Counselling Psychology Review

Transcription

1 Counselling Psychology Review Volume 24 Number 2 June 2009 Special Edition: Technology and Counselling Psychology: Theory, Research and Practice ISSN:

2 Counselling Psychology Review Editor: Heather Sequeira City University London Reference Library Editor Waseem Alladin Hull University, Centre for Couple, Marital & Sex Therapy and and Consulting Editor: Hull & East Riding Health NHS Trust Book Reviews Editor: Kasia Szymanska Centre for Stress Management Consulting Editors: Malcolm C. Cross City University Nicky Hart Wolverhampton University Stephen Palmer Centre for Stress Management and City University Linda Papadopoulos London Metropolitan University John Rowan The Minster Centre Mary Watts City University Editorial Antony Daly Regents College Advisory Board: Barbara Douglas The University of the West of England Jacqui Farrants City University London Alan Frankland APSI Nottingham and North East London Mental Health Trust Ruth Jordan Roehampton University Yvette Lewis University of Wolverhampton Del Lowenthal Roehampton University Peter Martin Private Practice Martin Milton Surrey University Naomi Moller The University of the West of England Vanja Orlans Metanoia Institute, London Fenella Quinn University of East London Sheelagh Strawbridge Áine Thompson Southern Health and Social Care Trust, Northern Ireland International Greg Harris University of Calgary, Canada Advisory Board Annie Maillard Independent Advisor to ACC (Accident Compensation Corporation), New Zealand Michael Duffy Counseling Psychology Program Texas A&M University Tim Carey University of Canberra, Australia Subscriptions Counselling Psychology Review is published quarterly by the Division of Counselling Psychology, and is distributed free of charge to members. It is available to non members (Individuals 12 per volume; Institutions 20 per volume) from: Division of Counselling Psychology, The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR. Tel: Advertising Advertising space is subject to availability, and is accepted at the discretion of the Editor. The cost is: Division Members Others Full Page Half Page High-quality camera-ready artwork should be sent by with the remittance to the Editor, Heather Sequeira. Cheques should be made payable to: Division of Counselling Psychology. Disclaimer Views expressed in Counselling Psychology Review are those of individual contributors and not necessarily of the Division of Counselling Psychology or the British Psychological Society. Publication of conferences, events, courses, organisations and advertisements does not necessarily imply approval or endorsement by the Division of Counselling Psychology. Any subsequent promotional piece or advertisement must not indicate that an advertisement has previously appeared in Counselling Psychology Review. Situations vacant cannot be accepted. It is the Society s policy that job vacancies are published in the Psychologist Appointments. For details, contact the Society s Leicester office. Copyright Copyright for published material rests with the Division of Counselling Psychology and the British Psychological Society unless otherwise stated. With agreement, an author will be allowed to republish an article elsewhere as long as a note is included stating: First published in Counselling Psychology Review, volume no. and date. Counselling psychologists and teachers of psychology may use material contained in this publication in any way that may help their teaching of counselling psychology. Permission should be obtained from the Society for any other use. Abstracting and Indexing Coverage PsycINFO

3 Guest Editorial Terry Hanley & Derek Richards IN MAY 2007, the European Science Foundation (ESF: funded the first ever exploratory workshop examining the use of technology in counselling and psychotherapy. It was convened at Trinity College Dublin by Derek Richards (one of the Guest Editors) and involved researchers, clinicians and academics from across Europe. This event gave the group the opportunity to meet together and share experiences of their work in the area of technology in psychological therapies. Topics included online counselling, computerised programmes for treatments of different psychological disorders, virtual reality, gaming, mobile telephones and more. Relationships from among the stakeholders were forged and from these several collaborations have emerged, one of which is this special edition of Counselling Psychology Review. Demands for mental health services is high, resources often stretched, yet there is some evidence of poorly targeted, population inappropriate interventions that are consequently ineffective and wasteful of resources (King et al., 2000). Technologically-mediated delivery of psychological therapy has the potential to target appropriate populations, for instance, underrepresented service users of traditional therapy and younger users, while at the same time potentially decrease the burden on resources. However, the expansion of technologically-mediated psychological therapies (e.g. those delivered using the telephone or the internet) needs to be based on evidence concerning effectiveness, an understanding of the nature, type and frequency of therapist contact required for success, and whether a given intervention is population appropriate. The scientist-practitioner model, an approach advocated by many counselling psychologists (e.g. Lane & Corrie, 2006), proves well suited to the examination of a dynamic practice which is constantly evolving due to technological advances. Counselling psychologists can, therefore, play centre stage in the development of this burgeoning field and contributions such as those included in this special edition greatly extend our understanding of online therapeutic practice. In relation to the papers gathered together here, it is evident that the contributions reflect work with differing age groups, practice settings, mode of communication and therapeutic paradigm. Such breadth, in such a small sample, provides an indication of the wide ranging ways that technology is impacting upon our work. One issue of concern for counselling psychologists is the potential for creating mediated relationships of a sufficient quality to promote therapeutic change. As Guest Editors we feel that it is a feature of this special edition that the papers presented provide insight into the quality of the relationship and communication that can occur in technologically-mediated environments. However, having said this, each reader is encouraged to read with an open mind. As with the breadth of approaches, work here includes research from quantitative, qualitative and mixed methods perspectives and, therefore, have appeal to a wide variety of readers. We would advocate viewing the whole edition as more important than the sum of its parts with each paper complementing one another and together narrating a fertile tale about the impact that technology is having upon counselling psychologists. The first paper in this series presents a review of the quantitative and qualitative research in the area of computer-mediated text-based counselling. The authors draw Counselling Psychology Review, Vol. 24, No. 2, June The British Psychological Society ISSN

4 Terry Hanley & Derek Richards together the research that is now available in this area and aim to help counter the common criticism regarding the validity of working therapeutically online. To aid this work they draw on a recent and comprehensive meta-review of online interventions and their effectiveness (see Barak et al., 2008). Hanley and Reynolds highlight that working online demonstrates promise and has to date demonstrated successful outcomes on par with face-to-face equivalents. Secondly, the authors go on to present a qualitative review of the online therapeutic alliance in online counselling. Although the review is small in the numbers of studies included/available, it does nonetheless begin to challenge a misconception that has existed in respect of how well a relationship can be established online. The paper is a positive milestone and a springboard for counselling psychologists to consider the potential of online text-based therapy. Continuing to a paper presented by Stummer, which again focuses upon work conducted using online text-based communication. Stummer presents a piece of work that is one aspect of a large action research project into developing and running an online sexual health and relationship skills website. In this paper Stummer considers contact styles used to engage with an online advice service. Alongside a general discussion and presentation of usage statistics for the project, the author identifies two distinct contact styles of users of the initiative. These are short question-response pairs and in-depth therapeutic dialogues. The author goes on to discuss the importance of these contact styles and their significance for working online in text-based communication. Fletcher and Vossler present work on trust in online therapeutic relationships. Unlike many papers in this area, their starting point does not question that a relationship online can exist, rather the work attempts to examine a key component of a healthy and working relationship, namely the establishment and maintenance of trust. Trust is a key construct in both interpersonal functioning and outcomes of any interactions. Their study is qualitative in nature and focuses on how therapists experience trust in online relationships and what factors can help or hinder its establishment and maintenance. They elicit some interesting themes that they explore further for the reader. Some key differences in trust online are noted and will be of interest to practitioners and researchers alike. The next paper investigates the use of client centred telephone counselling with individuals with Myalgic Encephalopathy (ME). This paper, alongside Stummer s work described above, automatically highlight the potential for supporting individuals who may not ordinarily access face-to-face services. The study utilises a mixed methods research strategy to explore the clients perspectives of person centred counselling. Scores on the CORE-OM showed significant improvement for the group who undertook the intervention when compared to a baseline gathered during a waiting period. This data was supported further by users qualitative comments and for the most part users rated highly the service. The authors demonstrate the usefulness of delivering counselling over the telephone for this unique population. Glasheen and Campbell reflect upon the development of school-based online counselling services in Australia. They provide a practitioner viewpoint based upon their own experiences and thoughts of setting up such a service. There is a strong rationale for the use of technology with younger people and the potential benefits that its use can bring within the area of mental health service delivery. Glasheen and Campbell elucidate these benefits for the reader and discuss potential challenges that may be encountered for practitioners and service developers entering into similar territory. The final paper in this special edition takes a more methodological turn. The work of Richards and Timulak reflects upon the setting up and evaluation of two online interventions for depression in a Higher Education setting notably a computerised 2 Counselling Psychology Review, Vol. 24, No. 2, June 2009

5 Guest Editorial intervention and a human intervention based upon the same cognitive behavioural principles. In the paper the authors describe and discuss the challenge of conducting a randomised controlled trial in this setting. They provide a unique insight into the methodological decisions and ethical challenges encountered when conducting such a project. Specifically the paper will provide those interested in developing and evaluating online services with much food for thought. Finally, in keeping with the subject matter of this special edition, we present two reviews of recent text books that have been published in this area. The works, Online Counselling and Guidance Skills by Jane Evans and Online Counselling: A handbook for practitioners by Gill Jones and Anne Stokes, cover similar territory and are reviewed by practitioners experienced in working online. Such commentaries may provide those interested in continuing their reading around mediated therapy with potential future directions. Thanks to both Gareth Williams and Lindsay Dobson for conducting the reviews and adding another dimension to this special edition. We hope that you find the content of this special edition thought-provoking, interesting and useful. Acknowledgments We would briefly like to thank all of those individuals who have supported the creation of this special edition. These include Liz Ballinger, Clare Lennie, John Morris, Heather Sequeira, and William West. Correspondence Terry Hanley Lecturer in Counselling, Educational Support & Inclusion, Ellen Wilkinson Building, The University of Manchester, Oxford Road, Manchester M13 9PL. Tel +44(0) [email protected] Derek Richards, Student Counselling, Pearse Street, Trinity College Dublin, College Green, Dublin 2, Ireland. Tel: +353 (0) [email protected] References Barak, A., Hen, L. Boniel-Nissim, M. & Shapira, N. (2008). A comprehensive review and a metaanalysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/3/4), King, M., Sibbald, B., Ward, E., Bower, P., Lloyd, M., Gabbay, M. & Byford, S. (2000). Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment, 4(19). Lane, D. & Corrie, S. (2006). Counselling Psychology: Its influences and future, Counselling Psychology Review, 21(1), Counselling Psychology Review, Vol. 24, No. 2, June

6 Counselling Psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy Terry Hanley & D Arcy J. Reynolds, Jr. Purpose: This paper examines the empirical research concerning counselling psychologists who utilise the internet in their practice. More specifically, we summarise the quantitative research of online therapeutic outcomes and alliances reported in text-based therapeutic encounters. Background: Online therapy creates much debate within the therapeutic world. Many question the validity of entering into these relatively uncharted waters, while others have begun working productively in this territory. To date, a small pool of research examining the efficacy of such work has emerged and provides the focus for this paper. Method: A review of the literature has been conducted with a two-fold strategy. Initially a review of 16 quantitative outcome studies investigating this area are presented and discussed these have been selected from Barak, Hen, Boniel-Nissim and Shapira s (2008) comprehensive review of the effectiveness of internetbased psychotherapeutic interventions. Following this, the focus is moved to the concept of the online therapeutic alliance. A systematic review of the existing literature outlines five pertinent quantitative studies and these are discussed in relation to key qualitative work in this area. Conclusions: Conclusions are drawn highlighting that work in this medium shows great promise, with both successful outcomes and strong alliances being reported online. Such findings, although limited due to the dearth of the research available, challenge the views of those sceptical of counselling psychologists entering into virtual arenas. Keywords: online therapy, counselling psychology, outcomes, therapeutic alliance. Technology and Therapy: A brief history ALTHOUGH online therapy is a relative newcomer to the therapeutic world, using technology is not. Taperecorded self-help approaches and computer programs which mimic personcentred therapists were experimented with during the 1970s (Lang, Melamed & Hart, 1970; Weizenbaum, 1976). More recently, computerised cognitive behavioural therapy (CCBT) has received considerable attention from researchers (Kaltenthaler, Parry & Beverley, 2004; Marks, Cavanagh & Gega, 2007) and has been included within the National Institute for Clinical Excellence (NICE) guidelines for good practice for both mild to moderate depression and the treatment of phobias (NICE, 2006). In contrast, less systematic research has focused upon the influence of human-to-human therapeutic interventions mediated through technology. This is the focus of our paper. Prior to discussing mediated therapy directly, we provide some statistics to contextualise changing health seeking behaviours within industrialised societies such as the UK. First, in 2007, 61 per cent of households within the UK had access to the internet from home (National Statistics, 2007). This is a dramatic increase from previous decades and has an inevitable impact upon online mental health services. Probably the most relevant and striking statistics available are those collected by the Samaritans 4 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

7 The quantitative research into online outcomes and alliances support service. It received and responded to 36,500 s in the year 2000, this increased to 72,000 during 2002, and more recently in 2006 they received 184,000 (Samaritans, 2004, 2007). This phenomenal increase reflects changing attitudes to the internet as a resource, a concept that is also supported by a recent MORI poll finding (2001) that 60 per cent of internet users would seek help for mental health problems online. However, many individuals still remain wary and appropriately question how prepared the mental health profession is for such developments (e.g. Alleman, 2002). Counselling Psychology and the internet Despite concerns regarding the development of online mental health care, therapeutic provision in this medium has become a burgeoning profession. The first recorded individual to pay for online therapy occurred in 1995 (Anthony, 2003). Presently there is no record of the number of online counselling sessions being offered. However, the increase in therapeutic services offered in this medium suggests a public demand for online access to therapists (Grover et al., 2002). This demand is also reflected in the increasing number of text books that include substantial reference to online practices (Fink, 1999; Goss & Anthony, 2003; Riva & Galimberti, 2001; Sanders, 2007; Wootton, Yellowlees & McLaren, 2003) or that have been solely written for counselling practitioners who wish to offer their services over the internet (Bloom & Walz, 2000; Bloom & Walz, 2004; Derrig-Palumbo & Zeine, 2005; Evans, 2009; Hsiung, 2002; Jones & Stokes, 2009; Kraus, Zack & Stricker, 2004). There are numerous ways of offering online therapy (e.g. , chat rooms, and videoconferencing) with the most prevalent (Chester & Glass, 2006; Heinlen, Welfel, Richmond, & Rak, 2003; Stofle, 2001). Such findings are not surprising given the ease of access and the perceived privacy of online services not typically available faceto-face (e.g. Rochlen, Zack & Speyer, 2004). Provision of online therapeutic services is, therefore, developing at a reasonable pace and individuals seeking support are not pushing for more sophisticated modes of computer-mediated communication. Online therapy appears to violate many of the fundamental principles of the therapeutic relationship. In particular, the physical distance between the counsellor and client is a point of great contention. Lago (1996) expresses this contention in the form of the following paradox: I have connected deeply with you psychologically and emotionally on my computer, yet still remain isolated from you in every physical sense (no vision, no sound, no touch). It is very personal and not personal at all (p.288). Critics challenge online practice because they believe relationships cannot reach sufficient levels of intimacy. For instance, Robson and Robson (1998) state that [u]sing computer communication runs the risk that the space between the two parties becomes filled with hardware (p.40) and Pelling and Renard (2000) note that without a high level of skill therapeutic interactions may be reduced to mere advice giving when face-toface interactions are translated to the electronic medium (p.68). Although these critical voices have subsided slightly in recent years, online therapy is still in its infancy and there has been little systematic focus upon the quality of the online therapeutic alliance. In applying therapeutic skills online, counsellors need to be mindful of the technical challenges that they can expect to encounter. Briefly summarised from the work of Rochlen, Zack and Speyer (2004) these include the missing non-verbal communication, the increased opportunity for miscommunication, the time delay present when using , the computer skill deficiency of either the counsellor or client, the inability to intervene when there is a crisis, the cultural clashes that may occur, the question of identity ( Is this really who they say they are? ), and the vulnerability of sending sensitive material over the internet. Counselling Psychology Review, Vol. 24, No. 2, June

8 Terry Hanley & D Arcy J. Reynolds, Jr. A growing literature is emerging that specifically articulates these challenges in online communication. This literature also adds considerable weight to not offering therapy through this medium. Therapists who work online have attempted to overcome a number of these technical challenges by familiarising themselves with the nuances of computer-mediated communication. A number of book chapters have been devoted to outlining some of the key components of such modes of communication to therapists. Authors explain how counsellors can develop innovative strategies for expressing themselves solely through text despite the absence of face-to-face cues. Written techniques such as emoticons ( ), abbreviations (u=you), acronyms (lol=laughs out loud), and emotional bracketing (see Murphy & Mitchell s [1998] descriptions of therap ) are all noted to add depth to the relationships that are created. Stofle (2002) uses the term non-textuals to describe everything other than the words themselves (p.94) within computer-mediated communication. In such instances, the words and key strokes create a mental representation of the individuals involved and facilitate the creation of relationships of a sufficient depth to produce positive change (e.g. Anthony, 2000a; Suler, 2004). In addition to the development of computer-mediated counselling skills that are utilised within sessions, individuals have also paid attention to the ethical concerns that have been raised (e.g. Anthony & Jamieson, 2005; Bloom, 1998; Childress, 2000; Goss & Anthony, 2004; King & Poulos, 1999; Kraus, 2004; Robson & Robson, 2000; Stofle, 1997). These works attempts to highlight the numerous pitfalls of working in virtual environments such as producing appropriate counselling contracts, being mindful of the limits of confidentiality, and protecting any electronic files that are stored. The online environment can provide a number of distinct opportunities that may be used to compensate for the lack of physical presence. Rochlen, Zack and Speyer (2004) note that it is convenient and increases access for clients, the client may feel safer and thus disinhibited by the online environment, provides a meditative zone of reflection, writing is therapeutic, individuals report feeling close to others they meet online (this has been described by Lombard & Ditton [1997] as Telepresence ), and it provides immediate access to internet-based resources. Thus, the theoretical retort to critics of e-therapy has developed substantially in recent years. It has shifted from examining how the nuances of face-to-face therapy can be mimicked solely using text, to considering how technology can actually complement and improve service provision. Rationale for the review As outlined above, online therapy is a growing field in which interested professionals have attempted to tackle the challenges posed by the online environment. However, there are still numerous questions of efficacy regarding counselling psychologists entering into virtual environments. Consequently, this work aims to investigate two key facets of such practice. First, What evidence suggests that text-based online therapy produces positive outcomes for clients? Second, What evidence suggests that therapeutic alliances of a sufficient quality to create positive change can be created online using text-based media? Review strategy This paper reviews the literature related to the work of counselling psychologists who utilise or online chat to mediate their practice. It specifically examines the quantitative research that has been conducted exploring therapeutic outcomes and the therapeutic alliance using online text-based modes of communication. The review strategy is a two-stage process: Stage 1: Initially this paper reflects upon Barak et al. s (2008) comprehensive review of internet based psychotherapeutic interventions. This review provides a systematic 6 Counselling Psychology Review, Vol. 24, No. 2, June 2009

9 The quantitative research into online outcomes and alliances overview up until March, 2006, of outcome studies related to various online interventions. For the purposes of this paper, only human-tohuman computer-mediated contact studies are extracted from the review and discussed. The effect size of the intervention calculated for each mode of communication is reported and Cohen s (1969) rule of thumb is used to interpret the data: 0.2 is a small effect, 0.5 a medium effect ( visible to the naked eye [p.23]), and 0.8 a large effect size ( grossly perceptible [p.23]). Stage 2: The second stage of the review involves reporting on part of an ongoing systematic review examining online therapeutic alliance (Reynolds & Hanley, in preparation). The analysis of the literature cited within several major electronic databases (PsycINFO, Medline, Scopus, and Google.Scholar) up until March, 2008, has been conducted. Although the work reported focuses solely on text-based communication, interested readers can also investigate the videoconference therapeutic work (e.g. Wade et al., 2005), the impact of using online technologies as an adjunct to face-to-face work (e.g. Murdoch & Connor- Greene, 2000), and as an adjunct to self-help materials (Klein, Richards & Austin, 2006). The major quantitative studies presented reflecting work conducted primarily with an adult population and reported in the English language. For work with younger populations, see Hanley (in press) and King et al. (2006). Findings Examining outcomes The Barak et al. (2008) study evaluates the effectiveness of internet-based psychotherapeutic interventions and provides a comprehensive summary of 92 studies involving 9764 clients. The review generally concludes that online work is moderately effective, with an overall mean weighted effect size of Barak and his colleagues remind the reader that this effect size is quite similar to the average effect size of traditional, face-to-face therapy (p.109). This finding is compelling evidence for those interested in the efficacy of online practice as it reflects a growing body of evidence indicating that online therapy can be of use to some clients. When limiting the work examined to only the effectiveness of one-on-one therapy, only 27 of the studies in question represent work conducted synchronously or asynchronously with a therapist. See Table 1 for a breakdown of the modalities utilised and the respective effect sizes. Upon further reflection, it is also evident that some of the interventions that reflect more sensory rich environments (notably audio and webcam) and those interventions through forums do not reflect one-to-one therapy. Excluding these findings leaves a total of 16 relevant studies for this review and cumulatively involve 614 clients. More specifically, they reflect effect sizes for text-based interventions using (Effect size=0.51) and chat (Effect size=0.53). According to Table 1: Effect size of online counselling by communication modality (27 studies). Communication Effect Size Number of studies Number of clients Modality involved Audio Chat Webcam Forum (Summary from Barak et al., 2008) Counselling Psychology Review, Vol. 24, No. 2, June

10 Terry Hanley & D Arcy J. Reynolds, Jr. Cohen (1969), such findings are indicative of moderate effect sizes. A further consideration with Barak et al. s (2008) meta-analysis is that it reflects more technical approaches to therapy (e.g. cognitive behavioural therapy), rather than those that place more emphasis upon the curative nature of the relationship (e.g. personcentred therapy). The whole study categorises the work that has been collated into three main psychotherapeutic approaches: cognitive behavioural therapy, psycho-educational interventions, and behavioural interventions. Only two studies within the analysis reflected different approaches to therapy. They both reflect therapy conducted through chat and used an unspecified therapeutic approach (Cohen & Kerr, 1998; Effect size=0.86) and a client-centred form of motivational interviewing (Woodruff, Edwards, Conway, & Elliott, 2001; Effect Size=0.56). In summary, this highlights the bias within the present research towards more technical approaches to therapy as opposed to those that are more relational in nature. Examining the alliance Similar to online outcomes, the online therapeutic alliance has received limited attention to date. From the on-going review of alliance, five studies have been selected from the electronic database searches. Table 2 outlines the participants involved in the studies (both those receiving online therapy and those in comparison groups), the type of text-based intervention employed, alliance measure used, and a brief summary of the main conclusions. The five studies had a total of 161 clients who took part in online therapy treatment conditions. Of the five studies all but one compared their data to face-to-face comparison groups (Prado & Meyer, 2006, compared findings to those of individuals who dropped out of therapy at earlier stages). In addition, three studies only utilised asynchronous communication and two utilised a combination of asynchronous and synchronous communication. Each of the studies outlined in Table 2 supports the notion that good therapeutic alliances can be developed online. Scores within the studies generally indicated that clients perceived the alliance between them and the counsellor to be moderate or strong in nature. It is also noteworthy that within three out of the four studies that made comparisons to face-to-face equivalents, the online alliance proved higher than the comparison group. Such findings provide persuasive evidence supporting online therapy and challenge theoretical assumptions that relationships of sufficient quality to create therapeutic change cannot be developed online. Discussion Previously, two questions were raised: What evidence suggests that text-based online therapy produces positive outcomes for clients? and What evidence suggests that therapeutic alliances of a sufficient quality to create positive change can be created online using text-based media? This section will discuss these questions in relation to the findings presented above. It will then move on to briefly consider the limitations of this work and future directions for research in this area. Within industrialised cultures, the internet is increasingly being used to seek out health care information and services. Broadly speaking, the findings from this review of the quantitative literature support the notion that individuals who seek out online mental health services can receive effective support. Specifically, 16 studies have reported positive outcomes from such encounters. These studies noted effect sizes for therapy to be 0.51 and therapy mediated through chat rooms to be These findings are comparable to face-toface outcomes studies (e.g. Lambert & Ogles, 2004), however, the limited number of studies in question limit the comparability. Although there is growing evidence that online therapy proves effective for some individuals, there is still much evaluative work to be undertaken. 8 Counselling Psychology Review, Vol. 24, No. 2, June 2009

11 The quantitative research into online outcomes and alliances Table 2: Table outlining the studies which examine the therapeutic alliance in text-based therapy. Authors (date) N= N= Asynchronous/ Alliance Conclusion Online Comparison Synchronous measure group group Cook & N=15 f2f archive Asynchronous Working Moderate TA scores Doyle (2002) N=25 & Synchronous Alliance higher than f2f Inventory (WAI) Knaevelsrud & N=48 Previous f2f Asynchronous Working High TA scores Maercker (2006) study with Alliance higher than f2f similar Inventory no distinction of client group short form scores for those N=270 (WAI-S) with different severity of need Leiber, Archer, N=52 f2f archive Asynchronous WAI-S Moderate TA scores Munson & N=46 & Synchronous weaker than f2f York (2006) Prado & Meyer N=29 Drop out Asynchronous WAI Moderate to (2006) N=19 Strong TA scores Drop out TA scores significantly lower than completion Reynolds, Stiles N=17 3 Previous Asynchronous Agnew Similar TA ratings & Grohol (2006) f2f studies Relationship as f2f using the Measure same short form measure (ARM-S) Key: f2f = face-to-face; TA = therapeutic alliance. The five studies that investigated the online therapeutic alliance in adult therapy add to our understanding of this phenomenon. They offer clear and compelling insight into the quality of online therapeutic relationships. In particular, each study reported alliance scores to be of moderate to high strength. Thus, it could be suggested that a high percentage of the 161 total participants felt the quality of the relationship to be of a sufficient quality to create therapeutic change. Similar to the positive outcomes reported by those who have accessed online therapy, this finding challenges those who question the efficacy of this way of working. More specifically, it calls into question the view that good quality relationships cannot be fostered in text based relationships (e.g. Pelling & Reynard, 2000). Further, it argues against the notion that mental health professionals are unprepared for technological advances (Alleman, 2002). The qualitative literature on the online therapeutic alliance supports the possibility of creating good quality relationships online. For instance, two UK-based studies have consulted small numbers of counsellors about the quality of the relationships that they develop with clients in their online practice (Anthony; 2000a; Hanley, 2004b; see also Anthony, 2000b). These studies suggest participants believe that good Counselling Psychology Review, Vol. 24, No. 2, June

12 Terry Hanley & D Arcy J. Reynolds, Jr. quality relationships can be developed online. There are fewer studies which reflect the views of clients, although these are not completely absent. In most of these reports, the focus is on practical concerns such as utilising the medium for therapy rather than the nature of the relationship itself (e.g. Haberstroh et al., 2007; Young, 2005). More sustained reports are emerging including researchers consulting with adolescents about their views of forming relationships with therapists online (Hanley, in press) and, on rare occasions, client reports of their experiences (e.g. Ainsworth, 2002). When reflecting upon the experience of receiving her first response from a therapist, Ainsworth captures the potential of online therapeutic relationships: It was a connection. Physically, we were separated by five states; but psychically we were more connected than if we had been in the same room (Ainsworth, 2002, p.198). Finally, we return to the view that mental health professionals are not prepared for working in such environments (Alleman, 2002). As is evident above, the studies presented here suggest that the therapists in question are adequately prepared for such work. One possible explanation for therapists preparation is the growth of the online therapy literature. Theoretical developments have evolved at a similar pace to the practice of online therapy. As noted earlier, numerous text books have been written and specific bodies of literature have emerged supporting practitioners in developing their skills base. Therefore, it may be this heightened interest in the nuances of computermedicated communication that has led to appropriately skilled therapists working in these studies. Limitations and future directions A major limitation to this review is the dearth of studies which it brings together. The study of outcomes and alliances within online therapy is an area still very much in its infancy and one that will undoubtedly be strengthened as time goes on. It is tempting to contrast this body of work to the large meta analyses of face-to-face equivalents (e.g. Lambert & Ogles, 2004, when contemplating outcome studies, and Horvath & Bedi, 2002, when contemplating alliance studies). Within these bodies of work there is a richness that is impossible to duplicate from the limited work examined here. For instance, it is not yet possible to examine specific nuances such as the use of different measures, variety of people completing the questionnaires, and variable times of questionnaire implementation. Such a problem goes to the core of this paper. Although trends that can be generalised from one group to another may not be identifiable, it is possible to say for certain that some individuals have benefited from online therapeutic support. Thus, the cumulative body of work strengthens the arguments in favour of online therapy. It does not claim to offer a cheap alternative for those who want face-to-face therapy, but it does suggest that online work can play an important part in supporting the psychological well-being of those seeking out such support. There is much need for continued research into the exploration of online therapeutic outcomes and alliances. For example, an important issue is the influence of online as opposed to face-to-face data collection of online therapy data (e.g. Reynolds & Stiles, 2007). The research that is presented here just scratches the surface but acts as a useful starting point for those entering into this area. As is mentioned above, studies which help to add to the richness of our understanding of online therapeutic work will provide more fodder for quantitative analysis. In addition, explanatory qualitative studies and theoretical developments have played an important part in the evolution of this work. With this in mind, it is difficult to identify specific research priorities. However, the continuation of such work feels essential for this growing area of the counselling psychology profession. 10 Counselling Psychology Review, Vol. 24, No. 2, June 2009

13 The quantitative research into online outcomes and alliances The Authors Terry Hanley Lecturer in Counselling at the University of Manchester. D Arcy J. Reynolds, Jr. Doctoral Student in the Department of Psychology at Miami University. Correspondence Terry Hanley Lecturer in Counselling, Educational Support & Inclusion, Ellen Wilkinson Building, The University of Manchester, Oxford Road, Manchester M13 9PL. Tel +44(0) [email protected] References Ainsworth, M. (2002). My life as an e-patient. In R. Hsiung (Ed.), E-Therapy: Case studies, guiding principles, and the clinical potential of the internet (pp ). New York: W.W. Norton & Co. Alleman, J. (2002). Online Counselling: The internet and metal health treatment. Psychotherapy, 39, Anthony, K. (2003). The use and role of technology in counselling and psychotherapy. In S. Goss & K. Anthony (Eds.), Technology in counselling and psychotherapy: A practitioner s guide (pp.13 34). London: Palgrave. Anthony, K. (2000a). Counselling in cyberspace. Counselling Journal, 11(10), , Anthony, K. (2000b). The nature of the therapeutic relationship within online counselling. Unpublished Dissertation, University of Greenwich, London Anthony, K. & Jamieson, A. (2005). Guidelines for online counselling and psychotherapy (2nd ed.). Rugby: BACP. Barak, A., Hen, L. Boniel-Nissim, M. & Shapira, N. (2008). A comprehensive review and a metaanalysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/3/4), Bloom, J. (1998). The ethical practice of webcounselling. British Journal of Guidance and Counselling, 26, Bloom, J. & Walz, G. (Eds.)(2004). Cybercounselling and cyberlearning: Strategies and resources for the millennium. Alexandria, VA: American Counseling Association. Bloom, J. & Walz, G. (Eds.)(2000). Cybercounselling and cyberlearning: An encore. Alexandria, VA: American Counseling Association. Chester, A. & Glass, C. (2006). Online counselling: A descriptive analysis of therapy services on the internet. British Journal of Guidance & Counselling, 34(2), Childress, C. (2000). Ethical issues in providing online psychotherapeutic interventions. Journal of Medical Internet Research, 2(1). Retrieved 21 December, 2007, from: articlerender.fcgi?artid= Cohen, G. & Kerr, B. (1998). Computer-mediated counselling: An empirical study of a new mental health treatment. Computers in Human Services, 15, Cohen, J. (1969). Statistical power analysis for the behavioural sciences. New York: Academic Press. Cook, J. & Doyle, C. (2002). Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. CyberPsychology & Behaviour, 5, Derrig-Palumbo, K. Zeine, F. (2005). Online therapy: A therapist s guide to expanding your practice. New York: W.W. Norton & Co. Evans, J. (2009). Online counselling and guidance skills: A practical resource for trainees and practitioners. London: Sage. Fink, J. (Ed.) (1999). How to use computers and cyberspace in the clinical practice of psychotherapy. New York: Jason Aronson Inc. Goss, S. & Anthony, K. (2004). Ethical and practical dimensions of online writing cures. In G. Bolton, S. Howlett, C. Lago & J. Wright (Eds.), Writing cures. East Sussex: Brunner-Routledge. Goss, S. & Anthony, K. (Eds.) (2003). Technology in counselling and psychotherapy. London: Palgrave. Grover, F., Jr., Wu, H.D., Blanford, C., Holcomb, S. & Tidler, D. (2002). Computer-using patients want internet services from family physicians. Journal of Family Practice, 51, Haberstroh, S., Duffey, T., Evans, M. & Trepal, H. (2007). The experience of online counselling. Journal of Mental Health Counseling, 29(3), Counselling Psychology Review, Vol. 24, No. 2, June

14 Terry Hanley & D Arcy J. Reynolds, Jr. Hanley, T. (in press). The Working Alliance in Online Therapy with Young People: Preliminary findings. British Journal of Guidance and Counselling. Hanley, T. (2004). Online counselling: A heuristic study examining the relational depth of computer-mediated relationships. Unpublished Dissertation, University of Manchester, Manchester. Heinlen, K., Welfel, E., Richmond, E. & Rak, C. (2003). The scope of web counselling: A survey of services and compliance with NBCC standards for the ethical practice of web counselling. Journal of Counselling and Development, 18, Horvath, A. & Bedi, R. (2002). The alliance. In J. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions responsive-ness to patients. New York: Oxford University Press Hsiung, R. (Ed.) (2002). E-Therapy: Case studies, guiding principles, and the clinical potential of the internet. New York: W.W. Norton & Co. Jones, G. & Stokes, A. (2009). Online Counselling: A handbook for practitioners. London: Palgrave. Kaltenthaler, E. Parry, G. & Beverley, C. (2004). Computerized cognitive behaviour therapy: A systematic review. Behavioural and Cognitive Psychotherapy, 32, King, R., Bambling, M., Reid, W. & Thomas, I. (2006). Telephone and online counselling for young people: A naturalistic comparison of session outcome, session impact and therapeutic alliance. Counselling and Psychotherapy Research, 6(3), King, S. & Poulos, S. (1999). Ethical guidelines for online therapy. In J. Fink, How to use computers and cyberspace in the clinical practice of psychotherapy (pp ). New York: Aronson Inc. Klein, B., Richards, J. & Austin, D. (2006). Efficacy of internet therapy for panic disorder. Journal of Behaviour Therapy and Experimental Psychiatry, 37(3), Knaevelsrud, C. & Maercker, A. (2006). Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients? Journal of Medical Internet Research, 8(4). Retrieved 21 December, 2007, from: articlerender.fcgi?artid= Kraus, R. (2004). Ethical and legal considerations for providers of mental health services online. In R. Kraus, J. Zack & G. Stricker (Eds.), Online counselling: A handbook for mental health professionals (pp ). London: Elsevier Academic Press. Kraus, R., Zack, J. & Stricker, G. (Eds.) (2004). Online counselling: A handbook for mental health professionals. London: Elsevier Academic Press Lago, C. (1996). Computer therapeutics. The Journal of the British Association for Counselling, 7(4), Lambert, M. & Ogles, B. (2004). The efficacy and effectiveness of psychotherapy. In M. Lambert (Ed.), Bergin and Garfield s handbook of psychotherapy and behaviour change (5th ed., pp ). New York: John Wiley. Lang, P., Melamed, B. & Hart, J. (1970). A psychophysiological analysis of fear modification using an automated desensitization procedure. Journal of Abnormal Psychology, 76, Leibert, T., Archer, J. Jr., Munson, J. & York, G. (2006). An exploratory study of client perceptions of internet counselling and the therapeutic alliance. Journal of Mental Health Counselling, 28, Lombard, M. & Ditton, T. (1997). At the heart of it all: The concept of presence. Journal of Computer Mediated Communication, 3(2). Retrieved 21 December, 2007, from: lombard.html Marks, I., Cavanagh, K. & Gega, L. (2007). Hands-on help: Computer-aided psychotherapy. East Sussex: Psychology Press. MORI. (2001). Nearly three out of five internet users would seek help for mental health problems on the net. Retrieved 21 December, 2007, from: Murdoch J. & Connor-Greene, P. (2000). Enhancing therapeutic impact and therapeutic alliance through electronic mail homework assignments. Journal of Psychotherapy Practice & Research, 9, Murphy, L. & Mitchell, D. (1998). When writing helps to heal: as therapy. British Journal of Guidance and Counselling, 26(1), National Statistics (2007). First release: Internet access: households and individuals. London: National Statistics. NICE (2006). Computerised cognitive behaviour therapy (CCBT) for the treatment of depression and anxiety. Technology Appraisal no. 97. London: NICE. Pelling, N. & Renard, D. (2000). Counselling via the internet. Can it be done well? The Psychotherapy Review, 2(2), Prado, O. & Meyer, S. (2006). Evaluation of therapeutic relations in asynchronous therapy via Internet through working alliance inventory [English translation retrieved 7 January, 2008, from: Psicologia em Estudo, 11(2), Reynolds, D. & Hanley, T. (in preparation). Reaching out across the virtual divide: an empirical review of text-based therapeutic relationships. Personal Correspondence, 20 April, Counselling Psychology Review, Vol. 24, No. 2, June 2009

15 The quantitative research into online outcomes and alliances Reynolds, D.J., Jr., & Stiles, W.B. (2007). Online data collection for psychotherapy process research. CyberPsychology & Behaviour, 10, Reynolds, D., Stiles, W. & Grohol, J. (2006). An investigation of session impact and alliance in internet-based psychotherapy: Preliminary results. Counselling and Psychotherapy Research, 6(3), Riva, G. & Galmiberti, C. (2005). Towards CyberPsychology: Mind, cognition and society in the internet age. Amsterdam: IOS Press. Robson, D. & Robson M. (2000). Ethical issues in internet counselling. Counselling Psychology Quarterly, 13(3), Robson, D. & Robson, M. (1998). Intimacy and computer communication. British Journal of Guidance and Counselling, 26(1), Rochlen, A., Zack, J. & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), Sanders, P. (2007). Using counselling skills on the telephone and in computer-mediated communication. Ross-on-Wye: PCCS Books. Samaritans (2007). Facts and figures. Retrieved 21 December, 2007, from: facts_and_figures.aspx Samaritans (2004). Personal correspondence. 14 February, Stofle, G. (2002). Chat room therapy. In R. Hsiung (Ed.), E-Therapy: Case studies, guiding principles, and the clinical potential of the internet (pp ). New York: W.W. Norton & Co. Stofle, G. (2001). Choosing an online therapist. Harrisburg, PA: White Hat Communications. Stofle, G. (1997). Thoughts about online psychotherapy: Ethical and practical considerations. Retrieved 21 December, 2007, from: onlinepsych.htm Suler, J. (2004). The psychology of text relationships. In R. Kraus, J. Zack & G. Stricker (Eds.), Online counselling: A handbook for mental health professionals (pp.19 50). London: Elsevier Academic Press. Wade, S.L., Wolfe, C., Brown, T.M. & Pestian, J.P. (2005). Putting the pieces together: Preliminary efficacy of a web-based family intervention for children with traumatic brain injury. Journal of Pediatric Psychology, 30(5), Weizenbaum, J. (1976). Computer power and human reason. London: W.H. Freeman. Woodruff, S., Edwards, C., Conway, T. & Elliott, S. (2001). Pilot test of an internet virtual chat room for rural teen smokers. Journal of Adolescent Health, 29, Wootton, R., Yellowlees, P. & McLaren, P. (Eds.) (2003). Telepsychiatry and e-mental health. New York: RSM Press. Young, K. (2005). An empirical examination of client attitudes towards online counselling. CyberPsychology and Behaviour, 8(2), Counselling Psychology Review, Vol. 24, No. 2, June

16 Client contact styles in online therapeutic work via Gudrun Stummer is a cost effective and convenient way of connecting clients and professionals. The emerging research into online psychotherapy, counselling and advice work suggests that does enable effective therapeutic work. The present article discusses client contact styles used to engage with an online advice service, which is part of an action research project into the development and running of an online sexual health and relationship skills website called Sex-and-Relationships 1. The methodology used for this study was action research, a cyclical process of enquiry, which uses both qualitative and quantitative data. It has been used to explore and develop practice-based and situational knowledge of how to best deliver an online advice or counselling service via Sex-and-Relationships. This article will present figures for overall usage of the advice service over two years to contextualise data on how service users have engaged with the service. Two client contact styles are identifiable in the data, namely single question-response pairs and in-depth, therapeutic dialogues, which will be illustrated by two case vignettes. Both contact styles are appropriate with respect to individual clients needs and can be supported via . Practitioners working online need to have considerable experience of offline long-term work to engage in therapeutic dialogue online, but also need to be able to tolerate the abruptness of the majority of short online exchanges. Keywords: action research, online counselling, sexual health, , advice. THE INTERNET is a recent, global phenomenon, which has managed to connect over 1.2 billion people by 2006 (Computer Industry Almanac, 2007) through a range of different communication channels. This technological revolution has created many new possibilities for health promotion and therapeutic work as the medium is cost effective, efficient and convenient for service users (Duffett-Leger & Lumsden, 2008). Figures show that many internet users do indeed use the internet to search for health information online (Brodie et al., 2000) and it has been estimated that in per cent of all internet searches worldwide were for information on health or health-related issues (Morahan-Martin, 2004). The internet as a medium is especially interesting to health professionals as it allows for two-way communication via a low-cost mass communication medium enabling service users to engage in active participation and dialogue with health professionals (Morrisett, 1996). The best known channel for two-way communication on the internet is via . is an asynchronous and mostly textual form of communication. Although it uses the internet s near instantaneous ability to distribute information once an is sent, its textual nature can encourage space for active thinking and reflection (Morrisett, 1996). Moreover, is convenient to use as it does not require in-depth technical knowledge and can be used for contacting health practitioners with complete anonymity via free online accounts. Psychologists, psychotherapists and other mental health professionals have been slow to Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

17 Client contact styles in online therapeutic work via take up the new medium (Binik, 2001; Duffett-Leger & Lumsden, 2008). Although some books have been published on online psychotherapy and counselling (Bloom & Walz, 2000 and 2004; Kraus et al., 2004; Goss & Anthony, 2003; Hsiung, 2002; Fink, 1999), comparatively little has been written and few research projects have looked into this emerging practice. One very inclusive definition for online counselling has been suggested by Rochlen et al. (2004), who defined it as any type of professional therapeutic interaction that makes use of the internet to connect qualified mental health professionals with their clients (Rochlen et al., 2004, p.270) and which, therefore, covers any therapeutic work online including psychotherapy, counselling, psychological consultation as well as support and advice work. No best practice recommendations have yet been established, however, both the British Association for Counselling and Psychotherapy (Anthony & Jamieson, 2005) and the International Society for Mental Health Online (ISMHO, 2000) have published guidelines for ethical practice. For a detailed discussion of the advantages and disadvantages of online therapeutic work please see Rochlen et al. (2004). The present paper presents part of an action research project into the development of an online sexual health and relationship skills website called Sex-and-Relationships (Stummer, 2009). Whilst mainly focusing on the development processes involved in creating and running a low-cost, practitionerled public health website, Stummer (2009) also investigated the development and running of a free online therapy and advice service via as an addition to the main website. The present article will present a brief overview of the literature on online therapy and advice via and then continue to discuss the parameters chosen for the online advice service on Sex-and-Relationships, which have arisen out of the action research process, and present quantitative figures for the service over two years. The author thereby hopes to provide context for the main focus of this article, namely data on different contact styles enquirers employed to engage with the service, which will be further illustrated by two case vignettes. The implications for therapeutic work via for practitioners will be discussed in detail. Literature review Studies on online therapy and counselling via are rare despite the fact that anecdotal evidence suggests that is a popular medium for service users (Samaritans, 2007). Anthony (2000a and 2000b) researched the components, which made online counselling therapeutic by interviewing seven online practitioners and one online client. Her findings suggest that rapport, presence, openness and the quality of the written communication are important. Some studies have compared online psychotherapy with traditional face-to-face approaches (Cohen & Kerr, 1998; Day & Schneider, 2002) and their results support working online with clients. However, sample sizes in these studies are generally very small and their results need to be treated with caution. Online counselling has also been compared to waiting list control groups with positive outcomes for clients with panic disorders (Klein & Richards, 2001), eating disorders (Robinson & Serfaty, 2001) and post-traumatic stress disorder (Lange et al., 2001). Limited data exists on the uptake of paid online therapy via the internet. Chester and Glass (2006) surveyed 67 online therapists and found that their clients were predominantly female and had presented mostly with relationship issues. Clients on average completed five sessions, suggesting that online therapy involved mostly brief work. One study into advice work comes from the field of IT support. Hahn (1998) conducted a study evaluating the advice service of an IT student support service at a University. She found that most service exchanges were brief and that most discussions were initiated by staff seeking further information. Missing information was often experienced as a problem. A key Counselling Psychology Review, Vol. 24, No. 2, June

18 Gudrun Stummer finding was that service users and staff seemed to hold different expectations for the advice exchanges. Staff were more likely to consider a longer exchange as normal, whereas service users seemed to expect a single message-response pair. Therefore, Hahn (1998) concluded that staff may write incomplete responses to enquiries due to their expectation of a continuing dialogue, whereas service users expected a quick response with clear and simple instructions. Few studies have investigated the use of an advice or support service in conjunction with a public health website. Kanzaki et al. (2004) studied the daily coping mechanisms of patients with rheumatoid arthritis in Japan. One of their data collection methods was to invite participants to leave daily, qualitative diary entries via a web-based asynchronous medium to which a researcher would reply. Many participants found that taking part in the research had been beneficial to them in terms of symptom management and counselling. Further information comes from an Australian study by Pinnock and Jones (2003), who investigated an information website for prostate cancer, which also featured an integrated advice service. Their advice service received 353 serious enquiries over two years, which were posted together with practitioner s replies in a question-and-answer section of the website. The possibility for complete anonymity via the internet has opened important opportunities in the field of sexual health education and psychosexual psychotherapy (Cooper et al., 2002). Within the field of sexual health and psychosexual psychotherapy some studies have investigated the use of (Graugaard & Winther, 1998; Flowers-Coulson et al., 2000; Hall 2004; Leusink & Aarts, 2006; Van Diest et al., 2007). Flowers-Coulson et al. (2000) reviewed more than 200 s sent to an ask the expert feature of a teenage sex education website in late They suggest that the best strategy for answering s is to provide as much information as possible to educate and refer the enquirer to other appropriate sources. Hall (2004) conducted a piece of practitioner-research into providing psychosexual psychotherapy online with six clients, who began task-based psychosexual treatment. Hall concludes that s allow for good therapeutic work and that the extra anonymity afforded by the internet seemed to help clients disclose important information early on in treatment. Finally, Leusink and Aarts (2006) and Van Diest et al. (2007) investigated online medical consultations and psychosexual treatment for men suffering from simple erectile dysfunction. Both studies support the use of the internet and Van Diest et al. (2007) suggest that the positive features of working via for clients are easy access, anonymity, self pacing, own time management and lack of travel and waiting time. In summary, the reviewed literature supports the use of for a wide range of health interventions such as online counselling and psychotherapy, chronic disease management, sexual health advice and psychosexual psychotherapy. However, the literature also includes suggestions that therapists may need to be willing to adapt their way of working to the online environment and that online work often seems to be short-term. Methodology Due to a focus on service development and improvement of practice, action research (Lewin, 1946, 1948; Reason & Bradbury, 2001; Costello, 2003) was chosen to investigate and develop Sex-and-Relationships and its advice service. Action research methodology involves a cyclical pattern of planning, acting, observing and reflecting (Lewin, 1946). Action research is especially suited to developing practice-based knowledge (Park, 2001) for local and often complex situations and as such is widely used in nursing, teaching and community development work (Hart & Bond, 1995; Elliott, 1991; Zeichner, 2001; Lees, 2001). Each piece of action research constitutes a unique 16 Counselling Psychology Review, Vol. 24, No. 2, June 2009

19 Client contact styles in online therapeutic work via case study, which searches for local knowledge and practical solutions (Elden & Chisholm, 1993). Within a wide range of action research approaches, this project can be located within the tradition of professionalizing action research (Hart & Bond, 1995), were action research cycles are used by individual or groups of practitioners to investigate and develop their own practice. To this end both quantitative and qualitative data is used to first investigate and critically analyse the status quo of a practice (planning). Subsequently, an action intervention is developed and implemented to improve practice (action) and its effects are monitored (observing). Finally, the new data is used to improve ones understanding of the situation under investigation (reflection). Action research and the knowledge it generates deepens with successive cycles. In this study (Stummer, 2009) both quantitative and qualitative data was used to investigate the development and running of the advice service of Sex-and-Relationships. Quantitative data used included numbers of queries received, numbers of s exchanged with each enquirer, numbers of completed feedback surveys and frequencies of types of issues enquired about. Qualitative data collected included the queries sent by service users, the types of questions asked and the ongoing, reflexive dialogue about the advice service between practitioners. The action research process with respect to the advice service developed as follows: Firstly, different options for service delivery were discussed by the two practitioners developing Sex-and-Relationships, one of which is the present author, based on their knowledge of the literature and their existing professional practice (planning). Secondly, the team of practitioners decided to opt for a low-cost and easy-access service via , which was set up via a contact us web page on Sex-and-Relationships (action). Thirdly, enquiries, which the service received, were answered by the team of one male and one female practitioner, who also collected data about numbers of s exchanged and types of queries received. In addition, a link to a feedback survey was sent out to enquirers one week after the professional s first reply. Data analysis involved simple descriptive statistics, qualitative content analysis (Morgan, 1993) and an ongoing reflexive dialogue between practitioners (observing). Both quantitative and qualitative data was used to evaluate service delivery and implement action points to further improve the service (reflection and further action). The study has taken account of ethical thinking about online research (BPS, 2007), online counselling (Anthony & Jamieson, 2005; ISHMO, 2000), research in counselling and psychotherapy (Bond, 2004, 2006), and in action research (William & Prosser, 2002). Participation in the advice service was offered with complete anonymity and with the option of not taking part in the research. All synonyms used by participants have been changed for this article. The following section concentrates on the results of the exchanges with one practitioner over the two-year period to allow for a more in-depth discussion of client contact styles (for a complete presentation of findings please refer to Stummer, 2009). Results Considerations for the advice service via Sex-and-Relationships Questions about best practice and ethical issues (Anthony & Jamieson, 2005; ISHMO, 2000) were at the forefront of the practitioner s considerations during planning of the service. Given that the aim was to offer free advice via and that the research focused on the development of Sex-and- Relationships as a low-cost service, the practitioners decided against investing in a dedicated, but expensive, software platform which could ensure confidentiality of data in transit. On the one hand, this allowed the service to stay with as a well-known form of Counselling Psychology Review, Vol. 24, No. 2, June

20 Gudrun Stummer communication, which would enhance accessibility for clients as they did not have to learn and interact with a more complicated software application. However, this meant that to ensure confidentiality of information whilst in transit on the internet, the practitioners decided to run the counselling service as a completely anonymous service encouraging users to write from anonymous accounts whilst omitting any information that could identify them. Another consideration was protection for the two practitioners, who would answer s, including legal liability across national boundaries and their vulnerability to harassment online. As both issues involved many unknown variables, the researcher decided to introduce a number of safeguards such as calling the counselling service on Sex-and-Relationships an advice service only and to display clear information regarding the importance of accessing qualified medical advice as well as a disclaimer. Additionally, the two practitioners, who answered s, a female qualified psychotherapist and a specialist in male sexual health education, used gendered synonyms to invite queries and when replying to s. Figures for service usage over two years The advice service was accessible via a web page linked to the home page of Sexand-Relationships from January, 2006, onwards. Numbers of queries received were intrinsically linked to the development of the main sex education website. As more and more visitors accessed Sex-and-Relationships, the number of queries also increased steadily. During the first year, the advice service to Sex-and-Relationships received 20 queries to its female health professional, 14 were from men and six from women. Most queries seemed to originate from industrialised countries such as North America, Europe, Australia and New Zealand, whilst two participants explicitly stated they were located in India. Twelve queries consisted of one-off exchanges and eight developed into longer dialogues ranging from a total of four exchanged s to 16. During the second year of operation 68 queries were sent to the female address. Thirty-four of those suggested a female enquirer, 29 suggested a male enquirer and five remained ambiguous as to the author s sex. From a total of 68 enquiries, 46 involved a single exchange of s whilst 22 developed into longer dialogues, the longest of which has resulted in 15 s by the enquirer and 13 responses from the health professional. Thirty-six out of 68 questions involved a complex issue, which impacted more than one area of the enquirer s life and which required in-depth psychotherapeutic expertise to answer. Thirty-one out of 68 enquiries could be answered with a single piece of information and required no specialist skills beyond providing accurate information. Over the two years, 28 enquirers completed the subsequent web-based feedback survey for the online advice service. Of the 28 participants, 23 stated that they had been offered an ongoing dialogue by the practitioner, of which 14 had taken up the offer. On the other hand, 14 enquirers stated that they had chosen not to continue a dialogue with two of those stating that they had not received the original reply by the practitioner. Seven additional comments to the question of why enquirers had not taken up the offer of an ongoing dialogue were given by participants mentioning lack of time (four), no particular reason (one), by the time I had received the problem had resolved itself (one) and waiting to put recommendations into practice (one). To complement the above quoted quantitative data I will now present two case vignettes to illustrate the professional dilemmas created by client s different ways of engaging with the advice service. 18 Counselling Psychology Review, Vol. 24, No. 2, June 2009

21 Client contact styles in online therapeutic work via Case vignette 1: Shimla During 2006, the practitioner-researcher received an from a woman in India, Shimla, who was in a state of crisis after having been sexually assaulted. This case forced me to develop the service to a point where it could support long-term psychotherapeutic work, for example, through giving clear direction to service users about confidentiality, turn over time and boundaries of the service we offered. As our dialogue developed into a deeper, therapeutic exchange, I felt it necessary to give her my real name, so that she could check my credentials online through independent websites. My dialogue with Shimla developed well despite my fears about the medium and our contact seemed to help her to get grounded and keep herself and her child safe. Shimla and I exchanged 16 s in 2006 and my support seemed to help her in reducing her anxiety and making appropriate choices for herself. She wrote to me twice again in 2007 to let me know that she was well and enjoying life with her husband and child. My exchange with Shimla supported my belief in the usefulness of online advice/ therapy and its ability to cross cultural boundaries successfully. By being removed from her immediate social and cultural context I was able to become for Shimla what she needed at the time without needing to fear judgement. Shimla suggested to me that she was not willing to take anybody in her own immediate vicinity into her confidences as she feared people would talk about what had happened to her, which could result in the end of her marriage. In Shimla s case, online support may have been especially suitable due to its anonymity and distance from her own cultural norms (Ma, 1996). Case vignette 2: Unknown enquirer A major issue at the start of running the advice service was the lack of followup replies I received from many enquirers despite my offers of continuing dialogue. I was used to working slowly as a psychotherapist. This meant that I always made an assessment of a client first before delivering an intervention. My strategy of taking time and trying to assess people first was highlighted through an exchange with a woman in June. Her suggested that she had developed a case of vaginismus (involuntary muscle spasms preventing penetrative sex). As is sometimes the case with this problem, the picture she presented suggested that she thought the problem may be with her partner rather than herself, i.e. that her partner had problems with his erections. I decided I could not challenge her assumptions about the cause of the issue in my first response to her, but thought it would be better to invite her into a dialogue and prepare the ground for an in-depth response in case she found my suggestion challenging. However, the enquirer did not reply to my response, which meant that I had not given her all the information she could have received from me in my one . In particular, I had not mentioned the term vaginismus, which I believed could have made it much easier for her to access information elsewhere on the web. Discussion: Reflexive learning for the practitioner-researcher Overall, the advice service of Sex-and- Relationships recorded fewer queries than other online health promotion projects (Flowers-Coulson et al., 2000; Pinnock & Jones, 2003), namely 88 to its female health professional over two years. Fifty-eight enquiries resulted in a single questionresponse pair whilst 30 developed into longer dialogues between enquirer and psychotherapist. Unfortunately, no comparative data is available on length of exchanges between enquirers and practitioners in the studies by Flowers-Coulson et al. (2000) and Pinnock and Jones (2003). Only Hahn (1998) investigates client s agendas further. The following discussion will focus on contact styles of enquirers only. Counselling Psychology Review, Vol. 24, No. 2, June

22 Gudrun Stummer The presented literature seems to assume that online therapeutic work involves ongoing dialogues with clients (Cohen & Kerr, 1998; Day & Schneider, 2002, Hall, 2004; Kanzaki et al., 2004; Leusink & Aarts, 2006; Van Diest et al., 2007) albeit mostly brief ones (Chester & Glass, 2006). Only the work by Hahn (1998) suggests that working via may involve different ways clients may have of engaging with an online support service. The two case vignettes hoped to illustrate two ways of working therapeutically online via , which were both apparent in the collected data. The practitioner s engagement with Shimla developed very similar to her normal offline work as a psychotherapist. However, the practitioner had much less information about her client compared to working in an offline context. Therefore, the author suggests that practitioners working with clients in-depth online need to have extensive experience of working with people offline to be able to work effectively within the more ambiguous online environment. With respect to the practitioner s work with the unknown enquirer, although many interpretations of her silence are plausible, it is possible that she only wanted a very brief and informative exchange rather than an ongoing dialogue (Hahn, 1998). As can be seen from the data gathered through the feedback survey, enquirers, who did not take up an offer of dialogue, had in most cases received and read the practitioner s original reply and had found it sufficient for their needs. Their silence can, therefore, be interpreted as purposeful and planned on the part of the enquirer. However, accepting that many service users may want only brief and informative question-response exchanges means that it would be important for practitioners to include all of the relevant information in the first reply to enquirers (Hahn, 1998; Flowers-Coulson et al., 2000) whilst trusting them to use answers in a way that was supportive of themselves. To minimise the possibility of a negative impact of an indepth response, the practitioner subsequently always reiterated that she was offering only suggestions and that service users needed to use their own common sense when applying them. Additionally, the practitioner stressed the importance of enquirers seeking medical help or additional offline therapy in all replies. Over the two-year period of the research project the practitioner-researcher was not able to find a pattern, either with respect to the presenting issue or the style of writing in people s first to be able to categorise them into clients, who wanted and would subsequently engage in an ongoing dialogue and those who did not. It is likely that such an assessment cannot be made based on just one . Nevertheless, both contact styles of clients, namely an interest in ongoing dialogue and relationship or only the briefest of possible exchanges to gain specific information, are valuable to clients and can be supported by as a medium. Practitioners working online need to be able to respond and account for both contact styles in their first by giving a sufficiently detailed response, including cautions and recommendations to seek further offline help and by offering further dialogue with the practitioner should this be deemed necessary or possible. Both client contact styles may be a normal part of service users interacting with any therapeutic online service via irrespective of it being labelled as an advice, counselling or psychotherapy service. Finally, practitioners, who are more familiar with ongoing therapeutic work, may easily experience a black hole effect (Suler, 1997) when clients do not reply again. However, this type of contact is appropriate for the medium and clients may have gained what they needed from even a brief online exchange. Conclusion The presented research must be seen as a pilot study only into the running of an advice service in combination with a health promotion website. Sample sizes for analysed 20 Counselling Psychology Review, Vol. 24, No. 2, June 2009

23 Client contact styles in online therapeutic work via queries were comparatively small and limit the transferability of findings. Additionally, the type of data collected was according to the requirements of the practitioner in action research to evaluate implemented action and plan for further improvements. Therefore, further research needs to be conducted into the clients experiences of both single question-response pairs and ongoing dialogues with practitioners to evaluate online work via . Moreover, the presented advice service is connected with a health promotion website in the field of sexual health, and may, therefore, constitute a specialist field within health promotion and online therapeutic work To summarise, practitioners working online need to have experience of offline long-term work to manage the added ambiguities of ongoing therapeutic work in the online environment, but on the other hand also need to be able to tolerate experiencing the black hole effect and the abruptness of some online exchanges without doubting the usefulness of their work to clients. This article endeavoured to contribute to the emerging practice of therapeutic work via by underlining different contact styles of enquirers and suggesting ways in which practitioners can accommodate a range of clients. Correspondence Gudrun Stummer Integrative Psychotherapy Centre Manchester, 274A Upper Chorlton Road, Manchester M16 0BN. [email protected] References Anthony, K. (2000a). The nature of the therapeutic relationship within online counselling. Unpublished MSc Dissertation, University of Greenwich. Accessed 13 March, 2008, from: Anthony, K. (2000b). Counselling in Cyberspace. Counselling Journal, 11(10), Anthony, K. & Jamieson, A. (2005). BACP Guidelines for online counselling and psychotherapy, with guidelines for online supervision. Rugby: BACP. Binik, Y., (2001). Sexuality and the internet: Lots of hyp(otheses): Only a little data. The Journal of Sex Research, 38(4), Bloom, J.W. & Walz, G.R. (Eds.) (2000). Cybercounselling and cyberlearning: Strategies and resources for the millennium. American Counselling Association. Bloom, J.W. & Walz, G.R. (Eds.) (2004). Cybercounselling and cyberlearning: An encore. American Counselling Association. Bond, T. (2004), Ethical guidelines for researching counselling and psychotherapy. Counselling and Psychotherapy Research, 4(2), Bond, T. (2006). Intimacy, risk, and reciprocity in psychotherapy: Intricate ethical challenges. Transactional Analysis Journal, 36(2), British Psychological Society (2007). Conducting research on the internet: Guidelines for the ethical practice in psychological research online. Available online at: Brodie, M., Flournoy, R.E., Altman, D.E., Blendon, R.J., Benson, J.M. & Rosenbaum, M.D. (2000). Health information, the internet, and the digital divide. Health Affairs 19(6), Chester, A. & Glass, C.A. (2006). Online counselling: A descriptive analysis of therapy services on the internet. British Journal of Guidance and Counselling 34(2), Cohen, G. & Kerr, B. (1998). Computer-mediated counselling: An empirical study of a new mental health treatment. Computer in Human Services 15, Computer Industry Almanac Inc. (2007). Worldwide internet users top 1.2 billion in USA TOPS 210M internet users. Accessed 5 March, 2008, from: Cooper, A., Scherer, C. & Marcus, D.I. (2002). Harnessing the power of the internet to improve sexual relationships. In A. Cooper (Ed.), Sex and the internet. A guidebook for clinicians (pp ). New York & London: Brunner Routledge. Costello, P.J.M. (2003). Action research. London & New York: Continuum. Day, S.X. & Schneider, P.L. (2002). Psychotherapy using distance technology: A comparison of faceto-face, video, and audio treatment. Journal of Counseling Psychology, 49. Counselling Psychology Review, Vol. 24, No. 2, June

24 Gudrun Stummer Duffett-Leger, J. & Lumsden, J. (2008). Interactive online health promotion interventions: A health check. Proceedings of the 2008 IEEE International Symposium on Technology & Society (ISTAS 08). Fredericton, New Brunswick, Canada. Elden, M. & Chisholm, R.F. (1993). Emerging varieties of action research: Introduction to the special issue. Human Relations, 46(2), Elliott, J. (1991). Action research for educational change. Milton Keynes: Open University Press. Fink, J. (Ed.) (1999). How to use computers and cyberspace in the clinical practice of psychotherapy. New Jersey: Jason Aronson Inc. Flowers-Coulson, P.A., Kushner, M.A. & Bankowski, S. (2000). The information is out there, but is anyone getting it? Adolescent misconceptions about sexuality education and reproductive health and the use of the internet to get answers. Journal of Sex Education and Therapy, 25, Goss, S. & Anthony, K. (2003). Technology in counselling and psychotherapy. A practitioner s guide. Palgrave Macmillan. Graugaard, C. & Winther, G. (1998). Sex counselling on the internet a year with Scandinavian Journal of Sexology, 1(4), Hahn, K. (1998). Qualitative investigation of an mediated help service. Internet Research: Electronic Networking Applications and Policy 8(2), Hall, P. (2004). Online psychosexual therapy: A summary of pilot study findings. Sexual and Relationship Therapy, 19(2), Hart, E. & Bond, M. (1995). Action research for health and social care. A guide to practice. Milton Keynes: Open University Press. Hsiung, R. (Ed.) (2002). E-Therapy: Case studies, guiding principles, and the clinical potential of the internet. New York: W.W. Norton & Co. ISMHO (2000). Suggested principles for the online provision of mental health, version Kanzaki, H., Makimoto, K., Takemura, T. & Ashida, N. (2004). Development of web-based qualitative and quantitative data collection systems: Study on daily symptoms and coping strategies among Japanese rheumatoid arthritis patients. Nursing and Health Sciences, 6, Klein, B. & Richards, J. (2001). A brief internet-based treatment for panic disorder. Behavioural and Cognitive Psychotherapy, 29, Kraus, R., Zack & J. Stricker, G. (Eds.) (2004). Online counselling: A handbook for mental health professionals. London: Elsevier Academic Press. Lange, A., van de Ven, J., Schrieken, B. & Emmelkamp, P. (2001). Interapy. Treatment of post-traumatic stress and pathological stress through the internet: A controlled trial. Journal of Behaviour Therapy and Experimental Psychiatry, 2, Lees, J. (2001). Reflexive action research: Developing knowledge through practice. Counselling and Psychotherapy Research, 1(2), Leusink, P.M. & Aarts, E. (2006). Treating erectile dysfunction through electronic consultation: A pilot study. Journal of Sex & Marital Therapy, 32, Lewin, K. (1946). Action research and minority problems. Journal of Social Issues, 2, Lewin, K. (1948). Resolving social conflicts. New York: Harper. Ma, R. (1996). Computer-mediated conversations as a new dimension of intercultural communication between East Asian and North American college students. In S. Herring (Ed.), Computer-mediated communication: Linguistics, social and cross-cultural perspectives (pp ). Amsterdam: John Benjamins Publishing. Morahan-Martin, J.M. (2004). How internet users find, evaluate, and use online health information: A cross-cultural review. CyberPsychology & Behaviour, 7, Morgan, D. (1993). Qualitative content analysis: A guide to paths not taken. Qualitative Health Research, 3, Morrisett, L.N. (1996). Habits of mind and a new technology of freedom. index.html Park, P. (2001). Knowledge and participatory research. In P. Reason & H. Bradbury, Handbook of action research. Participative inquiry and practice (pp.81 90). London: Sage. Pinnock, C. & Jones, C. (2003). Meeting the information needs of Australian men with prostate cancer by way of the internet. Urology 61(6), Rochlen, A.B., Zack, J.S. & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates and current empirical support. Journal of Clinical Psychology, 60(3), Robinson, P. & Serfaty, M. (2001). The use of in the identification of bulimia nervosa and its treatment. European Eating Disorders Review, 9, Samaritans (2007). Facts and figures. Online at: facts_and_figures.aspx Stummer, G. (2009). A reflexive action research project to investigate the development of an educational public health website with an integrated online advice service. Unpublished PhD thesis, University of Manchester. Suler, J. (1997). The black hole of cyberspace. From J. Suler, The psychology of cyberspace. Accessed 18 August, 2008, from www-usr.rider.edu/~suler/psycyber/ blackhole.html 22 Counselling Psychology Review, Vol. 24, No. 2, June 2009

25 Client contact styles in online therapeutic work via Van Diest, S.L., Van Lankveld, J.J.D.M., Leusink, P.M., Slob, A.K. & Gijs, L. (2007). Sex therapy through the internet for men with sexual dysfunction: A pilot study. Journal of Sex & Marital Therapy, 33, Williamson, G. & Prosser, S. (2002). Illustrating the ethical dimensions of action research. Nursing Researcher, 10(2), Zeichner, K. (2001). Educational action research. In P. Reason & H. Bradbury, H., Handbook of action research. Participative inquiry and practice. London: Sage. Counselling Psychology Review, Vol. 24, No. 2, June

26 Trust in online therapeutic relationships: The therapist s experience Leon Joseph Fletcher-Tomenius & Andreas Vossler Trust is one of the most important constructs in psychology to explain interpersonal functioning and outcomes of interactions. As with traditional face-to-face counselling, it can be assumed that trust plays an important role in developing a working alliance in online counselling and therapy. However, due to the fact that this is a relatively new field, most previous studies have only focussed on the analysis of factors influencing the therapeutic relationship in a face-to-face context. This qualitative study, therefore, investigates how online counsellors define and experience trust in online therapeutic environments and what effect the presence or absence of trust has on the therapeutic relationship online. Using Interpretative Phenomenological Analysis (IPA), semi-structured interviews were conducted with six online counsellors who were accredited with the BACP and had at least three years post-qualification experience. Three main themes arose through the process of analysis: (1) The role of anonymity in trust online; (2) the impact of the medium of communication; and (3) similar issues to forming trust in face-toface contexts. The findings have practical implications for the provision of counselling and therapy online. Keywords: online counselling, trust, therapeutic relationship, IPA. ONLINE COUNSELLING is a current and topical area and is also a growing medium of providing counselling. Within the UK, mental health services and professional counselling and psychotherapy services have developed a major presence online in recent years. In this context, several authors (e.g. VandenBos & Williams, 2000) have highlighted that it is important that counselling psychologists develop a presence in what appears to be a rapidly growing area. Given the firm grounding in the scientist-practitioner paradigm and the emphasis on the importance of the therapeutic relationship, authors such as Mallen et al. (2005, p.820) consider that Counselling psychologists are in a unique position not only to extend their services to online modes of treatment, but also to conduct research in this area to determine whether online counselling practices are therapeutically beneficial for clients. This paper reports on a research study that investigated a specific aspect of the therapeutic relationship that can be crucial for process and outcome in online counselling the development of trust between client and therapist. After a brief review of relevant literature, the methods employed and the findings of the study on trust in online therapeutic relationships from the perspective of therapists are presented and discussed. Background and literature In a face-to-face context, the therapeutic relationship has long been an area of widespread interest. The working alliance between client and therapist can be defined as the extent to which both work collaboratively and purposefully and connect emotionally (Horvath & Luborsky, 1993). From numerous studies on therapeutic interactions it has emerged that the therapeutic relationship is a key aspect affecting the process and outcome of a therapeutic intervention. It is considered to be the largest significant single factor affecting the outcome of successful therapy in face-to-face counselling (e.g. Krupnick et al., 1996; Robbins, 1992; Wampold, 2000; Lambert & Ogles, 2004), accounting for approximately 24 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

27 Trust in online therapeutic relationships 30 per cent of the therapeutic outcome across theoretical orientations (Lambert, 2002). A number of research studies have demonstrated that online counselling can be effective in reducing clients presenting problems (e.g. Cohen & Kerr, 1998; Day & Schneider, 2002; Glueckauf et al., 2002; Hopps et al., 2003; Lange et al., 2001). However, a number of authors highlight that there is uncertainty about the possibilities to re-create the important qualities of the faceto-face relationship that lead to change in an online environment without the benefit of contextual and non-verbal cues (e.g. Goss & Anthony, 2006; Bambling et al., 2008). Cohen and Kerr (1998) and Cook and Doyle (2002) reported no significant differences in the therapeutic alliance between online and face-to-face interventions, whereas, for example, the findings of Hanley (2008) and Hufford et al. (1999) suggest that a considerable amount of online clients (21 per cent in Hanley, 2008) are not satisfied with the therapeutic alliance in an online context. Knaevelsrud and Maercker (2006) found that, although it seems to be possible to establish a stable and positive therapeutic relationship online, this factor was a less relevant predictor of the therapy outcome than in the face-to-face context. Such inconsistent findings indicate that further research is needed to attain a greater understanding of therapeutic alliance variables in online interactions. Trust in therapeutic relationships Among the factors identified in psychotherapy research as important underlying and multi-faceted features of the therapeutic relationship is the client s trust in their therapist and therapy (Marshall & Serran, 2004) and from a person-centred perspective, the therapist s trust in the client (e.g. Mearns & Thorne, 1999). Trust is a multidimensional, complex concept that can be construed and understood in different ways (e.g. trust as person-centered disposition vs. trust as interpersonal orientation; Simpson, 2007). From a dyadic perspective, trust can be understood as a psychological state or orientation of an actor (the truster) toward a specific partner (the trustee) with whom the actor is in some way interdependent (Simpson, 2007, p.264). However, trust can have varying meaning and importance at different stages of a relationship. Koehn (2003, p.3) states that trust is thought to be an action, an attitude or orientation, a state of character, a relationship or a choice. He highlights that trust has been described as cognitive (e.g. a matter of opinion or prediction that things will turn out in a certain way or that people will behave in a certain way), affective (i.e. a matter of feeling) or conative (i.e. a matter of choice or will). Trust has been commented upon as being a particularly important aspect of online interactions, especially in regard to the fact that cues and signals such as facial expression, tone of voice and gesture are not available online. However, there are only a few studies investigating this factor in the context of an online therapeutic relationship. Haberstroh et al. s (2007) study of five clients who partook in online counselling sessions suggests that trust was important from the sample interviewed. They found that participants varied in their trust of a communication forum which was devoid of visual and auditory feedback. For some this seemed to alleviate inter-personal pressure and encourage self-reflection and a feeling of safety when disclosing personal issues, although for others, the missing interpersonal cues possibly had the affect of limiting their self-expression and level of trust. Young s (2005) study on perceptions of clients who used online counselling also suggests trust is an important factor in online therapy. She highlights that the lack of perceived privacy and security during online chat sessions and the fear of being caught while conducting online sessions were significant concerns reported by e-clients. Little evidence is available regarding how trust in online therapy is experienced and understood by online therapists, although Counselling Psychology Review, Vol. 24, No. 2, June

28 Leon Joseph Fletcher-Tomenius & Andreas Vossler several authors have discussed the relevance of these issues for therapy process and outcome (e.g. Rochlen et al., 2004; Leibert et al., 2006). This study, therefore, aims to explore trust in online counselling through analysing the views and experiences of online therapists. The main questions the study addresses are: 1. How do online counsellors experience trust in the therapeutic relationship? 2. How does trust in online environments differ with online counsellors experiences of trust in face-to-face contexts? 3. What effect does the presence or absence of trust have on online counsellors therapeutic relationships? Methods The study took a qualitative approach to investigate trust in online therapeutic relationships from the perspective of the therapist. People appear to construct their individual perspectives of trust very subjectively to suit their own perceptions and needs (Dutton & Shepherd, 2006, p.435). This suggests a qualitative and phenomenological approach would be appropriate for investigating this. The British Psychological Society Ethical Principles for Conducting Research with Human Participants were authoritative in conducting the research (BPS, 2004). Participants For this study, semi-structured interviews were conducted by the first author with six online counsellors in a face-to-face setting. The interviewees were all counsellors accredited with the BACP and all had at least three years post-qualification experience. All had worked online for at least one year and had experience of face-to-face counselling. One participant worked mainly in group chat room situations and so only had experience of synchronous online counselling. All others had worked with both asynchronous and synchronous methods online. One of the six worked predominantly from a psycho-dynamic perspective and all others described themselves as working from either an integrative or primarily person-centred perspective. Procedure Participants were recruited via initial contact to ask if they would be interested in finding out further details of the study. Following a participant expressing interest in the study, online counsellors were sent a participant information sheet to consider. Before the interview occurred, they were asked to sign a consent form. Participants were told that they could withdraw from the interview at any time if they so wished. Interviews usually lasted about an hour. An interview schedule was used but, in keeping with the approach of Interpretative Phenomenological Analysis (IPA), this was used flexibly. Questions were adapted in response to participants discourse and the schedule was not always followed in the same order or the questions asked in exactly the same way. At the end of the interview, participants were de-briefed on the aims of the research and asked if they had any queries or questions. Analysis IPA (Smith & Osborn, 2003) was utilised as the method of analysis to investigate online therapist s experiences of trust in their therapeutic work. This model of qualitative analysis was chosen, because it allowed for the deep exploration of an area with the aim of understanding personal experiences through the generation and analysis of narratives. The transcripts of the interviews were analysed in accordance to the steps described by Osborn and Smith (1998). Findings Three master themes emerged from an analysis of data from six participants, each with a number of sub-themes. The three master themes included: 1. The role of anonymity for trust in online relationships. 2. The impact of the medium of communication on trust. 26 Counselling Psychology Review, Vol. 24, No. 2, June 2009

29 Trust in online therapeutic relationships 3. The same or similar issues as face-to-face therapy regarding trust. The themes often inter-relate and so should not be viewed as discrete and independent from each other. The current discussion will focus on the first two master themes since they contain issues specific for online counselling: The role of anonymity for trust in online relationships and The impact of the medium of communication on trust. 1. The role of anonymity for trust in online relationships The role of anonymity for the development of trust in online therapeutic relationships emerged as a main theme in the interviews with all participants. Interviewees stated that they generally experienced a high level of trust in therapeutic relationships online and that their clients seemed to find the initial stages of therapy easier to establish when compared with face-to-face contact. This was related to the speed an online relationship seemed to progress and the amount of self disclosure at an early stage in the therapy. they do seem very, very open and I don t have to tease a lot of information out of them, err, especially initially. Normally, with face-to-face therapy, there s certain, initial periods where everybody is feeling their way. Setting the stall out, and they re you re getting to know each other. But online, people seem very ready to go, almost from square nought. More specific issues that were discussed around the role of anonymity can be conceptualised in the following three sub-themes. Leap of faith A theme that appeared linked with the phenomenon of immediacy of trust is the therapists trust in self and the leap of faith they described when working online. One interviewee discussed how working online could make trusting easier. They highlighted how trust was a pre-condition for working in an environment where there was a lack of cues which could inform feelings of trust to the other person. It was, therefore, necessary to start the therapeutic process with a leap of faith since therapists did not feel fully informed of the personal characteristics of the other. It can be, sometimes easier than trust in a face-to-face scenario because of trusting yourself and trusting the other person. And it being a leap of faith into an unknown journey with an unknown other person. Whereas face-to-face, you have got different clues or cues rather from the physical appearance and the way someone talks and their accent and erm the words they choose, etc. Whereas of course you haven t got that online. Linked to the notion of a leap of faith was the feeling that online therapists needed to trust their internal representation of the client (mental picture). The participants expressed that when working with their clients, there was a large element of uncertainty as regards this mental picture. The interviewees highlighted that there is no way to know how accurate the picture they have of the client was and that there is always the possibility to err or to be beguiled. I can only imagine that s what it is, it s my imagination from what they are saying and the situation they are in and the details that I can tease out of them I can build up a mental picture which I have no idea how accurate it is Absolutely none at all. Interviewees expressed that one way to cope with this uncertainty was to have trust in themselves and their clients. They expressed that their leap of faith which they took with their clients could aid the development of a meaningful therapeutic relationship. Processes of disinhibition Another sub-theme that can be discussed in the context of the immediacy of a trusting relationship online is disinhibition. Interviewees highlighted that online clients appeared to bring issues which they may not so readily bring to face-to-face counselling. The quote below highlights the role of disin- Counselling Psychology Review, Vol. 24, No. 2, June

30 Leon Joseph Fletcher-Tomenius & Andreas Vossler hibition and contrasts interaction in a faceto-face environment. I think a lot of the time people are quite embarrassed by particular things and I think they feel kind of guilty for feeling that way, and sometimes when you sit there face-to-face with somebody It s quite difficult. Whereas online, they are not seeing you, they are never likely to see you, they can just come out with anything. The experience described here is aligned with observations from practitioners that clients are more direct and divulge problems very quickly in this medium. Stigmatised problems like depression, eating disorders and self-harming behaviour appear to be disclosed more frequently online than in face-to-face counselling. It is possible that for many clients online counselling and therapy is the place where they share an experienced trauma with others for the first time (Vossler & Hanley, 2008). Impact of therapist s anonymity The impact of the therapist s anonymity on the therapeutic process in general and specifically on issues of trust seems to be twofold. On one hand, there is the feeling that as the therapist cannot be seen in his/her online work, this was beneficial to forming trust with his/her clients, because the therapist could not be judged on the basis of his/her appearance. And you know our first impressions are important on what people think of other people. So if they looked at me they may say, cor, he looks big, fat and ugly. Right, which may well lead them to think: I don t know if I can trust this guy. Where as online, they don t see me. So they don t know what I look like. However, the anonymity of the therapist also has the potential to raise concerns regarding the accountability of online therapists, which refers to the theme of safety in an online environment. This is illustrated by the following quote on the anonymity of online therapists in general. I have some concerns over people who will only work in an online capacity, because I wonder if that is about them kind of almost like hiding behind the computer. It s faceless. They can preserve their own anonymity and I guess they can t necessarily be judged. And I wonder if that is a good thing. 2. The impact of the medium of communication on trust The medium of communication was considered by all participants as something which affects trust in online therapeutic work positively as well as negatively. The experiences related to this theme can be clustered in the following three sub-themes. Control and power The client s ability to control at the touch of a button the length of the communication and the amount of self-disclosure was considered unique to the method of online counselling, compared to face-to-face counselling. The following quote illustrates how this could have a direct effect on trust within the online counselling relationship. in a face-to-face situation, if the client doesn t trust you or loses trust in you, then its still quite unlikely they would walk out. They would be more reserved, but, I don t think I have ever had a faceto-face client walk out. Online, it s easier for the client to withdraw from the relationship and they can do that literally by pulling the plug, leaving the session or, changing their address. Online therapists may feel reassured that there is a trusting relationship only by virtue of the fact that their clients remain online. This is related to their experience that it is obviously much easier for online clients than for clients in a face-to-face context to express their mistrust or discomfort with the therapeutic relationship and to interrupt or terminate the therapeutic contact. The greater autonomy and control online clients seem to have is possibly afforded through the anonymous context of online therapy and facili- 28 Counselling Psychology Review, Vol. 24, No. 2, June 2009

31 Trust in online therapeutic relationships tated through the above mentioned processes of disinhibition. Interviewees also stated that they felt the power balance was equalised through the online medium and the related effects of this on the development of the therapeutic relationship. With working on the internet, the context the client has chosen, the modality, and because there isn t the concept of two chairs and a box of tissues and things like that the power balance is very much equal. The empowering effect of having more control through the online medium of communication is potentially reinforced by the absence of racial and ethnic cues in an online environment. The action on typing/writing Most interviewees commented how the action of typing had an effect on the relationship formed between counsellor and client. One aspect mentioned in this context was that through the process of typing, the typist was engaged with their thoughts and feelings in a way that was unique to the method of communication. What I think may be happening though is that people engage more readily with these deep feelings that perhaps in other circumstances they were very ashamed and they were avoiding talking about it in therapy. It s more difficult to avoid online because online is very focussed. Interviewees also thought that the possibility to re-read text passages could be beneficial for clients. It is possible that through internalisation processes this method of communication acts as an aid to the therapeutic relationship and trust between therapist and counsellor. when I have written my response, they can then study that and really kind of read that several times and think about that, whereas in face-to-face counselling once its said, it s then remembering all of what was said. Technological limitations A further sub-theme identified was how it could be harder to build trust online because of certain difficulties and limitations inherent to the online medium. The lack of cues and methods specific to a face-to-face context was commented on by all interviewees. Many interviewees felt that this made understanding the client harder and that this in turn could impact on the development of trust. If a client is upset They may say something like I m crying, but with body language and personal contact, you can see to what extent that crying is. When they say they are crying they could just have tears running down their face or they could be fully sobbing. So, that s difficult to evaluate, things like that. However, interviewees also described ways and techniques which could help to establish an effective and trusting therapeutic relationship even in the absence of cues and factors pertinent to the face-to-face environment. Acronyms and abbreviations, for example, were considered as alternative ways of conveying emotions: I like working with those, those facets of netiket (sic) it makes the work a lot easier for me being in tune with the client at any given point. Whether they are sad, whether they can smile at something. Same for acronyms if they joke, put LOL (laugh out loud) then I can trust that they are laughing. 3. The same or similar issues to face-toface counselling This third master theme highlights how participants viewed trust in their online therapeutic relationships in a similar way to how they viewed trust in face-to-face therapeutic interactions. This included trust being seen as an integral part of the therapeutic relationship and how the core conditions (Rogers, 1951) are also central to building a trusting relationship online as they are faceto-face. Counselling Psychology Review, Vol. 24, No. 2, June

32 Leon Joseph Fletcher-Tomenius & Andreas Vossler Discussion As discussed above, Mashall and Serran (2004) highlighted how trust is an important multi-faceted feature of the therapeutic relationship. This study also illustrates that trust is key to the process of therapeutic intervention online. Although trust was discussed as having similarities to the face-to-face environment, there were essential differences between trusting online and face-to-face. In particular, trust was discussed as being tied to the anonymity afforded by online counselling. Interviewees discussed how this affected the speed that online therapeutic relationships developed through processes of disinhibition, feelings of safety, a neutral power balance and a process of internalising the other. Similarly, on the basis of her research findings Anthony (2000) comes to the conclusion that the rapport between counsellor and client in cyberspace is developed not by reacting to another person s physical presence and spoken word, but by entering the client s mental constructs via the written word (p.626). The idiosyncratic aspects of the medium of communication were also discussed as having a number of key effects on the processes involved in building trust in the therapeutic relationship. In particular, this involved issues specific to the client s control of the length of communication and the use of techniques specific to the medium of communication such as emoticons and writing skills to overcome the lack of cues available in the face-to-face online environment. Wright (2002) has highlighted the similarities between online counselling and writing therapy. She describes the power of reflective, focused writing, which draws on imagination and creativity to enable some people to become much more knowledgeable about themselves and to increase their sense of agency (p.295). The findings could be considered as representing broader facets of the online relationship. Cooper (2005, p.87) discusses the concept of relational depth as a feeling of profound contact and engagement with another and highlights how the notion can be conceptualised as a form of co-experiencing of person-centred core conditions. The key themes arising from this study might also be considered representative of some of the factors supporting the development of online relational depth and they could be explored further as perhaps some of a number of themes, which compound this concept in online therapeutic contact. Limitations It is important to note some of the limitations of the research. These include that one cannot generalise the results to online counsellors as a whole and the interpretations are made by the researchers whose outlook and approach are unique to them. One could also argue that it is not surprising that the therapists commented on the importance of trust in their online relationships because most of the participants had training from a person-centred perspective where the importance of trust is emphasised. However, this is still a credible finding, but does emphasise the need for further research to explore issues arising from this study in more detail. Future research A question for future research will be how different therapeutic perspectives might impact upon the development of trust in online relationships. It is also important to explore experiences of trust in more detail from the client s perspective, which could help to understand how such processes as anonymity and disinhibition might be related to trusting. Such issues have begun to be explored by some more recent studies (e.g. Schultze, 2006; Haberstroh et al., 2007). It could, for example, be interesting to investigate if and how online clients create trust-test -situations (Simpson, 2007) to question whether they can truly trust their therapist. It is also important to explore the role of anonymity of the therapist further and address the question of how a lack of face-to-face contact with clients over a longer period might impact upon the therapeutic 30 Counselling Psychology Review, Vol. 24, No. 2, June 2009

33 Trust in online therapeutic relationships relationship. Other relevant research questions include how appropriate supervision and support for online counsellors working across cultural divides is ensured and the question of how web sites might affect the development of the therapeutic relationship. As technology changes and develops, it is also important that research tackles questions regarding the use of new technology such as virtual methods of computer mediated communication. Such technological advances are likely candidates for new methods of synchronous counselling and the impact of this will need to be explored and understood. The evidence to date suggests that research in online counselling is only beginning to tackle key issues and much further work is needed. An interesting question that this study highlights is if perceived limitations (often cited are the lack of typical cues available in the online environment) might actually function as strengths as the respondents in this study have also suggested. Key questions related to this involve exploring in more detail how anonymity, disinhibition and other processes idiosyncratic to the method of online communication impact upon the therapeutic relationship. Conclusion On the basis of the findings it can be concluded with Grohol (1999) that trusting in the therapeutic relationship online should be considered different to trusting and relating in a face-to-face context, rather than better or worse. Particularly noticeable in this context are the empowering aspects of online counselling which subvert traditional power relations between counsellors and clients. Correspondence Leon Joseph Fletcher-Tomenius London Metropolitan University. [email protected] Dr Andreas Vossler School of Psychology, Faculty of Life Science, London Metropolitan University, London E1 7NT. [email protected] Counselling Psychology Review, Vol. 24, No. 2, June

34 Leon Joseph Fletcher-Tomenius & Andreas Vossler References Anthony, K. (2000). Counselling in Cyberspace. Counselling, 11, Bambling, M., King, R., Reid, W. & Wegner, K. (2008). Online counselling: The experience of counsellors providing synchronous single-session counselling to young people. Counselling and Psychotherapy Research, 8, British Psychological Society (2004). Guidelines for minimum standards of ethical approval in psychological research. Leicester: BPS. Cohen, G.E. & Kerr, B.A. (1998). Computermediated counselling: An empirical study of a new mental health treatment. Computers in Human Services, 15, Cook, J.E. & Doyle, C. (2002).Working alliance in online therapy as compared to face-to-face therapy: Preliminary results. CyberPsychology & Behaviour, 5, Cooper, M. (2005). Therapists experiences of relational depth: A qualitative interview study. Counselling and Psychotherapy Research, 5(2), Day, S.X. & Schneider, P.L. (2002). Psychotherapy using distance technology: A comparison of faceto-face, video, and audio treatment. Journal of Counselling Psychology, 49, Dutton, W.H. & Shepherd, A. (2006). Trust in the internet as an experience technology. Information, Communication & Society, 9, Garfield, S.L. (1992). Issues and methods in psychotherapy process research. Journal of Conusulting and Clinical Ppsychology, 58, Glueckauf, R.L., Whitton, J.D. & Nickelson, D.W. (2001). Telehealth: The new frontier in rehabilitation and health care. In M.J. Scherer (Ed.), Assistive technology: Matching device and consumer for successful rehabilitation (pp ). Washington, DC: APA. Goss, L & Anthony, K. (2006). Technology in counselling and psychotherapy. A practitioner s guide. Counselling and Psychotherapy Research, 6, Grohol, J. (1999). The insider s guide to mental health resources online. New York: Guilford. Haberstroh, S., Duffey, T., Evans, M. & Trepal, H. (2007). The experience of online counselling. Journal of Mental Health Counseling, 29, Hanley, T. (2008). The therapeutic alliance in online youth counselling. Unpublished PhD Thesis, University of Manchester. Hopps, S.L., Pepin, M. & Boisvert, J. (2003). The effectiveness of cognitive-behavioural group therapy for loneliness via inter-relay chat among people with physical disabilities. Psychotherapy: Theory, Research, Practice, Training, 40, Horvath, A.O. & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, Hufford, B.J., Glueckauf, R.L. & Webb, P.M. (1999). Home-based interactive video-conferencing for adolescents with epilepsy and their families. Rehabilitation Psychology, 44, Knaevelsrud, C. & Maercker, A. (2006). Does the quality of the working alliance predict outcome in outline psychotherapy for traumatized patients. Journal of Medical Internet Treatment, 8(4), e:31. Koehn, D. (2003). The nature of and conditions for online trust. Journal of Business Ethics, 43, Krupnick, J.L., Sotsky, S.M., Simmens, S., Moyer, J., Elkin, I. & Watkins, J. (1996). The role of the therapeutic alliances in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health treatment of depression collaborative research programe. Journal of Consulting and Clinical Psychology, 64, Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectical therapists. In M.R. Goldfried & J.C. Norcross (Eds.), Handbook of psychotherapy integration (pp ). New York: Basic Books. Lambert, M.J. & Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield s handbook of psychotherapy and behaviour change (5th ed., pp ). New York: John Wiley & Sons. Leibert, T., Archer, A., Munson, M. & York, Y. (2006). An exploratory study of client perceptions of internet counselling and the therapeutic alliance. Journal of Mental Health Counselling, 28, Marshall, W.L. & Serran, G.A. (2004). The role of the therapist in offender treatment. Psychology, Crime & Law, 10, Mallen, M.J., Vogel, D.L., Rochlen, B. & Day, S. (2005). Online counselling: Reviewing the literature from a counselling psychology framework. The Counselling Psychologist, 33, Mearns, D. & Thorne. B. (1999). Person-centred counselling in action. London: Sage. Osborn, M. & Smith, J. (1998). The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis. British Journal of Health Psychology, 3, Robbins, S.B. (1992). The working alliance. In M. Patton & N. Meara (Eds.), Psychoanalytic counselling (pp ). Chichester, UK: Wiley. Rochlen, A.B., Zack, J.S. & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60, Rogers, C.R. (1951). Client-centred therapy: It s current practice, implications and theory. London: Constable. 32 Counselling Psychology Review, Vol. 24, No. 2, June 2009

35 Trust in online therapeutic relationships Schultze, N.-G. (2006). Rapid communication. Success factors in internet-based psychological counselling. Cyberpsychology & Behaviour, 9, Simpson, J.A. (2007). Psychological foundations of trust. Current Directions in Psychological Science, 16, Smith, J. & Osborn, M. (2003). Interpretative Phenomenological Analysis. In J. Smith (Ed.), Qualitative Psychology (pp.51 80). London: Sage. VandenBos, G.R. & Williams, S. (2000). The internet versus the telephone: What is telehealth, anyway? Professional Psychology: Research and Practice, 31, Vossler, A. & Hanley, T. (2009, in press). Online counselling: Meeting the needs of young people in late-modern societies. In J. Leaman & M. Woersching (Eds.), Youth in contemporary Europe. London: Routledge. Wampold, B.E. (2000). Outcomes of individual counselling and psychotherapy: Empirical evidence addressing two fundamental questions. In S.D. Brown & R.W. Lent (Eds.), Handbook of counselling psychology (3rd ed., pp ). New York: John Wiley. Wright, J. (2002). Online counselling: Learning from writing therapy. Journal of Guidance and Counselling, 30, Young, K. (2005). An empirical examination of client attitudes towards online counselling. CyberPsychology and Behaviour, 8, Counselling Psychologists TalkShop The aim of this group is to provide a place to talk about counselling psychology. We are especially interested in issues that concern trainees but don t want to limit the group to this. If an issue is important to you, the chances are it is important to others too. To join the group send an to [email protected]. You will then be sent an invite from Yahoo! If you are not already a Yahoo user you will have to sign up first. The whole process of joining Yahoo! and the TalkShop takes about five minutes. (Counselling Psychologists TalkShop is an e-group run on a voluntary basis by Therese Paterson, the Independent Trainee Representative to the Division of Counselling Psychology.) Counselling Psychology Review, Vol. 24, No. 2, June

36 A trial of client-centred counselling over the telephone for persons with ME Tony Ward & Kevin Hogan The study described in this paper was designed to evaluate the potential of client-centred telephone counselling for people with Myalgic Encephalopathy (ME). Fourteen participants were recruited via the main ME associations, and offered up to eight sessions of telephone counselling. The CORE measure was completed before and after, and change compared to scores collected during a waiting list phase. A paired t-test showed that overall scores improved significantly, and the counselling was rated very highly in terms of usefulness. Clients were followed up several weeks after the end of the counselling and asked to rate, using a 10-point Likert scale, the intervention in terms of the core client-centred principles. They were asked about their reactions to the counselling, how useful it was, and whether they had any comments on the work being telephone-based. These interviews were transcribed and subject to thematic analysis. Session transcripts were also reviewed to identify the core presenting issues. Whilst telephone counselling might seem somewhat limited compared to face-to-face methods, participant feedback suggested that it was acceptable. The conclusion is that client-centred methods delivered over the telephone can be an effective form of intervention for clients with ME. Keywords: client-centred, telephone counselling, myalgic encephalopathy. MYALGIC ENCEPHALOPATHY (ME)/ Chronic Fatigue Syndrome (CFS) is characterised by fatigue, post exertion malaise, sleep dysfunction and pain. There are also typically neurological and/or cognitive symptoms such as difficulties with memory and concentration. Furthermore, some definitions also specify issues in at least one of either neuroendocrine, immunological or autonomic domains. For a diagnosis this pattern should have been ongoing for more than six months (Carruthers et al., 2003). ME is a complex condition which presents clients with many challenges. The onset of puzzling symptoms which are difficult to make sense of can cause considerable anxiety. Persistent symptoms of fatigue and cognitive processing deficits can be highly disruptive to clients lives, provoking changes in relationship and loss of role (Sterling, 2003; Ward et al., 2008). Furthermore, the contested nature of ME presents additional difficulties (Clark & James, 2003). Clients may have to face sceptical views from both relatives and health professionals, and indeed may have to examine their own past attitudes towards the condition. The notion that ME is predominantly psychological persists, despite good evidence for physical aetiology in at least a subset of cases (Komaroff, 2006). Psychological interventions for ME have tended to be based on Cognitive Behaviour Therapy (CBT), and the notion that there may be perpetuating factors (Ridsdale et al., 2001). Such factors might include negative cognitions or unhelpful beliefs, for example, about the effects of trying to increase levels of activity. There have been many trials of such approaches, for example, Ridsdale et al. (2001) and Wittowski (2004). Such interventions appear to yield some long-term benefits (Deale et al., 2001). However, not all such trials have proved effective for example Bazelmans et al. (2005). There is debate in the literature about what the aims of such interventions should be, either to maximise the clients level of functioning or reduce fatigue to 34 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

37 A trial of client centred-counselling over the telephone for persons with ME non-clinical levels. If the latter is the case then such interventions are not particularly effective, for example, Severens et al. (2004) achieved 27 per cent remission in a group receiving CBT, compared to 20 per cent in a control group. Whilst some clients with ME describe their past experiences of CBT in very positive terms, some are highly critical (Ward et al., 2008). There is evidence for effectiveness of more generic counselling interventions (Thomas et al., 2006; Thomas & Smith, 2007). However, these studies are eclectic in terms of intervention design, leaving it unclear as to which specific components are effective. A large-scale study (Ridsdale et al., 2001) appears to indicate that non-directive, client-centred therapy is as effective as CBT. The authors of this study describe the intervention in these terms: This model of counselling is non-directive and client-centred; it offers the patient an opportunity to talk through their concerns and difficulties in a non-judgmental and supportive environment. (p.20). However, in another part of their paper they describe the approach as psychodynamic, making it unclear exactly what approach the counsellors were using, other than that it was originally intended to serve as a control for comparison with CBT. Thus whilst there are some indications that interventions other than CBT can be helpful for ME, there is scope for further work on this issue. In addition it is clear that many people with ME suffer from restricted mobility (Thomas & Smith, 2007), and they often, therefore, access services remotely (Ward, 2008). It would be useful, therefore, to evaluate the efficacy of services provided at a distance. Whilst telephone counselling undoubtedly has limitations (see, for example, Haas et al., 1996), there are indications that it can be an effective medium for offering therapy (Rosenfield, 1996; Sanders, 2007). Previous research has found that clients who have had telephone counselling rate the quality of relationship as high as those that have had face-to-face interventions, and outcomes can be equivalent (Reese et al., 2002). Encouragingly from the perspective of potential clients with ME, the attractive features of the telephone medium tend to be its convenience and accessibility (Reese et al., 2006). This study, therefore, set out to evaluate the provision of telephone counselling for clients with ME, using a client-centred approach (Rogers, 1951; Gillon, 2007). Our rationale for this choice of model was that people with ME may benefit from exploring some of the issues which affect them in an accepting and supportive environment, over and above the focus on perpetuating factors at the heart of many CBT studies. Of course, this is not to say that a clientcentred approach would preclude any examination of perpetuating factors, only that this would be done at a point appropriate to the client and on their terms. The study aims to evaluate the intervention both in terms of routinely used outcome measures (Evans et al., 2000, 2002) and in terms of client ratings of utility and perception of the core conditions (Rogers, 1951). The latter were based on four, Likert-scale items, each of 10 points. We also wished to gain some idea of the kinds of issues discussed by clients with ME, and gain some impression of their perceptions of working therapeutically via the telephone, and determined that qualitative methods would best suit this purpose. The study, therefore, uses mixed methods to evaluate the approach (Creswell, 2003). Methodology Participants Fourteen participants were recruited via announcements in the newsletters of the ME Association and the Action for ME charity. The mean age was 48 (standard deviation 12, range 28 to 63), and there were 10 females and four males. The data from a single 58-year-old female participant was not included, since it emerged during sessions that there was a co-morbid medical issue which predominated. Counselling Psychology Review, Vol. 24, No. 2, June

38 Tony Ward & Kevin Hogan Ethics This study was approved by the ethics committee of Newman University College. The researchers and the College ethics committee work with the British Psychological Society s ethics code in mind (BPS, 2006). All participants signed a consent form, after being briefed about the study via telephone and receiving a written information pack. On receipt of the signed consent form they were entered into the study. Procedure Once accepted into the study, clients completed the 34-item CORE outcomes forms (Evans et al., 2000, 2002). They were then placed on a waiting list. After eight weeks on the waiting list, clients were asked to complete a second CORE form. This then provides a baseline of change across eight weeks of time spent on the waiting list. After completion of the second CORE form, clients were slotted into the next available intervention. A third CORE form was completed at the start of the intervention phase. Clients were offered up to eight sessions of telephone counselling, with the option of extending this if it was felt appropriate, for example, if there were concerns for the clients welfare at that point. All clients were offered the possibility of referral to local services. At the end of the intervention, clients completed a final fourth CORE form. All of the counselling sessions were offered by the first author, who is trained in the client-centred approach. Sessions were recorded so that themes could later be identified. The work was supervised by a chartered counselling psychologist. Approximately two weeks after the end of the final counselling sessions, the clients were contacted by the second author and interviewed about their experiences. During this interview the clients were asked to rate the counsellor in terms of their understanding of the clients issues (empathy), being genuine as a person (congruence) and valuing them as a person (unconditional positive regard). Each of these was rated out of 10, with zero being low and 10 being high. They were also asked to rate how useful they felt the sessions had been, again out of 10. During the semi-structured interviews, clients were invited to discuss their experience of telephone counselling as opposed to face-to-face counselling. (Two clients had previous experience of counselling, the rest did not. Thus for most clients this discussion was based on their expectations of how faceto-face counselling would differ.) These interviews were then subject to a thematic analysis to identify the main points raised. Session transcripts were also reviewed using thematic analysis to derive the main presenting issues. We were guided by Braun and Clark (2006) in conducting these analyses. Results Table 1 shows the mean process ratings given by clients after the end of the intervention. As can be seen from the table, clients rated the counsellor highly on the three dimensions. The usefulness of the intervention was rated reasonably highly on average, with the majority of ratings being six or more. The overall average was depressed by the ratings of two clients, who rated usefulness as one and three respectively. Table 1: Process ratings. Mean SD Counsellor understanding Valuing Genuineness Usefulness Table 2 shows the changes observed in the CORE measure in terms of the three subscales and the total score. The change across the intervention in the three CORE dimensions of well-being, problems and functioning was negative. This suggests that scores were improving. To see if the change during intervention was significantly different from that during the waiting list 36 Counselling Psychology Review, Vol. 24, No. 2, June 2009

39 A trial of client centred-counselling over the telephone for persons with ME Table 2: Means (and SDs) of CORE subscales, showing change and significance. Measure Waiting list Intervention CORE well-being CORE problems CORE functioning CORE risk CORE total score Before After Change Before After Change Significance 6.6 (2.6) 7.5 (3.4) 0.9 (1.9) 7.9 (3.6) 5.8 (3.2) 2.2 (3.8) t=2.1, p< (8.4) 23.6 (8.8) 1.6 (3.4) 24.0 (8.7) 19.5 (7.6) 4.5 (9.3) t=1.9, p< (5.8) 18.8 (6.2) 1.4 (2.6) 19.1 (6.5) 15.6 (8.1) 3.5 (6.3) t=2.2, p< (1.2) 2.4 (2.2) 0.6 (1.6) 1.5 (1.8) 2.7 (4.4) 1.2 (4.6) t=0.5, p> (13.5) 52.5 (15.8) 4.5 (5.8) 52.5 (16.2) 43.6 (21.4) 8.8 (22.0) t=2.0, p<0.05 phase, paired t-tests were carried out on the change scores, using a one-tailed test. The degree of change was significantly different to that observed during the waiting list period for these three variables. In contrast, the change in risk score across the intervention was positive, suggesting a deterioration, though there was no significant difference compared to the waiting list phase. The apparent deterioration in risk scores is due to three clients. All other clients either stayed the same or improved. For the three clients whose scores deteriorated, the changes were from zero to 14, one to seven and three to eight respectively. These clients will be considered further in the discussion. Themes covered during sessions Session transcripts were reviewed to identify the nature of client issues discussed. These included: Loss resulting from ME (e.g. of jobs, status, relationships). Difficulty in relating to others due to the misunderstandings of and attitudes about ME. Anger due to the way in which relatives had reacted to the client developing ME. Loneliness and isolation due to the physical and mental constraints of ME. Regret at not having made more of life prior to the onset of ME. Trying to adjust to the constraints of living with ME. Concern at whether one could be doing more to overcome ME. Of these the two themes which recur most frequently were dealing with the attitudes and misunderstandings of others, and the difficulty of making an adequate adjustment. In particular, clients are acutely aware of the need to pace themselves, but find this difficult because of the delay in their bodies physical reaction to exertion. Reactions to telephone counselling There were both positive and negative reactions to telephone counselling. On the positive side some clients recognised that it enabled them to access counselling because they were housebound. One client commented that it was pleasant being able to lie on the sofa and talk to someone, and use their imagination to think about what the other party might look like. One client felt it was helpful as she felt very self conscious. Negative comments were mainly about the disadvantage of lack of face-to-face contact, not being able to see what the other person is doing and not being able to access non verbal communication. On balance, therefore, whilst many clients felt there is something lacking in telephone work, there is a recognition that it offers a practical alternative where people are not able to get out and about, and where there is no local counselling provision. Counselling Psychology Review, Vol. 24, No. 2, June

40 Tony Ward & Kevin Hogan Discussion This study has reported a small trial of clientcentred telephone counselling for participants with ME. The clients rated the counsellor highly on dimensions of understanding, being genuine and valuing. There were significant improvements on three of the four dimensions measured by the CORE outcomes scale, and in the overall scores. The intervention was on the whole given high ratings for usefulness. These results, therefore, support those of previous studies such as Ridsdale et al. (2001) which have shown non-directive counselling to be a useful intervention for people with ME. They extend such findings in demonstrating that such beneficial effects can be delivered via the telephone, supporting previous studies on the use of this medium (Reese et al., 2002). Although this study has produced favourable outcomes on most of the dimensions measured by the CORE outcomes scale, it should be noted that this appears to be in part due to the fact that scores tended to increase slightly during the waiting list comparison phase of the study. Having said that, there were clear improvements across the intervention phase. The risk dimension of the CORE measure was the exception to the pattern described above. This showed a slight deterioration in scores, though this was not significant. This decline was due to three clients, one of whom showed a marked change from zero to 14. This client had suffered considerable work-related trauma due to trying to work for a number of years with the condition in the face of unsupportive management. During the sessions they were able to recognise the feelings they had been suppressing. The client was provided with additional sessions and subsequently they sought a referral from their GP and when followed up they were working with a trauma specialist. Thus the intervention allowed this client to recognise the impact of the condition and seek appropriate further referral. Of the other two clients whose risk scores increased, one had developed a physical complaint during the intervention which was affecting her mood, whilst the other had ongoing depression which she was being referred to a specialist for. To our knowledge, one additional client accessed further counselling after the study. In their feedback this client stated that she felt the intervention had been very useful in prompting her to explore some of her personal issues and that she had purposely sought out a clientcentred counsellor for this. The above discussion highlights that a short eight-session contract is insufficient for some clients in this population. This was recognised as a potential issue at the outset. We were very careful to inform the participants that this study was evaluating the use of a short contract. The possibility of additional sessions was held out, in case clients were in a difficult place in their process to terminate in session eight. It would be interesting to see in further work whether other types of client might come forward if a longer contract was offered. During the sessions, clients discussed a range of issues. Coming to terms with the condition, adjusting to its constraints and accepting the losses it imposed were common themes. The effects on relationships both within and outside the family were also explored by the majority of clients. The intervention was scored highly for usefulness by most clients, with a minimum of six and many eight and nines. There were, however, two exceptions to this who gave scores of one and three respectively. Both of these clients seemed to be trying out the intervention to see if it could make a real difference to their physical condition and symptoms. Such expectations seem to be around in the ME community due to the focus of many CBT services on restoring function. In the current authors opinion, this may be an unrealistic expectation for many clients with severe enduring ME, and therapists should be careful to explore client expectations at the outset of any intervention. 38 Counselling Psychology Review, Vol. 24, No. 2, June 2009

41 A trial of client centred-counselling over the telephone for persons with ME Following on from the above point, it may be important to consider the characteristics of the sample in this study. All participants were drawn from established ME charities. It may be that people who join and attend support groups represent a particular portion of the population of people with ME. In particular they may be people with more severe versions of the condition and experiencing enduring symptoms. All of the participants in this study had experienced serious impacts on their lives and work due to their condition. Most had experienced break up of relationships, and virtually all had been unable to continue work. Thus it is difficult to say how useful this intervention might have been with less severely affected clients. Another possible factor in recruiting people from support groups is that they may have been influenced by the support group s agenda. The ME support groups tend to lobby for services, and tend to take the view that ME is poorly supported and services offered are not always seen as appropriate. Thus the participants in the study may have seen taking part as a way of trying to ensure more resources are made available to the ME community. If so, they may have been more inclined to give positive results. Thus further work could usefully be carried out with clients recruited from other sources. In terms of the telephone intervention itself, this was felt to have limitations, but offered a practical way of accessing a service. The counsellor was aware of having to rely much more on the non-verbal cues offered through vocal intonation. Given that clients were in their own homes, interruptions to sessions were sometimes experienced, but this was not felt to be overly detrimental. Client comments about working on the telephone are very much in line with previous researchers in emphasising accessibility and convenience (Reese et al., 2006). It would be interesting to extend this research to see whether needing to feel in control and feeling inhibited are factors in the preferences for telephone counselling of clients with ME, as they were in the Reese et al. study (2006). It would also be interesting to see if there are members of the client group who would prefer to access services online as opposed to via the telephone, as some workers have found (King et al., 2006a), though there is some evidence that outcomes are better using the telephone (King et al., 2006b). This latter finding may be due to the limitations of text as a form of communication in online chat rooms (King et al., 2006a). It would also be interesting to explore the potential of online video conferencing systems for provision of counselling psychology services, as availability of broadband coupled with webcams and headsets is becoming widespread. A number of studies such as those mentioned above have looked at the provision of telephone counselling in terms of acceptability, effectiveness and outcomes, but there appears to be little work in terms of process. For example, one of our clients mentioned being able to lie back and imagine what the counsellor might look like. This prompts us to wonder what one might make of this mode of counselling utilising psychodynamic concepts such as transference. Also, this study utilised a client-centred approach, and, therefore, the question remains as to whether this medium can be effective for other ways of working. In conclusion, a client-centred telephone-based intervention does appear to allow clients to explore their experiences and challenges of ME in a supportive relationship, following their own direction. This allows clients to set their own agenda, and gives them a wide scope. In contrast, clients with ME can find other approaches limited and narrow in focus (Ward et al., 2008). Of course, we would expect counselling psychologists using a client-centred approach to be able to bring a wide variety of theoretical and psychological insights to bear on developing their empathy (Gillon, 2007), the exploration of which could provide additional fruitful avenues for research investigation. Counselling Psychology Review, Vol. 24, No. 2, June

42 Tony Ward & Kevin Hogan Acknowledgements This paper was presented to the Annual Conference of the British Psychological Society s Division of Counselling Psychology, Dublin, Some aspects of the work benefited from the financial support of the ME Association. We would like to thank Dr Brian Simpson, for his role in supervising the counselling work reported in this study. The Authors Dr Tony Ward Dr Tony Ward s background is in health and neuropsychology, and he has more recently moved into the counselling sphere. He is head of Psychology and Counselling at Newman University College and works mainly with clients who have ME, MS or head injury. Kevin Hogan. Kevin Hogan is a trainee counselling psychologist at Newman University College. Correspondence Dr Tony Ward Head of Psychology and Counselling, Newman University College, Bartley Green, Birmingham B32 3NT. [email protected] 40 Counselling Psychology Review, Vol. 24, No. 2, June 2009

43 A trial of client centred-counselling over the telephone for persons with ME References Bazelmans, E., Huibers, M.J.H. & Bleijenberg, G. (2005). A qualitative analysis of the failure of CBT for chronic fatigue conducted by general practitioners. Behavioural and Cognitive Psychotherapy, 33, British Psychological Society (2006). Code of ethics and conduct. Leicester: BPS. Braun, V. & Clark, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, Carruthers, B.M., Jain, A.K., De Meirleir, K.L., Peterson, D.L., Klimas, N.G., Lerner, A.M., Bested, A.C., Flor-Henry, P., Joshi., P., Powles, A.C.P., Sherkey, J.A. & van de Sande, M. (2003). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical working case definition, diagnostic and treatment protocols. Journal of Chronic Fatigue Syndrome: Multidisciplinary Innovations in Research, Theory, and Clinical Practice, 11, Clarke, J.N. & James, S. (2003). The radicalized self: The impact on the self of the contested nature of the diagnosis of chronic fatigue syndrome. Social Science & Medicine, 57, Creswell, J.W. (2003). Research design: Qualitative, quantitative, and mixed methods approaches (2nd ed.). Thousand Oaks, CA: Sage. Evans, C., Mellor-Clark, J., Margison, F., Barkham, M., McGrath, G., Connell, J. & Audin, K. (2000) Clinical outcomes in routine evaluation: The CORE-OM. Journal of Mental Health, 9, Evans, C, Connell, J., Barkham, M., Margison, F., Mellor-Clark, J., McGrath, G. & Audin, K. (2002). Towards a standardised brief outcome measure: Psychometric properties and utility of the CORE-OM. British Journal of Psychiatry, 180, Gillon, E. (2007). Person-centred counselling psychology an introduction. London, Thousand Oaks & New Dehli: Sage. Haas, L., Benedict, J. & Kobos, J. (1996). Psychotherapy by telephone: Risks benefits for psychologists and consumers. Professional Psychology: Research and Practice, 27, King, R., Bambling, M., Lloyd, C., Gomurra, R., Smith, S., Reid, W. & Wegner, K. (2006a). Online Counselling: The motives and experiences of young people who choose the internet instead of face-to-face or telephone counselling. Counselling and Psychotherapy Research, 6, King, R., Bambling, M., Reid, W. & Thomas, I. (2006b). Telephone and online counselling for young people: A naturalistic comparison of session outcome, session impact and therapeutic alliance. Counselling and Psychotherapy Research, 6, Komaroff, A.L. (2006). Is human herpesvirus-6 a trigger for chronic fatigue syndrome? Journal of Clinical Virology, 37, Reese, R., Conoley, C. & Brossart, D. (2002). Effectiveness of telephone counselling: A fieldbased investigation. Journal of Counselling Psychology, 49, Reese, R., Conoley, C. & Brossart, D. (2006). The attractiveness of telephone counselling an empirical investigation of client perceptions. Journal of Counselling and Development, 84, Ridsdale, L., Godfrey, E., Chalder, T., Seed, P., King, M., Wallace, P. & Wessely, S. (2001). Chronic fatigue in general practice: Is counselling as good as cognitive behaviour therapy? A UK randomised trial. British Journal of General Practice, 51, Rogers, C.R. (1951). Client-centered therapy. London: Constable & Robinson. Rosenfield, M. (1996). Counselling by telephone. London, Thousand Oaks & New Dehli: Sage. Sanders, P., (2007). Using counselling skills on the telephone. Ross-on-Wye: PCCS Books. Severens, J.L, Prins, I.B, van der Wilt, G.J, van der Meer, J.W.M. & Bleijenberg, G. (2004). Costeffectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM: An International Journal of Medicine, 97, Sterling, S. (2003). Clinical perspectives and patient experiences. In L.A. Jason, P.A. Fennell & R.R. Taylor, Handbook of chronic fatigue syndrome (pp ). Hoboken, NJ: John Wiley & Sons. Thomas, M., Sadlier, M. & Smith, A. (2006). The effect of multi-convergent therapy on the psychopathology, mood and performance of chronic fatigue syndrome patients: A preliminary study. Counselling and Psychotherapy Research, 6, Thomas, M. & Smith, A. (2007). An evaluation of counselling and rehabilitation courses for chronic fatigue syndrome. Counselling and Psychotherapy Research, 7, Ward, T., Hogan, K., Stuart, V. & Singleton, E. (2008). The experience of counselling for people with ME. Counselling and Psychotherapy Research, 8, Wittkowski, A., Toye, K. & Richards, H.L. (2004). A cognitive behaviour therapy group for patients with chronic fatigue syndrome: A preliminary investigation. Behavioural and Cognitive Psychotherapy, 32, Counselling Psychology Review, Vol. 24, No. 2, June

44 The use of online counselling within an Australian secondary school setting: A practitioner s viewpoint Kevin Glasheen & Marilyn Campbell This paper proposes that the provision of online counselling services for young people accessed through their local school website has the potential to assist students with mental health issues as well as increasing their help seeking behaviours. It stems from the work of the authors who trialled an online counselling service within one Australian secondary school. In Australia, online counselling with the adult population is now an accepted part of the provision of mental health services. Online provision of mental health information for young people is also well accepted. However, online counselling for young people is provided by only a few community organisations such as Kids Help Line within Australia. School-based counselling services which are integral to most secondary schools in Australia, seem slow to provide this service in spite of initial interest and enthusiasm by individual school counsellors. This discussion is the product of reflection on the potential benefits of this trial with a consideration of relevant research of the issues raised. It highlights the need for further research into the use of computer-mediated communication in the provision of counselling within a school setting. Keywords: online counselling, adolescents, school, mental health. THE INCREASING prevalence of mental health difficulties among young people is of major concern in Australian society (Sawyer et al., 2001). As many as onein-five Australian children aged from 4 to 17 have significant mental health concerns (Zubrick et al., 2000). It is calculated that by the age of 18, one-in-four teenagers will have at least one major episode of depression (Kessler, Avenevoli & Merikangas, 2001). The incidence of depression and anxiety amongst adolescents has profound consequences for their school performance, selfesteem and relationships (Avenevoli et al., 2008; Woodward & Ferguson, 2001). Further, many of these adolescents are reluctant to seek help, especially young men. Yet young Australian males have been shown to have poorer educational outcomes, more incarceration, illness and completed suicides than young women (Kids Help Line, 2003b; Sawyer et al., 2001). Australian governments have recognised the school as an appropriate place for delivering programmes which promote mental health and consequently have implemented such initiatives as MindMatters and KidsMatter (Department of Health and Ageing, 2000a, 2000b). As well as a venue for providing preventative programmes, the school is also seen as the front line for the identification and referral of students with major needs in the area of mental health to counselling services (Campbell, 2004). The Western world generally accepts counselling interventions as a means of providing the support for those who are experiencing intrapersonal and interpersonal difficulties. It is now common place to find counselling services within most communities. It is also increasingly common practice for counsellors to work in Australian schools, as it is logical to provide support at the place where most young people spend a great deal of time. School counsellors already play a significant role in assisting students who seek help (Rickwood, 1995) as after their general practitioner, school-based counselling services are 42 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

45 Online school counselling the most sought-out option by Australian young people (Sawyer, Miller-Lewis & Clark, 2007). Although there is acknowledgement that young people are at risk of developing mental health problems, it is just as concerning that many who do have such difficulties are reluctant to seek professional help. Just as there are gender differences in the incidence of mental health problems, so too there exists a gender imbalance in helpseeking behaviours. It has been established that boys are socialised to seek less help than girls (Rickwood et al., 2005). A survey of young male callers to Kids Help Line, a national telephone and online counselling service for Australian youth, found that although nearly half (49 per cent) wanted to discuss their emotional experiences, more often they were concerned that people would react negatively and they would be judged as crazy or uncool (Kids Help Line, 2003b). Additionally, they were afraid of being seen as weak and, therefore, concerned about being teased (Glasheen, 1998). These realities highlight the need for schools to instigate strategies such as internet counselling that assist young people to seek help at this crucial time of their development (Birleson, Sawyer & Storm, 2000). The internet and communication technologies play an ever increasing role in the social lives of young people in Western societies at present. Young people treat the mobile telephone as an essential necessity of life and often prefer to use synchronous chat such as Windows Live Messenger (MSN) to communicate with their friends (Campbell, 2005) as well as accessing social networking websites such as MySpace, FaceBook and the Australian site Ozlounge (for same-sex attracted youth). As technology and the internet are a familiar resource for young people, it is logical that they could seek assistance from this source. This has been shown by the increase in websites that provide therapeutic information for young people. A number of youth-friendly websites have been developed in Australia such as Reachout ( and Sane Australia s itsallright.org ( org) mental health site. The information presented often takes the form of Frequently Asked Questions, fact sheets and suggested links. Another form of using technology to assist in mental health problems is online counselling. For adults online counselling is available with the development of texts for practitioners (Kraus et al, 2004; Mallen et al., 2005). Online counselling for adults has shown a rapid increase in Australia (Gedge, 2002), however, there are not as many online counselling services for young people. Some community-based services provide online counselling which are open to young people, though these are often restricted to specific issues such as drug and alcohol use. CounsellingOnline ( org.au) is an Australian Government website where qualified drug and alcohol counsellors provide free online text-based counselling. The Australian community-based youth service, Kids Help Line, introduced and web counselling to complement the telephone help line in 1999 and 2000 (Kids Help Line, 2003a). In the UK, E-motion ( and Kooth ( provide online community counselling for youth (Hanley, 2004; 2007). In Singapore Metoyou ( org.sg) is an external counselling service which schools can subscribe to and make available to their students (Moulding, 2007). As young people have been shown to utilise these various, although limited online counselling services, there is a case for providing online counselling within the school setting by the resident school counsellor. Background One school-based online counselling initiative The difficulties faced by young people, the fact that many are reluctant to seek help and the popularity of technology led the authors to trial a limited service of online counselling in one Australian secondary school. An earlier study had indicated that student perceptions of counselling often caused Counselling Psychology Review, Vol. 24, No. 2, June

46 Kevin Glasheen & Marilyn Campbell males to be reluctant to seek out the school counsellor for assistance (Glasheen, 1998). Accumulated counselling data in the school, also confirmed the fact that boys in particular were reluctant to self-refer. Therefore, informal discussions were conducted with a group of male students to determine their views on using an online counselling facility through the school website. The themes of attractiveness, privacy and relative anonymity were identified by the students. That is, these male students believed a chat facility needed to be visually attractive and suggested inclusion of comic figures. Further, the importance of chat room security providing privacy as well as users not being required to reveal their identity, giving them relative anonymity, were the main factors valued by this group of boys (Glasheen & Campbell, 2008). Over a period of two years, which involved negotiations with computer technicians and school personnel, the ideas slowly crystallised into reality and the process became functional. By using software available through a systemic learning platform, a secure chat room was established through the school website. Students were able to request an appointment through an link on the website which prompted an automatic duty of care response which included telephone numbers and other directions for students experiencing an immediate crisis. Once the counsellor confirmed an appointment time, a unique log-on and password was forwarded to the student as an attachment. The student could then chat with the school counsellor at the appointed time in either a text-based or speech bubble (comic chat) genre. The choice of comic chat or textbased interaction was up to the student based on their needs, interests and age. If students chose to use the comic chat, they would select their own avatar. These avatars, which included a range of human and animal characters, were responsive to verbal cues. For example, if a student typed the word sad or angry, the facial expression of the character would be cued accordingly. As the initiative was planned in response to need, and not as a formal research project, there is no systematic data in the traditional sense for this trial. However, the following observations were noted. As the online service was utilised, it became obvious that in most cases, students followed up the online appointment with subsequent faceto-face consultations with the counsellor. The trial found that a diverse group of students use the online mode. Students with disabilities appeared to be less inhibited online and possibly they were less selfconscious of their impairments compared to face-to-face discussions with the counsellor. This supports earlier research conducted with adults with disabilities who felt a freedom to use the computer tools without the difficulties usually experienced by people who usually had difficulty manipulating various physical materials (Collie et al., 2002). The service was used across all secondary school year levels (12 to 18 age group). Boys were the main users and some students found a combination of face-toface and online modes beneficial depending on the presenting issue at the time. The issues discussed online included family conflict, sexual orientation and interpersonal conflict. These students also indicated some symptoms consistent with depression and anxiety which led to referrals to community agencies and general practitioners. The potential of developing mediation and conflict resolution processes was noted and the fact that hard or electronic copies of the counselling script could be used for reflection, analysis and record keeping, was considered useful. Students with more pressing issues and older students, tended to opt for the text-based genre. It was found that the students who chose to use avatars also enjoyed changing and playing with the options. This suggested to the authors the possibility of future research into the choice of avatars and how they may be a means of symbolic projection or a form of transference in the counselling process. By posing questions to the young person about 44 Counselling Psychology Review, Vol. 24, No. 2, June 2009

47 Online school counselling their selection of avatar, valuable insights may be gained into the young person s immediate mental state or mood. A study of how avatar selection can contribute to presenting a more comprehensive impression of the client and possibly how it compensates for the lack of other visual cues could contribute to a more effective counselling process. Awareness of this online counselling initiative in a secondary school setting resulted in the authors being asked to address various professional groups. Individual counsellors sought further information about the initiative and a number of seminars and local workshops were arranged. It was of interest to the authors that even though participants at these events showed great interest and enthusiasm, to date, there has been no uptake of online counselling in schools. This lack of implementation by school counsellors has challenged the authors to consider the factors that inhibit the practice of online counselling within the school setting, and a review of the relevant research provides possible insights. Why could there be a reluctance to use technology in school counselling? Counsellor competencies There are many school counsellors who are reluctant to fully engage with the new technology. Owen and Weikel (1999) found school counsellors were only moderately confident in their use of computers with some authors speculating that the personality types who are attracted to school counselling are wary of technology (Myrick & Sabella, 1995). They describe themselves as people people or not technically minded. Othman (2000) in an exploratory study indicated that school counsellors were unready and unprepared to use the internet to conduct online counselling sessions. Another difficulty could be the issue of a perceived lack of control by counsellors in the therapeutic relationship conducted online. As Wright (2002) argues, this is because online work subverts traditional power relationships between counsellors and clients. School counsellors might be even more susceptible to the loss of this traditional power relationship than others because of the additional adult-child relationship already existing within the therapeutic relationship and the school. Another major difficulty that faces school counsellors at the moment is the lack of training in counselling with the new technologies. This applies both to the courses of preparation for school counsellors as well as professional development for practicing school counsellors. Often counsellors are concerned (as are some clients) that the lack of non-verbal messages will hinder the counselling therapeutic process and will fundamentally undermine the achievement of an effective counselling relationship. The absence of voice tone, body language, expression and eye contact seem fundamental to the practice of traditional counselling. Counsellors at Kids Help Line found that apart from the many advantages of the online mode, the lack of emotional cues did make it difficult to ascertain the severity of the young person s emotional state and there was a need for strategies to overcome this difficulty (Bambling et al., 2008). Courses in the development of skills particular to a process that lacks visual and auditory communication cues, would need to be readily available to ensure effective therapeutic relationships are developed. The importance of such professional development was highlighted in the recommendations for youth online services in the UK (Hanley, 2006). Ethical issues Another concern for school counsellors is ethical issues; that is, will the students be properly cared for when engaging in online counselling? There are concerns about confidentiality, is it safe to talk? can be intercepted and unless the website is secure, confidentiality cannot be ensured. However, messages can either be encrypted or pass- Counselling Psychology Review, Vol. 24, No. 2, June

48 Kevin Glasheen & Marilyn Campbell word protected. Furthermore, it is very easy for the client to terminate counselling. However, this is a similar problem to telephone counselling which could also be overcome by asking the student for a telephone number, or an address for an emergency. Additionally, because the client can choose to be anonymous, there can be issues with informed consent if the client is a minor. There are, however, professional associations which publish ethical guidelines for practitioners wishing to use online counselling, such as the American Psychological Association (2003) and the Australian Psychological Society (1999). Guidelines specifically designed for online practice have also been published by the British Association for Counselling and Psychotherapy (Anthony & Jamieson, 2005). In some ways, ethical issues do not change with different mediums. However, as information and communication technology continues to change, ethical guidelines need to keep pace and be constantly updated. In particular, these guidelines need to specifically address the counselling of young people online, and promote the specialised skills required by practitioners when working with minors and vulnerable young people. Legal issues A further concern for school counsellors is what if something goes wrong? As members of a school community, school counsellors have a duty of care to the students. In an emergency situation, contact may need to be made with police or ambulance or a child welfare agency. However, it may not be possible to assist an anonymous client in locating support services (Robson, 2000). For Kids Help Line in 2002 there were six per cent of calls where help could not be given either because of the client terminating or that there was no appropriate service available in their area (Kids Help Line, 2003b). This needs to be weighed against the potential likelihood of the client not accessing help at all. Lack of evidence that online counselling is effective To date the research on the effectiveness of online counselling is limited in scope and breadth. Research with online counselling and adolescents is even scarcer, while online counselling by school counsellors is almost non-existent. Some researchers contend that as online relationships are different from face-to-face counselling relationships, no better or no worse, then comparing them is misguided (Anthony, 2000). However, research at least confirming that online counselling does no harm is needed. This can be reliably studied by comparing the results of the same type of programme or counselling conducted in both media. Some research comparing the effectiveness of online with face-to-face counselling has shown no difference in effectiveness between the modalities. For example, Cohen and Kerr (1998) compared the impact of computer-assisted and face-to-face techniques on client s level of anxiety and attitudes towards counselling and found no significant difference. King et al. (2006) have been tracking the effectiveness of the Kids Help Line counselling services and found that online counselling had less session impact and alliances than telephone counselling. However, this work indicated that online counselling has distinct advantages for some clients, and the factors that contribute to its effectiveness need further research. Potential benefits of online counselling There are instances where school counsellors embrace new technology, such as those who participated in innovative supervision of their counselling (McMahon, 2002). Others have participated in discussion groups (Rust, 1995), and use the internet for resources for students for providing information, especially career information and analysing assessments (Guillot-Miller & Partin, 2003). School counsellors also are using the internet for their own information, for professional development accessing websites, online journals and 46 Counselling Psychology Review, Vol. 24, No. 2, June 2009

49 Online school counselling newsletters (Myrick & Sabella, 1995). In addition, some school counsellors are using the internet to communicate effectively with diverse and troubled students (Guanipa, 2001). Zimmerman (1987) investigated the differences between computermediated and face-to-face interactions among emotionally disturbed adolescents. He found that computer-mediated communication was more expressive of feelings and made more frequent mention of interpersonal issues. The online counselling mode Research is developing on how to overcome the perceived inadequacies of the online modality such lack of emotional cues in textbased messages and promote the advantages. There are conventions which people use in text-based messages outside of therapy such as the size of the font, capitals for emphasis or SHOUTING, emoticons, semi-pictorial symbols for specific emotions, reactions or facial expressions, acronyms, changes in fonts and other techniques specific to online communication that help increase understanding (Wright, 2002). Moreover, Kids Help Line has developed interactive visual tools to enhance their online counselling service (KHL, 2003c). These tools, developed in conjunction with Queensland University of Technology s Creative Industries Faculty, provide more ways for young people to express themselves by showing their emotions rather than limiting their exchanges to describing their feelings in words. A counsellor can present to the client a set of icons or emoticons (coloured jewels) representing the most common emotions and a sliding scale from one to 10 to rate the intensity or frequency of their feelings. This gives added emotional expression to facilitate greater understanding similar to Murphy and Mitchell s (1998) emotional bracketing. In addition, an audio graphic telecommunication system that supports counselling by speech and sharable computer drawings which can be used with standard home computers is being developed with adults (Collie, Cubranic & Long, 2002). The system supports five tasks of speaking within the group, drawing, passing drawings, maintaining awareness of other group members activities and showing drawings to the other group members. The authors suggest that adolescents who might be averse to face-toface counselling are candidates for this mode of counselling delivery. The possible implications for working with students with disabilities were also highlighted by Collie s work. Though there is a lack of research into the effectiveness of online counselling, adult clients have accepted and adopted this mode of psychological support. These services are limited to fee for service private practices targeted at adult clients, or are communitybased health- and drug-related agencies. Much of the research of online counselling has been with university or college students. A study which investigated students perceptions of online counselling in an American suburban church school by Lunt (2004) found that almost 50 per cent of students would like the opportunity to access a counsellor from their home and also almost 40 per cent were comfortable giving information about themselves in their home setting, however fewer than 10 per cent were prepared to contact an online counsellor. Apart from this study which included student perceptions of online counselling, there appears to be a lack of research specifically into online counselling within schools. Online counselling in schools The provision of counselling within schools, gives students immediate access to a counsellor, who is usually known to them. This provision means that young people are not reliant on their parents to arrange and pay for professional counselling within the community. The ability of the adolescent to seek help without a parent s consent is appreciated in secondary schools. Even though most Australian schools have access to a school-based counsellor there are many students who do not make use of this service. Counselling Psychology Review, Vol. 24, No. 2, June

50 Kevin Glasheen & Marilyn Campbell A barrier to help-seeking behaviour in school situations could be the lack of anonymity for students in accessing the school counsellor, sometimes caused by the placing of the counsellor s room in the administration block. In addition, students need to be excused from classes to see the counsellor. Online counselling has the advantage of more flexibility. Instead of students missing classes, they can access the school counsellor at other times. The availability of an online counselling service within the school setting would give the young person more privacy and since no one is aware of the student accessing the school counsellor, it has the potential to reduce stigmatism from others. Online interactions by their nature are also more balanced in the power relationship between counsellor and client rather than the counsellor being deemed to be in charge of the session when conducted face-to-face. The client has more control online and there is a levelling of power differences between counsellor and client (Murphy & Mitchell, 1998). This is closely allied with the privacy online counselling affords, especially to boys who feel they might not be able to contain their emotions and embarrass themselves face-toface and are able, through an online counselling consultation, to stay relatively one-step-removed from the counsellor. Using computers may be particularly empowering for people who feel intimidated initially and adolescents who are familiar with technology and are averse to face-toface counselling could benefit by cyber counselling (Collie et al., 2002). This relative anonymity of the client is one of the main benefits that has been claimed for online counselling. There are some research studies which address how the anonymity of internet communications affects the quality of relationships formed online (Lea & Spears, 1995). Anonymity may make communication through the internet easier for young people who are socially awkward but nonetheless eager to connect to others (Wolak, Mitchell & Finkelhor, 2002). Kids Help Line (2003d) reported that many young people say they would never have sought help if online counselling was not available. Further, it has been reported that the issues that they discuss on line are more severe and complex. The young people reported that deeply personal issues and difficult and sensitive topics are easier to write than talk about (Kids Help Line, 2003c). Compared to those who used the Kids Help Line telephone service, those who accessed online counselling were three times more likely in 2002, to seek help for eating behaviours, mental health, suicide ideation, emotional and behaviour management, sexual assault and self-image. This could be explained by Huang and Alessi s (1996) finding that relationships formed online seem to be less inhibited, leading to faster intimate disclosures and frank, authentic responses. The benefits of technology for young people in particular have been identified as a way of overcoming their shyness and paranoia of meeting a therapist (Moulding, 2007; Nicholas, 2004) Additionally, the disinhibition effect of online communication creates the potential for students to be more open with the counsellor than in a face-to-face situation (Suler, 2003) Furthermore, both parties are able to make a record of the transaction and the student has more time to consider comments in what has been termed the zone of reflection and can re-read the counsellor s comment before responding to prompts and questions. Online counselling also means that there is a permanent record of the sessions. National helping agencies in Australia have limitations. Kids Help Line cannot provide online services to all the young people who are currently trying to access them (Kids Help Line, 2003d). Feedback from online clients, while acknowledging their satisfaction with the quality of the counselling, are dissatisfied with the accessibility to the services and the delays in response. School counsellors could meet some of this demand. Furthermore, from a school 48 Counselling Psychology Review, Vol. 24, No. 2, June 2009

51 Online school counselling perspective the advantage over a national helpline is that the counsellor is able to offer face-to-face counselling if trust is built over time. As Sampson and Kolodinsky (1997) suggest, after becoming more secure in the counselling relationship the client may be willing to meet in person. Adolescents already meet in person with each other after chatting online, especially if the new friend lives in the vicinity (Wolak et al., 2002). Further, the school counsellor, being in the same area as the student, can offer further help and support by knowing and accessing local services within the student s own community, which is difficult through a national helpline. Cooper (2006) in his evaluation of Scottish counselling services has highlighted the preference of students for counsellors to be school-based. However, online counselling has to be used appropriately. As Harun, Sainudin and Hamzah (2001) found in their study, while 52 per cent of students from a private Malaysian college were willing to participate in e-counselling sessions, 42 per cent were unsure, with the remainder totally rejecting the idea. One 17-year-old student commented to the school counsellor that contact was OK but he felt that face-toface was also required for a real relationship (Campbell & Gardner, 2003). As the relevant research suggests, online counselling services in schools may provide an alternative pathway to appropriate professional help for students. Therefore, its implementation deserves consideration by school counsellors. However, training needs to be available based on current research findings as well as ongoing research relevant to practitioners in the school is necessary. The challenge for professional school counsellors is how to utilise this exciting and dynamic resource. Conclusion Online counselling could be a valuable tool for the school-based counsellor in assisting young people to seek appropriate professional mental health care. It has become an accepted psychological intervention with the adult population and as young people turn increasingly to the internet and online services for information and assistance, it is logical that this form of counselling needs to exist within the school domain. As school counsellors often identify students at risk, they are well placed to know the local factors and the networks operating in the young person s local environment. Students are usually aware of the school counsellor, and being able to communicate with this person online allows them to safeguard their identity, privacy and sense of control yet knowing who the counsellor is. This is particularly important for boys who seek counselling. The implementation of such a school-based service by the authors indicated the potential of online counselling in a school setting. The many concerns often posed by those wary of such initiatives were not evident in this small trial and further research into its use in schools would provide valuable information for those practitioners wishing to utilise this form of computer mediated communication in the counselling process in schools. The Authors Kevin Glasheen & Marilyn Campbell Queensland University of Technology. Correspondence Mr Kevin Glasheen School of Learning and Professional Studies Education Faculty, Queensland University of Technology, Kelvin Grove 4059, Brisbane, Australia. Tel: Fax: [email protected] Counselling Psychology Review, Vol. 24, No. 2, June

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54 The experience of implementing, recruiting and screening for an online treatment for depression in a naturalistic setting Derek Richards, Ladislav Timulak, Yvonne Tone, Chuck Rashleigh, Annemarie Naughton, Deir dre Flynn & Orla McLoughlin At a time when the prevalence and severity of mental health difficulties presented at mental health services increases alongside a continuing demand on resources, services are beginning to look at new ways to innovate service delivery. Using technology to provide psychological treatments is relatively new, but has demonstrated positive results. Students are high users of the internet and related technologies and are of an age most associated with internet use for seeking health information and even treatments online. An online treatment for depression was implemented at the Student Counselling Service, Trinity College Dublin (TCD). The paper describes the online treatment, its implementation as a pilot and discusses the experiences both positive and challenging that were met in recruiting and screening participants. The experience will be useful and of interest to clinicians and researchers who may be considering similar online interventions as part of routine mental health service delivery. Keywords: RCT design, depression, online treatments, online counselling, ccbt. IT IS ESTIMATED that approximately one-in-four people experience a significant episode of mental illness during their lifetime (Knapp et al., 2007). For students it is this period of life that witnesses the onset for numerous mental health disorders such as depression, phobias, eating disorders and schizophrenia (Rana, Smith & Wlaking, 1999; Health Service Executive, 2005). The prevalence and severity of mental ill health among students has increased placing a greater demand on Mental Health Services that generally have not seen increases in resources (Rana et al., 1999; Stanley & Manthorpe, 2002). Reduced or delayed access can diminish the benefit of early intervention (Royal College of Psychiatrists, 2003). In response some services have made efforts at innovating delivery. Since 2005 Trinity College Dublin has successfully delivered mental health care using technology, providing to students online counselling, online peer support and psycho-educational content (Richards & Tangney, 2008). Students are the highest users of the internet and related tools in Ireland (Demeuter, 2005); therefore, it made sense to innovate using technology. The perceived benefits of engaging technology, such as accessing a wider audience, acting as a gateway to other services, extending opening hours, and providing an on-time, on-demand service, have been realised (Richards & Tangney, 2008; Richards, 2008, in press). This paper describes a pilot implementation of an online treatment for depression in a naturalistic setting and discusses the experiences, positive and challenging, that the recruitment and screening presented. The paper does not seek to report the users treatment outcomes, but rather seeks to elucidate some of the issues that a mental health service can face in implementing an online intervention. 52 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

55 The experience of implementing, recruiting and screening Background and literature Depression and students In the last number of years mental health services have noted an increase in depression and related mood disorders (Rana et al, 1999). This is a concern because there is an established link between depression, mood disorders and suicidal ideation and plans (Gotlib, & Hammen, 2002). Issues such as age (Rana et al., 1999), academic stress (Tyrell, 1992; Stewart-Brown et al., 2000), financial constraints (Stanley & Manthorpe, 2002), drug and alcohol use, and poor coping strategies (Hope et al., 2005; Ramstedt & Hope, 2005), can increase vulnerability to mental health difficulties. Generally the first episode of depression is experienced in the early 20s (Rana et al., 1999), and many young adults may be reluctant to seek traditional forms of help and may appreciate the option of online support (Mitchell & Gordon, 2007). In response to the high incidence of depressed students seeking help at the University counselling service it was decided to implement an online treatment for depression. The implementation of the online treatment is part of a Randomised Controlled Trial (RCT) investigating therapist-led and client-administered treatments for depression (Richards & Timulak, 2008). Online treatments and screening Studies have been published investigating online treatments for depression. Many of these have been randomised controlled trials, others open trials and the populations investigated largely community samples. A noted exception is the O Kearney (O Kearney et al., 2006) study investigating an online treatment for depression with high school students. Online treatments have mostly been cognitive and behavioural (CBT) based programmes, usually comprising six to eight sessions of specific CBT strategies and homework tasks. The numbers investigated in these studies have varied (Wright et al., 2005; Clarke et al., 2005; Van Straten et al., 2008; Spek et al., 2007, 2008). Some studies include therapist contact with users throughout the programmes, others include no contact and still others include contact with some other, though not a trained therapist (Marks et al., 2007). The results of these investigations have been largely positive. For example, based on the research conducted on the Beating the Blues programme led the National Institute for Clinical Excellence (NICE) to recommend the programme for the treatment of depression and anxiety (NICE, 2006). Marks (2007) recent review of the studies in this area concludes that the results of clinical effectiveness are encouraging. However, research is required to determine the best type, frequency, and duration of human support for users, and the cost implications of various implementation models (Marks et al., 2007). The studies referenced include screening measures administered online. The literature on online screening is generally positive, demonstrating that data collected equals results produced in face-to-face data collection, without compromising psychometric properties (Spek et al., 2008; Vallejo et al., 2007). Computerised measures have advantages over paper-and-pencil administration, for instance, all data are collected and stored in real-time and human error in post-screening data entry is eliminated (Barak & English, 2002). Design and implementation This paper describes the implementation of an online treatment for depression in a naturalistic setting. The pilot is part of a large Randomised Controlled Trial (RCT) researching the effectiveness of online interventions for depression (Richards & Timulak, 2008). What follows describes the online treatments that were available, the screening procedure and eligibility criteria that applied, and the results of the recruitment and allocation of participants. Finally, the discussion attempts to elucidate some of the key issues for mental health services in implementing an online intervention. Counselling Psychology Review, Vol. 24, No. 2, June

56 Derek Richards et al. Description of the treatments CBT for depression has been shown to be at least as effective as other treatments and has an enduring effect in preventing relapse (Hollon et al., 2002). The online interventions included two CBT-based online treatments for depression. One consisted of therapist-led online counselling. The second was a self-administered software programme called Beating the Blues, with minimal therapist contact. Beating the Blues is a ccbt (computerised cognitive behavioural therapy) programme utilised to treat depression and anxiety (Proudfoot et al., 2003b; 2004). Each intervention includes eight sessions of online treatment comprising cognitive-behavioural interventions, including psycho-education, written assignments, self-monitoring, cognitive-restructuring, behavioural change, and relapse prevention strategies. In addition to the specific CBT aspects of the treatment, the online counselling condition included counsellors, through text, cultivating non-specific treatment factors that develop the therapeutic relationship including such generic skills as conveying of empathy, normalising, responding to the client s emotions, and validating successes. Eligibility and access to the online treatments A range of screening measures were used to determine suitability including the Brief Symptom Inventory (BSI), The Beck Depression Inventory (BDI), the Clinical Outcomes in Routine Evaluation (CORE-OM-10), and a locally constructed measure that assessed for medication use, alcohol and drug use and any recent medical diagnosis. The primary eligibility criteria were that participants scored 14 to 29 on the BDI. This ensured a mild to moderate range in symptoms of depression. Table 1 outlines the exclusion criteria established for each of the instruments. Screening was entirely online and eligible participants were randomly assigned to either therapist-led Online counselling [OC] using CBT principles or client-led Beating the Blues [BTB] CBT depression programme. Methodologically, online screening and psychological interventions online are a departure from traditional delivery, therefore, each phase of the design was independently assessed and granted ethical approval by the School of Psychology Ethics Committee. Implementation of the pilot On 30 March, 2008, the college community (N=15,000) were invited by to take part in the online treatment for depression study. Students of the university self-selected to participate. The provided a link to a website that described the study and the available treatments. Recruitment stayed open for two weeks. Participants registered with the website and after receiving informed consent progressed through an online screening, completing the measures outlined earlier. Computer algorithms determined scores on the questionnaires and whether or not a participant met any of the established exclusion criteria (Table 1). After screening participants were randomly allocated to either of the active treatments or deemed ineligible and excluded. Results Seventy-eight students chose to participate and initially 20 were assigned to one or other of the two active treatment conditions. The remainder (N=58) were excluded because they were deemed ineligible (see Table 1). After screening (see Figure 1) seven were excluded on the basis of Exclusion A: participants who scored below the 14 cut-off point on the BDI and in addition were not excluded on any other criteria. Five were excluded on Exclusion B: those who scored above the 29 cut-of point on the BDI and in addition were not excluded on any other criteria. The 12 students who met Exclusion A or B were offered use of the Beating the Blues programme, but not as part of the study: two availed of the programme. The remaining 46 were excluded on the basis of Exclusion C: they met, on one count or more; the established exclusion criteria (see Table 2). 54 Counselling Psychology Review, Vol. 24, No. 2, June 2009

57 The experience of implementing, recruiting and screening Table 1: Exclusion criteria as established for each of the instruments. Instrument Item No. Indicator Scale Criteria BDI 9 Suicidal thoughts or wishes or above BDI 2 Pessimism or above CORE-OM-10 6 Suicidal plans or above BSI 3 Psychoticism or above BSI 9 Suicidal ideation or above BSI 24 Paranoid ideation or above HISTORY 7 Currently on medication More/less than More than 6 months 6 months HISTORY 8 Alcohol and drug misuse Yes/No Yes HISTORY 9 Recent medical diagnosis Yes/No Yes HISTORY 11 Organic mental health disorder Yes/No Yes diagnosis BDI=Beck Depression Inventory; CORE-OM=Clinical Outcomes in Routine Evaluation Outcome Measure; BSI=Brief Symptom Inventory. Figure 1: Exclusions. Counselling Psychology Review, Vol. 24, No. 2, June

58 Derek Richards et al. Table 2 Students who met the exclusion criteria (N=46). Instrument Item No. Indicator Criteria No. of participants BDI score 29 Borderline and into severe Range or above symptoms BDI score cut off BDI 9 Suicidal thoughts or wishes 2 or above 7 A: I would like to kill myself A: I would kill myself if I had the chance BDI 2 Pessimism 3 or above 10 A: I do not expect things to work out for me A: I feel my future is hopeless and will only get worse CORE-OM-10 6 Suicidal plans 1 or above 20 Q: I have made plans to end my life BSI 3 Psychoticism 2 or above 12 Q: The idea that someone else can control your thoughts BSI 9 Suicidal ideation 1 or above 38 Q: Thoughts of ending your life BSI 24 Paranoid ideation 1 or above 41 Q: Feeling that you are watched or talked about by others HISTORY 7 Currently on medication More than 3 Q: Are you currently on 6 months medication for depression? HISTORY 8 Alcohol and drug misuse Yes 15 Q: Has your use of alcohol or other drugs ever meant that you couldn't fulfil your commitments to your studies? HISTORY 9 Recent medical diagnosis Yes 1 Q: Has your experience of depression been preceded or coincided with a diagnosis of a severe medical condition? HISTORY 11 Organic mental health disorder Yes 0 diagnosis Q: Have you ever been diagnosed with schizophrenia or other psychotic disorder? 56 Counselling Psychology Review, Vol. 24, No. 2, June 2009

59 The experience of implementing, recruiting and screening Table 3: Excluded based on second assessment (N=22). Assessment Outcome Number F:F assessment No further follow-up required case closed 7 F:F assessment Referred to GP 1 F:F assessment Ongoing F:F counselling 9 Telephone assessment No further follow-up required case closed 1 Referred to tutor for follow-up Tutor followed-up with client case closed 4 F:F = face-to-face Table 2 shows the number of participants who scored above the cut-off points on each of the established exclusion criteria. The criteria are not mutually exclusive and many participants scored above the cut-off on more than one item. As part of the research study the primary author, Derek Richards, had already devised a protocol for how to proceed with clients who met exclusion C criteria. The Exclusion C cohort (N=46) were further assessed through a variety of means (Face-to-Face (F:F) assessment, telephone calls, ) and 22 were further excluded from the study and, if deemed appropriate, referred to other appropriate sources of help (Table 3). Of the remaining 24, 20 students did not receive a F:F assessment, an assessment was made of their screening scores and a clinical decision made. Students were informed by of the outcome of this assessment: 11 were deemed eligible to use Beating the Blues independent of the study, nine were deemed eligible and incorporated into the study being assigned to either Beating the Blues (N=6) or online counselling (N=3). The remaining four students received a F:F assessment, one was deemed eligible to use Beating the Blues outside of the study, three were eligible for inclusion into the study and assigned to either Beating the Blues (N=1) or online counselling (N=2). All 22 students were initially called by telephone and/or contacted by before receiving F:F assessments. The TCD tutorial system assigns a tutor to each student for their time at the university they act as a support academically and personally for students. Figure 2 displays the flow of participants. Of the 78 screened, 56 (72 per cent) were offered online treatment of whom 46 (59 per cent) went on to receive treatment online. 32 (41 per cent) were included in the study (BTB:16 and OC:16) and 14 using BTB outside of the study. 10 (13 per cent) declined the offer of treatment online. The remaining 22 (28 per cent) were referred to appropriate support (Table 3) and only nine (12 per cent) went into F:F counselling. Discussion The implementation, recruitment and screening for the online treatment presented clinical and administrative challenges for the service. This experience is a useful learning in bringing online treatments forward in a positive and manageable way. Some of the more salient aspects of this experience are discussed. Follow-up It is hard to predict the uptake of online services which makes resource allocation a challenge. This service was marketed to the college population (N=15,000). After two weeks, based on high interest and the numbers of participants meeting the established exclusion criteria, the study was closed. This included participants scoring above the 29 cut-off mark on the Beck Depression Inventory (BDI), potentially representing severe symptoms of depression (N=34); it also included those who were deemed ineligible due to suicidal ideation (N=7 on the BDI; N=38 on the BSI) or suicidal plans (N=20 on CORE-OM), or Counselling Psychology Review, Vol. 24, No. 2, June

60 Derek Richards et al. Figure 2: Flow of participants. Participants screened N=78 Included N=7 Excluded A N=7 N=1 BTB Excluded B N=5 N=1 BTB Excluded C Further Assessed N=46 OC N=11 BTB N=9 OC N=5 BTB N=7 BTB Ex Study N=14 Excluded N=22 OC N=16 BTB N=16 BTB = Beating the Blues programmr; OC = Online Counselling; BTB Ex Study = Using the Beating the Blues programme but not as part of the study. 58 Counselling Psychology Review, Vol. 24, No. 2, June 2009

61 The experience of implementing, recruiting and screening other criteria (see Table 2). The numbers excluded (N=46) were high in proportion to the number of students screened (N=78). The exclusions presented the service with a duty of care to follow-up as described earlier in this paper. The launch was at peak time for appointments and follow-up by telephone, , and face-to-face assessment for 46 students, some potentially at risk, meant prioritizing tasks. The follow-up thus placed a notable strain on resources. All 46 were contacted by telephone/ and 26 received a further face-to-face assessment of one hour. While follow-up was demanding, it was also positive as 24 students were thereafter referred into the online treatment for depression. Assessing risk over the telephone and at a distance required a different skill for counsellors. Some students proved difficult to contact, for example, Erasmus students located in other European countries. These are significant points and demonstrate the importance of counsellor training for assessment and online work. It also demonstrates the positive potential for access to services delivered online, and highlights the importance of providing adequate duty of care to such users. Protocols need to be developed for working online with students who are abroad. These will need to address both clinical and administrative issues. While it is difficult to predict uptake and potential exclusions it is now obvious that inviting the whole college community to participate in the first week was incredibly ambitious. A phased offering to the student population is advised. The timing of the launch of projects like this is also important due to the unpredictability. The treatments offered were eight-week programmes. The College is on a 10-week term, and the timing may not have allowed clients enough flexible time to complete the eight sessions as the exams were approaching. This may have implications for take-up and/or attrition rates. Online Screening While the literature to date regarding online screening is positive our own experience would challenge this. For example, of the 20 students who indicated suicidal plans (Table 2), after assessment those deemed to be actively suicidal were very few. This is similar to the experience of counsellors in face-toface counselling. Similarly students who expressed suicidal thoughts or wishes on the BDI measure (N=7) when checked in with did not appear suicidal. Again, this was similar for the 38 students who answered positively to the question assessing suicidal ideation on the BSI measure. One hypothesis may relate to the fact that this reporting-pattern relates to the online disinhibition effect, another hypothesis may be that it highlights how online screening may be open to a high level of inaccurate reporting. Further research is required to attempt to answer these questions. At the same time online screening has many benefits and exploiting these can be useful to researchers (Barak & English, 2002). Furthermore, and on reflection, our eligibility criteria were set too high and consequently biased towards excluding participants. Online screening for depression, while efficient, requires enormous resources for follow-up in discharging professional duty of care when students are excluded, especially if they indicate suicidal ideation or intent. One recommendation is to screen face-to-face, which can allow the counsellor to do an immediate assessment with the student if they are excluded due to risk. Preference for online Students had opted for an online intervention (and not face-to-face). Students who met exclusion C were asked to contact the counselling service. Very few actually followed through on this request. Many students did not appreciate being contacted by a counsellor to follow up their exclusion and expressed anger at what they saw as intrusion. It seems that some students may prefer online to face-to-face treatments and it is important to be open to the preferences Counselling Psychology Review, Vol. 24, No. 2, June

62 Derek Richards et al. of users and attempt to find ways to accommodate this preference. Depression and students The number of interested students and the high response rate in such a short space of time may be indicative of a need for such a treatment within the community. Average depression scores as measured by the BDI for those included in the study were (N=32) and for the total cohort screened was (N=78). These are high scores. Ninety per cent (N=70) of the 78 screened were above the 14 cut-off point for inclusion as measured by the BDI. The average depression score for this group was and the range in scores for this group was 14 to 48, which is broad. Of the 90 per cent (N=70), 34 (49 per cent) scored equal to or above the 29 BDI cut-of point for exclusion. The average BDI for this group was 37 and the range 30 to 48, which is high and indicates the presence of severe depressive symptoms. In contrast, in a sample of 383 face-to-face clients 20 per cent (N=77) report depression. In face-to-face counselling the highest referral reason students quote when presenting to the SCS, after stress, is depression (12 per cent). Although many of these students are depressed it should be noted that when assessed by counsellors not all of them are clinically depressed. Furthermore, 63 per cent (N=49) of the 78 students screened indicated suicidal intent and or plans, this contrasts greatly with face-to-face services. For example, of 383 students attending face-to-face counselling only seven per cent (27) report suicidality. In this pilot of those who reported suicidal ideation or plans when assessed it was much less. This may be indicative of the true extent of unreported depressive symptomology and related co-morbidity including suicidal ideation and intent present within the student population. Alternatively it may also be due to the online reporting pattern referenced earlier. Hidden population A positive aspect of offering online treatments is that it potentially offers access and help to a hidden population of students who may be suffering from symptoms of depression but are reluctant to seek face-to-face intervention. The average BDI score for the Exclusion C cohort was 32, the range being 6 to 40. Followup engaged with students who may not otherwise have come for counselling and who were experiencing moderate to severe depressive symptoms and in some cases accompanied by suicidal thoughts. It is clear that online treatments may serve the needs of students who might not otherwise be effectively helped. Therefore, online treatments can have a place within a mental health care setting (Mitchell & Gordon, 2007). Some students followed-up were referred to face-to-face counselling (N=9). Clinical staff noted that the online treatment and study attracted a different type of client than the usual who attended face-to-face counselling. This could indicate that the study was accessing students who were in need of face-to-face counselling but perhaps would not have come forward through traditional means and that online option acted as a gateway for appropriate support. Some students seeking online support, but scoring too high on various items, were previous clients of the service and ended up back with face-to-face. One may speculate about how many such clients might be out there who don t get on well in face-to-face for whatever reason, but are simply not suited to online work (at least not in an RCT that is so strictly monitored). Clinicians reported that these clients were severely depressed, had at least a one-year history of depression, and each required intensive face-to-face support. 60 Counselling Psychology Review, Vol. 24, No. 2, June 2009

63 The experience of implementing, recruiting and screening Online help-seeking The positive response to the invitation sent to students highlights their willingness to seek help online. Recent evidence suggests a strong willingness among Irish people to use the internet as a source of health information (Gallagher et al., 2008). Significantly, a substantial proportion of people with poor mental health use the internet to search for health information (Gallagher et al., 2008). Making treatments available online can potentially help in destigmatising and encourage online help seeking behaviours and in turn facilitate users in accessing the help they may need when they need it. Online delivery A key objective of online delivery is to innovate and compliment current services. Advertising online treatments helps advertise traditional services too, and this can raise anxieties as mental health services are already expanding in the number of clients seen annually. However, our analysis shows that of the 78 individuals screened, 56 (72 per cent) were offered online treatment of whom 46 (59 per cent) went on to receive treatment online, and 10 (13 per cent) declined. The remaining 22 (28 per cent) were referred to other appropriate support (Table 3) and only nine (12 per cent) went into face-to-face counselling. The majority (59 per cent), therefore, received online treatment while only 12 per cent (N=9) went on to face-to-face counselling. This provides some evidence of meeting the objective for online delivery. Evidence-based treatments Many practitioners are sceptical about the efficacy of online therapy. Research to boost the evidence base for online treatments is needed. Anecdotally, one of the clinical team had one client complete the eight-week Beating the Blues programme and found it to be fantastic. She said it was great learning, and allowed her to prime herself for doing more effective one-to-one work with her counsellor. Clinical scepticism may relate to a lack of knowledge about the available CBT program and counsellors were encouraged to become familiar with the programme themselves. To contribute to establishing evidence the current treatment was part of an RCT designed to investigate effectives of the treatments (Richards & Timulak, 2008). Conclusion Despite the challenges presented online treatments provide an opportunity which seems to be useful particularly for a college population who are computer literate and rely on the internet for accessing information so naturally. Online access to therapy may reach a cohort of students who may not otherwise seek help for low mood or depression and access to such therapy needs to be a focus for ongoing research and evaluation Acknowledgements Thanks to the staff at the Student Counselling Service, in particular Betty Gleeson. Thanks to ESB Electric Aid for funding this pilot project. The Authors Derek Richards, Ladislav Timulak, Yvonne Tone, Chuck Rashleigh, Annemarie Naughton, Deirdre Flynn & Orla McLoughlin Trinity College Dublin. Correspondence Derek Richards Student Counselling, Pearse Street, Trinity College Dublin, College Green, Dublin 2, Ireland. Counselling Psychology Review, Vol. 24, No. 2, June

64 Derek Richards et al. References Barak, A., Hen, L., & Boniel-Nissim, M. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/3/4), Barak, A. & Buchanan, T. (2003). Internet-based psychological testing and assessment. In R. Kraus, J. Zack & G. Stricker (Eds.), Online counselling: A handbook for mental health professionals (pp ). San Diego, CA: Elsevier. Clarke, G., Reid, E., Eubanks, D., O Connor, E., DeBar, L.L., Kelleher, C., Lynch, F. & Nunley, S. (2005). Overcoming depression on the internet (ODIN-2): A randomized trial of a self-help depression skills programme with reminders. Journal of Medical Internet Research, 7(2), e16. Gallagher, S., Tedstone Doherty, D., Moran, R. & Kartalova-Doherty, Y. (2008). Internet use and seeking health information online in Ireland: Demographic characteristics and mental health characteristics of users and non-users. HRB Research Series 4. Dublin: Health Research Board. Gotlib, I.H. & Hammen, C.H. (2002). Handbook of depression. New York: The Guilford Press. Health Service Executive, N.S.R.G., Department of Health and Children (2005). Reach Out: National strategy for action on suicide prevention Dublin. Hollon S.D, & Beck A.T (2002). Cognitive behavioural therapies. In M.J. Lambert (Ed.), Garfield and Bergin handbook of psychotherapy and behaviour change: An empirical analysis (5th ed., pp ). New York: Wiley. Hope, A., Dring, C. & Dring, J. (2005). The health of Irish students: College Lifestyle and Attitudinal National (CLAN) Survey. Dublin: Department of Health and Children. Knapp, M., McDaid, D., Mossialos, E. & Thornicroft, G. (2007). Mental health policy and practice across Europe. New York: Open University Press. Marks, I.M., Cavanagh, K. & Gega, L. (2007). Hands on help: Computer-aided psychotherapy (Vol. 49). Hove: Psychology Press. Mitchell, N. & Gordon, P.K. (2007). Attitudes towards computerized CBT for depression amongst a student population. Behavioural and Cognitive Psychotherapy, 35, NICE (2006). Computerised cognitive behaviour therapy for depression and anxiety. London: National Institute for Health and Clinical Excellence. O Kearney, R., Gibson, M., Christensen, H. & Griffiths, K.M. (2006). Effects of a cognitivebehavioural internet programme on depression, vulnerability to depression and stigma in adolescent males: A school-based controlled trial. Cognitive Behaviour Therapy, 35(1), Proudfoot, J., Swain, S., Widmer, S., Watkins, E., Goldberg, D., Marks, I., Mann, A. & Gray, J.A. (2003b). The development and beta-test of a computer-therapy programme for anxiety and depression: Hurdles and preliminary outcomes. Computers in Human Behaviour, 19, Proudfoot, J., Ryden, C., Shapiro, D.A., Goldberg, D., Mann, A., Everitt, B., Tylee, A., Marks, I. & Gray, I.A. (2004). Clinical efficacy of computerised cognitive behavioural therapy for anxiety and depression in primary care: Randomised controlled trial. British Journal of Psychiatry, 185, Ramstedt, M. & Hope, A. (2005). The Irish drinking habits of 2002: Drinking and drinking-related harm, a European comparative perspective. Journal of Substance Abuse, 10, Rana, R., Smith, E. & Wlaking, J. (1999). Degrees of disturbance: The new agenda. UK: British Association for Counselling. Royal College of Psychiatrists (2003). The mental health of students in higher education. London: Author. Stanley, N. & Manthorpe, J. (2001). Responding to students mental health needs. Journal of Mental Health, 10(1), Richards, D. (2008). Students use and perception of online counselling at university. In A. Giovazolias, E. Karademas & A. Kalantzi-Azizi (Eds.), Crossing internal and external borders: Practices for an effective psychological counselling in the European Higher Education (pp ). Athens: Ellinika Grammata Publishers. Richards, D. & Timulak, L. (2008). Treatment of depression via the internet: A randomised controlled trial on a third level student population. Proceedings of the Joint Conference of the Divisions of Counselling Psychology. Dublin. Richards, D. & Tangney, B. (2008). An informal online learning community for student mental health at university: A preliminary investigation. British Journal of Guidance and Counselling, 36(1) Richards, D. (in press). Online counselling: Trinity College online mental health community. British Journal of Guidance and Counselling. Spek, V., Nyklicek, I., Smits, N., Cuijpers, P., Riper, H., Keyzer, J. & POP, V. (2007). Internet-based cognitive behavioural therapy for sub-threshold depression in people over 50 years old: A randomized controlled clinical trial. Psychological Medicine, 37, Counselling Psychology Review, Vol. 24, No. 2, June 2009

65 The experience of implementing, recruiting and screening Spek, V., Nyklicek, I., Smits, N., Cuijpers, P., Riper, H., Keyzer, J. & POP, V. (2008). One-year follow-up results of a randomized controlled clinical trial on internet-based cognitive behavioural therapy for sub-threshold depression in people over 50 years old. Psychological Medicine, 38, Stanley, N. & Manthorpe, J. (Eds.) (2002). Students mental health needs: Problems and responses. London: Jessica Kingsley Publishers. Stewart-Brown, S., Evans, J., Patterson, J., Petersen, S., Doll, H., Balding, J. & Regis, D. (2000). The health of students in institutions of higher education: An important and neglected public health problem. Journal of Public Health Medicine, 22, Tyrell J. (1992). Sources of stress among psychology undergraduates. Irish Journal of Psychology, 13, Vallejo, M.A., Jordan, C.M., Diaz, M.I., Comeche, M.I. & Ortega, J. (2007). Psychological assessment via the internet: A reliability and validity study of online (vs paper-and-pencil) versions of the General Health Questionnaire-28 (GHQ-28) and the Symptoms Check-List-90-Revised (SCL-90-R). J Med Internet Res, 9(1), e2. Van Straten, A., Cuijpers, P.& Smits, N. (2008). Effectiveness of a web-based self-help intervention for symptoms of depression, anxiety, and stress: Randomized controlled trial. Journal of Medical Internet Research, 10(1), Wright, J., Wright, A.S., Albano, A., Basco, M.R., Goldsmith, L.J., Raffield, T. & Otto, M.W. (2005). Computer-assisted cognitive therapy for depression: Maintaining efficacy while reducing therapist time. American Journal of Psychiatry, 162(6), Counselling Psychology Review, Vol. 24, No. 2, June

66 Further reflections on the future of Counselling Psychology The centrality and consistency of Counselling Psychology: Before during and after 2008 Pam James NEWSLETTER SECTION AT FIRST GLANCE, this perhaps looks like a considerable length of time to address, namely from 1982 (when the Counselling Psychology Section was formed, through to 1992 when the British Psychological Society s Division of Counselling Psychology was set up, and then 16 further years forward to the present time). However, if we are thinking about Counselling Psychology s philosophy, then this does have a centrality and consistency that spans across these years. Centrality and consistency of Counselling Psychology s philosophy There are many statements of the philosophy of Counselling Psychology, perhaps one that has a meaning for me comes from Chapter 1 in the Handbook of Counselling Psychology (Woolfe, Dryden & Strawbridge, 2003). These central points of philosophy can be summarised as: Clients presenting issues are heard as described in their subjective experience; These issues are heard in the context of the therapeutic relationship, usually individually on a one-to-one basis, but also in group settings; The meaning that these issues have to the respective client are aimed to be understood in the therapeutic relationship; beliefs are also considered in context; These processes are constructed by the client both in inter-personal interaction and within the person themselves. Hence both inter and intra personal factors are involved. The Counselling Psychology s professional training is rooted in theory, but no particular theory is held as dogma. Theories are helpful as they inform the client s view of the world and assist in working with presenting difficulties. This means that different theories can be included as long as they fit in with the criteria of the philosophy and have a reliable research base. The nature of that base may be in evidence-based practice, and also in practice-based evidence. Counselling Psychology is not exclusive in its theoretical choices. Its philosophy does, however, emphasise that the client s work is done in relationship. It is important: how and when the client feels, thinks and acts in the way that he or she does; how this might be changed; how resistant this might be to change; or how this may be accepted. The aspect of causality, i.e. why the client feels or thinks in a particular way usually remains at the level of hypothesis. These conversations can be put together as formulations that are hypotheses put forward to explain the client s experiences. In some ways formulations are the cerebral or intellectual descriptions of the client s experience. Within this is the interface 64 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

67 The centrality and consistency of Counselling Psychology between one person (therapist) and another (client) where so much has the opportunity to be communicated. The counselling psychologist aims to be receptive to the communication to assist the client. Counselling psychologists work in the language of formulation and not the language of diagnosis. Yet there is a need to know the language of diagnosis as clients themselves use this, as do other professionals that are involved with the client. There would be a focus on the quality of the relationship, so that ways of working that aspire to be efficient, manualised and standardised are not preferred. Clients experiences Let s look at some casework to understand the application of Counselling Psychology. An elderly man is referred to therapy with recurrent nightmares, depression (understood here as suppressed feelings). He had epilepsy since his early 20s that has resulted in serious accidents and relationship difficulties. The man is able to begin to work through the losses in his life connected with his epilepsy; the manner is similar to the grieving process. He continues to be puzzled by his nightmare. When he becomes able to self-suggest what the dream may mean for him, he begins to accept his current life position. He begins to realise the origins of some of his sad and angry feelings; he can see that he has control over some of the events that happen in his life, but little control in other situations. A man is concerned about his lack of ability to be spontaneous in personal relationships with the opposite sex, he can t commit to one person and has a number of relationships open at the same time. A part of him realises that the early loss of his mother is associated in some way, but it is only when he explores this in therapy, and finds that he wants to stay connected with the therapist, that he realises his difficulties in letting go and separating. He recognises that he has been defending against the awful finality of death and the subsequent loneliness and lack of belongingness. A man is misusing alcohol and is described as depressed in the doctor s referral letter. When he describes his life experience, it is recognised by the therapist that he has helped others continuously throughout his life. He feels empty. In the transference he describes a feeling of being heard in the sessions and this reminds him of his maternal relationship. He also connects with the loss of his mother when he was 10. He comes to realise that he has continually helped others to avoid the pain of this early separation through her death. He grieves her afresh and comes to realise his own need to be cared for as well as caring for others. His need for alcohol becomes less dominant and is eventually moderated. These are just some examples of clients life stories. The consistency and centrality here is seen in the fact that each client s story is individual, special and particular to him or her. Centrality and consistency is seen in the difference of each. The counselling psychologist in working with the client tries to find meaning in each person s experience, so that he or she can manage his/her life in a way that is less affected by distress. The feelings of depression that are so often the described presenting issue, actually have underlying feelings that can be understood as sadness, loneliness, frustration or anger, depending on the client s story. In addition, learnt thinking patterns may be entrenched that re-iterate these feelings. Clients stories consistently include difficulties in affect (feelings), cognition (thought) and behaviour. These domains are consistently involved as they comprise the person s experience. A woman who has lost her father several years ago is still in the early stages of grieving and cries regularly. She is concerned that her grief is continuing. In therapy she realises that she has been the member of the family who has taken on responsibility for the upset of all the other family members. This becomes clear in the narrative of the work in therapy, and the therapist challenges her thought process. With increased insight, the NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

68 Pam James NEWSLETTER SECTION woman becomes aware of her thinking patterns and begins to stop taking on others responsibilities. She eventually works through the grieving stages and is able to complete therapy. Disturbed early relationships Sometimes, there is so much disturbance in the development of the clients life, that there is no sense of emotional stability. In cases such as this the client is often described diagnostically as having a personality disorder. These clients usually have a history of childhood disturbance (real or perceived), which includes sexual, emotional or physical abuse. Their internalised parental others may be critical and rejecting, or only relate to the child in terms of what he or she can do for them, almost treating the child like an object not a person. When the client is engaged with life experiences, their intra-personal relating is self-critical and at times self-harming or suicidal. The child has often built coping defences or survival techniques that have become so entrenched that by adulthood these behaviours are not successful in protecting the self, they may be maladaptive and even harmful. Counselling psychology has the theoretical background to understand and work with such people, but the time that is required to provide a consistent internalised parent (therapist) is often lengthy. Burton s (1998) text is excellent in its explanation of the association between the effect of early losses and the need for full assessment of this, and if relevant, longer-term therapy. Case examples Consider the example of a young girl who has been consistently emotionally abused and criticised by her mother as being a waste of time and bad through and through. Her father was violent and left the family home when she was 2. Family stories of him said that he was no good. The young girl tried hard to manage her life. When things went wrong, she turned to her mother for help, but she was constantly rebuffed and asked to do some household work. She felt alone, always hoping that if she did enough in the home she would be praised and have affection, but this never happened. She thought she was a failure and bad and often tried to self-harm. This is a typical pattern of a person who has had abusive early years. It is a familiar story in therapy, with this pattern of parenting. Therapy is often seen to fail such people due to the strength of the early learning patterns, and the length of therapeutic time that is needed to develop a sense of hope and self-belief. Which therapy and what outcome? Does it matter which therapy is used? Thorough assessment is helpful to indicate short or longer-term work. Roth and Fonagy (2005) would say that as long as the relationship remains the focus, then working humanistically, cognitively or dynamically can each be helpful; the counselling psychologist often utilises integrative approaches to working with clients. However, personality disordered clients may need much longerterm work that is underpinned by cognitive and dynamic theories. The outcomes of all therapy sessions are not always considered a cure by the client. This is realistic. For example, multiple bereavements after therapy may result in the client feeling less depressed, but there may be a sad acceptance. Onging anxiety from early maternal rejection, after therapy, may result in an increased insight into the roots of the anxiety, and also an ongoing need to manage these feelings. Therapy is not the panacea for all ills. It is a realistic multi-theoretical basis for understanding and working with human distress. It appreciates the difference of each individual. There is individual difference, yet there is consistency and constancy also in the fact that people are generally upset by real and/or perceived threats to the self. If the self is in psychological danger of harassment, embarrassment, shame, ridicule, fear or anxiety; or any of the emotions concerned with hurt, 66 Counselling Psychology Review, Vol. 24, No. 2, June 2009

69 The centrality and consistency of Counselling Psychology i.e. resentment, anger or disappointment then the person will set up a defence to protect from further distress. This defence may or may not serve a protective function, e.g. withdrawal, avoidance, denial, repression. These all function to assist the safety of the self, but in doing so, set up further problems by rendering the person less socially available. The counselling psychologist is well-placed to understand the person s system and to work with them to find meaning, see the development of corebeliefs, see the origins of negative automatic thoughts, understand the defences, stay with the client as they unpack their experiences. As far as research goes, counselling psychologists can draw on research studies carried out by researchers from a variety of perspectives. What is the domain of the counselling psychologist s research? The research agenda In the Handbook of Counselling Psychology (Woolfe, Dryden & Strawbridge, 2003), there are three chapters concerned with research and evaluation. These represent an overview of quantitative and qualitative research on psychotherapeutic interventions over the past 50 years. Chapter 4 by Barkham and Barker focuses on practice-based evidence and locates this firmly in a model that integrates practice-based evidence with evidence-based practice. Networks for organising practice-based evidence would benefit from further exploitation. Does the discipline of counselling psychology have a research field that is particular to this discipline alone? What makes a research study the precinct of counselling psychology? I would argue that counselling psychology s research field can extend to being described as the area of psychotherapeutic intervention, and hence is a wide umbrella. Consequently, research by counsellors is relevant to counselling psychologists. A search over past issues of the Journal of the British Association for Counselling and Psychotherapy finds articles that involve data collection about the outcomes from therapy, the application of therapy to a range of client issues; articles about different research methodologies. Articles in this sister discipline are of benefit to the counselling psychologist. They are perhaps at the point of overlap with the counselling psychologist in terms of philosophy and professional content. Looking back through the years at Counselling Psychology Review, the articles are more discursive; fewer involve data collection; many comment of the practice use of different approaches. Perhaps 12 to 14 years ago articles often had the word counselling in the title; almost as though the discipline of counselling psychology was emerging and separating from that of counselling. A part of the British Journal of Psychology and Psychotherapy is more specifically devoted to empirically-based studies from counselling psychologists. The umbrella of counselling psychology is wide enough to incorporate the findings from all of these to inform the therapeutic relationship. Could it be that counselling psychology can t claim a distinct boundary around its research field? Why? Is this possibly because of the overlap between professionals in terms of theoretical applications and practice outcomes? Is this because there is so much overlap of professional practices between counselling and psychotherapy? Could it be that counselling psychology s research field is predominately practicebased evidence? Do we need to argue long and hard that randomised controlled trials are not the way in which meaningful evidence is collected? Certainly Rowan (2001) agrees with this viewpoint when he says that superficial approaches like CBT for symptom reduction can be evaluated using superficial symptom-based evaluations. Deep-rooted explorations of experience and personal change will not be accessed by superficial evaluation techniques. Can this kind of change be evaluated at all? Interestingly, the salient factor from many studies is that the nature of the therapeutic relationship is the single most thera- NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

70 Pam James NEWSLETTER SECTION peutic factor. However, what does this mean? Is it the core conditions from person-centred work of empathy, congruence and UPR? Is it trust, consistency, respect and clarity? Is it working with concepts in the relationshiplike congruence, transference and countertransference? Some answers to these questions are found in Barkham s chapter in the Handbook of Counselling Psychology where he states that the client s ratings of the therapeutic alliance are the most predictive of outcome. He also states that the components of alliance have not been fully researched in terms of the clients descriptions of these. Research from a related field into the nature of subjective well-being is suggesting that there could be a personality variable in the beneficial outcomes of therapy. The concept of extraversion is associated with SWB. Could it be that personality might be an indicator of the benefit from therapy in the direction of those with a more openness being more likely to show beneficial change after therapy? Myself and a colleague at JMU are researching in this area. Where does this place the centrality and consistency of the research agenda for counselling psychology at the current time? Whilst the location of the philosophy underpinning practice is unchanging in the development of counselling psychology since 1982, the research agenda is wider and has no specific focus and no specific British Journal of Counselling Psychology. Is the apparent lack of a research focus perhaps a strength in the way that it allows many topics to be investigated and research material incorporated from related disciplines? However, perhaps it is a weakness as the discipline of counselling psychology cannot be easily defended in the face of challenges, criticism or political action that apparently fails to appreciate its value? Is the very nature of the research field, i.e. people s life experience and their varied response to trauma and difficulty, such a diversity that it is not possible to form a focus? UK Counselling Psychology in the National Health Service in 2008 The embracing discipline of counselling psychology, and the counselling psychologist as a therapist is now under threat in NHS UK Trusts. This possibly includes colleagues in clinical psychology in their therapeutic role. This may appear to be a dramatic statement, but I will explain how I come to make such a statement, which I own as my statement and I am willing to be challenged on this perspective and to discuss it. The following picture has been emerging since More clients have been asking for talking therapies, more doctors have become aware of talking therapies, research studies have been published in the media that say anti-depressants are not helpful in the majority of cases (except for more severe depression), more research studies have been published in the media that say that cognitive-behavioural therapy (CBT) is helpful as a response to anxiety and depression. Research has been published that has shown the advantages of cognitive therapies in working with clients who hear voices and may have some psychotic features. Mental Health Trusts in the NHS have built up long waiting lists of clients for therapy. The Government s agenda is to reduce waiting times to be seen to 11 weeks and eventually less. Taking stock of the two years or more waiting times a couple of years ago, this has been deemed unacceptable by the Government and procedures have been put in place so that clients can see someone as quickly as possible after referral by the doctor (GP). This system has come to be known as the Stepped Care model. Typically the steps in this model move from: GP or practice nurse referral to: Step 1: A psychometric assessment of anxiety (British Anxiety Inventory, BAI) and depression (PHQ-9) by a case manager (who would be a mental health practitioner), including an assessment of risk, to: Step 2: If depression is mild, then guided self-help, CBT, Computerised CBT from a 68 Counselling Psychology Review, Vol. 24, No. 2, June 2009

71 The centrality and consistency of Counselling Psychology primary care mental health worker (low intensity worker, part of the Improving Access to Psychological Therapy programme) or counselling; and/or medication; Step 3: If depression is more severe, then the same range of treatments, delivered by the same range of professionals, but a high intensity worker (IAPT); also possibly a psychologist; Step 4: If depression persists and is described as treatment resistant, recurrent, atypical and psychotic, then complex psychological interventions are appropriate from a psychologist; medication; Step 5: if there is high risk of suicide then the Home Treatment team is likely to be involved. The Doncaster model as discussed by White (2008) is suggesting that there are benefits in a Stepped Care model. He comments in the article on numbers of clients who have been assigned counselling or CBT by the case manager. This shows that clients have continued to be assigned to counsellors as well as to those trained through the IAPT model (i.e. low or high intensity worker) using CBT. It has also allowed counsellors to broaden their ways of working by becoming familiar with CCBT; because their waiting lists are shorter as a result of the role of case managers. counsellors also say that they can allow more sessions for longer term work. The Government has launched 300 million pounds over the next three years into the IAPT agenda (a scheme for training workers in CBT) which will gradually result in more workers able to offer CBT for depression and anxiety. Waiting lists are reducing, but is this a rationalisation for efficiency, at the expense of quality? What will be the effect of the increase in workers trained by the IAPT programmes on psychologists in the NHS? One way of trying to answer these questions is to look at what may be helpful and what may be not helpful to the clients themselves and the mental health context. Helpful? Able to talk to someone more quickly than before; See a case manager who assesses whether the next step is self-help, CCBT, counselling or CBT therapy (IAPT: low/high intensity); Receive one of the above interventions. Symptoms of depression or anxiety probably reduced as interventions are focussed on symptom reduction (research supports the reduction of depressed symptoms using CBT); Psychometric test describes level of severity of issues; Workers are less expensive than the chartered psychologist. Psychologists can be retained for the later steps, i.e. Steps 3 and 4. Hindering? The person may see different mental health professionals and hence continuity of relationship is lost; Symptoms may be alleviated, but later reappear; Presenting problems may not have been addressed in context, as symptoms only have been assessed and not the complex nature of the issues; There are other presenting problems, not just depression and anxiety; Although psychometric scores have been taken, the level of severity of upset may not be appreciated. For example, the impact of early losses may not have been taken into account; personality disorders may be overlooked. Underlying theoretical debates Perhaps one of the central issues of debate comes from within the heart of psychology. Is it possible to change or re-frame thoughts and behaviours without being aware of the origins and sources of the way in which a person thinks, or the context in which the behaviour occurs. A strict behaviourist would say that it is not essential to change cognition to change behaviour. A cognitive approach NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

72 Pam James NEWSLETTER SECTION would say that it is not necessary to know the developmental origins of a thought pattern to begin to challenge its irrationality. Both these viewpoints have research to say that behaviour change and cognitive change is possible. The counselling psychologist would not disagree with these views; however, most counselling psychologists would regard either behavioural or cognitive approaches alone as rather narrow and reductionist in an understanding of the person. One has only to return to the philosophy of the counselling psychologist to see that a CBT approach alone is theoretically weak and not sufficient to provide a person with a full approach to coping with his or her issues, particularly when these issues are complex. What is the place now of the psychologist in the stepped care system? In answering that question, a look back through the last three years may answer some questions. The New Ways of Working for Applied Psychologists project The New Ways of Working for Applied Psychologists project was established in July 2005, reporting back in July 2007, as part of a wider programme looking at modernising mental health services. There were seven psychology project groups, focussing on new roles, career pathways, improving access to psychological therapies, training models in applied psychology, organising, managing and leading services, working in teams, and mental health legislation. Throughout the project an applied psychology stance was taken and there was full involvement by the counselling psychology representatives in all the project groups. I was a member of the Core Group for the NWW-AP project and particularly recall the contributions from service users during the meetings of the project. The emphasis here was to keep in focus the needs of service users. For counselling psychologists outside the NHS, the requirements and demands of the NHS are not relevant to a significant number of members and there is a danger in allowing those requirements to dominate the development of the entire profession. For counselling psychology in particular this is an acute difficulty, because we estimate that around half of the profession work for at least part of their time in the NHS, which means that half do not, and the profession itself is founded on values and philosophies that sometimes sit uneasily alongside NHS practices. Therefore, engagement in NWW- AP and similar NHS projects, working parties and committees is never going to be straightforward for counselling psychology. Since 2007, the Government s modernisation agenda is proceeding rapidly and having an increasing effect on the availability of psychology posts. Applied psychologists are expensive to employ, and so must be able to offer added value over and above the contribution made by less expensive colleagues such as community psychiatric nurses and CBT therapists. Is the counselling psychologists therapy role being eroded by other workers who can carry out manualised therapies? Where does this leave counselling psychologists? Are we expensive therapists whose work can be done by lesser-qualified workers? Are we compromised by our apparent similarity with counsellors and psychotherapists? What argument would you put forward to continuing to employ counselling psychologists? The answers to this question may vary depending on primary care or Community Mental Health Team contexts. The future for counselling psychology in the NHS Arising from the NWW-AP it seems that there will be an increased recognition of the part played by psychological factors in both physical and mental ill-health, and a consequent acknowledgement of the importance of psychological understanding and skills in treatment planning and delivery in both 70 Counselling Psychology Review, Vol. 24, No. 2, June 2009

73 The centrality and consistency of Counselling Psychology primary and secondary care. However, although psychologists are involved in levels of care, they may not always be the professionals delivering the therapy. Primary Care Historically, therapy has been provided in the NHS by counsellors, clinical and counselling psychologists. Will it continue this way? Primary Care departments have been placed in a position where they have had to tender for the contract to continue their work. Those who have been successful in obtaining contracts are those who have made use of a new Government development as described below. The Improving Access to Psychological Therapies project (IAPT) and the changes to professional roles and responsibilities seen in the new Mental Health Act of 2007 are integral developments in the New Ways of Working. Turpin (2007) has given a thorough discussion of the IAPT project as it applies in England. Beginning with the recommendations of Layard (2004, 2006), and initial outcome data from two pilot sites, IAPT envisages a network of psychological therapy centres in primary care where shortterm CBT will be widely available to the public as part of a stepped-care mental health and well-being structure. The IAPT programme is putting forward in-service posts for what is described as low and high intensity workers. Training in universities and working in the NHS practice setting is the shape of the work. Fully qualified clinical and counselling psychologists are even being asked to train on an IAPT programme which is CBT-based only. The onset of the IAPT programme is accredited by the British Association for Behavioural Cognitive Psychology; some psychologists are feeling side-lined and pushed aside. Discussions are on-going within the Society about this development. How can the philosophy of counselling psychology sit with this agenda? If jobs are scarce, the qualified counselling psychology may have to incorporate the IAPT/CBT training. Does this make logical sense? The trend is towards an increasingly streamlined workforce, with more generically trained workers providing shorter and more standardised treatments as cost pressures mount across the NHS. The emphasis on short-term CBT in IAPT, and the increasing number of posts for generically trained psychological therapists are examples of this. Any added value is likely to be seen in terms of supervision, consultancy and clinical leadership. Chartered clinical and counselling psychologists will be also probably be required to see more complex clients whose presentations do not fit anxiety and depression and who may also have elements of personality disorder. Secondary Care The new Mental Health Act of 2007 replaced the role of Responsible Medical Officer with that of Responsible Clinician (Department of Health, 2007), with the expectation that senior applied psychologists in the NHS will take on the role in addition to consultant psychiatrists. The Act thereby recognises the place of psychological understanding alongside psychiatric expertise. Practitioners from both clinical and counselling psychology are relating their clinical experience and aware of the complex needs of some clients in secondary care. For example, clients who are described as having a borderline personality, and those with both mental health and drugs and alcohol problems often have complex needs. There is an on-going role for counselling psychologists in the NHS to constantly be shaping the use of the work-force where their thinking is driven by psychological formulation and practitioner experience. The secondary care context comprises psychiatrists, community psychiatric workers and social workers and are located in Community Mental Health Teams. Here the role of the counselling psychologist is as a therapist, as a supervisor of non-psychologist NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

74 Pam James NEWSLETTER SECTION health professionals to encourage the language of formulation, and as a leader of services. Other professionals in the CMHT, namely psychiatrists and CPNs are most usually trained in the language of diagnosis; there are hierarchies of relationship where the psychiatrist is in a role that historically has been the lead role. Perhaps this is because they hold the power of prescription, as people s distress in secondary care often needs medication to bring it into manageable control. Languages of diagnosis and formulation can cause complexities for the client. How should they understand their distress when they are offered only medication and a diagnostic label from a psychiatrist who holds a powerful status figure? It may be that the future for counselling psychologists in health lies outside of the NHS, in private consultancies with whom the NHS may contract to manage, supervise and/or deliver services. The challenge to counselling psychology will then be to hold on to its core philosophy in a more commercial environment. The Statutory Regulation of Psychologists with the Health Professionals Council is planned to occur during 2008, bringing to a focus the need to have registration at chartered level. The concept of accredited prechartered training arose from the New Roles group in NWW-AP and was being explored in the Society; however, the IAPT programme has cut across this. Proposed pre-chartered applied psychologists, rather like the existing assistant psychologists would be able to offer psychoeducation, run anxiety and stress management groups, identify those with complex needs, deliver CBT programmes under supervision, assist in preventing the onset of psychosis, offer active listening where appropriate using basic counselling skills. All these tasks would occur under the supervision of a chartered psychologist. However, the development of these roles is not progressing with speed. So, given the above, can the contribution that counselling psychologists has made to the field of therapy be sustained in the future, whether within or without the NHS? Can they sail with the wind of change, or will they be blown off course? One way of looking at this is that counselling psychologists provide a continuing reminder that patients are people, and that people exist in relationship. It is all too easy when faced with long waiting lists, severe distress and disturbance, and the demands of a large bureaucratic organisation, to adopt a dehumanising medical model of treatment. Clinical psychology colleagues have defended a humanistic position in the NHS for many years, and counselling psychology, less rooted in NHS culture, has been able to reinforce that and extend it further. The constant threat to the development of NHS counselling psychology will probably be in the form of tensions produced by competition and professional jealousies in an atmosphere of difficult work-related content and diminished resources. Can this be contained? Work by Obholzer and Roberts (1994) is helpful in looking at dynamic factors in organisational development. The challenge is to hold on to all that is good in our profession, our beliefs in our central philosophies, whilst fully engaging and sailing with the wind of political change. Correspondence Pam James Professor of Counselling Psychology, School of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool L3 2ET. [email protected] 72 Counselling Psychology Review, Vol. 24, No. 2, June 2009

75 The centrality and consistency of Counselling Psychology References Barkham, M. & Baker, C. (2003). Establishing practice-based evidence for counselling psychology. In R. Woolfe, W. Dryden & S. Strawbridge (Eds.), Handbook of Counselling Psychology (pp ). London: Sage. British Psychological Society (2007). New Ways of Working for Applied Psychologists in Health and Social Care. Leicester: British Psychological Society. Burton, M. (1998). Psychotherapy, counselling and primary mental health care, assessment for brief or longer-term treatment. Chichester: Wiley. Department of Health (2007). The Mental Health Act. ukpga_ _en_1). Lavender, T. & Paxton, R. (2004). Estimating the applied psychology demand in adult mental health. Leicester: British Psychological Society. Layard, R. (2004). Mental Health: Britain s biggest social problem? Cabinet Office: December. Layard, R. (2006). The case for psychological treatment centres. British Medical Journal, 332, Obholzer, A. & Roberts, V.Z. (Eds.) (1994). The unconscious at work. London & New York: Routledge. Roth, A. & Fonagy, P. (2005). What works for whom? A critical review of psychotherapy research. New York: Guilford Press. Rowan, J. (2001). Counselling psychology and research. Counselling Psychology Review, 16(1), 7 8. Turpin, G. (2005). New ways of shaping and delivering psychology services. Reflections after the NIMHE/BPS Conference in Birmingham, February. Counselling Psychology Review, 20(2), Turpin, G. (2007). Good practice guide on the contribution of Applied Psychologists to improving access for psychological therapies. Leicester: British Psychological Society. White, D. (2008). Good going at the Doncaster IAPT. Therapy Today, 19(2), Woolfe, R. (1996) The nature of counselling psychology. In R. Woolfe, W. Dryden & S. Strawbridge (Eds.), Handbook of Counselling Psychology (pp.3 20). London: Sage. Woolfe, R., Dryden, W. & Strawbridge, S. (Eds.) (2003). Handbook of Counselling Psychology. London: Sage. NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

76 NEWSLETTER SECTION 74 Counselling Psychology Review, Vol. 24, No. 2, June 2009

77 An invitation to Warwick Tony Ward Division of Counselling Psychology Annual Conference, University of Warwick, 9 11 July, Dear colleagues, In this issue you will find an advertisement for our annual conference which this year is taking place in Warwick in July. This year s conference is a little different in format to previous years, and I firmly believe that it has much to offer, whatever range of experience you are looking for. Our theme this year is Riding the Tide. This is potentially a momentous year for the applied psychologies, as we progress to statutory regulation. For the first time responsibility for the regulation of our standards, practice and training will fall to an outside body. The Society will have to change in many ways to reflect these developments. At the same time there are many pressures within the therapeutic contexts within which we work. As many of us will be aware, there are pressures to work in particular ways with particular clients. Within the applied psychologies there are notable pressures and tensions. This wave of change and challenge we characterise as a Tide, and we see the task of the profession as navigating these processes, to arrive at a safe harbour, in good shape. We believe that the annual conference has an important role to play, perhaps providing the maps, charts and navigational devices required for this onerous task. This year, after consultation, we changed the timing to July. A key reason for this is that it allows us to make use of university facilities, which can help us to keep costs down whilst providing a full conference experience. The Division has decided that as a service to the membership this year s conference will be subsidised to a significant degree. This means that this year s conference fee represents phenomenal value for money. Delegates will be able to attend for the whole conference, Thursday to Saturday, including two half-day workshops, four keynote speakers, a debate and plenary. For all of this, with standard accommodation and all meals, the total package will be 290. This must be the best value conference on offer of any of the Society s subsections this year. On the Thursday, delegates will be able to choose two half-day workshops from a choice of eight. These cover a range of themes, which we have aligned to members interests as expressed in the recent membership survey (the results of which will be written up and presented in a future issue of Counselling Psychology Review). There will be a very interesting workshop providing the opportunity for those in private practice to share their experience, and thus reduce the isolation which practitioners often experience. An old favourite will make a reappearance, in the shape of an exploration of the commonalities and differences between person-centred and cognitive approaches. In another workshop delegates will be able to explore the pitfalls and possibilities of working as a counselling psychologist in the NHS. I myself will be inviting delegates to explore the relevance and issues which arise from the use of psychometrics in counselling psychology practice. This has been an issue of some debate within these pages in recent issues. Several workshops will explore the theme of integration, including an opportunity to explore one s own integrative stance. Finally there are several workshops related to relationships, in terms of both the relationship we have with ourselves as counselling psychologists, and our relationships with others. By providing these longer workshops across the whole first day of the conference, NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June The British Psychological Society ISSN

78 Tony Ward NEWSLETTER SECTION we hope that colleagues will feel that the event will better meet their CPD needs. Moving on to the Friday, we commence with a keynote speech by Diane Hammersley, who will be exploring past, present and future developments in counselling psychology. Other keynote speakers include Professor Mick Cooper, Phil Mollon and Professor Stephen Joseph. Mick Cooper is a widely known psychotherapist, who has authored many books within the humanist tradition. He is currently engaging with the HPC as they consider the regulation of counsellors and psychotherapists. He is involved in the new Counselling Psychology doctorate which is jointly hosted by Glasgow Caledonian University and Strathclyde University. Phil Mollon is a senior clinical psychologist within the NHS, who works from an integrative stance founded on psychodynamic principles. He is the author of a number of works, including a respected text on Heinz Kohut. Recently he has expressed views in The Psychologist objecting to the homogenisation of therapy under the IAPT initiative. Finally, Stephen Joseph is a professor at the University of Nottingham where he also directs an NHS Centre for trauma care. He is a leading proponent of positive psychology in clinical work. In between the various keynote speakers, delegates will find the usual diet of stimulating academic papers. We are pleased once again to have received some very high quality submissions enabling us to put together a full conference programme. We are aware at this point in time that there is something of a debate going on within the profession about our future shape and development. This is nowhere more evident than in the March 2009 edition of Counselling Psychology Review. Readers may recall the two challenging articles by the clinical psychologists Peter Kinderman and Graham Turpin. Both of these authors question the future survival of Counselling Psychology as an independent entity, separate to Clinical Psychology. Turpin, in particular, seems to be advocating for a merger of these two branches of applied psychology. In the same issue of Counselling Psychology Review a number of counselling psychologists note the challenges ahead. The overall tone set is perhaps somewhat less than optimistic. The conference committee believe, as do several authors in the special edition of Counselling Psychology Review, that Counselling Psychology has a bright future and something distinctive to offer. Perhaps Turpin gives a hint of his real motivations when he describes how clinical psychology has had to battle against the perception of being a jack of all trades profession. We, the new kids on the block, clearly know what our strengths are and we play to these. Turpin very helpfully maps out the kinds of competencies we will need to demonstrate in the future to further consolidate our position as a strong and unique profession within the various clinical contexts in which we operate. It is clear that we need to be confident about our strengths, and be willing to articulate these in a way which highlights our differences to psychological therapists and counsellors. In the interests of taking this debate further, the conference committee will be organising a symposium debate on the future and shape of counselling psychology in the UK. Also, the conference will end with a final plenary session which we hope will also take up many of these issues. The outgoing division chair, several current course directors and several of the keynote speakers have agreed to take part in what looks likely to be an exciting end to the conference. The conference is well worth an investment of your time this year. On behalf of the conference committee, I very much look forward to seeing and welcoming you to Warwick. Tony Ward Conference Chair 76 Counselling Psychology Review, Vol. 24, No. 2, June 2009

79 Division of Counselling Psychology Conference 2009 University of Warwick 9th to 11th July 2009 Riding the Tide Counselling Psychology Goes Forward The conference will run over three days with the first day being a pre-conference workshop day and days two and three as the main conference. The following eight half-day workshops will run over the course of the first day: Riding the Tide: Confessions of a Private Practitioner; Working with the building bricks of healthy and damaging relationships to facilitate 'riding the tide' as individuals and as counselling psychologists; PCCP A D(a)emonstration Workshop Revisited; An integrative approach to complexity: Adaptation-based process therapy; Pitfalls and Possibilities; An introduction to psychometrics for Counselling Psychologists; Opening the Heart an experiential workshop; What integration could work for me? Discovering and developing your own theoretical and operational approach to the practice of Counselling Psychology. Confirmed Keynote Speakers The way forward? Re-humanising therapy an existential-humanistic ethics at the core of psychological practice Mick Cooper, Professor of Counselling at the University of Strathclyde, and co-director of the Doctorate in Counselling Psychology, Glasgow Caledonian University/University of Strathclyde, currently seeking accreditation. The way forward? Treasures old and new in a decade of change Diane Hammersley, Private Practice, Outstanding contribution to Counselling Psychology Award The way forward? Positive Psychology for all resilience and growth for psychologists Stephen Joseph, Professor of Psychology, Health and Social Care, Centre for Trauma, Resilience and Growth, University of Nottingham. Integration of perspectives Phil Mollon, Psychoanalyst and Head of Psychology and Psychotherapy Services, Lister Hospital, Stevenage. Please download the full and detailed conference programme from: Registration To register for the conference, please visit the conference website and download a form. For further information please visit or contact BPS Conferences. Tel: ; Fax: ; [email protected] NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

80 Reflections of a trainee on the Independent Route Marina Christina Skourteli NEWSLETTER SECTION IAM a Trainee Counselling Psychologist on the Society s Independent Route but hopefully not for long. I am hoping to be able to take my Viva Examination in June 2009 (given that I have passed my final three papers) and the prospect-dream of becoming a Chartered Psychologist seems to be becoming a reality. In the light of the recent debate surrounding the Qualification and the diverse views and experiences expressed by different trainees, I found myself being reflective on my own experience of what seems to be a very personal journey. I enrolled in the Qualification in June 2006 as I was coming up to the end of my first year as an MA counselling student at Manchester University. Having had a first degree in psychology I found that my MA course provided a good experiential context within which I could begin to study my passion, human relatedness, but it did not stretch me academically to the level I had anticipated. The Qualification seemed to combine the disciplines of psychotherapy/ counselling and psychology and seemed an ideal next step in my professional development. Although immensely attracted to it, the idea of the Qualification and the workload it involved seemed overwhelming to me at that stage of my training. I still remember the feeling of uncertainty (verging on despair at times) when my friend and I began to look in the yellow handbook and the diagram a few pages in, outlining the training process. The task seemed daunting and I was only on the first box of that diagram! My approach was to take one thing at a time and the first job was to find a training co-ordinator. I was lucky enough to work with a co-ordinator of training who has been supportive, kind and wise throughout and this, in my opinion, is a critical factor for trainees on the Independent Route. I soon embarked on the task of composing my plan of training which was in itself an arduous task requiring a lot of research around my future professional and personal development as a trainee. The plan really seemed to invite trainees to think carefully in terms of a process of development based on the notion of integration, whilst allowing us great freedom to express aspects of ourselves through the choice of theoretical orientation, research and personal development. The process of training over the next three years felt easier and more fluid than expected. Each piece of academic work seemed to evolve naturally from the previous one in a process that felt meaningful, from the individual (through case studies), to the organisation, to the wider social, economic and political contexts of counselling and psychotherapy. As a trainee, I felt challenged to dissect my own philosophical assumptions about the nature of reality and notions of psychological health and illness and reflect on how these inform my choice of theory and clinical work. The requirement for personal therapy in my view, perfectly complimented the training process. I have always felt that personal therapy, although often difficult emotionally and financially, should be a necessary element in the training of psychological therapists, as it can promote ethical and competent practice; it was thus reassuring to see that the Qualification acknowledged this issue. Returning to the issue of the debate and from a reflexive viewpoint, I have wondered whether trainees experiences on the 78 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

81 Reflections of a trainee on the Independent Route Qualification may depend to some extent on aspects of our own relatedness. The Independent Route in my experience requires a lot of self-discipline, initiative and ability to work independently; being an only child, the sense of aloneness many trainees report as being a difficult aspect of the route, has instead represented a familial and comfortable place for me and has allowed me to enjoy the process of self-determining my professional identity I value my experience of studying for the Qualification. It has been a deeply fulfilling experience that has helped me evolve professionally and personally and I would say that ultimately it represents a very significant time of my life. Correspondence Marina Christina Skourteli North West Centre for Eating Disorders, Oakwood House, 251 Wellington Road South, Stockport SK2 6NG. Tel: NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

82 Centre for Stress Management promoting the cognitive behavioural approach for over 20 years Recognised Modular Programmes Advanced Certificate in Cognitive Behavioural Approaches to Counselling and Psychotherapy Advanced Certificate in Rational Emotive and Cognitive Behavioural Therapy Diploma in Stress Management a cognitive behavioural approach Primary Certificate Courses (2 days unless shown otherwise) Stress Management Occupational Stress Management Cognitive Behavioural Therapy and Training Rational Emotive Behaviour Therapy Problem Focused Counselling, Coaching & Training Assertion and Communication Skills Training Relaxation Skills Training Multimodal Therapy Trauma and PTSD Advanced Cognitive-Behavioural Therapy Skills Advanced Rational Emotive Behavioural Therapy Skills Mediation Skills Other Courses Certificate in Cognitive Behavioural Therapies Certificate in Rational Emotive Behavioural Therapies Correspondence Course in Stress Management June; 8 9 Oct 8 9 Jul May; Jul; Sept; Nov 3 4 Sept June; Oct 5 6 Aug Aug; Dec tbc Apr; 6 7 Oct (3 days) Sept; 30 Nov 2 Dec (3 days) June ; 4 6 Nov tbc NEWSLETTER SECTION Centre for Postgraduate Studies and Research Ltd Primary Certificate in Cognitive Behaviour Therapies & Hypnosis/Certificate in Cognitive Hypnotherapy A two-part modular programme Part 1: either Rational Emotive Behaviour Therapy 3 4 Sept or Cognitive Behavioural Therapy & Training May; Jul; Sept; Nov Part 2: Primary Certificate in Cognitive Hypnotherapy May Tel [email protected] Recognised by the Institute of Health Promotion and Education as a Centre of Expertise Courses held in London unless otherwise stated. Trainers include: Professor Stephen Palmer PhD Michael Neenan Kasia Szymanska Liz Doggart Irene Tubbs Nick Edgerton Courses recognised by the Institute of Health Promotion and Education for Continuing Professional Development 80 Counselling Psychology Review, Vol. 24, No. 2, June 2009

83 The British Psychological Society Qualification in Counselling Psychology Training Days for 2009 Thursday 14 May am to 4.00pm Enrolment Assessors Training Day The Enrolment Assessors Training Day, presented by the Registrar for the Board of Assessors in Counselling Psychology, will focus on assessing new enrolments and also assisting potential trainees to enrol. It is recommended for Chartered Counselling Psychologists who wish to become, or have already trained as, enrolment assessors for the Qualification as well as those Co ordinators of Training who wish to be fully informed in order to guide your new trainees through the enrolment process. This event will be held at the Society s London office, 30 Tabernacle Street, London EC2A 4UE. Places are limited and will be allocated on a first-come first-served basis. Bookings must be received no less than 14 days prior to the event. There is a nominal attendance fee of 25. The attendance fee is non-refundable unless the Society cancels the event. Attendee expenses for travelling to this event will not be paid by the Society. For both of these events, refreshments will be available during the day and a sandwich lunch will be provided. These training days may also contribute towards your CPD needs. Attendance at these events will count towards the requirement of minimum attendance at a CoT training event every two years. To reserve a place at either training event, please contact: Bethan Carley, British Psychological Society, St Andrews House, 48 Princess Street East, Leicester LE1 7DR or telephone or [email protected] NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

84 Letters to the Editor Dear Editor NEWSLETTER SECTION I would like to express my thanks to the editors and contributors of Counselling Psychology Review (Vol. 24, issue 1). I am truly grateful for what they have provided us. Being grateful though doesn t mean I enjoyed reading it. Seldom have I read such a disturbing assessment of the state (or potential state) of our profession. Nor such a clear call for us to think, participate and make some decisions. The experience of receiving, reading and responding to the issue has been an interesting one, somewhat akin to a bout of food poisoning I had recently. With both there was the initial delight of being served up an offering which I had been looking forward to and an expectation that I was going to enjoy what had been prepared. And initially the delight was there in relation to the Counselling Psychology Review I was delighted to see that there were contributions from colleagues I have worked with and respect a great deal. I was, a little narcissistically perhaps, delighted that the vox-pop idea we trialled in Counselling Psychology Review, Vol. 23, issue 2, was again being used. A sure-fire recipe for small, digestible and sometimes spicy contributions to a smorgasbord. Unfortunately, like with my salmon recently, the pleasure was short lived. After having partaken of both, I started to feel queasy. While I did not need to retreat to the bathroom with Counselling Psychology Review I did find myself reacting violently, literally throwing this shit into the corner on at least a couple of occasions. Once I was able to take a breath and do what we ask counselling psychologists to do stop and have a think I realised that this was a potentially useful reaction. An emotional response to something unpleasant and potentially toxic in my system. This time though it was not my digestive system that registered the toxin, but my professional system, my interpersonal world and the very values that have traditionally shaped our view of people, distress, well-being and ways to assist in people s lives. I was trying to forcefully expel this shit from my system. But when responding to the ingestion of something distasteful vomiting isn t enough. Like the cook, we need to review the ingredients used, look for mould, signs of decay, what caused this reaction? We need to take a close look, maybe steel ourselves and take a big sniff and assess what is good for us and what isn t. Once I started to think about it I realised how brave these contributors were to reach down into the dirty underbelly of the world our profession exists in at this point in time; how strong they had to be to face this, bring it into the open and ask us to think about some key factors that go to the very heart of our profession and to reflect on whether it had reached its sell-by date, whether it was top grade ingredients or whether it was full of contaminants. Unless we take stock, some of these modern aspects of our lives will be like undigested food in the stomach, silently sitting there making us feel bad, limiting our actions no matter how much we try to feign health. I am grateful to the editors as a debate is long overdue not just about our little profession but much more importantly about the values upon which our profession is based, our concern for coherent, holistic thinking in a world that increasingly rejects thoughtfulness. We need to be thinking how our values can continue to guide us in a world that wants to simply diagnose and treat the identified problem and leave it at that. What about those needing more time, more relational approaches, more care and more faith? It s the same world that force feeds the nation with fast food and TV dinners (under the guise of choice ) rather than letting us have the time to grow our own seasonal food. The world that tells us the global financial crisis is unrelated to climate change, poverty in Africa or the kinds of mental health provision available through the state. 82 Counselling Psychology Review, Vol. 24, No. 2, June 2009

85 Letters to the Editor It is a complex debate. If we think broadly we will most likely be accused of attending to our own self-interest but it s much more than this. As well as thinking of the preference(s) we have for the shape, form and nature of our profession, it is much more about the ways in which our core values, talents and knowledge base remain important even in these days of processed food and rapid consumption. We have to think about the tension of helping individuals and about the needs of the population; we need to debate (again) whether the essence of counselling psychology has to look the same across all contexts or should health service psychologists apply their craft in ways that are different to those that work in other contexts. Equally can we work with good faith, resist damaging change and push for the importance of psychologists in other contexts tailoring practice to the needs of those we encounter without the push to medicalised, standardise and control? The special issue also reminds us of one of the key concepts of counselling psychology that of relational understandings. While many of these developments are presented as standalone tasks or issues, this is not really the case. While each of the current professional developments is worthy of attention, engagement and maybe resistance in its own right, we need to consider the way that the phenomenon of evidence based practice, IAPT, National Occupational Standards, HPC, compliance or ethical non-compliance are inter-related. The debate has started with eminent colleagues noting that: HPC regulation cannot be separated from the creation of National Occupational Standards; Skills for Health definitions of competences ; NICE clinical guidelines privileging a single evidence-based therapy; and the so called Improved Access to Psychological Therapies scheme. All these developments will reduce access to long-term, relationally oriented therapy and counselling; reduce client choice; medicalise the field; rigidify training and inflate its cost, and hence the cost of therapy, making access even harder for the economically disadvantaged. HPC regulation is also likely to exclude many parttimers and volunteers, and make it harder for counselling services using volunteers to survive. (Alliance for Counselling and Psychotherapy, 2009) I would add that these questions are also related to wider political factors and how we split off awareness, feel able to use and consume each other this underlines our understandings of mental health and distress, the provision of services, as well as our attitude to food, gender and the environment. True relational thinking will allow us a chance to consider the system we are in as much as each individual issue. This debate may be a bit like cooking, it s how we engage that will help us reap the benefits and avoid the toxins, if we engage thoughtfully and openly we might enjoy what we create, if we simply do as we are told we will fare no better than simply adding water and popping in the microwave for three minutes. It might suffice, but nourish it will not. I wonder what kind of future we will cook up for ourselves. Thanks for prompting us editors! Let s hope it s a useful debate. Martin Milton University of Surrey. Reference Alliance for Counselling and Psychotherapy (2009). Retrieved on 13 March, 2009, from: NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

86 Letters to the Editor Whose future? A response to Kinderman s View from outside Dear Editor Not wishing to over-dramatise at all, I read the contribution of Kinderman (2009) to the special issue of Counselling Psychology Review with growing alarm. According to Kinderman the only way that we can survive as a profession is to prove that we have unique competencies unshared by any other related profession. This seems bizarre and highly reductionist. The whole, after all, is more than, and different from, the sum of the parts. Horses exist as distinct species despite the fact that no one anatomical feature is distinct to horses. In my view we should not accede to Kinderman s definition of the issue that is, that our profession can be captured (moreover, assimilated by clinical psychology (p.16)) through a tick-box list of competencies. Kinderman s position fails to give any credence to the notion that philosophy and values have any important function. Counselling Psychology has striven towards practising from a coherent and explicit value base, understanding that skills and competencies can guides our doings but not our being. If we consider that reflexive (not merely reflective) thinking is a core premise of Counselling Psychology, then we are considering not a competency but a philosophy and commitment that profoundly influences how we do what we do in our work with clients. In my view our competencies are not a collection of discrete measurable commodities. We do perhaps share the ideal of a strong philosophical grounding with many psychotherapies, and we share a wealth of psychological knowledge and skill with Clinical Psychology, but we should not fragment ourselves until we disappear into a collection of subsumables to be assimilated by whoever thinks that they hold more territory. We would not reduce our clients into collections of problems upon which we can map our competencies, so we should not collude in our own destruction through reduction. Yvette Lewis Wolverhampton University. Reference Kinderman, P. (2009). The future of counselling psychology: A view from outside. Counselling Psychology Review, Special Edition: Counselling Psychology The Next 10 Years, 24(1), NEWSLETTER SECTION 84 Counselling Psychology Review, Vol. 24, No. 2, June 2009

87 Diplomas Advanced Certificates Modular programmes in coaching, psychological coaching & coaching psychology Centre for Coaching in association with Centre for Stress Management promoting the cognitive behavioural approach Certificate Courses * Coaching Coaching Conversion - counsellors/psychotherapists Psychological Coaching Coaching Psychology Stress Management and Performance Coaching Stress Management and Health Coaching Primary Certificate Courses Performance Coaching Health Coaching Stress Management Assertion & Communication Skills Problem Focused Counselling, Coaching & Training Redundancy Coaching and Counselling May; Jul; Sept; Oct Aug 29 June 3 Jul 29 June 3 Jul modular modular May; 30 Sept 1 Oct Oct June; 8 9 Oct 5 6 Aug June; Oct Jul; 8 9 Sept The Centre for Coaching is an ILM Recognised Provider. As a recognised provider, the Centre runs a wide range of coaching and management development programmes which are suitable for Continuing Professional Development. Correspondence Course Life Coaching - a CBC approach The Director of the Centre is Professor Stephen Palmer PhD CPsychol. Trainers include: Professor Stephen Palmer Nick Edgerton Gladeana McMahon Michael Neenan Dr Siobhain O Riordan Kasia Szymanska Irene Tubbs Courses held in London unless otherwise stated. * Courses recognised by the Association for Coaching Courses accredited by Middlesex University Society for Coaching Psychology Recognised Course NEWSLETTER SECTION Counselling Psychology Review, Vol. 24, No. 2, June

88 Book Reviews Online Counselling and Guidance Skills: A practical resource for Trainees and Practitioners Jane Evans Sage Publications, Paperback; 208 pp. ISBN: Reviewed by Gareth Williams Online Counselling and Guidance Skills is a well constructed text that presents an overview of the practical aspects of offering counselling and support over the internet. It is aimed at counsellors, therapists and health professionals, who want to provide a service to people using computer-mediated communications (CMC). It is very much a skills-based approach and could be adopted by practitioners of any school of therapy. It will serve as an excellent preparation for practitioners intending to venture into internet counselling, describing the basic competencies needed to communicate with a wide range of clients. It is very comprehensive in its scope, covering areas that include, online presence, relationship and expression; assessment and contracting; professional boundaries; diversity; and data protection. It covers both synchronous (real time chat) and asynchronous ( ) communications, and is filled with exercises that question the reader and prompt selfreflection on relevant issues. Throughout the book, the author, Jane Evans, invites readers to give consideration to their prior experiences of counselling and guidance, and how they can transfer these from a face-to-face context to a cyberspace arena. Additionally, she flags up areas of concern where further awareness is required, for example, obtaining the appropriate insurance for working on the internet. Each chapter is illustrated with simulated counsellor-client interactions, ends with a summary and provides many very useful references with links to several online resources. Online Counselling and Guidance Skills is aimed primarily at people new to the internet field, although as an experienced practitioner of online counselling/support, I did find the book interesting, the material within its pages helping me to clarify and name skills which I had previously taken for granted. It also supplemented my knowledge in several valuable ways, including the use of avatars (online images); the relevance of identifying clients' level of familiarity and ability with electronic communications; and the potential importance for an online relationship of opening and closing greetings. Online Counselling and Guidance Skills would make a good choice of textbook for trainees considering or intending to work online. I imagine the exercises would work well in the context of a study group, serving as good starting points for discussion. Gareth Williams Counsellor. 86 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

89 Book Reviews Online Counselling: A handbook for practitioners Gill Jones & Anne Stokes Palgrave Macmillan, Paperback; 192 pp. ISBN: Reviewed by Lindsay Dobson This is a book about, as it says, counselling online. It explores the motives of clients and counsellors who may or may not choose to work online, as well as looking briefly at the history of online work. It walks you through the skills and tools you would need to start working online and how to set up an online practice. Additionally it takes a look at how you may build relationships when you only have text to work with, and gives consideration to the issue of contracting, ethics, boundaries, training, insurance and supervision online. These issues are considered for work using , message boards and live chat rooms and the advantages and disadvantages of working in these ways are discussed. For me, the chapters that I most enjoyed were the ones looking at how different theories can be used online, the use of text to explore feelings and how you may use sound and image to work therapeutically online. These chapters gave the reader a taste of how interesting and creative working online can be, and illustrated that work online can incorporate many different ways of working. I also found the exercises at the end of each chapter provided you with a chance to practice skills and think more about the subject matter of that. This book is readable; it flows nicely and at no point was I left feeling it was hard work to read. However, I felt it was more a beginner s guide to online counselling rather than something that delved deeply into the subjects and issues of working online. Therefore, if you re new to online work I would recommend this book. As described above, it introduces the idea of working online and explores everything from why people may choose to work online and getting started, through to how different theories can be incorporated in your work. Specifically I found the chapters discussing contracting and boundaries, coupled with the glossary of terms, informative, practical and useful. As someone who is experienced at working online, I would have loved something that explored some issues of working online in more in depth. Issues such as the online therapeutic alliance and issues around how people present differently online, the capacity to either hide or to expose oneself more fully (online disinhibition) and how these things can become part of the therapy experience online, would have been interesting and taken this book out of the beginners guide realm. The authors draw deeply on their own experiences of working and training others to work online and this adds richness to the text. However, it might have been interesting to hear a bit more about other opinions and perspectives of working online and on current research findings within this area. To sum up, this book looks at the pro s and con s of working online and encourages you to understand your own motives for wanting to do so whilst not being too scary or off-putting about the challenges of working online. If you re new to this area of work, or interested in pursuing it, then this book could be what you re looking for. If however, you are looking for something a bit more in depth, something to explore and add meat to the bones of the issues faced working online, then you might want to look for something else. Lindsay Dobson Counsellor on kooth.com Counselling Psychology Review, Vol. 24, No. 2, June

90 Counselling Psychology Review Networking If you are interested in networking with other Counselling Psychologists within your area of specialty or geographic area, please send exact details that you wish to be published to the Editor, Heather Sequeira, by to: REGIONAL NETWORKING North West Branch: Sylvia Dillon is looking to establish a North West branch. Contact: [email protected] Central England Counselling Psychology Forum: [email protected] Contacts in East Midlands (Nottingham/Derbyshire) [email protected] Tel: [email protected] Tel: Contacts in South East (Kent): Tim Moore is seeking networking contacts near Hastings. [email protected] Contacts in South West (Hampshire/Dorset): Steve Barton: [email protected] Private Practice in Northamptonshire: Richard Alexander: Tel: CAMHS North West/Preston Area: Suzanne Jones. Tel: Division of Counselling Psychology Scotland (DCoP Scotland) Psychology and the natural world [email protected] Psychotherapy and Brain Injury (acquired) Maureen Gallagher [email protected] 88 Counselling Psychology Review, Vol. 24, No. 2, June 2009 The British Psychological Society ISSN

91 NETWORKING: FIELD OF WORK Personality disorder, vicarious trauma, sexual abuse and energy psychology Tel: Dissociation, primary care, private practice, abuse issues, depression Tel: CAMHS North West/Preston Area: Suzanne Jones. Tel: Research Study: Attachment and Relationship to Psychotherapeutic Outcome I am currently exploring the interaction of patient and therapist attachment style and its relationship to establishment of therapeutic alliance and psychotherapeutic outcome. This research forms part of a top-up doctorate in Counselling Psychology at City University. The research component is being supervised by Tirril Harris, Socio-medical Research Group, Institute of Psychiatry, London. If you are interested in participating and would like further information, please contact me at [email protected] Are you a qualified counselling psychologist? Do you work with individuals who self-harm? I am a counselling psychologist in training at the University of East London completing my doctoral thesis. I am interested in hearing from any qualified therapists who provide therapy for individuals aged between 13- to 19-years-old and who self-cut. I would like to interview you for approximately one hour at a place of your convenience about your understanding of selfcutting and the therapeutic relationship with young people who harm themselves. This could be an opportunity for you to express your thoughts and opinions on this complex phenomenon that may have a significant and important impact on our future practise. Please do not hesitate to contact me, Amy Bloxham, by telephone on or [email protected] Therapists perceptions of the effects of deciding to live without a Christian faith on clinical practice Have you decided to live without your Christian faith? Would you like to share your story to increase understanding in this area? If you were practicing as a psychologist/therapist during the period in which you chose to live without your Christian faith, I would greatly appreciate your time. I would like to meet with you to discuss how you perceive this transition to have impacted on your clinical work. All interviews will be held at a location convenient to you. If interested please contact me for more information Jeremy Rowe, PsychD Counselling Psychology. [email protected] Counselling Psychology Review, Vol. 24, No. 2, June

92 Notes for Contributors Counselling Psychology Review Submissions should conform to the guidelines below. Academic Papers: Research, theoretical papers, critical literature reviews and in-depth case discussions. Approximately 3000 to 4000 words. Abstract of no more than 250 words. Longer papers occasionally considered. Subject to anonymous peer review. Issues from Practice: Approximately 1000 to 3000 words, that discuss and debate practice issues. Can include anonymised case material, and/or the client s perspective. Abstract of no more than 250 words. Subject to anonymous peer review. Newsletter and Other Submissions: News items, reports, controversial perspectives, letters to the editor, book reviews and details on forthcoming events. Not refereed but evaluated by the Editor. Submissions guidelines: 1. The front page (which will be removed prior to anonymous review) should give the author(s) s name, current professional/ training affiliation and contact details. One author should be identified as the author responsible for correspondence. A statement should be included to state that the paper has not been published elsewhere and is not under consideration elsewhere. Contact details will be published if the paper is accepted. 2. Apart from the front page, the document should be free of information identifying the author(s). 3. Authors should follow the Society s guidelines for the use of non-sexist language and all references must be presented in APA style (the Style Guide, available from the Society). 4. Graphs, diagrams, etc., must have titles. Written permission should be obtained by the author for the reproduction of tables, diagrams, etc., taken from other sources. 5. Submissions should be sent as attachments. Word document attachments should be saved under an abbreviated title of your submission. Include no author names in the title. Please add CPR Submission in the subject bar. Indicate whether your submission is submitted as an Academic Paper, Issue from Practice or Newsletter/Other Submission. Please expect an acknowledgment of your submission. 6. Proofs of accepted papers will be sent to authors as attachments for minor corrections only. These will need to be returned promptly. Deadlines for notices of forthcoming events, letters and advertisements are listed below: For publication in Copy must be received by February 1 December May 1 March August 1 June November 1 September All submissions should be sent to: Dr Heather Sequeira. [email protected] Book reviews and books for review should be sent to: Kasia Szymanska (CPR Book Reviews Editor), Centre for Stress Management, Broadway House, 3 High Street, Bromley, BR1 1LF.

93 Contents 1 Guest Editorial Terry Hanley & Derek Richards 4 Counselling Psychology and the internet: A review of the quantitative research into online outcomes and alliances within text-based therapy Terry Hanley & D Arcy J. Reynolds, Jr. 14 Client contact styles in online therapeutic work via Gudrun Stummer 24 Trust in online therapeutic relationships: The therapist s experience Leon Joseph Fletcher-Tomenius & Andreas Vossler 34 A trial of client-centred counselling over the telephone for persons with ME Tony Ward & Kevin Hogan 42 The use of online counselling within an Australian secondary school setting: A practitioner s viewpoint Kevin Glasheen & Marilyn Campbell 52 The experience of implementing, recruiting and screening for an online treatment for depression in a naturalistic setting Derek Richards, Ladislav Timulak, Yvonne Tone, Chuck Rashleigh, Annemarie Naughton, Deirdre Flynn & Orla McLoughlin Newsletter Section 64 Further reflections on the future of Counselling Psychology Pam James 75 An invitation to Warwick Tony Ward 78 Reflections of a trainee on the Independent Route Marina Christina Skourtelli 82 Letters to the Editor 86 Book Reviews St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK Tel: Fax: [email protected] The British Psychological Society 2009 Incorporated by Royal Charter Registered Charity No