with an
ongoing client and the young person was also often engaging in selfinjury. The proportion of contacts about emotional and/or behavioural
management concerns via online (18%) was substantially higher
than via the telephone (10%)
Mental
Health
issues
Mental
Health
issues
Mental health concerns were the second most common online
counselling concern.
Mental health concerns were presented in proportionally higher
rates online (15%) compared with telephone (8%).
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Suicidality
A higher proportion of suicide concerns were presented via online
counselling (4.1%) than on the phone (2.8% of calls). The proportion
of young people with current thoughts of suicide presenting for online
counselling (8% of sessions) was more than the rate of the telephone
service (6% of calls)
(* above information cited from Kids Helpline 2007 report)
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Procedures for KHL e-mail
KHL Shift Supervisors read all e-mails to the service and allocate a
priority to them according to urgency i.e., whether they need to be
replied to immediately or within 24 hrs, within 3 day, within 5-7
days.
In cases of Duty of Care callers are asked to telephone Kids Helpline
if they need immediate help and are sometimes given a time frame
by which they need to contact us by to ensure their safety.
When clients have not replied and there is concern for their safety or
it is assessed therapeutically useful, counsellor can send an ‘outreach’
email to client to check on their safety and/or encourage them to
reengage with the service.
Clients are able to request to speak to a male or female counsellor
and to speak to the same counsellor on an ongoing basis.
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Issues in delivering online counselling: strengths
and limitations
Issues of privacy and confidentiality
KHL provides information on the KHL web site which users need to
read before reaching the e-mail address. Issues of confidentiality,
information keeping and security are outlined.
Client’s then read the following information to allow them to decide
which mode of counselling e-mail, web or phone best meets their
needs at the present moment:“Some times an email response can take up to 2 weeks. How long
depends on how many young people have written to us all at the
same time.
If you need to talk to someone straight away it is quicker to ring us
on 1800 55 1800.”
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Increased flexibility and accessibility for many
clients
Strength
Clients can send an e-mail to KHL at anytime so they can write about their
feelings as they feel them (for instance in the middle of night when in crisis).
When the counsellor replies s/he can invite the caller to reflect upon what was
happening for them at the time. This has an advantage over face to face
counselling where, by the time the client comes to their next face to face
session, they may have forgotten or may downplay the intensity of feeling
they felt when in crisis.
Accessible to clients with speech or hearing difficulties. Clients with literacy
difficulties can look up the meaning of any words of which they are unsure
Limitation
Clients could abuse the client/counsellor relationship by sending numerous
and constant e-mails.
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Clients generally feel a greater sense of anonymity
and privacy in e-mail counselling.
Strength
The absence of visual and auditory cues can facilitate a rapid rapport
as people often feel less inhibited in e-mail communications due to a
sense of anonymity and invisibility.
Limitation
In reality e-mail counselling is no more ‘confidential than telephone
counselling and the limits of confidentiality need to be carefully
explained to clients. Also, the greater sense of anonymity can mean
that some clients are slower in taking responsibly for their actions.
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On-line counselling can be attractive to clients
who feel too stigmatised to reach out for face to
face counselling
Strengths
Clients with issues that are Shame based e.g., Child Abuse Issues,
Eating Disorders, Domestic Violence, Low Self-esteem, Addictions,
often feel more comfortable to begin counselling Online before
moving to face to face. On-line counselling may also be attractive to
client who find it difficult to leave the home e.g., new parents,
anxiety and social phobias, agoraphobia. The lack of nonverbal cues
allows a greater focus on emotional issues rather than appearance.
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Text based counselling could result in
miscommunication due to loss of non-verbal cues.
Strengths
Counsellors can flag with clients that misunderstandings can easily
arise through text and model strategies for facilitating clear
communication (I will outline these strategies further below)
Clients have time to think about their reply before responding.
As the client is less likely to be distracted by the counsellors reactions
Online, they are more likely to put issues ‘on the table’ more quickly
than they would in face to face work where they rationalise or ‘sugar
coat’ issues for longer.
Both the client and counsellor can point to actual words the other has
used to seek clarification of their meaning.
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Counsellors can take client’s e-mails and their
replies to supervision as a learning tool
Usually in supervision the supervisor is hearing only the counsellors’
perception of the clients concerns whereas with e-mail the client is
actually ‘present’.
Turn around time for messages for e-mail counselling can lead
to anxiety as responses are awaited
- Can allow clients time to reflect on and manage anxiety
generated between the e-mail Counselling sessions.
Can result in more thoughtful and reflective replies and clients can
refer back to earlier sessions and notice positive changes for
themselves.
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Maintaining contact with a client can be difficult
with email communications.
How are lack or e-mail replies to be interpreted? Clients can easily
not respond to an e-mail. It is harder for them to leave a face to face
session or hang up during a telephone session.
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Writing techniques for conveying warmth and
caring through text:
Emotional Bracketing and Descriptive Immediacy
Emotional Bracketing: “One technique that helps to overcome the
lack of non-verbal information is to include relevant emotional
material in brackets”
E.g. “it has been a few weeks since your last e-mail Rebecca
(concern, worry) and we would really appreciate it if you could write
back as soon as possible (feeling pushy, demanding)
Descriptive Immediacy: “Another technique involves providing the
client with images that give them a context for understanding our
words”.
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“If you were standing beside me as I write this Tanya, you would
notice me stopping often, falling back against the back of my chair
saying “that’s incredible” to myself. Your recent successes against
guilt are so wonderful that even now I find myself (right now!)
stopping in the middle of my sentence, my hands towards the
computer screen, my mouth wide open as if to say” this is amazing.
How did she defeat guilty?”
*above quotes in section on writing techniques cited from
‘When writing helps to heal e-mail as therapy’ by Lawrence J Murphy & Dan L
Mithcell
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Other writing styles to consider:
Use of text e.g. using lower case ‘i’ to refer to themselves (does this
indicate shyness?). Words written entirely in capitals (does this
indicate shouting, emphasising a point?)
When the client writes in one long sentence (e.g., does this indicate the
pressure of thought the client is feeling?)
Misspelt words (is this an indication of the client being in too distressed
or in too much of a hurry to check their spelling or is this an
indication of their literacy level)
Using a series of dots…. (denotes emphasising an important point)
Stretching the length of words (e.g. I was soooo angry)
(cited from ‘E-mailing counselling: skills for maximum impact’)
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Ongoing E-Mail Case Study
How the counsellor attempted to challenge the callers
dominate story: A journey from feelings of Shame to
Empowerment.
A 17 yr old girl contacted KHL by e-mail disclosing that she had been
sexually abused when age 12 and the abuse was still happening. She
described feeling of intense fear and asked for a female counsellor.
In this first e-mail the client disclosed the ‘secret’ that she has been
abused. It seemed that the sense of anonymity (‘telling someone
without actually telling anyone’) feel safe enough to start to talk
about her experience.
In the counsellors first reply she acknowledged the callers feeling of
self blame and normalised these feelings as being a typical response
to the trauma of sexual abuse.
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The use of Narrative therapy (rewriting dominate story) and Solution
Focused Therapy (find exceptions) have been found to be very useful
in e-mail counselling. The Counsellor introduced the idea of the
abuser being a ‘robber’ in her life story of her safety as a child and
that in talking about the abuse she was starting to reclaim her voice.
To deepen the connection between the counsellor and client the
counsellor used the clients own words. E.g.. I notice that you say that
you are angry with yourself for “letting him” do this to you. You also
say that “you felt like you had no choice”
The counsellor acknowledged the callers feeling by saying “I can
hear….how painful this is for you”.
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2. GUILT
The client expressed feelings that it is “her fault” that she is being
abused and had an expectation of herself that she ‘should’ be able to
do something to stop it.
The counsellor encouraged the caller to write back as if she was
‘journaling’ her feeling towards the abuser (to start externalising the
anger). She was also asked to think about exception times to when
she is frozen with fear (if you were able to relax around him enough
to speak…what would you like to say to him?)
The counsellor invited the client to describe more about herself and
her life in general To give the message that she is a human being of
value and ‘the problem is the problem’ not the client..
The client was asked if she would consider calling (letting her know
that counselling by e-mail can be slow and we could cover a lot more
on the phone)
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3. DESPERATION
Client described how she had been in tears in writing e-mails and
could not imagine calling because she thought she would be too
angry and upset to speak.
She said she wanted him to know that the abuse makes her feel
worthless and she wants him to stop but blames herself for not being
able to make him. She said she “hates him but hates herself more”
(clients underlying belief about herself that she is to blame and is
worthless)
She said she could not tell her parents and she is worried that her
parents would not believe her.
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The Counsellor:-
was aware that as anger is a secondary emotion and the primary
feeling would be one of loss and hurt, that it was a healthy sign that
the caller said she was able to cry when writing the e-mail to KHL.
-
acknowledged feelings of it being so difficult to talk on the pone
(being choked up with anger). Asked her what she thought it would
feel like if she was able to let all those feelings out?
The E-mails and replies to date were analysed in Supervision and as
a result the counsellor was then able to reflect back the issues to the
client with a clearer perspective.
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The Counsellor wrote:“I have been thinking about our counselling so far…. And wanted to
share some of my reflections with you and see what you think…”
Information was shared with the client that her ‘freeze response’ is a
sign that her Uncle is a threat to her and gave the message that it is
not HER job to stop him. The clients belief that ‘if she told him how
she felt’ that the abuse would magically stop was challenged and
instead the focus was put on ‘what realistically needs to happen for
the abuse to stop?’.
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5. ACTION
It had already been flagged with the client that the abuse could not be
allowed to go on and that it was not realistic to expect her to do this all by
herself.
The counsellor then acknowledged the callers strength, courage and coping
skills (self harming, avoidance) but then let the caller know that it was time to
take action for the abuse to stop.
The counsellor wrote:“I am glad that you have found ways to help you feel a little better…BUT…I
also think it is only a temporary solution to an ongoing situation that needs to
be stopped (otherwise, it is a bit like placing a band-aid over a wound which is
infected. It is not going to heal without being cleaned out first)”.
The use of metaphorical language is very useful in e-mail counselling to create
vivid images to compensate for lack of voice tone.
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The counsellor explained that she had talked to her Supervisor about
the e-mails and the central dilemma posed in helping her
I.e. “how do I help (…..) to stop the abuse and be safe when she is
not in a position to stop the abuse and be safe?” (Modelling to the
client that it is OK to take ‘her problems’ to a higher authority outside
of the dilemma as a means of change).
KHL gave the caller three choices to report the abuse. To emphasise
the seriousness of this matter the choices were written on three
distinct lines with double space in between..
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We could go with your first thought of contacting the police
We could do a three-way (you and I contacting the Police or a
child protection service together)
Kids Helpline pass on information to the Police ourselves.
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The counsellor acknowledged that the caller may be upset and feel
like “I am taking your power away” but that her intention was to help
the caller to get her power back. That it may not feel like this now
but may down the track. (picking up again on the theme of a story
and that we can jump ahead and anticipate what the next chapters
may contain)
To further the narrative theme of ‘rewriting her story and reclaiming
her life” the counsellor asked the client to think about the relief she
will feel when she can talk about the abuse in the past tense.
The client wrote back in a very different ‘tone of voice’ and said that
she had been to the police and was advised of her options. One
option, now that she had turned 18, was to take out an AVO on her
Uncle. She had relayed this to her Uncle and felt very empowered by
the experience.
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Conclusion
Most research indicates that the techniques used in therapy are not
as important as the therapeutic alliance between the counsellor and
the client. Online counselling is about clear communication through
text. It terms of therapeutic alliance it does not seem to matter much
whether these words are communicated verbally or through text as
much as whether they are used with skill which convey warmth,
understanding and presence to the client.
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