Consensus statement on the problem of terminology in psychological interventions using the internet or digital components.

Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders.

Development of a Suicidal Ideation Detection Tool for Primary Healthcare Settings: Using Open Access Online Psychosocial Data.

BACKGROUND: Suicidal patients often visit healthcare professionals in their last month before suicide, but medical practitioners are unlikely to raise the issue of suicide with patients because of time constraints and uncertainty regarding an appropriate approach. INTRODUCTION: A brief tool called the e-PASS Suicidal Ideation Detector (eSID) was developed for medical practitioners to help detect the presence of suicidal ideation (SI) in their clients. If SI is detected, the system alerts medical practitioners to address this issue with a client. The eSID tool was developed due to the absence of an easy-to-use, evidence-based SI detection tool for general practice. MATERIAL AND METHODS: The tool was developed using binary logistic regression analyses of data provided by clients accessing an online psychological assessment function. Ten primary healthcare professionals provided advice regarding the use of the tool. RESULTS: The analysis identified eleven factors in addition to the Kessler-6 for inclusion in the model used to predict the probability of recent SI. The model performed well across gender and age groups 18-64 (AUR 0.834, 95% CI 0.828-0.841, N = 16,703). Healthcare professionals were interviewed; they recommended that the tool be incorporated into existing medical software systems and that additional resources be supplied, tailored to the level of risk identified. CONCLUSION: The eSID is expected to trigger risk assessments by healthcare professionals when this is necessary. Initial reactions of healthcare professionals to the tool were favorable, but further testing and in situ development are required.

Linguistic analysis of communication in therapist-assisted internet-delivered cognitive behavior therapy for generalized anxiety disorder.

Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) involves elements of expressive writing through secure messaging with a therapist. Expressive writing has been associated with psychological and physical health benefits in past research; furthermore, certain linguistic dimensions in expressive writing have been identified as particularly beneficial to health, such as less frequent use of negative emotion words and greater use of positive emotion words. No research, to date, has analyzed linguistic dimensions in client communication over the course of therapist-assisted ICBT for individuals with symptoms of generalized anxiety. This naturalistic study examined messages sent to therapists during the course of ICBT using linguistic analysis, and explored covariation of word use with symptom improvement. Data were obtained from patients with symptoms of generalized anxiety (N = 59) who completed 12 modules of therapist-assisted ICBT and rated symptoms of anxiety, depression, and panic at the beginning of each module. Linguistic analysis categorized text submitted to therapists into different word categories. Results found that patients' use of negative emotion, anxiety, causation, and insight words reduced over the course of treatment, while past tense words increased. Furthermore, negative emotion words significantly covaried with symptom ratings over the course of treatment. While causal statements cannot be made, findings improve our understanding of patient communication in ICBT and suggest that the further study of linguistic dimensions as psychological indicators and the potential utility of expressive writing strategies in therapist-assisted ICBT may be worthwhile.

The therapeutic value of adolescents' blogging about social-emotional difficulties.

Research shows that writing a personal diary is a valuable therapeutic means for relieving emotional distress and promoting well-being, and that diary writing during adolescence helps in coping with developmental challenges. Current technologies and cultural trends make it possible and normative to publish personal diaries on the Internet through blogs--interactive, online forms of the traditional personal diary. We examined the therapeutic value of blogging for adolescents who experience social-emotional difficulties. The field experiment included randomly assigned adolescents, preassessed as having social-emotional difficulties, to 6 groups (26-28 participants in each): Four groups were assigned to blogging (writing about their difficulties or free writing; either open or closed to responses), a group assigned to writing a diary on personal computers, and a no-treatment control group. Participants in the 5 writing groups were instructed to post messages at least twice a week over 10 weeks. Outcome measures included scales of social-emotional difficulties and self-esteem, a social activities checklist, and textual analyses of participants' posts. Measurement took place at pre- and postintervention and at follow-up 2 months later. Results showed that participants maintaining a blog significantly improved on all measures. Participants writing about their difficulties in blogs open to responses gained the most. These results were consistent in the follow-up evaluation.

Establishing guidelines for executing and reporting Internet intervention research.

The field of Internet interventions is growing rapidly. New programs are continually being developed to facilitate health and mental health promotion, disease and emotional distress prevention, risk factor management, treatment, and relapse prevention. However, a clear definition of Internet interventions, guidelines for research, and evidence of effectiveness have been slower to follow. This article focuses on the quality standardization of research on Internet-delivered psychological and behavioural interventions. Although the science underpinning Internet interventions is just starting to be established, across research studies there are often conceptual and methodological difficulties. The authors argue that this situation is due to the lack of universally accepted operational guidelines and evaluation methods. Following a critical appraisal of existing codes of conduct and guidelines for Internet-assisted psychological and health interventions, the authors developed a framework of guidelines for Internet intervention research utilizing aspects of facet theory (Guttman & Greenbaum, 1998). The framework of facets, elements, and guidelines of best practice in reporting Internet intervention research was then sent to several leading researchers in the field for their comment and input, so that a consensus framework could be agreed on. The authors outline 12 key facets to be considered when evaluating and reporting Internet intervention studies. Each facet consists of a range of recommended elements, designed as the minimum features for reporting Internet intervention studies. The authors propose that this framework be utilized when designing and reporting Internet intervention research, so results across studies can be replicated, extended, compared, and contrasted with greater ease and clarity.

Defining internet-supported therapeutic interventions.

BACKGROUND: The field of Internet-supported therapeutic interventions has suffered from a lack of clarity and consistency. The absence of professional leadership and of accepted governing approaches, terminology, professional standards, and methodologies has caused this field to be diffused and unstructured. Numerous terms have been used to label and describe the activities conducted over the Internet for mental and physical health purposes: web-based therapy, e-therapy, cybertherapy, eHealth, e-Interventions, computer-mediated interventions, and online therapy (or counseling), among others. METHODS: Following a comprehensive review, we conceptualized Internet-supported interventions, using four categories based on prime practice approaches: web-based interventions, online counseling and therapy, Internet-operated therapeutic software, and other online activities (e.g., as supplements to face-to-face therapy). We provide a working definition and detailed description of each category, accompanied by numerous examples. CONCLUSIONS: These categories may now serve as guiding definitions and related terminologies for further research and development in this emerging field.

[Intervention for the promotion of sexual health through the internet: theory, empirical evidence and application].

The current article suggests that the core characteristics of the Internet--its anonymity, accessibility, affordability, privacy, and acceptability--make it ideally suited as an efficient and effective channel for delivery of sexual and reproductive health promotion interventions. The authors analysis also asserts that it is essential to create Internet-based sexual and reproductive health promotion efforts that are based upon comprehensive and empirically validated models of the initiation and maintenance of health behavior change. Accumulated research shows that the Internet is indeed a widely used and important resource for information concerning sexuality for many individuals, with particularly widespread utilization among younger individuals. In this context, numerous successful attempts have been made to exploit the Internet for the promotion of behaviors essential to sexuality and reproductive health, although these effects have often been limited in scope. The current discussion concludes with theoretical and practical illustrations of Internet-based sexual and reproductive health interventions, employing a theoretical foundation, the Information- motivation-behavioral skills model of sexual and reproductive health, and an internet delivery vehicle, www.sexualityandu.ca, that is based upon it.

Degree and reciprocity of self-disclosure in online forums.

Cyberspace has become a common social environment in which people interact and operate in many ways. The purpose of the present study was to investigate the occurrence and reciprocity of self-disclosure, two subjects that are extensively studied in face-to-face interactions but only to a limited degree in virtual, computer-mediated, textual communication. Data was based on 240 first messages in a thread, sampled in equal numbers from six Internet forums (three discussion and three support groups), and written in equal numbers by each gender, and 240 first responses to them (a total of 480 forum messages). Trained, expert judges blindly rated each message on the degree to which it disclosed personal information, thoughts, and feelings. Linguistic parameters (total number of words and number of first-voice words) were also used as dependent variables. Results showed the following: (a) self-disclosure in support forums was much higher than in discussion forums, in terms of both total number and type of disclosure; (b) messages in support forums were longer and included more first-voice words than in discussion forums; (c) there were no gender differences interacting with level of self-disclosure; (d) reciprocity of self-disclosure was evident, yielding positive correlations between the measures of self-disclosure in messages and responses to them; (e) some differences appeared in level of reciprocity of self-disclosure between male and female participants, with female respondents tending to be more reciprocal than male respondents. The implications of these results are discussed in light of growing social interactions online, and possible applications are suggested.

Factors related to perceived helpfulness in supporting highly distressed individuals through an online support chat.

The purpose of the study was to examine the contribution made by dimensions of session-impact factors (depth and smoothness), end-of-session factors of client's mood (positivity and emotional arousal), and several textual variables (use of positive and negative emotional words; helper's and client's writing lengths) to perceived helpfulness of emotional support conversations carried on by trained, paraprofessional helpers through an Internet chat with highly distressed individuals. Two studies were conducted at an Israeli, exclusively online emotional support service for suicidal and highly distressed people who have undergone various negative experiences (SAHAR). Study 1 compared 40 chat conversations deliberately indicated by clients as having been helpful at the termination stage of session with 40 other conversations, using expert judgments of session-impact factors, as well as objective word counts for textual variables. Study 2 examined correlations between helpers' evaluation of the sessions' helpfulness to clients in 60 (other) chat support conversations and session-impact factors and textual variables. The findings of Study 1 showed that all four impact factors significantly differentiated between helpful and other conversations, while textual variables did not. In Study 2, the results showed that all four session-impact factors positively correlated with session helpfulness, yielding multiple R = 0.54, as well as the length of helper's and client's writing. The implications of these studies are similar to offline counseling sessions: deep, smooth conversations that yield positive responses and arouse clients' emotions in online support are more helpful than shallow, bumping conversations that leave clients emotionally indifferent. Longer writing, by both helpers and clients, seems to be an important factor, as well.

Writing characteristics of suicidal people on the Internet: a psychological investigation of emerging social environments.

Three studies were carried out to investigate the writings of suicidal people on the Internet, hypothesizing consistent findings to equivalent research of offline writing. In Study 1, suicidal persons' (n = 34) attributions as the cause of their condition, as expressed in their free online writing, were compared to those of emotionally distressed, nonsuicidal (n = 16) and to nondistressed (n = 15) individuals. Results showed that suicidal persons have significantly more stable and global attributions than do the other groups. In Study 2, expressions of self-focus in online written messages were compared among suicidal, two levels of nonsuicidal but distressed, and nondistressed individuals (200 messages in each group). With the use of various expressions of self-focus, findings showed that suicidal people were distinctively self-focused in their writing, unlike their counterparts. In Study 3, psychologically relevant themes in the online writing of suicidal (n = 39) and highly distressed, nonsuicidal persons (n = 24) were compared. Results revealed that the former expressed significantly more unbearable psychological pain and cognitive constriction than did the latter. The findings of the three studies are consistent with those found in examinations of offline writing. The research has important implications for the use of online environments for psychological research and means for assessment, as well as for understanding suicidality.

Myths and realities of online clinical work.

An international, multi-disciplinary group of online mental health professionals, under the auspices of the International Society for Mental Health Online, presents this 3rd-year report. This article highlights the experiences of ISMHO's Clinical Case Study Group members with regard to online clinical work across several Internet-based modalities as well as integrated online/offline approaches to mental health treatment and consultation. A number of online approaches and paradigms are presented, often combining several aspects of synchronous and asynchronous online mental health practice. The discussion is organized around case presentation material shared among colleagues as part of a unique model combining peer supervision with systematic efforts to further develop a body of shared experience and observation relevant to online clinical practice. Readers are invited to virtually "listen in" to the collective voice of the group as it reconsiders whether 10 common conceptions of Internet-based practice are in fact myth or reality. Topics range from the nature of online behavior, communication, and technology, to cultural and ethical issues, to working with populations commonly seen as not being amenable to online clinical work.