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A Manual on Cyber Counselling with Children and Youth

Prepared By: Faye Mishna Lea Tufford

Charlene Cook Marion Bogo

Rob MacFadden

2008

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TABLE OF CONTENTS

Contents INTRODUCTION .............................................................................................................. 3 

Traditional Counselling .................................................................................................. 3 Cyber Counselling .......................................................................................................... 4 

THERAPEUTIC ALLIANCE ............................................................................................ 6 Traditional Counselling .................................................................................................. 6 Cyber Counselling .......................................................................................................... 7 

ASSESSMENT ................................................................................................................... 8 Traditional Counselling .................................................................................................. 8 Cyber Counselling .......................................................................................................... 8 

TERMINATION ................................................................................................................. 9 Traditional Counselling .................................................................................................. 9 Cyber Counselling ........................................................................................................ 10 

CULTURE AND GENDER ............................................................................................. 10 Traditional Counselling ................................................................................................ 10 Cyber Counselling ........................................................................................................ 11 

ETHICAL AND LEGAL ASPECTS ................................................................................ 12 Traditional Counselling ................................................................................................ 12 Cyber Counselling ........................................................................................................ 13 

RESEARCH SUMMARY ................................................................................................ 14 Process Evaluation ........................................................................................................ 14 Qualitative Interviews: Thematic Analysis ................................................................... 14 Content Analysis ........................................................................................................... 18 

CONCLUSION ................................................................................................................. 19 References ......................................................................................................................... 20 Appendix 1 ........................................................................................................................ 23 Guidelines to Traditional and Cyber Counselling ............................................................ 23 Appendix 2 ........................................................................................................................ 24 Traditional and Cyber Counselling Competencies - Similarities and Differences ........... 24 

Similarities ................................................................................................................ 24 Appendix 3 ........................................................................................................................ 28 A Conceptual Model of the Integration of Cyber Counselling and Traditional Counselling Modalities ......................................................................................................................... 28 Appendix 4 ........................................................................................................................ 29 Content Analysis Rating Scale .......................................................................................... 29 

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INTRODUCTION

This guide, prepared for the Ministry of the Attorney General, Victims Secretariat, compares traditional and cyber counselling competencies as reviewed by the Factor-Inwentash Faculty of Social Work, University of Toronto. Traditional Counselling Since the early days of Sigmund Freud, traditional therapy has been typically conducted face to face whereby client and therapist meet in a pre-arranged, established setting for a time limited appointment. Since then however, multiple variations in conducting counselling have arisen including crisis counselling, telephone counselling, drop-in counselling, and outreach to marginalized or impoverished populations. These variations may or may not include pre-arranged limited appointments. Many of these newer modalities have direct implications to working with children and youth, given the flexibility of these approaches and the limited resources available to children and youth. In the decades in which traditional therapy has been practiced a number of core competencies have been identified, which are considered essential to efficacious practice. Given the increasing number of modalities however, through which counselling is offered, this core skill set has grown and diversified. Some competencies are now unique to certain modalities while others are similar across variations of counselling. Our understanding of the development and application of these competencies is still growing, particularly in new areas of practice. Bennett-Levy (2006) identifies two types of competencies: declarative and procedural. Declarative competency refers to the acquisition of factual knowledge, for example understanding the cognitive model involved in panic disorder, which is obtained through lectures, supervision or reading assignments. Procedural competency refers to the direct application of learned skills within a session. Over time, therapist competency in the procedural area becomes more elaborate and refined. Therapy does not occur in a vacuum but rather, takes place within the larger context of the client’s extended family, community, and geographic locale. Therapists understand the limited nature of the service they provide (generally two to four hours per month) and utilize community resources as an adjunct to treatment (Hilarski, 2007). Knowledge is contextualized by competent therapists, who adjust clinical approaches for clients based on factors such as clients’ education, finances, culture and mobility (Lam, 2006). Further adjunctive services include reading material, sometimes called bibliotherapy, for clients who would benefit from this type of intervention as well as websites of an instructional or educative nature (Lyneham & Rapee, 2006). In order to achieve the goals of therapy, a variety of competencies must be demonstrated by the therapist. An essential competency across all variations of counselling is the therapist’s ability to forge a working alliance with the client in the early stages of therapy

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(Messer & Wampold, 2002) through the integration of verbal and non-verbal communication such as warmth, acceptance, empathy and compassion. An additional key aspect of clinical or practice skills is knowledge of therapeutic models for example, systemic, solution focussed, narrative, psychodynamic, and brief with the concomitant theoretical framework to guide interactions, and knowledge of specific interventions to achieve the desired cognitive, affective or behavioural changes (Rigazio-DiGilio, 2002; Shaw & Dobson, 1988;). In order to ensure competent and effective intervention, therapists also strive for in-depth knowledge of the particular population whom they counsel, such as developmental stages in working with children or adolescents and intervention strategies such as the stages of change in working with individuals who present with addictions (Prochaska & DiClemente, 1992). Cyber Counselling Over the past decade, cyber counselling has arisen as a new counselling modality and a variant to the tradition of face to face. Collie (1999) aptly notes that computers and the Internet make it possible for counselling to occur without the counsellor and client(s) being in the same physical place at the same time. Online counselling falls into the general category of telehealth, that is, the use of telecommunications technologies to make health care available to anyone who, whether by choice or necessity, receives care without the physical presence of a practitioner. Since its inception, the demand for Internet counselling has continued to increase at an overwhelming rate. Millions of people worldwide now have Internet access. Statistics show that a high percentage of children and youth are increasingly technologically savvy. A survey of children and adolescents in grades 4 through 11 revealed the following: 37% own their own computer; 61% have high-speed Internet; children and youth with their own computers spend 4-8 hours daily online; and 30% of youth have personal websites (Young Canadians in a Wired World, 2005). Over 90% of school age Canadians have access to the Internet through locations other than school, such as home and Internet cafes. According to a recent study 99% of students in grades six/seven and ten/eleven have a computer in their home and 67% have two or more computers, and two thirds of the students, communicate via the Internet with a friend once a day or more (Mishna, Cook, Gadalla, Daciuk, Solomon, & MacFadden, in preparation). As the numbers of individuals, including children and youth, who seek counselling and help online escalates, mental health professionals and organizations are increasingly offering counselling and other services online. There is insufficient guidance however, available to ensure “that this mode of psychoeducation and prevention is safe and accurate” (Mallen et al., 2005, p. 820). What is missing are clearly defined methods of providing Internet counselling that have been evaluated for effectiveness and that form the basis of empirically-based approaches in this new medium. In many cases, cyber counselling is offered without key issues adequately addressed, such as counsellor-client boundaries, confidentiality and duty-to-warn in situations of abuse (Mallen et al., 2005).

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Cyber counselling is an ideal medium through which to reach children and youth not only because many youth have access to the Internet, but also because many youth feel comfortable with the Internet, and may be embarrassed to seek therapy or support in a face-to-face situation. A number of general benefits of online counselling have been identified, including: increased accessibility for clients (e.g., those who live in rural communities with few counselling services, those with physical disabilities such as issues with hearing or mobility, and those who do not have the means or time to travel to a counsellor’s office) (Oravec, 2000); availability to clients who are afraid to seek therapy in person due to issues such as anxiety or stigma; and increased comfort for those who prefer the shield afforded by the technology (Mallen et al., 2005) or the anonymous nature of the medium, in revealing intimate issues (Miller & Gergen, 1998). One conclusion of our research initiative on Cyber Abuse of Children and Youth, funded by Bell, is that there is a clear and urgent need to develop capacity and expertise related to cyber counselling. This initiative comprised several components including focus groups with students in grades 5-12 in two school boards in the Greater Toronto area in order to obtain their views of cyber bullying and a survey administered to over 2000 students in the GTA on cyber bullying. Findings underscore the accessibility of cyber counselling, as almost all participants (99%) had a computer in their home and 98% of all participants used the computer for at least one hour daily. Results indicate that the Internet is a site of significant victimization for children and youth, as 21% reported being bullied in the last three months and 35% reported bullying others online in the same time period. A further component of our cyber abuse initiative involved analysis of posts made by children and youth to the Kids Help Phone ‘Ask a Counsellor’ website. This service is run anonymously whereby children and youth can post a question without disclosing their name or other identifying information. Other online counselling services may be similarly anonymous or may require users to disclose identifying information. Ever since Kids Help Phone launched its ‘Ask a Counsellor’ website in 2004, there has been a veritable explosion of traffic through the Kids Help Phone website. During 2005, Kids Help Phone received just over 19,000 web posts from children and youth across Canada. In 2006 they experienced a 25% increase in demand for this service, receiving approximately 26,000 posts from kids. This dramatic yearly increase continues. In fact, Kids Help Phone has to block kids’ ability to use the ‘Ask a Counsellor’ service approximately 30% of the time in order to manage the volume that they receive. Responding to this crisis faced by Kids Help Phone, the Factor-Inwentash Faculty of Social Work in cooperation with Kids Help Phone developed and offered two semesters of a faculty-based pilot project. The aims of this program were 1) to teach Master of Social Work (MSW) students the necessary skills for online counselling, 2) to provide assistance to Kids Help Phone (KHP) in responding to child and youth postings, and 3) to evaluate this pilot project. Building on this successful pilot project and in response to the growing and urgent need for training in online counselling, the Factor-Inwentash Faculty of Social Work was well positioned to expand this pilot project. Reflecting our commitment to develop expertise and capacity related to cyber counselling we applied for

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and received a grant from the Ministry of the Attorney General, Ontario Victim Services Secretariat. This grant of $75,000 allowed us to begin to evaluate the current program and identify competencies and skills required for web-based counselling, and to develop a draft of a training manual for cyber counselling. As a result of an extensive literature review, we were able to identify the following key competencies and explore their differential expression in traditional and cyber counselling. There are many forms of cyber counselling, including asynchronous counseling, which is typically conducted by email and involves client and practitioner composing and replying to emails at their convenience. Cyber counseling can also take place in a synchronous format, which involves both parties online concurrently in a therapeutic conversation that occurs in real time. The type of cyber counseling investigated in this project is the form utilized by KHP; children and youth post anonymously to the KHP website and KHP counselors respond to their post on the website for both the writer and other children and youth to review. Therefore, the KHP approach is much briefer than other forms of cyber counseling. THERAPEUTIC ALLIANCE Therapeutic Alliance (Components)

Forge an alliance in the early stages of therapy.

Recall past information about a client.

Exhibit warmth, empathy, and regard for the client.

Help clients overcome a sense of being alone.

Display a non-judgmental attitude. Do not impose own value system. Focus on strengths, normalizing,

exploring options, paraphrasing.

Therapeutic Alliance: Traditional Forge alliance through such

activities as physical posture of head nodding, leaning forward, active listening in traditional counselling.

Therapeutic Alliance: Cyber

Forge alliance through encouraging future posting and matching client’s language, metaphors and style of writing in web-based counselling.

Traditional Counselling The therapist’s ability to forge a working alliance with the client, preferably in the very early stages of therapy, is a core competency and is a common factor in therapeutic practice (Messer & Wampold, 2002). Indeed, in separate meta-analyses, Lambert and Barley (2000) note that the therapeutic alliance accounts for 30% of treatment outcome, while Horvath (2001) writes that the alliance accounts for at least 50% of the favourable effects of therapy. The therapeutic alliance is integral across treatment modalities and is a powerful predictor of outcome despite clinician adherence to specific therapeutic approaches (Chatoor & Krupnick, 2001; Luborsky, 2000). Therapists develop an alliance with clients through basic elements of verbal communication such as matching the speed

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and tone of the client’s speech and adopting the client’s use of language and metaphor as well as through non-verbal communication such as head nodding, eye contact, and active listening (D’Elia, 2001). In addition to the basic elements of verbal and non-verbal communication, therapists create an interpersonal environment which is conducive to growth and learning through exhibiting warmth, acceptance, empathy, and compassion for client concerns. Critical within this relationship is the ability to recall prior information about the client which fosters a sense of caring (Cooper, 1975). Strupp (1986) comments on the balance between a therapist’s interpersonal and technical skills: “therapist skill is significantly manifested by an ability to create an interpersonal context and, within that context, to foster certain kinds of learning. The goal is to promote learning within a benign and constructive context” (p. 126). Cyber Counselling Within the realm of cyber counselling whereby the therapist does not have access to visual and non-verbal communication, there are a variety of strategies utilized to compensate for this lack of cues. One such form is the use of emoticons (e.g., , , :-S), which are creative designs that imitate facial expressions and thus denote the sender’s feelings or acknowledgement of the recipient’s feelings. In addition, changing font size or text can delineate a change in tone for the reader. The ability to engage in dynamic emoticon use such as identifying when it is useful, when it may trivialize a situation or confuse a client, or when it may lead to overuse is a skill in cyber counselling. Other online communication skills include emotional bracketing for example, “[feeling worried as I write this for I am not sure about your reaction],” descriptive immediacy for example, “[if we were to meet face to face I would offer you the chair on my left,]” and the use of similes, metaphors and stories to convey warmth, empathy, and support in the absence of nonverbal cues. To enhance the feeling of ‘telepresence’ – the feeling of experiencing a virtual therapist as present without sharing immediate physical space, online therapists can learn to describe nonverbal reactions to a client’s situation, such as “smiled at your response” or “my body tensed up as I felt your frustration.” Another technique that can foster communication and a sense of connection is to write as though the therapist and client are speaking for example, “I am so glad you felt comfortable to talk to me about that.”

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ASSESSMENT Assessment (Components)

Specific variables: risk of harm to self or others, substance use, depression.

Assessment: Traditional Use of genograms, standardized

instruments (e.g., Beck Depression, Child Behaviour Check List)

Verbal communication patterns Assesment: Cyber

How to assess clients through their text based representation

Written communication patterns

Traditional Counselling Assessment represents another core competency and is used for matters such as determining risk of harm to self or to others, substance use, or depression (Cohen & Schouten, 2007). Many therapists utilize common assessment tools such as the Beck Depression Inventory, Beck Anxiety Inventory, or ADHD Inventories to assist them in assessing a client’s depression or anxiety as well as other issues with which the client may be struggling. An important component of assessment takes place by paying attention to the communication patterns of individuals, couples, and families while in the session. Many therapists use genograms or other pictorial representations of family history as tools through which to help identify patterns (Braverman, 2002). Cyber Counselling Assessment within the realm of cyber counselling can take the form of asking clients to complete online assessment tools. This enables the therapist to determine quickly and efficiently potential problems such as depression or anxiety. Posing questions to clients within the body of the therapist’s response to the client forms another method through which to assess clients. Unlike face to face counselling, this questioning must be done in a deliberate and somewhat directive manner. For example, the therapist tells a client that he or she is going to pose a series of questions, numbers the questions sequentially, and asks the client to respond to each question in its entirety. This approach encourages the client to spend adequate time and attention responding to each question and provides the therapist with responses that help to move the counselling forward.

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TERMINATION Termination (Components)

Providing resources to clients for follow-up.

Ending both sessions and the counselling relationship in a manner in which the client does not feel abandoned.

Termination: Traditional Terminations occur on a continuum

according to the counselling and thus can occur after only one session or following many sessions.

Terminations occur with individuals, couples, families, and groups.

Termination: Cyber

Termination might include encouragement to continue to post and engage or referral to other resources.

Traditional Counselling Two issues related to termination include providing resources to clients for follow-up (Hilarski, 2007) and ending therapy in a manner in which the client does not feel abandoned (Joyce, Piper, Ogrodniczuk, & Klein, 2007). In an effort to meet the growing demand for therapy services while reducing costs and wait times, single session therapy is emerging as a new model of service delivery. Furthermore, providing service to clients at peak moments of intensity and motivation may engender a client’s receptiveness to change (Hubble, Duncan, & Miller, 1999; Prochaska & DiClemente, 1992). Perkins (2006), in a study of single session therapy with children and adolescents in an urban mental health clinic, found that the use of solution focused therapy resulted in a clinically significant reduction in the level of psychopathology one month following treatment. Miller (1997) surveyed 417 adult clients following single session therapy and found that 83.3% reported high satisfaction with the overall quality of the service. Slaff (1995) reviewed the use of single session psychotherapy with adolescents and found that crisis intervention techniques provided in a single session were sufficient as adolescent disturbances were often short-lived. In order to be effective however, using this type of intervention with adolescents, therapists had to shift from a passive to a leadership position and be more directive with adolescents. Given that the model of the cyber counselling training offered through Kids Help Phone is based on a single session format, it is essential to examine this modality in a face to face environment as well.1 When an intervention comprises only one session, the refinement of competencies is essential due to the time-limited nature of the interaction. The goal of the single session format is client empowerment and constructive movement as opposed to the search for a “cure” (Hoyt, Rosenbaum, & Talmon, 1992). Therapists

1 It is important to note that there are formats that offer more than one session, which will require competencies that are both similar and distinct.

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assist the client to stay focused in order to delineate the problematic situation, determine what they have attempted in order to alleviate the problem, and set clear and attainable goals. Gibbons and Plath (2005) note some of the essential skills required to provide single contact service: “engaging clients, establishing rapport, assessing, providing information, validating, challenging beliefs and behaviour, and counselling” (pg. 24). Cyber Counselling As mentioned in the introduction, single session cyber counselling occurs as at Kids Help Phone, whereby a child or youth posts a question and receives a response with no guarantee the child or youth may post again. Moreover, even if the child or youth does post again, it will likely be another counsellor who responds; thus each post constitutes “a single session” intervention. Just as in traditional short-term therapy, issues of uncertainty as to what happened to the young person and coping with this anxiety exist in the cyber counselling world. Information and resources must be current and reliable given the archived nature of web-based counselling and the changing resources on the Internet. CULTURE AND GENDER Culture and Gender

Integrating issues of gender and culture across all aspects of therapy, where appropriate

Issues of Gender and Culture: Traditional Addressing issues of gender and

culture Issues of Gender and Culture: Cyber

Cognizance and understanding of gender and culture in the absence of visual cues

Traditional Counselling Within the realm of traditional counselling, cultural competence involves knowledge of cultures besides one’s own and an awareness of the impact of cross-cultural counselling on issues of power, individuation, and authority (Shonfeld-Ringel, 2001). Cross cultural competency is relational and may be understood to occur as part of the relationship between counsellor and client. To deny difference between counsellor and client is antithetical to working relationally. Cross cultural competency manifests itself at several levels including knowledge, skills, and awareness and represents inclusive perspectives such as gender, class spirituality, ethnicity, and race. There are four possible cultural configurations between counsellor and client with majority representing the dominant culture: Majority counsellor – majority client Minority counsellor – minority client

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Majority counsellor – minority client Minority counsellor – majority client Cyber Counselling Within the realm of cyber counselling, the lack of visual and verbal cues eliminates surface-level differences such as age, sex, race, and accent. Cyber counselling may decrease the potential to stereotype certain cultural groups while at the same time may increase the potential for stereotyping in the absence of visual cues that may disconfirm prior beliefs. There is increased importance in discussing roles of client and therapist, as clients from diverse backgrounds may not understand these roles, for example. A role of the therapist might therefore be to ask questions of the client to ensure full understanding of the client’s situation. With regards to gender, female clients may be more expressive than male clients in a cyber counselling environment and may prepare (Huffaker & Calvert, 2005) to use emoticons for self-expression. Thus, therapists working with male clients online may need to assist males to become more comfortable in writing about their emotions. A core competency in cyber counselling is the avoidance of therapist assumptions when viewing the client’s writing. For example, a client who has English as a second language may have difficulty writing online. The therapist may assume the client a) is anxious, b) has low intellect, or c) lacks commitment to the session, when none of these situations may, in fact, the case. To avoid misunderstandings and assumptions, it is recommended that therapists inform clients that culture is an appropriate topic for discussion in cyber counselling and that therapists initiate conversations regarding cultural difference with clients. Counsellors’ perceptions of their cross cultural competency may considerably differ from their actual cross cultural competency in practice. For example, counsellors may mistakenly assume that a grammatically correct post signifies a majority client while in reality the client is a second generation Canadian being raised by immigrant grandparents. Similarly, a poorly written post may not signify a minority client but a client with a learning disability.

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ETHICAL AND LEGAL ASPECTS Ethical and Legal Guidelines (Components)

Having knowledge of and adhering to ethical guidelines.

Understanding legal requirements as they pertain to therapy, including such issues as confidentiality, threats of harm to self or to others, and reporting suspected child maltreatment.

Outlining the limits to confidentiality to clients, prior to beginning therapy.

Having competency regarding identifying such issues as “duty to warn” and knowing how to proceed/refer and who to contact when necessary.

Ethical and Legal Guidelines: Traditional Having knowledge of ethical and

legal guidelines within one’s jurisdiction, province or state.

Explaining the limits to confidentiality.

Having awareness of issues related to duty to warn and procedures for disclosure.

Ethical and Legal Guidelines: Cyber

Having knowledge of ethical and legal standards outside of one’s jurisdiction.

Web-based counselling is archived and therapists’ words are documented.

Providing clients with a secure email system.

Explaining to clients such matters as the importance of working on their cyber email or posting in private, not giving out their password to others and not leaving the correspondence on a computer in a public space

Traditional Counselling Adherence to ethical guidelines falls under the auspices of a therapist’s regulatory body, such as the Social Work Code of Ethics 2008. Ethical guidelines serve to delineate the distinction between therapist and client and as such, protect clients from their therapists acting in ways that overstep boundaries, for example engaging in a dual relationship with a client (Cohen & Schouten, 2007). Membership in a regulatory body requires a basic understanding of that body’s ethical guidelines to ensure boundaries do not become porous and diffuse. Coupled with knowledge of ethical issues is an understanding of legal requirements as they pertain to therapy including issues of confidentiality, threats of harm to self or to others, and the reporting of suspected child maltreatment (Cohen & Schouten, 2007). Competent therapists outline the limits to confidentiality in a forthright manner prior to beginning therapy which fosters a spirit of transparency, elucidates the boundaries under which therapists operate and leads to informed consent (Bromley & Riolo, 1988; Crenshaw & Lichtenberg, 1993; Nicolai & Scott, 1994). Introducing the limits to

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confidentiality in tandem with or on the cusp of a reportable disclosure may lead to anger and feelings of betrayal on the part of the client and constitutes poor therapeutic practice. Steinberg, Levine, and Doueck (1997) found that a frank discussion of the limits to confidentiality led to a more positive emotional response on the part of the client when reportable material surfaced in session. Cyber Counselling Cyber counselling differs from traditional counselling in that it is conducted in an online environment, clearly different from face to face. This online environment carries a host of additional considerations when conducting therapy. Counsellors interested in engaging in online therapy are advised to offer clients a secure email system which will protect their correspondence from the view of others such as family members and online hackers. Questions related to jurisdictional differences and obligations also surface, for example, if a therapist is working with a client in another country and that client discloses child maltreatment, a therapist must consider his or her ethical and legal obligations. Professional associations throughout Canada and the United States are currently grappling with such issues due to the proliferation of cyber counselling.

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RESEARCH SUMMARY Two cyber counselling courses, commencing in January 2008 and again in April 2008, were provided to Master of Social Work students at the Factor-Inwentash Faculty of Social Work and to counsellors at Kids Help Phone. These courses focused on the development of cyber counselling competencies, were facilitated by senior Kids Help Phone clinical staff, and involved lectures, small group activities and supervised practice. In order to evaluate the course, the following evaluative tools were utilized: a process evaluation; a content analysis of sample clinical responses prepared by course participants; and interviews with course participants. In total, 40 MSW students and KHP employees completed the cyber counselling training course. All of these participants completed sample clinical responses that were included in content analysis, and 17 of these participants completed interviews at the completion of the course. Ethics approval was obtained from the University of Toronto Health Sciences Research Ethics Board. Process Evaluation A process analysis evaluation form was administered to course participants on the final day of class. A total of 31 participants in both courses completed the process evaluation, which was administered to assess student perception of the manner in which the course was offered. Results indicate that 90% of participants found the course both comprehensive and relevant to their work or future work, and participants found the course instructor to be knowledgeable (94%) and a good communicator (100%). All but one participant indicated that they would recommend the cyber counselling course to others. Course participants were particularly pleased that the course allowed for collaborative learning between MSW students and KHP staff, and that the course focused on the detailed and hands-on applications of the course content. Participants felt the course would have been improved by the inclusion of more content on cross-cultural cyber counselling, and they felt a greater focus should have been applied to other approaches to cyber counselling beyond that of the Kids Help Phone. Qualitative Interviews: Thematic Analysis Seventeen individual interviews were conducted with course participants who consented to participate in the course evaluation. Interviews were transcribed, and transcripts were loaded in NVivo, a qualitative software program. Multiple readings of the transcripts were performed, using a narrative thematic analysis to identify major themes (Strauss & Corbin, 1998). The data was analyzed through constant comparison to develop groupings of similar concepts of participants’ perspectives (Creswell, 1998). Consistent and contradictory themes were identified and compared within specific groups of participants and across groups of participants.

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Demographics Cyber Course participants comprised MSW students and Kids Help Phone (KHP) staff ranging in age from 24 to 57 years with a mode of 25 years of age and a mean age of 32 years. MSW students, on average, were considerably younger than their KHP counterparts with a mean age of 27.5 years and 48.4 years respectively. Consistent with the age difference, MSW students reported having less practice experience than the KHP staff with an average of 3.2 years compared to 12.25 years of practice experience by KHP staff. Despite the differences in age and practice experience however, the majority of the participants identified similar levels of computer ability based on proficiency operating Microsoft Office program applications as well as engaging in Internet activities such as surfing the web, texting, using Skype, Face book, email and downloading music, blogging, and conducting research online. Years of computer use varied from 6 years to 13 years with a mean of 9.4 years. Practice experience Traditional counselling experience varied among the cyber course participants with five participants reporting 10 or more years of practice experience, 7 participants having 2 to 5 years of practice experience, and 4 participants one year or less practice experience. The vast majority of participants indicated experience working with both children and adolescents and areas of practice included children’s mental health, family counselling, youth justice, group home work, schools, and child welfare. Cyber counselling experience was significantly less with 11 of the 16 participants who responded to this question indicating that they had no cyber counselling experience prior to attending the cyber counselling course. The four respondents with previous cyber counselling experience indicated limited experience with a range of two years to 4 years and a mean of 2.9 years. Competency The majority of participants described competency as a demonstration of proficiency in knowledge and skills specific to an area with little need for direction or correction. Conceptualisations of competent practice among the participants included practitioner understanding and correct application of theory; practice skills such as listening, reflecting, paraphrasing, and expressing empathy; and remaining non-judgemental of clients. Most participants perceived practice experience gained through work or practicum to be an important contribution to competent practice in addition to theory application, and clinical supervision. While several participants identified education and training as important to becoming a competent counsellor, most participants did not directly indicate the need for professional qualifications such as an MSW and instead favoured direct experience with clients as a means to becoming a competent practitioner.

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One participant summarised her thoughts about developing competency in this way: “I think it’s very helpful for counsellors to work beside more seasoned counsellors because you can reassure them on all the things that they’re worried about are usually not things that you’d have to really worry about. It comes with more time. You know, you’re always worried you’re not doing a good job and that sort of thing” (Course participant, 4 yrs cyber counselling experience). Another participant discussed processes within the course that facilitated her learning:

“…We kind of went through other posts and discussed what we liked about the responses that we did. So it was a lot of learning through doing as an observation which I feel is a learning style that I really like. And another thing was as we started to write our won posts, they have counsellors there that would come by and give feedback and things like that like I said before there was a lot of how I think you develop different competencies is by having like a supervisor come in with a lot of experience and just kind of give you a little feedback during that part of the course. We posted these things live, I think that part of the course was really important because it really made it seem real and it was a lot almost easier or more necessary to kind of take advantage of all of the other parts of the course and all the expertise in the room and each other and things like that. I really didn’t think that I would feel as confident about being able to do that type of work as I did after six weeks” (Course participant, age 25).

A participant discussed competency in terms of respecting the limitations of an individual’s skills and experience: “I think to be a competent counselling practice to stay within the guidelines of whatever you’re deciding to do, whether it’s here, one on one whatever, that the organization in particular that you’re working for and the background that you have, you stay within what you know” (Course participant, age 43). One participant emphasised the importance of practice experience as a fundamental aspect of becoming a competent counsellor:

“Practice, practice, practice! I mean absolutely it starts with education and learning about theory and learning I guess different skills and you know just come up with these skills on your own; so education is a huge piece. But I also think it’s practice, it’s hands on for me that has been the trial tested and true piece. I mean obviously the education is first to help guide your path I guess, and then it’s been the hands on, like both in my undergrad and here the practicum piece is the hands on piece when you get to utilise the theories and then implement it into practice” (Course participant, age 28).

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Motivation to take the course: The primary impetus for participating in the course was identified by most participants as an opportunity to gain additional training and practice in an increasingly important, ‘up and coming’ relevant area. For those with cyber counselling experience, most identified a desire to keep their skills current. Limited practice experience was mentioned as an important reason for taking the course among MSW students who sought education focused more directly on developing practice skills than they typically experienced in their coursework. Although the majority of students cited interest, opportunities for learning, practice skill development, maintaining skills, and offering more developmentally and age appropriate support to youth as principle reasons for taking the course, one student admitted the course offered a preferred alternative to attending her field practicum. While interest and desire to increase marketability in the workforce appeared to be primary motivators among cyber course participants, the majority of participants expressed having few expectations of the course and many did not attend the course with specific expectations or learning goals; although several developed learning goals shortly after beginning the course. Course participants stated that active involvement in learning to write responses to youth requests for assistance and or support was the most beneficial learning experience. Students identified the collegial learning environment with active and accessible supervision, and being paired with other students as highly advantageous to their learning and training in cyber counselling. Many students identified gaining skills in practice approaches to be highly valuable. Practice approaches included Solution Focused, crisis intervention, and trauma counselling in addition to other skills including assessing, analysing, and communicating with youth. Cultural competency The majority of participants concluded that they received little instruction on cultural competency in the course. Most students identified challenges associated with identifying cultural issues and implications in the on-line posts from youth who did not directly discuss or mention cultural issues. Participants who considered cultural competency covered in the course were those who were assigned posts explicitly identifying issues impacted by cultural background of the youth involved. Students who were privy to the small discussions with colleagues who were assigned these posts also identified culturally competent practice as covered in the course. Several students recommended that there be more open dialogue of posts in which culture was directly identified as a means to address the lack of focus on cultural competency many participants identified. The majority of participants praised course staff who shared perspectives and insights from their personal cultures during the course.

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Applicability to future work All participants for whom this course marked their first exposure to cyber counselling identified changing their perception of cyber counselling as a result of taking the course. Overall, course participants increased their understanding of the value of cyber counselling in terms of increasing the accessibility to help for youth. Cyber counselling was identified by the majority of participants as providing a preferred medium of communication for youth generally and also as providing youth with privacy and anonymity. One participant believed cyber counselling reduced barriers for her as a counsellor to therapeutically engage with youth who might normally be hesitant to work with her based on her gender, age, or racial background. All but one participant identified the course lessons as applicable to their future work. Most considered learning about issues that commonly impact youth to be highly beneficial to their ability to support youth in the future. Others indicated that learning to identify and respond to issues relating to youth suicide and trauma changed their perception of youth issues, which they believed would be influential to their future practice. One participant described the value the course had for her: “Yeah, I mean think it helped, it definitely helped with analytical skills, especially since kids post things on message boards and they’re saying something and you have to address what they’re saying, you can see underneath it, but it’s like oh what they really need is some positive, some hope or some confirmation that they’re doing the right things, that they’re good people, because they have low self-esteem or something like that. So it’s really identifying what they want and identifying directly what they’re saying and what’s lying underneath it. So I found it was good for analytical skills…” (Course participant, age 26). Content Analysis The content analysis form was developed to guide evaluation of clinical responses by course participants (Appendix 4). The responses were in response to sample posts submitted to KHP by children and youth. The content analysis focused on cyber counselling competencies in the areas of assessment, intervention, termination, relationship-building, cross-cultural and cross-linguistic issues (where appropriate), and an overall assessment of the response. Course participants responded, in groups of two or three, to three posts from children and youth. The first post was related to bullying, the second centred on feeling marginalized as an African-Canadian girl at a predominantly Italian-Catholic school, and the final post focused on a youth who was concerned for a friend with an abusive parent. Participant responses, drafted in groups, were rated on a scale from one to five for each item with five representing an exemplary expression of cyber counselling competency. Mean values of these scores are presented in the below table.

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Cyber Counselling Competency Average Score across Participants Assessment: Responses to client’s situation 3.7 Assessment: Demonstrates ethical/legal knowledge in cases of threat to harm or child maltreatment

3.8

Intervention: Validates client experience 3.9 Intervention: Supports client in moving forward

3.9

Termination 3.7 Relationship Building: Communicates understanding of client’s thoughts/feelings

3.5

Relationship Building: Enhances telepresence

3.4

Cross-cultural & Cross-linguistic Issues 2.1 Overall Assessment of Competencies 3.9 The results reflect the difficulties associated with cyber counselling. While assessment and intervention scores were quite high, areas of cyber-specific competency expression were more difficult. In particular, relationship building in counselling online was a particular challenge. The ability to project a clinical presence online proved more difficult for course participants than may have been expected, and underlines the importance of training in this field. The most significant issue highlighted by the content analysis related to cross-cultural and cross-linguistic issues. While scores in this area were very high in responses to posts in which cross-cultural issues were made explicit by the child or youth writer, scores were low in response to posts in which cross-cultural issues were not so clear. This finding highlights thematic findings from interviews with course participants, who expressed reluctance to address issues related to ethnicity or culture unless these issues were noted clearly by the writer in the original post. This is a very important finding regarding cyber counselling, particularly given the benefits of cyber counselling to reach a diverse client population. CONCLUSION Our literature review detailed extensive and nuanced differences in the expression of key clinical competencies between traditional and cyber counseling. The evaluation of our two cyber counseling courses for MSW students and KHP staff on a one-post anonymous web counseling serve, underscored the differences between traditional and cyber counseling. The evaluation highlights the need for extensive and detailed training in cyber counseling for future practitioners. It is particularly evident that cyber counseling may represent the future of practice with children and youth, and generating knowledge regarding efficacious cyber counseling is pivotal to serving this population.

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Appendix 1 Guidelines to Traditional and Cyber Counselling Traditional Counselling Knowledge of various counselling modalities including crisis counselling, telephonic counselling, drop-in counselling, anonymous telephonic counselling and outreach to marginalized or impoverished populations. Competency in one’s mode of counselling modality is paramount. The ability to forge a working alliance with the client in the early stages of therapy is integral to successful treatment. Practitioners need to learn basic counselling skills such as warmth, acceptance, empathy and compassion. Practice skills include knowledge of therapeutic models including systemic, solution focussed, narrative, psychodynamic, and brief with the concomitant theoretical framework to guide interactions, and knowledge of specific interventions to achieve the desired cognitive, affective or behavioural changes. Therapists should strive for in-depth knowledge of the particular population whom they counsel such as developmental stages in working with children or adolescents as well as intervention strategies such as the stages of change in working with individuals who present with addictions in order to ensure competent and effective intervention. Understanding of the contextual nature of therapy is essential including clients’ education, finances, culture, and mobility. Competent therapists know the resources in their community and utilize these resources as an adjunct to treatment. Cyber Counselling Therapists offering or considering added cyber counselling to their practice must be sufficiently and adequately trained to offer this service modality. Key areas in cyber counselling include counsellor-client boundaries, confidentiality and duty-to-warn in situations of abuse. Benefits to cyber counselling include increased accessibility for clients; availability to those clients who are afraid to seek therapy in person due to issues such as anxiety or stigma; and increased comfort for those who prefer the shield afforded by the technology or the anonymous nature of the medium, in revealing intimate issues.

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Appendix 2 Traditional and Cyber Counselling Competencies - Similarities and Differences

Similarities Differences Assessment

Specific variables: risk of harm to self or others, substance use, depression.

Assessment: Face to Face Use of genograms, instruments

(Beck Depression) Verbal communication patterns

Assessment: Cyber

How to assess clients through their text based representation

Written communication patterns

Terminations Providing resources to clients for

follow-up. Ending the session in a manner by

which the client does not feel abandoned.

Terminations: Face to Face Terminations generally occur after a

longer period of contact Terminations: Cyber

Terminations include encouragement to continue to post and engage

Ethical and Legal Guidelines

Knowledge of and adherence to ethical guidelines.

Understanding of legal requirements as they pertain to therapy including issues of confidentiality, threats of harm to self or to others, and the reporting of suspected child maltreatment.

Outlining the limits of confidentiality to clients prior to beginning therapy.

Competency regarding identifying issues of “duty to warn” and knowing how to proceed/refer and who to contact when necessary.

Ethical and Legal Guidelines: Cyber Knowledge of ethical and legal

standards outside of one’s jurisdiction.

Web-based counselling is archived and therapists’ words are documented.

Self-Reflection Consideration of experiences in

practice during and after session, exploration of feelings invoked through working with clients, and understanding the meanings they

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Similarities Differences ascribe to interactions. Ensuring Confidentiality: Face to Face

Familiarity with hard –copy record-keeping protocols for face to face counselling.

Ensuring Confidentiality: Cyber

Familiarity with electronic record-keeping protocols for web-based counselling.

Marginalization and Oppression

Determining the personal and social location of the therapist with respect to the client along the continuum of privilege and oppression.

Understanding how clients may experience marginalization and oppression in their lives in both overt and subtle ways.

Contextual Knowledge Knowledge of resources adjusting

for factors such as clients’ education, finances, culture, and mobility.

Communication Skills – Issues of Gender and Culture

Addressing issues of gender and culture

Communication Skills – Issues of Gender and Culture

Cognizance and understanding of gender and culture in absence of visual cues

Communication Skills – Compensate for lack of verbal cues/ Creating presence: Cyber

Awareness of and use of emoticons and other online conventions, such as changing font size or text to denote change in tone.

Ability to engage in dynamic emoticon use – identifying when it is useful, when it may trivialize a situation or confuse a client, or

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Similarities Differences when it may lead to overuse in a way that undermines sense of listening and empathy.

Online communication skills including emotional bracketing, descriptive immediacy, and the use of similes, metaphors and stories.

An ability to convey warmth, empathy, and support in absence of nonverbal cues.

Enhancing feeling of ‘telepresence’ – the feeling of experiencing a real or virtual therapist as present without sharing immediate physical space, seems to enable increased self-disclosure.

Self-expression through text. Display enthusiasm and

commitment in posts, so clients feel cared for and prioritized.

Able to display mood counsellors are in. Adolescent clients highly influenced by mood of person they are divulging to, as they perceive counsellor mood as a cue to their normality or how odd or marginalizing their disclosure was.

Learn to describe nonverbal reactions to client’s situation, such as “smiled at your response” or “my body tensed up as I felt your frustration.”

Creating therapeutic space by noting own emotional responses and nonverbal cues, describing setting, scene, and counsellor, sentence construction and use of spacing.

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Similarities Differences Computer/Technology Proficiency: Cyber

Typing speed and accuracy, and facility with the various technologies

Familiarity with internet shorthand.

Contextual Knowledge

Knowledge of the client’s extended family, community, and geographic locale usually occurs in face to face counselling but may not occur in web-based counselling.

Therapeutic Alliance

Forge an alliance in the early stages of therapy.

Recall past information about a client.

Exhibit warmth, empathy, and regard for the client.

Help clients overcome a sense of being alone.

Displaying a non-judgmental attitude.

Not imposing one’s value system. Focus on strengths, normalizing,

exploring options, paraphrasing.

Therapeutic Alliance: Face to Face Forge alliance through physical

posture of head nodding, leaning forward, active listening in face to face counselling.

Therapeutic Alliance: Cyber

Forge alliance through encouraging future posting and matching client’s language, metaphors and style of writing in web-based counselling.

Goal setting Goals should be clear, client

centered, and attainable

Ruptures Attempt to repair perceived or

stated ruptures.

Communication Skills Efficiency of communication with

regards to time on post or in session.

Boundaries Clarity what is / is not acceptable.

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Appendix 3 A Conceptual Model of the Integration of Cyber Counselling and Traditional Counselling Modalities

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Appendix 4 Content Analysis Rating Scale

I. Assessment

Responds to client’s situation 1 2 3 4 5

Response does not seem to reflect client’s

situation

Response reflects general but not specific

concerns of client

Response reflects primary need of client

as identified in post text

Response reflects need of client based on

client text as well as tone

Response reflects need of client based on

client text, tone, chosen nickname, and post

title

Demonstrates ethical/legal knowledge in cases of threat to harm of self or others/child maltreatment (where appropriate)

1 2 3 4 5 Response does not

address issues evident in client post

Response inconsistently mentions issues evident in client post; does not convey urgency or severity of

situation

Response has some mention of issues

evident in client post; little attention to urgency/severity

Response reflects severity and urgency of issue, provides details for referral/follow-up

Response meaningfully and consistently

reflects severity and urgency of issue, and provides details for referral/follow-up

II. Intervention

Validate client experience 1 2 3 4 5

Response does not express empathy

Response inconsistently

expresses empathy and normalizing of client

experience

Response contains some level of empathy

and normalizing of client experience

Response largely expresses empathy and normalizing of client

experience

Response meaningfully and consistently

expresses empathy and normalizing of client

experience

Support client in moving forward 1 2 3 4 5

Response does not address client strengths or explore options for

client

Response inconsistently discusses

client strengths; little focus on effectively

supporting client

Response has some focus on client

strengths; adequate focus on options and

referrals lacking

Response consistently incorporates client strengths, explores

options and suggests referrals

Response meaningfully and consistently

identifies/encourages strengths, explores options, includes

referral

III. Termination

1 2 3 4 5 Response is terminated

abruptly Response is terminated in a friendly manner; no reference to future

client feelings or future contact with KHP

Response is terminated in a friendly manner

and client is encouraged to re-

contact KHP

Response is terminated with some discussion

of reoccurring feelings; client encouraged to re-

contact KHP

Response is terminated with discussion of

reoccurring feelings, client strengths; client encouraged to contact

KHP

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IV. Relationship Building

Communicate understanding of client’s thoughts and feelings 1 2 3 4 5

Response does not reflect client’s tone or

stated thoughts and feelings

Response inconsistently reflects client’s overall tone

Response has some focus on client’s

overall tone, language, intensity or style of

writing

Response largely reflects client tone, style of writing and

intensity; client’s post is quoted in response

Response meaningfully and consistently

reflects client tone, style of writing and

intensity; portions of client’s post quoted in

response; greeting matches client post

Enhance Telepresence

1 2 3 4 5 Response does not

incorporate elements to enhance telepresence

Response inconsistently

incorporates elements to enhance telepresence

Response uses “you” and “I”, or changes

font/font size/punctuation to

make points

Response largely describes nonverbal reactions to client’s situation (smiled at

response); uses emoticons; changes

font/font size/punctuation

Response meaningfully describes nonverbal reactions to client’s situation (smiled at

response); uses emoticons; changes

font/font size/punctuation

V. Cross-cultural and Cross-Linguistic Issues (where appropriate)

1 2 3 4 5

Response does not address cross-cultural

or cross-linguistic issues evident in client

post

Response inconsistently

addresses cross-cultural or cross-linguistic

issues evident in post

Response has some inclusion of cross-cultural or cross-

linguistic issues evident in post

Response consistently addresses cross-cultural

or cross-linguistic issues evident in post

Response avoids slang and informs client of

possibility of misinterpretation;

encourages client re-contact if this occurs

VI. Overall Assessment of the Competencies Demonstrated in the Response

Based on your impression of the candidate’s performance, this candidate demonstrated competence at the level of…

1 2 3 4 5 Inferior Poor Borderline Good Excellent

Lack of initiative or attention to assessment,

intervention, termination, and

relationship building

Inconsistent attention to assessment, intervention,

termination, and relationship building

Some consistent attention to assessment,

intervention, termination, and

relationship building

Most often consistent in attention to assessment, intervention,

termination, and relationship building

Meaningful and consistent attention to

assessment, intervention,

termination, and relationship building