Etherapy Clinical Principles & Treatment Modalities
Instructor: Dr. Dawn-Elise Snipes
Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery
~ Review the different modalities and most common usages in counseling
~ Identify potential clinical and ethical issues
~ Learn about at least 3 unique ideas for doing online counseling
~ Define Treatment Structure
Text Reading
~ Review Online Counseling: A Handbook for Mental Health Professionals
~ Emails
~ Blogs
~ Secure Forms
~ Forums
~ Chat rooms
~ IM/Tweets
~ Video Chat
~ Second Life
~ Good ole telephone
~ This is a great way to push out positive thoughts for the day.
~ I have used this for morning focus meditations and evening roundup meditations.
~ It is NOT secure, so no PHI here. This includes graduation announcements or congrats.
~ Good way to get the word out about you and your approach.
~ This is not a therapy approach.

~ Technical
~ Use a secure service.
~ If you are not using a secure service, then make sure your email address does not give away who you are.
~ Services offering Secure Email: Hushmail, ZixMail,
~ Are considered part of the clinical record and can be subponeaed just like progress notes.
~ Provide clients with a response time frame
~ Benefits
~ Can provide a running “diary” of progress
~ Are excellent for people who like to write and ponder. (Introverts and Reflective learners)

Email Cont…
~ Drawbacks
~ Can miss a lot when you do not see the rate of responding (increase in rate or errors in typing etc)
~ Gives patients time to go back and edit which may remove some of the underlying meanings
~ Not appropriate for patients in crisis
~ Formats
~ Diary—freeform
~ Diary—Structured
~ Worksheet completion (i.e. CBT, relapse prevention)
~ Questions to ponder (i.e. Miracle Question)
~ Activities to do (digital collage)

~ Provide information to people
~ Not secure or HIPAA compliant unless you make them that way
~ A secure blog can be a good place for clients to journal as an option to daily emails.
~ Excellent activity to inform patients about conditions, new treatments and new programs
~ Excellent for patients who have something to say to the world—Awareness/Advocacy Campaigns

Blogs cont…
~ Secure Blog Formats
~ Video Blog:
~ Can be used for daily check-ins for clients—excellent for addictions, eating disorders and major depression
~ Blog with pictures
~ Can be used to as a means of creative and therapeutic expression for some clients
~ Can also be created like an online scrap-book with pages for: What means the most to me, My Goals, My accomplishments, About Me (Best with teens)
~ Text Blog
~ Can be used as a running diary
~ Blogs must be regularly checked
~ Rules for appropriate use of blogs must be set forth

~ Forums are a good place to ask a question to a group and let them provide answers
~ Forums must be moderated
~ Appropriate forum behavior must be communicated and maintained
~ Group members can see each others responses and comment and/or learn
~ More than some other modalities, it is imperative to be clear about appropriate behavior in the forums.
~ If you do not have something nice or constructive to say, don’t say anything at all
~ This is not a place for Borderline behavior
Secure Forms & Worksheets
~ Useful to get information quickly such as intakes, client’s week in review and CBT or DBT worksheets
~ Can be created as fillable PDFs and securely emailed to you.
~ Used as an adjunct to therapy for people who like using workbooks etc.
Instant Messaging (IM)
~ Mainstream communication for the younger generation
~ Can be done via mobile devices
~ Whether SMS or Internet Texting you must have a business associate agreement
~ Can provide real-time text-based interaction (can be asynchronous as well)
~ Nonverbals include
~ Color, font, size of text
~ Emojis
~ Speed of response and error rate
~ You must set boundaries
~ You must know the lingo
Video Chat
~ Next best thing to face-to-face
~ Can connect patients and clinicians at a distance
~ Must be done on a secure connection from a provider who has SIGNED a business associate agreement
~ Provided internet connection is adequate, provides nonverbals
~ Drawbacks—You must have a backup plan for:
~ Internet issues
~ Software issues
~ Firewall issues
~ Power issues
Second Life
~ Appealing due to avatars
~ Does not meet HIPAA security standards
~ Has had incidents of being hacked and losing user data
~ Does not provide subtle nonverbals
~ May reinforce a fantasy persona in those with an unfavorable or unstable sense of self
~ Most people are comfortable talking on the phone
~ It requires a high amount of concentration on your part
~ Traditional nonverbals are not available
~ Format
~ Cell Phone
~ Data is minimally available when it hits cell towers
~ Low risk of being “hacked” or “breeched”
~ Land Line
~ Excellent as a backup in the event of a power or internet outage
Clinical Principles
~ Above All Do No Harm
~ Evaluating appropriateness (diagnosis, crisis, age, comfort with computer technologies)
~ Developing a safety plan
~ Making appropriate referrals
~ Netiquette
~ Master the lingo

Above All Do No Harm
~ Evaluate appropriateness
~ Can you and the patient type?
~ If no, look into video or phone counseling
~ Is the condition appropriate for that level of treatment?

~ Develop a safety plan
~ Make appropriate referrals
~ Ensure confidentiality and privacy of PHI
~ Ensure your communications are encrypted
~ In transit
~ On your computer (whole disc encryption)

~ General
~ Don’t overuse exclamation points!!!!!!!!!!!!!
~ Use italics, different colors, fonts and font weight to emphasize ideas
~ This is awful! I am totally over it.
~ This is awful! I am TOTALLY over it.
~ Paraphrase and check your understanding B4 U get offended
~ Email
~ Return emails in a timely fashion
~ Add responses within the persons email to you
Netiquette cont…
~ Chat Rooms
~ No Lurking
~ Say hello and Goodbye
~ If you step away, say BRB as appropriate
~ Use private messaging for “side” conversations if allowed
~ Ensure rooms are moderated
~ IM
~ Never have multiple private chats going at the same time
~ Respond quickly
~ If you have to step away from a chat, tell the client BRB
~ Video
~ Ensure you have a signed business associate agreement with the provider
~ Conduct therapy in a private room

Treatment Structure
~ Options
~ Email/IM/Phone/Video Only
~ Email/IM/Phone/Video + weekly or monthly F2F
~ Email/IM/Phone + weekly/monthly Video
~ Considerations
~ Cost
~ Time effectiveness
~ Patient preference
~ Acute issues: Crisis, medication changes, impending triggers

Neat Techniques and Tricks
~ Have people review their emails or chat logs for patterns or improvements
~ Use information documented in email and chat logs as “evidence” when confronting a client
~ Have a client do a video tribute to someone who has passed away
~ Have someone do a blog or email in the words of someone they have lost…What Mom would have said
~ Have clients tweet commitments and/or statuses

Tips and Tricks cont…
~ Have clients research
~ 3 famous people who have encountered similar situations
~ About depression, temperament, CBT etc.
~ Resources for coping with _____
~ How nutrition and/or exercise can help them
~ Different hobbies
~ Local clubs and social groups
~ And the list goes on….

~ See TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services for more tips, tricks and tools
~ Online Counseling and etherapy make it possible for patients to access services
~ Easier
~ With Greater Confidentiality
~ With experts who are not accessible in person
~ *Note in most states the therapist has to be licensed in the state in which he/she practices AND the state in which the client resides
~ It appeals to the younger generation and those who are very visual.
~ Just like any other new modality, etherapy has its own techniques, language and netiquette.
~ It will be important for etherapists to stay in tune to the evolving regulations regarding online services