Internet supported psychological interventions

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1 Internet supported psychological interventions A guide to navigating the online world of psychological programs APS Professional Practice October 2012

2 Acknowledgements This guide was developed by Dr Thomas Fuller, Mr David Stokes and Dr Rebecca Mathews. We are grateful to the following people who reviewed a draft version of this document: Associate Professor Britt Klein Professor David Kavanagh Ms Julia Reynolds Dr Sally Rooke Professor Robert King Dr Jan Copeland All information and materials produced by the APS are protected by copyright. Any reproduction permitted by the APS must acknowledge the APS as the source of any selected passage, extract, diagram or other information or material reproduced and must include a copy of the original copyright and disclaimer notices as set out here. Copyright 2012 The Australian Psychological Society Limited. This work is copyrighted. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced without prior permission from the Australian Psychological Society.

3 Internet supported psychological interventions Guide to navigating online psychological programs Table of Contents Introduction... 4 Scope of the review Web-based interventions... 6 Efficacy of web-based interventions Web-based Education Interventions Self-guided web-based therapeutic interventions Human supported web-based therapeutic interventions Online Counselling and Therapy...13 Online and computer assisted diagnostic tools Providing online psychological therapy Internet-Operated Therapeutic Software (robotic simulation, rule-based expert systems, therapeutic games)...16 A comment about Brain training games Other Online Activities (blogs, chat rooms, social networking)...19 Blogs Chat rooms Social network sites References...21 Appendix Meta-analyses and systematic reviews of web-based therapeutic interventions Appendix Selected Links and Resources Suggested further reading

4 Introduction To write that the reach of new and emerging digital communication technologies such as the internet and smart phones are developing and expanding at a rapid rate is an understatement. As the technologies are introduced and become more reliable and accessible, psychologists are developing new and innovative applications and methods through which to provide services. There exists enormous potential for increasing the publics access to evidence based health and wellbeing services, as well as offering psychologists increased choice and flexibility for delivering services to populations whom they might not have previously been able to reach. New modes and mediums of communication and service delivery offer the chance for consumers to access cost-effective treatments when, from where, and how they want. Similarly, psychologists working online can choose when, from where, and how they want to provide a service to a client. The abundance of choice promises much, and can be overwhelming when not familiar with the language and terminology being used. This guide has been developed to assist psychologists to navigate the world of internet-supported psychological interventions, by providing an understanding of the types of programs that are available online and how they can be used to enhance client treatment. Scope of the review This resource aims to give the reader an idea of the types of internet-supported interventions that are available and some of their strengths, issues and limitations. It provides descriptions and commentary on four types of internet supported interventions as defined by Barak, Klein and Proudfoot (2009). It covers: 1. Web-based interventions, including: a) Web-based education interventions b) Self-guided web-based therapeutic interventions c) Human-supported web-based therapeutic interventions 2. Online counselling (e.g. via or secure video-based chat) 3. Internet operated therapeutic software, including: robotic simulation, games and virtual environments; and, 4. Other online activities including blogs, podcasts, support groups, assessments. In many instances, websites providing internet-supported interventions incorporate multiple modes or types of service delivery, for example, a website might predominantly provide web-based educational materials, but might also have a blog, and offer online counselling. This guide includes in the appendices a list of systematic reviews of web-based therapeutic interventions across a selection of psychological disorders, as well as a selected compendium of guidelines, training and other resources that are available in this area. 4 Internet supported psychological interventions: Guide to navigating online psychological programs

5 Background to the resource This is a revised resource for psychologists (originally Internet based psychological products and services and made available online in 2010) and describes and reviews a range of psychological products and services supported by the internet. Whereas the original version described internet supported interventions by mode and type of technology used, this revised version has been restructured based on the terminology proposed and defined in the article by Barak, Klein, and Proudfoot (2009), Defining Internet Supported Interventions. These definitions of internet supported interventions focus more on the purpose of the intervention rather than the specific modes of use or components incorporated by an intervention. In adopting this terminology, the resource implicitly aims to encourage clinicians and researchers to also utilise this terminology in order to help establish a common language for describing and reporting internet supported psychological interventions in publications, guidelines and practice. After citing the definition of each mode of internet-supported intervention, examples and a brief summary of each are provided. The websites and programs included in this review have been selected by virtue of the fact that they are evidence based (wherever possible), and an example of a particular type of internet supported intervention. Where possible, the examples provided have been developed by Australian researchers and practitioners and are easily located using a keyword search in online search engines. Disclaimer The information in this review includes links to websites operated by third parties. These web sites are not controlled by the APS and the APS is not responsible for the contents of any of these sites. Furthermore, the inclusion of their web site in this review does not imply any endorsement by the APS and you visit any sub website at your own risk. In addition, this review contains references to information materials developed by third parties. These materials were not developed by the APS and the APS is not responsible for the contents of the materials. The information provided throughout the review is intended for information purposes only. This review is not designed to be used as a resource to treat mental disorders. The diagnosis and treatment of mental disorders requires an appropriately qualified mental health professional. 5

6 1. Web-based interventions Barak, Klein, and Proudfoot (2009) define a web-based intervention as: a primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental-health related assistance. The intervention program itself attempts to create positive change and or improve/enhance knowledge, awareness, and understanding via the provision of sound health-related material and use of interactive web-based components. On the basis of this broad and inclusive description of web-based interventions, three additional subcategories have been delineated. These are: web-based education interventions; self-guided web-based therapeutic interventions; and human-supported web-based therapeutic interventions. Although each of these categories aims to support or direct cognitive, emotional or behavioural change, they primarily differ with regards to their level of interactivity, support, structure and directiveness. Efficacy of web-based interventions It is beyond the scope of this review to examine the efficacy of all the web-based therapeutic interventions currently available. However, it is clear the interest in and evidence-base of internet supported interventions is growing rapidly. The broadest and most comprehensive meta-analytic study of the efficacy of internet supported therapeutic interventions has revealed moderate to large effect sizes in targeted cognitions, emotions and/or behaviours (Barak, Hen, Boniel-Nissim, & Shapira, 2008). Importantly, evidence exists for the efficacy of each mode/type of web-based intervention (Barak et al., 2008) though the effect sizes vary. Importantly, there is also evidence indicating that treatment effects are generally maintained at follow-up (Andersson, Carlbring, Berger, Almlov, & Cuijpers, 2009). While there is variability in the quality of studies examining the efficacy of internet supported interventions, and large amounts of variation between the respective therapeutic interventions, these overall findings are very encouraging for the support of on-going development and proliferation of web-based therapeutic interventions. It is hoped that web-based therapeutic interventions are capable and will go some way toward meeting the demands for cost-effective, evidence-based treatment for a broad range of physical and mental health concerns for large numbers of consumers who might not otherwise have had access to services. While the quality of web-based interventions is improving there are, as with all forms of service delivery, limitations. Some of the limitations of web-based interventions include, risks associated with self-diagnosis, difficulties verifying identity, and the fact that most web-based programs as many state are not suitable for people with severe or multiple disorders. (Note: While many web-based interventions are disorder specific and target mild to moderate symptomatology, work is underway or being planned, within Australia to develop programs for symptoms of psychosis and programs capable of addressing a range of problems.) There is also the potential for these web-based interventions to be susceptible to risks or problems associated with confidentiality of data access and storage. If considering providing services via the web, ensure that any service provider you employ can provide secure, stable and reliable modes of communication and data storage to protect confidentiality. (See also Software for Psychologists in Private Practice for additional information, available from A list of meta-analyses and systematic reviews of web-base therapeutic interventions published prior to January 2012 is provided in Appendix 1. The meta-analyses and systematic reviews include webbased therapeutic interventions for: anxiety disorders; depression; anxiety and depression combined; physical health conditions and behaviour change; somatoform disorders; substance use disorders; and weight management. 6 Internet supported psychological interventions: Guide to navigating online psychological programs

7 1.1 Web-based Education Interventions Web-based education interventions aim to provide information about a range of, or, specific mental or physical health conditions. The content might be available or presented in a range of modes (e.g. video, audio or text), but is not a prescriptive, structured intervention that directs a person how to make cognitive, emotional or behavioural changes (Barak, Klein, & Proudfoot, 2009). Given concerns about the accuracy and reliability of web-based education interventions, several organisations have developed an accreditation service. These accreditation services verify the information presented on the respective websites in order to help consumers have confidence in and access quality health related information on the internet. Some also act as portals to websites that have been independently assessed (e.g., Beacon; and verified as providing accurate and reliable information (e.g. Health Insite; while others [e.g. Health on the Net Foundation(HON); also offer guidance to internet users on how to assess the quality of information they locate. It is also important to note that in some instances this verification is against generic criteria for information quality and may not actually assess whether the specific content is consistent with current best practice or clinical guidelines for particular client groups. Psychologists may therefore need to take responsibility for judging the adequacy or appropriateness of information on, for example, mental health related sites for a particular client. It is also highly recommended that psychologists review and become familiar with any site before referring a client to them Web-based education interventions focussing on a single condition are typically developed by national foundations (e.g. Heart Foundation, Alzheimer s Australia). Others that are broader in the scope of health-related information they provide (e.g. Better Health Channel) and are often developed by a State or the Federal Government. The content on web-based educational interventions is usually free to access, but in some instances requires membership of the particular organisation to access the complete content and services provided. Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Beacon Information and evidence based educational portal that facilitates access to internet supported interventions. Centre for Mental Health Research, The Australian National University A web portal for accessing physical and mental health related interventions. Beacon has independent reviewers evaluate and rate online interventions for mental and physical health conditions. Information is collected on how registered users seek and access webbased interventions. To gain full access to the site, Beacon requires users register. Beacon utilises images and text to convey information about how the site works, has an application for mobile phone use, contact information, a FAQ section, privacy policy and information for contacting emergency services. Beacon provides access to an extensive range of mental and physical health related, web-based interventions and is transparent with regard to how the site works, and what information is collected for research purposes. 7

8 Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Better Health Channel Information provision related to mental and physical health All material is approved by the Victorian Department of Human Services, but might be developed by organisations with specialist knowledge. Provides over 1,770 facts sheets (most also available in audio), hundreds of healthy recipes, interactive features and calculators, directories and links to relevant, external websites. (Note: the Better Health Channel will be adding a binge drinking program for young people April 2012 to its resources, indicating that it is beginning to move beyond information provision.) Content is approved by HON Code and Health Insite. Better Health Channel provides multiple modes of searching for health related information, has a navigation bar, links to social media sites to follow for updated information, multiple modes of presenting information, and enables feedback to be given to the site through an online form. Extensive range of quality assured information on mental and physical health conditions. Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Health on The Net Foundation (HON) HON is a portal site that provides access to information and services tailored to the public, health professionals and website publishers respectively. HON is a non-profit, non-governmental organisation accredited by the Economic and Social Council of the United Nations and was created in HON aims to help consumers and health professionals by providing access to reliable sites, and help web publishers by independently verifying their content. A text-based site with information tailored for health professionals, patients and web publishers respectively. HON provides links to their Twitter and Facebook pages, and online forms to provide feedback. HON provides a range of resources, services and guidelines designed to help consumers and professionals access and provide respectively, high quality health related information. Similar sites include but are not limited to: 1. Health Talk Online (http://www.healthtalkonline.org) A multimedia site that provides access to qualitative data (collected by researchers at Oxford University) from people about their experiences of living with mental and or physical health conditions. There are additional, linked, sites tailored for young people (www.youthhealthtalkonline.org) and health professionals in teaching or educational roles (http://www.healthtalkonline.org/teachingandlearning). Psychologists in academic or teaching positions can access and or request qualitative data to be included in lectures or training activities. 8 Internet supported psychological interventions: Guide to navigating online psychological programs

9 1.2 Self-guided web-based therapeutic interventions Another type of online service that is growing steadily is evidence-based, self-guided online therapy sites for mental health conditions. The main purpose of/for self-guided web-based therapeutic interventions is to support consumers to make cognitive, behavioural and emotional change to address particular problems they experience. Self-guided web-based interventions have, to name a few, been developed for problems with: mood disorders and anxiety (e.g. e-couch, MoodGym, Mood Swings) insomnia (e.g. Shut-i). Self-guided web-based therapeutic interventions have typically been developed by a team of staff (including for example, web-designers and consumer representatives) and led by psychologists within a university setting. In addition, commercial groups are beginning to provide these services and include the amalgamation of multiple partners from all sectors of the industry. In contrast to web-based educational interventions, self-guided web-based therapeutic interventions are highly structured, derived from theory (e.g., CBT, interpersonal therapy), and modelled on standardised or manualised face-to-face psychological therapy (Barak, Klein, & Proudfoot, 2009). The interventions also typically provide automatically generated feedback or a means by which people can monitor their progress as they complete stages of a program. Self-guided web-based therapeutic interventions typically require people to register and consent to data being collected and stored for evaluation and research purposes. This process has enabled the evidence base for the efficacy of self-guided web-based interventions to be assessed and continues to grow at a rapid pace. Findings frequently demonstrate moderate to large effect sizes for people who complete self-guided web-based interventions (Barak, Hen, Boniel-Nissim, & Shapira, 2008). Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: e-couch Self-guided web-based therapeutic intervention The content of the website was developed by Prof. Helen Christensen, and Prof. Kathy Griffiths at the Centre of Mental Health Research at Australian National University, with funding and support from Beyond Blue. e-couch provides evidence-based information and counselling for emotional problems focusing on depression and anxiety disorders respectively. e-couch is not a crisis support service but provides directions to appropriate services. The information and nature of the service is designed for the general public. Although the website is free of commercial interests, information is collected for research purposes, and users are required to register before gaining access to the content. It is not indicated when the website was last updated, but the content is written in plain language and the website uses text and images to explain information. A high quality, evidence-based, free to use, self-guided web-based therapeutic intervention. 9

10 Name: URL: Purpose: Authority: Knowledge/content: Usability: Overall: Mood Gym Self-guided, web-based therapeutic intervention The content of the website was developed by Prof. Helen Christensen, and Assoc. Prof. Kathy Griffiths at the Centre of Mental Health Research at Australian National University. Mood Gym provides evidence-based information, strategies and activities designed to help people identify and prevent symptoms of depression. The content of the website is based on cognitive behavioural and interpersonal therapy respectively. Mood Gym is not a crisis service but provides directions to appropriate services. The site requires users to register before gaining full access to the site. MoodGym s information and service is designed for the general public, written in plain language, has links to a MoodGym Facebook page, and an FAQ section. It is also now possible for clinicians to purchase a manual that helps them incorporate/use Mood Gym with their practice. A high quality, evidence-based, free to use, self-guided web-based therapeutic intervention focussing on emotional wellbeing. Name: URL: Purpose: Authority: Knowledge/content: Usability: Overall: On Track https://www.ontrack.org.au/web/ontrack/home Self-guided web-based therapeutic and educational intervention. A team of psychologists, led by Prof. David Kavanagh from Queensland University of Technology developed the programs. A web-based therapeutic intervention with a suite of programs for depression, diabetes, alcohol use, psychotic symptoms, and a program for families and friends of people with a mental illness. On Track also provides factsheets, quizzes related to alcohol use, mood and psychosis, and referral information to emergency services. Psychologists are also able to access the programs material after approval from the providers. Information is provided for the public and health professionals respectively. People can access information and quizzes (results are presented in relation to Australian population norms) without registering, but to complete programs need to register. Information is collected for research and evaluation purposes, an online feedback form is provided. A high quality, evidence-based, free to use, self-guided web-based therapeutic intervention addressing some high and low prevalence mental and physical health conditions. 10 Internet supported psychological interventions: Guide to navigating online psychological programs

11 Similar sites include, but are not limited to: 1. Mood Swings (http://www.moodswings.net.au/) a self-guided web-based therapeutic intervention for people with Bipolar disorder. The website and content was developed by a consortium of psychologists and psychiatrists from Melbourne based universities that include: University of Melbourne, Royal Melbourne Institute of Technology, Monash University, Swinburne University and the Mental Health Research Institute. 2. Internet Beating the Blues (http://www.beatingtheblues.co.uk/) - A UK based site providing evidence based, CBT treatment for people with symptoms of depression and anxiety. The program was written for the UK, National Health Service (NHS) by National Institute of Health and Clinical Excellence (NICE) and can be accessed (for a fee) for non-residents of the UK. 3. The Desk (http://www.thedesk.org.au) - A self-guided service developed by the University of Queensland for tertiary students. Users are required to register to access the services, which includes educational material, quizzes and a forum to interact with other users to discuss way of maintaining wellbeing. 1.3 Human supported web-based therapeutic interventions Human-supported web-based therapeutic interventions incorporate a human (usually a health/ mental health professional or, in some cases, peer supporters) to provide support, guidance, and feedback (Barak, Klein, & Proudfoot, 2009, p. 8). The human support complementing the web-based material can vary by mode (i.e. video, , chat), frequency and whether or not it is synchronous or asynchronous. For example, Anxiety Online provides a human-supported web-based therapeutic intervention where provisionally or fully registered psychologists provide feedback and guidance via once a week in addition to the self-help, CBT, web-based material. Human-supported web-based therapeutic interventions differ from self-help web-based interventions and online counselling interventions by specifically combining the human support/feedback with the self-help material. The feedback and guidance provided by the mental health professional is seen as an additional, active and critical component of the program (Barak, Klein, & Proudfoot, 2009). Additionally, and as is the case with the human-supported interventions provided by Anxiety Online, the programs are tailored for people with moderate to severe levels of distress compared with self-help web-based interventions which support people with mild to moderate levels of distress. Online counselling, as with face-to-face psychological support provides services to people across the whole spectrum of levels of distress. 11

12 Name: URL: Purpose: Authority: Knowledge/content: Usability: Overall: Anxiety online Anxiety Online delivers a stepped-care approach to web-based interventions for anxiety disorders it provides both therapist assisted and self-guided programs. Anxiety Online was conceptualised and developed by Prof. Britt Klein and Assoc. Prof. David Austin from the National e-therapy Centre (NeTC) at Swinburne University of Technology funded by the Federal Department of Health and Ageing. Anxiety online provides an evidence-based, virtual treatment clinic with a focus on treating anxiety disorders (i.e. Generalised Anxiety Disorder, Social Phobia, Posttraumatic Stress Disorder, and Panic Disorder with or without Agoraphobia). Anxiety Online provides web-based education, self-guided and therapist supported interventions respectively. Information on the causation, diagnosis and treatment of anxiety disorders as well as providing extensive references and resources for consumers (including those in crisis) is available. An online psychological assessment ( e-pass ) addresses anxiety, mood, eating, somatoform, sleep, substance use and psychotic disorders. A disclaimer notes that the assessment is not intended to replace face-toface psychological assessment. Clear and easy to use with a variety of levels of engagement. Psychologists are also able to register with Anxiety Online and are encouraged to use the resources within their practice. Registered users of the site complete e-pass assessment and receive information about likely diagnoses and suggestions for appropriate treatments depending on reported levels of distress. Therapist-assisted programs are recommended for individuals who report a disorder at a clinical level and are provided at low cost, although a person can opt for the free, self-help program if they prefer. The free, self-help web-based therapeutic interventions are recommended for individuals with subclinical anxiety levels. When people meet criteria for disorders that Anxiety Online does not provide treatment for, they are advised to seek help from a psychologist or an appropriate medical professional, or use Anxiety Online in conjunction with a mental health professional. Data is collected for research and evaluation purposes. People who complete an assessment and treatment program will be contacted on an annual basis for 5 years for a follow-up assessment. A high quality, evidence-based service and website focusing on the needs of people with anxiety disorders. Anxiety Online differentiates the type of services it provides depending on a consumer's assessed level of anxiety symptomatology. 12 Internet supported psychological interventions: Guide to navigating online psychological programs

13 Name: URL: Purpose: Authority: Knowledge/content: Usability: Overall: ecentreclinic An online clinic that provides both human supported and self-guided web-based interventions for people with mood, anxiety, and chronic pain. ecentreclinic is led by Assoc. Prof. Nikolai Titov and Dr. Blake Dear, from the Centre for Emotional Health, Macquarie University. The team involved is made up of psychologists, psychiatrists and researchers. ecentreclinic provides treatment and education programs for people with anxiety, mood and chronic pain. People utilising the treatment service also participate in trial of the programs Resources and information including research results are available for both the public and health professionals. Research results and outcomes are published on the site. Treatment programs and information are available for free for the public, as well as being tailored for Macquairie University students (also includes a course for Chinese speaking overseas students), and people over 65. Links to the ecentreclinic Facebook page, feedback forms, and a virtual tour of the service are also available. A high quality, evidence based human supported and self-guided treatment service with a focus on research. 2. Online Counselling and Therapy Online counselling and therapy refers to the provision of a psychological service directly between a psychologist and client via the Internet. The communication between psychologist and client can be through a variety of modes including , synchronous (that is, real-time) chat, video and/or phone services such as those mediated by a secure online video chat/conference service, and might be between individuals or shared within a group. Online therapy, can, but does not necessarily, include the administration of assessments, questionnaires, provision of information, collection of demographic or personal information and realtime or delayed therapeutic interventions. As with face-to-face therapeutic services, there is a large variety in the content, presentation of, and costs associated with using an online counselling or therapeutic site. Some, for example, provide 24 hour per day, synchronous, free and anonymous online counselling (e.g., Counselling online, Gambling help online, while others might, for example, charge per sent. 13

14 Online and computer assisted diagnostic tools Online psychological assessment and diagnostic tools are available for both psychologists and the public. Some of those tools directed at the public can be accessed after registering with a site (e.g. e-pass assessment via Anxiety Online), while others such as the Mood Assessment Program (MAP; are only available to people who have been given an access code by a mental health professional who is registered as a MAP referrer. Additionally, health professionals and researchers can download, for a fee, validated, diagnostic programs (e.g., the Mini International Neuropsychiatric Interview; https://www.medical-outcomes.com) to aid psychological assessment. Anecdotal reports suggest that it is becoming more common for clients to present with printouts of results and reports from psychological assessments and quizzes completed online. Psychologists should thus be aware of this possibility and engage with clients on the nature, validity and results of any report presented during a session. Providing online psychological therapy Psychologists considering or providing psychological services via the internet are advised to read the APS Guidelines for providing psychological services and products using the internet and telecommunications technologies. This resource provides specific information and guidance relating to issues such as informed consent, confidentiality, disclosure of information, high-risk situations, client suitability for online counselling, psychologist competence and limits of online psychological counselling, record keeping and many other important issues that should be considered. Compared with the amount of research conducted on the efficacy of web-based therapeutic interventions, there is relatively little on the practice of online counselling. The limited amount of research conducted on the issue of psychologists and counsellors adhering to ethical standards of practice, has consistently concluded that there needs to be greater adherence to ethical practices. For example, the findings of two American studies (Heinlen et al., 2003a, 2003b) examined how well websites offering e-therapy complied with the American Psychological Association (APA) and National Board of Certified Counselors (NBCC) codes of ethics respectively. (Note: no equivalent study exists regarding how online therapy providers comply with APS ethical guidelines.) Both studies concluded that there was, overall, poor or at best, variable compliance with ethical guidelines and that many of the websites/services were no longer available when re-visited only 8 13 months later. In relation to privacy issues, Heinlen et al. (2003a) commented: The absence of these [privacy] protections suggests that e-therapists may be less concerned about clients need for privacy of psychological information, or may be more interested in their own needs than in client welfare. (p. 122) Despite many developments and the expansion of services provided in the area, the concerns for practitioners uncertainty and disregard for online privacy and confidentiality still exists (Finn & Barak, 2010). (Note: the concerns raised in these findings do not specifically refer to the examples below. Service users should contact the service provider to find out what measures are taken to ensure data protection and confidentiality.) The issue of registration and jurisdiction 14 Internet supported psychological interventions: Guide to navigating online psychological programs

15 One of the many significant, practical and ethical issues facing psychologists providing online therapy regards the question of their registration and where it extends. That is, is it necessary for the psychologist providing online therapy to be registered in the state, territory or country where the client accesses the service from (i.e. akin to a home visit ) or only the country in which the service is provided from (i.e. akin to a client visiting the psychologist s office). Within Australia, to our knowledge, this question has not been legally tested. However this scenario has been tested in court in America. Some states require psychologists to be registered in the state the client lives in. That is, a therapist is viewed as virtually travelling to the state of the consumer rather than the consumer virtually travelling to the therapist s state (Zack, 2008). Additionally, some states if they do not actually require the psychologist to be registered in the state, have the scope to prosecute the psychologist under the state s laws if a suit is filed against the psychologist (Zack, 2008). Psychologists are thus strongly advised to consider the issue of registration requirements, and seek legal advice before providing therapy to clients living outside of Australia. For more information about the ethical and legal issues related to providing online therapy refer to the articles cited in the Resources Section. Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Lifeline Online crisis chat Synchronous chat service for people in crisis. Lifeline Online Chat service is provided by trained counsellors within Lifeline. In addition to synchronous chat, educational and self-help material on mental health and wellbeing, and information on accessing crisis services is provided. Online chat is available between 7:30 10:30pm Monday Thursday. Outside these times, users are advised to call the telephone helpline, emergency services if necessary, or refer to the educational material. Lifeline online chat provides an important web-based counselling for people in crisis, although at limited times. Name: URL: Kids Helpline Purpose/type: Online counselling, and educational interventions for people aged Authority: Kids Helpline is a service provided by Boys Town (http://www.boystown.com.au/) Knowledge/content: A large amount of age appropriate information presented for kids and teens respectively, regarding social, emotional and development issues. Information about the service and to support help-seeking is provided as well as games, downloads, feedback forms and competitions. Usability: Kids Helpline provides 24 hour per day, web-based synchronous and asynchronous counseling, and telephone counselling. The service is free to access, and users can re-contact a counsellor they have communicated with previously. Information is tailored to kids and teens. Overall: A well established (KidsHelpline have provided online counselling for over 10 years), young person orientated service available for free, 24 hours per day. 15

16 Similar sites include, but are not limited to: 1. eheadspace (https://eheadspace.org.au/) - provides free, secure, , online chat and telephone counselling for people aged who have registered with the service. 2. Counselling online (http://www.counsellingonline.org.au/en/) - a free, online counselling service available 24 hours per day supporting people with alcohol and other drug related problems. The service is run by Turning Point, Alcohol and Drug Centre and the website also provides a large amount of educational material. 3. Gambling help online (http://www.gamblinghelponline.org.au/) - a free online counselling service run by Turning Point. The website also provides information, referrals, advice for people concerned about someone who might have a gambling problem, and self-help information. 3. Internet-Operated Therapeutic Software (robotic simulation, rule-based expert systems, therapeutic games) 3. Internet-Operated Therapeutic Software (robotic simulation, rule-based expert systems, therapeutic games) Internet-operated therapeutic software refers to therapeutic software that uses advanced computer capabilities such as artificial intelligence principles for (a) robotic simulation of therapists providing dialog-based therapy with patients, (b) rule-based expert systems, and (c) gaming and three-dimensional (3D) virtual environments (Barak, Klein, & Proudfoot, 2009, p.11). Simulation of therapists, through programs such as Eliza (http://www.manifestation.com/neurotoys/eliza.php3) were developed originally as a test of the development and ability of artificial intelligence to mimic human interaction rather than to necessarily represent a genuine therapeutic interaction between a client and therapist. Presently, for example, while Eliza is designed to mimic a Rogerian therapist, the interface through which one communicates with Eliza, leaves no potential for a user to think they are actually interacting with a human. Rule based expert systems on the other hand, while not designed to engage in dialogue, are designed to provide expert /evidence-based/clinical guideline based advice and feedback to users based on the responses they provide to questionnaires for a specific problem or concern they have. Of the three, however, therapeutic games and the application of 3D or virtual reality environments are the most prominent and commonly used in research and bought by consumers respectively. Virtual reality programs/environments have been successfully developed and applied to treat, for example, specific phobias and other anxiety disorders. Therapeutic games while they are primarily designed to have health, cognitive, behavioural, or educational benefits they are also intended to be entertaining for the user. The games are often based on research findings and are generally designed for a specific target group (e.g., children with moderate to severe autism) or a broad (commercial) market. Access to and cost of the games varies. 16 Internet supported psychological interventions: Guide to navigating online psychological programs

17 Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Autism Games and Therapeutic game Autism Games is a collaboration between Swinburne University s Multimedia Design Program, Bulleen Heights Specialist School, Swinburne Autism Bio-Research Initiative (SABRI) and the National etherapy Centre (NeTC). Autism Games provides the background information to Whiz Kid Games a portal to specialised games for children with moderate to severe autism. The games are free to access and use and aim to help autistic children develop independent living skills. Autism Games also has forums to facilitate discussions about the games and make suggestions for new games. Clear easy to use site that does not require registration. A specialised, evidence-based site to assist children with moderate to severe autism. Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Reach Out Central An online game designed for young people. Reach Out Central was created by Reach Out (www.reachout.com) which in turn is an initiative of the Inspire Foundation (http://www.inspire.org.au/) An online game designed to help young people improve communication, social and problem solving skills. The game also aims to develop skills to self-manage mood. The game is based on real life scenarios, and players are enabled to make decisions about their course of action in particular situations and manage the consequences of their decisions. Players of Reach Out Central are required to register with the (free) service before commencing the game. They can opt in/out of completing a mood diary each time they login to play the game. A free, online game for young people designed to improve social and emotional functioning. 17

18 A comment about Brain training games Due to the proliferation and scale of the brain training game industry a comment about this sub genre is warranted. Brain training refers to a range of specific tasks that people undertake/practice to reportedly develop, improve and retain specific cognitive functions (e.g., memory and information processing speed). There are now many commercial websites established to market and sell their respective computer programs that have been designed to improve or maintain aspects of cognitive function. The products are usually developed by neuroscientists in conjunction with software designers and programmers and are intended to be both challenging and entertaining. The websites typically emphasise the credibility of the developers, favourable empirical data and the benefits of using their products. Conversely, little, if anything, is stated about any adverse findings. A recent, large-scale study by Owen et al. (2010), however, concluded that the benefits of brain training games might not be as large or generalisable as the producers claim. Specifically, Owen et al. state: Although improvements were observed in every one of the cognitive tasks that were trained, no evidence was found for transfer effects to untrained tasks, even when those tasks were cognitively closely related. Buyer beware! Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: CogMed Brain training CogMed is a privately held company founded in Stockholm, Sweden in The founders are two neuroscientists (one of whom is Torkel Klingberg, Senior Scientific Advisor, and Professor of cognitive neuroscience at the Stockholm Brain Institute, Karolinska Institute in Stockholm) and two computer game developers. The content of the website is designed to promote sales in products claimed to improve cognitive functioning (especially working memory) and thereby delay some of the effects of ageing. CogMed website refers to publications in reputable journals and makes efforts to establish scientific credibility. The working memory guide however includes Indicators that a working memory needs exercise that are not specifically associated with ageing or cognitive decline e.g., falls asleep or zones out during lectures. The website contains a lot of information and promotional material about the products and is easy to navigate. Additionally, it provides video based presentations/demonstrations on the how the training works. A commercial site promoting the purported benefits of the CogMed training programme. The site is easy to navigate through, and provides access to post purchase services. 18 Internet supported psychological interventions: Guide to navigating online psychological programs

19 Name: URL: Purpose/type: Authority: Knowledge/content: Usability: Overall: Posit Science Brain training Posit Science co-founder and Chief Scientific Officer Michael Merzenich, (working at University of California, San Francisco) is responsible for the development of content and products in conjunction with a scientific advisory board (details - science_team/). * Content of website provides information regarding the effects of ageing and cognitive decline, and aims to promote products and establish their credibility and validity. A summary of the published and unpublished literature that tests Posit Science products is provided and includes links to abstracts on PubMed where relevant it can be accessed via - positscience.com/science/studies_results/all_studies.php A clear easy to navigate website. It is not clear how frequently, nor when the website was last updated. It is possible to access and use demonstration versions of the products. Technical and practical support is available after purchase, and there is also access to consumer forums through Posit. A commercial site promoting the purported benefits of the Posit Science products, which were developed by neuroscientists. The site is easy to navigate through, and provides access to post purchase service. *NB: The Alzheimer s Association, Western Australia branch, has endorsed Posit Science products and has information and links regarding the products. 4. Other Online Activities (blogs, chat rooms, social networking) The fourth category of online services - Other online activities - incorporates a range of media that facilitate varying modes of communication and levels of interaction. Other online activities include, blogs, chat rooms or forums, Twitter and social networking sites. Blogs Blogs or weblogs are shared online websites written in the form of journals by individuals, groups or corporations about any topic. Blogs are usually free to set-up and maintain and the content can include multi-media, and be updated as frequently as the blogger (i.e. the person or group writing the blog) wants. Blogs usually have the facility for readers to leave comments that might or might not lead to discussions or threads being generated between readers and the author(s) of the blog. (For more information on blogs see the Weblog matrix website (http://www.weblogmatrix.org/) which provides information and facilities that compare the features of a wide range of weblog software.) Twitter acts as micro-blogging provider allowing users to post tweets of up to 140 characters in length. Examples of blogs focusing on psychology British Psychological Society Research Digest (http://bps-research-digest.blogspot.com/) Mind Hacks (http://mindhacks.com/) PsyBlog (http://www.spring.org.uk/) 19

20 Chat rooms Chat rooms and Internet forums on the other hand are purposefully designed to facilitate discussions. They are websites that provide facilities where users can communicate in real (synchronised) or asynchronised time on a particular topic. Chat rooms may or may not be moderated depending on the website and who is running it. (It is usually the moderator s role to check, censor or edit messages from registered users to ensure accuracy of information and advice, and prevent or remove inappropriate material, and that other user s rights are not infringed.) Chat rooms that operate under the auspices of an organisation, community service, or government are more likely to be moderated than those set up by individuals or on a more informal basis. Examples of chat rooms and forums 1. Blue Board (http://blueboard.anu.edu.au/) is a moderated online forum/bulletin board for people experiencing depression or anxiety disorders, their friends and carers. Blue Board was established by the Centre for Mental Health Research at Australian National University, and is also used for research purposes. 2. Brain Talk Communities (http://brain.hastypastry.net/forums/) a portal site to forums for neurology patients and their carers. 3. Cure Together Open Source Research (http://www.curetogether.com/) - Cure Together helps people anonymously track and compare health data, to better understand their bodies, make more informed treatment decisions and contribute data to research. 4. Suicide Callback Service (http://forum.suicidecallbackservice.org.au/) an online forum for carers or people affected by suicide. A 24-hour call back service is available for people feeling suicidal. Social network sites A social network service focuses on building online communities of people who share interests and/ or activities, or who are interested in exploring the interests and activities of others. Most, but not all, social network services provide a variety of ways for users to interact, such as , instant messaging services, the sharing of photos, music, sound and/or video recordings. Examples of social networking sites 1. Care2 (http://www.care2.com/) a social networking website designed to help people with interests in social and environmental issues connect with other individuals, organisations and responsible businesses. Care2 aims to help people make a better world Daily Strength (http://dailystrength.org) a social networking website designed to help people connect and provide one another with informal practical and emotional support. Medical professionals are also available to contact and treatments for a variety of illnesses and problems are also listed on the site. 3. Facebook (www.facebook.com) - a social networking site that also hosts pages of organisations that provide psychological services and products (e.g., https://www.facebook.com/reachoutpro). 20 Internet supported psychological interventions: Guide to navigating online psychological programs

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