Catherine Jackson explores the digital revolution and its power to transform the therapeutic relationship
E-therapy, equality and access
Three quarters of households in the UK are connected to the internet. On average, we spend over two hours a day online. Nearly everyone in the UK (around 91 per cent) has a mobile phone; nearly a third (30 per cent) of all adults has a smartphone; among younger adults (under 24) this rises to 52 per cent.
To the non-digital, the arrival in the early 2000s of Web 2.0 means little. To the digitally literate, it heralded a revolution. Web 2.0 brought to the internet the potential for interactivity. No longer was it simply a vast, passive store of information – a British Library in the ether. Web 2.0 allows internet users to communicate with each other, and to establish specialist communities of activity and interest. Thence has emerged the babble of social networking sites, wikis and blogs; thence has come its radical potential for the democratisation of knowledge and power.
With Web 2.0, in medicine, doctors can no longer claim special status as experts in human health. People began turning up at their GP surgery with some idea of what might be wrong with them. People with shared medical conditions began exchanging information about symptoms and treatments not just within physically proximate communities but across continents.
The ripples from this revolution might be expected to have less impact on the world of counselling and psychotherapy, which – in principle at least – relies to a much lesser extent on the certainties of diagnosis and, in most modalities, claims to eschew the mystique of the all-powerful professional. Kate Anthony, who has worked in the world of e-therapy for many years and is co-founder and co-Director, with her US-based business partner DeeAnna Merz Nagel, of the Online Therapy Institute, argues this is far from the case: ‘Web 2.0 offers equal power to us all – clients and practitioners alike. I see a future where the “expert” is anyone. People use Google to find communities, to talk to other people and, if that takes them down the road to therapy, to choose the kind of therapy they want and the therapist. Many people with milder depression and anxiety symptoms will find a solution without going anywhere near a professional. I can only see this continuing, particularly with the development of platforms such as FaceTime on smart phones.’
The days when e-therapy and online counselling were expected to prove themselves are over: ‘E-therapy is here to stay. It’s time to move on,’ says Amanda Hawkins, Chair of BACP. She is heading up a new BACP Expert Reference Group established to keep the organisation abreast and ahead of developments as digitalisation takes hold within the counselling community. A very recent convert after training in online counselling, Hawkins says it isn’t a question of ‘whether’ but ‘how’. In her day job (she is Senior Manager of the RNIB’s Emotional Support Services), she says their clients are demanding it. And, she points out, they are not, on the whole, the typical e-demographic: they are blind or partially sighted and most are over 65.
‘If that is how they want to engage with and explore their emotional world, we, as a profession, have to respond. After all, that is how most people relate these days, and why should our relationships with our clients not reflect that?’ she argues. Nor is it a question of ‘either/or’: ‘Online therapy gives people more choice about how they engage with counselling. We are moving towards a much more blended model, whereby we offer people what works for them in a way that works for them,’ she argues.
Access and engagement
This is certainly the experience at PsychologyOnline, one of the earliest organisations to offer e-therapy when it launched in 2000. Today it has some 100 CRB-checked and accredited CBT therapists on its books offering online supported CBT packages through instant messaging. Says Chief Executive Barnaby Perks: ‘Coming to us is a positive, informed choice.’ And, he says, their results confirm this. Not only do they get good outcomes; very often clients achieve their goals far quicker than with conventional face-to-face CBT. ‘Our therapists report that people are able to drill down to the issues that matter more quickly. They also appear more ready to disclose personal information when they can’t actually see or be seen by their therapist.’ Clients also like the time flexibility. ‘Most of our clients prefer evenings, 6–10pm, Monday to Thursday. They want, or need, to do therapy in their own time when it doesn’t interfere with their working, family or social life.’
These benefits are also reported by the specialist young people’s online counselling service Kooth.com, which was launched by the online counselling organisation Xenzone nearly 11 years ago. Kooth.com offers drop-in chats and booked one-to-one sessions with a counsellor, themed message board forums, secure web-based email contact and an online magazine. Some 10,000 young people aged 11–25 use its services, and it has about 100,000 registered members. A resounding 89 per cent of its users say they prefer it to face-to-face counselling. Says counsellor Aaron Sefi: ‘There’s qualitative research in Australia reporting that young people prefer to use counselling online precisely because the therapist can’t see them and that makes them feel safer. Typically they’ll say, “Online, the therapist can’t see me crying.” For some young people, this can be a massive shift in power dynamics.’
They also like the immediacy of access. ‘They can use it as and when and where they want and need to,’ Sefi says. ‘In face-to-face services, by the time the young person sees the counsellor, what has brought them to the referral has often ceased to be so relevant.’
Sefi believes a large part of Kooth.com’s success with young people is that they are in control. ‘Kooth.com makes the young person the agent of their own change. In my experience of managing face-to-face and online services in Cornwall, face-to-face counselling has a lower engagement rate; young people very often don’t turn up for their appointments. Online, it’s demand-led. They don’t log on just because someone has told them to. They are able to invest more in it because it’s on their terms.’ He does admit it can be disconcerting for the counsellor when the young person goes offline halfway through a conversation. It generally turns out that it’s teatime, or The X-Factor is on the television.
Kooth.com is noticeably well used by young people from minority ethnic groups. ‘Online counselling is equalising. If you go into a chat room or forum, you don’t know who the other people are, their race, age, sexuality. You are all the same. The power dynamics and potential for discrimination are all evened out,’ Clinical Lead Sally Evans says.
Kooth.com provides its service under contract to several PCTs and local authorities. IAPT services are also, increasingly, commissioning online therapy organisations to provide CBT to their clients. Rotherham, Doncaster and South Humber (RDash) NHS Foundation Trust is one of the very few NHS trusts to have developed its own, in-house e-clinic, as an adjunct to its IAPT service, and is now offering to provide the service for other trusts. The Talkingsense.org e-clinic was launched last July. Patients seeking psychological therapy are assessed and, if deemed suitable, offered the e-clinic as a quicker alternative to face-to-face therapy. They get a password, access to self-help material and up to six scheduled sessions with counsellors through live synchronous chat.
The range of clients who have accessed the service reflects IAPT’s 17–65 years client profile, says Michelle Larkin, RDash Business Development Manager. ‘The younger adults choose it out of preference, sometimes because of anxiety about engaging with the service; the 27 to 40 age group choose it out of necessity because of work or childcare commitments, for example, and the 55 to 65 age group choose it equally for convenience and health reasons that make it hard for them to access a physical location.’
Larkin says RDash is reflecting trends in the wider worlds of the health service and digital technology. ‘What is happening nationally is driving this change, particularly the increasing demands for psychological therapies and finite resources. You wouldn’t want to do it just because it’s cheaper. It does tick that box but there are many other reasons. The way people communicate with each other has completely changed and if we want to make our service more accessible – and the whole point of IAPT is to improve access – the e-clinic means someone who might not otherwise engage with our service gets the help they need. My hope is that we are tapping into a pool of untreated patients because we can offer this. I think, wherever you can add to patient choice, that’s a good thing.’
Apps and empowerment
Individual empowerment is also driving the development of apps and other digital methods of engaging people in their treatment and monitoring progress. At Reading University PhD student Alex Gyani has created an app called Mood Mate for his research study to see whether regular monitoring of levels of anxiety and depression helps people seek help by, for example, referring themselves to their nearest IAPT service. ‘Getting through the health system to find help can be a labyrinthine experience, especially if you are feeling depressed and your motivation is anyway very low. Even if you know help is available, you might not think the service is for you. The barriers can mean people get lost in the system so they don’t get the help when they need it,’ he says.
‘Buddy’ was developed by the social innovations company Sidekick Studios, initially in partnership with the South London and Maudsley NHS Foundation Trust (SLAM), with funding from the Department of Health Innovations Fund. It’s an SMS and web-based tool for use jointly by the clinician and client to support mental health care planning. Sidekick decided not to develop it as an app as fewer people own a smart phone.
Buddy uses daily text messages to prompt the service user to log onto an online record shared with their clinician where they can rate their mood on a scale of one to five and write about their thoughts, feelings and behaviours. It will also send the service user a reminder by text 24 hours before their appointment with their clinician, invite them to review their week and set the agenda for what they want to discuss at the meeting. It can also be used to prompt the user to take any actions towards the goals they have agreed with their care co-ordinator as part of their recovery plan.
‘It’s putting the control back with the user and enabling them to take a more proactive stance in their therapy session,’ says Aisling Treanor, Research and Development Manager.’
Sidekick Studios has personalised the system, so Buddy greets the service user by name. ‘We very much wanted it to be user-led, so users can use it to set their own recovery goals and can also opt out of receiving the text messages if they want,’ says Treanor. ‘But most people who use it say they like getting the messages. Often they are quite socially isolated and may be depressed and vulnerable; they tell us they like feeling someone is checking on them every day to see how they are doing. It gives them encouragement and a little boost.’
There is something a little sad about someone with mental health problems feeling so isolated that an automated message from a mobile phone text makes them feel cared about. Phil Topham, senior researcher in counselling psychology at the University of the West of England, says people have always personalised their tools; we give our cars names and buy our smart phones natty little body covers. ‘The evidence is emerging that people can become emotionally attached to their smartphones.’
Topham has been working with colleagues in the university’s computer science department to develop a self-help app for anxiety. It is, he says, ‘a CBT app with a humanistic ethos’: it adds games, humour and a touch of idiosyncrasy to the conventional CBT techniques. ‘Some of the apps on the market are a bit too clinical,’ Topham believes. ‘Apps are increasingly common for social, recreational and physical health purposes; there’s no reason why they shouldn’t also perform a psycho-educational function. It could reduce people’s use of GPs and other health services. It’s a good way to reach thousands of people and to offer self-help in an accessible and flexible format.’
A self-help app can be used to support internal dialogue about making changes, Topham explains. ‘There is an idea in psychological therapy that the working alliance is created between the adult of the client and the adult of the therapist; the adult of the client takes their distressed parts to the therapist and the therapist contracts with them to engage in therapy. If you think about the self-help dialogues that people have, that process of “Am I well enough to go to work?”, a useful app will enable you to have that conversation, if you have enough adult self to make use of it.
‘But that means people have to engage with it, to commit themselves to it, and that means that the app has to help by being warm, friendly, engaging, credible and, through its functions, instil a sense of hope. People have to feel comfortable with it. In the world of mobile self-help, user engagement and the working alliance may be parallel concepts.’
The app also links to a confidential ‘social cloud’, so users can share comments and advice with each other. ‘We hope that will be a strength of the app,’ Topham says. ‘It aims to duplicate the social support that you get from friends and family when trying to make changes in your life.’
Communities of support
Kooth.com also believes its message boards and forums are an essential feature of the support it offers. ‘It’s important to young people to feel they are not alone and that other young people are experiencing the same things and have come through it. They are more likely to believe they will also come through if it comes from another young person. It’s incredibly empowering in that way. It also gives young people a chance to give back; they like that,’ Sally Evans says.
Big White Wall was originally developed as a self-help online community. More recently, in collaboration with the Tavistock and Portman NHS Foundation Trust, it has developed into a comprehensive counselling/self-help/peer support platform offering asynchronous guided self-help and psycho-education, moderated message boards and chat forums and, since last summer, live therapy via audio, video and instant messaging. It has its own community of some 10,000 users, but also provides the same choice of support services under contract to other organisations, including several IAPT services and NHS trusts and the Ministry of Defence, for which it provides an online support service for war veterans.
Jen Hyatt, founder and Chief Executive, says: ‘I don’t want Big White Wall to be just a software platform. I’m interested in the potential of digital technology to improve mental health care.’ It isn’t rocket science, she argues; the principles are those that informed telephone helplines: help should be there when you need it. But digital technology allows that help to take many different forms, and places the user in the driving seat. That is what makes Big White Wall transformational, Hyatt believes. ‘We think of Big White Wall as a therapeutic community where the support is provided by the members and enhanced by us. It’s turning healthcare on its head in terms of people leading their journey to wellness. Our philosophy is, you are in control.’
The overall client engagement and recovery rates are impressive. More than two thirds of those referred to the site as part of their treatment plan take up the referral and recovery rates are around 70 per cent, compared with the 50 per cent target set for IAPT services (and its current 46 per cent recovery score).
As need outstrips demand and the cost and consequences for society and our economy of not caring for people’s mental wellbeing become increasingly clear, digital services like Big White Wall will play an ever more central role, Hyatt predicts. Hyatt doesn’t believe online counselling will ever replace face-to-face therapy but she’s confident that in five years’ time it will overtake it in volume: ‘You won’t even need a computer. You will be able to access our services by tablet and android by this summer.’