Undergraduate Student Experiences with Text-Based Online Counselling

Undergraduate Student Experiences with Text-Based Online Counselling Abstract Online counselling is gaining momentum in the field of social work. The aim of this study was to understand the benefits, challenges and user experiences of a text-based online counselling programme for undergraduate students. Hosted by a social work school in a large, urban university in Canada, the counselling programme trains Master of Social Work (MSW) student counsellors to provide service online as well as offline. Qualitative content analysis was employed to analyse transcripts of 385 e-mail sessions and eighty-five chat exchanges between twenty-two MSW student counsellors and thirty-three undergraduate clients. Analysis identified advantages (increased accessibility, flexibility and immediacy; allowing room for reflections; increased sense of safety) and disadvantages (technical difficulties and increasing ‘work-load’). This study provides evidence of the unique benefits and challenges of online counselling with undergraduate clients and illuminates user experiences that illustrate the uniqueness of online counselling practice. Online counselling, text-based, information and communication technology, undergraduate students, student counsellors Introduction New digital technologies have deeply penetrated contemporary lives. From 1995 to 2014, the internet use among American adults increased from 14 per cent to 87 per cent (Pew Research Center, 2014a). The highest American users of the internet among age groups are aged eighteen to twenty-nine, many of whom access the internet via mobile devices including smartphones and tablets (Pew Research Center, 2014b). The rapid surge in internet-enabled digital technology use has changed how people communicate and attain information, and has provided alternatives to counselling service provision. Online counselling—also known as ‘e-therapy’, ‘cyber-counselling’ and ‘internet-therapy’—has gained strong momentum in recent years. Facilitated by digital technologies, in online counselling, the therapist and the client can interact synchronously using text messages, chat rooms or video conferencing or asynchronously using e-mails or online discussion boards. Evidence concerning the strengths of online counselling has begun to emerge. Studies have found that internet-enabled digital technology promotes access to counselling for those who are in isolated communities and increases flexibility around scheduling (Callahan and Inckle, 2012; Moessner and Bauer, 2012; Russo et al., 2017). Moreover, the online format provides a sense or perception of anonymity and privacy and thus encourages clients to share sensitive information during therapy sessions (Callahan and Inckle, 2012; Dunn, 2012; Moessner and Bauer, 2012; Gleeson et al., 2014). Despite the lack of face-to-face contact, clients who use online counselling, including text-based formats, can enjoy a medium to high quality of therapeutic alliance with their therapists (Sucala et al., 2012; Clarke et al., 2016; Hadjistavropoulos et al., 2017). Studies have also demonstrated the effectiveness of online counselling. For example, a randomised control trial concluded that online therapy is efficacious in decreasing suicidal thoughts among medical students (Slomski, 2015) and another trial showed that e-mail sessions are efficacious in increasing users’ self-confidence (Nieuwboer et al., 2015). Systematic reviews have indicated that online therapy has a similar effect size to that of traditional, face-to-face therapy (Gratzer and Khalid-Khan, 2016), particularly in helping clients with issues such as eating disorders (Schlegl et al., 2015) and depression (Rice et al., 2014), as well as emotional distress related to physical illness (Gratzer and Khalid-Khan, 2016). Counselling services for university students University counselling centres provide critical support to undergraduate students and assist them to maintain well-being. Students can use counselling centres for help with issues ranging from academic pressure, transition to adulthood and relationship problems to more complex mental health problems such as depression, anxiety and addictions (Ibrahim et al., 2013; Goodwin et al., 2014; Villacura et al., 2015). While mental health concerns have been increasingly prevalent among undergraduate students (Ibrahim et al., 2013; Holm-Hadulla and Koutsoukou-Argyraki, 2015; Prince, 2015), many students do not seek any services for these problems due to issues such as the lack of time (Czyz et al., 2013) and stigma (Lally et al., 2013; Pedersen and Paves, 2014). Clearly, there is a need to further engage more students in university counselling services (Harris and Birnbaum, 2015). Rendering counselling services through different delivery formats, such as counselling online, may help to decrease the help-seeking stigma and increase the uptake of counselling services among students. In their Standards for Technology and Social Work Practice, the National Association of Social Workers and Association of Social Work Boards (2005) clearly indicate that ‘[s]ocial workers shall strive to become and remain knowledgeable about the dynamics of online relationships, the advantages and drawbacks of non-face-to-face interactions, and the ways in which technology-based social work practice can be safely and appropriately conducted’ (p. 14). As online counselling continues to grow, more research is needed to further investigate the nuances of online counselling (Callahan and Inckle, 2012; Mishna et al., 2013a). This study aims to contribute the knowledge development of the use of technology, specifically on online counselling, in social work practice and education. Methods The present study and research questions We conducted a qualitative content analysis study with the aim of eliciting user perspectives based on an online counselling programme in a large public university in Canada. The online counselling programme is unique in that the counselling service is provided by Master of Social Work (MSW) student counsellors as part of their internship, while supervised by experienced social workers. Moreover, the service allows clients to combine text-based, asynchronous and synchronous online counselling services with traditional face-to-face counselling. The online counselling programme examined in this study is located in the University of Toronto. The university’s Faculty of Social Work has developed an innovative counselling programme providing both online and offline counselling for undergraduate student clients (Mishna et al., 2013a). Staffed by MSW student counsellors undertaking an eight-month internship from September through April, between four and seven counsellors provide counselling to undergraduate students seeking services. At the beginning of the year, counsellors receive intensive training from a certified clinician who is an expert in online counselling. Throughout the practicum, the counsellors are supervised by experienced social workers. Notably, the counselling service comprises online counselling (i.e. asynchronous e-mail, synchronous chat) and/or traditional face-to-face counselling. The modality undertaken for each client (i.e. face-to-face, online or both) is selected based on the client’s particular needs, availability and preferences. Counsellors provide relatively short-term counselling to clients and maintain a caseload of approximately twenty clients over the course of the academic year. All clients are required to meet with their counsellor for one face-to-face session at the beginning of counselling to complete an intake assessment. In this study, we used the content analysis method (Elo and Kyngäs, 2008) to review and code transcripts of online counselling sessions of this programme collected from 2008 to 2015 with the objective of answering two research questions: (i) What are the features, benefits and challenges of online counselling offered by MSW student counsellors to post-secondary undergraduate clients? (ii) What are the participant user experiences of online counselling? Participants and recruitment This study was approved by the University of Toronto’s Health Sciences Research Ethics Board for the researchers to collect and analyse the e-mail and chat sessions. All counsellors and clients participating in the counselling programme were offered the opportunity to participate in this study. Out of a total of forty-one counsellors and seventy-four clients who engaged in the online counselling service over the 2008–15 academic years, twenty-two counsellors (53.4 per cent) and thirty-three undergraduate clients (44.6 per cent) consented to participate. Clients’ and counsellors’ identities were masked by a randomly assigned ID by an independent research assistant. While clients in our study had the flexibility to combine online and in-person therapy sessions, the face-to-face sessions were not covered by the ethics protocol and therefore were not analysed. The number of online sessions ranged from one to twenty-one sessions per individual client. There were a total of 385 asynchronous e-mail sessions and eighty-five synchronous chat exchanges between counsellors and clients, for a total of 265 chat messages. Asynchronous e-mail sessions included individual e-mails sent between counsellor and client. Complete chats sessions included full synchronous conversations from start to end (comprising a varied number of individual chat sessions). All communications between counsellors and clients occurred through a secure password-protected database specifically designed for online counselling. Due to the level of client openness/interest or the counsellor’s ability to engage clients, the range of counselling sessions and chat sessions was wide, with transcripts varying from one to 250 pages in length. As a result, the content of client–counsellor interaction differed in intensity and depth. Basic background information was collected from both counsellors and clients. Client age ranged from eighteen to forty-five years (M = 23.0 years) and the majority of clients (93.9 per cent) were females. Most clients reported feeling depressed, isolated, stressed and anxiety as the main reasons for seeking counselling services. Counsellors (86.4 per cent females) in the study were aged between twenty-three and sixty-one (M = 30.8) years. They reported some previous experience with face-to-face counselling (M = 1.4 years), but none had prior online counselling experience. Data collection All electronic transcripts were extracted from an encrypted, web-based server. The number of interactions for both chat and e-mail sessions in a single transcript ranged from one to 111, with transcripts ranging from one to 250 pages in length. In all, 880 pages of data were analysed. Each of the transcripts analysed comprised all of the online sessions between a single client–counsellor pair. These therapeutic pairings occasionally occurred entirely through online sessions (excluding the intake assessment), but more commonly online sessions had been led by, followed by and/or were interspersed with face-to-face counselling sessions. Data analysis Prior to analysis, an independent research assistant anonymised all transcripts by removing identifying information (e.g. names, family members, intimate partners) and converted original transcripts to basic file formats to ensure that no information could be traced to participants. Then, two trained doctoral students independently coded the transcripts. The research team that consisted of the study lead researcher and the two trained doctoral students met regularly to review emerging themes and codes, explored any discrepancies and resolved differences by in-depth discussion. Qualitative content analysis (QCA; Elo and Kyngäs, 2008) was undertaken to generate themes related to the research questions. QCA was selected due to its systematic ability to improve understanding of specific phenomenon utilising data that have already been collected—in this case, transcripts of online counselling sessions. QCA emphasises the careful analysis of sensitive written communication and is suitable for analysing textual communications to develop knowledge of lived experiences (Elo and Kyngäs, 2008). Inductive QCA draws inferences and builds theories through a process of cyclical analysis, utilising ongoing analysis of textual data to investigate preliminary themes, categories and patterns generated from the content. In our study, the coders each conducted a cross-group analysis, detecting and coding themes from the text-based interactions between counsellors and clients while identifying repeated themes. Following the review of the data, any text that represented preliminary themes was coded into broad themes and sub-themes. This allowed the research team to establish definitions, name themes and eliminate duplication or redundancy. The themes emerged during analysis of the data. All in-text quotes were extracted from the transcripts without alteration, including spelling. Using authentic citations increases the trustworthiness of the research while not identifying participants (Callahan and Inckle, 2012; Moessner and Bauer, 2012). Results Analysis of e-mail and chat sessions resulted in three overarching themes: (i) distinctive advantages of online counselling, (ii) distinctive challenges of online counselling and (iii) personal experiences of using online counselling. Each overarching theme comprises several sub-themes, supported by direct quotes from the transcripts. We included the following information to contextualise each quote: (i) age of counsellor/age of client, (ii) gender (if disclosed), (iii) chat/e-mail message and (iv) estimated phase of counselling at the time of the response, which includes: beginning of counselling (approximately one or two sessions), midpoint (approximately three or four sessions) and end of counselling (approximately over five sessions). Table 1 also summarises the themes and sub-themes of study findings. Table 1 Text-based online counselling: advantages, disadvantages and user experiences Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Table 1 Text-based online counselling: advantages, disadvantages and user experiences Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Distinctive advantages of online counselling Participants reported several advantages of using the online counselling service, either in conjunction with face-to-face counselling or solely through online sessions. Some of the advantages included accessibility and a sense of anonymity. A number had selected the text-based online counselling programme because they felt uncomfortable with accessing face-to-face services, and they felt requiring an in-person meeting was discomforting. One client wrote: It has always been easier for me to be eloquent and expressive in writing—this is one of the things that drew me to this program over the other counseling services offered by [the University]. I’m not so good in person for some reason (Client, #1108, female, aged twenty-two, e-mail message, beginning of counselling). In fact, some clients were frustrated that an in-person visit was required at the beginning of the therapy. For example, one client stated: Frankly, I was a little disappointed when I got a phone call from you mentioning that we had to meet in person at least once before we started the online therapy. I was hoping to remain totally anonymous even to you, my councillor [sic] (Client, #1414, gender undisclosed, age undisclosed, e-mail message, beginning of counselling). In addition, advantages emerging from the transcripts included flexibility of the online service for clients who were busy with school, work and personal commitments, or struggling with individual challenges or mental health difficulties that would have otherwise made it difficult to participate in counselling. Participants reported an appreciation of the flexibility that online counselling provided, particularly with regard to scheduling or difficulties commuting: I had a really great experience with this … [online] counseling. I liked being able to fit it around my schedule (I don’t think I’d have been able to make it to meetings during test days and essay deadlines!) (Client, #1434, chat, female, aged nineteen, end of counselling). Meeting might be a bit difficult for me since I do work now and I’m moving as of Saturday so I’ll be busy for a while until exams. But chatting through [online counselling] sounds good (Client, #1213, female, aged nineteen, e-mail message, midpoint of counselling). Many clients reported that they appreciated the opportunity to record their feelings immediately, rather than waiting for the next scheduled counselling session. Having the ability to select a point in time when they felt compelled to write an e-mail to their counsellor allowed autonomy and agency in the counselling process. For example, one client wrote: ‘I actually decided to write you right now because I’m sitting in the library having a mini-freak out because of all the work I have, feeling overwhelmed and some stuff with my Mum’ (Client, #1412, female, aged twenty-five, e-mail message, midpoint of counselling). Many clients commented on their appreciation of the journal-like quality of the text-based online format. For some clients, writing was easier for them to express themselves than talking face to face. Several stated that the process of writing down their feelings was very cathartic. Many highlighted this benefit as particularly important to them: I like expressing myself through writing, so that was really helpful (Client, #1434, chat, female, aged nineteen, end of counselling). … [I]t is much easier for me to do this stuff over the computer, just sitting here in my bedroom typing stuff out in whatever order I feel like, taking as much time as I need to, directing the conversation however I want and in whatever order I want. It has always been easier for me to be eloquent and expressive in writing—this is one of the things that drew me to this program over the other counseling services offered by [the University] (Client, #1108, gender undisclosed, aged twenty-two, e-mail message, beginning of counselling). Just to let you know, I’m writing in the state of mind as if this were a journal, one of my entries or night session of thoughts flowing through my subconscious. If something doesn’t make sense that’s okay, just take it for what it is (Client, #1204, gender undisclosed, age undisclosed, e-mail message, midpoint of counselling). Clients also benefitted from the ability to re-read previous sessions for use in subsequent sessions or after participation in the counselling programme had ended. Having the ability to re-read counselling sessions gave some participants an option to reflect on what was discussed during counselling at a later time. For example, one client stated: Over the above dates I kept a journal of re-occurring thoughts. I edited immensely … and thought I could express the main ideas and points by copying and pasting the following into the e-mail (if it’s way too much, we can go over it in the session instead, I have a feeling I wrote too much but I didn’t want to leave out any important stuff) (Client, #1336, female, aged nineteen, e-mail message, beginning of counselling). A final advantage was the ability of counsellors to provide instant resources, online tools and links to clients. Counsellors were able to easily make referrals to community mental health resources by sending information (e.g. phone number, address, website) or simply a link to the community or academic service: Have you considered re-engaging with a psychiatrist or a counselor? I will send you an email with resources that you can review and see if there is a service that might meet your needs (Counsellor, #421, aged thirty-five, e-mail message, end of counselling). Let me know if you need any other information regarding this referral, or if I can help in any way. Otherwise, let me know how it goes (Counsellor, #407, aged twenty-seven, chat message, end of counselling). I’ve inserted a link below … it is a list of meditative and mindfulness-based sessions on campus (free of charge!) that are secular, inclusive, and accessible to all students. I invite you to at least check out the website and see if anything on there sparks an interest. Might be a great way over the next week to practice a little self-care:) (Counsellor, #433, female, aged twenty-nine, e-mail message, midpoint of counselling). Distinctive challenges of online counselling Despite the advantages of online counselling for many of the participating clients, there were also notable challenges to the online format. One of the most prevalent was technical and procedural difficulties for many clients when using the secure online counselling programme. Some of these technical challenges included participants struggling to negotiate the online experience and difficulties managing administrative issues (e.g. login issues, lost e-mails). In some cases, online sessions were cut short (e.g. loss of internet signal, clients logging off before end of sessions). Several student participants highlighted that the process of remembering their password, learning how to use new software and signing in was frustrating. For example, one client wrote: I promised to write back to you on Saturday, which I thought I did, only I hit the wrong button and saved a draft instead of sending out the email! It seems like technical difficulties keep happening to me when I try to write to you :) (Client, #1446, female, aged twenty-seven, e-mail message, midpoint of counselling). Another challenge was general resistance, frustration, or discomfort with text-based online counselling, including the online format and process. For some clients, writing down their responses felt like significant work (in a context where most were already overburdened by schoolwork) and many found the nuances of the online procedure complex and confusing early in the process. Several clients stated that it was difficult to draft an e-mail to their counsellor because they did not know how to begin or they did not understand the parameters of the e-mails. A few clients indicated that it was challenging to devote time to writing an e-mail, as compared to attending an appointment: I guess after reading through this again, once you sent it back to me, I felt a little frustrated with myself. I think it is difficult for me within this email format, to actually reflect on what I am saying, even if I revise it. It seems to require a lot more effort than a session in person (Client, #1105, female, aged thirty, e-mail message, midpoint of counselling). A large part of me says, ‘I don’t want to write to Counselor, maybe I’ll just send her a short email saying that I am too busy this weekend.’ I am annoyed and resistant toward completing this ‘assignment’. Perhaps those feelings are reflective of how I see this … [online] counseling: work. I have to admit after going through the housekeeping message this morning when I first attempted to write, I was overwhelmed by how complicated and serious this online session is. I guess the sense of ‘work’ is derived from feeling obliged to obey the ‘rules’ of … [online] counseling. Now, as I type, I am realizing that perhaps I was over reacting to the ‘rules’. After all, they are merely suggestions served to enhance my experience in … [online] counseling. (haha..) (Client, #1102, female, aged twenty-three, e-mail message, beginning of counselling). Personal experiences of using online counselling The majority of the clients reported satisfaction with the overall online counselling services, and both counsellors and clients noted that the online format had offered insights and opportunities that their face-to-face sessions had not. Several clients expressed their appreciation for their counsellor towards the end of counselling during the termination period. Clients stated that they were able to ‘open up’, experienced a sense of relief, and felt that they could better understand their issues and had become more self-aware after online counselling. For example, one client stated: [Since counselling] I’ve also tried to be a little less anti-social (I noticed it made me very cynical and unhappy about others. I think I was maybe just projecting my own discontent about myself onto others). I’ve been a little more open; trying to talk (or at least hang out) with new people in social gatherings, and talking to people in class. It is nice to know I can get along with people! (Client, #436, female, aged twenty-five, e-mail message, end of counselling). The distant quality of online counselling also created some sense of security in discussing challenging issues, and helped many clients to address their personal discomfort with accessing counselling and other similar services, such as feeling guilty about talking about one’s own issues. For example, one client wrote: I feel so far that these sessions are helping me to understand myself better. That has always been my goal in life, self-understanding, personal happiness. I would like a better understanding of what is coming in the way of these things these days. I’m fairly good at assessing myself and being self-critical, but lately I have been prone to a negative bias I signed up for the … [online] counseling because I was feeling very low for a long time and I wanted to talk about it with someone without feeling guilty that I was wasting their time (Client, #1105, female, aged thirty, e-mail message, end of counselling). Clients appreciated counsellors’ support, and overall expressed satisfaction with the programme and their participation in it. Most clients were positive about their online counselling experiences and many indicated they felt supported by their counsellor throughout the online counselling process. For example, some clients stated: Just want to say how much these sessions meant to me and how much they’ve helped … Thank you Counselor for everything … and most of all thanks for being so supportive these last few weeks with everything going on. I have had an amazing time sharing my experiences with you (Client, #1336, female, aged nineteen, chat message, end of counselling). I’m feeling better about myself in this regard—I can recognise that everyone gets these feelings to some extent, and that if I want to help ease these feelings, there are healthy ways to gain more self-esteem. Also, the article you gave me to read about social anxiety gave me a new perspective on how to deal with feeling of inadequacy that I might get when interacting with others—that it is too much of a focus on the self to always be thinking ‘what do others think of me?’ Other people’s attention is not totally focussed on me and my perceived faults at any moment, and it’s ok to make mistakes (Client, #1650, male, aged twenty, end of counselling). Discussion As the majority of contemporary university students have grown up with internet-enabled digital and mobile technologies, online counselling has the potential to meet their needs and communication preferences. Based on a comprehensive analysis of session transcripts collected in an innovative, university-based online counselling programme, this study identified the characteristics, benefits and challenges of a text-based online counselling service. Study findings provide insight for practitioners from social work or other disciplines to better understand online counselling, as well as the experiences of undergraduate clients. Study findings show that the sense of inhibition and anonymity offered by text-based online counselling was what motivated some clients to seek online counselling in the first place. In addition, several clients stated that the flexible, accessible and immediate nature of online counselling was helpful. Students appreciated having the autonomy to select a point in time when they felt compelled to write an e-mail to their counsellor. Some clients reported that the ease of online counselling made the process appear less constrained than face-to-face counselling, especially with regard to setting and keeping appointments, and travelling to sessions. These findings are supported by findings identified in previous research (Richards and Viganó, 2013). Our study demonstrates that counsellors can take advantage of the internet medium to share resources and psycho-educational information with their clients, conduct assessments and make referrals to other services. Consistently with the limited number of existing studies, a central beneficial quality of text-based online counselling is a journal-like or storytelling quality (Richards and Viganó, 2013). Scholars have noted the therapeutic benefits of journaling in the treatment of psychologically distressed clients (Miller, 2014). Our findings similarly suggest that clients appreciated the opportunity to reflect on their feelings and thoughts, both writing them down in the moment and reviewing these narratives later. Despite the rapid development of computer technology and the ease of online counselling (Harrad and Banks, 2016), the administrative and technological challenges experienced by clients in our study suggest that user-friendly technology interference continues to be a practical concern when implementing an online programme. In addition, it is critical to note that, while online counselling can be a viable option for service provision, it may not be suitable for all. In our study, some clients became apprehensive towards the online counselling service and resisted the required procedures such as writing back to their counsellor. Implications for practice and education The study documents the experiences of counsellors and clients of a university online counselling programme. Study results underscore that online counselling offered by MSW students holds promise and can be a viable option for undergraduate students who seek psychological support. Online counselling can provide a sense of safety to those who find traditional face-to-face counselling intimidating, and allow increased accessibility and flexibility. As the vast majority of university students today are members of the millennial generation who grew up with virtually ubiquitous internet-enabled digital technologies (McHaney, 2012; Roseberry-McKibbin et al., 2016), university counselling centres should consider incorporating online counselling in their service provision. In addition to the face-to-face counselling sessions, universities may consider different types of services to maximise the reach and relevance of their counselling services. Furthermore, our online counselling service is text-based, using chat messages and e-mails as intervention mediums. While some participants appreciate the cathartic and therapeutic effects of writing, enjoying the sense of privacy, others expressed frustrations and felt burdened by writing. This highlights the needs for different modes of online therapies. While text-based services are appealing to some clients, providers can also consider other delivery mediums, such as web-conferencing that allows both instantaneous audio and video. Lastly, regardless of the medium utilised for delivery, providers who are interested in providing counselling through online platforms require proper training. There continue to be limited training and educational opportunities, however, that prepare social work students to meet this growing demand (Mishna et al., 2013b). Social work educators can support and educate social work practitioners by introducing online counselling into the curriculum, classrooms and practicum settings. This may include courses, workshops and/or seminars that focus on integrating the use of information and communication technologies into practice (Chan and Holosko, 2015). Formal online counselling training, direct practicum experiences and specialised online counselling courses can further strengthen student preparedness of online clinical practice, providing skills and intervention techniques to better address a variety presenting problems such as depression, anxiety and stress online (Mishna et al., 2013a). Educational opportunities provided through interactive e-learning platforms such as chat rooms, live webinars, online learning or supervision forums can help to immerse students for the emerging online practice environment (Anthony, 2015; Goldingay and Boddy, 2017) while allowing them to build awareness concerning pivotal ethical, privacy and boundaries issues (Fantus and Mishna, 2013; Dombo et al., 2014; Fang et al., 2014; Reamer, 2015). These experiences and learning gained by students can be translated into future practice (Cooner, 2014). Limitations The study has several limitations. First, we were confined by the available content in the transcripts and could not seek clarifications or elaborations from counsellors and clients who participated in the study. Second, the experiences we learned about from the counsellors and clients are limited to text-based online counselling practice in a university setting. The study results cannot be generalised to counselling practice that uses web-conferencing technology where users and clients can see and speak to each other, and online counselling practice that takes place in other settings or with different populations. Lastly, study data emphasised the counselling experience of clients with less focus on the counsellor’s personal and professional experience with online counselling other than sharing resources, limiting the counsellor’s perspective of online counselling and the therapeutic relationship. Conclusion Advancements in technology have augmented the development of online counselling. Although social work scholarship has begun to document the potential benefits of online counselling in direct practice literature (Eamon et al., 2013; Mishna et al., 2015) and disseminating information and services (Nah and Saxton, 2013; Svensson et al., 2015), very few social work schools provide specific training to students and equip them with the knowledge and skills needed to deliver counselling service online (Mishna et al., 2013a). Based on a university-based online counselling service rendered by MSW student interns, this study informs social work education and practice, as well as contributes to the nascent scholarship on online counselling and provides evidence on the unique benefits and challenges of online counselling with undergraduate clients and illuminates the uniqueness of online counselling practice. With the continued growth of mobile technologies and the increasing demand for flexible counselling modalities, we anticipate that more online counselling practices will be developed with different clienteles. As therapeutic modalities continue to diversify and advance, there is a need to further understand the experiences of clients who are engaged with online counselling. Future social work studies should continue to unpack the client experiences, understand gender-specific perspectives and assess the long-term effects of different types of online counselling practices. Such knowledge will not only increase the knowledge base of online counselling, but also help to enhance clinical competencies of social workers in the digital era. Acknowledgements We acknowledge the support of the University of Toronto Health and Wellness and Faculty of Arts and Science Undergraduate Colleges of St George Campus as well as the support of Professor Marion Bogo and Lawrence Murphy. References Anthony K. ( 2015 ) ‘Training therapists to work effectively online and offline within digital culture’ , British Journal of Guidance & Counselling , 43 ( 1 ), pp. 36 – 42 . Google Scholar CrossRef Search ADS Callahan A. , Inckle K. ( 2012 ) ‘ Cybertherapy or psychobabble? A mixed methods study of online emotional support’, British Journal of Guidance & Counselling , 40 ( 3 ), pp. 261 – 78 . Google Scholar CrossRef Search ADS Chan C. , Holosko M. J. ( 2015 ) ‘ A Review of Information and Communication Technology Enhanced Social Work Interventions ’, Research on Social Work Practice , 26 ( 1 ), 88 – 100 . Google Scholar CrossRef Search ADS Clarke J. , Proudfoot J. , Whitton A. , Birch M.-R. , Boyd M. , Parker G. , Manicavasagar V. , Hadzi-Pavlovic D. , Fogarty A. ( 2016 ) ‘ Therapeutic alliance with a fully automated mobile phone and web-based intervention: Secondary analysis of a randomized controlled trial’, JMIR Mental Health , 3 ( 1 ), p. e10 . Google Scholar CrossRef Search ADS PubMed Cooner T. S. ( 2014 ) ‘ Using Facebook to explore boundary issues for social workers in a networked society: Students’ perceptions of learning’, British Journal of Social Work , 44 ( 4 ), pp. 1063 – 80 . Google Scholar CrossRef Search ADS Czyz E. K. , Horwitz A. G. , Eisenberg D. , Kramer A. , King C. A. ( 2013 ) ‘ Self-reported barriers to professional help seeking among college students at elevated risk for suicide’, Journal of American College Health , 61 ( 7 ), pp. 398 – 406 . Google Scholar CrossRef Search ADS PubMed Dombo E. A. , Kays L. , Weller K. ( 2014 ) ‘ Clinical social work practice and technology: Personal, practical, regulatory, and ethical considerations for the twenty-first century’, Social Work in Health Care , 53 ( 9 ), pp. 900 – 19 . Google Scholar CrossRef Search ADS PubMed Dunn K. ( 2012 ) ‘ A qualitative investigation into the online counselling relationship: To meet or not to meet, that is the question’, Counselling and Psychotherapy Research , 12 ( 4 ), pp. 316 – 26 . Google Scholar CrossRef Search ADS Eamon M. K. , Wu C.-F. , Moroney G. , Cundari M. ( 2013 ) ‘ Teaching the importance and use of web-based services to assist clients in obtaining public benefits’, Journal of Teaching in Social Work , 33 ( 2 ), pp. 143 – 58 . Google Scholar CrossRef Search ADS Elo S. , Kyngäs H. ( 2008 ) ‘ The qualitative content analysis process’, Journal of Advanced Nursing , 62 ( 1 ), pp. 107 – 15 . Google Scholar CrossRef Search ADS PubMed Fang L. , Mishna F. , Zhang V. F. , Van Wert M. , Bogo M. ( 2014 ) ‘ Social media and social work education: Understanding and dealing with the new digital world’, Social Work in Health Care , 53 ( 9 ), pp. 800 – 14 . Google Scholar CrossRef Search ADS PubMed Fantus S. , Mishna F. ( 2013 ) ‘ The ethical and clinical implications of utilizing cybercommunication in face-to-face therapy’, Smith College Studies in Social Work , 83 ( 4 ), pp. 466 – 80 . Google Scholar CrossRef Search ADS Gleeson J. F. , Lederman R. , Wadley G. , Bendall S. , McGorry P. D. , Alvarez-Jimenez M. ( 2014 ) ‘ Safety and privacy outcomes from a moderated online social therapy for young people with first-episode psychosis’, Psychiatric Services , 65 ( 4 ), pp. 546 – 50 . Google Scholar CrossRef Search ADS PubMed Goldingay S. , Boddy J. ( 2017 ) ‘ Preparing social work graduates for digital practice: Ethical pedagogies for effective learning’, Australian Social Work , 70 ( 2 ), pp. 209 – 20 . Google Scholar CrossRef Search ADS Goodwin R. D. , Grinberg A. , Shapiro J. , Keith D. , McNeil M. P. , Taha F. , Jiang B. , Hart C. L. ( 2014 ) ‘ Hookah use among college students: Prevalence, drug use, and mental health’, Drug and Alcohol Dependence , 141 , pp. 16 – 20 . Google Scholar CrossRef Search ADS PubMed Gratzer D. , Khalid-Khan F. ( 2016 ) ‘ Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness’, Canadian Medical Association Journal , 188 ( 4 ), pp. 263 – 72 . Google Scholar CrossRef Search ADS PubMed Hadjistavropoulos H. D. , Pugh N. E. , Hesser H. , Andersson G. ( 2017 ) ‘ Therapeutic alliance in internet-delivered cognitive behaviour therapy for depression or generalized anxiety’, Clinical Psychology & Psychotherapy , 24 ( 2 ), pp. 451 – 61 . Google Scholar CrossRef Search ADS PubMed Harrad R. , Banks N. ( 2016 ) ‘Counselling in online environments’, in Attrill A. , Fullwood C. (eds), Applied Cyberpsychology: Practical Applications of Cyberpsychological Theory and Research , London , Palgrave Macmillan UK . Harris B. , Birnbaum R. ( 2015 ) ‘ Ethical and legal implications on the use of technology in counselling’, Clinical Social Work Journal , 43 ( 2 ), pp. 133 – 41 . Google Scholar CrossRef Search ADS Holm-Hadulla R. M. , Koutsoukou-Argyraki A. ( 2015 ) ‘ Mental health of students in a globalized world: Prevalence of complaints and disorders, methods and effectivity of counseling, structure of mental health services for students’, Mental Health & Prevention , 3 ( 1–2 ), pp. 1 – 4 . Google Scholar CrossRef Search ADS Ibrahim A. K. , Kelly S. J. , Adams C. E. , Glazebrook C. ( 2013 ) ‘ A systematic review of studies of depression prevalence in university students’ , Journal of Psychiatric Research , 47 ( 3 ), pp. 391 – 400 . Google Scholar CrossRef Search ADS PubMed Lally J. , ó Conghaile A. , Quigley S. , Bainbridge E. , McDonald C. ( 2013 ) ‘Stigma of mental illness and help-seeking intention in university students’ , The Psychiatrist , 37 ( 8 ), pp. 253 – 60 . Google Scholar CrossRef Search ADS McHaney R. ( 2012 ) The New Digital Shoreline: How Web 2.0 and Millennials Are Revolutionizing Higher Education, Sterling, Virginia, Stylus Publishing, LLC. Miller W. ( 2014 ) ‘ Interactive journaling as a clinical tool’ , Journal of Mental Health Counseling , 36 ( 1 ), pp. 31 – 42 . Google Scholar CrossRef Search ADS Mishna F. , Levine D. , Bogo M. , Van Wert M. ( 2013a ) ‘Cyber counselling: An innovative field education pilot project’ , Social Work Education , 32 ( 4 ), pp. 484 – 92 . Google Scholar CrossRef Search ADS Mishna F. , Tufford L. , Cook C. , Bogo M. ( 2013b ) ‘Research note—a pilot cyber counseling course in a graduate social work program’ , Journal of Social Work Education , 49 ( 3 ), pp. 515 – 24 . Mishna F. , Bogo M. , Sawyer J.-L. ( 2015 ) ‘Cyber counseling: Illuminating benefits and challenges’ , Clinical Social Work Journal , 43 ( 2 ), pp. 169 – 78 . Google Scholar CrossRef Search ADS Moessner M. , Bauer S. ( 2012 ) ‘ Online counselling for eating disorders: Reaching an underserved population?’, Journal of Mental Health , 21 ( 4 ), pp. 336 – 45 . Google Scholar CrossRef Search ADS PubMed Nah S. , Saxton G. D. ( 2013 ) ‘Modeling the adoption and use of social media by nonprofit organizations’ , New Media & Society , 15 ( 2 ), pp. 294 – 313 . Google Scholar CrossRef Search ADS National Association of Social Workers and Association of Social Work Boards ( 2005 ) Standards for Technology and Social Work Practice, Washington, DC, Author. Nieuwboer C. C. , Fukkink R. G. , Hermanns J. M. A. ( 2015 ) ‘Single session email consultation for parents: An evaluation of its effect on empowerment’ , British Journal of Guidance & Counselling , 43 ( 1 ), pp. 131 – 43 . Google Scholar CrossRef Search ADS Pedersen E. R. , Paves A. P. ( 2014 ) ‘ Comparing perceived public stigma and personal stigma of mental health treatment seeking in a young adult sample’ , Psychiatry Research , 219 ( 1 ), pp. 143 – 50 . Google Scholar CrossRef Search ADS PubMed Pew Research Center ( 2014a ) Internet Use Over Time , Pew Internet & American Life Project , Washington, DC , Author. Pew Research Center ( 2014b ) Internet User Demographics , Pew Internet & American Life Project , Washington, DC , Author. Prince J. P. ( 2015 ) ‘University student counseling and mental health in the United States: Trends and challenges’ , Mental Health & Prevention , 3 ( 1–2 ), pp. 5 – 10 . Google Scholar CrossRef Search ADS Reamer F. G. ( 2015 ) ‘ Clinical social work in a digital environment: Ethical and risk-management challenges’, Clinical Social Work Journal , 43 ( 2 ), pp. 120 – 32 . Google Scholar CrossRef Search ADS Rice M. S. , Goodall J. , Hetrick E. S. , Parker G. A. , Gilbertson T. , Amminger P. G. , Davey G. C. , McGorry D. P. , Gleeson J. , Alvarez-Jimenez M. ( 2014 ) ‘ Online and social networking interventions for the treatment of depression in young people: A systematic review’, Journal of Medical Internet Research , 16 ( 9 ), p. e206 . Google Scholar CrossRef Search ADS PubMed Richards D. , Viganó N. ( 2013 ) ‘ Online counseling: A narrative and critical review of the literature’, Journal of Clinical Psychology , 69 ( 9 ), pp. 994 – 1011 . Google Scholar CrossRef Search ADS PubMed Roseberry-McKibbin C. , Pieretti R. , Haberstock K. , Estrada J. ( 2016 ) ‘ Effective pedagogical strategies for millennial university students in communication sciences and disorders’, Communication Disorders Quarterly , 37 ( 3 ), pp. 180 – 3 . Google Scholar CrossRef Search ADS Russo J. V. , Bruce M. A. , Scull R. ( 2017 ) ‘Click here for mental health support: Extending mental health services to the isolated learner’ , Recruiting & Retaining Adult Learners , 19 ( 4 ), pp. 1 – 7 . Google Scholar CrossRef Search ADS Schlegl S. , Bürger C. , Schmidt L. , Herbst N. , Voderholzer U. ( 2015 ) ‘ The potential of technology-based psychological interventions for anorexia and bulimia nervosa: A systematic review and recommendations for future research’, Journal of Medical Internet Research , 17 ( 3 ), p. e85 . Google Scholar CrossRef Search ADS PubMed Slomski A. ( 2015 ) ‘ Online therapy reduces suicide ideation in medical interns’, JAMA , 314 ( 24 ), p. 2608 . Sucala M. , Schnur J. B. , Constantino M. J. , Miller S. J. , Brackman E. H. , Montgomery G. H. ( 2012 ) ‘ The therapeutic relationship in e-therapy for mental health: A systematic review’ , Journal of Medical Internet Research , 14 ( 4 ), p. e110 . Google Scholar CrossRef Search ADS PubMed Svensson P. G. , Mahoney T. Q. , Hambrick M. E. ( 2015 ) ‘ Twitter as a communication tool for nonprofits: A study of sport-for-development organizations’ , Nonprofit and Voluntary Sector Quarterly , 44 ( 6 ), pp. 1086 – 1106 . Google Scholar CrossRef Search ADS Villacura L. , Irarrázabal N. , Dörr A. , Zamorano C. , Manosalva J. , Cánovas C. , Zamorano M. , Barra N. ( 2015 ) ‘ Mental disorders of students at the University of Chile’ , Mental Health & Prevention , 3 ( 1–2 ), pp. 21 – 5 . Google Scholar CrossRef Search ADS © The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

Undergraduate Student Experiences with Text-Based Online Counselling

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
ISSN
0045-3102
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1468-263X
D.O.I.
10.1093/bjsw/bcx111
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Abstract

Abstract Online counselling is gaining momentum in the field of social work. The aim of this study was to understand the benefits, challenges and user experiences of a text-based online counselling programme for undergraduate students. Hosted by a social work school in a large, urban university in Canada, the counselling programme trains Master of Social Work (MSW) student counsellors to provide service online as well as offline. Qualitative content analysis was employed to analyse transcripts of 385 e-mail sessions and eighty-five chat exchanges between twenty-two MSW student counsellors and thirty-three undergraduate clients. Analysis identified advantages (increased accessibility, flexibility and immediacy; allowing room for reflections; increased sense of safety) and disadvantages (technical difficulties and increasing ‘work-load’). This study provides evidence of the unique benefits and challenges of online counselling with undergraduate clients and illuminates user experiences that illustrate the uniqueness of online counselling practice. Online counselling, text-based, information and communication technology, undergraduate students, student counsellors Introduction New digital technologies have deeply penetrated contemporary lives. From 1995 to 2014, the internet use among American adults increased from 14 per cent to 87 per cent (Pew Research Center, 2014a). The highest American users of the internet among age groups are aged eighteen to twenty-nine, many of whom access the internet via mobile devices including smartphones and tablets (Pew Research Center, 2014b). The rapid surge in internet-enabled digital technology use has changed how people communicate and attain information, and has provided alternatives to counselling service provision. Online counselling—also known as ‘e-therapy’, ‘cyber-counselling’ and ‘internet-therapy’—has gained strong momentum in recent years. Facilitated by digital technologies, in online counselling, the therapist and the client can interact synchronously using text messages, chat rooms or video conferencing or asynchronously using e-mails or online discussion boards. Evidence concerning the strengths of online counselling has begun to emerge. Studies have found that internet-enabled digital technology promotes access to counselling for those who are in isolated communities and increases flexibility around scheduling (Callahan and Inckle, 2012; Moessner and Bauer, 2012; Russo et al., 2017). Moreover, the online format provides a sense or perception of anonymity and privacy and thus encourages clients to share sensitive information during therapy sessions (Callahan and Inckle, 2012; Dunn, 2012; Moessner and Bauer, 2012; Gleeson et al., 2014). Despite the lack of face-to-face contact, clients who use online counselling, including text-based formats, can enjoy a medium to high quality of therapeutic alliance with their therapists (Sucala et al., 2012; Clarke et al., 2016; Hadjistavropoulos et al., 2017). Studies have also demonstrated the effectiveness of online counselling. For example, a randomised control trial concluded that online therapy is efficacious in decreasing suicidal thoughts among medical students (Slomski, 2015) and another trial showed that e-mail sessions are efficacious in increasing users’ self-confidence (Nieuwboer et al., 2015). Systematic reviews have indicated that online therapy has a similar effect size to that of traditional, face-to-face therapy (Gratzer and Khalid-Khan, 2016), particularly in helping clients with issues such as eating disorders (Schlegl et al., 2015) and depression (Rice et al., 2014), as well as emotional distress related to physical illness (Gratzer and Khalid-Khan, 2016). Counselling services for university students University counselling centres provide critical support to undergraduate students and assist them to maintain well-being. Students can use counselling centres for help with issues ranging from academic pressure, transition to adulthood and relationship problems to more complex mental health problems such as depression, anxiety and addictions (Ibrahim et al., 2013; Goodwin et al., 2014; Villacura et al., 2015). While mental health concerns have been increasingly prevalent among undergraduate students (Ibrahim et al., 2013; Holm-Hadulla and Koutsoukou-Argyraki, 2015; Prince, 2015), many students do not seek any services for these problems due to issues such as the lack of time (Czyz et al., 2013) and stigma (Lally et al., 2013; Pedersen and Paves, 2014). Clearly, there is a need to further engage more students in university counselling services (Harris and Birnbaum, 2015). Rendering counselling services through different delivery formats, such as counselling online, may help to decrease the help-seeking stigma and increase the uptake of counselling services among students. In their Standards for Technology and Social Work Practice, the National Association of Social Workers and Association of Social Work Boards (2005) clearly indicate that ‘[s]ocial workers shall strive to become and remain knowledgeable about the dynamics of online relationships, the advantages and drawbacks of non-face-to-face interactions, and the ways in which technology-based social work practice can be safely and appropriately conducted’ (p. 14). As online counselling continues to grow, more research is needed to further investigate the nuances of online counselling (Callahan and Inckle, 2012; Mishna et al., 2013a). This study aims to contribute the knowledge development of the use of technology, specifically on online counselling, in social work practice and education. Methods The present study and research questions We conducted a qualitative content analysis study with the aim of eliciting user perspectives based on an online counselling programme in a large public university in Canada. The online counselling programme is unique in that the counselling service is provided by Master of Social Work (MSW) student counsellors as part of their internship, while supervised by experienced social workers. Moreover, the service allows clients to combine text-based, asynchronous and synchronous online counselling services with traditional face-to-face counselling. The online counselling programme examined in this study is located in the University of Toronto. The university’s Faculty of Social Work has developed an innovative counselling programme providing both online and offline counselling for undergraduate student clients (Mishna et al., 2013a). Staffed by MSW student counsellors undertaking an eight-month internship from September through April, between four and seven counsellors provide counselling to undergraduate students seeking services. At the beginning of the year, counsellors receive intensive training from a certified clinician who is an expert in online counselling. Throughout the practicum, the counsellors are supervised by experienced social workers. Notably, the counselling service comprises online counselling (i.e. asynchronous e-mail, synchronous chat) and/or traditional face-to-face counselling. The modality undertaken for each client (i.e. face-to-face, online or both) is selected based on the client’s particular needs, availability and preferences. Counsellors provide relatively short-term counselling to clients and maintain a caseload of approximately twenty clients over the course of the academic year. All clients are required to meet with their counsellor for one face-to-face session at the beginning of counselling to complete an intake assessment. In this study, we used the content analysis method (Elo and Kyngäs, 2008) to review and code transcripts of online counselling sessions of this programme collected from 2008 to 2015 with the objective of answering two research questions: (i) What are the features, benefits and challenges of online counselling offered by MSW student counsellors to post-secondary undergraduate clients? (ii) What are the participant user experiences of online counselling? Participants and recruitment This study was approved by the University of Toronto’s Health Sciences Research Ethics Board for the researchers to collect and analyse the e-mail and chat sessions. All counsellors and clients participating in the counselling programme were offered the opportunity to participate in this study. Out of a total of forty-one counsellors and seventy-four clients who engaged in the online counselling service over the 2008–15 academic years, twenty-two counsellors (53.4 per cent) and thirty-three undergraduate clients (44.6 per cent) consented to participate. Clients’ and counsellors’ identities were masked by a randomly assigned ID by an independent research assistant. While clients in our study had the flexibility to combine online and in-person therapy sessions, the face-to-face sessions were not covered by the ethics protocol and therefore were not analysed. The number of online sessions ranged from one to twenty-one sessions per individual client. There were a total of 385 asynchronous e-mail sessions and eighty-five synchronous chat exchanges between counsellors and clients, for a total of 265 chat messages. Asynchronous e-mail sessions included individual e-mails sent between counsellor and client. Complete chats sessions included full synchronous conversations from start to end (comprising a varied number of individual chat sessions). All communications between counsellors and clients occurred through a secure password-protected database specifically designed for online counselling. Due to the level of client openness/interest or the counsellor’s ability to engage clients, the range of counselling sessions and chat sessions was wide, with transcripts varying from one to 250 pages in length. As a result, the content of client–counsellor interaction differed in intensity and depth. Basic background information was collected from both counsellors and clients. Client age ranged from eighteen to forty-five years (M = 23.0 years) and the majority of clients (93.9 per cent) were females. Most clients reported feeling depressed, isolated, stressed and anxiety as the main reasons for seeking counselling services. Counsellors (86.4 per cent females) in the study were aged between twenty-three and sixty-one (M = 30.8) years. They reported some previous experience with face-to-face counselling (M = 1.4 years), but none had prior online counselling experience. Data collection All electronic transcripts were extracted from an encrypted, web-based server. The number of interactions for both chat and e-mail sessions in a single transcript ranged from one to 111, with transcripts ranging from one to 250 pages in length. In all, 880 pages of data were analysed. Each of the transcripts analysed comprised all of the online sessions between a single client–counsellor pair. These therapeutic pairings occasionally occurred entirely through online sessions (excluding the intake assessment), but more commonly online sessions had been led by, followed by and/or were interspersed with face-to-face counselling sessions. Data analysis Prior to analysis, an independent research assistant anonymised all transcripts by removing identifying information (e.g. names, family members, intimate partners) and converted original transcripts to basic file formats to ensure that no information could be traced to participants. Then, two trained doctoral students independently coded the transcripts. The research team that consisted of the study lead researcher and the two trained doctoral students met regularly to review emerging themes and codes, explored any discrepancies and resolved differences by in-depth discussion. Qualitative content analysis (QCA; Elo and Kyngäs, 2008) was undertaken to generate themes related to the research questions. QCA was selected due to its systematic ability to improve understanding of specific phenomenon utilising data that have already been collected—in this case, transcripts of online counselling sessions. QCA emphasises the careful analysis of sensitive written communication and is suitable for analysing textual communications to develop knowledge of lived experiences (Elo and Kyngäs, 2008). Inductive QCA draws inferences and builds theories through a process of cyclical analysis, utilising ongoing analysis of textual data to investigate preliminary themes, categories and patterns generated from the content. In our study, the coders each conducted a cross-group analysis, detecting and coding themes from the text-based interactions between counsellors and clients while identifying repeated themes. Following the review of the data, any text that represented preliminary themes was coded into broad themes and sub-themes. This allowed the research team to establish definitions, name themes and eliminate duplication or redundancy. The themes emerged during analysis of the data. All in-text quotes were extracted from the transcripts without alteration, including spelling. Using authentic citations increases the trustworthiness of the research while not identifying participants (Callahan and Inckle, 2012; Moessner and Bauer, 2012). Results Analysis of e-mail and chat sessions resulted in three overarching themes: (i) distinctive advantages of online counselling, (ii) distinctive challenges of online counselling and (iii) personal experiences of using online counselling. Each overarching theme comprises several sub-themes, supported by direct quotes from the transcripts. We included the following information to contextualise each quote: (i) age of counsellor/age of client, (ii) gender (if disclosed), (iii) chat/e-mail message and (iv) estimated phase of counselling at the time of the response, which includes: beginning of counselling (approximately one or two sessions), midpoint (approximately three or four sessions) and end of counselling (approximately over five sessions). Table 1 also summarises the themes and sub-themes of study findings. Table 1 Text-based online counselling: advantages, disadvantages and user experiences Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Table 1 Text-based online counselling: advantages, disadvantages and user experiences Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Theme 1: Advantages of online counselling Accessibility A sense of anonymity Flexibility Immediacy Journal-like quality Ability to re-visit previous text counselling sessions Ability to provide instant resources, online tools and links to clients Theme 2: Disadvantages of online counselling Technical and procedural difficulties General resistance, frustration, or discomfort with the text-based features and requirements Theme 3: User experiences An overall satisfaction with the text-based online counselling services: The opportunities and insights that are not presented in face-to-face sessions The ability to engage clients who resist face-to-face counselling due to personal discomfort The ability to facilitate therapeutic alliance and support through the online format Distinctive advantages of online counselling Participants reported several advantages of using the online counselling service, either in conjunction with face-to-face counselling or solely through online sessions. Some of the advantages included accessibility and a sense of anonymity. A number had selected the text-based online counselling programme because they felt uncomfortable with accessing face-to-face services, and they felt requiring an in-person meeting was discomforting. One client wrote: It has always been easier for me to be eloquent and expressive in writing—this is one of the things that drew me to this program over the other counseling services offered by [the University]. I’m not so good in person for some reason (Client, #1108, female, aged twenty-two, e-mail message, beginning of counselling). In fact, some clients were frustrated that an in-person visit was required at the beginning of the therapy. For example, one client stated: Frankly, I was a little disappointed when I got a phone call from you mentioning that we had to meet in person at least once before we started the online therapy. I was hoping to remain totally anonymous even to you, my councillor [sic] (Client, #1414, gender undisclosed, age undisclosed, e-mail message, beginning of counselling). In addition, advantages emerging from the transcripts included flexibility of the online service for clients who were busy with school, work and personal commitments, or struggling with individual challenges or mental health difficulties that would have otherwise made it difficult to participate in counselling. Participants reported an appreciation of the flexibility that online counselling provided, particularly with regard to scheduling or difficulties commuting: I had a really great experience with this … [online] counseling. I liked being able to fit it around my schedule (I don’t think I’d have been able to make it to meetings during test days and essay deadlines!) (Client, #1434, chat, female, aged nineteen, end of counselling). Meeting might be a bit difficult for me since I do work now and I’m moving as of Saturday so I’ll be busy for a while until exams. But chatting through [online counselling] sounds good (Client, #1213, female, aged nineteen, e-mail message, midpoint of counselling). Many clients reported that they appreciated the opportunity to record their feelings immediately, rather than waiting for the next scheduled counselling session. Having the ability to select a point in time when they felt compelled to write an e-mail to their counsellor allowed autonomy and agency in the counselling process. For example, one client wrote: ‘I actually decided to write you right now because I’m sitting in the library having a mini-freak out because of all the work I have, feeling overwhelmed and some stuff with my Mum’ (Client, #1412, female, aged twenty-five, e-mail message, midpoint of counselling). Many clients commented on their appreciation of the journal-like quality of the text-based online format. For some clients, writing was easier for them to express themselves than talking face to face. Several stated that the process of writing down their feelings was very cathartic. Many highlighted this benefit as particularly important to them: I like expressing myself through writing, so that was really helpful (Client, #1434, chat, female, aged nineteen, end of counselling). … [I]t is much easier for me to do this stuff over the computer, just sitting here in my bedroom typing stuff out in whatever order I feel like, taking as much time as I need to, directing the conversation however I want and in whatever order I want. It has always been easier for me to be eloquent and expressive in writing—this is one of the things that drew me to this program over the other counseling services offered by [the University] (Client, #1108, gender undisclosed, aged twenty-two, e-mail message, beginning of counselling). Just to let you know, I’m writing in the state of mind as if this were a journal, one of my entries or night session of thoughts flowing through my subconscious. If something doesn’t make sense that’s okay, just take it for what it is (Client, #1204, gender undisclosed, age undisclosed, e-mail message, midpoint of counselling). Clients also benefitted from the ability to re-read previous sessions for use in subsequent sessions or after participation in the counselling programme had ended. Having the ability to re-read counselling sessions gave some participants an option to reflect on what was discussed during counselling at a later time. For example, one client stated: Over the above dates I kept a journal of re-occurring thoughts. I edited immensely … and thought I could express the main ideas and points by copying and pasting the following into the e-mail (if it’s way too much, we can go over it in the session instead, I have a feeling I wrote too much but I didn’t want to leave out any important stuff) (Client, #1336, female, aged nineteen, e-mail message, beginning of counselling). A final advantage was the ability of counsellors to provide instant resources, online tools and links to clients. Counsellors were able to easily make referrals to community mental health resources by sending information (e.g. phone number, address, website) or simply a link to the community or academic service: Have you considered re-engaging with a psychiatrist or a counselor? I will send you an email with resources that you can review and see if there is a service that might meet your needs (Counsellor, #421, aged thirty-five, e-mail message, end of counselling). Let me know if you need any other information regarding this referral, or if I can help in any way. Otherwise, let me know how it goes (Counsellor, #407, aged twenty-seven, chat message, end of counselling). I’ve inserted a link below … it is a list of meditative and mindfulness-based sessions on campus (free of charge!) that are secular, inclusive, and accessible to all students. I invite you to at least check out the website and see if anything on there sparks an interest. Might be a great way over the next week to practice a little self-care:) (Counsellor, #433, female, aged twenty-nine, e-mail message, midpoint of counselling). Distinctive challenges of online counselling Despite the advantages of online counselling for many of the participating clients, there were also notable challenges to the online format. One of the most prevalent was technical and procedural difficulties for many clients when using the secure online counselling programme. Some of these technical challenges included participants struggling to negotiate the online experience and difficulties managing administrative issues (e.g. login issues, lost e-mails). In some cases, online sessions were cut short (e.g. loss of internet signal, clients logging off before end of sessions). Several student participants highlighted that the process of remembering their password, learning how to use new software and signing in was frustrating. For example, one client wrote: I promised to write back to you on Saturday, which I thought I did, only I hit the wrong button and saved a draft instead of sending out the email! It seems like technical difficulties keep happening to me when I try to write to you :) (Client, #1446, female, aged twenty-seven, e-mail message, midpoint of counselling). Another challenge was general resistance, frustration, or discomfort with text-based online counselling, including the online format and process. For some clients, writing down their responses felt like significant work (in a context where most were already overburdened by schoolwork) and many found the nuances of the online procedure complex and confusing early in the process. Several clients stated that it was difficult to draft an e-mail to their counsellor because they did not know how to begin or they did not understand the parameters of the e-mails. A few clients indicated that it was challenging to devote time to writing an e-mail, as compared to attending an appointment: I guess after reading through this again, once you sent it back to me, I felt a little frustrated with myself. I think it is difficult for me within this email format, to actually reflect on what I am saying, even if I revise it. It seems to require a lot more effort than a session in person (Client, #1105, female, aged thirty, e-mail message, midpoint of counselling). A large part of me says, ‘I don’t want to write to Counselor, maybe I’ll just send her a short email saying that I am too busy this weekend.’ I am annoyed and resistant toward completing this ‘assignment’. Perhaps those feelings are reflective of how I see this … [online] counseling: work. I have to admit after going through the housekeeping message this morning when I first attempted to write, I was overwhelmed by how complicated and serious this online session is. I guess the sense of ‘work’ is derived from feeling obliged to obey the ‘rules’ of … [online] counseling. Now, as I type, I am realizing that perhaps I was over reacting to the ‘rules’. After all, they are merely suggestions served to enhance my experience in … [online] counseling. (haha..) (Client, #1102, female, aged twenty-three, e-mail message, beginning of counselling). Personal experiences of using online counselling The majority of the clients reported satisfaction with the overall online counselling services, and both counsellors and clients noted that the online format had offered insights and opportunities that their face-to-face sessions had not. Several clients expressed their appreciation for their counsellor towards the end of counselling during the termination period. Clients stated that they were able to ‘open up’, experienced a sense of relief, and felt that they could better understand their issues and had become more self-aware after online counselling. For example, one client stated: [Since counselling] I’ve also tried to be a little less anti-social (I noticed it made me very cynical and unhappy about others. I think I was maybe just projecting my own discontent about myself onto others). I’ve been a little more open; trying to talk (or at least hang out) with new people in social gatherings, and talking to people in class. It is nice to know I can get along with people! (Client, #436, female, aged twenty-five, e-mail message, end of counselling). The distant quality of online counselling also created some sense of security in discussing challenging issues, and helped many clients to address their personal discomfort with accessing counselling and other similar services, such as feeling guilty about talking about one’s own issues. For example, one client wrote: I feel so far that these sessions are helping me to understand myself better. That has always been my goal in life, self-understanding, personal happiness. I would like a better understanding of what is coming in the way of these things these days. I’m fairly good at assessing myself and being self-critical, but lately I have been prone to a negative bias I signed up for the … [online] counseling because I was feeling very low for a long time and I wanted to talk about it with someone without feeling guilty that I was wasting their time (Client, #1105, female, aged thirty, e-mail message, end of counselling). Clients appreciated counsellors’ support, and overall expressed satisfaction with the programme and their participation in it. Most clients were positive about their online counselling experiences and many indicated they felt supported by their counsellor throughout the online counselling process. For example, some clients stated: Just want to say how much these sessions meant to me and how much they’ve helped … Thank you Counselor for everything … and most of all thanks for being so supportive these last few weeks with everything going on. I have had an amazing time sharing my experiences with you (Client, #1336, female, aged nineteen, chat message, end of counselling). I’m feeling better about myself in this regard—I can recognise that everyone gets these feelings to some extent, and that if I want to help ease these feelings, there are healthy ways to gain more self-esteem. Also, the article you gave me to read about social anxiety gave me a new perspective on how to deal with feeling of inadequacy that I might get when interacting with others—that it is too much of a focus on the self to always be thinking ‘what do others think of me?’ Other people’s attention is not totally focussed on me and my perceived faults at any moment, and it’s ok to make mistakes (Client, #1650, male, aged twenty, end of counselling). Discussion As the majority of contemporary university students have grown up with internet-enabled digital and mobile technologies, online counselling has the potential to meet their needs and communication preferences. Based on a comprehensive analysis of session transcripts collected in an innovative, university-based online counselling programme, this study identified the characteristics, benefits and challenges of a text-based online counselling service. Study findings provide insight for practitioners from social work or other disciplines to better understand online counselling, as well as the experiences of undergraduate clients. Study findings show that the sense of inhibition and anonymity offered by text-based online counselling was what motivated some clients to seek online counselling in the first place. In addition, several clients stated that the flexible, accessible and immediate nature of online counselling was helpful. Students appreciated having the autonomy to select a point in time when they felt compelled to write an e-mail to their counsellor. Some clients reported that the ease of online counselling made the process appear less constrained than face-to-face counselling, especially with regard to setting and keeping appointments, and travelling to sessions. These findings are supported by findings identified in previous research (Richards and Viganó, 2013). Our study demonstrates that counsellors can take advantage of the internet medium to share resources and psycho-educational information with their clients, conduct assessments and make referrals to other services. Consistently with the limited number of existing studies, a central beneficial quality of text-based online counselling is a journal-like or storytelling quality (Richards and Viganó, 2013). Scholars have noted the therapeutic benefits of journaling in the treatment of psychologically distressed clients (Miller, 2014). Our findings similarly suggest that clients appreciated the opportunity to reflect on their feelings and thoughts, both writing them down in the moment and reviewing these narratives later. Despite the rapid development of computer technology and the ease of online counselling (Harrad and Banks, 2016), the administrative and technological challenges experienced by clients in our study suggest that user-friendly technology interference continues to be a practical concern when implementing an online programme. In addition, it is critical to note that, while online counselling can be a viable option for service provision, it may not be suitable for all. In our study, some clients became apprehensive towards the online counselling service and resisted the required procedures such as writing back to their counsellor. Implications for practice and education The study documents the experiences of counsellors and clients of a university online counselling programme. Study results underscore that online counselling offered by MSW students holds promise and can be a viable option for undergraduate students who seek psychological support. Online counselling can provide a sense of safety to those who find traditional face-to-face counselling intimidating, and allow increased accessibility and flexibility. As the vast majority of university students today are members of the millennial generation who grew up with virtually ubiquitous internet-enabled digital technologies (McHaney, 2012; Roseberry-McKibbin et al., 2016), university counselling centres should consider incorporating online counselling in their service provision. In addition to the face-to-face counselling sessions, universities may consider different types of services to maximise the reach and relevance of their counselling services. Furthermore, our online counselling service is text-based, using chat messages and e-mails as intervention mediums. While some participants appreciate the cathartic and therapeutic effects of writing, enjoying the sense of privacy, others expressed frustrations and felt burdened by writing. This highlights the needs for different modes of online therapies. While text-based services are appealing to some clients, providers can also consider other delivery mediums, such as web-conferencing that allows both instantaneous audio and video. Lastly, regardless of the medium utilised for delivery, providers who are interested in providing counselling through online platforms require proper training. There continue to be limited training and educational opportunities, however, that prepare social work students to meet this growing demand (Mishna et al., 2013b). Social work educators can support and educate social work practitioners by introducing online counselling into the curriculum, classrooms and practicum settings. This may include courses, workshops and/or seminars that focus on integrating the use of information and communication technologies into practice (Chan and Holosko, 2015). Formal online counselling training, direct practicum experiences and specialised online counselling courses can further strengthen student preparedness of online clinical practice, providing skills and intervention techniques to better address a variety presenting problems such as depression, anxiety and stress online (Mishna et al., 2013a). Educational opportunities provided through interactive e-learning platforms such as chat rooms, live webinars, online learning or supervision forums can help to immerse students for the emerging online practice environment (Anthony, 2015; Goldingay and Boddy, 2017) while allowing them to build awareness concerning pivotal ethical, privacy and boundaries issues (Fantus and Mishna, 2013; Dombo et al., 2014; Fang et al., 2014; Reamer, 2015). These experiences and learning gained by students can be translated into future practice (Cooner, 2014). Limitations The study has several limitations. First, we were confined by the available content in the transcripts and could not seek clarifications or elaborations from counsellors and clients who participated in the study. Second, the experiences we learned about from the counsellors and clients are limited to text-based online counselling practice in a university setting. The study results cannot be generalised to counselling practice that uses web-conferencing technology where users and clients can see and speak to each other, and online counselling practice that takes place in other settings or with different populations. Lastly, study data emphasised the counselling experience of clients with less focus on the counsellor’s personal and professional experience with online counselling other than sharing resources, limiting the counsellor’s perspective of online counselling and the therapeutic relationship. Conclusion Advancements in technology have augmented the development of online counselling. Although social work scholarship has begun to document the potential benefits of online counselling in direct practice literature (Eamon et al., 2013; Mishna et al., 2015) and disseminating information and services (Nah and Saxton, 2013; Svensson et al., 2015), very few social work schools provide specific training to students and equip them with the knowledge and skills needed to deliver counselling service online (Mishna et al., 2013a). Based on a university-based online counselling service rendered by MSW student interns, this study informs social work education and practice, as well as contributes to the nascent scholarship on online counselling and provides evidence on the unique benefits and challenges of online counselling with undergraduate clients and illuminates the uniqueness of online counselling practice. With the continued growth of mobile technologies and the increasing demand for flexible counselling modalities, we anticipate that more online counselling practices will be developed with different clienteles. As therapeutic modalities continue to diversify and advance, there is a need to further understand the experiences of clients who are engaged with online counselling. Future social work studies should continue to unpack the client experiences, understand gender-specific perspectives and assess the long-term effects of different types of online counselling practices. Such knowledge will not only increase the knowledge base of online counselling, but also help to enhance clinical competencies of social workers in the digital era. Acknowledgements We acknowledge the support of the University of Toronto Health and Wellness and Faculty of Arts and Science Undergraduate Colleges of St George Campus as well as the support of Professor Marion Bogo and Lawrence Murphy. References Anthony K. ( 2015 ) ‘Training therapists to work effectively online and offline within digital culture’ , British Journal of Guidance & Counselling , 43 ( 1 ), pp. 36 – 42 . Google Scholar CrossRef Search ADS Callahan A. , Inckle K. ( 2012 ) ‘ Cybertherapy or psychobabble? A mixed methods study of online emotional support’, British Journal of Guidance & Counselling , 40 ( 3 ), pp. 261 – 78 . Google Scholar CrossRef Search ADS Chan C. , Holosko M. J. ( 2015 ) ‘ A Review of Information and Communication Technology Enhanced Social Work Interventions ’, Research on Social Work Practice , 26 ( 1 ), 88 – 100 . Google Scholar CrossRef Search ADS Clarke J. , Proudfoot J. , Whitton A. , Birch M.-R. , Boyd M. , Parker G. , Manicavasagar V. , Hadzi-Pavlovic D. , Fogarty A. ( 2016 ) ‘ Therapeutic alliance with a fully automated mobile phone and web-based intervention: Secondary analysis of a randomized controlled trial’, JMIR Mental Health , 3 ( 1 ), p. e10 . Google Scholar CrossRef Search ADS PubMed Cooner T. S. ( 2014 ) ‘ Using Facebook to explore boundary issues for social workers in a networked society: Students’ perceptions of learning’, British Journal of Social Work , 44 ( 4 ), pp. 1063 – 80 . Google Scholar CrossRef Search ADS Czyz E. K. , Horwitz A. G. , Eisenberg D. , Kramer A. , King C. A. ( 2013 ) ‘ Self-reported barriers to professional help seeking among college students at elevated risk for suicide’, Journal of American College Health , 61 ( 7 ), pp. 398 – 406 . Google Scholar CrossRef Search ADS PubMed Dombo E. A. , Kays L. , Weller K. ( 2014 ) ‘ Clinical social work practice and technology: Personal, practical, regulatory, and ethical considerations for the twenty-first century’, Social Work in Health Care , 53 ( 9 ), pp. 900 – 19 . Google Scholar CrossRef Search ADS PubMed Dunn K. ( 2012 ) ‘ A qualitative investigation into the online counselling relationship: To meet or not to meet, that is the question’, Counselling and Psychotherapy Research , 12 ( 4 ), pp. 316 – 26 . Google Scholar CrossRef Search ADS Eamon M. K. , Wu C.-F. , Moroney G. , Cundari M. ( 2013 ) ‘ Teaching the importance and use of web-based services to assist clients in obtaining public benefits’, Journal of Teaching in Social Work , 33 ( 2 ), pp. 143 – 58 . Google Scholar CrossRef Search ADS Elo S. , Kyngäs H. ( 2008 ) ‘ The qualitative content analysis process’, Journal of Advanced Nursing , 62 ( 1 ), pp. 107 – 15 . Google Scholar CrossRef Search ADS PubMed Fang L. , Mishna F. , Zhang V. F. , Van Wert M. , Bogo M. ( 2014 ) ‘ Social media and social work education: Understanding and dealing with the new digital world’, Social Work in Health Care , 53 ( 9 ), pp. 800 – 14 . Google Scholar CrossRef Search ADS PubMed Fantus S. , Mishna F. ( 2013 ) ‘ The ethical and clinical implications of utilizing cybercommunication in face-to-face therapy’, Smith College Studies in Social Work , 83 ( 4 ), pp. 466 – 80 . Google Scholar CrossRef Search ADS Gleeson J. F. , Lederman R. , Wadley G. , Bendall S. , McGorry P. D. , Alvarez-Jimenez M. ( 2014 ) ‘ Safety and privacy outcomes from a moderated online social therapy for young people with first-episode psychosis’, Psychiatric Services , 65 ( 4 ), pp. 546 – 50 . Google Scholar CrossRef Search ADS PubMed Goldingay S. , Boddy J. ( 2017 ) ‘ Preparing social work graduates for digital practice: Ethical pedagogies for effective learning’, Australian Social Work , 70 ( 2 ), pp. 209 – 20 . Google Scholar CrossRef Search ADS Goodwin R. D. , Grinberg A. , Shapiro J. , Keith D. , McNeil M. P. , Taha F. , Jiang B. , Hart C. L. ( 2014 ) ‘ Hookah use among college students: Prevalence, drug use, and mental health’, Drug and Alcohol Dependence , 141 , pp. 16 – 20 . Google Scholar CrossRef Search ADS PubMed Gratzer D. , Khalid-Khan F. ( 2016 ) ‘ Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness’, Canadian Medical Association Journal , 188 ( 4 ), pp. 263 – 72 . Google Scholar CrossRef Search ADS PubMed Hadjistavropoulos H. D. , Pugh N. E. , Hesser H. , Andersson G. ( 2017 ) ‘ Therapeutic alliance in internet-delivered cognitive behaviour therapy for depression or generalized anxiety’, Clinical Psychology & Psychotherapy , 24 ( 2 ), pp. 451 – 61 . Google Scholar CrossRef Search ADS PubMed Harrad R. , Banks N. ( 2016 ) ‘Counselling in online environments’, in Attrill A. , Fullwood C. (eds), Applied Cyberpsychology: Practical Applications of Cyberpsychological Theory and Research , London , Palgrave Macmillan UK . Harris B. , Birnbaum R. ( 2015 ) ‘ Ethical and legal implications on the use of technology in counselling’, Clinical Social Work Journal , 43 ( 2 ), pp. 133 – 41 . Google Scholar CrossRef Search ADS Holm-Hadulla R. M. , Koutsoukou-Argyraki A. ( 2015 ) ‘ Mental health of students in a globalized world: Prevalence of complaints and disorders, methods and effectivity of counseling, structure of mental health services for students’, Mental Health & Prevention , 3 ( 1–2 ), pp. 1 – 4 . Google Scholar CrossRef Search ADS Ibrahim A. K. , Kelly S. J. , Adams C. E. , Glazebrook C. ( 2013 ) ‘ A systematic review of studies of depression prevalence in university students’ , Journal of Psychiatric Research , 47 ( 3 ), pp. 391 – 400 . Google Scholar CrossRef Search ADS PubMed Lally J. , ó Conghaile A. , Quigley S. , Bainbridge E. , McDonald C. ( 2013 ) ‘Stigma of mental illness and help-seeking intention in university students’ , The Psychiatrist , 37 ( 8 ), pp. 253 – 60 . Google Scholar CrossRef Search ADS McHaney R. ( 2012 ) The New Digital Shoreline: How Web 2.0 and Millennials Are Revolutionizing Higher Education, Sterling, Virginia, Stylus Publishing, LLC. Miller W. ( 2014 ) ‘ Interactive journaling as a clinical tool’ , Journal of Mental Health Counseling , 36 ( 1 ), pp. 31 – 42 . Google Scholar CrossRef Search ADS Mishna F. , Levine D. , Bogo M. , Van Wert M. ( 2013a ) ‘Cyber counselling: An innovative field education pilot project’ , Social Work Education , 32 ( 4 ), pp. 484 – 92 . Google Scholar CrossRef Search ADS Mishna F. , Tufford L. , Cook C. , Bogo M. ( 2013b ) ‘Research note—a pilot cyber counseling course in a graduate social work program’ , Journal of Social Work Education , 49 ( 3 ), pp. 515 – 24 . Mishna F. , Bogo M. , Sawyer J.-L. ( 2015 ) ‘Cyber counseling: Illuminating benefits and challenges’ , Clinical Social Work Journal , 43 ( 2 ), pp. 169 – 78 . Google Scholar CrossRef Search ADS Moessner M. , Bauer S. ( 2012 ) ‘ Online counselling for eating disorders: Reaching an underserved population?’, Journal of Mental Health , 21 ( 4 ), pp. 336 – 45 . Google Scholar CrossRef Search ADS PubMed Nah S. , Saxton G. D. ( 2013 ) ‘Modeling the adoption and use of social media by nonprofit organizations’ , New Media & Society , 15 ( 2 ), pp. 294 – 313 . Google Scholar CrossRef Search ADS National Association of Social Workers and Association of Social Work Boards ( 2005 ) Standards for Technology and Social Work Practice, Washington, DC, Author. Nieuwboer C. C. , Fukkink R. G. , Hermanns J. M. A. ( 2015 ) ‘Single session email consultation for parents: An evaluation of its effect on empowerment’ , British Journal of Guidance & Counselling , 43 ( 1 ), pp. 131 – 43 . Google Scholar CrossRef Search ADS Pedersen E. R. , Paves A. P. ( 2014 ) ‘ Comparing perceived public stigma and personal stigma of mental health treatment seeking in a young adult sample’ , Psychiatry Research , 219 ( 1 ), pp. 143 – 50 . Google Scholar CrossRef Search ADS PubMed Pew Research Center ( 2014a ) Internet Use Over Time , Pew Internet & American Life Project , Washington, DC , Author. Pew Research Center ( 2014b ) Internet User Demographics , Pew Internet & American Life Project , Washington, DC , Author. Prince J. P. ( 2015 ) ‘University student counseling and mental health in the United States: Trends and challenges’ , Mental Health & Prevention , 3 ( 1–2 ), pp. 5 – 10 . Google Scholar CrossRef Search ADS Reamer F. G. ( 2015 ) ‘ Clinical social work in a digital environment: Ethical and risk-management challenges’, Clinical Social Work Journal , 43 ( 2 ), pp. 120 – 32 . Google Scholar CrossRef Search ADS Rice M. S. , Goodall J. , Hetrick E. S. , Parker G. A. , Gilbertson T. , Amminger P. G. , Davey G. C. , McGorry D. P. , Gleeson J. , Alvarez-Jimenez M. ( 2014 ) ‘ Online and social networking interventions for the treatment of depression in young people: A systematic review’, Journal of Medical Internet Research , 16 ( 9 ), p. e206 . Google Scholar CrossRef Search ADS PubMed Richards D. , Viganó N. ( 2013 ) ‘ Online counseling: A narrative and critical review of the literature’, Journal of Clinical Psychology , 69 ( 9 ), pp. 994 – 1011 . Google Scholar CrossRef Search ADS PubMed Roseberry-McKibbin C. , Pieretti R. , Haberstock K. , Estrada J. ( 2016 ) ‘ Effective pedagogical strategies for millennial university students in communication sciences and disorders’, Communication Disorders Quarterly , 37 ( 3 ), pp. 180 – 3 . Google Scholar CrossRef Search ADS Russo J. V. , Bruce M. A. , Scull R. ( 2017 ) ‘Click here for mental health support: Extending mental health services to the isolated learner’ , Recruiting & Retaining Adult Learners , 19 ( 4 ), pp. 1 – 7 . Google Scholar CrossRef Search ADS Schlegl S. , Bürger C. , Schmidt L. , Herbst N. , Voderholzer U. ( 2015 ) ‘ The potential of technology-based psychological interventions for anorexia and bulimia nervosa: A systematic review and recommendations for future research’, Journal of Medical Internet Research , 17 ( 3 ), p. e85 . Google Scholar CrossRef Search ADS PubMed Slomski A. ( 2015 ) ‘ Online therapy reduces suicide ideation in medical interns’, JAMA , 314 ( 24 ), p. 2608 . Sucala M. , Schnur J. B. , Constantino M. J. , Miller S. J. , Brackman E. H. , Montgomery G. H. ( 2012 ) ‘ The therapeutic relationship in e-therapy for mental health: A systematic review’ , Journal of Medical Internet Research , 14 ( 4 ), p. e110 . Google Scholar CrossRef Search ADS PubMed Svensson P. G. , Mahoney T. Q. , Hambrick M. E. ( 2015 ) ‘ Twitter as a communication tool for nonprofits: A study of sport-for-development organizations’ , Nonprofit and Voluntary Sector Quarterly , 44 ( 6 ), pp. 1086 – 1106 . Google Scholar CrossRef Search ADS Villacura L. , Irarrázabal N. , Dörr A. , Zamorano C. , Manosalva J. , Cánovas C. , Zamorano M. , Barra N. ( 2015 ) ‘ Mental disorders of students at the University of Chile’ , Mental Health & Prevention , 3 ( 1–2 ), pp. 21 – 5 . Google Scholar CrossRef Search ADS © The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.

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The British Journal of Social WorkOxford University Press

Published: Nov 14, 2017

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