Beruflich Dokumente
Kultur Dokumente
Tayside Institute for Health Studies, University of Abertay Dundee, Scotland; bConsultant and
trainer-practitioner, OnlineCounsellors.co.uk, UK
(Received 12 September 2008; final version received 24 February 2009)
Counselling and psychotherapy has been influenced by technology for over 50
years. During this time, the rate at which ways that technology of one kind or
another can assist therapists and counsellors has seemed to increase exponentially.
This paper introduces and summarises contributions to the subject of technological enhancements or extensions of routine practice. While the variety of
technologies referred to is far from exhaustive, the paper offers a representative
sampling of the range available to practitioners from the now relatively familiar
email, internet chat and video conferencing through to the cutting edge of
developments in virtual reality, mood influencing packages and services that, like
Web 2.0, can be based upon the needs and designs of the users themselves.
Keywords: technology; Web 2.0; video; email; internet relay chat; virtual reality;
mobile telephone
In May of 2007, Derek Richards and his colleagues at Trinity College Dublin won
funding from the European Science Foundation (ESF) to run an exploratory meeting
of leading experts in the use of a variety of technologies used, or proposed, to
enhance or extend normal practice in counselling and psychotherapy. This
symposium comprises papers that have been developed and brought up to date
since the presentations given at that meeting and represents a sample of the cutting
edge of technological applications available in some cases only just becoming
available to practitioners today. It examines recent developments, current research
and emerging possibilities and issues, even dangers, associated with them.
The ESF event sought to bring together practitioners, trainers and, above all,
researchers from all over Europe, insofar as possible deliberately representing the
breadth of cultural contexts, therapeutic practices and technological interventions
present across the whole continent. This diversity is represented here in the range of
the innovative, developing practices and applications of technology reported.
Since its beginnings technology has often been, and sometimes still is, an area of
therapeutic work that seems to provoke somewhat polarised reactions. While some
are overtly enthusiastic and unhesitating, it is more often met either with a mixture of
careful optimism and appropriate caution at one end of the scale (Goss & Anthony,
2003; Goss, Robson, Pelling, & Renard, 1999; Lago, Baughan, & Copinger-Binns,
1999; Pelling & Renard, 2000) or, at the other, downright dismissive scepticism in the
face of what is merely unfamiliar (Goss & Anthony, 2002; Reynolds & Morris, 2002).
*Corresponding author. Email: s.goss@abertay.ac.uk
ISSN 0306-9885 print/ISSN 1469-3534 online
# 2009 Taylor & Francis
DOI: 10.1080/03069880902956967
http://www.informaworld.com
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Hanley then considers the potential for, and qualities of, the working alliance that
can be built with young people via synchronous and asynchronous test-based
communication based on the experience of one particular website. Whether the
moderately encouraging findings that could be reported at this stage will be replicable elsewhere will need to be tested with suitable strategies to ensure that adequate
service standards are maintained.
Simpson then turns to the rather different technological interface of videoconferencing, sometimes seen as an enhancement of the more familiar audiotelephony which has long been seen as an accepted form of counselling (Rosenfield,
1997, 2003; Payne et al., 2006). She notes the limited but now expanding research
base for such work and offers a thorough, detailed and exhaustive systematic review
of the evidence to date. Studies were identified from 1961 to the present day and,
while only three randomised controlled trials were found and despite the often small
sample sizes used and the inevitably tentative and exploratory nature of studies
appropriate for innovations in therapeutic care, clear evidence of benefits is reported
and the findings overall are encouraging. Positive outcomes were found in most
studies and satisfaction with video-linked services was higher than for face-to-face
work for at least some clients. Indeed, the evidence base presented is sufficiently
strong to raise the question of whether, perhaps in common with other forms of
technologically mediated therapy, it may even be considered unethical to withhold
them from those who are willing to use them and are otherwise unable to access
suitable services.
Alcan iz, Botella, Ban os, Zaragoza and Guixeres then consider the use of
intelligent computer systems in the treatment of obesity, focusing especially on a
specific program developed by the authors in Spain. The costs associated with a
number of specific behaviour-related or mental health-related conditions, including
the example of obesity discussed in this paper, are such that investment in developing
effective treatments can be expected to offer good value for money, especially if
indirect costs (such as days off work) are included. The system proposed here
combines network and sensor technologies with the increasing ubiquity of technological means and could include use of virtual reality, augmented reality, natural
interfaces and virtual agents.
Botella, Gallego, Garcia-Palacios, Banos, Quero and Alcan iz then offer a detailed
account of a randomised controlled trial, again carried out in Spain, of an internetbased self-help package designed to treat fear of public speaking compared with the
same treatment delivered in person by a therapist. Consistent with previous findings,
which are also briefly reviewed, the interventions were found to be equally effective
with participants in both arms of the study also reporting equivalent satisfaction
rates. Outcomes were sustained 12 months later. High levels of acceptance of the
internet in general, and this program in particular, as a means of treating
psychological problems were found. Furthermore, less aversion to the internetdelivered treatment compared with face-to-face work with a therapist in vivo was
reported at 12-month follow up. An obvious implication of this paper, echoed by the
findings of some others here, is that direct contact with a therapist is not, or at least is
not always, necessary. This is consistent not only with findings of other technologically mediated therapies such as fully computerised versions of Cognitive
Behavioural Therapy (CBT) (Cavanagh et al., 2003a, 2003b; Marks, Cavanagh, &
Gega, 2007) but also with the concept, most recently developed by Bohart and
Tallman (1999) that it is clients that make therapy work for themselves despite not
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always being well fitted to the intervention chosen out of the whole panoply of
possible therapeutic options. Positive psychotherapeutic change, clearly, is achievable
even in the absence of that most cherished element of what counsellors and therapists
can offer: a personal therapeutic relationship.
Preziosa, Grassi, Giaggioli and Riva turn to applications of mobile phones in
support of mental health care. Given the near ubiquity of such devices, effective
programs delivered through them clearly hold much potential for extending the reach
of, and ease of access to, therapeutic services. After reviewing some of the previous
literature on the use of mobile telephony, noting that much is focused on pretreatment assessment and post-treatment support rather than on the direct delivery
of interventions designed to be beneficial in themselves, they then offer an account of
two contrasting studies that have dealt with the question prompted by that gap: can
people benefit directly from working with programs delivered via the restricted
(e.g. from screen size and keyboard controls) but relatively familiar technology of a
mobile phone? In both studies, one addressing exam stress and the other a more
general intervention for stress management, the findings are, once again, encouraging
despite the need for further research and development.
Specialist computer programs then come under the spotlight. Early findings of a
study of a clinician-supported computerised treatment for eating disorders offered
over the internet for a university counselling service are discussed by Bauer,
Moessner, Wolf, Haug and Kordy. Despite high attrition rates, this pilot study
already suggests that such systems can prove an effective means of both extending the
reach of face-to-face services and of screening potential clients for the severity of
their condition. Linked to a stepped-care approach, it is then possible to provide wellinformed, targeted allocation to a variety of treatments, ranging from low intensity
access to information, through medium intensity options such as the use of a
clinically moderated discussion board, or to much higher intensity out- or in-patient
treatment. Moreover, the authors suggest that this can be done in a far more timely,
more easily accessed and less costly manner, although they too note the need for
further research and, possibly, development of such systems.
Two further papers then consider examples of the use of virtual reality (VR). Riva
offers a thorough summation of the potential uses of VR in the treatment of
disorders such as phobias, body-image distortion or for neuropsychological testing
and rehabilitation. Perhaps the most obvious potential for VR is in its ability to
provide clients with a means by which they can achieve a self-evidently safe exposure
to feared, avoided or otherwise problematic stimuli, combined with the possibility of
manipulating specific images to control the virtual environments to suit their need at
that time. An intermediate step between actual exposure and merely imaginal
techniques, the potential of VR can now be further enhanced through the use of
devices such as full-immersion head sets, control gloves and other haptic devices that
enable kinaesthetic manipulation of virtual objects and even of the virtual
environment as a whole. Riva then provides an account of a specific cost-free and
open-access VR tool, known as NeuroVR, designed to allow non-experts to develop
their own VR environments and treatments in their own clinical context, for specific
client groups and, possibly, even for individual clients.
Ban os, Botella, Guillen, Garcia-Palacios, Quero, Breto n-Lopez and Alcaniz go
on to explore the theme of VR environments further by looking in some detail at one
specific package, developed by the authors, known as EMMAs World. The paper
examines the effects of EMMAs World, which was deliberately intended to be a
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flexible platform that can be used with a wide range of clinical populations. The
program is designed to respond actively to the users affective state. With the
therapist and client working together to manipulate the virtual environment as
appropriate, a variety of emotional stimuli can be provided. The preliminary findings
presented are, once again, encouraging and, while further research is required, they
suggest that affectively oriented VR tools can support clinically significant change.
Interestingly, in the case of EMMAs World, this is achieved not by creating realistic
representations of specific real-world objects or events, but by providing a virtual
environment that evokes a specific emotional response in the client whether that be of
fear, in the case of de-sensitisation, or calmness, where a reduction in excitation is
required. The focus on fostering general emotional states rather than recreating the
external, real world, suggests that the benefits of such programs are rather less reliant
than would otherwise be the case on developments in the quality and sophistication
of the hardware, software and graphical capabilities required to make VR everincreasingly realistic. Perhaps unsurprisingly, the EMMAs World approach was
rated by clients as a less threatening, less aversive form of treatment than those that
are based on re-experiencing even simulations of traumatic events, suggesting that
facing engaging with such a treatment may be easier and carry less risk of iatrogenic
(intervention-induced) harm. The absence of reliance on representing particular
objects or situations also means that the program can be used by a wide range of
clients, regardless of the specific stressors that brought them to treatment, while still
allowing it to be responsive to their individual needs.
The future of the profession, particularly with reference to ethical frameworks,
will also be affected by the use of technology in guidance and counselling. The phrase
Web 2.0 denotes the use of World Wide Web technology to foster the collaboration of
end-users to create a vibrant and resourceful society that exists online. More
discussion of Web 2.0 and its origins can be found at Wikipedia (http://
en.wikipedia.org/wiki/Web_2.0), but the implication of it for our profession is an
important one, not least because the concept of it shows us that the clients, not the
practitioners, will be the people who decide how guidance and therapy exist in the
future. Therefore, the clients will dictate development of the approach to online
therapy, the development of global guidelines and standards, and social networking
sites such as FaceBook or MySpace, and online communities such as Second Life will
create the first point of contact for therapeutic intervention. Many virtual therapy
clinics already exist in cyberspace commercially in response to the way societys
attitude to therapy is changing in the face of the new technologies (Wilson, in press).
The impact of Web 3.0 (http://en.wikipedia.org/wiki/Web_3.0), of which Wikipedia
itself is an example of end-user created information and is predicted to mature in the
second decade of the century, will hold even more issues for the profession, not least
around confidentiality because of the nature of open identity (OpenID) and the loss
of usernames and passwords. This means there will be no organisation or authority
to confirm a clients, or indeed a practitioners, identity.
This sampling of the possibilities offered by making use of technology to extend
or improve existing therapeutic practices and ideas represents an exciting foray to the
cutting edge of what technology can offer counsellors, therapists and their clients at
present. That further work remains to be done is an inherent feature of a field that,
despite having emerged over 50 years ago with the advent of electronic recording
devices (Rogers, 1942), still regularly sees immense leaps into realms previously
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undreamed of. The question that remains to be addressed, of course, is of where these
possibilities will take us next and what we all practitioners and clients alike should
do about them once they are there.
Notes on contributors
Stephen Goss, PhD, is Service Manager for the Campaign Against Living Miserably. He has
been involved in providing, researching and publishing on technologically mediated counselling and mental health care for over a quarter of a century. With Kate Anthony, he co-authored
the BACP Guidelines for Online Counselling and Psychotherapy, the leading ethical guidance on
the subject, and co-edited Technology in Counselling and Psychotherapy: A Practitioners Guide.
His other research interests include the development of pluralism in counselling and research
methods and the application of evidence based practice in mental health care.
Kate Anthony, MSc, is a Fellow of the British Association of Counselling and Psychotherapy,
and past-President and Fellow of the International Society for Mental Health Online. She is a
consultant, widely published author and trainer for practitioners using technology in mental
health services as CEO of OnlineCounsellors.co.uk and joint-CEO of the Online Therapy
Institute. Forthcoming books include Therapy Online [a practical guide] and Mental Health
and the Impact of Technological Development.
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