(p. 459) Training clinicians online to be e-therapists: the ‘Anxiety Online’ model
Anxiety Online is a ‘virtual’ online clinical assessment and treatment service, funded by the Australian Department of Health and Ageing and provided by Swinburne University’s National e-therapy Centre (NeTC). This chapter describes an online clinician training program for online low intensity practitioners (‘etherapists’) to work ‘in’ the Anxiety Online virtual clinic (http://www.anxietyonline.org.au), and the challenges and solutions involved.
Anxiety Online comprises four main parts:
◆ A freely available, open access, psycho-educational information website
◆ An automated, online Psychological Assessment (e-PASS) and referral system
◆ Two versions (self-help and therapist-assisted) of a 12-week cognitive behavioural therapy (CBT)-based treatment program for five Anxiety Disorders (Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Panic Disorder, Post-traumatic Stress Disorder, and Social Anxiety Disorder)
◆ Online training programs (for e-therapists and clinical supervisors).
In this chapter we will only be concerned with the online training program for e-therapists and the ways in which the competency and performance of the e-therapist is evaluated. In order to work as an e-therapist within the Anxiety Online service, all clinicians must:
◆ Complete a 5–6-hour online training program
◆ Complete at least 1–2 hours of clinical supervision
◆ Pass an online multiple-choice final assessment task.
Once the clinician commences work as an e-therapist, ongoing treatment data collected from clients throughout the duration of treatment (e.g. e-mail communications, online interactivity behaviours, e-PASS assessments, and client feedback) further assists in evaluating the clinician’s performance as an e-therapist.
(p. 460) Challenges
The unique challenges facing the Anxiety Online service relate to three key areas: workforce, competencies and system issues. Workforce challenges include developing the means to be able to train up a sizeable workforce of e-therapists that is flexible enough to enable rapid up-scaling in response to anticipated annual demand increases and periodic demand ‘spikes’. It is also important to ensure that the service is not limited to recruiting from any one place or even to the major cities. Additional challenges have involved determining the most appropriate educational model to ensure e-therapists can be easily, efficiently, and cost-effectively trained.
The Anxiety Online service is also faced with challenges in regards to determining how best to ensure clinicians meet, and maintain, a reasonable standard of competency as an e-therapist. For example, defining the populations that e-therapists will be recruited from; determining the most suitable online training model and content; and ensuring, following completion of the training program, that the clinician has, indeed, met a necessary level of competency to be considered a ‘competent’ e-therapist.
A final set of challenges centre on system issues. That is, determining how best to maintain security of the Anxiety Online site to ensure both the client and e-therapist data is protected, and the stability of the site is maintained. How we have chosen to address these challenges is outlined below.
To best meet the initial needs of the Anxiety Online service a process model was chosen utilizing a partially-automated online training system that is maintained by traditional face-to-face supervision once the e-therapist ‘graduates’ into actual practice. As will be discussed in greater detail in the competencies section below, postgraduate psychology students on clinical placement are recruited as e-therapists and, consequently, all students will already have a clinical supervisor. This model enables the service to recruit and train multiple e-therapists from any university in the country (and conceivably, at least, anywhere in the world), whilst maintaining best-practice standards of ongoing face-to-face supervision.
It is intended that the e-therapist training and supervision model will become a fully online process in the future. That is, not only will the clinician complete a training program online, but supervision will also be conducted online. One potential pitfall with remote training and supervision is that the supervisor may miss signs that the e-therapist is nervous, frustrated or anxious (Mallen et al. 2005). A second potential problem is the extent of availability of the supervisor for debriefing during or after training. For Anxiety Online, measures will be taken to ensure that there is also a consultant at the NeTC who is available to answer any questions related to e-therapy training or supervision. Other technologies, for example, a Bulletin Board (see Griffiths and Reynolds, Chapter 30) or videoconferencing may also be potentially useful, but have not, at this stage, been utilized.
(p. 461) Competencies
For the first phase of Anxiety Online, e-therapists will be postgraduate psychology students with provisional registration as a psychologist. Consequently, the key competencies of the online training program primarily relate to the delivery of e-therapy generically and the use of the Anxiety Online management system specifically. It is anticipated, however, that as the Anxiety Online service matures and develops, e-therapists will be drawn from a broader healthcare background (e.g. nursing, occupational therapy, counselling) enabling a larger pool of e-therapists to be recruited.
Our approach differs from some online CBT training programs, such as OCTC ONLINE (http://www.octc.co.uk) and PRAXIS CBT (http://www.praxiscbtonline.co.uk), in that it does not focus on core CBT competencies. The first cohort of Anxiety Online e-therapists will all have existing CBT skills and so at this stage the online training program deals specifically with the unique challenges inherent in providing asynchronous (e-mail) support to clients undergoing a structured online CBT program (Klein et al. 2009) (see also Titov, Chapter 29). The e-therapy training program does, however, include a basic CBT module, which acts as a ‘refresher’ course. This is particularly important for the ongoing maintenance and growth of Anxiety Online, as in the future, a broader range of healthcare professionals, with differing levels of CBT knowledge, will be recruited into the e-therapy role. As Anxiety Online enters that phase, the CBT component will be significantly extended to ensure new e-therapists have the core CBT competencies that postgraduate psychology students in Australia already have.
An additional level of duty of care and quality control as it relates to e-therapist standards is provided by an online training program that is provided to all clinical supervisors of all e-therapists. This program contains essentially the same material as in the e-therapist program, with an additional module on the supervisor’s responsibilities. The provision of this program ensures that all supervisors of e-therapists have an understanding of the work that their students are undertaking and, at least, the same level of basic competencies in e-therapy.
The training programs include an introduction to Anxiety Online, information about the administration and electronic data collection process, guided virtual tours through the online clinical assessment program (e-PASS) and therapist-assisted treatment programs, a refresher CBT module, details pertaining to the e-therapist’s responsibilities, plus evaluation and assessment modules. Additional modules cover legal and ethical issues, clinical issues (e.g. encouraging engagement, managing dropouts, homework, avoidance, client distress) and communicating via e-mail (e.g. creating a therapeutic alliance, writing and language style, structuring e-mails, challenging clients).
The training model
The core theoretical foundation of the training program is experiential learning and ‘self-practice.’ The application of therapeutic techniques to oneself can result in deeper levels of understanding and confidence that the techniques do work and lead to personal change (Bennett-Levy et al. 2001, 2003). This model was chosen as the necessary competencies (p. 462) required of clinicians do not represent quantum leaps in learning domains, but rather an extension of existing learning in the areas of CBT, psychopathology, counselling, and communication into a novel domain (i.e. online, asynchronous e-mail). All clinicians will, by definition, already have existing competence in delivering CBT. However, they do not necessarily have any experience or ideas about how one would conduct such work without ever actually encountering the patient in real time or in person.
As a means to maximize the efficiency by which clinicians develop an understanding of the online modality, the training program prompts the clinician (via learning activities) to not only consider how they would manage a range of situations, but also to adopt the perspective of a client (rather than an e-therapist). In addition to the ‘self-practice’ approach, future versions of the online training program will utilize a social modelling paradigm whereby a ‘credible other’ is shown to be conducting the desired behaviour. To this extent, the training program will utilize recognized experts in the field of CBT and e-therapy promoting effective e-practice via audio/video demonstrations.
Legal and ethical issues
Training of e-therapists includes education on legal and ethical issues pertinent to e-therapy, such as informed consent, confidentiality, disclosure of client information, duty of care, maintaining health records, and boundaries of competence. Practice guidelines, including those set by the Australian Psychological Society (2004) are reviewed prior to commencing work as an e-therapist. For example, e-therapists are educated about the unique elements of confidentiality as they relate to an e-therapy environment, such as potential breaches to confidentiality via illegal electronic hacking and the risks of forwarding e-mails outside of the Anxiety Online management program. Potential ethical dilemmas and appropriate responses are included in the e-therapist training program, such as the example whereby a client expresses a desire to stay in touch with the e-therapist following completion of a treatment program.
Clinical issues and communicating via e-mail
Training emphasizes the coaching and monitoring role of the e-therapist, continually reinforcing the client’s goal to complete their treatment program successfully. The program demonstrates the e-therapist showing empathy, addressing obstacles, dilemmas and difficulties, and empowering the client as they work through the program. While monitoring and reinforcement is also important in face-to-face counselling, it is critical in e-therapy, given the lack of ‘real time’ verbal dialogue and visual cues that are present in face-to-face therapy (Abbott et al. 2008).
e-Therapists are taught specific techniques to counter the challenge of lack of visual cues in e-therapy. One of these techniques is emotional bracketing, whereby the e-therapist brackets the emotional content behind their words (Murphy and Mitchell 1998). Emotional bracketing may also be used by the client, most likely after it has been modelled by the e-therapist. Emotional bracketing can be used to convey warmth and concern, and it may be particularly useful when clients have not been in contact with their e-therapist for some time. An example is provided in Box 49.1. Training of e-therapists (p. 463) also includes specific examples of e-mail exchanges, including examples of both poor and effective communications. An example of a poorly constructed e-mail that lacks warmth and concern is provided in Box 49.2. Box 49.3 provides an example of an appropriate e-mail for the client who has not completed a treatment program exercise.
E-therapists are taught how to become overt in communicating empathy, and receive feedback and supervision about writing clearly and conveying empathy in their e-mails. One option is for e-therapists to use ‘emoticons’ in their messages, for example, to indicate happiness or a positive outcome. However, e-therapists are cautioned about the overuse of emoticons and not relying upon them solely to communicate feelings as they can be misinterpreted, minimize an important message or come across as condescending. Another option is for e-therapists to describe their non-verbal reactions, for example, ‘I am smiling right now because it sounds like you are making such great progress’ or to be explicit in expressing their verbal empathy in text, for example, ‘I can hear that completing the exposure exercise was a real challenge for you and has shaken your confidence.’ These are the same skills required by all LI workers (see Richards, Chapter 44). (p. 464)
Competency assessment and evaluation in becoming an e-therapist
At the completion of each module, the clinician is prompted to complete a learning activity, such as a true/false quiz, case scenario, or critical thinking exercise. For example, e-therapists are asked to construct appropriate e-mails in response to a range of scenarios, including a client who has failed to complete treatment program exercises for a number of weeks and a client who is exhibiting signs of elevated distress. Critical thinking exercises encourage the clinician to consider what they would do if faced with a range of situations. For example, one question relates to a situation where a client requests to see the e-therapist for face-to-face counselling. Clinicians are also required to pass a final multiple-choice assessment task in order to be considered a ‘competent’ e-therapist with the Anxiety Online service. Multiple-choice items cover key topic areas from the training program, issues relating to writing client e-mails and questions relating to the specific anxiety health disorders treated by Anxiety Online.
Monitoring and evaluation of the e-therapist’s skills and overall performance
The supervisor is able to monitor and evaluate the skills and work performance of the e-therapist by both direct and indirect methods. The direct (and primary) method (p. 465) involves the supervisor reviewing, discussing and evaluating the therapeutic communications between the e-therapist and their online clients. Indirect means include assessing the e-therapist’s performance by reviewing how the online client responds during, and at the end of treatment. For example, does the client follow recommendations made by the e-therapist, such as repeating an earlier treatment program exercise to prepare for an exposure task?
Apart from reviewing the e-mail communications, the e-therapist and supervisor are able to monitor the client’s online activity and improvements or deterioration via a range of means displayed in Fig. 49.1.
Comparing the client’s pre- and post-treatment assessment (e-PASS) data allows the e-therapist and supervisor to measure how much clinical change has occurred with respect to the client’s initial diagnosis and related symptom severity indices, as well as changes to the client’s major life functioning areas (e.g. work, social, family), general quality of life, and improvements in self-reported general physical health. The Treatment Satisfaction Questionnaire allows the client to rate the numerous components of the Anxiety Online service, including the performance of their e-therapist. For example, clients rate their level of satisfaction with the e-therapist support received, whether they felt that a therapeutic alliance was established and whether they felt the need to source (p. 466) additional mental health assistance during their online treatment period. Normative e-therapist performance data will be compiled, and will eventually be used as a standardized e-therapist competency and performance evaluation measure.
Maintaining security of electronic client information (e.g. contact details, assessment data, e-mail communications, client feedback) is of crucial importance in an online environment. Anxiety Online has been set up with a secure and encrypted storage system to protect communications between client and e-therapist, and archived communications. All communication and content is accessed over a HTTPS protocol that enforces the use of Secure Sockets Layer (SSL). This is the same level of security as provided by banks and e-commerce sites to ensure that all data sent between users and the website is encrypted. It protects against a broad range of attacks, such as theft of user data whilst in transit (for example, it protects users who access the e-PASS website from an unsecured network, such as a public wireless network). e-Therapists can also educate clients about maximizing security at their end. For example, installing firewalls, using encrypted e-mail software, limiting access to the computer in the client’s household (Midkiff and Wyatt 2008). (See Whitehead and Proudfoot, Chapter 24 for further discussion).
Take home messages
◆ The use of automated online e-therapist training facilitates rapid, standardized, and high volume training of the e-therapy workforce
◆ Because Anxiety Online training programs are standardized, online, and automated, they are an inexpensive way to deliver ongoing training (once development costs are accounted for)
◆ The educational foundations of the training program (self-practice and experiential learning) are based on validated models specific to the training of cognitive behavioural therapists
◆ The training program will be suitable for a range of health professionals and focus on the key competencies relating to delivering remote, asynchronous therapeutic communications
◆ Online training, monitoring, and evaluation systems provide multiple avenues whereby the core expected competencies of the e-therapist can be assessed regularly, precisely, and objectively.
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