E-therapy and social work practice: Benefits,barriers,and training

Abstract

The use of information and communication technologies has greatly expanded and has far-reaching implications for social work practice. Following an international review of the literature, this study explored how social workers consider the issues associated with integration of e-therapy into their social work practice. A survey of Israeli social workers revealed that only 4 percent have actual experience with e-therapy. Respondents judged disabled persons and those with mobility restrictions, caregivers of the chronically ill, new parents, the chronically ill, and teenagers as the most appropriate target populations. Attitudes toward benefits, barriers, and training predicted the applicability of e-therapy in practice.

Keywords

Diffusion of innovation information technology suitability for practice target populations

Introduction

The expansion and adoption of information and communication technologies (ICT) provide new opportunities for facilitating the delivery of welfare and health care services (Finn and Schoech, 2014; Fitch, 2015; Parker-Oliver and Demiris, 2006), while at the same time posing significant challenges to the social work profession (Parker-Oliver and Demiris, 2006; Reamer, 2013). This article reports on an online survey of the actual use of e-therapy, together with their preferences and attitudes of Israeli social workers, and compares it with international literature on the use of e-therapy in social work.

Changes in social work practice have followed the integration of different waves or generations of ICT. First generation ICT, starting in the 1980s, included computer databases used for statistics and recording information. The second generation, starting in the late 1980s and gaining momentum into the 1990s and 2000s, referred to expert systems, computer-based assessment programs, therapeutic games, and treatment packages on computers (Grebel and Steyaert, 1995; Oravec, 2000; Parker-Oliver and Demiris, 2006). With the growth of the Internet, e-health or e-therapy has become an established means of providing psychological interventions, health care, and psycho-education in the past decade and is deemed the third generation of ICT integration into social work (Grady et al., 2011; Oravec, 2000; Wells et al., 2007; Wodarski and Frimpong, 2015). The third generation treatment modalities used by social workers can be divided into (1) social worker-assisted interventions (e.g. through Skype, email, FaceTime, or texting) with a live, online practitioner, synchronously or asynchronously, either in an individual or group format, and (2) web-based treatment programs such as self-help workbooks and smartphone treatment apps, which may or may not be therapist supported (Barak et al., 2009; Manhal-Baugus, 2001; Reamer, 2013; Zur, 2012). In addition, there are Internet-operated therapeutic programs that include robotic simulations, gaming, and 3D virtual environments, which are either independent or have minimal professional input of professional guidance (Barak et al., 2009). These fourth-generation advanced information technologies are so new that their interface with social work practice is still minimal and thus they are not included in this study (Goldkind et al., 2016).

Early on, social workers raised questions regarding how ICT in social work may raise ethical dilemmas for practice. These concerns included the preservation of individualized care, maintenance of flexibility in treatment choices, links with community networks and optimizing the use of treatment time, ensuring confidentiality and data security, limiting depersonalization, and understanding non-verbal communication that may be lost in translation (Csiernik et al., 2006; Fitch, 2015). Some types of social media, such as Facebook and Instagram, are public-use websites and can compromise the privacy of clients as well as that of social work practitioners (Beaumont et al., 2017). A wide selection of creative treatment methods based on ICT, suitable for children, adolescents, and adults with mental health challenges, have been described (Barak et al., 2008; Grady et al., 2011; Resnick and Anderson, 2002; Strobl-Reichel, 2015; Taylor and Luce, 2003). To encourage social workers’ use of ICT, a list of over 60 mobile applications, websites, treatment programs, and apps that are suitable for social workers and their clients is available (Scott, 2014) – for example a study used a tracking app (iWander) to monitor the wandering of dementia patients, giving caregivers and practitioners a way to identify an elderly person who had gone astray and was unsupervised, alleviating stress among family members (Sposaro et al., 2010). However, this article did not discuss the implications of data security and protecting the rights of the clients and their families. In a recent study from Melbourne, Australia, a clinical social worker joined a team of clinical psychologists to mount a field study testing the feasibility and acceptability of an Internet-based intervention (Rebound) to foster post-hospital coping skills and prevent relapse among young people who had a recent diagnosis of major depression. Rebound is unique in its combination of social networking, tailored interventions moderated by mental health professionals, and peer support of others in the web-paced program (Rice et al., 2018).

While the integration of ICT into social work practice appeared early in the field of health and mental health, recently it has also been incorporated into community-based social work practice. For example, in the Basque area of Spain, a model program called Saregune was developed in the town of Vitoria to reduce ‘e-exclusion’ and promote ‘e-inclusion’ of unemployed young people in order to promote supportive social networks and job training. The model was recognized by the ‘Leonardo Da Vinci Multilateral Projects, Transfer of Innovation Lifelong Learning Programme’ as an effective intervention for reducing the e-technology divide between social strata through inter-linking programs working at the individual, group, and community levels (Raya Diez, 2018). In this research, we use the following definition of e-therapy (synonymous with telehealth, telemental health, and online counseling) (Grady et al., 2011; Harris and Birnbaum, 2015; McCarty and Clancy, 2002): the establishment of a therapeutic session between a social worker and a client, using ICT such as webcam, email, or video-conferencing to establish a therapeutic encounter, synchronously or asynchronously (Manhal-Baugus, 2001; Menon and Miller-Cribbs, 2002; Parker-Oliver and Demiris, 2006; Strobl-Reichel, 2015). The advantage of e-therapy is that it provides opportunities for private communication, unlimited by geographic barriers. These features, coupled with the relative low-cost and increasing access to electronic communication, contribute to the current trend toward provision of online mental health and social welfare services by use of e-therapy (Harris and Birnbaum, 2015). Sometimes social workers may start to use e-therapy when a client moves away and wishes to remain in contact through Skype or email. At other times, social workers may offer e-therapy to their clients outside of regular clinic or office hours.

Meta-analyses of different e-therapy interventions by mental health professionals (not necessarily social workers) have shown their efficacy relative to other types of face-to-face interventions and in comparison to control groups receiving a placebo care option (Andersson et al., 2005; Grady et al., 2011; Kuester et al., 2016; Reger and Gahm, 2009). Examples of empirically tested e-therapy protocols include cognitive behavioral therapy (CBT) for the treatment of depression (Andersson and Cuijpers, 2009; Kessler et al., 2009), Internet-based treatment for anxiety (Andersson et al., 2005; Austin et al., 2010), preventing eating disorders (Beintner et al., 2012; Celio et al., 2000), and alcohol addiction (Blankers et al., 2011). A more recent study from Sweden showed that six sessions of Internet-based CBT (iCBT) delivered to pregnant women (weeks 12–28) with depressive symptoms, supplemented by phone feedback on a regular basis from a CBT-trained therapist, was an effective way to treat their depression (Forsell et al., 2017). Studies have shown that Internet-based interventions based on iCBT can be an effective method of service delivery for mothers facing symptoms of post-partum depression (PPD) (Danaher et al., 2013; King, 2009; Pugh et al., 2014, 2016). A joint Australian–US group developed a web-based workbook with a dedicated website (MomMoodBooster), delivered over six sessions to mothers with symptoms of PPD (Danaher et al., 2013; Milgrom et al., 2016; O’Mahen et al., 2014, 2015). A further study by this group showed that when supported by low-intensity phone coaching, the program was effective in reducing depressive symptoms and had good adherence (Milgrom et al., 2016).

By contrast, a recent study found that iCBT programs were not better than the usual care treatment by a general practitioner (GP) for clinical depression, and there were many problems with uptake and dropout, despite telephone support and reminders (Gilbody et al., 2015). Others have noted that the overall research designs were relatively weak, generating small effect sizes in most studies of e-therapy for mental health problems (Postel et al., 2008). Hence, e-therapy has become a legitimate tool for clinical interventions in social work, yet it is not a therapeutic panacea (Csiernik et al., 2006; Fitch, 2015; McCarty and Clancy, 2002; Parker-Oliver and Demiris, 2006; Ramsey and Montgomery, 2014; Wodarski and Frimpong, 2015).

Advantages of e-therapy include greater access to underserved populations, to persons with difficulties with physical access, such as the disabled, the incarcerated, parents caring for infants, the elderly and those living in remote locations, and providing possibilities for treatment access outside of regular service hours (McCarty and Clancy, 2002; Reamer, 2013, 2015). This wider access is particularly relevant to those who suffer from stigma, which may stymie their motivation to seek social work services and mental health treatment (Capurro et al., 2014; Csiernik et al., 2006; Parker-Oliver and Demiris, 2006; Reamer, 2013; Taintor, 2002). However, providing e-therapy and using Internet therapeutic programs may require technical skills from both clients and social workers in order to overcome glitches with hardware and software (Atkinson et al., 2009; Barak and Grohol, 2011; Grady et al., 2011; McCarty and Clancy, 2002).

While many have extolled the advantages of e-therapy, the Clinical Social Work Federation (CSWF) warned in 2001 that the use of e-therapy could accentuate the already prevalent disconnection between individuals and promote alienation (Menon and Miller-Cribbs, 2002). A series of articles have focused on how integrating ICT into social work practice can avoid ‘e-exclusion’ of already disadvantaged populations (Eito et al., 2018; Lopez, 2015; López Peláez and Marcuello-Servós, 2018; López Peláez et al., 2018; Raya Diez, 2018). This also prompted an examination by the National Association of Social Workers (NASW), which issued standards for ethical and legal social work care using ICT (Lopez, 2014; NASW, 2006). The Australian Association of Social Workers (AASW) similarly updated its Code of Ethics to relate specifically to social workers’ ethical responsibilities in the use of ICT including e-therapy (AASW, 2016; McAuliffe and Nipperess, 2017). Both of these national codes emphasized the need for added security and protection of data, and recommended adding informed consent procedures and the use of secure encrypted digital software to protect client confidentiality (AASW, 2016; Lopez, 2014; Reamer, 2017).

However, studies of the actual use of e-therapy in social work have shown that few have ventured to include e-therapy in their practice. For example, in a 2007 survey of social workers, psychologists and other mental health professionals in the United States, Wells found that the vast majority could not see themselves using e-therapy in practice, and in fact less than 2 percent of the social workers had ever done so (Wells et al., 2007). A study of direct practice social workers showed that only 3.7 percent used email with clients, and 87.7 percent believed that it was unethical to conduct therapy through email with clients (Finn, 2006). A recent study that proposed to interview 20 social workers who had used e-therapy eventually managed to interview only two practitioners who had done so (Strobl-Reichel, 2015). A study of social work supervisors in mental health agencies found that the use of ICT for therapeutic purposes ranged from 10.5 percent (mobile therapeutic games) to 18 percent (e-therapy), with a higher level of usage among supervisors’ agencies with a positive approach to technology (14% of agencies) (Goldkind et al., 2016).

A recent review of all available social work mental health ICT interventions found but six studies that included social workers and used valid outcome measures (studied published between 2004 and 2013; Ramsey and Montgomery, 2014). Another review of all types of ICT interventions used by social workers found 17 articles published up until 2012. Only seven were rated good quality in terms of research design. Seven of the articles dealt with parenting, five with health care, and five with families with children (Chan and Holosko, 2016). Another recent review of ICT and social work practice found 70 different articles published between 2006 and 2016 including ICT and social work; however, the bulk focused on social work practitioners and students, and only 16 articles had a population intervention focus (child/youth [6 articles], elderly [4 articles], and low socioeconomic status [SES] or social service consumers [6 articles]). Furthermore, 77 percent were from Anglophone countries, primarily the United States and the United Kingdom, suggesting that there is still a need for diffusion of ICT into global social work practice (López Peláez et al., 2018).

According to Rogers’ diffusion of innovation theory (1995), a practice innovation can be characterized by certain patterns of adoption, with individuals ranging from early to late adopters of innovations. Specifically, innovators (2.5% of a typical group) were found to be interested in social trends and in touch with innovative groups outside their own community. Early adopters (13.5% of a typical group) were considered more discriminating about the innovations they adopted and were effective opinion leaders in their social network. These two groups comprise the change agents who introduce innovations to others, made up of early majority (34%), late majority (34%), and laggards (16%). Thus, those who introduce innovation are a select group within their profession (Borbas et al., 2000). This model of innovation diffusion has often been used to describe the uptake of IT technology in different professions and is suitable for understanding the diffusion of e-therapy into social work practice (Helitzer et al., 2003; Moore and Benbasat, 1991). According to the literature reviewed, it appears that social workers are still in an early stage of adoption of e-therapy practices (Ramsey and Montgomery, 2014; Wells et al., 2007). In fact social workers as a group were characterized as ‘late adopters’ of ICT in general (Goldkind et al., 2016).

The research aim of the present study was to describe the extent of use of the e-therapy by social workers and the populations they see as suitable for e-therapy in their practice. The first goal of the survey was to evaluate at what stage of innovation social work practice is in relation to diffusion of innovation theory. Are we in the early adopter stage or in the broad diffusion stage? The second goal was to describe the target populations deemed appropriate for e-therapy by the social work professional community. The third goal was to understand which of the factors influence the perceived quality of communication and perceived comfort using e-therapy with clients.

Methods

Procedures

Based on the results of the international literature review on e-therapy use in social work, we developed a questionnaire (Barak et al., 2009; Finn and Barak, 2010; Finn and Schoech, 2014; Parker-Oliver and Demiris, 2006; Reamer, 2013; Strobl-Reichel, 2015). Given the lack of definitive research on who is more likely to use e-therapy in social work, we did not propose specific hypotheses. The questionnaire included topics such as the use of e-therapy in practice, attitudes toward the suitability of e-therapy techniques for various target populations, and various therapeutic tasks, for example intake, supervision, using projective treatment tools such as therapeutic cards or art making, crisis intervention, establishing a treatment setting (10 questions). The questionnaire had 25 questions, of which 9 asked about the suitability for specific populations (see Tables 2 and 3 and the factor analysis below), and 5 questions asked about training and supervision, on a 1- to 5-point Likert-type scale reflecting endorsement of the statement (1 = strongly disagree to 5 = strongly agree). In addition, the questionnaire included information about the participants’ professional background and experience with other electronic media (e.g. Skype, email, WhatsApp) along with standard demographic questions. Dependent variables included the degree of agreement with the following: ‘e-therapy allows for quality communication with clients’; ‘I feel comfortable giving treatment using e-therapy’ (both on a 1 to 5 Likert-type scale, with 5 indicating high quality or comfort); and ‘Is e-therapy suitable for your target population (treatment suitability, yes–no)?’

The questionnaire was distributed to social workers attending a national social work conference, and they were supplied with an addressed envelope to return the completed questionnaires, with signed informed consent. Of the 55 questionnaires distributed, 38 were returned completed (return rate 69%). The questionnaire was then uploaded to Qualtrics and widely distributed via social media to Israeli social workers currently employed in the field. An additional sample of 85 useable questionnaires was completed, creating a final sample of N = 123 (questionnaires = 30.9% and online questionnaires = 69.1%).

Statistical procedures

We first examined the distributions of the descriptive variables regarding the demographic features of the population, and then tested for differences between demographic and professional groups on the mean value of the dependent variables relating to e-therapy, using t-tests or chi-square analyses. We used a general linear model, with repeated measures analysis of variance (ANOVA) to test the differences between the suitability of different treatment elements and different populations with post hoc tests of differences between variables. Finally, the questions about the use of e-therapy in social work practice were factor analyzed using a Varimax rotation to reveal the major factors that explained support or lack of support for e-therapy practice. The factor analysis is a common data reduction statistical procedure, which shows the major factors that explain the observed variance in the data. In order to characterize the different experiences with e-therapy, each respondent received a factor score that was generated from the factor analyses results, and these were used to predict the perceived quality and convenience of e-therapy as an intervention in social work.

Sample

Our sample was 11 percent men and 86 percent women.¹ The mean age was 45.21 (SD = 10.88): 19 percent of the sample were aged between 70 and 55 years, 25 percent were between 54 and 45 years, 28 percent between 44 and 35 years, and 24 percent between the ages of 34 and 25 years.² Most were married (63%), 19 percent were single or living with a partner, and 15 percent had a different family status (divorced, widowed). The majority were secular (68%), 18 percent traditional, and 14 percent religious. The mean of education was 17.5 years (SD = 2.55), which shows that the mean fell at 2.5 years of post-Bachelor of Social Work (BSW) education (BSW educational level is 15 years since Israel has a 3-year BSW program). The mean number of years of professional experience was 16.19 years (SD = 11.15): 22 percent had between 0 and 5 years of experience, 24 percent between 6 and 15 years, 25 percent between 16 and 25 years, and 24 percent between 26 and 41 years. Approximately half worked full time (46% were working part time and 54% full time).

In terms of field of specialization in social work, respondents could choose more than one answer: 24 percent were in management, 53 percent family and casework, 17 percent case management, 12 percent community work, 11 percent empowerment and clients’ rights, and 8 percent research. The professional work environment was 27 percent in families and the welfare services, 45 percent health and mental health, and 25 percent other professional environments such as criminal justice or educational frameworks.

Results

Only 4 percent of the sample had actual experience with e-therapy and had received training; 96 percent had never used it or received training. Those with e-therapy experience worked in the fields of health, in treatment of drug addicts and mental health, had 18 or more years of experience, and had an advanced degree in social work. The small number of persons with e-therapy experience invalidated statistical comparisons with the subsample that had never used e-therapy in practice. However, approximately one-third (37%) thought that the population they were working with was suitable for e-therapy treatment, and 28 percent thought that was feasible in their current work environment. The mean value for agreement with the statement (scaled from 1 (disagree) to 5 (strongly agree): ‘e-therapy allows for quality communication’ was 2.7 (SD = 0.92, 20.2% agreeing or strongly agreeing), while slightly fewer ‘feel comfortable delivering e-therapy’ (mean = 2.34, SD = 1.34, 18.7% agreeing or strongly agreeing). Those who thought that e-therapy was suitable for their target population were much more likely to agree with ‘e-therapy being a quality communication’ and to ‘feel comfortable delivering e-therapy to my target population’ (t(113) = 5.45, p < 0.001, t(111) = 3.95, p < 0.001, respectively).

While 51 percent received supervision regarding social work with clients, only 4 percent had received training for e-therapy. When asked whether they regularly used other types of electronic communication (Skype, WhatsApp, SMS, etc.) for their own daily use, 81 percent said they used SMS and WhatsApp regularly, 57 percent used Facebook, and only 15 percent said they regularly used Skype. On checking whether social workers who used Skype on a regular basis felt more comfortable using e-therapy with their target population, we found a significant difference between social workers who do not use Skype (mean = 2.17, SD = 1.25) and the ones who do (mean = 3.41, SD = 1.46) (t(117) = –3.707, p < 0.05). There were no significant relationships between other types of electronic communication and any other dependent variable, except that Skype use increased agreement that e-therapy is suitable for their target population (reached near significance (p = 0.06)).

We analyzed the relationship between age and comfort of using e-therapy with their target population using chi-square analysis. The relationship between age and perceived fit of e-therapy for their target population was significant, with older workers (those aged 45–55 years) more likely to endorse e-therapy for their target population and younger workers (aged 25–44 years) more likely to say that e-therapy was not suitable (χ²(3) = 8.74, p = 0.03).

Younger social workers were more likely to work with families and in the welfare services and the older social workers more likely to work in areas of health and mental health (average age of welfare workers was 41.8 years (SD = 10.02) and in the health group, 46.5 years (SD = 10.8), t = –2.01 (df = 83), p < 0.05). When examining the relationship between age and endorsing e-therapy, controlling for target population (welfare vs health/mental health), the chi-square between age and e-therapy suitability was no longer significant. The relationship between gender and perceived fit of e-therapy was not significant (χ²(1) = 0.156, p = n.s.). Those who worked full time were more likely to think e-therapy was suitable for their target population compared to those who worked part time (47.5% and 29.1%, respectively, χ²(1) = 4.05, p < 0.05). This relationship, however, was not explained by the different type of target population as the chi-square remained significant even after controlling for target population (χ²(1) = 3.58, p < 0.05).

We evaluated whether professional experience was associated with judging e-therapy as a quality communication mode. Using ANOVA and post hoc tests, we found that experienced social workers (16–25 years of experience) ranked the quality of e-therapy higher than those with less experience (6–15 years), F(3) = 2.819, p < 0.01. We found that social workers with experience of using e-therapy were more comfortable using the technique than those without experience (mean = 4.67, SD = 0.58 compared with mean = 2.42, SD = 1.297) (t(80) = 2.978, p < 0.05). However, the small number of respondents renders this result preliminary and in need of further research.

There were significant differences in the evaluation of whether e-therapy is feasible for different social work interventions using repeated measures ANOVA with post hoc tests (F = 30.71, p = 0.000; see Table 1). All values above ‘3’ indicate a positive endorsement, values close to the mean of ‘3’ indicate a neutral position, and all those below ‘3’ demonstrate a somewhat negative or negative evaluation. The rank shows which variables differed from one another, so that, for example, all those ranked ‘2’ did not differ from each other significantly but were significantly different from the other ranks. The most endorsed aspect of social work intervention using e-therapy tools was supervision, which was significantly more positive than all other aspects of social work intervention. This was followed by establishing a therapeutic setting, making a treatment contract and setting treatment goals. Neutral values were given to conducting an intake interview, using crisis intervention and being able to use a wide variety of treatment modalities. The ability to terminate treatment and to use projective treatment tools were deemed less appropriate for use in e-therapy. The limitations on understanding non-verbal communication were seen as a negative aspect of e-therapy.

Table 1.

Rank, mean, and SD of perceived fit of e-therapy to social work interventions.

Rank	Intervention task	Mean	SD
1	Can receive online supervision	3.53	1.11
2	Can establish a stable therapeutic setting using e-therapy	3.38	1.12
2	Specifying a therapeutic contract can be done online	3.24	1.14
3	Setting treatment goals can be done online	3.07	1.00
3	Intake can be made online	3.00	1.30
3	Suitable for crisis intervention	2.86	1.20
3	Useful with a variety of intervention techniques	2.78	1.07
4	Meaningful termination of treatment can be managed online	2.41	1.11
4	Can be used with projective tools (cards, art making, etc.)	2.17	1.07
4	The use of e-therapy allows the therapist to perceive the client’s non-verbal communications	1.99	1.19

SD: standard deviation.

Again using a repeated measures ANOVA, we examined the mean difference between the perceived suitability of using e-therapy with different target populations (F = 49.64, p = 0.000) and found a significant difference between the first-ranked population (the disabled and those with restricted mobility) and all other populations. Caregivers, parents, those who are chronically ill, and teenagers were given a positive endorsement, while working with the elderly was thought to be less appropriate. The lowest level of fit was found for families living in poverty, which was significantly different from all populations except people in trauma (see Table 2).

Table 2.

Rank, mean, and SD of perceived fit of e-therapy to client populations.

Rank	Population	Mean	SD
1	The disabled and those with restricted mobility	3.95	0.89
2	Caregivers of disabled	3.63	1.1
2	Parents of babies	3.46	1.07
2	Chronically ill	3.47	1.04
3	Teenagers	3.11	1.22
4	Elderly	2.59	1.20
4	People who have experienced trauma	2.47	1.11
5	Families coping with poverty	2.22	0.96

SD: standard deviation.

Finally, we examined what issues and barriers are identified by practitioners with regard to e-therapy. The foremost issue was the need for quality training by an experienced practitioner and the need for technological support in real time. These concerns were strongly endorsed by the sample, following the ability to conduct evaluations and use questionnaires online, scheduling flexibility, and the need to deal with complex ethical issues. E-therapy was deemed appropriate for specific populations, limiting its applicability in practice, as shown in Table 3. There was significant concern about the technological side of using e-therapy, which was ranked in a similar fashion to the statement that e-therapy improves access to populations that otherwise would not receive services. Respondents were neutral about the ability of e-therapy to maintain privacy and confidentiality and whether it is the appropriate modality in times of crisis. There was concern about the external interference during sessions, which was ranked with the lowest endorsement.

Table 3.

Characteristics of e-therapy that affect social work practice.

Rank	Characteristic	Mean	SD
1	Requires training by an experienced e-therapist	4.42	0.91
1	Requires training to use e-therapy	4.38	0.96
2	Requires unique professional supervision	4.23	0.93
2	Requires accessible technical support in real time	4.23	0.93
2	Can be used with evaluation questionnaires	4.08	0.99
2	Allows flexibility in scheduling, which is an advantage	4.04	0.96
3	Appropriate for specific populations	3.76	1.05
3	Raises complex ethical issues	3.68	1.11
3	Might cause technological difficulties, which I do not know how to handle	3.64	1.07
3	Improves access to services for populations that otherwise would not receive them	3.58	0.99
3	Suitable for evaluating progress in treatment	3.54	0.89
4	Can be combined with other Internet technologies such as WhatsApp	3.36	1.15
4	Can maintain the client’s privacy when using online treatment	3.32	1.15
4	Confidentiality of client data is possible	3.18	1.13
4	Limits appropriate professional treatment response in times of crisis	3.12	1.19
5	Can minimize external interference during sessions	2.72	1.05

SD: standard deviation.

In order to understand the relationships between beliefs regarding e-therapy and the perception that e-therapy is a quality way to communicate with clients, we used factor analysis with Varimax rotation for data reduction and to generate factor scores that later predicted the applicability of e-therapy in their practice. Two variables were loaded after being reverse recoded (limits a variety of treatment techniques and interventions in times of crisis). Three factors resulted: benefits, the need for training, and barriers to e-therapy use, together explaining 51.13 percent of the variance (see Table 4).

Table 4.

Factor analysis about applying e-therapy in practice.

Variable	Benefits	Training	Barriers
Intake can be made online	0.732
Can establish a stable therapeutic setting while using e-therapy	0.706
Meaningful termination of treatment can be managed online	0.700
Allows flexibility in scheduling, which is an advantage	0.691
Can make an assessment of treatment progress online	0.684
Suitable for evaluation forms and program evaluation	0.684
Specifying a therapeutic contract including goals and objectives can be done online	0.647
Using e-therapy enables meeting therapeutic goals	0.602
Can maintain the client’s privacy when using online treatment	0.568
Easy to integrate the online treatment with other technological means such as SMS, Instagram, WhatsApp	0.561
The use of e-therapy requires supervision from a person who is experienced in e-therapy		0.861
Before starting to use e-therapy, a social worker must undergo appropriate training		0.842
Requires an appropriate unique professional training		0.826
Requires accessible technical support in real time		0.607
May cause technological difficulties, which I do not know how to handle			–0.780
Limits the use of a variety of intervention techniques			–0.597
Raises complex ethical issues			–0.579
Limits appropriate professional treatment response in times of crisis			–0.508
During e-therapy, external interference can be minimized
Suitable only for specific populations
Can be used with projective tools (cards, art making, etc.)
Improves access to services for populations that otherwise would not receive them
Allows the therapist to perceive the client’s non-verbal communications
Can receive online supervision
% variance explained	25.2%	14.3%	11.6%

Loading included only when values are >0.50; items in italics not included in factor analysis.

The three factors were then entered into two regressions to explain the perceived quality of e-therapy and the convenience of e-therapy. As Table 5 demonstrates, only benefits and barriers are good predictors of e-therapy perceived quality of communication (adjusted R² = 0.497, p < 0.001). As Table 6 demonstrates, all three factors – benefits, training, and barriers – are significant predictors of the perceived convenience in using e-therapy (adj. R²= 0.282, p < 0.001).

Table 5.

Estimates of the factors when predicting e-therapy perceived quality.

Factor	Estimate	Significance
Intercept	2.607	0.000
Benefits	0.592	0.000
Training	0.015	0.834
Barriers	0.292	0.000

Table 6.

Estimates of the factors when predicting convenience of using e-therapy.

Factor	Estimate	Significance
Intercept	2.323	0.000
Benefits	0.608	0.000
Training	–0.288	0.025
Barriers	0.332	0.009

Discussion

The first goal of this study was to evaluate at which stage of innovation professional social work is in relation to diffusion of innovation theory. We showed that in Israel, the social work profession is still in the innovator–early adopter stage as only 4 percent of social workers in our sample had used e-therapy, similar to what was found in other studies, despite the years that have passed since its inception (Ramsey and Montgomery, 2014; Wells et al., 2007). The early adopters of this new technology and those who felt most comfortable with contemplating using e-therapy were more experienced in social work in general and in Skype use specifically, and more likely to work in health or mental health frameworks and to work full time. Apparently, these populations feel the most comfortable trying innovative modes of practice and should be the target of training for e-therapy. These results contrast with other findings showing that older people in general have more negative attitudes toward using IT, perhaps because they have fewer years of experience of using it on a daily basis (see e.g. Woodward et al., 2011). However, the population of social workers with experience are still in the midst of their professional career and apparently have more confidence in their clinical skills, similar to findings in a study of social work supervisors (Goldkind et al., 2016). However, there was a significant portion of social workers in our study who felt that e-therapy was suitable for their target population, who could be viewed as the ‘early majority’ who are ready to consider using e-therapy in practice with appropriate agency supports.

The second goal was to describe the social work interventions and target populations deemed appropriate for e-therapy by the social work professional community. The highest ranked type of practice endorsed by social workers was receiving online supervision, following by establishing a therapeutic milieu, therapeutic contract, and goals. This suggests that given the lack of actual experience, social workers would prefer to use ICT methods under supervision, which is a protected work relationship, before trying out e-therapy skills on their client populations. Establishing a therapeutic alliance was viewed as an important issue among our respondents, consistent with a study showing that therapeutic alliance could be just as easily established in both e-therapy and face-to-face client interactions (Cook and Doyle, 2002) and another study showing that e-therapy can promote a positive therapeutic alliance among practitioners who receive training (Lopez, 2015).

Conducting an intake was given a neutral ranking, while crisis intervention, using a variety of techniques, termination of treatment, using projective tools, and perceiving non-verbal communication were all seen as less appropriate or difficult to do using e-therapy. E-therapy limits the understanding of non-verbal communication, a concern raised by several in the field (Grady et al., 2011; Oravec, 2000; Recupero and Rainey, 2005; Sucala et al., 2012). Social workers recognized that e-therapy can be adapted for establishing a therapeutic contract and articulating goals in therapy. However, respondents were not sure about conducting an intake interview or engaging in crisis intervention using e-therapy.

The preferred populations for e-therapy use included the disabled and those with restricted mobility, caregivers to those who are housebound, parents of infants or small children, those who are chronically ill, and teenagers. There were negative attitudes toward the use of e-therapy with the poor or elderly, closely reflecting the existence of barriers of income and education, both shown to curtail ICT use in the general population (Wright and Hill, 2009). While clients with limited mobility were considered a highly suitable population among our surveyed social workers, research shows that this population group has significant limitations in using e-therapy and IT technologies (Newby, 2016). Furthermore, older adults with physical limitations were less likely to make use of IT interventions than those without limitations (Gell et al., 2013).

Interestingly enough, the ranked intervention methods and populations closely reflect the recommendations of the American Telemedicine Association (Grady et al., 2011) and a Canadian review on e-therapy (Harris and Birnbaum, 2015). These position statements suggest that e-therapy is suitable for community and outpatient settings and can be used in diagnostic assessments. For example, the Internet was found suitable for screening for PPD among mothers in the community (Le et al., 2009; Teaford et al., 2015). Furthermore, the challenges of overcoming technological glitches were of concern to the potential e-therapist in concordance with other research, which showed that technology is viewed as a barrier to establishing good therapeutic alliance in e-therapy, particularly for clients with low levels of computer literacy (Haberstroh et al., 2008). Similarly, attention to ethical issues was a major concern in our study as well as in others (Manhal-Baugus, 2001; Reamer, 2013).

As noted by several researchers, the issues of training and developing confidence in e-therapy skills has rarely been addressed in undergraduate, graduate, or continuing education for social worker practitioners (Fitch, 2015; Perron et al., 2010; Robbins et al., 2016). Training at the undergraduate, graduate, and continuing education levels is the obvious route to greater incorporation of e-therapy into practice and the development of ‘e-social work’ which includes all types of ICT interfaces (Eito et al., 2018; López Peláez and Marcuello-Servós, 2018; López Peláez et al., 2018). One exception is an innovative practicum that taught e-therapy and face-to-face counseling skills to Master of Social Work (MSW) students, who then developed practice skills by providing e-therapy to undergraduate social work students (Mishna et al., 2013). Our findings point to the importance of training and supervision in establishing confidence in the use of e-therapy in social work practice, by increasing the functional or psychological benefits and decreasing the barriers associated with e-therapy use in practice (Zeithaml, 1988). Benefits that should be emphasized in training, which were cited by social workers in our study, include the following: the ability to establish a therapeutic setting, flexibility in scheduling, suitability for developing assessment or for use with evaluation questionnaires, integration with other technologies, and that it improves access to populations who might not otherwise receive services. Frank discussion of the ethical issues in the use of e-therapy in practice is also warranted and supported by findings from a recent review. Each practitioner should take responsibility for safeguarding the confidentiality of client data and should use e-therapy within the security and ethical guidelines in their regional jurisdiction in accordance with ethical codes of practice (Lopez, 2014; Reamer, 2017).

While this survey used both online and direct survey collection, the sample may not be representative of all different sectors of social workers. Furthermore, it would be advisable to replicate this study with other samples of social workers in other countries, to make international comparisons. The small number of social workers with e-therapy experience also limited the analyses in the study. Future research should use mixed methods to incorporate the experiences of social workers who have used e-therapy into practice, and to give real-life suggestions for the successful incorporation of e-therapy into social work practice.

The diffusion of innovation theory suggests that in order to promote the use of e-therapy and other ICT methods in social work practice, it would be wise to start by training and supervising social workers in the field. Training should focus on developing e-therapy skills by emphasizing responsibilities such as for data security, benefits, and barriers in the adaptation of this innovation. Supervision using ICT seems to be the best way to start social workers on the road to digital literacy, followed by supervised clinical work with clients.

In the international social work community, it is clear that some countries are beginning to incorporate ICT into social work practice, while other countries are just in the initial stages of adapting this innovation. National social work associations can be proactive in setting ethical guidelines for ICT practice, thus reducing some of the barriers reported by social workers in trying to devise the optimal way of using ICT. However, undergraduate and graduate programs in schools of social work and in-service training have a crucial role to play in order to ensure that these tools offer the most benefit to social work clients and practitioners.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

ORCID iD

Julie Cwikel

Author biographies

Julie Cwikel is the founder and Director of Israel’s first academic center on women’s health at Ben-Gurion University of the Negev.

Enav Friedmann is a lecturer at Bar-Ilan University in Israel. She is working in the field of consumer behavior and decision-making, as well as social marketing.

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