Internet-delivered interventions in mental health rehabilitation:
A recovery-oriented online service platform
Eitan Ben Itzhak Klutch, MA
Liat Libling, MPH
Nirit Benyamini, MSW
Max Lachman, Ph.D
Senior Lecture, Community Mental Health Department, Haifa University, firstname.lastname@example.org
Ayala Friedlander Katz, BSW, MA
Israel Psychiatric Rehabilitation Association (ISPRA) email@example.com
Citation:Klutch EBI, Libling L, Benyamini N, Lachman M & Katz AF.(2016) Internet-delivered interventions
in mental health rehabilitation: A recovery-oriented online service platform.
International Journal of Psychosocial Rehabilitation. Vol 20 (2) 62-73
programs presented in this article are supported in part by the Israeli
Ministry of Health, Department of mental health services; the JDC
Israel non-profit organization; and the Israel Institution for Social
security. The first three authors are staff members in the programs
presented in this article. All authors guarantee their sufficient
participation in this manuscript.
Liat libling, Hashoftim 27/4, Tel Aviv, Israel. firstname.lastname@example.org
The purpose of this article is to present an online service platform
applied in Israel, which comprises various technological tools aimed at
assisting recovery-oriented psychiatric rehabilitation processes. Method:
We describe the technological tools and preliminary results of the
e-social and e-occupational programs, developed as part of national
initiatives in Israel. Descriptive data, satisfaction evaluation
results, survey results of reasons for participation and perceived
contributions are presented. Findings:
Within e-social programs, peer-led social groups showed high
satisfaction rates among clients. Reported contributions included
finding friends, emotional, vocational, and self-confidence
improvements, acquiring knowledge and helping others. "Safety net"
social project has been reported to be beneficial in increasing the
sense of security during national emergencies. An e-vocational service
for professionals with psychiatric disabilities showed high rates of
placement. Conclusions and Implications:
Makshivim-Net offers an online assistance for recovery-goals promotion,
with preliminary positive results. Rigorous research with standardized
measures is needed.
Key-words: Mental health; Rehabilitation; Internet intervention; Online-recovery-assistance; Peer-support.
use of the internet as a rehabilitation tool carries unique potential
advantages unavailable in traditional rehabilitation services. A
majority of mental health (MH) consumers use internet and Smartphone
communication for diverse purposes, such as email, text message
communication, employment, medical information search, and social
networks participation (Carras, Mojtabai, Furr-Holden, Eaton, &
Cullen, 2014). In this paper we aim to address existing knowledge of
internet technology as a form of intervention with MH consumers and
then focus on our experience in developing and implementing
internet-based technologies to advance consumers' rehabilitation and
Advantages of internet-delivered interventions in mental health
large body of research supports the use of internet as a form of
delivering therapy for common mental disorders (Andersson & Titov,
2014; Cunningham, Gulliver, Farrer, Bennett, & Carron-Arthur,
2014), addressing its advantages compared to face-to-face delivery
forms. Internet interventions increase accessibility to professional
assistance for people who seek to remain anonymous (Christensen &
Griffiths, 2002), enable to deliver help for people who did not
approach services previously (Ybarra & Eaton, 2005), and to provide
availability of services for people living in remote areas (Farrell,
& McKinnon, 2003). Other advantages include high frequency of
contact and quick response, allowing effective collaborative
interactions (Andersson & Titov, 2014), with low economical costs
for clients (Ybarra & Eaton, 2005) and relatively high
cost-effectiveness compared to other forms of service delivery (Donker
et al., 2015). Organizationally, internet interventions allow
efficiency at work settings as the focus during work shifts from time
of work to outcomes; decreased costs and increased profits; service
delivery improvement; and reduction of environmental damage with the
decreased need for transportation (Cascio, 2000).
addition to these advantages, the literature shows positive clinical
outcomes of internet and Smartphone interventions for psychiatric
disorders, and positive potential for relapse prevention (Alleman,
2002; Ybarra & Eaton, 2005). Most research assessed internet-
delivered interventions for mood and anxiety disorders. For example,
Andersson and colleagues (Andersson et al., 2013) compared internet-CBT
with face-to face CBT for depression and found equivalent outcomes with
long-term sustained gains. Richards and colleagues (Richards et al.,
2015) presented a randomized controlled trial of a weekly
internet-delivered CBT treatment for depression, compared to waiting
list control group.
Their results showed positive outcomes in
depressive symptoms and maintained gains at 6- month follow-up.
Zabinski and colleagues (Zabinski et al., 2001) evaluated an 8-week
internet treatment for eating disorders among 60 women, delivering
different intervention tools each week, such as text use, video, group
discussion, and self-behavior assessment. A 3- months follow-up showed
a significant decrease in participants' will to lose weight, and an
enhanced body image. Lange and colleagues (Lange, van de Ven,
Schrieken, Bredeweg, & Emmelkamp, 2000) explored internet CBT
treatment for 24 participants diagnosed with PTSD. Their results
demonstrated significant decreases in anxiety, depression,
somatization, and sleeping problems following a 5-week intervention, as
well as at 6-month follow-up.
Most participants reported
anonymity of internet-based treatment as an advantage, and this group
showed the most symptom relief. Yet, 40% noted the lack of in-person
contact as a disadvantage. Generally, symptom relief was reported as
similar to that of patients who received traditional treatment.
accumulated findings led researchers to suggest that internet treatment
could serve as an alternative for people who are reluctant towards
in-person therapy (Lange et al., 2000) or as an initial step that
encourages people to later approach face-to-face treatment (Metanoia,
2001). This suggests the need for an integrated approach to practice,
considering internet and in-person treatments as complementary
services (Andersson & Titov, 2014; Ybarra & Eaton, 2005).
Internet-delivered interventions in psychiatric rehabilitation
less research has been conducted to explore internet use within the
field of psychiatric- rehabilitation. Haslett and colleagues (Haslett,
McHugo, Bond, & Drake, 2014) studied a tablet-based intervention
and showed its' contribution to increased involvement in supported
employment compared to a control group. Another occupational project
(Nilsson & Lodestad Misa, 2014) assessed the effectiveness of
shifting from in-person meetings to internet chat between clients and
supported employment experts. Results showed that internet coaching was
perceived as a good complementing form of communication, though not as
an exclusive one. Both clients and employment experts experienced
internet coaching as useful for the purpose of practical and
informative communication, and as a good way to save clients' time,
energy, and money. Yet, both clients and experts identified difficulty
in reading personal moods and responses via internet chat.
and colleagues (Ben-Zeev et al., 2013) described a development and
usability testing process of a Smartphone system for illness
self-management for people with schizophrenia. This project involved
clients diagnosed with schizophrenia-spectrum or schizoaffective
disorders, and practitioners in a community rehab agency: First,
surveys collected interests and expectations from 904 clients and 8
practitioners, concerning the use of mobile intervention; then a
multidisciplinary team incorporated consumer and practitioner input,
and eventually provided design principles for the development of mobile
intervention. Next, 12 consumers participated in laboratory usability
sessions, performing tasks involved in operating the new system. They
provided feedback about their needs and preferences, and usability
ratings. As a result, the designed system is focused on five dimensions
of self- management: medication adherence; mood regulation; sleep;
social functioning; and coping with symptoms. This inspiring process
demonstrates a way to involve clients and practitioners in a shared
process of learning and creating, leading to a shared intervention-
product. Such processes and outcomes seem to put into practice
principles of mutual partnership, empowerment, self-determination and
hope in recovery-oriented services (Farkas, 2007), and further
demonstrate the adoption of a co-productive practice, addressed to in
other recovery-oriented interventions (e.g. Tew et al. 2015;
Thorneycroft & Dobel-Ober, 2015). This project illuminates the
potential of mobile technologies to assist illness self- management,
yet need for systemic evaluation in real-world conditions (Ben-Zeev et
Challenges in using internet-delivered interventions in mental health
challenges arise while using internet technologies in MH therapy and
rehabilitation. Anonymity, which might be an advantage to some, may
cause difficulties for practitioners to identify the person with whom
they are interacting, and to control accessibility of people with
negative intentions. With the growing ability for online anonymity, new
problems emerge, such as cyber-bullying, gossip, or shaming. These
phenomena may lead to depression, and even suicide. Furthermore,
clients' and providers' concerns about documentation and information
confidentiality in technological systems, give rise to the need for
clear guidelines for online interventions (Richards et al., 2016;
Ybarra & Eaton, 2005). Several researchers addressed difficulties
in interpreting vague messages or identifying authentic moods online,
with the absence of non-verbal cues, usually integral to therapeutic
discourse (Andersson & Titov, 2014; Ybarra & Eaton, 2005).
Additionally, high availability of electronic communication opens
possible expectations for immediate response, which may not suite
practitioner's working hours. This might expose relationships between
clients and practitioners to increased occupation with boundaries
issues, when it becomes hard to ignore clients' repeated requests,
questions, or comments.
Additionally, technology assimilation
may be challenging for professional teams used to traditional work,
demanding adjustment of their professional practice. Moreover, online
or mobile communication is usually preformed while a worker is alone,
which may cause lack of interaction with colleagues, as their working
hours may not overlap (Cascio, 2000; Sucala et al., 2012).
Makshivim-Net: A technological-professional platform for online rehabilitation services
(MN) is a platform for rehabilitation services delivered through
Internet and mobile communications, combined with some face-to-face
work. This platform has been developed and applied since 2005, in a
shared collaborative process with clients (Ben-Itzhak- Klutch, 2008).
This collaborative process included focus-group discussions aimed at
clarifying participants' needs and specified expectations regarding
features and information to be placed on site platforms. Participants'
involvement also included choosing a name and logo for the project by
MN provides a range of online programs, offering support
services targeting two main goals- domains: employment, and social
networks. Additionally, two other services, which will not be presented
in the current paper, include virtual supported education and virtual
mentoring/coaching, both function in initial phases to date, and
delivered as private services.
The platform offers varied
online tools to assist recovery-goals achievement for each of these
domains. These services have been assimilated within the national
mental health rehabilitation system in Israel and function as part of
the "Mental health rehabilitation basket" under the ministry of health,
in compliance with the "Community rehabilitation for people with mental
disabilities" law (Aviram, Ginath, & Roe, 2012).
system was developed with high standards of security and privacy
protection, using different updated technologies. Staff is trained to
use these tools, learn about their advantages and limitations.
Supervision is provided online, both individually and in a group, and
face-to-face staff meetings and workshops provide training and
Assessment of clients' needs and
preferences is preformed face-to-face (in occupational services) or
online (in social services), aimed at getting to know each other,
discussing and choosing relevant service\s for each individual.
Assessment and intervention planning consider the preferred combination
of virtual and face-to-face encounters, and preferred individual and\or
group supports. We next describe the main service programs and tools
offered to clients on this platform.
Despite lacking empirical
academic research, much can be learnt through examination of existing
data and accumulated experience among staff and clients. Each of the
services to be presented provides regular reports to the ministry of
health, or other formal partners, including number of participants and
outcomes. Additionally, the services are regularly inspected as part of
the procedural measure of quality performance in rehabilitation
services by the ministry of health. Other data includes participants'
responses to satisfaction surveys conducted by the ministry of health,
and other measures used as part of organizational developmental
Assistive Rehabilitation Technologies: ARTech, ARChat, ARContact, and ARPackage
Technologies include four software functions designed to assist the
rehabilitation process, used by client and worker to manage the
rehabilitation process and follow-up goals achievement:
A monitoring system to follow and assist in managing the online
recovery process. This tool is equivalent to "client file" where
information is collected and a personal rehabilitation plan is created
and modified. The system allows building a process plan, that contains
all the information gathered by client and practitioner, from intake
interview, to rehabilitation goals and preferences, and following
gradual steps, in accordance with the determined recovery goal. The
collected data may be displayed according to authorization determined
by client and worker, deciding who can access the system, and which
information will be presented (either partial (e.g. occupational), or
full ARTech information). The system was developed to provide
accessibility for clients with various disabilities within a framework
of positive reinforcement, where accomplished tasks are marked
graphically. It is designed as a user friendly site, enabling
independent operation and self-management of the rehabilitation plan,
aimed for increased use of the system over time;
A Chat program for both individuals and groups on website or Smartphone
App. This program provides a space for personal private conversations
between client and worker, and serves as a platform for group
discussions. It allows participants to receive supportive response from
their worker or peers.
monitoring external system that serves to receive data from the
participant's support community, such as employers, family, or
teachers. It allows receiving (but not exporting) input from others
involved in the rehabilitation process, in order to integrate important
information and feedback into the shared process of client and worker.
This input can be used for discussion and consideration in decision
ARPackage: A system that
incorporates all of the applications and their data that is collected
in real-time. The system can supply observations on individual clients
in each of the services which they are using, and thus provide a
detailed large picture of the individual rehabilitation progress at all
relevant goal-domains. In addition, ARPackage can provide a wider,
bird’s eye view observation on the system's different programs, while
incorporating several client-files and\or services hence allowing to
examine overall success in goal achievement.
is a large format which contains four system-ingredients which serve as
tools to assist personal rehabilitation processes in the e-Social and
e-Occupational domains, which we detail next.
e-Social rehabilitation services
services are offered to clients who wish to focus on social goals:
Peer-led mixed-online and face-to-face group intervention; and "Safety
Net" for improved community resilience.
Peer-led social online groups combined with face-to-face monthly
meetings: This service, opened in 2005, aimed to meet clients' needs
for connectedness to peers and enhancement of social networks. Group
participation requires accessibility to the technology in use, so that
practitioners need to ensure that a client who joins a group is
connected and equipped with the technological tools and the knowledge
necessary to use it. Groups vary in their nature - from general social
groups to specified-content groups (e.g. healthy life-style). Group
coordinators (all consumers-providers) facilitate the group, and also
arrange special guest- talks occasionally, who join the chat in order
to present specific topics of interest. For example: government
officials’ guest talks, addressing disability rights and benefits; a
Clubhouse representative guest, presenting the Clubhouse principles and
activities; and many more.
The first step in joining a group is
by creating a "personal profile" as a way to present oneself to group
members. Group chats eventually lead to "real-world" face-to-face group
meetings, planned and organized by group participants with coordinator.
satisfaction survey (Dereh Halev. 2007) initiated by the ministry of
health during 2007 (conducted by peer-pollsters as part of a national
evaluation project) showed high rates of satisfaction with staff, with
group contents, activities and atmosphere, and with activity time
schedule. In January 2009 an anonymous "Project efficiency survey"
(Makshivim-Net, 2009) was sent by the agency’s professional management
to all groups' participants (N=129) in order to assess their reasons
for joining the group, the expected areas of improvement as a result of
participation, and their perceived actual progress in those areas.
Thirty-nine participants responded, and expressed their consent to
answer the survey questions without providing any personal details.
Participants revealed varied reasons for participation in social-
groups. Finding friends, improving wellbeing, and hope to find a
spouse, were prominent reasons. Table 1 shows reasons for joining
groups, expected areas of contribution and perceived actual
contribution of group participation.
1 shows that most participants (82%, n=32) joined a group for the
purpose of friendship, while 68% reported actual progress in achieving
this purpose. 76% of those who expected to improve their mental
wellbeing reported actual improvement, though only 17% reported actual
perceived progress in their hope to find a spouse. Nonetheless, one
couple of group members who met in the project is getting married and
two other couples are now living together.
"Safety Net": Improving community resilience: This service was
initiated together with the JDC Israel non-profit organization, as a
response to the stressful times followed by a military operation in
southern Israel during 2014. During that time, people were not allowed
to gather in large groups or be far away from a bomb shelter. They
could not go to work, school or other everyday activities. Obviously,
stress levels are raised when missiles and sirens become a daily
experience, which in some may trigger more severe symptoms, while
having fewer opportunities for social support. Thus, "Safety Net"
offered online group meetings, scheduled in advance, and with higher
frequency during emergency events. Additionally, a professional worker
was available at all times, and participants were given the option to
speak to him over the phone or meet face-to-face. This project now
continues to function as a general community support for regular times.
experiences in this program were assessed using a self-report
questionnaire designed for this purpose (Makshivim-Net, 2015).
Participants were informed about the purpose of the survey and twenty
provided their consent and completed the survey online, anonymously.
Two-thirds (66%) of participants reported that group members were
helpful to them and contributed to their sense of security. From this
group, 88.89% reported that using the chat service with peers was
helpful in providing relief during real-time emergency events.
reported that the group was "very helpful" during those times.
Furthermore, fewer participants reported turning to the professional
support compared to using group peer- support during stressful times.
Nevertheless, one third (33%) of participants did not consider the
group chat as helpful in feeling more secure.
The positive feedback
from participants in this program led to expanding it to all people
with disabilities, with the opening of the "online center for
independent living" model, providing virtual tools for independent
living and social integration, not exclusively for times of crises, but
rather at all times. This new project is consistent with the principal
of peer-led intervention, employing group coordinators with different
types of disabilities.
e-Occupational rehabilitation services
MN platforms offer two vocational assistive programs:
Online supported employment: This program is supported by the Israeli
Social Security Institution and open to all people with disabilities
who wish to receive supported employment services online, as an
alternative to such services provided traditionally. This service
adopted supported employment model principles (Bond, Drake, &
Becker, 2012), while shifting communication between client and
practitioner to MN technology platform, allowing ongoing follow up of
goals achievement in a collaborative relationship. The service is
available to all people with disabilities as a pilot program opened in
January 2016. A research conducted to evaluate the program's
effectiveness will collect data over two years, and initial results are
expected by the end of 2016.
(2) Figure 1 - Occupational characteristics summarizing 12 months during 2015 (N=80)
(2) Online supported employment for academics and professionals with psychiatric disabilities:
program combines internet communication and face-to-face meetings aimed
to assist professionals with psychiatric disabilities to overcome
barriers to competitive employment within their professional field.
This program provides personal coaching, focusing on structured stages
leading to work placement. These stages include preferences definition,
job search, and interview preparation, follow up communication and
ongoing support. Initial statistics among 80 participants, preformed as
part of a service documentation, reported to the ministry of
health (Ben-Itzhak Klutch, Benyamini, & Libling, 2015) showed high
placement rates – 82% during 2015 (13% higher than 2014) of which 58%
worked over 6 months. Age characteristics in this sample show higher
placement rates for those aged 30-50. Two thirds (67%) of placements
were within client's professional expertise, while one third were
working in non-professional jobs. This data is presented in Figure 1:
Emerging challenges and difficulties through implementation of MN
the years of developing and assimilating MN, challenges and
difficulties emerged and search for solutions influenced the programs'
design and development. As in literature, sometimes workers find it
difficult to interpret participants' partial or unclear messages
(Andersson & Titov, 2014). Boundaries of working hours are also
challenged, as technological communication's availability is unlimited
(Ybarra & Eaton, 2005). Such issues are discussed during
supervision, in search of individualized solutions for different
Confidentiality of medical and other private
information is another challenge, as technology allows keeping group
discussions on personal computers' and mobile phone's memory. While
social media such as WhatsApp can serve as a platform for interesting
and important discussions, it also exposes personal identifiable
details of participants. For this reason, rehabilitation interventions
need other platforms, which allow confidentiality. MN solved this issue
by developing the chat platform (ARChat) software that prevents
exposure of all information systems, open only to clients and
practitioners in the program.
Providing online support for
people with mental illness may bring about professional dilemmas for
practitioners. For example, when clients argue about personal issues
and reveal personal details in group, or when clients express extreme
emotional states, such as anxiety, depression, or suicidal thoughts, to
either online group or practitioner. In such situations, practitioners
might feel helpless, and program's policy should consider and address
ways to handle them. Training and supervision are highly important as a
space for discussion about emerging dilemmas, challenging situations
with clients, feelings of loneliness in this unique work environment,
or difficulties in keeping professional boundaries (Cascio, 2000). In
MN, daily communication between staff members allows continuous online
contact, which seems to strengthen workers' sense of belonging in spite
of little face-to-face contact. Nevertheless, individual and group
supervision also take place, online and face-to-face, as well as staff
meetings in both forms.
varied programs described above allow a range of technological tools to
support rehabilitation processes, adjusted to individual needs. In
order to use these tools effectively it is necessary to understand each
technology, the type of intervention that it may provide, and how it
may (or may not) fit specific goals in rehabilitation processes. The
services presented above differ in their goal focus, format (individual
or group), and balance of virtual vs. face- to-face communication.
These differences should be considered while tailoring a rehabilitation
plan. For example, when the client's goal is focused on enlarging their
social network, and enhancing the quality of their relationships, group
interventions may be better suited - either general peer-facilitated
support groups, or topic-specified groups. Group interventions provide
additional value where clients may find the group of equals as a source
for support and encouragement in goal pursuit. Real-world meetings
offered in facilitated groups may further contribute to enhancement of
social integration, while relationships among group members are
encouraged to continue and develop beyond facilitated sessions.
for some goals, group online interventions may have advantages over
individual intervention. For others, personal relationships conducted
online can meet the need for an individualized process and the high
availability of the practitioner assists their personal recovery. For
example, in our experience, occupational processes would usually
benefit from a personal individualized process. More generally,
considering dynamic changes in client's goals may lead to the
recommendation of using individual intervention first, and then
shifting to group intervention as client's goals evolve. Thus, our
experience indicates that choosing an individualized combination of
group and individual supports can bring about better rehabilitation
Another important consideration is the balance of
online and face-to-face encounters, following each individual's
rehabilitation plan. The process of planning with each client
emphasizes the combination of possibilities in both forms of meeting –
online and face-to- face. Following an initial face-to-face meeting,
client and practitioner discuss the best form of communication along
their relationship process. Yet, most of the time the online
communication dominates, which makes the helping relationship more
intense and frequent compared to traditional therapy. This seems to
increase clients' involvement, catalyze task performance, and thus
enhance self-agency and advance goals achievement. Variations in use of
online versus face-to-face communications may also be related to the
program’s main target – social, occupational, educational, etc.
the possibility to combine both forms of communication (online and
face-to-face), either individually or in a group, enables individual
adjustments of the intervention plan throughout the process, in
accordance with personal changed priorities, preferences, or needs
(Alleman, 2002; Andersson & Titov, 2014). This is a unique aspect
of MN that provides clients with the possibility to receive both
individual and group support, both online and face- to-face, allowing a
wide range of individualized intervention plans.
and colleagues (Richards et al., 2016) suggested guiding elements for
quality online interventions delivered by MH professionals. These
include the use of empirically valid contents, ensuring that
technologies are strong, secure, engaging and responsive, and that MH
professionals' input shape these technologies. Moreover, technological
tools' development and design should employ client-centered principles,
and focus on desired clinical outcomes. Such technologies should rely
on effectiveness evaluation and research, and employ well-established
implementation methods (Richards et al., 2016).
support the efforts made during the gradual development of MN over the
last decade, to ensure effective and secure service delivery of
mixed-online and direct interventions in psychiatric rehabilitation.
Furthermore, employing consumers-providers in MN programs and providing
online peer-support interventions is consistent with recovery- oriented
practice (Farkas & Anthony, 2010; Kaplan, Salzer, Solomon,
Brusilovskiy, & Cousounis, 2011). This approach may as well
contribute to a variety of work opportunities for people in recovery
from mental illness as peer-specialists.
Strengths and limitations
paper presented a well-implemented yet still-developing service
platform, which demonstrates an online practice model applied in the
field of psychiatric rehabilitation. Initial results from ongoing
documentation, formal reports and evaluations suggest positive
potential of the assessed services to assist recovery processes among
Nonetheless, the existing data is partial and more
investigation is required with more rigorous methodologies in order to
clarify rehabilitation outcomes and understand more deeply the value of
internet services for people in recovery. Future research may
contribute to further development, towards realizing the positive
potential of such tools through assimilation into MH systems.
service programs presented in this article are supported in part by the
Israeli ministry of health, department of mental health services; the
JDC Israel non-profit organization; and the Israel Institution for
Social security. We acknowledge their financial and professional
contributions to delivering and evaluating these services.
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