Chat 2 Recovery is a unique online addiction treatment program for individuals age 21 and over. Nick Lessa, founder of Chat 2 Recovery, provided this presentation at the The 45th Annual Addictions Institute Conference, held in NYC June of 2013
4. E-therapy is the use of electronic media and information
technologies to provide services for participants in different
locations. It is used by skilled and knowledgeable professionals
(e.g. counselors, therapists) to address a variety of individual,
familial, and social issues. E-therapy can (1) include a range of
services, including screening, assessment, primary treatment,
and after care; (2) provide accessible modes of treatment than
the traditional ones to those who actively use the recent
development of technology (i.e. adolescents and young adults);
(3) help people access treatment services who traditionally would
not seek services because of barriers related to geography,
shame and guilt, stigma, or other issues; and (4) be provided as
a sole treatment modality, or in combination with other
treatment modalities, like traditional or existing programs.
(SAMHSA, 2009)
5. “18.6 million Americans needed treatment for a
serious alcohol problem, and 7.7 million
people needed treatment for a diagnosable
drug problem. Fewer than 3 million obtained
treatment in 2002.” (Stofle, 2004).
6. Convenient and flexible
Not confined to a specific location
Available 24 hrs. a day
Accessible w/o regard to normal business hrs., set apt. times; or
waiting lists
The immediacy of online services can capitalize on fluctuating
motivation to seek treatment
May result in feeling less dependent on the therapist
Allows client time to reflect without pressure to think quickly
Anonymity eases discomfort and potentially embarrassing and
stigmatizing disclosure of behavior and thoughts
Adults and children have disclosed higher levels of personal
information sooner on a computer than FtF. (Alleman, 2002).
“clients of online counseling have reported they feel less self-
conscious, less inhibited, and better able to express themselves than
they would sitting in someone‟s therapy room, and therapists have
reported they feel more focused and that their responses are more
powerful when they have time to reflect before responding to a
client‟s input (Alleman, 2002)
7. Security and privacy concerns
Legal concerns (jurisdiction, adequate care)
Misunderstanding due to lack of non-verbal
cues or misunderstanding of written response
Inappropriate training may affect clinical
competence
Inappropriate online relationships through
social media sites
(Facebook, Twitter, LinkedIn, etc.)***
8. Asynchronous Communication: E-
mail, Forums, Listservs
Synchronous Communication: Audio
Conferencing, Videoconferencing; chat, IM
Many who sought online therapy later used
ftf counseling
90% felt online therapy helped them
Many felt they would not have initially sought
ftf therapy (Alleman, 2002) (SAMSHA, 2009)
9. “Thus far, research findings indicate that
online counseling may be beneficial for clients
who do not have easy access to traditional FtF
therapy.” (Mallen & Vogel, 2005)
10. CBT to change drinking behavior as effective
when delivered online (Copeland and Martin,
2004) (SAMHSA, 2005)
Alcohol interventions conducted over the
internet showed promising results (Copeland
and Martin, 2004)
“There is good evidence that computer-
delivered interventions for mental health and
behavioral problems can be effective.”
(Copeland & Martin)
11. Does the person possess the written language skills
and able to express emotion through text?
How might the person‟s computer skills, knowledge,
platform and Internet access affect the therapy?
How knowledgeable is the person about online
communication and relationships?
How well suited is the person for the reading and
writing involved in text communication?
How might physical and medical factors affect the
online therapy?
Assessing a Person‟s Suitability for Online Therapy at:
http://www.ismho.org/therapy_suitability_assessmen
t.asp.
12. Can one express empathy online?
Can one express Presence online?
The Disinhibition Effect – the perceived safety
of the distance between clients and therapist
makes them much more willing to admit the
uncomfortable thoughts
Issues of Fantasy online
13. Determining what methods of Internet delivery is
best suited for client and therapist
Adequate typing skills, comfort with downloading
programs, using various platforms & software,
basic computer skills, ease of use with web links,
ability to protect communication of clients
including use of encryption, expressive writing
skills, comfort in text-only environment, skill at
clarifying online communication, desire to be
online, experience w/ online relationships, belief
that online relationships can be meaningful, able
to handle computer glitches, able to handle
various methods of delivery (Fenichel, 2000)
14. Attending and Acknowledging – “Jane, I did
receive your email today and will respond by
tomorrow. Take care.”
Probing – “Can you clarify for me what you
meant when you said…?”
Supporting – shows warmth. Physicality
through emotional bracketing [take my
hand], expressing emotion
[smiling], emoticons, hugs ((((Jane))))
Checking Perceptions – “What I hear you
saying is…”
15. See “Ethical Framework for the Use of
Technology in Mental Health”***
Informed Consent – should have a page on
website dedicated to this.
Practitioner Competence – experience,
training, supervision, computer skills,
verification of qualifications
Clear Client Exclusionary Criteria – age,
severity of illness, computer savvy, location
16. Privacy and Security Protections – encryption,
back-up, use of passwords, firewalls, virus
protection, etc.
Initial Intake and Screening Process
17. Should begin at first client contact
Screening form/questionnaire
Screen for client‟s technology skills
Screen for client‟s language skills
Presenting problem (Why seeking therapy
online?)
Client identity verification
Clinical screening
See example questionnaire***
18. The process (what to expect,
misunderstandings that may occur,
turnaround time, safeguards)
About the practitioner(s) (credentials, contact
info, training)
Potential risks and benefits
Alternative treatment services
Emergency procedures
Should be acknowledged as read and
understood
19. Always obtain demographic info. (name,
address, contact info, emergency contact
info)
If located in a different geographic location,
look up community emergency and safety
resources (hospitals, SOs, clinicians, police)
If you don‟t know exact location of client in
an emergency, contact local police dept.
20. Jurisdiction Issues
Confidentiality and privacy protections
(Hushmail, Office 365)
Determine what constitutes the clinical record
(chat transcripts, video recordings, email
exchanges, etc.) and who owns it
Important to have an attorney review your
website, forms, procedures
21. Issue of Jurisdiction (lack of inter-state
reciprocity)
How can we be assured that we are not
violating laws around jurisdiction? Answer –
“Damn near impossible” (Jason S. Zack)
To date, no known lawsuits brought up in any
states which address online therapy
specifically
22. “Consistent with the Model Act, the Technology
Standards admonish social workers to „abide by
all regulations of their professional practice
with the understanding that their practice may
be subject to regulation in both the jurisdiction
in which the client receives services as well as
the jurisdiction in which the social worker
provides services.‟ (NASW &ASWB, 2005).
23. “This highlights the requirement that social
work practices that operate in more than one
state must review and interpret the laws and
regulations for social work practice in each
state and determine how the practice should
be structured to avoid conflicting
requirements and afford clients the greatest
level of protection from unregulated
practice.”
24. Know the laws of your state
Know the laws of your client‟s state
Check out the National Telehealth Policy
Resource Center (provides state-by-state laws)
Understand the scope of practice related to your
license, certification, education and law
Determine whether your insurance carrier will
cover an out-of-state claim
Seek legal consultation for your practice
If your website indicates that you consider
services rendered to be at your location, seek
legal advice
25. Specific Online Training is strongly
recommended in most Guidelines
Distance Credentialed Counselor (DCC)
Training Program and Credential at
www.readyminds.com. A 2-day (15-hr.)
program. $595.
Online Therapy Specialist Certification at
www.onlinetherapyinstitute.com. 60-hour,
online modules. $2,000.
26. The Importance of a Website (important to speak
to the client‟s need)
6 Characteristics that top therapist websites share
(Truffo, 2007):
1. Speaks about services that client can appreciate
2. Has a clear „call to action‟ & contacting therapist
is easy
3. Offers something for free
4. Reflects personality and picture of therapist
5. Geared towards the ideal client
6. Simple and to the point, presented in caring
manner
27. Crisis Intervention Information
Contact Information
Practitioner
Education, Licensure, Certification
Information
Terms of Use and Privacy Policy
Explanation of security/privacy (personal info)
An Initial Screening form/questionnaire
An Informed Consent
Costs of treatment and payment info.
29. Deciding Whether to Join an E-Clinic or Private
Practice
Joining Online Therapist Directories (e.g., Psychology
Today, Find-a Therapist.com., Nat. Directory of
Online Counselors)
Blogs
Pay-Per-Click Advertising
Ask questions on home page
Offer free information
Use audio
Write articles
Create a Podcast
Join social networks
Write a Press Release
31. Use emoticons – the creative use of keyboard
characters to indicate to the other person
what is happening at your end of the
conversation (e.g., the wink when you‟re not
wholly serious). Should be led by client.
Learn acronyms and abbreviations
Enhancing Text – makes it more „alive‟ (e.g.,
use of capitalization, underlining, bolding,
exclamation marks, emotional bracketing,
and parenthetical use
32. Signature files (not used in therapeutic
emails)
CCing, BCCing and address books (never to
be used)
Greeting and sign-offs (less formal as time
goes on)
Subject lines
Paragraphing (many shorter paragraphs)
33. Enormous benefit for those with mobility
problems (elderly, rural, military, agoraphobia)
Majority of studies: little difference in outcome
Excellent and inexpensive applications:
WebEx, Go-To-Meeting (HIPAA compliant)
Use of headphones with microphone
Held in private area - important
Initial set-up and training required
Great feeling of “Presence”
Clients seem to love it (feel safer, comfortable)
34. Involves a level of honesty about substance
use
Decision on recording sessions
Suggested maximum size of group – 6
Do all members see each other?
Work assignments in between sessions
(e.g., Wellness Self-Management Plus)
Sign-in Sheet (days C &S, distress level, self-
help, self-efficacy, completion of
assignments)
Join 15 min. prior to group
35. Chat rooms usually “open” rooms
IM usually a private dialogue
Common use of abbreviated words &
emoticons. Follow client‟s lead.
How do we know we are speaking to client?
Clients reports getting to their root issues
more quickly that ftf.
Use secure chat service providers (HIPAA
compliant). Encrypted & proper storage.
36. Proficient typing recommended
Understand the reason why someone may be
choosing this modality
Best served by adolescents and young adults
Eliminating ftf presence reduces anxiety
Useful in couples therapy
Useful for those who lack a private area in
home to speak
37. Preparing to begin services for over a year
Start-up began in January, 2013
OASAS would not consider endorsing product
No insurance accepted
6-week program (twice weekly groups, 3
individual sessions, weekly educational
assignments, access to counselor by
phone/email)
Cost - $899
www.chat2recovery.com.
38. Alleman, J.R. (2002) Online Counseling.
Psychotherapy:Theory/Research/Practice/Trainin
g, vol. 39, No. 2, 199-209.
Anthony, K. and Nagel, D. (2010) Therapy Online:
A Practical Guide
Anthony, K., Nagel, D. and Goss, S. (2010) The
Use of Technology in Mental Health: Applications,
Ethics and Practice
Copeland, J. & Martin, G. (2004) Web-based
interventions for substance use disorders: A
qualitative review. J. of Sub. Abuse Treatment,
26, 109-116.
39. Hsiung, Robert C. (2002) e-Therapy: Case Studies,
Guiding Principles, and the Clinical Potential of the
Internet
Kraus, R., Zack, J. and Stricker, G. (2004) Online
Counseling: A Handbook for Mental Health
Professionals
Mallen, M.J. & Vogel, D.L. (2005) Counseling
Psychology and Online Counseling. The Counseling
Psychologist, Vol. 33 No.6, Nov., 761-775.
Substance Abuse and Mental Health Services
Administration (2009) Considerations for the
Provision of E-Therapy.
Stofle, G.S. (2004) Addiction Treatment Online.
Behavioral Health Management, March/April, 53-55.