Cybertherapy Or Psychobabble?

A Mixed Methods Study into Online Emotional Support

Amy Callahan Supervisor: Dr Kay Inckle

A thesis submitted in partial fulfilment of the requirements for the degree of Masters of Science in Applied Social Research School of Social Work and Social Policy Trinity College Dublin

After all, if people can have sexual relationships online in a chat room, using a keyboard and typing… Then if they can do that, then presumably you can communicate therapeutically. (Eamon, Interview Participant)

Declaration

This thesis is entirely my own work. It has not been submitted to this university or any other institution for publication. I authorise the University of Dublin to lend this thesis to other institutes or individuals for the purpose of scholarly research.

Signature:

I further authorize the University of Dublin to reproduce this thesis by photocopying or by other means, in total or in part, at the request of other institutes or individuals for the purpose of scholarly research.

Signature:

Acknowledgements

Dear Reader, I realise you have been waiting (with baited breath) to read this thesis. And while typically the acknowledgements are the most read page, I know you will want to read this work in its entirety. Possibly more than once! Before we start this journey together, I want to thank a few people, without whom, this would be a far inferior piece of research. In addition, they have helped me keep somewhat sane.

First, to my participants; in the focus group, Bosco, Molly, Optimus Prime, Superman, and Molly; and the interview participants, Claire, Brian, Darren, Eamonn, Jenny, Linda, Mary, Madeleine, and Natalie. Quite literally this would not have been possible without you.

My sincere thanks to Dr. Kay Inckle, who has been so incredibly kind and supportive. Without her suggestions, comments, and thoughts this would not have been possible. I have learned so much and I enjoyed it at the same time! I cannot say enough to express how thankful I am to have met Kay and been able to work with her. I have never failed to be impressed with her ability to find something nice to say and to provide guidance around the parts that have, quite simply, fallen to pieces!

Thanks also to Dr. Philip Curry and Professor Robbie Gilligan, for the advice and for the opportunity to work alongside you. And to the Director of the MSc, Dr. Evelyn Mahon - and all the teaching staff: Dr. Brid McGrath, Mark Ward, Jessica Davis-Breen, and Jemimah Bailey.

Finally thanks to my friends and family, especially to Connor.

Abstract

This study uses a mixed-methods approach to investigate the area of online mental health support. A detailed statistical analysis of quantitative data from an Irish Children’s Helpline was combined with in-depth qualitative interviews with a variety of counsellors and other practitioners and a focus group with young people. Quantitative data yielded statistically significant differences in topic of conversation between telephone and online data, with online conversations more likely to be focused on mental health topics, requests for information, or peer relationships. Telephone conversations tended to be focussed on everyday life issues. Practitioners and young people had concerns about online clients concealing their identity or misrepresenting themselves, participants also pointed out how online supports mediate the sense of a power imbalance in a therapeutic relationship, how online supports have a therapeutic quality by simply allowing a client time to express themselves, and how they allow a client increased access to information. However, more research needs to be undertaken exploring the effectiveness of online supports and the types of clients they are most appropriate and helpful in reaching. Online services have great potential, but practitioners need to overcome their fear of technology and become more comfortable online before they begin providing these services.

Table of Contents

Chapter One: Introduction ...... 9 Chapter Two: Existing Research Regarding Online Mental Health Support ...... 13 Overview ...... 13 Counselling and Status of Counselling in Ireland ...... 13 Technologies Used in Mental Health and Emotional Support ...... 16 Lack of Visual / Verbal Cues ...... 18 Anonymity and Confidentiality ...... 19 Ethical Issues / Appropriateness for Clients ...... 20 Effectiveness of Online Supports ...... 22 Summary ...... 23 Chapter Three: Methodology Overview and Hypothesis ...... 25 Chapter Four: Results and Discussion ...... 37 Overview ...... 37 Profiles of Young People Accessing Online Support ...... 38 Misrepresentation and Identity Concealment ...... 43 Topic of Conversation ...... 44 Lack of Visual / Verbal Cues ...... 52 Anonymity and Confidentiality ...... 54 Ethical Issues / Appropriateness for Clients ...... 55 Effectiveness of Online Supports ...... 56 Access to Information ...... 57 Time and Space ...... 58 Summary ...... 60 Chapter Five: Conclusion ...... 62

Appendix I: Ethics Approval ...... 71 Appendix II: Participant Information Sheet ...... 73 Appendix III: Young Participant Information Sheet ...... 74 Appendix IV: Participant Consent Form ...... 75 Appendix V: Young Participant Consent Form ...... 76

Appendix VI: Parental/Guardian Consent Form ...... 77 Appendix VII: Parental/ Guardian Consent Form ...... 78 Appendix VIII: Topic of Conversation as outlined by Child Helplines International ...... 79 Appendix IX: Interview Schedule ...... 82 Appendix X: Focus Group Schedule ...... 84 Appendix XI: Coding for Qualitative Data ...... 86 Appendix XII: Boxplot of Age for Sample of Phone Calls to an Irish Children's Helpline ...... 88 Appendix XIII: Frequency and Percent of Topics in an Irish children's helpline - Overall and Broken into Method of Contact ...... 89

List of Figures

Figure 1. Professional Interventions as a Continuum (Grohol 1999) ...... 14 Figure 2. Fictional representation of raw data collected from an Irish Children's Helpline ...... 29 Figure 3. Topic of Conversations in an Irish Children's Helpline (%) ...... 45 Figure 4. Topic of Telephone Conversations in an Irish Children's Helpline (%) ...... 46 Figure 5. Topic of Online Chat Conversations in an Irish Children's Helpline (%) ...... 47 Figure 6. Topic of Mobile Text Conversations in an Irish Children's Helpline (%) ...... 47 Figure 7. Topic of Private Message / Email Conversations in an Irish Children's Helpline (%) ...... 48 Figure 8. Topic of Public Message / Email Conversations in an Irish Children's Helpline (%) ...... 48

List of Tables

Table 1. Sample of conversations from an Irish Children's Helpline broken down by method of contact (Total N=57,866) ...... 31 Table 2. Average Age of Sample of Conversations to an Irish Children's Helpline Broken Down by Method of Communication ...... 39 Table 3. Average Age Broken Down by Method of Communication (18 and younger) ...... 41 Table 4. Results of Mann-Whitney tests for age comparing different methods of contact to an Irish Children's Helpline (Excluding those aged 19 and over) ...... 42 Table 5. Standardized Residuals for Topic of Conversation and Method of Communication ...... 50

Phrases Used

• Therapist, counsellor, and psychotherapist are all used to refer to a professional in the field of counselling/psychotherapy, a person who has some kind of professional training. • Practitioner refers to either a non-professional or a professional and is used in this thesis when, for ethical reasons, I did not want to make a distinction between which participant was a professional. • Dandelion refers to the Irish Children’s Helpline whose statistics were used for the quantitative analysis. • Juniper and Rosehip refer to other voluntary organisations that provide online emotional support.

Chapter One: Introduction

“There are two mistakes one can make along the road to truth … not going all the way, and not starting.” – Gautama Siddhartha (founder of Buddhism, 563-483 BC)

The issues of how best to use internet and mobile technologies to provide mental health support and whether therapy or counselling can be done without face-to-face interaction are subjects of serious debate. Some argue that the only appropriate way to provide support is face-to-face (Robson and Robson 1998). Others see a potential for reaching out to people over the internet, but are unsure about the usefulness or effectiveness of online counselling or therapy (Alleman 2002; Holmes 1997). Additionally, there are some who are strong advocates of online therapy and mental health supports (Anthony and Goss 2009; Barak 2007).

There are a variety of opinions about whether therapy or counselling can be done without face-to-face interaction. Previous authors have cited numerous ideological as well as ethical issues; some involving client protection, unclear legal jurisdictions, and the danger that text is more susceptible to misinterpretation than spoken words. These are all areas of ambiguity that leave would-be providers feeling apprehensive. However, regardless of what individual providers (be they therapists, counsellors or mental health agencies) think about online counselling, people are increasingly looking for therapeutic services to be provided online (King and Moreggi 1998; Metanoia 2010).

It has been suggested that people unwilling to seek face-to-face counselling, for embarrassment or other reasons, will use an online service if it is available (Alleman 2002; Tait 1999). However, it has also been argued that online support is simply impossible because of the lack of visual cues, tone of voice, body language, and facial expression (Rochlen et al. 2004). Others cite apprehension about how a therapist or counsellor might be able to build trust and argue that the lack of physical presence reduces the level of intimacy and trust that is so important in therapeutic relationships (Suler 2004).

On the other hand, it cannot be ignored that people, especially many younger people are demanding that mental health supports be provided online. Furthermore, the idea that online communication may have unique features that allow for conversation to be more focussed on emotional disclosure and allow greater opportunity for empathetic concern warrants further investigation (Caplan and Turner 2007).

I became interested in this area through my own work and experience inside an Irish charity, where I worked for several years helping to develop the online and mobile phone technologies to give front-line support to children and teenagers. In order to protect the anonymity of the charity, I refer to it throughout this thesis as Dandelion or as an Irish Children’s Helpline. Dandelion provides anonymous support and aims to empower young people by providing a listening service about any topic or concern.

When I began working in Dandelion, I began listening to phone calls that were coming in to the telephone support line and looking at the mobile phone text messages that were received. I was immediately struck by the differences in how young people were using these services. Many young people ring and wait to get through, then immediately hang up. Others who seemingly have something they want to talk about appeared unable to say it aloud and instead end up talking about television or their favourite pop-star. When I observed the mobile phone text messages, it seemed that young people were talking about difficult issues not just more frequently but also with directness and greater ease.

Despite this, there was very real reluctance among staff to embrace online and mobile phone technologies in other areas of their work with clients. Those working with young people who had been referred for face-to-face support felt the technology would create distance, and had worries about whether clients would be able to type and express their thoughts and feelings. In addition, there were more general concerns about the technology.

At the same time there were also a number of perceived advantages to embracing technology. Providing online or text support would cut down on travel time and could allow staff to get in touch with more clients, potentially allowing them to give more support. Several young people had in fact requested it as a support that they wanted to have. This service might help a teenager shy around adults who might find it easier to talk online and in addition would help a young person who is deaf or hard-of-hearing who would be unable to express themselves without an interpreter.

I became interested in how people experienced providing support services online, both in voluntary organizations similar to Dandelion and also the experiences of professional counsellors and therapists. How did they find it? Did they have similar concerns about how it would work? What have their clients

10 said about it? In what ways do they feel it is useful? Is there any reason still to believe it might actually just create more distance between people?

In addition I wanted to take a closer look at the situation in the Irish Children's Helpline; are there real differences in the ways that young people use these services (or was that simply my subjective observation)? Are there differences in gender and age?

This study attempts to look at the phenomenon of online mental health support, through voluntary mental health or emotional support agencies and through professional counsellors and therapist. It uses descriptive narratives to illustrate the opinions and experiences of different providers as well as focussed group discussions with young people regarding what they see as the potential benefits and drawbacks.

This also examines how online counselling or mental health support is experienced. The research questions are three-fold: • Is there a difference in how clients use and perceive online mental health supports? • What do providers see as the advantages and / or challenges to using the internet for mental health support? • Why is there still reluctance to providing support online?

Both qualitative and quantitative methodologies are used to answer these research questions. As Tashakkori and Teddlie (2003) point out, using mixed methods can allow for a deeper engagement with a research topic and also allows for the generation of more valid and complete data. This project involved a detailed statistical analysis on the online and telephone statistics from an Irish Children’s Helpline and followed with qualitative in-depth interviews with a variety of providers, as well as a focus group of young people.

For the individual interviews, two of the participants were professional online counsellors, contacted with help from the Online Counselling Association of Ireland (OCAI 2010) and seven participants were people working in voluntary organizations who were contacted directly. The organizations are as follows 1: • Dandelion offer face-to-face, telephone, email, and online individual support. • Juniper offer face-to-face group support, telephone, email, and online group support.

1 In order to protect anonymity, fictional names were chosen for each organisation.

• Rosehip offer face-to-face group support, email, online group support, and online individual support.

For ethical reasons that I discuss in the methodology chapter, I have chosen not to individually describe the organizations any further; however, collectively, they work with people who have a variety of emotional difficulties. The clients may be feeling depressed, suicidal, have an eating disorder, may have been physically or sexually assaulted or have experienced a recent bereavement. In addition, they may just have general questions about their sexual orientation or be dealing with an unexpected pregnancy. There are a wide range of issues that the organizations deal with, some specialize in a specific area and others offer more general mental health or emotional support. All three of the organizations deal with younger people, one exclusively with people under the age of 18 and the others with young adults until the age of twenty-five. All provide services to their clients free of charge, some would employ professional counsellors while others would be run by trained staff / volunteers.

The results from the statistical analysis combined with findings from interviews and the focus group helped to explore the research questions and to help guide future decisions around service provision. The following chapters will discuss the existing research on online mental health supports, the methodology for this study, the research findings, and will conclude with final remarks and recommendations for service provision and for further research.

Chapter Two: Existing Research Regarding Online Mental Health Support

“Every new beginning comes from some other beginning’s end.” – Seneca (Roman Philosopher, mid-1st century AD)

Overview This study will address some of the issues associated with providing mental health and emotional support through online and text based technologies, concentrating on an Irish Children’s Helpline as well as the opinions and experiences of a variety of providers and a group of young people. The existing research concerning online and text based mental health services is comprised of studies in the area of professional online counselling as well as research done from within voluntary agencies. In addition, there have been a number of articles published which are more theoretical and include the opinions of counsellors or psychotherapists regarding the provision of online mental health services.

In this chapter, I provide a definition of counselling and discuss the situation of counselling as a profession in Ireland. Following this, I review some of the different types of technologies used in mental health / emotional support. Finally, I describe some of the key areas emerging from previous research regarding online counselling and online emotional support, including the lack of visual and verbal cues, issues around anonymity and confidentiality, problems with providing an ethical online support service, and questions around evaluating the effectiveness of online supports.

Counselling and Status of Counselling in Ireland Counselling is a broad term which describes a variety of different methods for helping people dealing with psychological or psychosomatic difficulties (Feltham and Horton 2006). While there is no one universally accepted definition of counselling, Feltham (2006) defines counselling as: ‘…listening-and- talking-based methods of addressing psychological … problems including deep and prolonged human suffering, situational dilemmas, crises and developmental needs, and aspirations towards the realization of human potential’ (p. 3).

While this appears to be a straight-forward definition, there are a wide range of intricate techniques and processes used under the umbrella term ‘counselling.’ A counsellor may practice psychotherapy, cognitive-behavioural therapy, motivational interviewing, biomedical therapy, play therapy, solution- focussed therapy, or cognitive-analytical therapy, to name a few. Anthony and Nagel (2010) argue that while there are many different forms of therapy or counselling, they all contain the same basic therapeutic processes and same aims – to help an individual solve problems or plan for their future.

Grohol (1999) provides a useful framework for understanding mental health interventions (See Fig. 1). He argues that often online counselling or ‘e-therapies’ can be understood as a continnum and practitioners may draw upon different mediums to meet a client where the client is more comfortable and where it is most appropriate. Often, methods of communication in therapy are not separate but used concurrently. For example, a client may first see a therapist in person and later on use email to keep in touch about certain issues as they arise. Alternatively, they may solely use email and telephone to keep in touch with a therapist.

Figure 1. Professional Interventions as a Continuum (Grohol 1999)

A number of previous studies have focused on mental health support provided by people who are not necessarily trained counsellors, but who are trained to listen and provide front line support in helpcentres / helplines (Bambling et al. 2008; Barak 2007; Fukkink and Hermanns 2009; Hanley 2009; King et al. 2006a; King et al. 2006b). In many ways this type of service differs from other types of online counselling. For example, the ‘counsellor’ may not be a trained therapist, the service is often provided free of charge, and in the case of a helpline, the support is often completely anonymous. However, the aim for both a professional practitioner and someone in a support role, is to provide non- judgmental acceptance, listening and support to a client. A professional may have more expertise, more training, and be able to diagnose and treat a problem, but their aims are similar and the skills and techniques they use online will be analogous.

The aim of this research is not to investigate the differences between professionals and non- professionals, but rather to explore the experiences of providing online mental health support. In this study, I have interviewed both professional online counsellors and those who are involved in voluntary organizations. All of the practitioners interviewed meet their clients in a non-judgmental, safe, confidential space, and whether that happens online, over the telephone, or in person, they aim to listen to and address matters that are of importance to their clients.

There are a wide range of professional counsellors available in Ireland, including many who specialise in a particular area such as marriage breakdown or addiction. However, counselling as a profession in Ireland has no statutory regulation (IACT 2010; NCII 2010). As such, any person in Ireland can call themselves a counsellor. They may be a professional psychologist, may have done a short course in counselling, may simply have some relevant experience, or they may have no experience or qualifications at all.

In 2008, several counselling organizations together submitted a formal letter of recommendations to the Department of Health and Children, calling for the creation of an official registration board and for the protection and regulation of the titles of Counsellor and Psychotherapist. That document pointed out the lack of national statistics on the number of people who identify themselves as Counsellors or Psychotherapists and highlighted the lack of regulation for academic training, experience, and qualifications (Moloney 2008).

The profession of Counselling and Psychotherapy is currently regulated by over 20 Professional Bodies – organisations like the IACP and NCII, as well as others like the Association for Psychoanalysis and Psychotherapy in Ireland (AAPI), Irish Council for Psychotherapy (ICP), and Irish Institute of Counselling and Hypnotherapy (IICH). Each of these organisations outline different ethical codes and best practice guidelines. There is a call for the profession to come under the remit of the Health and Social Care Professional Act 2005 so that official standards of professional conduct, professional education, training, and competence are put into place. However, the Department of Health and Children has yet to respond to the submission on Statutory Registration of Counsellors and Psychotherapists in Ireland. Like professional counsellors / therapists across Ireland, participants in this research will have different ethical codes, training, and education; however, they all have some experience of what it is like to provide emotional support online.

Technologies Used in Mental Health and Emotional Support There is debate in the field of counselling over the concept of providing mental health supports on the internet. During the 1980s people began experimenting with computers and technology for the provision of mental health services (Grohol 2004). In the late 1990s, Martha Ainsworth set up Metanoia, a non-profit mental health consumer advocacy and education website (Metanoia 2010) and by 2000 her database held over 900 therapists who were practicing therapy over the internet (Alleman 2002).

Online counselling is sometimes referred to as electronic therapy, e-therapy, web counselling, cybertherapy or computer-mediated psychotherapy. All of these terms generally refer to some type of contact between a counsellor and a client over the internet, but counsellors and therapists employ a variety of different methods when they meet clients online. There are several practical benefits to providing services over the internet; it can help reach geographically isolated clients (Chechele and Stofle 2003; Robinson 2009), it can save money and time because the client does not need to travel to an office (Bauer et al. 2003; Richards and Tangney 2008), a client can find support any time of any day (Robinson 2009), clients with communication difficulties, deafness, or physical disabilities can access support they would otherwise not be able to receive (Richards and Tangney 2008), and finally the client and the therapist can look back at the conversation at any time (Haberstroh et al. 2008; Slack and Slack 1977).

Barak (1999) reviewed several psychological / therapeutic interventions on the Internet and found there were several types of applications that worked in different ways, including: information resources for psychological issues, self-help guides, psychological testing and assessment, help in deciding to attend therapy, information around specific psychological services, single-session psychological advice through email, advice through online bulletin boards, ongoing personal counselling / therapy through email, ongoing real time counselling through chat, and synchronous or asynchronous support groups. Some of these methods involve contact with a counsellor while others are entirely computer-mediated and do not involve any type of communication between a client and a practitioner.

Anthony (2006), Grohol (2004), and Rochlen, Zack and Speyer (2004) have all outlined some of the more widely used methods in interactive online counselling and psychotherapy, these include: • Block Text Email Consultation (asynchronous) – one of the most commonly employed methods, where a therapist and client correspond back and forth in a time-delayed manner. It is usually used for short term therapy and therapists tend to use encrypton software to ensure privacy and confidentiality. • Dynamic Email Consultation (asynchronous) – similar to the block text email, but the therapist inserts responses into the client’s email using different fonts and colours. Again, this is typically used for short term therapy and uses encryption software. • Internet Chat Consultation (synchronous) – where a therapist and client correspond directly and immediately in real time. Usually the therapist uses some kind of private internet chat room or instant messaging software. Again, therapist usually uses some kind of software to ensure confidentiality and privacy. • Online Group or Forum (either synchronous or asynchronous) – where a therapist leads a group discussion and provides sources of support and information to a group of people who meet online. This typically occurs in password protected bulletin boards or chat rooms, therapists may set up a specific time for all members to meet or members may leave messages that are read by members at different times. • Mobile Phone Texting (either synchronous or asynchronous) – generally used by therapists as a way of monitoring and / or following up with patients who have left counselling, though occasionally a therapist and client may communicate in real time through texting. • Video-Counselling (synchronous)– where a therapist and client correspond using a video and audio link which allows client and therapist to both see and talk with each other.

Among mental health practitioners there are a variety of opinions about the legal, ethical, and professional issues raised in relation to online counselling. Some therapists would never use the internet for therapeutic interventions, some might combine face-to-face sessions with occasional email, and others may only meet and correspond with a client using online synchronous chat.

In Ireland, several professional counsellors 2 and voluntary organisations have started to provide therapeutic services over the internet. But, much like the profession of counselling and psychotherapy

2 https://www.aboutyoucounselling.ie/index.php ; http://www.securecounselling.ie/ ; http://www.cbtsolutions.ie/_mgxroot/page_10750.html ; http://www.counsellorsonline.ie/

17 itself, there is no single directory that lists all online counselling services. Consequently, a person looking for an online support must seek it out specifically or ask for a recommendation.

Many counsellors and therapists have published opinion papers which tend to simultaneously praise and critique online therapy, in an attempt to provide some guidelines and recommendations for other practioners (Alleman 2002; Fenichel et al. 2002; Rippen and Risk 2000; Suler 2001). While some, like Allenman (2002) point out the benefits online services have for allowing therapeutic expressive and reflective writing, others like Childress (2000) and Holmes (1997) caution about the dangers associated with providing therapy online.

Childress (2000) points out how little research has been done on the process and outcomes of online therapy. While counsellors and therapists have a responsibility to reach out and provide services to people who need help, they also have an ethical responsibility to provide effective interventions and must themselves be competent in the area. Conoscenti and Litz (2007) caution that computer-aided psychotherapy may be a passing fad and highlight how clients may have logistical, cultural, or personal barriers that make them resistant towards using the internet for therapy.

Some of the key areas highlighted in previous research are regarding the lack of visual and verbal cues, the idea that online supports offer anonymity and confidentiality, the need to remain extra vigilant around ethical practice, and hesitancy regarding the effectiveness of online supports.

Lack of Visual / Verbal Cues Counsellors and therapists have expressed a number of difficulties with working therapeutically over the internet, but one of the most prominent concerns is the lack of visual and auditory cues (Grohol 1998; Haberstroh et al. 2008; Robson and Robson 1998). Non-verbal messages and cues are seen as essential to creating an atmosphere of trust and mutual understanding between the client and the therapist (Gray 1999). In addition, some argue that it can be very difficult to create an atmosphere of intimacy and trust online (Haberstroh et al. 2008).

Lewis, Cursol and Herting (2004) used in-depth interviews to explore in detail what the experience was like for both the counsellor and the client. While the counsellor reported the interaction felt flat and two- dimensional and that it lacked emotional connection, she also commented that it allowed her to be more focussed on the client and more in tune to what her client was saying. Furthermore, the client

18 found the experience was both less intimidating and more comfortable than regular face-to-face counselling precisely because of this increased distance from the therapist. Similarly, Carlbring, Westling, Ljungstrand, Ekselius and Andersson (2001) reported that clients suffering from panic disorders found the lack of eye contact and visual cues helped them to talk about sensitive issues.

A study into the experience of online counsellors working in an Australian children’s helpline found that counsellors felt more emotionally distant to their clients online and that the absence of non-verbal cues made it difficult to communicate and many increase the possibility that they miss the severity of a client’s problem (Bambling et al. 2008). In a follow up study which used semi-structured online group interviews, young people who used the service reported they felt the online environment was more private and emotionally safe because they did not see or hear the counsellor (King et al. 2006a). While the young people pointed out occasional difficulties around miscommunication, this was typically in regard to the counsellor’s inability to pick up on feelings or emotions through text.

Several studies have attempted to investigate how clients rate the therapeutic relationship online and look at whether a client can trust and feel close to a therapist that they have only met online (Cohen and Kerr 1998; Cook and Doyle 2002; Murphy et al. 2009). Many have found that online clients, when compared to those receiving face-to-face support rated their counsellor equally (Cohen and Kerr 1998; Murphy et al. 2009). Cook and Doyle (2002) found that online clients actually rated their therapeutic alliance higher than those who met a counsellor face-to-face. All of these studies suggest that while from a client’s point of view, a relationship of mutual trust and understanding can be developed online, therapists are still quite reluctant about online support. In summary, while the loss of visual cues can lead to misunderstandings and misperception, it appears that the lack of tone of voice, eye contact and body language can also be beneficial and help a client talk about difficult issues.

Anonymity and Confidentiality Some authors speculate that internet and mobile technologies help a client to talk because they afford a degree of anonymity and confidentiality that are not as palpable in a telephone or face-to-face environment. Mitchell and Murphy (1998) point out that the privacy the internet provides may make it easier for clients to talk about difficult issues, even when they are not completely anonymous to their therapist / counsellor. Research done in organisations that already provide anonymous telephone support, have pointed out that the internet provides an extra degree of anonymity that can encourage a

19 client to talk and share emotionally distressing information (Bambling et al. 2008; Barak 2007; Fukkink and Hermanns 2009; Hanley 2009; King et al. 2006a; King et al. 2006b).

Suler (2004) called this the ‘Online Disinhibition Effect’ and hypothesized that some clients may fear a therapist’s reaction and can feel more invisible in an online conversation. For example, a client who is self-injuring may fear telling a therapist about what’s happening, but might find it easier to talk online because their therapist does not know who they are. On the other hand, some therapists believe that online supports can allow clients to avoid talking about issues and make it more difficult for the therapist to pursue discussion into certain topics (Grohol 1998; Rochlen et al. 2004).

A concept that has been cited as both a strength and a weakness of online therapy is that clients may have more control than in face-to-face sessions (Stritzke et al. 2004). Mallen et al. (2005) argue that people who are more inhibited or shy, may find online therapy useful and may find it easier to express themselves. They also note that some clients find the process of online therapy more satisfying and feel closer to an online therapist than one that they meet face-to-face. Others see this as a weakness and argue that this isolation is negative and that therapist and client need to meet to establish what is truly happening for the client (Anthony and Nagel 2010).

Regardless of the potentials for online therapy, there is still great reluctance for therapists to begin working online. In the UK, not only are the majority of counsellors not using the internet or mobile technologies for counselling, but most are negative or unsure about the idea of using the internet for mental health support (Gray 1999). Despite this, it seems that once the technologies are embraced, counsellors do see some benefits. Anthony (2000b), interviewed several counsellors in the UK who had been using the internet for therapy and found very few concerns overall. Instead they were very open about the fact that the technology allowed their clients to bring up difficult issues.

Ethical Issues / Appropriateness for Clients Outside of practitioner’s concerns, there are a myriad of legal and ethical issues which make online counselling difficult. For example, there are issues of client confidentiality when emails and servers are not necessarily in the therapist’s control and unresolved questions about the therapist’s role in ensuring client safety when the client may be using a computer that is shared with other people (Miller 2009). For many therapists, there are too many concerns about how to react to potentially dangerous disclosures.

For example, if a client discloses intent to commit suicide, homicide, or child abuse, it is argued a therapist online will be unable to deal with the situation appropriately and in time (Mallen et al. 2005). Kraus (2004) outlines several situations in which online therapy is inappropriate: • If a client has suicidal thoughts • If a client has thought of hurting someone else • If a client has a history of suicidal, violent or abusive behaviour • If a client is delusional or has hallucinations • If a client is abusing drugs or alcohol

While many agree that online therapy is inappropriate for certain clients, especially those who are suicidal or who have severe psychiatric disorders (Lovejoy et al. 2009), others are more open to the possibility that online therapy may benefit clients in crisis (Barak 2007; Fenichel et al. 2002). Fenichel et al. (2002) points out the successes of anonymous telephone hotlines for offering front line support to severely distressed and vulnerable people, theorising that some of these people would never reach out to access any support if it were not for these services.

In an Israeli study regarding the development of a web-based suicide support service, Barak (2007) points out how the internet can reach out especially to those who are shy, unconfident or who fear exposure from a face-to-face meeting. He argues that anonymous online support services can reach out to those who are suicidal by providing supportive, anonymous, and non-judgmental help.

In response to the numerous ethical concerns around online mental health support, several organisations have issued guidelines for online counselling,3 outlining steps a practitioner must take to provide ethical and appropriate support. Generally, counsellors who work online are under the same ethical obligations and must follow the same procedures as those that work face-to-face. However, there are concerns: practitioners are unsure about how to uphold confidentiality, what to do in case of an emergency when the therapist is geographically distant from the client, and how to communicate the potential benefits and risks of the medium to the client.

For many therapists and counsellors, concerns about the appropriateness of online counselling render it’s provision impossible (Robson and Robson 1998), others propose it should only be used for clients

3 American Counselling Asssociation, 1999; American Mental Health Counsellors Association, 2000; International Society for Mental Health Online, 2000

21 who have less serious or complex concerns (Haberstroh et al. 2008). And others caution generally, pointing out how little empirical evidence exists on the outcomes of online based mental health support (Fukkink and Hermanns 2009). There is little existing research into what types of clients and what types of issues online and text based supports might be most useful for reaching.

Effectiveness of Online Supports The issue of whether online therapy is actually effective in reducing symptoms or helping people cope long-term with the difficulties they face remains an open question amongst therapists and counsellors. Much of the research into clients has been conducted through randomized controlled trials (RCTs), that attempt to measure and compare some kind of online therapeutic intervention to a control group in order to identify whether the online therapy is effective in reducing symptoms (Kaltenthaler et al. 2008; Postel et al. 2008). Many of these RCT studies have had small sample sizes and numerous methodological issues; for instance many have a high drop-out rate, do not report on client’s preference for type of therapy, and have poor outcome measures.

Furthermore, while many of the studies find internet based therapy effective at reducing symptoms, many include clients on waiting lists as a control group (Carlbring et al. 2001; Knaevelsrud and Maercker 2007; Wagner et al. 2006). As Postel (2008) points out, there is a need for a comparable control group in these types of studies, rather than simply people who receive no treatment at all.

Several meta-analyses have been completed which attempt to collate and examine the results of studies to identify whether online counselling is effective (Barak et al. 2008; Kaltenthaler et al. 2008; Postel et al. 2008; Reger and Gahm 2009; Spek et al. 2007). Each of these meta-analyses has a systematic searching methodology and specific inclusion criteria. For example, Spek et al. (2007) and Reger and Gahm (2009) both looked at the effectiveness of online counselling specifically for people with depression or anxiety and both found that the provision of online support can be beneficial for those issues. Barak et al. (2008) had a broader inclusion criteria looking at studies that compared face- to-face and online interventions and found no difference in the effectiveness.

A number of studies have focused on mental health support provided by people who are not necessarily trained counsellors, but who are trained to listen and provide front line support in helpcentres / helplines. Fukkinck and Hermanns (2009) carried out a quantitative content analysis of Dutch based telephone and web based helpline. They analyzed the motivations of young people who

22 choose either chat or telephone based service and found that while both types of support (online and telephone) improved the young person’s report of well-being and decreased their perceived burden of problem, the online clients indicated that the quality of their interaction was higher than those who used the telephone. Similarly, Hanley (2009), in a study of a UK-based service for young people, used a quantitative measure to examine therapeutic alliance and found most of the respondents reported that they felt close to the person who they talked with online.

Postel et al. (2008) points out the field is still very new and remains cautiously optimistic about the potential online therapy has for helping people. However, at the moment a gap exists between people’s mental health needs and the actual treatment which is being delivered. Providing support online may improve access to supports and services by breaking down some of the logistical barriers and allow providers may be able to reach out to more clients than is currently possible with face-to-face interventions.

Summary While there is a growing interest as well as a growing demand for online mental health supports, an investigation into how they are being used and the differences that occur between online, face-to-face, and telephone support systems is required. According to Child Helplines International (CHI 2008), over thirteen countries outside of Ireland have a helpline for young people and provide support via a live online-based chat application. Quantitative analysis of these statistics yielded several key differences in the types of conversations young people have online versus on the telephone, for example, the majority of conversations for online-based communication were concerning abuse and violence (19%), whereas the majority of conversations for telephone-based communication were people requesting information (24%). The pattern of conversations and types of clients within Dandelion (an Irish Children’s Helpline) will be investigated in this research, and in addition, the experiences and thoughts of practitioners as well as young people will give greater depth and knowledge to the topic of online and text based supports.

This chapter has highlighted the key issues relevant to this study in terms of the existing research. Overall, while there is huge interest in online mental health supports, there remains little exploratory research into the profile of clients who use online supports and the experiences of those who provide online supports. There are still questions about how to deal with the lack of visual / verbal cues, ideas about online services providing increased anonymity, concerns about whether professionals can work

23 ethically online, and questions about whether online supports are effective. However, regardless of the apprehension counsellors and therapists have about providing online therapy, there is demand for online mental health and emotional support. This research explores the potential of online and text based supports for reaching out to clients, it attempts to discover the profile of clients, the nature of their issues, and identify areas that need further exploration in order to help guide policy and service delivery.

Chapter Three: Methodology Overview and Hypothesis

“Though this be madness, yet there is method in’t.” -Shakespeare, Hamlet Act 2, Scene 2

This chapter outlines how the data for this project was collected and analysed and considers the general philosophies upon which mixed-methods methodology is based. The intent of this research was to explore the phenomenon of online mental health support, using both quantitative and qualitative data. I explore in this chapter not only the methods of data collection and analysis, but also discuss my philosophical approach to this research.

Mixed methods involves ‘a plurality of philosophical paradigms, theoretical assumptions, methodological traditions, data gathering and analysis techniques… [to build] a collective generation of better understanding of the phenonema being studied’ (Green 2009, p. 13). Tashakkori and Teddlie (2003) point out that data triangulation can allow a researcher to confirm or cross-validate findings, and it also can be used to investigate questions that cannot be answered using solely one method. The aim of this research was not to simply confirm or deny the provision of online mental health supports, but to explore the situation in more depth and use a mixture of methods to add to the topic.

The idea for doing this research grew out of personal experience. Working in a helpline, it seemed that many young people find it easier to open up about difficult issues in an online context rather than over the telephone or face-to-face. I wanted to investigate not only whether this was something that played out as statistically significant, but also to explore the experiences of online mental health providers and allow young people to express their thoughts and ideas about the topic.

Armitage (2007) expresses some of the difficulties a researcher faces when attempting to carry out qualitative research:

Much of our work focuses upon the multiplicity and pluralism of the ‘real world’ which is occupied by ‘real problems’ that are possessed by ‘real people’ in ‘real situations’ and we contend that it is impossible to separate our lives as researchers into neat partitions that cannot be crossed (p. 6).

As such, I have tried to be open and honest about what I am bringing to this research but also attempted at all times to distinguish my beliefs and experiences from those of my participants. In order

25 to be transparent and reflexive throughout, I have shared with participants information about my own background as well as my thoughts about how online work might be useful in allowing people to talk about extremely difficult or sensitive issues. At the same time, I have been careful to remain open to the concerns and difficulties providers and young people have around communicating and providing or receiving help online.

I adopted the following mixed-methods approach: • A detailed statistical analysis was done on the online and telephone statistics from an Irish children’s charity. These findings helped guide the areas for exploration with the focus group and the interviews. • Qualitative in-depth interviews were carried out with a variety of providers, both those working as professional counsellors and those working in voluntary organizations. This was done in order to investigate the experiences providers have in providing a range of online mental health support. • Finally, a focus group was carried out with five young people who serve as part of a consultation group within the same Irish children's charity. The opinions of young people were included as part of this research because online supports are seen as especially useful or helpful in reaching out to children and teenagers (Richards and Tangney 2008; Robinson 2009; Whitlock et al. 2006). I included these young people so that they were allowed an opinion and an active voice regarding supports that are aimed towards them.

Overall, my approach to this research was to be both pragmatic and flexible in techniques and in philosophy (Maxcy 2003; Onwuegbuzie and Leech 2005). Armitage (2007) outlined the ‘pragmatic paradigm’ which emphasizes the connection between epistemological concerns and technical concerns about the methods used to generate knowledge. Rather than attempt to explain or define a phenomenon, this research uses a mixed-methods approach to allow comprehensive and integrated exploration and to help investigate the research topic.

Tashakkori and Teddlie (2003) point out mixed methods designs do more than simply incorporate techniques from qualitative and quantitative traditions, they combine techniques in unique ways to allow for a more complete engagement with the research topic. By allowing for the amalgamation of multiple data sources, this topic of online counselling and support can be explored in more depth and can provide stronger conclusions than a method that relies solely on one approach.

Ethical issues were at the forefront of how this research was undertaken, in particular in how the interviews and focus groups were conducted as well as how the data was analysed and findings disseminated (Denscombe 2003). Considerable efforts were made to protect the anonymity of participants and organizations as well as to avoid causing any harm or distress. The names of all organisations are anonymised and participants are all give pseudo-names. In addition, great care was taken in reporting the content of interviews / focus group so that no participant could be linked back to any particular organisation or counselling service and thereby be identified. A number of participants expressed concern about how the interview transcripts would be used and I reassured them that transcripts in their entirety would not be included in this or any other project.

The research proposal was submitted and accepted by the ethical approval board in the School of Social Work / Social Research Department of Trinity College Dublin (See Appendix I). The interests of participants were protected at all times and the research was conducted with honesty and integrity. All participants gave informed consent and were given the option of withdrawing at any stage.

The following steps were taken to ensure compliance with ethical principles: • Participants were given an information sheet containing the aims and objectives of the research as well as the contact details of the researcher (See Appendix II and III). • Each participant along with the researcher signed a consent form which covered information about the research, confidentiality, security of data, permission to record and right to withdraw consent (See Appendix IV and V). • Parental / guardians were given information forms and permission was obtained before the focus group for participants under the age of 18 (See Appendix VI and VII) • Researcher obtained Garda (Police) clearance prior to commencing data collection. • Any questions or concerns raised by participants were addressed. • Participants were assured that their anonymity would be kept by changing all names, places, and any other identifying information. • Each participant was allowed opportunity to read a transcript of the interview and make any changes or edits deemed necessary.

In the initial quantitative data collection, a sample of 57,866 telephone, online, and mobile text conversations from an Irish Children’s Helpline were collected and analysed. The helpline has been in existence in Ireland for over 20 years and since its inception a number of different technology formats

27 have been adopted to allow young people different opportunities to access support. These formats include: • Telephone (24 Hours) • Mobile Phone Texting (6pm-10pm) • Online Chat (6pm-10pm) • Online Private Message (similar to email, young person contacts anytime, volunteer replies within 3 days) • Online Public Message (similar to an online message board, young person contacts anytime, volunteer replies within 3 days and it is posted to a online board where anyone could read the message)

Each format allows a young person to contact a volunteer / staff member directly, though several important distinctions need to be highlighted. For example, the telephone is open 24 hours a day and 7 days a week whereas the online chat, mobile texting are open from 6pm-10pm 7 days a week. Quantitative data on each conversation is manually collected at the time of conversation and stored in secure client management database systems.

A range of variables are recorded including: • Time of Initial Contact • Length of Conversation • Age (Note: At times, clients may give a false age like 840 years or 2 months) • Gender (Note: It is possible for the volunteer to confuse the gender, for example with a name like Sam and also possible for clients to purposely misrepresent their gender) • Topic of conversation as defined by the Child Helplines International Protocol (See Appendix VIII) • Summary about the conversation, which can be used if the person wishes to contact again.

Irrespective of which format they are working on, a person working in the helpline must record information as the conversation is happening; however, separate client management systems are used for online versus the telephone sessions. So, the while the systems used to collect data are the same, they are not integrated.

Information from the telephone calls required reformatting so that it was suitable for use in a statistical package. For example, as seen in Fig. 2 below, raw data from each phone call was produced in the following format 4.

Figure 2. Fictional representation of raw data collected from an Irish Children's Helpline

Time Date Gender Name, Age, Summary of Topic of Conversation Conversation

18:44 4/5/2009 Female Lisa-12 talking about Current Events holidays

18:45 4/5/2009 Male Tom16 worried about his Unspecified/Other ex-girlfriend because he thinks she might be upset because he broke up with her

18:45 4/5/2009 Male Jim aged 14 likes to play Hobbies/Interests football with his friends and wondered how late Dandelion was open and also asked how old I am

18:46 4/5/2009 Hang Up Call

18:46 4/5/2009 Male Dr. Tayto Crisps , aged Unspecified/Other 840 years, says Tayto crisps are the best, sang a song about crisps

4 This is a fictional account, none of these are actual phone calls received

Not only did the raw data take a considerable amount of time to download and save (approximately 40 hours), it also required considerable editing and reformatting before it could be input into a statistical package. All potentially identifying information was deleted immediately after collection so that no potentially sensitive information would be included in the final dataset. For example, names and summary of conversations were edited out, but it was decided to retain information about age, gender and topic of conversation.

Another difficulty in the quantitative data was some data was misclassified. For instance, in the above example ‘Dr. Tayto Crisps’ and ‘Tom’ it would be difficult to know whether the Unspecified / Other was originally intended to be in the overall Everyday Life category or in the Peer Relationships category. Also, it is difficult to know whether ‘Dr. Tayto Crisps’ is male or female, though it can be assumed there was some indication to believe the caller was male because it was recorded as such. It was decided due to the large scale of the data and limited time-frame for this thesis not to attempt re-categorisation and instead to retain the original data. The category called Unspecified / Other, accounted for 2% (N=1010) of the phone calls and none of the online conversations.

This was not a problem for the online statistics because the data was collected through a separate content management system that retained the original main categories. While this is potentially problematic, the data is still useful for exploring the main research questions and guiding the qualitative interviews and focus group discussion.

A random sample of the phone calls and online conversations were collected, which gave a total of 57,866 conversations. A large number of these were silent conversations, in other words where the client does not speak and instead either hung up the phone immediately or stayed silent. As seen in Table 1, 53% of online chat conversations and 48% of phone calls are silent, while very small percentages of mobile text, public or private messages are silent (3%, 3% and 2% respectively). Because the main interest for this research is on the analysis of topic of conversation, all silent conversations were excluded from the final quantitative analysis.

Table 1. Sample of conversations from an Irish Children's Helpline broken down by method of contact (Total N=57,866)

Complete Silent or Hangs Total N= Conversations Up Immediately

Telephone 26,277 (52%) 25,311 (48%) 52,600

Mobile Phone Texting 3,359 (97%) 95 (3%) 3,454

Online Chat 544 (47%) 606 (53%) 1,150

Online Private Message 500 (98%) 9 (2%) 509

Online Public Message 149 (97%) 4 (3%) 153

The quantitative data was used to give an overview of how young people are using the different mediums to communicate issues affecting their lives and for exploring whether there are significant differences in age, gender, and topic of conversation. But, I also wanted to explore the personal experience of giving and receiving support online. Qualitative methods are ideal for this because they allow for a more nuanced, in-depth look at experiences and allow for a more focussed exploration of the issues that came up from the quantitative results (Silverman 2001; Snape and Spencer 2003; Tashakkori and Teddlie 2003).

My approach to this research was to be both pragmatic and phenomenological. The analysis of quantitative data yielded descriptive and inferential results that were useful for looking at how young people use online supports. I then used these results to guide the qualitative component of the research. By sharing with participants some of the statistical analysis and then focussing in on their first-hand experiences and opinions, I accessed detailed, rich, and full descriptions that add depth and interest to the topic (Bryman 2008; Denscombe 2003).

Stratified purposive sampling was used to recruit participants for the in-depth qualitative interviews. These participants, called Brian, Claire, Darren, Eamonn, Jenny, Linda, Mary, Madeleine and Natalie, were chosen based on their experience of providing mental health supports over the internet.

Two of the participants were professional online counsellors and were contacted with help from the Online Counselling Association of Ireland (OCAI 2010) and through snowballing. The other seven participants were people working in voluntary organizations who were contacted directly. One of the organisations describe their services as ‘support’ rather than ‘counselling’ because, they found that 'when you were talking about various supports that would be in place for [clients], quite often there was a barrier for them when you mentioned the word counselling.' Similarly, many of the voluntary agencies would draw upon counselling skills like non-judgemental active listening and client- centeredness, but would not market themselves as counselling services. Two of the organisations had services administered by trained volunteers rather than professional counsellors. Because the main interest for this project is on the provision of supports online, it was decided to include both professionals and non-professionals for the qualitative interviews.

The organizations are as follows5: • Dandelion offer face-to-face, telephone, email, and online individual support. • Juniper offer face-to-face group support, telephone, email, and online group support. • Rosehip offer face-to-face group support, email, online group support, and online individual support.

Anonymity was of immense concern to participants, both for protecting their own identity and for that of their clients. For this reason, illustrative quotes in the discussion and conclusion are not linked back to any particular participant or to any particular organisation. And again, the transcripts in their entirety are not included as part of this research.

5 These are fictional names for organisations

Participants were given the choice of attending an interview either face-to-face or over the internet using a real-time chat application or by email. Four participants were interviewed in person while three chose to be interviewed online and two by email. In addition, several participants followed up interviews with emails that were included as part of the analysis. It was decided to make use of the internet in light of the research topic and in order to experience first-hand how these mediums affected an interview.

Flick (2009) points out using the internet can help facilitate participation of people that are unprepared to participate in a face-to-face interview, writing:

At first sight, using the Internet for your study makes many things easier. You can reach distant people with your interview without travelling, you save time and money for transcription, you can access existing groups interested in a topic, you can maintain the anonymity of your participants more easily… [but] exchanging e-mails is different from asking questions and receiving answers face-to-face… problems of authenticity and contextualization result from the anonymity of participants (p. 278).

There is also a need to consider the ethical and theoretical implications to using the internet for qualitative research (Mann and Stewart 2000). Each participant that agreed to online interviews was sent an information sheet and consent form in the post which was received before any data was collected. In addition, I have given consideration as to how the textual data gathered in my online interviews differs from my face-to-face interviews and to how the interaction affects the manner in which people present themselves. Each participant was given a choice of how they wanted to participate and allowed a chance to change or combine methods.

In depth semi-structured interviews were used with service providers because each of the participants was seen as having privileged information and unique experiences that could not have been captured using other research strategies. A very simple interview guide was used that contained a list of open- ended questions (See Appendix IX). It was decided a simple interview guide would benefit the research by allowing participants more control and space to share their opinions and depth of experiences (Rubin and Rubin 1995). Attempts were made to maintain reliability by asking all participants the same set of questions.

While the aim of the research was to concentrate on the participant’s ideas and views, I was aware throughout of my own involvement, not only interacting within each participant, but also in carrying my

33 own opinions and ideas during the analysis and the conclusions. Mark (1996) argues that the researcher should embrace their role in the process, making sure to document and delineate their own opinions from the participants. As such, while I shared information about my own background and experience, and talked about the findings that emerged from the quantitative analysis, I avoided leading questions at all times. Instead participants were encouraged to express their own opinions, views, and experiences.

Following Seale’s (1999) suggestions, I kept extensive field notes throughout the process and used a digital audio recorder to ensure accurate verbatim accounts were made of the face-to-face interviews. Notwithstanding the need for interpretation of the data at a later stage, this prevented misrepresentation of the initial data. In all cases, interviews went smoothly and without any significant interruptions, each lasting between 40-90 minutes.

For the focus group, a convenience sample of five young people were recruited in order to investigate how younger people viewed the provision of online supports and in particular what they thought of the statistics from Dandelion. I was acutely aware of how traditionally in research, young people have not been given the time or space to speak for themselves (France 2004). In other words, much research has been done on young people but not with them. This gives us an incomplete picture of the issues facing young people and how best to deliver services for them. A focus group was thought especially useful for young people because it could allow for a more relaxed atmosphere where open discussion and debate could be encouraged. Focus groups often allow a more comfortable space and synergistic atmosphere, whereby participants can listen, reflect, and comment on what is being said (Finch and Lewis 2003).

These young people, who ranged in age from 12-17, already served on a board for Dandelion. They were originally recruited from schools around the country to meet up and discuss issues of relevance to services provided for young people or about issues that affect young people in general. Special care was taken to ensure participants understood how not only I would uphold anonymity and confidentiality but also their role in the research. The names they wanted to be known at in this research were Bosco, Molly, Optimus Prime, Superman, and Volvic. I should indicate that four of the participants were girls and one was a boy, so their pseudonyms, much like the names given by young people who contact the helpline, are not necessarily indicative of their gender.

Much of the research points out the potential usefulness of online technology to reach out to young people (Alleman 2003; Hills and Argyle 2003; Moulding 2007); therefore, it was important to include their voices in this research. A focus group allowed data to be generated by interaction between group participants and was useful in eliciting debate and discussion (Finch and Lewis 2003).

Again, a simple guide was used for structuring the focus group which included a discussion of the quantitative results (See Appendix X). This was used to prompt discussion and efforts were made on the part of the researcher to encourage participants to lead discussion. For all participants, written consent was obtained from their parent / guardian as well as from the young person themselves. The focus group met for one hour and drinks and snacks were provided for the meeting. As child protection guidelines stipulate, a focus group was more appropriate because an additional Garda / Police vetted adult was present at all times.

Analysis of the interviews and the focus group involved repeated readings of these transcripts and creation of a chart with headings and subheadings that related to the research questions and to the research on the topic (See Appendix XI). Throughout the process, notes were also kept about emerging themes and divergent patterns. I also charted and mapped the data set as a whole in order to describe the phenomena of online mental health support and work towards some recommendations for future development of services.

As Spencer, Ritchie, and O’Connor (2003) point out, the analysis of qualitative data is both challenging and exciting, requiring: 'a mix of creativity and systematic searching, a blend of inspiration and diligent detection (p. 199).' Each interview and focus group was digitally recorded and listened to several times to ensure accurate transcriptions were obtained, then thematic analysis techniques were used to uncover key common features that relate back to the research questions (Silverman 2001; Tonkiss 2000).

Thematic analysis was used not only to find common themes in the interviews and focus group, but also to highlight any differences in opinion or experience (Spencer et al. 2003). Again, the aim was to investigate the phenomenon of online supports rather than attempt to simply endorse or reject service provision. The thematic approach allowed for themes to be drawn across all participants which also ensured anonymity of participants so that no participant could be identified or linked back to any particular organisation (Flick et al. 2004).

To conclude, the nature of the research questions suggested that a mixed-methods approach was most suitable for this project, allowing for quantitative analysis of a large amount of data collected in Dandelion as well as in depth interviews with service providers and a focus group with young people. Discussion in this chapter focussed on sample selection, access to participants, ethical considerations, and data analysis as well more broadly the epistemological and theoretical issues. The following chapter will present in more detail the statistical findings and delineate the themes that emerged from the interviews and focus group.

Chapter Four: Results and Discussion

“However beautiful the strategy, you should occasionally look at the results” - Winston Churchill

Overview In this chapter the qualitative and quantitative findings have been combined to illustrate some of the stronger ideas and themes. I have given primacy to the findings, both quantitative and qualitative, which either diverged from the literature or had most use in guiding policy and areas for further research.

I begin discussion about the types of clients and the nature of issues in the context of an Irish Children’s Helpline. I consider the gender and age profile of clients broken down by method of communication (telephone, online, mobile text, private message / email, or public message / email). It emerges from this data that some people are misrepresenting themselves, in particular by giving false ages, which is a theme that also emerges from the interview and focus group participants. I discuss these findings together to explore how and why clients may misrepresent themselves. I then use the quantitative data to explore the difference in topics of conversations between the online and telephone services and consider how this relates to some of the qualitative findings.

With the qualitative data, I gave eminence to ideas that diverged from the findings from earlier research and which could not be explored in the quantitative analysis. These included the need for practitioners to learn how to communicate without visual / verbal cues, issues around how online supports may not be as anonymous or confidential for clients as previously thought, the potential for working online with suicidal and at risk clients, and the need to address difficulties around evaluating the effectiveness of online supports. Several additional themes emerged regarding the benefit online supports have for increasing a client’s access to information, the increased amount of time and space online services provide, and the diminished feeling of authority and power.

I want to briefly note that some of the themes that emerged from the qualitative data were reflected in previous studies and research. While I have chosen not to explore these themes in great depth, they still remain important characteristics of online mental health and emotional support. As previously

37 noted, mobile and internet technologies have great potential for reaching people who are geographically isolated and can be useful for people with disabilities that may limit their mobility or their ability to communicate verbally (Chechele and Stofle 2003; Richards and Tangney 2008). Many participants spoke about this in detail, highlighting how clients who need a specialist about a certain issue may not be able to travel across the country each week for a session and that online supports are very accessible for clients who are deaf or hard of hearing. In addition, participants pointed out some limitations of online supports discussed in previous research, especially how online technologies are only accessible to people who have computers and who are literate (Alleman 2003; Barak 2007; Robinson 2009). Participants also noted some of the difficulties with technology, in particular the difficulty around poor internet connection and internet speed in Ireland (OECD 2009). While these issues are important when considering the appropriateness of online mental and emotional health supports, the aim of this study is to focus on issues that guide policy and provide further insight into the area.

Profiles of Young People Accessing Online Support For the quantitative analysis, a random sample of 57,866 conversations were chosen from within the Irish Children’s Helpline. These included phone calls, text conversations, online conversations, private messages / emails, and public messages / emails. Conversations are session based, so while each individual phone call counts as one conversation, an on-line conversation may consist of a series of text messages or e-mails sent between the client and the service over a set period. We can assume that many of these 57,866 conversations are repeat contacts / returning clients. The majority, 85% (N=52,600) of conversations were handled by telephone, whereas 11% (N=3,454) of the conversations were by text message and much smaller percentages were via online chat (2%, N=1,150), private message / email (2%, N=509) or public message / email (1%, N=153). In the interviews, many participants noted that the online services were not necessarily the most popular part of the support they provide. Darren illustrated this point in detail:

We put a lot of investment and time into advertising it, and that didn’t correlate with an increase in usage. So that was really interesting that there was absolutely no correlation, from what I remember. So, I’m really saying that being aware that it’s very hard to quantify support, as I’m sure you know. So it wasn’t the busiest service, but at the same time it did provide really valuable support.

When the exploring the gender of young people who contact the helpline, it emerges that for online chat, girls account for majority of conversations (80%, N=924). The same pattern is evident in mobile text (72%, N=1705), private messages / emails (85%, N=432), and public messages / emails (76%, N=117). Boys, on the other hand account for 65% (N=16,176) of telephone calls. According to Child Helplines International (CHI 2008), girls tend to contact for support slightly more often than boys on a global level. This is consistent with studies which show that while boys have higher levels of internet use, they tend to be more exploration-focused whereas girls are more communication-focused (Mumtaz 2001; Tsai 2010). It is important to point out that in Ireland, more boys will contact over the telephone, and this pattern is not reflected in many other countries with child helplines (CHI 2008). Interview and focus group participants did not speak about a difference in gender regarding clients who use online supports.

As seen in Table 2, the average ages of the contacts were 31.08 years through telephone, 14.84 years through online chat, 14.57 years through mobile text, 14.52 years through private message, and 14.22 years through public message. This older average age for telephone contacts is attributable to a number of outliers. The distribution of age for telephone contacts is very highly positively skewed with some people responding they are 67, 1000 and even 200,000 years old (See Appendix XII). It’s likely that some young people are misrepresenting their age, either as a joke or because they extremely cautious about giving their true age. Also, a number adults who have concerns may contact in order to discuss an issue in confidence.

Table 2. Average Age of Sample of Conversations to an Irish Children's Helpline Broken Down by Method of Communication

Average Age and Standard Range of Ages

Deviation

Online Chat 14.82 years (SD=1.91) Range: 9 - 37

Mobile Text 14.57 years (SD=2.63) Range: 3 - 101

Phone Call 30.74 years (SD=1660.97) Range: 0 - 200,006

Private Message (Email) 14.51 years (SD=3.40) Range: 0 - 54

Public Message (Email) 14.18 years (SD=2.02) Range: 7 - 19

While many of the previous studies pointed out that online mental health supports might be particularly useful for reaching younger people (Richards and Tangney 2008; Robinson 2009; Whitlock et al. 2006), most of the participants pointed out it was not necessarily about age, but more about a client’s personal level of comfort.

There is an individual fit for people. In other words, some people communicate very well online, they’re very articulate online , they feel much safer online , they feel more dis-inhibited and those people I think you can assess better online perhaps even than face-to-face. (Eamonn)

I would have thought younger people would be more suited to online work but that hasn't happened so far for us. Obviously 'younger' in the sense that they are computer literate [but] we have only actually started the youth group a couple of months ago and the take up has been slow … they are much less forthcoming with topics and the conversation is very slow. (Madeleine)

This was picked up on in the focus group with young people as well. Some of the participants, particularly the younger ones, aged 12-13, said they thought a face-to-face meeting would be better and that a person with difficulties could get more support in person.

Personally, I think face-to-face is better. If you don’t want your parents or your friends or your family to know what you’re talking about, you can trust in the person, in your counsellor, not to tell anybody. (Molly)

I think it would be better face-to-face. If you saw them face-to-face then they would remember who you are. (Bosco)

The older focus group participants, who were 16-17 years old, were more open about what method might be useful for people.

Maybe people who are having problems with their mental health, the internet would be how they talk to other people. … It might be how they relate to other people and if they have problems communicating with other people the internet would be easier. (Superman)

It depends, if people feel a little more comfortable with it, if they’re at their computer at home, than talking to somebody to their face….If people find it easier to talk about some things through any of these ways, then that service should defiantly be provided. (Optimus Prime)

As the helpline is specifically focused on young people under the age of 18, it was decided to restrict respondents to those who said they were under the age of 18. As seen in Table 3, when limited to those aged 18 and younger, those that contact through online chat are oldest, with an average age of 14.77 while those that contact through the telephone are youngest at 13.15 years.

Table 3. Average Age Broken Down by Method of Communication (18 and younger)

Average Age and Standard Range of Ages

Deviation

Online Chat 14.77 years (SD=1.69) Range: 9 - 18

Mobile Text 14.52 years (SD=2.11) Range: 3 - 18

Phone Call 13.15 years (SD=3.34) Range: 0 - 18

Private Message / Email 14.22 years (SD=1.93) Range: 0 - 18

Public Message / Email 14.15 years (SD=1.99) Range: 7 - 17

A Kruskal-Wallis ranks test 6 was used to examine whether statistically significant differences occurred in the age between those that contacted on the phones, through online chat, through text, or through a private / public message. There were significant differences in terms of age between the 5 groups [H(4)=584.955, p=.000].

6 Kruskal-Wallis tests are used to compare 3 or more nominal variables (in this case method of communication) on a scale measurement (in this case age)

Mann-Whitney tests 7 were used to follow up this finding and a Bonferroni correction was applied so that all effects are reported at a 0.01 level of significance. As seen in Table 4, these results suggest that those who use the telephone to contact the helpline are significantly younger, whereas teenagers are more likely to use mobile and online technologies. However, it is important to remain aware of the fact that there are a number of adults who telephone expressing a concern for a young person and also some of the clients have provided a false age.

Table 4. Results of Mann-Whitney tests for age comparing different methods of contact to an Irish Children's Helpline (Excluding those aged 19 and over)

Phone Call Online Chat Mobile Text Private Message / Email

Online Chat U= 6154040.00 R= -0.12 P= 0.000

Mobile Text U= 1.852E7 No Significant R= -0.15 Differences P= 0.000

Private U= 3133979.50 U= 238986.50 U= 719862.50 Message / R= -0.04 R= -0.13 R= -0.07 Email P= 0.000 P= 0.000 P= 0.000

Public U= 964971.00 U= 71612.50 U= 216140.00 No Significant Message / R= -0.02 R= -0.10 R= -0.05 Difference Email P= 0.01 P= 0.000 P= 0.01

7 Mann-Whitney tests are used to examine whether there are statistically significant differences between two levels of a nominal variable on one equal interval scale variable (in this case, age)

Misrepresentation and Identity Concealment

In the interviews, participants had concerns about how people may lie or misrepresent themselves online. Several of the young people who participated in the focus group pointed out how people can seem different online and also how it might be easier for someone to change what they talk about.

If I was online, I could say to somebody that I was ok, even if I wasn’t. Whereas face-to-face they’d know, because they could tell by your expression. On the internet you can say, ‘Yeah, I’m grand.’ But you’re actually not. (Molly)

You can’t tell what they’re thinking … people [can] change the way they act on the internet because they have a few minutes to think things through before they say it. (Optimus Prime)

Some research also posits that some clients may find it easier to lie online or avoid issues (Grohol 1998; Rochlen et al. 2004). Most of the mental health practitioners interviewed also mentioned this, but they were more acutely aware of how clients may be misrepresenting their age or gender. Many of the participants who noted this as a concern provided free, anonymous, out of hours support services specifically for children and young people. Madeleine, Darren, and Jenny all had concerns about the identity of their clients:

One other thing that was a bit of a concern for us, before we had the youth group at least, was that we never really know who is online, like sometimes we got the idea that the participants were younger than 16, which was the cut off for the adult groups.

An ongoing question for me, was, we are very specifically a youth organisation and one of the questions I had was, how do we know the person using the online support service isn’t 56? And there was no way of knowing that. It’s not that somebody whose 56 doesn’t deserve the support but that we’re not the people for it.

I understand that it is possible to lie online, for example, misrepresent your gender or age, but with regards to emotional issues, it's also possible to lie when face to face. I think that people require different kinds of supports depending on their needs.

This is an area that needs further investigation, looking at the experiences of service providers (voluntary and professionals) as well as clients themselves. As Superman (a focus group participant) pointed out,

People can also lie face-to-face … like it may be easier to tell if they’re lying but you could still lie. And so, if you feel more comfortable on the internet then there might be less of chance that that they would lie.

Many participants pointed out that it can be easier for a client to change how they appear online, to appear as a different age or gender or change their personality and appear more confident. Paradoxically, while online methods of communication may allow clients to avoid issues, they can also provide people with an opportunity to expressing feelings that they otherwise would not communicate. It could also indicate that adults who need support may turn to an on-line service due to financial constraints or to avoid social stigma associated with needing mental health care.

Topic of Conversation Previous studies regarding online mental health support suggested that online conversations can be more focussed on emotional and personal issues (Anthony 2000a, b; Caplan and Turner 2007; Grohol 1998; Joinson 1998; Suler 2004). However, there is debate, and some authors point out that individual clients will have a strong preference for method of communication (Fukkink and Hermanns 2009; Marks et al. 2007; Suler 2001). Many of the mental health providers interviewed in this research spoke about the desire to provide several support methods, for example face-to-face as well as email and online chat. This gives their clients an additional way of keeping in touch and finding help. When describing their decision to begin offering services online, many of them spoke about wanting to give their clients additional options.

I think that people require different kinds of supports depending on their needs and that online support is beneficial for many people, even as a stepping stone to working towards accessing other kinds of support. (Jenny)

So far I haven’t done that much online work that has been only online. But what I have been doing is adding online work with people that I meet face to face. And I find that a very useful addition. So that they have that option. (Eamonn)

I think it’s about giving [clients] a choice and I feel that especially with teenagers, that the mobile phone and online are technologies that they feel comfortable with. And we need to kind of keep in line with where they are at and what mediums they like to use. (Mary)

Practitioners pointed out that it is important to provide individuals with support that is tailored to them, and this study aims to explore whether there are differences in the ways clients are actually using online mental health supports.

In regard s to the topic of conversation in Dandelion, as seen in Fig. 3, the majority of conversations (57%) are about everyday life issues, in other words, the conversations are about hobbies, interests, or current events (See CHI Topics in Appendix VIII). However, o ver 1 in 10 conversations (11%) are about abuse or violence and 10% are ab out sexuality or sexual issues (See Appendix XIII for details of frequency / percent).

Figure 3. Topic of Conversations in an Irish Children's Helpline (%)

60 50 40 30

Percent 20 10 0

When investigating the main topic of conversation, it appears there is a difference in the type of conversations young people have depending on the medium they use for getting in touch (telephone, online chat, mobile text message, private / public message / email). Several categories of topics were collapsed into one category, entitled ‘rare topics’ because frequencies were so small. These categories were as follows: • Commercial Exploitation • Homelessness / Runaway • HIV / AIDS • Legal Issues

• Differently-Abled Young People • Bereavement and Loss • Discrimination • Other • Internet Issues

As seen in Figs. 4-8, phone and text message contacts are most likely to talk about everyday live issues whereas those online or on the private messages / emails talk about mental health issues, and those on the public messages / emails are talking about peer relationships.

Figure 4. Topic of Telephone Conversations in an Irish Children's Helpline (%)

60 50 40 30 Percent 20 10 0

Figure 5. Topic of Online Chat Conversations in an Irish Children's Helpline (%)

60 50 40 30 Percent 20 10 0

Figure 6. Topic of Mobile Text Conversations in an Irish Children's Helpline (% )

60 50 40 30 Percent 20 10 0

Figure 7. Topic of Private Message / Email Conversations in an Irish Children's Helpline (%)

60 50 40 30 Percent 20 10 0

Figure 8. Topic of Public Message / Email Conversations in an Irish Children's Helpline (%)

60 50 40 30

Percent 20 10 0

A cross-tabulation chi-square test 8 was performed to find out whether statistically significant differences in conversation occurred depending on method of communication. Due to small frequencies, private messages / emails and public messages / emails were collapsed into one category representing all messages / emails.

The chi-square test found that there were statistically significant differences in topic of conversation depending on method of communication [χ2 (33) = 6.590E3 p=.00]. Using knowledge about method of contact would lead to a 2% reduction in error in predicting topic of conversation. In other words, while there is a significant difference in the topic of conversation depending on the method for communication, it remains a very small difference.

To find where the differences lie, standardized residuals were examined for each method along with topics of conversation (See Table 5 on following page). According to Garson (2010), the residual, or difference between the observed frequency and the expected frequency, is a reliable indicator for determining which cells produced a statistically significant difference. Standardized residuals which have a positive value signify the cell was over-represented in the sample (that there were more cases in this category than expected), whereas the standardized residuals that have a negative value signify the cell was under-represented in the sample (that there were fewer cases in this category than expected).

Considerable departures from expected frequencies occur across all of the categories examined except physical health in online chat. The biggest differences are in the categories of mental health (lower on the telephone, higher on the online chat, higher on the mobile text and higher on the messages / emails), information requested (lower on the telephone, higher on the online chat, higher on the mobile text, higher on the messages / emails) peer relationships (fewer on the telephone, more on the mobile text, and more on the messages / emails), and everyday life (higher on the telephone, lower on the online chat, lower on the mobile text, and lower on the messages / emails).

8 Chi-Square texts are used to examine whether two variables are independent of each other, it determines how much the observed frequencies differ from the expected frequencies.

Table 5. Standardized Residuals for Topic of Conversation and Method of Communication

Public and Private Phone Call Online Chat Mobile Text Message (Email)

Abuse and Violence 3.3 3.5 -11.7 2.8

Peer Relationships -13.0 7.5 26.4 15.9

School Related -6.8 5.8 13.2 8.0

Drugs and Alcohol 1.9 -1.3 -3.5 -2.6

Sexuality 1.4 -2.3 -1.8 -2.6

Family Relationships -7.2 14.2 7.6 15.7

Mental Health -11.7 27.3 11.7 22.7

Physical Health -2.7 -0.3* 6.9 1.8

Information Requested -15.0 10.1 30.2 17.3

Everyday Life 9.6 -15.4 -12.6 -18.1

Unspecified/Other -5.1 -4.2 -10.5 -4.6

Rare Topics -5.5 4.0 11.3 5.4 *Not a considerable departure from expected frequencies

Therefore, those who are getting in touch with Dandelion on the telephone are less likely to talk about mental health issues, request information, or talk about their friends; but are more likely to talk about everyday life issues. On the online chat, mobile phone, and messages / emails they are more likely to talk about mental health issues, request information, and talk about their friendships and less likely to talk about everyday life issues.

This idea that online conversations have a potential for being more emotionally-focussed has also been reflected in previous research (Anthony 2000a, b; Grohol 1998; Lewis et al. 2004; Mitchell and Murphy 1998; Robson and Robson 1998; Rochlen et al. 2004; Suler 2004). Service providers who participated in the qualitative interviews spoke about clients who were particularly honest and open online. They pointed out that some clients seemed to find it easier to talk about difficult or embarrassing issues and do this more quickly over the internet, highlighting a few particularly pertinent issues including sexual identity, self-injury, sexual problems, relationship issues, and bereavement. Mary and Eamonn spoke in detail about issues that clients found particularly difficult.

It’s an issue that people feel very stigmatised and a lot of people do feel very uncomfortable and quite embarrassed and quite ashamed about themselves. It’s an issue that they feel a lot of shame around and so we have found that at least with some people [it is an] easier way to open up that subject and check out the help online rather than coming in and sitting face-to- face. (Eamonn)

I remember a client who… felt embarrassed and ashamed and this was really something that upset him greatly. He didn’t want to talk about it face-to-face. It’s like he felt some shame associated with it … And he did talk online, you know, it was something that he was able to talk about online. (Mary)

In addition, participants spoke generally about how clients seemed to feel less embarrassed online. They spoke about how intimidating it can be to look for support and help, and how online a client may not find it is as difficult. And therefore, clients will talk about very emotional and emotive issues online perhaps more quickly and easily than they do through other methods.

I think it’s that they feel a bit safer [online] and maybe less embarrassed. Because [clients], if they haven’t been given permission to talk about emotions they can find that uncomfortable and embarrassing, they’re afraid that maybe their voice will kind of break a little bit if they sound upset and they feel embarrassed by that. Whereas online, they don’t have that. (Mary)

Some [clients] feel more anonymous through text / online and that it's easier to type things out than to say out loud. It can be less intimidating. Online can help someone to be their true selves without worrying about how they look or sound. (Jenny)

For some [clients] it can be very, very difficult to open up face-to-face and they would open up [only] a certain amount. A couple of [clients] who [I worked with] for specific issues didn’t want to talk face-to-face, but chose to talk online because they found it easier. I mean if they’re very emotive issues. (Mary)

Lack of Visual / Verbal Cues Many of the participants were acutely aware of the lack of visual and verbal signals in online conversations. Counsellors and psychotherapists are trained to pick up on and to use non-verbal communication, to pick up on changes in facial expression, tone of voice, posture and to use non- verbal communication themselves to convey interest, trust, and empathy (Feltham and Horton 2006). As Robson and Robson (1998) note, some practitioners are unsure about how mental health support can be done without these non-verbal cues. Claire and Linda pointed out, ‘People's physical reactions to questions or comments can also tell a lot more than other words they speak’ and ‘It's more difficult [online, when compared to face-to-face] because one cannot see the client’s reaction or emotions, trust is difficult to build up.’ Most participants had a positive opinion of online supports but were aware of the disapproval in the field generally. Eamonn reflected on this:

We’ve learned so much that it must all be based on non-verbal communication that it’s hard for people to imagine that the same things could be based on another form of communication. It’s a theoretical shift that some people maybe just don’t want to make.

When I asked participants about how they found working with clients online, they spoke about how the communication was both comfortable and natural. As Chechele and Stofle (2003) point out, people have always found comfort and connection in writing letters and keeping journals, so email and internet chat may be considered a modern form of this type of communication. Perhaps because clients typically have a choice to see a practitioner face-to-face, if they choose an online service, they are already comfortable expressing themselves in writing. Brian and Eamonn both spoke about the manner in which their clients expressed themselves online.

Some [clients] are very honest and very detailed. The picture they paint, it can leave an impact.

Most people who have picked up on this sort of thing are people who are very comfortable with communicating through text and they don’t have any great problem putting across how they feel and they don’t particularly miss the verbal and the non-verbal visual cues.

Participants pointed out that their real challenge was learning how they, as service providers, would express themselves and come across to their clients. Many reflected on when they first started training or talking about doing online counselling / support and their feelings of apprehension because they themselves were unfamiliar with it. They talked about how they had to learn to express their tone of voice and change the way they phrased things when communication was written. Generally, it was hard for participants to express exactly how this was done, but more they spoke about wanting the client to feel there was an atmosphere of mutual trust and acceptance.

I probably would have been more worried about giving cues.. … I think because I wouldn’t have been a great texter [and] I think that’s where I most had to learn. I had to make sure that I didn’t just respond information-ally. To make sure that I responded with a bit of emotion and a bit of the online text equivalent of non-verbal communication. (Eamonn)

The written word can be very cold at times, no matter how you try to phrase things. Words on their own are open to all types of interpretation. I would always find myself checking what I was planning on sending and asking how would the [client] interpret this. (Claire)

It can be a little bit difficult to ensure that you are warm because you haven’t got tone of voice, etc. And my own personal thing, I found that, when I started working online I was nearly over- examining every word I wrote and analyzing it as well because it’s right there in front of you. But people learn ways to ensure way that what they write comes across as warm to the other person. (Mary)

What I learnt was that communication just does need to be different [online] and you know, the whole issue of how [to] communicate, the whole thing of netiquette and using emoticons and you know all that kind of abbreviations and the pacing of it. (Eamonn)

Pace during online conversation was another challenge that participants spoke about. This issue has been identified in reports of adolescent use of an Australian online helpline service and in a study in a Dutch helpline (Fukkink and Hermanns 2009; King et al. 2006a; King et al. 2006b). Interview participants noted:

Online you do not have silence and there is a need to be careful not to speak over another person and to keep focused when a conversation may be happening slowly. (Jenny)

Time restraints are definitely a big issue. It can take awhile for some [clients] to type out what they have to say. I felt it was slower and holding an engagement over a long period of time could be a little disjointed. (Claire)

You have to be careful about slightly different things like for instance if you’re in your office and you’re in contact online with a client, you do have to be extra careful about not getting

distracted. Like if they’re pausing thinking before they answer, you have to try and stay focused. (Eamonn)

I noticed this issue myself when conducting online interviews for this study. Some of the participants were very quick and expressive, while others were slower and perhaps distracted or not as comfortable online. For the slower responders, I needed to be careful keep focus and resist temptation to jump in with a different question or start looking at something else.

Anonymity and Confidentiality It seemed in the focus group that the younger participants saw more benefit in face-to-face support, perhaps because they placed more importance on confidentiality whereas the older participants could see the benefit in the anonymity that the internet can provide. This is interesting in light of the fact that online supports are typically being provided for younger people, and this might not necessarily be the type of support they desire.

Superman, Optimus Prime, and Molly highlighted how there are numerous factors that affect how anonymous the internet is for younger people and that is may not be as private as earlier research posits (Mitchell and Murphy 1998; Suler 2004).

Superman: I was just thinking about like ads on the TV about internet safety and they were talking about like for parents to leave the computer in a fixed place in the house, where you can walk past and look at what’s on the screen. And that’s probably another reason why young people might not [use online services] and why the phones are so popular because people have moved on from phone safety to internet safety. Because parents aren’t letting them use them alone.

Optimus Prime: My parents do that, they put the family computer away from where it was in the living room and into the hall so that everyone walking around could see what I’m doing. If I’m emailing people I would have to do it really really quickly.

Molly: Like that again, the face-to-face is better because then nobody could see what you’re talking about

Many of the practitioners highlighted how counselling or mental health support is an intensely personal experience and highlighted the need for a client to feel safe and comfortable. Some participants also pointed out how anonymity can be better facilitated by being online.

Some of [my clients] have said that one of the most difficult things they ever did was the first time they came to [counselling] for [specific issue]. Because they felt, I’m going to a [counsellor] and it’s all very anonymous of course and there’s no sign outside saying it, but they feel like there is. They feel like ‘everyone can see me going to someone.’ So, you know, certainly some of them have said, that they would have been quite interested if they had have had that option of maybe making that initial contact online. (Eamonn)

[The problem is] often a secret, sometimes even the people's families don't know, so it’s easier to just log on and chat for a couple of hours than have to make an excuse to go somewhere. (Madeleine)

[Clients] may feel they have that little bit more anonymity online service as their voice is removed. Sometimes it can be easier, to just write in with a question and not worry about having to explain yourself. (Claire)

However, as the focus group pointed out, there is a need for both clients and practitioners to be careful and aware of many different factors that affect how anonymous, private, and confidential the internet might be. It is important to be aware that some clients may feel online methods are more private while others will still prefer face-to-face methods.

Ethical Issues / Appropriateness for Clients Another issue that was prevalent in previous research and that participants had concerns about was the suitability of working online with certain clients (Kraus 2004; Mallen et al. 2005). As noted earlier, authors have been quite cautious generally about working online with clients who are suicidal or at risk. In addition, some argue that online counselling and support is most useful for clients with less severe problems or issues (Haberstroh et al. 2008; Lovejoy et al. 2009).

While one of my participants agreed online counselling would not be suitable for suicidal clients, most of the participants were open to the idea that online support could be of benefit to those feeling suicidal or in crisis. Eamonn pointed out in particular how you cannot decide in advance whether a client may become suicidal or may present with serious issues.

You do need to be very careful about suicidal clients because there is information you don’t have as in, you’re not seeing them … But you can’t decide that in advance, you can’t decide not to work with a client who might become suicidal. So if you’re working online with somebody and they’re indicating that they may have suicidal ideation or tendencies, then you may need to recommend that they come and see you or that they see somebody. But, you know, if you’re

really forming a strong connection with them online, whether it’s really the case that you have less of an idea and can less judge how suicidal they are – whether that’s really true or not, I’m not really sure. It may just be that people are being extra-cautious because it’s a new medium, you know? (Eamonn)

Others pointed out that they were generally worried about how to deal with a situation if it did arise and spoke about the need to think carefully about procedures for dealing with a disclosure of suicide. Many participants echoed Darren’s sentiment:

What I found a little bit harder, I suppose is that the worst case worry that would have been in my head would have been what if a person contacts the service, what if they – what if they’re at serious risk of suicide? How does that kick in? If you’re in [here] and if a person comes in and they’re actively suicidal and they disclose suicide ideation, we have a direct duty of care and they don’t leave the premises until we’re sure they’re going to be safe. And that’s just a whole different world when you’re online. (Darren)

Eamonn recognised how useful online supports can be for someone to trying to find help as they are faced with difficulties. A client dealing an issue may not be able to set up an immediate face-to-face appointment, but will be able to send an email or perhaps contact someone online.

In crisis situations … the simple fact is that sometimes people aren’t in the position to set up a face-to-face session… but they’re able to set up an online session. So if it was a matter of coming to see me they wouldn’t be able to, but we can set up half an hour online... the fact that it’s on the phone [or online] may not be the factor that decides whether they get helped or not. (Eamonn)

Practitioners do need to be cautious and give thought to how they might work online with clients who could have serious problems, who could disclose suicidal intent, homicidal intent, or child abuse. Guidelines should be in place to protect both the client and the practitioner; however, it seems most of the participants engaged in online work are open and positive to the idea that online supports can help a client who is suicidal or going through a very difficult time.

Effectiveness of Online Supports The issue of effectiveness of online supports needs further evaluation, especially in regards to outcomes and into what clients have said regarding the support. Many of the participants in this study worked with the aim to listen and support a client, not necessarily to fix or solve a person’s problem.

Rather than being solution-focussed, they aim to meet a client where they are and support them at whatever pace the client is comfortable with. Darren pointed out; ‘Their level of frustration is often so high and … [the person] just wants to be listened to.’ Many of the participants echoed Natalie’s sentiment;

There may be valid arguments as to why for some people online may not be as effective as face-to-face [but] I think it is important to remember that there are [clients] who are reluctant and may never use those methods or communication... As long as people continue to use online [services] then it is serving the purpose of supporting and listening. I don’t think it is possible to judge whether or not it is effective without considering those who use it and [for some people] without this service they may not open up or discuss their feelings or thoughts with anyone. (Natalie)

There needs to be further research into the best methods for approaching and evaluating the effectiveness of online counselling, mental health, and emotional support. As the preceding research suggests, there is a need to look at attrition rates, client’s preference for type of therapy, symptom reduction, and coping mechanisms. But, mental health support is a difficult concept to measure and is often an ongoing process, one that, as Darren pointed out, is ‘very hard to quantify.’ There is a need to include client’s thoughts and opinions in further research.

Access to Information One of the emerging themes that came from the interviews and the focus groups was around the versatility of internet technologies in allowing people access to information. Several of the participants talked about their own personal experiences. One participant, who I choose not to name in order to protect their anonymity, spoke about a personal experience with self-injury. They spoke about how little self-injury or mental health was talked about when they were in school and how they began looking for information and support online. They noted: ‘It took me a while to get used to it. It was kind of a strange environment...just the frankness and the honesty.’ Another participant, again not named in order to protect anonymity talked about a personal experience:

When I came out, there was no internet. And I remember there was a book in Eason’s 9, about being gay. And so I remember one Saturday afternoon walking up and down [the street], like about 17 times before I had the courage to go into Eason’s and take the book down from the shelf to look at it. And that’s a barrier. And now, with this portal of information that people have

9 Easons is a large Irish bookshop

out there, they can find out all of that without anybody knowing. You just have access to just this wealth of information.

A couple of participants talked more generally about information access. One participant talked about mobile phone applications that have been made for people to keep track of their stress levels and their negative thought patterns. Another said:

One of the other things that I really like about online [counselling] is that there’s a strong sort of educational aspect to it, you want people to become a bit expert in their own problems and in solutions to them and so … I know there’s a lot being developed on this, the use of multi-media resources where you can have some online contact and you’re also in this position where you can kind of send links to articles and send forms that can be filled in. And for people that’s very user-friendly. … Some people they wouldn’t dream of writing something with a pen and a bit of paper or going into Eason’s and buying a book. But if it’s online, they’ll use it so you know they can find useful resources and you can give them useful resources which they can use and send back to you. (Eamonn)

Participants overall were quite positive about the versatility of supports and information that could be provided online that would not be possible through other mediums. Particularly for stigmatizing issues, clients have access to information more immediately and more easily online.

Time and Space Previous research has pointed out that online a client has more time and space to reflect on what they might want to say (Robinson 2009). Both focus group and interview participants pointed out how the online environment was a familiar space where clients already felt comfortable and how this might facilitate conversation.

Online can allow young people time to think about their thoughts and feelings; an opportunity to reflect and explore their thoughts and feelings. (Natalie)

If they feel nervous about it they could have it typed up and they could be thinking it through for a few minutes before they press send. Instead of being put on the spot. (Superman)

I think it may possibly be in some cases a more relaxed experience as they can concentrate on the engagement as opposed to being distracted by what is happening in their surroundings i.e. is there someone nearby that might be able to overhear. (Natalie)

These comments suggest that the concept of communication in counselling is complex, rather than one mode of communication being superior or inferior to another, they may be seen as being more or less suitable in the context of different clients, topics and / or situations. Outside of counselling, there is evidence of this in everyday communication.

In the course of this research, one interview participant supplemented our face-to-face interview with follow up e-mails. While the interview was rather sparse in terms of content, the emails were thorough and very detailed. Two other participants in this study could only communicate with me through email due to scheduling constraints. These emails highlighted subjective differences in communication styles as one was expressive and vivid while the other gave short answers and did not elaborate on their thoughts and impressions.

While some clients may find it easier to communicate online, others may prefer face-to-face, and many may require mix of communication methods. However, as all modes have the potential to provide insight into a topic or into a person it would seem appropriate to provide alternative pathways to support and help clients.

Authority / Power A theme that was not as prevalent in the existing research was one about the issues of authority and control in a therapeutic setting. Stritzke et al. (2004) write about how in social situations, people often attempt to portray themselves in a particular way in order to avoid disapproval. They argue that online, some people, in particular people who are shy or intimidated by others, can engage in deeper discussion and disclosure because there are fewer indications of an imbalance in power and authority.

Several participants pointed out how there can be a difference in authority in a therapeutic relationship that even before a session has begun; a client may have a pre-conceived idea that the practitioner is the expert there to fix the problem. A client who finds it difficult to talk in a face-to-face setting may not be as intimidated online because there is less of a sense of the therapist being in control. Darren, Natalie & Eamonn spoke about this:

Some children or young people ... may feel [nervous] and when talking to an adult that they should fill these silences. For some these silences may in fact be intimidating or a hindrance. I think the advantage of online is that some children and young people may be more comfortable using this service.

Somebody who mightn’t come to your office, might contact you online. So you might actually access clients who might otherwise not make that decision. [They think] ‘Will I? No I won’t’. Some of them will be comfortable with the online contact. We hope that over the years there will be more who will get help because they’ll feel safe enough to make the online contact.

I would notice from young people dropping in here … I’ve seen it countless times where a young person comes in with an adult or with their friend and they’re kind of – it’s a big step, walking into a support organisation – and they’re kind of pretty shy and sometimes very quiet and sometimes the adult will do most of the talking you know, do more talking than they will. And whereas, just our general experience of information, of supporting young people through the online information service, it is more cut to the chase you know? ‘Tell me where you go to get support about [x,y,and z] …’ whereas in a one to one with a young person that might take an hour to get.

A couple of the focus group participants also noted that when you talk with someone online the experience can be less intimidating. Perhaps particularly for young people who are seeking help from an adult, the notion of talking to an authority-figure can be particularly anxiety-provoking.

But also, people seem to find it much easier if they’re not able to be read through facial expressions. From this, I guess that people find it easier when the other person isn’t able to use psychology on them and they can just talk to them. (Optimus Prime)

[Face-to-Face] they might feel under pressure, you know, like to say the right things. Or you might feel nervous anyway just like being there with yourself and this person – this stranger. You might just be nervous anyway. (Molly)

Summary In summary, this chapter discussed the major themes from both the quantitative analysis of statistics from an Irish Children’s Helpline and the qualitative themes emerging from interviews with service providers and a focus group with young people. There were statistically significant differences between the telephone and online conversations in the helpline. Girls were more likely to use the online services and in general the people who used online tended to be teenagers rather than younger children or adults. However, caution needs to be exercised around these statistics because it appears some clients will not honestly disclose their identity. Several participants thought it possible that people are misrepresenting their age or gender or issues when they seek support online. This is an area that needs further investigation. Because many of the participants who saw this as an issue worked in organisations provided services targeted at youth, and provided free and anonymous support, there is a possibility that people outside the targeted age groups misrepresent themselves in order to gain access to a support that is not intended for them.

There were also statistically significant differences in the topic of conversation in the quantitative data, those who contacted by telephone were more likely to talk about everyday life issues and online conversations more focussed on mental health issues. In the interviews and focus group, participants pointed out how there was potential for online conversations to be more focussed on emotionally difficult issues and that clients may find it easier to talk about embarrassing or stigmatising subjects.

Several additional themes emerged from the qualitative work that added to some of the previous research on online mental health supports. These included: • The lack of visual and verbal cues and the need for online practitioners to learn how to express themselves online. • A need to further explore the idea of anonymity and confidentiality in particular when working with younger clients. • The possibility of working online with clients who are suicidal or in crisis. • A need to further explore the idea of measuring effectiveness of online supports.

These themes diverged somewhat from the findings in previous studies. Furthermore, several new ideas emerged from this research, including the use of online supports to gain access to information, to allow a client more time and space for thought, and that a conversation online can mediate the feeling that the therapist is the expert, allowing a client to have more control over a conversation.

Chapter Five: Conclusion

"The place which may seem like the end may also be the beginning." — Ivy Baker Priest

This research aimed to investigate the nature of online mental health supports in Ireland by examining the statistics in an Irish Children’s Helpline and by allowing practitioners and young people a chance to reflect on the potential benefits or barriers towards providing support online. Practitioners were recruited for participation because of their extensive experience providing mental health supports online. The young people who met for the focus group added enormous insight into the topic particularly in light of how online supports have been seen as a viable way of reaching people under the age of eighteens.

The extent to which this research can be generalized is limited due to its small sample size and due to the very specific nature of the statistical data. However, efforts were made to choose a variety of participants that provide mental health supports, including professional counsellors and psychotherapists as well as those that volunteer or work in voluntary agencies. This gave the study a wider scope and more variety of experiences. Because the aim of this research was not to discuss differences between individuals or organisations, no distinction was made to identify which participants are professional counsellors. Further research may benefit from making that distinction.

While the method of convenience sampling through the use of a pre-existing focus group of young people may be limiting, the young people were of benefit to the study precisely because they had some knowledge of types of services offered and were familiar with each other and the experience of group discussions. The study focused on Irish experiences, because of the unique state of counselling as a profession in Ireland as well as a desire to make relevant recommendations at a national level.

As previously discussed, as a researcher, I played a significant role in the data collection, presentation, and interpretation. I have attempted at all times to be open and honest and to recognise my own thoughts and experiences, both when talking with participants and throughout the data analysis and process of writing. I have attempted to remain reflexive both in writing and during interviews and focus group in order to account for some of my own experiences without letting them overshadow those of the participants.

This research confirmed some of the findings from earlier research, highlighting a number of areas that need further consideration in the provision of online counselling or mental health support. The statistical analysis confirmed that within an Irish Children’s Helpline, the online conversations were more focussed on emotional issues (mental health, requests for information, and peer relationships) while the telephone conversations were more often focussed on everyday life issues. This gives further weight to the idea that people may be embarrassed to ask for support around certain issues verbally. For many reason, the online environment fosters a degree of anonymity and mediates the impression of authority and control which can allow clients to talk about sensitive and emotionally difficult topics.

Both the statistics and the participants pointed out the possibility of people misrepresenting themselves by giving a false age or by avoiding issues, but it seemed service providers were more concerned that clients may give a false age. Many of the organisations covered in this study are specifically targeted towards youth and provide free out-of-hours online support, so it is possible that clients are looking for a service that is simply not provided. In addition, it may give clients a way of expressing feelings they otherwise are not able to communicate. On the other hand, there may be phenomena associated with the internet that encourages people to misrepresent themselves and this may hamper a counsellor’s ability to help. This is an area that needs further investigation.

All of the providers stated that they wanted to reach out to clients and offer a different way for them to access support. Many invested significant time and money in advertising their services, but this did not necessarily reflect an increase in use. Within the helpline, the majority of young people still choose to contact on a telephone. Young people in the focus group pointed out how in many households, computers are placed in a public place and may not necessarily be the most accessible for a young person when trying to access support. However, this issue will likely become less important with the trend towards mobile internet devices. Providers pointed out the lack of complete internet coverage and the fact that some people will simply prefer a face-to-face session. On the other hand, those that are getting in touch online, by sending message / emails or using an online chat, at least within the Irish helpline, tend to be female adolescents who are talking about more emotive issues like mental health difficulties, or else they are requesting information about specific issues or talking about about relationships. There are huge opportunities to reach out to wider audiences by using online services, both boys / men and adults; however, more thought needs to be put into how boys / men use the internet and the methods they would most prefer. There have been suggestions that boys use the

63 internet more actively than girls, so perhaps boys could benefit from a more interactive type service, perhaps one that is less communication or talk focussed.

Similar to some of the findings from previous research, providers all cited concerns about how they might work with clients who are suicidal. However, providers spoke about how the internet can provide more anonymity and safety for clients who have very stigmatizing or difficult issues, for example sexual identity, self-injury, sexual problems, relationship issues, and bereavement. Some participants also thought online services have potential for helping those who are suicidal or in crisis; however, each highlighted the need to carefully consider how they would deal with a situation should it occur. Some participants were open to the idea of working online with a client who might be at risk while others were still uncomfortable with this. It is of critical importance for practitioners to have thought this through and to communicate clearly with the client what steps might be taken were they to express thoughts of suicide, homicide, or abuse of others.

Participants spoke at length about the need for online practitioners to adapt how they communicate, to compensate for the lack of visual and verbal cues. While it was difficult for participants to outline exactly how they communicate empathy and warmth online, they pointed out the need to think carefully about phrasing and timing of online conversations and the need to be expressive with words. A practitioner starting out in online support needs to consider to how this might be done and become comfortable themselves online. Some form of training and supervision needs to be in place so that practitioners can learn how to communicate online and discuss issues that are specific to online counselling and support.

Because online therapy can facilitate and empower a client with increased access to information, providers need to have a clear idea of who their client base is and supply information and supports that will be of most use. The statistics from an Irish Children's Helpline show adolescents may best benefit from information about mental health issues, anxiety, depression, panic, self-injury, and eating disorders. However, research could be undertaken into the type of information that would be most useful and most empowering for the client. In particular, more attention needs to be given to reaching adolescent males. For younger adolescents, the preferred method of services may still be face-to-face, so the progress of any service should not be to the detriment of another. Development needs to be done in close consultation with clients and have scope for further change.

Finally, further investigation is required into methods for measuring the effectiveness of online supports. Practitioners pointed out how the clients they worked with responded positively to the experience of receiving online counselling / support, but more research needs to be undertaken as to how and why these supports are most helpful. Rather than simply looking at whether online counselling (or any type of counselling) reduces symptoms or whether people respond positively, we need to look into which type of service is best for which type of person. Mental health is fluid and subjective and individual people require individual supports depending on their specific circumstances, their personalities, and needs.

Both the quantitative and qualitative data in this research has shown the potential benefits of online support for providing out-of-hours support for people struggling with embarrassing or stigmatizing issues. At the moment, in Ireland, online mental health services are still under-developed but demand is growing. Providers need to overcome their own fear of technology and continue to reach out to their clients using new mediums. In addition, future research needs to consider how online counselling is perceived from the point of view of the clients. It is essential for services to continue to reach out and provide appropriate and meaningful supports that are client-centred.

References

Alleman, JR. 2002. ‘Online counseling: The internet and mental health treatment.’ Psychotherapy: Theory/Research/Practice/Training 39(2):199-209.

Alleman, JR. 2003. ‘Providing Psychotherapy Over the Internet.’ Psychiatric Times 20(7).

Anthony, K. 2000a. ‘Counselling in cyberspace.’ Counselling 11(10) 625-627.

Anthony, K. 2000b. ‘The Nature of the Therapeutic Relationship Within Online Counselling.’

Anthony, K. 2006. ‘Electronically Delivered Therapies.’ In The Sage Handbook of Counselling and Psychotherapy Second Edition, eds. C Feltham and IE Horton. London: Sage Publications, Ltd.

Anthony, K and S Goss. 2009. Guidelines for online counseling and psychotherapy, 3 rd edition University of Abertay Dundee.

Anthony, K and DM Nagel. 2010. ‘Theoretical Aspects of Online Therapy.’ In Therapy Online [a practical guide], eds. K Anthony and DM Nagel. London Sage Publications Ltd.

Armitage, A. 2007. ‘Mutual Research Designs: Redefining Mixed Methods Research Design.’ In British Educational Research Association Annual Conference. Insitute of Education, University of London.

Bambling, M, R King, W Reid and K Wegner. 2008. ‘Online counselling: The experience of counsellors providing synchronous single-session counselling to young people.’ Counselling & Psychotherapy Research 8(2):110-116.

Barak, A. 1999. ‘Psychological applications on the Internet: A discipline on the threshold of a new millennium.’ Applied and Preventive Psychology 8:231-246.

Barak, A. 2007. ‘Emotional support and suicide prevention through the Internet: A field project report.’ Computers in Human Behavior 23(2):971-984.

Barak, A, L Hen, M Boneil-Nissim and N Shapira. 2008. ‘A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions.’ Journal of Technology in Human Services 26(2):109-160.

Bauer, S , R Percevic, E Okon, R Meermann and H Kordy. 2003. ‘Use of text messaging in the aftercare of patients with bulimia nervosa.’ European Eating Disorders Review 11(3):279-290.

Bryman, A. 2008. Social Research Methods, 3rd Edition. Oxford: Oxford University Press.

Caplan, SE and JS Turner. 2007. ‘Bringing theory to research on computer-mediated comforting communication.’ Computers in Human Behavior 23(2):985-998.

Carlbring, P, BE Westling, P Ljungstrand, L Ekselius and G Andersson. 2001. ‘Treatment of panic disorder via the internet: A randomized trial of a self-help program.’ Behavior Therapy 32(4):751-764.

Chechele, PJ and G Stofle. 2003. ‘Individual therapy online via email and Internet Relay Chat.’ In Technology in Counselling and Psychotherapy, ed. A & Anthony Goss, K. Hampshire UK: Palgrave MacMillian.

CHI. 2008. ‘Connecting to children: A compilation of child helpline data.’ Amsterdam: Child Helpline International. Available . [Accessed 9 June 2010]

Childress, CA. 2000. ‘Ethical Issues in Providing Online Psychotherapeutic Interventions.’ Journal of Medical Internet Research 2(1).

Cohen, GE and BA Kerr. 1998. ‘Computer-mediated counseling: an empirical study of a new mental health treatment.’ Computers in Human Services 15(4):13-26.

Conoscenti, LM and BT Litz. 2007. ‘Hands-on help: computer-aided psychotherapy ‘ American Journal of Psychiatry 165:142-143.

Cook, JE and C Doyle. 2002. ‘Working alliance in online therapy as compared to face-to-face therapy: Preliminary results.’ CyberPsychology and Behavior 5(2):95-105.

Denscombe, M. 2003. The Good Research Guide, 2nd Edition. United Kingdom: Open University Press.

Feltham, C. 2006. ‘What are Counselling and Psychotherapy?’ In The Sage Handbook of Counselling and Psychotherapy Second Edition, eds. C Feltham and IE Horton. London: Sage Publications Ltd.

Feltham, C and IE Horton eds. 2006. The SAGE handbook of counselling and psychotherapy. London: Sage.

Fenichel, M, J Suler, A Barak, E Zelvin, G Jones, K Munro, V Meunier and W Walker-Schmucker. 2002. ‘Myths and Realities of Online Clinical Work.’ CyberPsychology & Behavior 5(5):481-497.

Finch, H and J Lewis. 2003. ‘Focus Groups.’ In Qualitative Research Practice: A Guide for Social Science Students and Researchers, eds. J Ritchie and J Lewis. London: Sage Publications Ltd.

Flick, U. 2009. An Introduction to Qualitative Research. 4 Edition. London: Sage Publications Ltd.

Flick, U, E VonKardorff and I Steinke. 2004. A Companion to Qualitative Research. London: Sage.

France, A. 2004. ‘Young People.’ In Doing Research with Children and Young People, eds. S Fraser, V Lewis, S Ding, M Kellett and C Robinson. United Kingdom: Open University Press.

Fukkink, R and J Hermanns. 2009. ‘Counseling children at a helpline: chatting or calling? .’ Journal of Community Psychology 37(8):939-948.

Garson, G.D. 2010. ‘Chi-Square Significance Tests.’ In Statnotes: Topics in Multivariate Analysis.

Gray, P. 1999. ‘Counselling Online Opportunities and risks in counselling clients via the Internet.’ British Association for Counselling.

Greene, JC. 2009. Mixed Methods in Social Inquiry. San Francisco: John Wiley & Sons Inc.

Grohol, JM. 1998. ‘Future clinical directions: Professional development, pathology, and psychotherapy on-line.’ In Psychology and the Internet: Intrapersonal, interpersonal, and transpersonal implications, ed. J Gackenbach. San Diego: Academic Press.

Grohol, JM. 1999. ‘Best practices in e-therapy: Definition and scope of e-therapy.’

Grohol, JM. 2004. ‘Online Counselling: A Historical Perspective.’ In Online Counselling: A Handbook for Mental Health Professionals, eds. R Kraus, JS Zack and G Stricker. San Diego, CA: Elsevier.

Haberstroh, S, G Parr, L Bradley, B Morgan-Fleming and R Gee. 2008. ‘Facilitating online counseling: Perspectives from counselors in training.’ Journal of Counseling and Development 86(4):460-470.

Hanley, T. 2009. ‘The working alliance in online therapy with young people: Preliminary findings.’ British Journal of Guidance and counselling 37(3):257-269.

Hills, P and M Argyle. 2003. ‘Uses of the Internet and their relationships with individual differences in personality.’ Computers in Human Behaviour 19(1):59-70.

Holmes, LG (1997) You can't do Psychotherapy on the Net (yet) Originally Presented at the American Psychological Association Annual Convention, August 1997 Available: [Accessed 10 June 2010. 1997.

IACT. 2010. ‘Irish Association for Counselling and Psychotherapy.’ Available [Accessed 1 June 2010].

Joinson, A 1998. ‘Causes and implications of disinhibited behavious on the Internet.’ In Psychology and the Internet: Intrapersonal, interpersonal, and transpersonal implications, ed. J Gackenbach. San Diego: Academic Press.

Kaltenthaler, E, G Parry and C Beverley. 2008. ‘Computerized cognitive behaviour therapy for depression: a systematic review.’ British Journal of Psychiatry 193:181-184.

King, R, M Bambling, C Lloyd, R Gomurra, S Smith and W Reid. 2006a. ‘Online counselling: The motives and experiences of young people who choose the Internet instead of face to face or telephone counselling.’ Counselling and Psychotherapy Research 6(3):169-174.

King, R, M Bambling, W Reid and I Thomas. 2006b. ‘Telephone and Online Counselling for Young people: A Naturalistic Comparison of Session Outcome, Session Impact and Therapeutic Alliance.’ Counselling and Psychotherapy Research 6(3):175-181.

King, SA and D Moreggi. 1998. ‘Internet Therapy and Self-Help Groups - The Pros and Cons.’ In Psychology and the Internet: Intrapersonal, Interpersonal, and Transpersonal Implications, ed. J Gackenbach. San Diego, CA: Academic Press.

Knaevelsrud, C and A Maercker. 2007. ‘Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial.’ BMC Psychiatry 7(13). [Accessed 14 June 2010]

Kraus, R. 2004. ‘Ethical and Legal Considerations for Providers of Mental Health Services Online.’ In Online Counseling: A Handbook for Mental Health Professionals, eds. R Kraus, J Zack and G Stricker. San Diego CA: Elsevier Academic Press.

Lewis, J, D Cursol and W Herting. 2004. ‘Researching the cybercounseling process: A study of the client and counselor experience.’ In Cybercounseling & cyberlearning: An encore, eds. JW Bloom and GR Walz. Alexandria, VA: American Counseling Association.

Lovejoy, TI, PD Demireva, JL Grayson and JR McNamara. 2009. ‘Advancing the practice of online psychotherapy: An application of Rogers' diffusion of innovations theory.’ Psychotherapy: Theory, Research, Practice, Training 46(1):112-124.

Mallen, MJ, DL Vogel and AB Rochlen. 2005. ‘The practical aspects of online counseling. Ethics, training, technology, and competency.’ The Counseling Psychologist 33(6):776-818.

Mann, C and F Stewart. 2000. Internet Communication and Qualitative Research: A Handbook for Researching Online. London: Sage Publications Ltd.

Mark, R. 1996. Research Made Simple. London: Sage Publications Ltd.

Marks, IM, K Cavanagh and L Gega. 2007. ‘Computer-aided psychotherapy: revolution or bubble? .’ The British Journal of Psychiatry 191 191:471-473.

Maxcy, SJ. 2003. ‘Pragmatic Threads in Mixed Methods Research in the Social Sciences: The Search for Multiple Modes of Inquiry and the End of the Philosophy of Formalism.’ In Handbook of Mixed Methods in Social & Behavioral Research, eds. A Tashakkori and C Teddlie. Thousand Oaks CA: Sage Publications Inc.

Metanoia. 2010. ‘E-therapy: History and Survey.’ Available [Accessed 10 June 2010]

Miller, K. 2009. ‘The Potential of the Internet in Suicide Prevention.’ Counselling, Psychotherapy, and Health 5(1):109-130.

Mitchell, DL and LM Murphy. 1998. ‘Confronting the challenges of therapy online: A pilot project.’ In Seventh National and Fifth International Conference on Information Technology and Community Health. Victoria, British Columbia, Canada.

Moloney, J. 2008. ‘Presentation of Submission by the Psychological Therapies Forum regarding Statutory Registration of Counsellors & Psychotherapists in Ireland ‘, ed. Address by Mr John Moloney TD Minister for Equality Disability and Mental Health.

Moulding, N. 2007. ‘Online counseling: With particular focus on young people and support.’ Counselling, Psychotherapy, and Health 3(1):25-32.

Mumtaz, S. 2001. ‘Children's enjoyment and perception of computer use in the home and the school.’ Computers & Education 36(4):347-362.

Murphy, L, P Parnass, DL Mitchell, R Hallett, P Cayley and S Seagram. 2009. ‘Client satisfaction and outcome comparisons of online and face-to-face counselling methods.’ British Journal of Social Work 39(4):627-640.

NCII. 2010. ‘The National Counselling Institute of Ireland.’ Available [Accessed 1 June 2010]

OCAI. 2010. ‘Online Counselling Association of Ireland.’ Available [Accessed 1 June 2010]

OECD. 2009. ‘OECD Communications Outlook.’ Available [Accessed 1 June 2010]

Onwuegbuzie, AJ and NL Leech. 2005. ‘On becoming a pragmatic researcher: The importance of combining quantitative and qualitative research methodologies’ International Journal of Social Research Methodology: Theory and Practice 8(5):375-387.

Postel, MG, HA deHaan and AJ De Jong. 2008. ‘E-therapy for mental health problems: A systematic review.’ Telemedicine and e-Health 14(7):707-714.

Reger, MA and GA Gahm. 2009. ‘A meta-analysis of the effects of internet- and computer-based cognitive-behavioral treatments for anxiety.’ Journal of Clinical Psychology 65(1):53-75.

Richards, D and B Tangney. 2008. ‘An informal online learning community for student mental health at university: a preliminary investigation.’ British Journal of Guidance and counselling 36(1):1-17.

Rippen, H and A Risk. 2000. ‘e-Health Code of Ethics.’ Journal of Medical Internet Research 2(2).

Robinson, E. 2009. ‘Online counseling, therapy and dispute resolution. A review of research and its applications to family relationship services.’ Australian Family Relationships Clearinghouse 15:1-15.

Robson, D and M Robson. 1998. ‘Intimacy and computer communication.’ British Journal of Guidance and counselling 26(1):33-41.

Rochlen, AB, JS Zack and C Speyer. 2004. ‘Online therapy: Review of relevant definitions, debates, and current empirical support.’ Journal of Clinical Psychology 60(3):269-283.

Rubin, H and I Rubin. 1995. Qualitative Interviewing: The Art of Hearing Data. Thousand Oaks, California: Sage Publications Ltd.

Seale, C. 1999. The Quality of Qualitative Research. Oxford: Blackwell.

Silverman, D. 2001. Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction. London: Sage.

Slack, WV and CW Slack. 1977. ‘Talking to a computer about emotional problems; a comparative study.’ Psychotherapy: Theory, Research and Practice 14(2):156-164.

Snape, D and L Spencer. 2003. ‘The Foundations of Qualitative Research.’ In Qualitative Research Practice: A Guide for Social Science Students and Researchers, eds. J Ritchie and J Lewis. London: Sage Publications Ltd.

Spek, V, P Cuijpers, I Nyklicek, H Ripper, J Keyzer and V Pop. 2007. ‘Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis.’ Psychological Medicine 37(3):319- 328.

Spencer, L, J Ritchie and W O'Connor. 2003. ‘Analysis: Practices, Principles and Processes.’ In Qualitative Research Practice: A Guide for Social Science Students and Researchers, eds. J Ritchie and J Lewis. London: Sage Publications Ltd.

Stritzke, WGK, A Nguyen and K Durkin. 2004. ‘Shyness and computer-mediated communication: A self- presentational theory perspective.’ Media Psychology 6:1-22.

Suler, J. 2001. ‘Accessing a Person’s Suitability for Online Psychotherapy.’ CyberPsychology and Behavior 4(6):675-680.

Suler, J. 2004. ‘The online disinhibition effect.’ Journal of Cyberpsychology and Behaviour 7(3):321-326. Tait, A. 1999. ‘Face-to-face and at a distance: The mediation of guidance and counselling through the new technologies.’ British Journal of Guidance & Counselling 27(1):113 - 122.

Tashakkori, A and C Teddlie. 2003. Handbook of Mixed Methods in Social and Behavioral Research. Thousand Oaks CA: Sage Publications Inc.

Tonkiss, F. 2000. ‘Analysing Discourse.’ In Researching Society and Culture, ed. C Seale. London: Sage.

Tsai, MJ. 2010. ‘Junior high school students' Internet usage and self-efficacy: A re-examination of the gender gap.’ Computers & Education 54(4):1182-1192.

Wagner, B, C Knaevelsrud and A Maercker. 2006. ‘Internet-Based Cognitive-Behavioral Therapy for Complicated Grief: A Randomized Controlled Trial.’ Death Studies 30(5):429-453.

Whitlock, J, J Powers and J Eckenrode. 2006. ‘The virtual cutting edge: The internet and adolescent selfinjury.’ Developmental Psychology 42(3):407-417.

Appendix I: Ethics Approval

Research Ethical Approval Form 10 Forms must be submitted at least TWO WEEKS before a School Research Ethics Committee meeting. If you are a taught MSc student please submit form to your course administrator. If you are a member of staff or MPhil/MLitt/PhD please submit form to Olive Donnelly ([email protected] / Room 3053 / Arts Building)

Title of Project: Using the Internet to Provide Emotional Support: A Case Study of Helpline Statistics, Interviews with Counsellors and the Views of Children Name of Applicant(s): Amy Callahan Applicant(s) email address: [email protected] Application Date: 31 May 2010 ------Staff project (tick as appropriate) Student Project (tick as appropriate) √ Project start date: Student Number: 09262988 Lead researcher: Supervisor: Dr. Kay Inckle Title of Course: MSc Applied Social Res. Signature of lead researcher (if applicable) : ______

Recruitment Procedures Yes No N/A

Does your project include children under 18 years of age 11 ? X

Does your project include people with learning or X communication difficulties? Does your project include people in custody? X

Is your project likely to include people involved in illegal X activities? Does you project involve people belonging to a vulnerable X group, other than those listed above? Does your project include people who are, have been, or are X likely to become your clients or clients of the School? Does you project include people for whom English/Irish is not X their first language? Will you tell participants that their participation is voluntary? X

10 This form is an adapted version of an ethical approval form developed by the Cardiff School of Social Sciences. The School of Social Work and Social Policy gratefully acknowledges the generous permission to use and adapt their form. 11 Applicants undertaking research involving children under 18 years will be required to have Garda clearance.

Will you obtain written consent for participation? X

10. If the research is observational, will you ask participants for X their consent to being observed? 11. Will you tell participants that they may withdraw from the X research at any time and for any reasons? 12. Will you give the potential participants a significant period of X time to consider participation?

Possible harm to participants and/or researchers Yes No N/A 13. Is there any realistic risk of any participants experiencing either X physical or psychological distress or discomfort? 14. Is there any realistic risk of any participants experiencing a X detriment to their interests as a result of participation? 15. Does this research pose any risk of physical danger to the X

researcher? 16. Does this research pose any risk of mental harm to the X researcher?

Data Protection Yes No N/A 17. Will any non-anonymised and/or personalised data be X generated and/or stored?

18. Will you have access to documents containing sensitive 12 data X about living individuals? If ‘Yes’ will you gain the consent of the individuals concerned?

If there are any other potential ethical issues that you think that Committee should consider please explain them on a separate sheet. It is your obligation to bring to the attention of the Committee any ethical issues not covered on this form.

12 Sensitive data are inter alia data that relates to racial or ethnic origin, political opinions, religious beliefs, trade union membership, physical or mental health, sexual life, actual and alleged offences.

Appendix II: Participant Information Sheet

Title: Using the Internet to Provide Emotional Support

Location: Flexible

Researcher: Amy Callahan, School of Social Work and Social Policy, MSc in Applied Social Research, Trinity College Dublin

Phone Number: 086 086 5617

The above researcher agrees to be contacted at any stage prior to, during or after the research project.

Aims and Objectives:

There are conflicting views about using internet based technologies for emotional support. Some believe the only appropriate way to provide support is face-to-face while others have praised the potential the internet has for providing emotional support, especially for teenagers or young people.

This research hopes to take a deeper look into what people see as the advantages and disadvantages to the different types of communication.

Interview:

Those who agree to be interviewed can be seen in a public location or in their own home/office. Interviews should last between 30-90 minutes.

With your permission the researcher will digitally record and transcribe the interview. This recording will be kept under password protection and be destroyed in 13 months. Responses will be anonymised and confidentiality will be maintained. All names and places will be changed.

Data collected will be used for the purposes of a Master’s Thesis and may lead to publication in journal format.

Participation is entirely voluntary and can be ended at any time. If desired, a copy of the research will be made available to you upon completion.

Appendix III: Young Participant Information Sheet

Hi, my name is Amy Callahan, I am a student in Trinity College Dublin. I am interested in speaking with members of the Young Person's Advisory Board for a research project on using the internet for emotional support.

Title: Using the Internet for Emotional Support

Researcher: Amy Callahan, School of Social Work and Social Policy, MSc in Applied Social Research, Trinity College Dublin

Phone Number: 086 086 5617

The above researcher agrees to be contacted at any stage prior to, during or after the research project.

Aims and Objectives:

This research hopes to take a deeper look into what you see as the advantages and disadvantages to the different types of communication. Data collected will be used for the purposes of a Master’s Thesis and may lead to publication in journal format.

Focus Group:

Those who agree to participate in the focus group will meet in the office during the July meeting of the Young Person’s Advisory Board. The group will have a 20-30 minute discussion about the types of services that are provided on the internet, over the telephone or face-to-face.

With your permission the researcher will digitally record and transcribe the focus group. This recording will be kept under password protection and be destroyed in 13 months. Responses will be anonymised and confidentiality will be maintained. All names and places will be changed.

Participation is entirely voluntary and can be ended at any time. If you would like a copy of the research, it will be made available to you.

Appendix IV: Participant Consent Form

I ______am willing to be interviewed about my experiences, thoughts and opinions about the different types of communication used in support / counselling. I understand that the discussion will form the basis of a dissertation which is part of the MSc in Applied Social Research in Trinity College Dublin.

I have read the information leaflet for this project and I understand the contents. I have had the opportunity to ask questions and all my questions were answered to my satisfaction. I freely and voluntarily agree to be part of this research study.

I understand that my participation is completely voluntary and that this material in anonymised form may be the subject of discussion and may result in public consumption in text form. I have discussed issues of privacy and confidentiality with the interviewer and am agreeable for any information to be used by the researcher. I understand that I can withdraw at any time.

I agree to allow the researcher to digitally record and transcribe our conversation. I am satisfied that responses will be anonymised and confidentiality will be maintained. I recognise that my name will not be used in any way.

I have received a copy of the agreement and have been notified that I can receive a copy of the research if requested.

The data will be accessible only by the above named researcher and will be protected by password. All recordings will be destroyed on 09/30/2011.

Signature of Participant I have read and understood the written details provided for me about the research, and agree to participate in the project

Signed ______Date______

Signature of Researcher I undertake to uphold my obligation to ______during this research project.

Signed______Date______

Appendix V: Young Participant Consent Form

I ______am willing to be interviewed about my experiences, thoughts and opinions about the different kinds of services provided online.

I understand that the discussion I participate will form the basis of a dissertation which is part of the MSc in Applied Social Research in Trinity College Dublin (TCD).

I recognize that while this research is part of a Masters in Trinity College Dublin and information from the focus group may be published in a research journal.

I agree to allow the researcher to digitally record and transcribe the interview. I am satisfied that responses will be anonymized and confidentiality will be maintained. I recognize that my name will not be used in any way.

I have received a copy of the agreement and have been notified that I can receive a copy of the research if requested.

The data will be accessible only by the above named researcher and will be protected by password. All recordings will be destroyed on 09/30/2011.

Signature of Participant I have read and understood the written details provided for me about the research, and agree to participate in the project

Signed ______Date______

Signature of Researcher I undertake to uphold my obligation to ______during this research project.

Signed______Date______

Appendix VI: Parental/Guardian Consent Form

Title: Using the Internet for Emotional Support

Researcher: Amy Callahan, School of Social Work and Social Policy, MSc in Applied Social Research, Trinity College Dublin Phone Number: 086 086 5617

The above researcher agrees to be contacted at any stage prior to, during or after the research project.

Aims and Objectives:

This research hopes to take a deeper look into what people see as the advantages and disadvantages to the different types of communication. Data collected will be used for the purposes of a Master’s Thesis and may lead to publication in journal format.

Focus Group:

Those who agree to participate in the focus group will meet during the July meeting of the Young Person’s Advisory Board. The group will have a 30-40 minute discussion about the types of services that are provided on the internet, over the telephone or face-to-face.

With permission the researcher will digitally record and transcribe the focus group. This recording will be kept under password protection and be destroyed in 13 months. Responses will be anonymised and confidentiality will be maintained. All names and places will be changed.

Participation is entirely voluntary and can be ended at any time. If desired, a copy of the research will be made available to you and your child upon completion.

Appendix VII: Parental/ Guardian Consent Form

I/We the parent(s) of ______give permission for my/our child to participate in the group discussion regarding online service provision.

I understand that the discussion will form the basis of a dissertation which is part of the MSc in Applied Social Research in Trinity College Dublin.

I understand that my child’s participation is completely voluntary and that this material in anonymised form may be the subject of discussion and may result in public consumption in text form. I have discussed issues of privacy and confidentiality with the interviewer and am agreeable for any information to be used by the researcher. I understand that my child can withdraw at any time.

I agree to allow the researcher to digitally record and transcribe the focus group. I am satisfied that responses will be anonymised and confidentiality will be maintained. I recognise that my child’s name will not be used in any way.

I have received a copy of the agreement and have been notified that I can receive a copy of the research if requested.

The data will be accessible only by the above named researcher and will be protected by password. All recordings will be destroyed on 09/30/2011.

Signature of Parent I have read and understood the written details provided for me about the research, and agree to allow my child to participate in the project

Signed ______Date______

Signature of Researcher I undertake to uphold my obligation to ______during this research project.

Signed______Date______

Appendix VIII: Topic of Conversation as outlined by Child Helplines International

Abuse and Violence Physical Sexual Emotional Neglect Witness to violence Bullying Unspecified Commercial Exploitation Child prostitution / Sexual exploitation Other child labour Children used for begging Children used for criminal activity Unspecified and other Homelessness / Runaways / Basic Needs Seeking shelter Missing children Abandoned Resources and financial aid Unspecified and other HIV / AIDs infected / affected children Information about aids Unspecified and other Peer Relationships Relationships with friends Relationships with partner Unspecified School Related Teacher problems Other adult related problems Academic problems Performance anxiety Homework School drop-out Unspecified Legal Matters Advice and information Child witness Law in conflict with children's rights Children in conflict with law Child marriage Unspecified and other Child Substance Use and Abuse

Information on substances and misuse Alcohol use / misuse Drug use / misuse Addiction Unspecified and other Differently -abled Children Unspecified and other Sexuality Information about sexuality and facts of life Pregnancy Sexual identity STIs Contraception Atypical sexual behaviour Sexual fantasy Unspecified and other Family Relationships Divorced / Separated parents / Parents in conflict Child custody and access Parent / child relationships Sibling relationships New families / Blended families Young parents Adoption / Fostering issues Parents with addiction / mental health issues Children in care Unspecified or other Bereavement / Loss Psycho -Social, Mental Health Boredom Body / physical appearance Loneliness Lack of confidence Eating disorders Fear and anxiety Depression / Sadness Identity and purpose of life Phobias and obsessions Self harm Suicide Unspecified and other Physical Health Access to health care Concerns about illnesses Hospitalisation Unspecified and other Information Requested

About Organisation/Charity About Children's issues / rights Thank you for assistance Unspecified and other Discrimination Everyday Life Low-level contact Hobbies / interests Current events Unspecified and other Other Internet Issues Internet bullying Online safety Internet relationships Harmful content / Images viewed Looking for information Unspecified and other

Appendix IX: Interview Schedule

Off Tape: Hi and thanks for talking with me today. My name is Amy Callahan, and I’m studying for my masters in applied social research in Trinity College. For my dissertation, I am interested in what providers think about using the internet for therapy. I am interviewing online counsellors and people who work in charity or voluntary agencies, hoping to find some common themes and explore this topic in more depth.

All information you give me will be treated in total confidence. I may use extracts of our conversation in my dissertation, but all names and places will be changed. I have a form for the both of us to sign agreeing to those conditions. If you want to have a read over it before we talk and then we can both sign it that we both agree to its contents.

And just to reiterate that this is entirely voluntary, if at any stage you wish to end our conversation that’s ok. I can provide you with a transcript of our conversation if you like and in general if there’s anything I ask that you would rather not reply to that is ok. It would help me if I can tape our interview, is that ok with you? I promise that I will keep this recording under password protection at all times and will destroy it as promised. Do you have any questions for me at this stage?

On Tape:

Personal Information • To start with, can you tell me a bit about your practice/the agency you work for? • What kinds of services do you (or the organisation you work for) offer? • What kinds of clients do you typically see? • What are your own professional interests? (Any particular theoretical background, interest in special topics)

Online Support Services • What are the main reasons you decided to start offering services online? • How long have you been working online? • What times of the day can clients access your services online?

Communicating with Client • Can you walk me through what happens when you first set up an online session with a client? • What are the key things you cover in terms of confidentiality with a client online?

Impressions of Online Support Services • What was it like when you first heard of or started doing online support? • What were your first impressions of online counselling? • What kind of training did you have? • What kind of training do you think is needed to work in the field?

Advantages and Disadvantages • What do you see as the advantages to using online based technologies? • What do you find most interesting about online counselling/support? • What do you see as the disadvantages of online based technologies? • What do you find frustrating about online counselling/support?

• What is your favourite part of the job • What is your least favourite?

Clinents Online, Issues and Type of Person • What have your clients said about the process of doing online therapy? • What do you feel is most useful for clients about online therapy? (example of issues or types of clients) • What do you feel is most difficult for clients about online therapy? (example of issues or types of clients) • What types of work do you think would be best suited for working online? (example of issues or types of clients) • What kinds of issues or clients would you feel are least suited for working online?

Differences in Online and Other Support • Do you notice between clients that you see face-to-face (or talk to on the telephone) and ones that you see online? • I've found in my own analysis of statistics of an Irish children's helpline that online conversations are more often about mental health, where as the telephone conversations tend to be about everyday life. Would you have gotten that impression from your own work?

Appendix X: Focus Group Schedule

Off Tape: Hi everyone, thanks for coming. I hope today will be interesting for you. My name is Amy Callahan, I know you probably know that already from the consent forms. But, I just want to go over what we're going to be doing today. I’m studying for my masters in applied social research in Trinity College. For my dissertation, I am interested in what you all think about using the internet for counselling or emotional support. I am interviewing online counsellors and people who work in charity or voluntary agencies, hoping to find some common ideas and explore this topic more. But a lot of people talk about the internet being a useful way to reach out to young people and that's why I really wanted to talk with you today.

All information you give me will be treated in total confidence. I may use extracts of our conversation in my dissertation, but all names and places will be changed. You have all been given a form to sign. Did you have any questions about it or about what we're doing today? If not, then can you give them to me now?

I just want to say again that this is entirely voluntary, if at any stage you want to end our conversation that’s ok. And in general if there’s anything I ask that you would rather not reply to that is ok. It would help me if I can record this, is that ok with you? I promise that I will keep this recording under password protection at all times and will destroy it as promised. Do you have any questions for me at this stage?

On tape:

Introductions The first thing I want to do is just go around the room and for everyone to introduce themselves. I am a little forgetful with names, so f it's ok with you, can we all make name-tags to wear?

I don't want you all to be nervous about the recorder, so I thought first we would just play a game to get to know each other a little. What I've done is I have gotten some stickers so if everyone could take ten of them. Then, what we have to do for the next few minutes is try to not say the word ‘No’ and at the same time try to get someone else to say it. So I could ask someone, ‘Is today your birthday?’ and if they said ‘No’ then I would get one of their stickers. Is that ok?

Introducing the Topic So I want to talk with you a bit about what we're going to do today. I want to look at some of the services provided here in this charity and talk about what are the differences between them and what might be good about each service.

Different Types of Support Services Some of the different things we do here in this charity, do you guys know some of them already? [As they name them bring out pictures]

• Face-to-face support with kids who are going through a difficult time • Telephone support for kids who want to talk to someone • Online internet-based support for kids who want to talk to someone

If we could just brainstorm for a bit, what are some of the difference between these things?

[Prompt: For example, in person, you might meet up and talk with the other person. You can see them. You can hear them. You can tell if they’re crying. You can tell if they’re angry. Online it’s over a computer, so you can’t see and you can’t hear. What might you miss?]

Where Young People Need Help, Support, Information Overall, what kinds of things do you think people your age might want or need talk about? [Make a list of all the different things] What kinds of things do you think are important for people your age to talk about? Where do you think people go to get help and support about these things? [Not only this organisation, generally parents and friends]

Sharing Statistics regarding Topic of Conversation One of the things I've been really interested in, is just looking at what happens here in this organisation. So I looked at the topics of conversation overall and I wanted to show you what I found. [Give chart showing overall topic of conversations]

What do you think about this graph? The most common topic is everyday life, what do you think about that? Why do you think so many kids are just talking about everyday things?

The other thing I wanted to share with you was what it looks like when you look only at the telephone conversations and only at the online conversations. In other words when you break it apart. [Give charts showing break down by method of conversation]

What do you think about these graphs?

Thoughts on the Differences in Topic The most common topic is still everyday life on the phone, what do you think about that? The most common topic in the online conversations is mental health, what do you think about that? Do you have any ideas about why this might be happening?

Explore Different Methods for Support What do you think would be some of the good things about being able to talk with someone online? What about talk with someone on the phone? What about texting? What about emailing? What about chatting online?

Clarify Own Opinion I don't necessarily think it's a matter of one way being the right way or the wrong way. I do think that for some reason people might find it easier to talk about a difficult issue on the internet. And that's not going to be the same for everyone, but I wonder do you guys have any ideas about why we're seeing this pattern here?

Recap and Any Additional Important Topics [Wrap up by recapping on some of the main points and ideas that came out from the focus group] Do you think there is anything else important around providing help or counselling through any of these methods?

Appendix XI: Coding for Qualitative Data

1. Personal Details 1.1 Type of agency they work for 1.2 Types of clients they work with (ages, presenting issues) 1.3 How long working using online technologies 1.4 Types of technologies/supports they offer 1.5 Particular approach to counselling/mental health/emotional support

2. Nature of the therapeutic relationship online 2.1 Building Trust 2.2 Avoiding issues/telling lies 2.3 How to control and steer a conversation 2.4 Isolation of client

3. Lack of Visual Cues 3.1 Understanding the client’s issues 3.2 Misinterpretation 3.3 How they deal with not seeing, hearing the client

4. Timing 4.1 Chat, takes longer 4.2 Email, quick to the problem 4.3 Staying focussed 4.4 Email, client can contact at any time 4.5 Email, therapist can return contact at any time

5. Nature of the online conversation 5.1 Younger clients 5.2 Embarrassing subjects 5.3 Geographically isolated clients 5.4 Socially isolated clients 5.5 Client comfort with technologies 5.6 How clients express themselves

6. Ethical Issues 6.1 Privacy 6.2 Anonymity/Invisibility 6.3 Explaining Privacy 6.4 Ensuring Privacy 6.5 Suicidal or other disclosures

7. Effectiveness 7.1 What clients say 7.2 How to assess difficulty 7.3 Reduction in symptoms 7.4 Instances where online therapy might be particularly helpful 7.5 Stepping Stone

8. Access to information 8.1 Tools for knowledge 8.2 Access to other supports 8.3 Applications to promote positive mental/emotional health

9. Technological Issues 9.1 Internet Coverage 9.2 How to deal with being cut off

10. Therapist’s own comfort with online technologies 10.1 _Concerns about coming across to client 10.2 _Learning from others

Appendix XII: Boxplot of Age for Sample of Phone Calls to an Irish Children's Helpline

Appendix XIII: Frequency and Percent of Topics in an Irish children's helpline - Overall and Broken into Method of Contact

Private Public Online Mobile Overall Telephone Message/ Message/ Chat Text Email Email

57% 61% 7% 40% 3% 4% Everyday Life (N=17,418) (N=16011) (N=38) (N=1349) (N=14) (N=6)

Abuse and 11% 12% 17% 5% 16% 13% Violence (N=3526) (N=3184) (N=90) (N=154) (N=78) (N=20)

10% 10% 7% 9% 7% 6% Sex/Sexuality (N=3050) (N=2671) (N=37) (N=299) (N=34) (N=9)

Peer 5% 3% 12% 15% 16% 26% Relationships (N=1503) (N=815) (N=65) (N=502) (N=82) (N=39)

Family 4% 3% 16% 7% 18% 12% Relationships (N=1233) (N=816) (N=88) (N=223) (N=88) (N=18)

4% 2% 27% 8% 23% 18% Mental Health (N=1206) (N=653) (N=147) (N=266) (N=113) (N=27)

Unspecified / 3% 4% 0% 0% 0% 0% Other (N=1010) (N=1010) (N=0) (N=0) (N=0) (N=0)

Drugs and 1% 2% 1% 1% 0% 1% Alcohol (N=422) (N=395) (N=4) (N=22) (N=0) (N=1)

1% 1% 4% 4% 5% 4% School Related (N=388) (N=207) (N=22) (N=128) (N=25) (N=6)

1% 1% 1% 3% 2% 2% Physical Health (N=381) (N=276) (N=6) (N=86) (N=10) (N=3)

Information 1% 0.1% 6% 7% 7% 11% Requested (N=345) (N=37) (N=31) (N=223) (N=37) (N=17)

1% 1% 3% 3% 4% 2% Rare Topics (N=347) (N=202) (N=16) (N=107) (N=19) (N=3)