Chat 2 Recovery is a unique online addiction treatment program for individuals age 21 and over. Nick Lessa, founder of Chat 2 Recovery, provided this presentation at the The 45th Annual Addictions Institute Conference, held in NYC June of 2013

1. Presented by:
Nick Lessa, LCSW, MA, CASAC
Nlessa@inter-care.com

2. “Online therapy is not just an idea for the
future. Its time has come.”
Casey Truffo, MFT
CEO and Founder of the Therapist
Leadership Institute

3.  E-Therapy
 Online Therapy
 Online Counseling
 Cyber-Therapy
 Distance Counseling
 Telementalhealth Counseling
 Telecounseling
 Internet Psychotherapy
 Web-counseling

4. E-therapy is the use of electronic media and information
technologies to provide services for participants in different
locations. It is used by skilled and knowledgeable professionals
(e.g. counselors, therapists) to address a variety of individual,
familial, and social issues. E-therapy can (1) include a range of
services, including screening, assessment, primary treatment,
and after care; (2) provide accessible modes of treatment than
the traditional ones to those who actively use the recent
development of technology (i.e. adolescents and young adults);
(3) help people access treatment services who traditionally would
not seek services because of barriers related to geography,
shame and guilt, stigma, or other issues; and (4) be provided as
a sole treatment modality, or in combination with other
treatment modalities, like traditional or existing programs.
(SAMHSA, 2009)

5. “18.6 million Americans needed treatment for a
serious alcohol problem, and 7.7 million
people needed treatment for a diagnosable
drug problem. Fewer than 3 million obtained
treatment in 2002.” (Stofle, 2004).

6.  Convenient and flexible
 Not confined to a specific location
 Available 24 hrs. a day
 Accessible w/o regard to normal business hrs., set apt. times; or
waiting lists
 The immediacy of online services can capitalize on fluctuating
motivation to seek treatment
 May result in feeling less dependent on the therapist
 Allows client time to reflect without pressure to think quickly
 Anonymity eases discomfort and potentially embarrassing and
stigmatizing disclosure of behavior and thoughts
 Adults and children have disclosed higher levels of personal
information sooner on a computer than FtF. (Alleman, 2002).
 “clients of online counseling have reported they feel less self-
conscious, less inhibited, and better able to express themselves than
they would sitting in someone‟s therapy room, and therapists have
reported they feel more focused and that their responses are more
powerful when they have time to reflect before responding to a
client‟s input (Alleman, 2002)

7.  Security and privacy concerns
 Legal concerns (jurisdiction, adequate care)
 Misunderstanding due to lack of non-verbal
cues or misunderstanding of written response
 Inappropriate training may affect clinical
competence
 Inappropriate online relationships through
social media sites
(Facebook, Twitter, LinkedIn, etc.)***

8.  Asynchronous Communication: E-
mail, Forums, Listservs
 Synchronous Communication: Audio
Conferencing, Videoconferencing; chat, IM
 Many who sought online therapy later used
ftf counseling
 90% felt online therapy helped them
 Many felt they would not have initially sought
ftf therapy (Alleman, 2002) (SAMSHA, 2009)

9. “Thus far, research findings indicate that
online counseling may be beneficial for clients
who do not have easy access to traditional FtF
therapy.” (Mallen & Vogel, 2005)

10.  CBT to change drinking behavior as effective
when delivered online (Copeland and Martin,
2004) (SAMHSA, 2005)
 Alcohol interventions conducted over the
internet showed promising results (Copeland
and Martin, 2004)
 “There is good evidence that computer-
delivered interventions for mental health and
behavioral problems can be effective.”
(Copeland & Martin)

11.  Does the person possess the written language skills
and able to express emotion through text?
 How might the person‟s computer skills, knowledge,
platform and Internet access affect the therapy?
 How knowledgeable is the person about online
communication and relationships?
 How well suited is the person for the reading and
writing involved in text communication?
 How might physical and medical factors affect the
online therapy?
 Assessing a Person‟s Suitability for Online Therapy at:
http://www.ismho.org/therapy_suitability_assessmen
t.asp.

12.  Can one express empathy online?
 Can one express Presence online?
 The Disinhibition Effect – the perceived safety
of the distance between clients and therapist
makes them much more willing to admit the
uncomfortable thoughts
 Issues of Fantasy online

13.  Determining what methods of Internet delivery is
best suited for client and therapist
 Adequate typing skills, comfort with downloading
programs, using various platforms & software,
basic computer skills, ease of use with web links,
ability to protect communication of clients
including use of encryption, expressive writing
skills, comfort in text-only environment, skill at
clarifying online communication, desire to be
online, experience w/ online relationships, belief
that online relationships can be meaningful, able
to handle computer glitches, able to handle
various methods of delivery (Fenichel, 2000)

14.  Attending and Acknowledging – “Jane, I did
receive your email today and will respond by
tomorrow. Take care.”
 Probing – “Can you clarify for me what you
meant when you said…?”
 Supporting – shows warmth. Physicality
through emotional bracketing [take my
hand], expressing emotion
[smiling], emoticons, hugs ((((Jane))))
 Checking Perceptions – “What I hear you
saying is…”

15.  See “Ethical Framework for the Use of
Technology in Mental Health”***
 Informed Consent – should have a page on
website dedicated to this.
 Practitioner Competence – experience,
training, supervision, computer skills,
verification of qualifications
 Clear Client Exclusionary Criteria – age,
severity of illness, computer savvy, location

16.  Privacy and Security Protections – encryption,
back-up, use of passwords, firewalls, virus
protection, etc.
 Initial Intake and Screening Process

17.  Should begin at first client contact
 Screening form/questionnaire
 Screen for client‟s technology skills
 Screen for client‟s language skills
 Presenting problem (Why seeking therapy
online?)
 Client identity verification
 Clinical screening
 See example questionnaire***

18.  The process (what to expect,
misunderstandings that may occur,
turnaround time, safeguards)
 About the practitioner(s) (credentials, contact
info, training)
 Potential risks and benefits
 Alternative treatment services
 Emergency procedures
 Should be acknowledged as read and
understood

19.  Always obtain demographic info. (name,
address, contact info, emergency contact
info)
 If located in a different geographic location,
look up community emergency and safety
resources (hospitals, SOs, clinicians, police)
 If you don‟t know exact location of client in
an emergency, contact local police dept.

20.  Jurisdiction Issues
 Confidentiality and privacy protections
(Hushmail, Office 365)
 Determine what constitutes the clinical record
(chat transcripts, video recordings, email
exchanges, etc.) and who owns it
 Important to have an attorney review your
website, forms, procedures

21.  Issue of Jurisdiction (lack of inter-state
reciprocity)
 How can we be assured that we are not
violating laws around jurisdiction? Answer –
“Damn near impossible” (Jason S. Zack)
 To date, no known lawsuits brought up in any
states which address online therapy
specifically

22. “Consistent with the Model Act, the Technology
Standards admonish social workers to „abide by
all regulations of their professional practice
with the understanding that their practice may
be subject to regulation in both the jurisdiction
in which the client receives services as well as
the jurisdiction in which the social worker
provides services.‟ (NASW &ASWB, 2005).

23.  “This highlights the requirement that social
work practices that operate in more than one
state must review and interpret the laws and
regulations for social work practice in each
state and determine how the practice should
be structured to avoid conflicting
requirements and afford clients the greatest
level of protection from unregulated
practice.”

24.  Know the laws of your state
 Know the laws of your client‟s state
 Check out the National Telehealth Policy
Resource Center (provides state-by-state laws)
 Understand the scope of practice related to your
license, certification, education and law
 Determine whether your insurance carrier will
cover an out-of-state claim
 Seek legal consultation for your practice
 If your website indicates that you consider
services rendered to be at your location, seek
legal advice

25.  Specific Online Training is strongly
recommended in most Guidelines
 Distance Credentialed Counselor (DCC)
Training Program and Credential at
www.readyminds.com. A 2-day (15-hr.)
program. $595.
 Online Therapy Specialist Certification at
www.onlinetherapyinstitute.com. 60-hour,
online modules. $2,000.

26.  The Importance of a Website (important to speak
to the client‟s need)
6 Characteristics that top therapist websites share
(Truffo, 2007):
1. Speaks about services that client can appreciate
2. Has a clear „call to action‟ & contacting therapist
is easy
3. Offers something for free
4. Reflects personality and picture of therapist
5. Geared towards the ideal client
6. Simple and to the point, presented in caring
manner

27.  Crisis Intervention Information
 Contact Information
 Practitioner
Education, Licensure, Certification
Information
 Terms of Use and Privacy Policy
 Explanation of security/privacy (personal info)
 An Initial Screening form/questionnaire
 An Informed Consent
 Costs of treatment and payment info.

28. Consider using MedForward
(www.medforward.com): website design
for healthcare professionals and HIPAA
compliant online forms

29.  Deciding Whether to Join an E-Clinic or Private
Practice
 Joining Online Therapist Directories (e.g., Psychology
Today, Find-a Therapist.com., Nat. Directory of
Online Counselors)
 Blogs
 Pay-Per-Click Advertising
 Ask questions on home page
 Offer free information
 Use audio
 Write articles
 Create a Podcast
 Join social networks
 Write a Press Release

30.  E-Mail
 Videoconferencing
 Chat Rooms and Instant Messaging
 Cell/Mobile Phone SMS (text messaging)
 Audio Conferencing

31.  Use emoticons – the creative use of keyboard
characters to indicate to the other person
what is happening at your end of the
conversation (e.g., the wink when you‟re not
wholly serious). Should be led by client.
 Learn acronyms and abbreviations
 Enhancing Text – makes it more „alive‟ (e.g.,
use of capitalization, underlining, bolding,
exclamation marks, emotional bracketing,
and parenthetical use

32.  Signature files (not used in therapeutic
emails)
 CCing, BCCing and address books (never to
be used)
 Greeting and sign-offs (less formal as time
goes on)
 Subject lines
 Paragraphing (many shorter paragraphs)

33.  Enormous benefit for those with mobility
problems (elderly, rural, military, agoraphobia)
 Majority of studies: little difference in outcome
 Excellent and inexpensive applications:
WebEx, Go-To-Meeting (HIPAA compliant)
 Use of headphones with microphone
 Held in private area - important
 Initial set-up and training required
 Great feeling of “Presence”
 Clients seem to love it (feel safer, comfortable)

34.  Involves a level of honesty about substance
use
 Decision on recording sessions
 Suggested maximum size of group – 6
 Do all members see each other?
 Work assignments in between sessions
(e.g., Wellness Self-Management Plus)
 Sign-in Sheet (days C &S, distress level, self-
help, self-efficacy, completion of
assignments)
 Join 15 min. prior to group

35.  Chat rooms usually “open” rooms
 IM usually a private dialogue
 Common use of abbreviated words &
emoticons. Follow client‟s lead.
 How do we know we are speaking to client?
 Clients reports getting to their root issues
more quickly that ftf.
 Use secure chat service providers (HIPAA
compliant). Encrypted & proper storage.

36.  Proficient typing recommended
 Understand the reason why someone may be
choosing this modality
 Best served by adolescents and young adults
 Eliminating ftf presence reduces anxiety
 Useful in couples therapy
 Useful for those who lack a private area in
home to speak

37.  Preparing to begin services for over a year
 Start-up began in January, 2013
 OASAS would not consider endorsing product
 No insurance accepted
 6-week program (twice weekly groups, 3
individual sessions, weekly educational
assignments, access to counselor by
phone/email)
 Cost - $899
 www.chat2recovery.com.

38.  Alleman, J.R. (2002) Online Counseling.
Psychotherapy:Theory/Research/Practice/Trainin
g, vol. 39, No. 2, 199-209.
 Anthony, K. and Nagel, D. (2010) Therapy Online:
A Practical Guide
 Anthony, K., Nagel, D. and Goss, S. (2010) The
Use of Technology in Mental Health: Applications,
Ethics and Practice
 Copeland, J. & Martin, G. (2004) Web-based
interventions for substance use disorders: A
qualitative review. J. of Sub. Abuse Treatment,
26, 109-116.

39.  Hsiung, Robert C. (2002) e-Therapy: Case Studies,
Guiding Principles, and the Clinical Potential of the
Internet
 Kraus, R., Zack, J. and Stricker, G. (2004) Online
Counseling: A Handbook for Mental Health
Professionals
 Mallen, M.J. & Vogel, D.L. (2005) Counseling
Psychology and Online Counseling. The Counseling
Psychologist, Vol. 33 No.6, Nov., 761-775.
 Substance Abuse and Mental Health Services
Administration (2009) Considerations for the
Provision of E-Therapy.
 Stofle, G.S. (2004) Addiction Treatment Online.
Behavioral Health Management, March/April, 53-55.