Journal of Technology in Counseling

California State University, Fullerton collaborated on a hotline project to meet the sociological

and psychological needs of a campus community of 33,000 students. The initial idea for this collaboration came from an alum who suggested the campus may be able to benefit from a 24-hotline for students in emotional or educational crisis.

The primary goal of the collaborators was to increase retention and timely graduation rates for the CSUF student body by providing immediate services and resources to address many of the psychological, or sociological concerns that create barriers to learning and subsequent graduation.

According to Susie Johnson (2004), in an address at the Annual Conference for the British Association of Health Services at the University of Leeds, university and college campuses long ago abandoned “in loco parentis” responsibilities and higher education institutions are not considered to be therapeutic communities (2004). However, universities and colleges must find ways in which to respond to the increased demand for counseling and psychological services for psychologically high-risk students. Technology is part of the solution in delivering support and help to students while assuring graduation rates and retention rates are maintained.

University and colleges today are educating the first cohort of students raised on technology, and who are part of the image-based learning generation as opposed to the print-based learning generation. Online images and communication are a comfortable and approachable modality for the current college generation. With this effective way to outreach and communicate, it was the goal of the website technology to provide a 24-hour online hotline, staffed by interns and supervised by licensed therapists at California State University, Fullerton.

The phenomenon of online therapy (often referred to as E-Therapy) has become a central focus for Mental Health practitioners as a viable venue to offer mental health services. Individuals such as university and high school students who find themselves without the economic fortitude, time to dedicate to the fifty minute therapeutic hour and/or the desire to sit face-to-face with an individual who despite expert training, may or may not be able to avoid the classic clinical gaze, are a sub-population that is particularly amenable and interested in this form of therapy (Walter, 1996).

E-Therapy and the use of telecommunications are now intersecting, to provide access to behavioral health assessment, diagnosis, intervention, consultation, education, and information across distance via the various dimensions of this mode of communication. High tech university and high school students who are seeking such services and who prefer to communicate via the internet vs. the more typical in-person didactic experience, find E-Therapy to be a practical solution (Nickerson, 1988). E-Therapy services are most often sought out by students who suffer with: anxiety, relationship, gender identity, family, academic and sexual problems as well as eating disorders, bereavement, phobias and other such issues (Sommers, 1997).

Empirical studies of computer-based counseling for university students are nearly nonexistent (Finn, 1994). The theoretical framework used in the computer-based counseling approaches that have been studied reveal a variety of modalities and approaches: including cognitive-behavioral, journal writing, narrative, solution-focused, and self-help therapies/support (Suler, 1998). Given the limited research in this area, little can be deducted with accurate reliability and/or validity. Thus, most findings are at best preliminary and/or anecdotal in nature at this juncture.

Within the past few years, three major universities have assumed the challenge of providing student-based web sites that include a myriad of services, one of which is

E-Therapy. Texas A&M was among the first to design and pilot a student focused website/helpline/referral site to offer crisis intervention services and consultation on a full range of professional services such as: personal and career counseling, academic skill’s enhancement, testing, outreach programming, psychiatric services, among other services. The Texas A&M Help line is staffed primarily by trained peers and graduate assistants. Supervision is provided by the professional staff of the Texas A&M Student Counseling Service Department, whom offer extensive information about a wide variety of topics and provide referral information about services and programs at the Student Counseling Center and via community agencies (Texas A&M website, 2005).

The Texas A&M counseling website is inclusive in the services that they offer by meeting the needs of a variety of people, including students from diverse racial, ethno-cultural and national backgrounds, sexual orientations, gender identities, physical and mental abilities/disabilities, languages, ages, religious/spiritual beliefs, career aspirations, and socioeconomic backgrounds (Texas A&M website, 2005). Research is currently being conducted to benefit the practices of counseling, psychology and psychiatry, and to advance the website and counseling center at Texas A&M. The ultimate goal of the aforementioned student centered services is to increase the personal functioning level of all students attending Texas A&M, thereby nurturing the possibility of academic success.

The second counseling website breaking ground in the area of on-line counseling services for students is the University of Chicago. U of C is increasingly using the internet as an unconditional sounding board for counseling outreach to students. Their goal in doing so is to share information on issues common to university students via links to the Virtual Pamphlet Collection developed by Dr. Robert Hsiung. The Virtual Pamphlet Collection is made up of the best of the informational pamphlets targeted at university and college students. They are easily accessed on U of C’s website. They cover such topics as: depression, gender identity, anxiety, relationships, stress management, eating disorders, academic stress, suicide etc. (University of Chicago Website, 2005). U of C’s incorporation of The Virtual Pamphlet collection is a cost-effective form of bibliotherapy and/or information sharing that allows students to download and/or to read the materials without printing charges. The virtual pamphlets are also shared with other counseling centers, faculty, staff, and even students' families. The time and effort that goes into developing the material goes further, as the virtual pamphlets reach an audience far beyond the originating counseling center (U of C website, 2005).

There is growing debate on university campuses and in the therapeutic community about how best to use new technologies for the betterment of students' academic and psychosocial development. An analysis of online mental health information and referrals is always prudent as it relates to the clinical, ethical, and legal issues pertaining to "E-Therapy." Dr. Bob Hsiung’s book, E-Therapy (2004), offers numerous case studies and examples of active programs that deliver mental health information and therapy via new media and provides a comprehensive and cautious perspective on the ethics of E-Therapy. While speculation and scrutiny of on-line therapy is fierce, research related to the effectiveness of these methods used in online counseling is sparse, therefore making critics of this therapeutic modality more critical. In addition, the infancy of the field as well as the complexities in monitoring and measuring transactions in the cyberspace create even more debate on its efficacy (Suler, 1999). The research that exists currently tends to be of a qualitative nature based on extremely small samples.

What is not debatable, however, is the notion that communication via computer-based technology has been useful in business, military and academic realms for several years (Bloom, Walz, 2000). Powell (1998) reported that many people feel more comfortable describing socially deviant behaviors, like suicide, to a computer because it seems like a completely nonjudgmental entity. Other noted areas of strength in terms of computerized interaction include: information sharing, speed, increases in equality of participation among those of different statuses, increases anonymity, "heighten" intimacy and solidarity, uninhibited brainstorming, and increasing democratization (Walter, 1996).

Some critics of on-line therapy suggest that such a therapeutic modality creates isolation instead of increasing social functioning (Childress, 1998). One study indicated that it is the use of the Internet in general (not so much cybertherapy itself) that causes a decline in familial communication patterns, thereby decreasing one's social circle and thereby increases one's level of depression and loneliness (Kraut, 1998). Michaelson (1996) suggested that computer-mediated communication is best utilized to enhance already-existing communities, e.g., neighborhoods, schools, local volunteer networks, rather than to replace them with cyber-substitutes.

Online clinicians, not only use e-mail, yet often use other channels to communicate with their clients as well such as: instant messaging, chat, telephonic communication and in some cases occasional face-to-face meetings, thereby creating somewhat of a hybrid counseling scenario (Finn, 1996). For some clients, combining different communication modalities may prove to be a powerful strategy in that the total effect of the hybrid therapeutic session is greater than the sum of the two, causing a synergistic effect. People express themselves differently when communicating with voice, text, and visuals, which can therefore offer different levels of discovery for the therapist and most importantly for the client. What is clear is that unique aspects of identity and self emerge in the various forms of communication modalities (Miller, 1998).

Some clear advantages of therapeutic online relationships include: a greatly improved level of personal privacy, improved decision-making abilities, higher functioning interpersonal on-line relationships, increased levels of personal responsibility for self-help and interpersonal engagement (Lebow, 1998). In addition, E-Therapy can provide life saving services to those who might not have reached out at all was there not a promise of anonymity. Also, the home ridden, geographically challenged, or stigmatized clients who will not or cannot access treatment locally (i.e., individuals struggling with HIV/AIDS, cancer, sexual identity issues, STD's etc., who in no way want their identity or presenting problem to be revealed for both personal and professional reasons), can receive services that are not otherwise available to them.

Disabled persons such as those with visual or auditory impairments are also a population that might find E-Therapy as well as, self-help materials, bibliotherapy etc. now much more accessible online. The flexibility of location and of time, varying schedules, and flexibility to employ various online channels of contact is also appealing to many individuals seeking therapeutic assistance.

Michaelson (1996) states that another advantage of E-Therapy is that some individuals are less likely to feel judged in the therapeutic session, thus more likely to be honest during their session. In addition, some clients report feeling less inhibited, and more expressive in writing than face-to-face (King, 1996). Therapists as early as Freud have been encouraging clients to use writing as a form of expression and/or catharsis. By typing text, one is forced to choose words that express fears, frustrations, concerns etc. that will be understood by individuals on the other end of the therapeutic keyboard. The emotional meaning of such writings can be conveyed by the most novice of writers as it is writing that comes from the deepest parts of a person's self. Moreover, as suicidal notes are being posted in public online environments such as personal website, message boards (forums), and chat rooms it is becoming easier to identify and approach individuals in crisis (Cutter, 1996).

Thoughtful consideration about professional, ethical and risk management practice must be considered at all times in the E-Therapy session. One of the greatest ethical concerns for E-Therapist is that the Internet may not always be as protective, confidentially speaking, as is needed and required in the therapeutic relationship (King, 1998). An E-Therapist can in no way guarantee the privacy of his or her client online. Personal computers have as many strengths as they do fragilities. One current issue to contend with is that personal computers are relatively easy to break into. In essence, this could cause personal and confidential therapeutic matters to become available to unintended readers. This is particularly problematic, in that the therapeutic relationship is predicated on private matters only being shared with a very selective audience, namely the therapist.

Another issue of concern arising with online therapy is that of establishing identity, positively and absolutely (Lebow, 1998). A consumer must know unequivocally that they are working with a state licensed psychotherapist who has the state appropriate certifications and qualifications to guide them through a healthy therapeutic experience. Verifying appropriate training and expertise is prudent as an online client consumer.

Assessment of risk and initiation of appropriate suicide intervention is an area which many mental health professionals do not believe can (or should) be addressed via E-Therapy (King, 1996). Some conclude that it is impossible to do appropriate suicide evaluations if not face-to-face, to take advantage of visual and other suicidal cues in assessing the client's state of mind (King, 1996). No doubt there were similar critics when telephone hot lines were established, which today we consider a crucial part of the crisis intervention continuum of services process (especially as it relates to teens, runaways, domestic violence, rape, and other human tragedies (Miller, 1998). Most E-Therapists concur, that the suicidal client must be handled with great care and concern and that interventions may require more than the capabilities that on-line therapy has to offer.

The traditional therapist in clinical therapy as well as the E-Therapist must be concerned about safety, confidentiality and other issues that are well-known to arise in the therapeutic session. In addition, E-Therapists must take special care in recognizing significant psycho pathology that may emerge during the E-Therapy session that which may call for the need for more traditional forms of therapeutic intervention, such as a face-to-face session and or in extreme cases psychiatric hospitalization (Suler, 1999).

Addictions, as another example, are often difficult for the therapist to detect on-line. Even the most experienced addictions professional may miss serious cues such as the visual and/or aromatic signs that are often present for clients that suffer from addictions, (i.e., red eyes, odor of drugs and alcohol etc.) Substance abuse education, is certainly available on line but is often ignored by those needing it most. Hence, a hybrid of E-Therapy as well as the more traditional in office treatment may be called for.

Clients seeking help online are faced with a computer monitor rather than a receptionist and donot have the benefit of immediately seeing all the diplomas and licenses on the wall, nor experiencing through their own eyes a therapist's unconditional positive regard, warmth or smile. The lack of tactile connection as well as in- person chemistry are often missing in the E-Therapy session. Conversely, some clients may do better without the in-person clinical exchange.

The Human Services Department and Women’s Center at California State University, Fullerton has worked collaboratively and productively for over a decade. Given the collaborative nature of the departments, a unique aspect of developing a website was a focus on gender issues as well as sociological, developmental and psychological concerns for students on campus.

With the support and involvement of licensed professionals, faculty & community experts, students who were interested in careers in the “helping” professions were trained to be peer counselors (both online, by phone and in person). The online hotline was seen as an important resource for the campus community. It was intended that services be targeted toward CSUF students in need of immediate intervention, referrals, support and resources. The outcome was to increase retention rates and decrease barriers to graduation.

California State University, Fullerton is a richly diverse campus. It is a comprehensive, four-year public university located in North Orange County, about 30 miles southeast of central Los Angeles. CSUF’s surrounding communities, both in Orange and Los Angeles Counties, are extremely diverse in terms of socioeconomic and ethnic composition. Nearly half of the population in Orange County is comprised of individuals from underrepresented ethnic populations, including 14.9% Asian/Pacific Islander, 30.8% Latino/Hispanic, 2.1% African American, and 0.7% American Indian/Native Alaskan. Los Angeles County has a similarly diverse ethnic composition, with some of the cities closest to CSUF having particularly high Asian and Latino populations. As a result, CSUF’s student population is multi-ethnic in composition, with 50% from “minority” ethnicities. Table I illustrates the student diversity.

Table I: CSUF Ethnic Composition
AMERICAN INDIAN	1%	195
BLACK	3%	919
HISPANIC	24%	7767
ASIAN/PACIFIC ISLANDER	22%	7022
WHITE	35%	11422
UNKNOWN	12%	3846
INTERNATIONAL STUDENTS	4%	1421
		32592
Source: CSUF Institutional Research & Analytical Studies, Fall 2003.

Founded in 1957, CSUF is now the 4^th largest university in the California State University system, with a Fall 2003 enrollment of 32,592 students (23,428 FTES). First generation college students are the largest growing population on this campus.

Considering the aforementioned statistics as well as our university and department’s goals and objectives each year, the Human Services Department and Women’s Center created a peer supported online hotline. The hotline provides information and referrals on the following topics:

The name of the hotline is universityblues.org. The tagline is “What’s Got You Blue?” The University Blues Project was designed to provide a safe and non-threatening online/hotline (universityblues.org) through which university students could access support services and referrals for emotional and social concerns. Additionally, a face-to-face peer support counseling service was to be offered during regular campus hours. The University Blues Project was offered as an internship opportunity. Interns and peer educators were recruited from Human Services, Psychology and Counseling and Child and Adolescent Studies Departments.

The University Blues Project was an opportunity for student interns to become proficient in peer counseling and crisis hotline services and to provide these services under the supervision of licensed professionals. The University Blues Project trained students in counseling techniques, crisis intervention, gender socialization, sexual harassment, sexual assault, domestic violence, culture and ethnic perspectives and suicide prevention.

2. Support the timely graduation of students, by addressing the emotional concerns of students in a safe environment

3. Create a survey for all student participants to determine user profile and efficacy of program; publish results

4. Provide a well-supervised internship opportunity for undergraduate and graduate students in the helping professions.

1. Students will be adequately supervised and trained in paraprofessional counseling. Students will have immediate access to professional input when providing peer counseling.

2. Students accessing services will be linked as needed to appropriate campus and community services that might provide support and counseling for emotional struggles

3. Students will receive early interventions for personal problems that may be inhibiting academic performance, thereby increasing the probability of a timely graduation.

The Human Services Department and Women’s Center secured a university grant to fund the University Blues Project. The university funding source targeted projects designed to support student retention. After receiving the funding, work began to explore similar campus-related websites or hotlines in an effort to create the most advanced and inclusive internet website possible.

Website designers from Texas A&M and SUNY Buffalo were contacted and found to be collegial and supportive of any university interested in establishing online help for students. After several conversations and exchanges of information, it was apparent our efforts were appropriately focused.

The Human Service Departments and the Women’s Center’s vision incorporated the best of these two website’s concepts and added online peer counseling 24 hours a day for 7 days a week. To date, an online peer counseling site had not been offered or tested by a large educational institution. In the Spring of 2003, seven interns were chosen from a pool of applicants of Human Service, Psychology, Counseling and Child and Adolescent Studies majors. Interns were chosen based on their counseling competency. Many of the interns sought the internship, not only because they found the site valuable to university students, but because many of them had complicated personal and professional lives and looked forward to being trained to staff an online-hotline that would have such a wide range of hours from which to choose.

The Women’s Center met several times with the Counseling and Psychological Services (CAPS) on campus. CAPS expressed concern that providing peer counseling 24/7 would not only be logistically complicated, but it had ethical implications to explore. Supervision would be financially prohibitive and ethically prohibitive and legally problematic.

Further discussions with IT on campus as well as owners of websites and professionals in the community created a shift in focus from an online hotline to a “help site” for students who may be hesitant an/or resistant to seek counseling, but willing to explore some of their concerns in the privacy of their own residences.

Univesityblues.org was launched in December 2004. As of May 2005, the website has received 13, 855 hits. Ten (10) faculty members have incorporated this website into their classes as a resource for research papers, as a self-exploration exercise and as a tool for students seeking careers in the helping professions.

Data in the form of reaction papers have been collected from 16 CSUF and Chapman University students and guests to the website. The following is a sample of the positive and enthusiastic responses from site visitors:

I looked at the website and found it very informative. I think that it is a great resource for individuals that need information on life stressors and judgment calls that would affect their daily lives. I found my self interested in subjects that related to be personally such as anxiety, stress, healthy relationships, parenting issues and the counseling corner. I was also interested in issues that I was not familiar with such as interracial dating, gay/lesbian/bisexual issues and sexual assault. The format was user friendly and colorful making it more interesting to peruse the different topics listed.

This web site is very interesting! I navigated through the site for 20 minutes and really like the fact that it ties into both you8r calls and my theories of personality’s class. When I click though the tabs, I also feel like I am reviewing information that we have discussed in class and in our text book.

If I was entering this site as a therapist, it would be supply be tools to use as assessment guides on my clients. I find that part of the site helpful and useful. As a client going to this web-site, I can navigate easily. The on-line counseling is a nice touch. One final note; how long can I remain an “on-line” client and do I have to sign an authorization waiver before the therapists begins providing me advice?

As I reviewed the website Universityblues.org, I couldn’t find anything I didn’t like. The website is extremely interesting and easy to get around. I truly enjoyed the fact that the information given was brief and helpful. In addition, the website is colorful and creative, which made the website interesting to the public eye. Furthermore one of the things that I enjoyed mostly about the website is that there’s an online counselor. The counselor is there to answer any question or simply assist anyone that has a problem. For this reason, this website is one of the best things created so far on this campus.

The information given in this website, gave me enough information to help one of my closest friends. The feeling of being anxious, overwhelmed, depressed and afraid is common emotions that many people go through. It is not easy trying to deal with any of these emotions alone.

In previewing this site, I found there to be a lot of information about various types of issues that many people may explore. I enjoyed reading the articles and visiting the other website that were offered. It also had many different resources about each subject about mental health. The topics that were displayed on the website ranged from anxiety to healthy relationships. In each of these subjects there was advice and options to better way of living. This site also offered links to other websites that portrayed more information about each of the subjects. These links included more articles and journals about mental health and how to deal with the issues in a person’s life. I found this to be very helpful information for it also gives the viewer options for treatment and counseling. The new links had stories and articles written by professionals in the field. I know that with my schedule it is really hard to find someone to talk to. This is a healthy way to help myself and many others who need the help.

University Blues web page is great! What a wonderful resource for students to have. Itis easy to understand and to maneuver. Every link gives you another resource regarding that specific subject. I like the idea as a whole, since it opens the door to students who otherwise might be afraid or intimidated to seek help. The fact that you can talk about your specific problem to a license therapist online; someone that you know is reliable and will keep your problems confidential is a great asset to have. What about if someone is in need of immediate help? I know that the web page specifies that if you have an emergency to call 911, but one that has received this service before, might just become dependent and expect an immediate answer. I think posting something about this subject would be beneficial and informative. Overall, a great web page and fantastic idea! What a nice way to show students that you care and that you are only an email away.

Due to ethical and financial concerns, the final project was limited to a comprehensive resource, referral and information service with a licensed counselor available through e-mail. The online hotline with peer counselors was an eliminated feature of this site. This article will discuss the reasons for its elimination and will also explore obstacles and challenges this project experienced.

According to Meier, Scott, and Davis in Elements of Counseling, providing any kind of counseling online lacks “theoretical models of practices, supporting empirical evidence” and lacks any guarantee of confidentiality (Meier, et al, 2003). In 1997, the National Board of Certified Counselors offered web counseling standards. In 2003, Heinlen, et al examined 136 websites that offer online counseling and found widespread lack of compliance with these standards. The web counseling standards address some of the following limitations found inherent in the universityblues.org project:

1. Who would provide supervision? How would we arrange supervision for peer counseling 24/7? Who would compensate these supervisors

2. Liability concerns – should a peer counselor be communicating with a student who is suicidal, or otherwise at risk and that student engages in dangerous behavior, who is liable?

3. In essence we found ourselves confronting all the ethical concerns we often discuss in the classrooms with our students. Further, we were confronting all of the issues and complaints we lodge at online counselors and talk radio “therapists.”

Undoubtedly, therapists who use the Internet to provide therapy should get specific training in several aspects, including technology, theory, applications, and ethics (Polauf, 1998). Internet based mental health services should be seen as a new and emerging form of treatment in which case each practitioner is ethically bound to seek out and participate in appropriate training and ongoing supervision in order to develop and maintain their competency. The online mental health practitioner needs to develop skills that derive from training and experience in a professional discipline such as psychology, psychiatry, or clinical social work. The clinician must also learn effective techniques for using text to work synchronously and asynchronously with individuals and groups and should possess skills such as: fast or touch-typing, comforts with Internet modalities and software programs (e.g., IM, chat, email, downloading the latest browser) (Suler, 1998).

Therapists that participate in E-Therapy should also posses the following emotional skills: comfort describing own and others' feelings in text, comfort in a text-only environment, ability to make effective therapeutic interventions using only text, awareness of how the client perceives a therapist online, skill at clarifying accuracy of online communication, enjoy being online, experience with online relationships (synchronous and non-synchronous) flexibility in approach and conceptualization of therapeutic relationships (e.g., believing it's possible to form therapeutic relationships without visual cues or employing traditional psycho dynamic, frameworks, concepts, and techniques), confidence with technology and role as online authority, tolerance for computer glitches, ability to move between modalities (virtual and face-to-face) in response to a client need and circumstances, ability to handle acting-out behavior and intensity of emotion as expressed in client messages (ranging from frustration and anxiety to client projections, anger, boundary and abandonment issues, etc.) (Bloom, 2000).

Research (Kling, 1996) suggests that working online is only suitable for experienced face-to-face therapists. However, that may change in the next several year as using the Internet and working online becomes more widespread. As Internet usage grows, newly trained therapists will want to develop an online practice (perhaps with little or no face to face experience) and will want to concentrate on the skills of working online during their training. It is therefore very important that attention is paid to best practice for training therapists in this new medium.

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