Referring to online counselling + treatment services

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1 MODULE 4 Referring to online counselling + treatment services Online training package Support workers

2 Introduction Therapeutic intervention options have significantly increased with the development of digital technologies. Counselling and therapy, traditionally face-to-face interventions, have been successfully conducted through different practice methods such as the telephone, or videoconferencing. With a growing evidence base indicating that, for some people, these emerging practice methods offer similar positive outcomes to face-to-face interventions, it is important for us as practitioners to consider when online counselling could be an option for the young people we work with. 2

3 Introduction There are many different types of online services that offer support, information and treatment for issues that affect a young person s wellbeing. For some, online treatment services can offer all the support they require. However many young people we work with will still need face-to-face support as well, and in this context online treatment options can also be tailored to serve their individual support needs and preferences. This module is not intended to provide an extensive list of online counselling services; while a list of Referral Links has been gathered as a starting point, the focus of this module is to highlight the significance of counselling and therapeutic interventions delivered online and how we can identify when they may be helpful for the young people we work with. 3

4 MODULE 4: Referring to online counselling + treatment services Online services types and functions

5 Online counselling services As technologies have developed and continue to do so, the mechanisms or practice methodologies for the delivery of therapeutic interventions also grow. There are a multitude of online counselling services, some of which are free or fee for service, which offer various therapeutic models delivered through digital technologies, such as: synchronous or asynchronous chat cybertherapy video teleconferencing text Young people can access these services from a desktop, laptop or tablet, and many are also designed to be used through smartphones. While many services still predominantly rely on text-based communication, there are many online services that use graphics, audio, video recordings, animation and downloadable templates, in an effort to convey messages more effectively. applications. 5

6 Online treatment services There is also an increasing suite of online treatment programs developed and trialled by mental health research centres and service providers. These can include: self-help programs online self-assessments counselling and therapy case coordination and management group therapy. 6

7 Online treatment services Different therapeutic models and theories inform the design of these services or programs, such as cognitive behavioral therapy, dialectical behavior therapy, strengths based case management and acceptance commitment therapy, to name a few. Online treatment options can be self-managed by young people or can include support offered by one or more mental health professionals. There are mixed research findings in relation to attrition or completion rates for self-guided versus professionally assisted online treatment. 1 As practitioners, we can work with young people to identify if and when self-help or professionally assisted treatment options are appropriate and whether they would increase the likelihood of engagement for the young person. 7

8 Assess benefits + limitations Assessing the benefits and potential limitations of any online modality needs to be considered in relation to the needs, requirements, wants and capacities of the young people we work with. Consider the benefits of and restrictions to referring a young person to an online counselling service that uses each of the following practice methods. 8

9 Assess benefits + limitations It may provide the young person the ability to consider their thoughts and feelings as they are writing them down. It is text based and for some young people who prefer to be more reflective, can allow for their creativity and insights to be voiced. However for young people with literacy issues, may not be well suited. Being text based, it can be dense reading for a young person going back and forth with a counsellor, but as it is documented, a young person can go back and re-read important information, or bring the content to a face-to-face session for further clarification. It doesn t allow for full anonymity, as addresses are needed. As there can be time delays to , response times need to be clearly outlined to the young person. As non-verbal cues are not accounted for, young people will need guidance around how to convey some of their feelings in words and how to address any potential miscommunication. 9

10 Assess benefits + limitations Synchronous chat It can allow for optional anonymity (in some services). There is no time delay, as with , so responses can be timely and flow more conversationally. It can be far less confronting for a young person to access a counsellor who they don t have to sit across from and disclose to. As with , the non-verbal cues need to be communicated in other ways. 10

11 Assess benefits + limitations Videoconferencing It allows the young person and practitioner to see each other and take account of non-verbal cues. As with many face-to-face counselling sessions, videoconferencing can be confronting to the young person. It is not very common for many free services to provide this modality as an option. 11

12 Assess benefits + limitations As with the counselling modalities, different types of online treatment and assessment services offer many potential benefits as well. Consider some (there are many more) of the following benefits when referring a young person to these different kinds of online treatment services. 12

13 Assess benefits + limitations Online assessment Assessments can be self-administered and can produce the outcomes measurements without delay. Many can highlight how a young person is responding in comparison to others who have used the assessment. The assessment process can provide a young person with the mental health literacy needed to describe their current experiences. 13

14 Assess benefits + limitations Self-paced treatment program A young person can choose their own pace and revisit areas of the program that they may need further clarification with. While some young people may prefer to have a professional overseeing their progress online, others find that their responses are less filtered, as they are not as concerned about how their responses may be judged. 14

15 Assess benefits + limitations Clinician assisted treatment program (i.e. with regular phone or contact from a professional) Having a professional guide and support the young person s progress can increase engagement and provide tailored treatment options for the young person. A therapeutic relationship can develop, which can foster motivation, hope and clarity on the process of change. 15

16 Story from the field Even though many of the young people in my practice are referred to me for symptoms of depression or anxiety, I still like to ask if they have conducted any self-assessments for their symptoms. Many of my clients have been asked questionnaires that a GP has filled out for them and I feel that some may benefit from doing some of the assessments themselves, in order to feel more control over the situation they are finding themselves in. Sometimes it s a more efficient manner in which to use our face-to-face time together, to refer to online programs and then revisit their progress or otherwise in the following sessions. I also encourage young people to take screenshots, or print out copies of outcomes, to foster a growing sense of ownership of the therapeutic process. - Clinical psychologist in private practice 16

17 MODULE 4: Referring to online counselling + treatment services Referring to online counselling

18 Referring to online counselling As practitioners, we network with many other services in an effort to provide coordinated and relevant support options for the young people we are working with. Online counselling offers us more options to present alongside a suite of services available to young people. Online counselling can provide young people we support with: mental health guidance and advice support in-between sessions or an extension of the therapeutic relationship 2 crisis intervention tailored support for specific issues that they want to address access to services that otherwise would not be readily available geographically or within the timeframes needed support in a format that they may prefer an evidence based avenue for engagement with professionals the ability to revisit counselling communication, rather than relying solely on one off verbal exchanges. 3 18

19 Referring to online counselling When considering support options, the following points may assist in including online counselling services in our referral planning. Engagement As practitioners many of us operate with an awareness that counselling and therapy can be of greatest assistance if the young person is open and willing. Online counselling may be a soft entry for some young people engaging in therapeutic support. Needs With high demand on some free counselling services, delays from long waiting list may make timely access difficult. Many online services are available at times when face-to-face services are less convenient to reach. Online counselling can offer an alternative to 9-5 services, or more timely access to support for a young person who needs to wait weeks to get an appointment. 19

20 Referring to online counselling Crisis support Many online counselling service models are informed by crisis intervention principles, so they are often available for access when a young person s key workers are not. Often as practitioners, we list phone contact numbers for periods of crisis, however for some young people, talking on the phone during intense times of distress may be too challenging or they may be concerned that they can t have the conversation confidentially depending on their location. Including online crisis contacts in any information we present to young people can increase their options for support during crucial times. 20

21 Due diligence When referring to online counselling, it is important to: check who provides the support find out what help seeking it promotes create or revisit crisis / safety plans, and discuss other service options with the young people we work with, so there is clarity around which support to call upon and when it is appropriate. Some services make useful information available for professionals on their websites, or you can contact them via or phone to clarify the scope and practices of their service. 21

22 Referring to online counselling As with all the other online supports presented in the previous training modules, access to technology, with a broad concept of what that entails for the young person that we are working with, needs to also be considered. 4 The following quotes from young people highlight the role that online counselling services can play in supporting them to seek further assistance, or in providing the help they need at the time they need it. 22

23 Module 4: Referring to online counselling + treatment services Online counselling: Young person s perspective Crisis moments could occur anytime. For me it usually happens at home and is outside of business hours. So face-to-face services are not accessible at this time. It is important to have services that I could access when I needed it, wherever I needed it. Therefore online services play an important role in my journey of recovery. I still access my face-to-face services. However, there are some issues that could be quite confronting to be admitting to a counsellor who is sitting right across from you. Sometimes, it is easier to type it to someone online year old ReachOut.com user from NSW 23

24 Module 4: Referring to online counselling + treatment services Online counselling: Young person s perspective Before I had the courage to talk to my GP, I accessed Kids Helpline via their and web counselling services, and eventually by phone. The support I received from my counsellor there was vital in building my confidence enough to reach out to my GP year old ReachOut.com user from NSW 24

25 Module 4: Referring to online counselling + treatment services Practice activity Activity 1: Adjunct support for online services This activity will outline some ways in which you can tailor support to young people you work with in face-to-face services, as you provide a supported referral to an online counselling service. Download this activity PDF 25

26 Advice from young people Sometimes it s safer behind a computer screen. It can be a lot easier to talk to someone on the phone or in text chat, because you feel less pressured or exposed, and because it is available immediately when you need it. Being able to write something out also helps you think through what you re feeling. Explain the limits. Online counselling has its limits, and they need to be explained well. It can be very confusing and confronting if we don t understand when the service can help, how, or what to do if we re cut off from it. In extreme cases online counselling services do things like make a decision not to take contact from us any more, and we can t always ask for an explanation. Things like this can be very confronting and demoralising. Continues on next slide 26

27 Advice from young people Help us communicate clearly, and to be aware of a loss of subtlety in communication. There can often be miscommunication face-to-face, but it is even more likely when accessing online counselling. You can help us understand this and to think twice about how words that upset us might have been intended. It can be helpful to have contact with one or two people. Some services like Kids Helpline allow or encourage contact with the same one or two counsellors, to encourage continuity of care. If we re accessing online crisis support regularly this can help a lot, by reducing the burden of explaining ourselves. But sometimes they can be hard to get a hold of, and it s important we understand what to do in those situations. 27

28 MODULE 4: Referring to online counselling + treatment services Treatment programs

29 Treatment programs Whether accessing online or offline treatment options, a young person may need our assistance as a practitioner to fully and meaningfully engage with interventions. Some programs are self-guided (such as learning about symptom management), while others form a therapeutic relationship with a professional or trained peer. Either way, for a young person to experience some or all of the desired positive outcomes, we can play a clear role as youth workers, social workers and other supporting professionals, in encouraging engagement and supporting young people to practice newly acquired skills and knowledge. As with other online services, self-managed treatment programs can present some limitations. One limitation can be that the online program may not have professionals or peers overseeing responses, which can make it difficult to ascertain when more immediate mental health support is needed. 5 29

30 Online treatment: Guidelines for referral The following guidelines can be used to support a young person who is accessing an online treatment, or self-guided support program. Encourage access We can use face-to-face times with young people to discuss when and how they are accessing online treatment and to identify any potential barriers that they have, so we may address these together. Encourage participation We can utilise face-to-face times or other digital practice methodologies such as or text, to follow up on plans made by the young person to access or to continue with online treatment. 30

31 Online treatment: Guidelines for referral Help interpret information Some programs require a young person to read and interpret information that may not be fully tailored to the young person s specific capacities. We can help a young person to interpret information and to digest the parts that are of relevance to them. We can do this by modeling our engagement with their process of online treatment; asking questions about where they have progressed to, what is helpful to them, what they don t find relevant etc. These strategies all help a young person to utilise online treatment more effectively. 31

32 Online treatment: Guidelines for referral Be part of the support network, rather than the sole support Often as practitioners, we can be frustrated by the lack of service options in our geographical area that fit into the financial, social, emotional and cognitive requirements of the young people we work with. Whilst not without its limitations, online treatment can offer a young person increased choice and increased support. We can highlight the choice of support options, whether they are face-to-face or online, and discuss the implications for their use with the young people we are working with. We can help young people get started, reflect together on progress, learnings and skills, and set up follow up timeframes to do so. We can help young people establish support networks that foster their inter- and independence and hope. 32

33 Practice activity Activity 2: Referral to an online self-managed program In this activity, you are guided in referring a young person to MoodGym, one of the recommended online service options developed and delivered by the Australian National University. It takes a positive, non judgemental approach. It supports you to work through things in your own time, but doesn t give an answer. It allows you to help yourself, but also makes sure you have the tools to seek help by referring to other services such as GP s and mental health professionals year old ReachOut.com user from NSW Download this activity PDF 33

34 Module 4: Referring to online counselling + treatment services Practice activity Activity 3: Drawing up a support chart In this activity, you will be guided in working with a young person to create a support chart and are given some conversation starters for coordinating online support services. Download this activity PDF 34

35 Story from the field With some young people, referring to online counselling is quite straightforward, but with others I work with, it can cause issues around shared information and consent and the problem of overservicing. More services don t always mean better outcomes, but I find that some of the young people (and workers) I work with really believe this and use many online and offline services without any real coordination. This is where I feel I can have a real practical role as a youth worker and help the young person list out the services they use, ones they like, what they use them for and when and then we work together on assessing their impact, if we can do some shared support meetings and then we can get shared consent from them. That way if a young person tells me that they are getting confused, by what their online counselor said because it contradicts what their health worker said, we can sort it out without any negative consequences or labels. It also just helps a young person know who and what to call on and when. Just because the service is offered online, doesn t mean we can t coordinate support! - Youth worker in a case management setting 35

36 Advice from young people Talk to us about what to expect. We ll want to know things like how much work it will take, and when we can reasonably expect to start seeing results. We re skeptical of poorly designed programs. While the content might be very informative and helpful, some programs are designed with little consultation from young people and can feel like they are dumbed down, condescending, or alternatively very dense and hard to understand. Again, help set our expectations so we can get the most out of it. Continues on next slide 36

37 Advice from young people They can take a lot of motivation. Unsupported online treatment programs can feel a lot like homework, and they vary in ease of use. While some include regular support from a clinician, others don t, so we ll need you to help us put in place strategies for staying motivated. They work better with your support. Sometimes it can be easier to work through parts of online programs with you, to understand concepts better or to talk about our results or feelings with you. A mental health assessment in particular might be quite confronting. Continues on next slide 37

38 Concluding notes Online treatment programs provide young people and practitioners more options to engage therapeutically. They are often free, accessible, and offer evidence based outcomes. Both online counselling and online treatment programs can be tailored to the specific needs and requirements of the young people we work with. As practitioners, we can play a significant role in helping young people decipher which programs can be of benefit, and in encouraging them to continue engaging in online services and programs that provide potential for positive change. 38

39 Next steps Supporting resources Activity 1 Adjunct support for online services. Guidelines for practice Download PDF Activity 3 Drawing up a support chart. Guidelines for practice Activity 2 Referring to an online self-managed program. MoodGym online CBT Download PDF Referral list A list of recommended online counselling and treatment programs. Reflection Answer the discussion question on the Module 4 webpage. Return to the webpage Download PDF View online Learning assessment After completing Module 4, you should now be equipped to complete the learning assessment for this online training. Start the assessment now 39

40 References 1. Abbott, J. M., Klein, B. & Ciechomski, L. (2008). Best practices in online therapy. Journal Of Technology In Human Services, 26 (2-4), pp (p. 370) 2. Mattison, M. (2012) Social Work practice in the digital age: therapeutic as a direct practice methodology. Social Work. 57(3), p ibid, p Steyaert, J. & Gould, N. (2009). Social work and the changing face of the digital divide. British Journal Of Social Work, 39 (4), pp Barak, A. & Grohol, J. M. (2011). Current and future trends in internet-supported mental health interventions. Journal Of Technology In Human Services, 29 (3), pp (p. 166) 40

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