Online Therapies Research Articles

Internet-based treatment for Autistic Spectrum DisorderAn overview

Internet-based therapies have emerged as effective alternatives to traditional face-to-face therapies, demonstrating efficacy in treating mental health problems and providing accessible care, especially in this post-pandemic world. Moreover, the unique characteristics of the Internet offer promising opportunities to cater to the unique requirements of patients diagnosed with Autism Spectrum Disorder (ASD) , emphasizing profound impact that can be achieved through internet-based therapy in revolutionizing existing therapeutic paradigms. However, investigation of online therapy for adults and older individuals with ASD is currently limited. This systematic review provides a summary of the status of existing research investigating the application of Internet-based therapies on individuals with ASD, including Virtual Reality-based interventions, Artificial Intelligence-based interventions and other online therapies. The primary objectives are to assess the efficacy of Internet-based therapies as treatments for individuals with ASD. Additionally, potential differences between Internet-delivered therapies and traditional face-to-face therapies are also being explored. By providing a comprehensive analysis of both Internet-based and traditional therapy modalities, this review aims to contribute to our understanding and delivery of more effective therapeutic options available for individuals with ASD. Future directions on better therapeutic choices are discussed, as well as the need for addressing the existing research gap towards elder population.

Digital Mental Health: Role of Artificial Intelligence in Psychotherapy

Background: It is estimated that 6%–7% of the population suffers from mental disorders. WHO reported that one in four families is likely to have at least one member with a behavioural or mental disorder. Post-pandemic, the world has experienced a huge surge in mental health issues. Unfortunately, not everyone is able to access the available mental health services due to constraints such as lack of financial assistance, living in remote areas, fear of being stigmatised and lack of awareness. The emergence of online mental health services could solve some of these problems, as these are easily accessible to people from anywhere, are cost effective and also reduce the fear of being judged or labelled. Lots of efforts are being made today to integrate artificial intelligence with the traditional form of psychotherapy. The role of chatbots for mental health services in the form of e-therapies has been found to be highly relevant and important. Summary: The present study aims to systematically review the evidence on the use of AI-based methods for treating mental health issues. Overall, 95 studies were extracted using some of the popular databases such as Mendeley, PubM, INFO and DOAJ. The terms used in the search included ‘psychotherapy’, ‘online therapies’, ‘artificial intelligence’ and ‘online counselling’. Finally, after screening, 13 studies were selected based on the eligibility criteria. Most of these studies had employed conversational agents as an intervention. The results obtained showed the significant positive consequences of using AI-based approaches in treating mental health issues. Key Message: The study strongly suggests integrating AI with the traditional form of counselling.

Impact of COVID-19 on the use of online mental health services among adults in Riyadh: a cross-sectional study.

Online therapies are licensed online programs designed to aid the use of psychotherapy via the Internet or mobile phone applications by providing effective treatments through digital communication. The number of individuals seeking online therapy has increased during the COVID-19 pandemic. Thus, this study aimed to assess the impact of COVID-19 on the use of online mental health services among Saudi adults in Riyadh. The research design was a cross-sectional descriptive study. The data collection tool was an online survey distributed through social media and email. The survey consisted of two parts: a sociodemographic questionnaire and the e-Therapy Attitudes and Process (eTAP). A total of four hundred participants have completed the survey. Most of the respondents had used online therapy for the first time during the COVID-19 pandemic, and most of the users had a relatively positive experience with online interventions for mental health services. The findings showed that COVID-19 had an impact on the use of online therapy, as it caused an increase in the number of users of these services, and most of the users have found online therapy to be helpful.

Implementing internet-based cognitive behavioural therapy (moodgym) for African students with symptoms of low mood during the COVID-19 pandemic: a qualitative feasibilty study.

Online therapies have been shown to be effective in improving students' mental health. They are cost-effective and therefore have particular advantages in low-income countries like Zambia where mental health resources are limited. This study aimed to explore the perceived impact of the COVID-19 pandemic and the feasibility of implementing an Internet-Based Cognitive Behavioural Therapy (iCBT) intervention ('moodgym') to improve resilience in vulnerable Zambian students. The study was a qualitative interview study. Participants identifying as having symptoms of low mood and completing a baseline, online survey (n = 620) had the option to volunteer for a semi-structured interview to explore views about their experience of the pandemic and the acceptability and perceived benefits and limitations of using moodgym. A total of 50 students (n = 24 female, n = 26 male) participated in the study. One theme with 4 sub-themes, captured the severe emotional and social impact of the COVID-19 pandemic. A second, very strong theme, with 5 sub-themes, reflected the considerable negative effects of the pandemic on the students' educational experience. This included the challenges of online learning. The third theme, with three subthemes, captured the benefits and acceptability of moodgym, particularly in terms of understanding the relationship between thoughts and feelings and improving academic performance. The fourth theme described the technical difficulties experienced by students in attempting to use moodgym. COVID-19 caused fear and impacted wellbeing in vulnerable students and severely impaired the quality of students' educational experience. The findings suggest that moodgym might be a valuable support to students in a low-income country.

Digital Behavioural Interventions to Reduce Opioid Use in Chronic Non-Cancer Pain Patients: A Systematic Review

Abstract Introduction Opioid medications have become increasingly prevalent in the treatment of chronic non-cancer pain1. This increase in opioid usage has given rise to the ‘Opioid Crisis’ which refers to the significant increase in overdose, addiction, and deaths in the USA and Canada particularly2. Furthermore, the World Health Organisation has declared there to have been approximately 0.5 million deaths in relation to drug use worldwide, with more than 70% of those deaths related to opioids3. Advances in technology have paved the way for the use of digital behavioural interventions, such as mobile applications, virtual reality, and online therapies, to potentially mitigate opioid use in patients suffering from chronic non-cancer pain. These interventions aim to assist individuals in modifying health behaviours to promote overall well-being and may serve as a preventive measure against the detrimental effects of long-term opioid use. Aim This systematic review aimed to evaluate the current evidence regarding the effectiveness of digital behavioural interventions in reducing opioid use among chronic non-cancer pain patients. Methods A comprehensive search was conducted in three electronic databases (MEDLINE, EMBASE, and Web of Science) using specific search terms. Primary outcomes focused on opioid usage measurements, while secondary outcomes pertained to pain measurements. Eligible studies included adult patients with chronic non-cancer pain (excluding cancer/palliative patients) who received opioid prescriptions and engaged in digital behavioural interventions in any setting. Two researchers double-screened eligible studies based on titles and abstracts, excluding duplicates and those not meeting the eligibility criteria. Data extraction was performed, and study quality was assessed using the Cochrane Risk of Bias Tool (double-screened). Ethical approval was not required as this study was a systematic review. Results Out of 30,388 articles identified, six studies conducted in the USA met the inclusion criteria. Risk of bias assessment revealed one study with a low risk, two with some concerns, and the majority with a high risk of bias. The publication dates of the identified papers ranged from 2016 to 2021. There was an overall participant population of 605. The interventions included virtual reality, mobile health applications, web-based cognitive-behavioural therapy, guided audio-visual relaxation, and an electronic health toolkit. Two studies reported a specific reduction in opioid use, while three studies did not provide direct measurements for opioid use. However, these studies indicated a reduction in opioid analgesic usage by reporting either over-the-counter analgesic measures or a Current Opioid Misuse Measure score. Discussion/Conclusion This systematic review was conducted in response to the need for updated pain management strategies. The literature suggests that digital behavioural interventions hold promise for reducing opioid use among chronic non-cancer pain patients. However, due to limitations in the included studies, such as sample size, heterogeneity, and potential bias, further research is needed to fully understand their effectiveness. Future studies should focus on optimising the design and delivery of the interventions tailored to this patient population. Continued research in this area has the potential to address the societal burden of opioid misuse and improve patients' quality of life.

MorpheusNet: Resource efficient sleep stage classifier for embedded on-line systems.

Sleep Stage Classification (SSC) is a labor-intensive task, requiring experts to examine hours of electrophysiological recordings for manual classification. This is a limiting factor when it comes to leveraging sleep stages for therapeutic purposes. With increasing affordability and expansion of wearable devices, automating SSC may enable deployment of sleep-based therapies at scale. Deep Learning has gained increasing attention as a potential method to automate this process. Previous research has shown accuracy comparable to manual expert scores. However, previous approaches require sizable amount of memory and computational resources. This constrains the ability to classify in real time and deploy models on the edge. To address this gap, we aim to provide a model capable of predicting sleep stages in real-time, without requiring access to external computational sources (e.g., mobile phone, cloud). The algorithm is power efficient to enable use on embedded battery powered systems. Our compact sleep stage classifier can be deployed on most off-the-shelf microcontrollers (MCU) with constrained hardware settings. This is due to the memory footprint of our approach requiring significantly fewer operations. The model was tested on three publicly available data bases and achieved performance comparable to the state of the art, whilst reducing model complexity by orders of magnitude (up to 280 times smaller compared to state of the art). We further optimized the model with quantization of parameters to 8 bits with only an average drop of 0.95% in accuracy. When implemented in firmware, the quantized model achieves a latency of 1.6 seconds on an Arm Cortex-M4 processor, allowing its use for on-line SSC-based therapies.

Piloting the Acceptability, Practicality and Potential Benefits of Telehealth Dignity Therapy for Community-dwelling Older Adults

Older adults appear to experience high levels of sub-clinical emotional distress. Past literature has predominantly focussed on ameliorating suffering in individuals with diagnosed mental illnesses, while neglecting research investigating online therapies for enhancing wellbeing in community-dwelling older adults. A potential therapy might be Dignity Therapy, a brief psychotherapy originally designed to be delivered face-to-face for terminally ill patients. We piloted a Telehealth Dignity Therapy (TDT) program and tested its acceptability (e.g., satisfaction), practicality (e.g., time spent completing TDT), and the potential benefits for participants. Five community-dwelling older adults were recruited and completed TDT. Participants completed surveys on their satisfaction with TDT. Time spent completing TDT was recorded. We interviewed participants to identify the potential benefits of TDT; their responses were analysed with qualitative methods. All five participants successfully completed the study and reported high levels of satisfaction with TDT. Levels of acceptability and practicality were similar to another online Dignity Therapy study. Participants reported several benefits including: a chance to inscribe their legacy, a deeper connection with others, triggering new self-insight, a strengthened view of self, and heightened acceptance and self-compassion. TDT appears to be acceptable and practical, and provided numerous qualitative benefits for participants. These findings suggest that Dignity Therapy is suitable is suitable to be conducted online and advantageous for community-dwelling older adults without life-limiting illnesses. Further larger-scale, quantitative research on TDT needs to be completed to better ascertain its effectiveness and feasibility.

Review and tribute to Keith Tudor

This commentary is based on Julia, Catherine, and Keith’s article, ‘The challenge of security and accessibility: Critical perspectives on the rapid move to online therapies in the age of COVID-19’, published originally in 2021, which can be found here: https://ojs.aut.ac.nz/psychotherapy-politics-international/article/view/643.

Mental health outcomes and psychological interventions during the COVID-19 pandemic

In the aftermath of the new crown epidemic, people’s lives have been turned upside down and stress levels have increased, resulting in negative psychological and mental health outcomes. Anxiety, depression, insomnia, and other psychological symptoms ensued. And if appropriate measures are not taken in a timely manner, the “psychological crisis pandemic” will erode people more than COVID-19. To date, many experts have proposed interventions centred on maintaining the mental health of the population. Considering some special populations and the specificity of the epidemic period, researchers have given a variety of references, encompassing traditional psychological treatment methods and emerging online therapies. This paper reviews and summarizes the psychological problems that emerged in the population during the COVID-19 pandemic, and proposes appropriate interventions for different populations, providing feasible solutions for maintaining the mental health of the population, which will help people have a clearer understanding of mental health and prevent mental illness in time.

IMPACTS OF COVID-19 ON DIGITAL WORLD

ABSTRACT This article illustrates however the pandemic accelerated the adoption of digital technologies in some areas wherever uptake had been stalled or was solely slowly progressing, like information assortment techniques, e-health on-line appointments and therapies, on-line operating, learning, and social connection. New challenges were created, requiring the scaling of production, fast-tracking of digital provides, construction of on-line platforms and video-conferencing product. These transformations failed to return while not a cost: the pandemic exacerbated existing challenges, exacting government interventions to stop hurt associated social exclusion related to employment and social networking on an unprecedented scale. Even before the pandemic, social scientists recognised that technological development and economic process failed to essentially end in social progress. This shows however the innovative digital solutions embraced throughout the pandemic to prevent the unfold of the virus and avoid economic meltdown can also are wont to justify restrictions on personal freedom and styles of police investigation that risk being tough to reverse. KEYWORDS: covid-19, digital world, Economy

Benefits of Digital Mental Health Care Interventions for Correctional Workers and Other Public Safety Personnel: A Narrative Review

Chronic exposure to stressors and potentially psychologically traumatic events contributes to the high prevalence of mental health disorders in correctional workers (CWs) and other public safety personnel (PSP). Digital mental health interventions are an accessible and scalable method of improving and maintaining the mental health of this population. The current review explores the benefits of digital mental health interventions for PSP–with a focus on CWs–and how these innovations can address the limitations in in-person mental health care. A systematic literature search of five databases (Medline, PsycInfo, Embase, CINAHL, Google Scholar) was conducted until March 2022. The search yielded 16 publications that focused on digital mental health interventions or care available to CWs and other PSP. The benefits of digital innovations were summarized into five categories which discussed (1) their ability to enhance accessibility and reduce stigma; (2) the provision of evidence-based and structured psychotherapy programs; (3) variability in the degree of therapist engagement; (4) the integration of proactive interventions; and (5) enhancing engagement by acknowledging unique experiences and interpersonal relationships. Although digital mental health technologies for CWs are still in their infancy, there is strong evidence to support their effectiveness in ameliorating symptoms of mental distress. Future research should consider how ethnicity, gender, culture, sexual orientation, and socioeconomic status can be integrated into these therapies and how the interplay between different stakeholders and organizations can impact the effectiveness of online therapies and programs.

Lost in translation? Cultural adaptation of treatment content for Japanese internet-based cognitive therapy for social anxiety disorder

Studies that look to disseminate psychological therapies in different countries often discuss whether and how much cultural adaptation may be required. However, most do not provide sufficient descriptions of how language translation and cultural adaptations were performed, and rarely give examples of specific changes. This makes it hard to understand how much the adapted treatment differs from the original, causing difficulty when comparing studies. This study aimed to describe the translation and cultural adaptation process used to generate a Japanese version of a UK-developed online psychological therapy for social anxiety. It aimed to evaluate the translated and adapted content with a case series of Japanese patients. Following translation and back-translation, incorporating cultural adaptations where appropriate, the new Japanese content was reviewed and a list of adaptations collated and categorised. The Japanese treatment material was then evaluated using a guided self-study approach with six Japanese patients with social anxiety. Four categories of adaptation were identified: Linguistics and Metaphors, Social Systems, Social Behaviours, and Familiarity. Assigning instances of adaptation into these categories showed good interrater reliability (0.78). The Japanese materials showed excellent treatment efficacy (pre-post Hedges’ g = 2.31). Patient feedback highlighted areas of strength, and further suggestions to improve suitability for Japanese settings. The clinical outcomes observed suggest that the translation and adaptation procedures were effective. Ways of further improving the adaptation based on patient feedback were identified. It is hoped that the translation procedure and adaptation categories described in this study may help other clinicians/researchers working to disseminate both online or in-person psychological therapies cross-culturally.

Stress and Psychopathology Reduction in Pregnant Women through Online Cognitive Behavioural Therapy during COVID-19: A Feasibility Study.

Background: The global pandemic has affected the psychological health of the population, including pregnant women. Due to the difficulty of offering conventional therapies to reduce stress in this population, studies are needed to show the effect of online therapies. Therefore, the objective was to test the effect of online cognitive behavioural therapy in pregnant women during the pandemic on the main variables of stress and psychopathology. Methods: The sample consisted of 16 pregnant women who participated in a weekly cognitive behavioural intervention for 8 weeks. Prenatal concerns, general stress, stress vulnerability, resilience and psychopathology were assessed. Results: The results show a reduction in prenatal concerns, perceived stress, stress vulnerability and psychopathology, as well as an increase in resilience. Conclusions: Online cognitive behavioural intervention may be effective in pregnant women, so it is important to conduct a randomised controlled trial to certify these findings.

Exploring the influence of testimonial source on attitudes towards e-mental health interventions among university students: Four-group randomized controlled trial.

Electronic mental health services (eMHSs) offer additional options for the dissemination of psychological interventions for university students. Still, many university students are reluctant to use eMHSs. Narrative messages may help increase the awareness and acceptance of quality-approved programs. However, little is known about the usefulness of narrative messages to improve attitudes towards eMHSs. In this experiment, we thus aimed to explore in how far different ways of targeting information to students affect their attitudes towards eMHSs for stress prevention and therapy, and to identify potential determinants of attitude change. N = 451 students (Mean = 32.6 years, SD = 10.2, 75% female, 7% with eMHS experience) were randomly assigned to one of four study arms involving information designed to induce different levels of perceived similarity. While the active control condition only received general information (arm 1, “information only”, n = 116), the other experimental arms were additionally exposed to testimonials on specific eMHSs either addressing an unspecified audience (arm 2, n = 112), employees (arm 3, n = 115) or working university students (arm 4, n = 108). Two-way ANOVA revealed no impact of information on the alteration of attitudes towards eMHSs for stress coping (d = 0.20). Only a small effect of target-group specific testimonials on attitudes towards online therapies was identified at post-intervention (d = 0.29). Regression analyses demonstrated significant influences of source credibility and perceived similarity on attitudes for preventative eMHSs (ps<0.01), as well as a partial mediation effect of perceived similarity in favor of testimonials targeted to students (95% CI [0.22, 0.50]). Overall, this study indicated no meaningful impact of information on attitudes and limited evidence for benefits of tailored narrative messages. Since attitudes were already positive at baseline, further research with a representative student sample mimicking real-world decision scenarios is needed to gain an in-depth understanding of acceptance-facilitating message features that may contribute to promote the adoption of evidence-based eMHSs.

Adaptation of Music Therapists' Practice to the Outset of the COVID-19 Pandemic-Going Virtual: A Scoping Review.

Background: In the midst of a worldwide COVID-19 pandemic, music therapists previously not involved in telehealth had to develop effective remote forms of music therapy. The objective of this review was to systematically explore how music therapists previously working in-person adapted to the transfer to remote forms of therapy in the context of the coronavirus outbreak. Methods: We searched Scopus, Web of Science Core Collection, CINAHL, Medline, ProQuest Central, PubMed, EMBASE, PsycINFO and PsyARTICLES, grey literature (to October 2020), and websites of professional organizations. We followed the JBI methodology for scoping reviews. Results: Out of the 194 screened texts, we included ten very heterogeneous articles with an overall very low quality. Most texts described remote therapy in the form of synchronous video calls using the Internet, one paper described a concert in a patio of a residential home. We report the authors’ experience with the adaptation and activities, challenges and benefits of remote forms of therapy, recommendations of organizations, and examples and tips for online therapies. Conclusions: Music therapists have adapted the musical instruments, the hours, the technology used, the therapeutic goals, the way they prepared their clients for sessions, and other aspects. They needed to be more flexible, consult with colleagues more often, and mind the client-therapist relationship’s boundaries. It seems, when taken as a necessary short-term measure, online music therapy works sufficiently well. The majority of papers stated that benefits outweighed the challenges, although many benefits were directly linked with the pandemic context.

Impact of COVID-19 on autism spectrum disorder management - a therapist perspective

IntroductionTherapist led interventions form a core element in the management of children with Autism Spectrum Disorder (ASD) in India. COVID-19 pandemic has disrupted several aspects of ASD management.ObjectivesThis study aims to understand the impact of COVID-19 pandemic on ASD therapies from a therapist perspective.MethodsAn online survey was conducted using a google form questionnaire disseminated among ASD therapists. The form was open for response between 23rd of June and 23rd of July 2020. The responses were extracted into an excel sheet and analysed using descriptive statistics.Results41 out of 75 therapists with mean age of 44 years (21 – 58 years) responded to the survey. 48% were women. Majority of them were either special educators (49%) or ASD therapists (32%) with professional experience of &gt;5 years (63%). Majority of the therapists felt that there is significant disruption during the pandemic with reduction in conventional therapies (63% to 17%) and increase in online therapies (15% to 61%). They also felt that this disruption had moderate to severe impact on child’s learning (73%) and parents emotional and psychological well being (85%). Only 22% of therapists were using digital based therapy (DBT) before the pandemic. Although 51% of the therapists were not entirely sure whether DBT augments parents and therapists’ efforts, majority (65%) were willing to use them.ConclusionsCOVID-19 pandemic has significantly disrupted ASD therapy in India. Willingness to use online and digital based therapies could open up a new dimension. Reliable and effective Artificial-Intelligence based therapies are the need of the day.DisclosureMedical advisor for CognitiveBotics

Predictors of smoking cessation treatment attrition in individuals with substance use disorders

IntroductionAttrition rates in smoking cessation treatments are high, particularly in persons with substance use disorders. It is estimated that about 55%% disengage prematurely at treatment, meaning that a large portion will not benefit from smoking abstinence. So far, no previous studies have examined predictors of dropouts in a smoking cessation treatment with persons with SUD.ObjectivesThe study was two-fold: 1) to analyze the percentage of early-, late-dropouts and completers, and 2) to examine sociodemographic, psychological, and substance-related predictors of dropouts.MethodsA total of 86 participants (69.8% males; Mage=43.84, SD=9.917) were randomly assigned to two psychological smoking cessation treatment: cognitive-behavioral treatment (CBT) (n=51) or CBT + contingency management (CM) (n=35). Interventions were delivered during eight consecutive weeksResultsOf the 86 participants who completed the baseline assessment, 21 did not start treatment, 17 dropped out of treatment during treatment, and the remaining 48 completed the treatment. Predictors of early-dropout were younger age (B=-.234; p=.024; OR=.792) and lower number of days in SUD treatment (B= -.005; p=.026; OR=.995). Patients’ primary substance of use was associated with reduced early-dropouts; compared to cocaine users, alcohol (B=-1.827; p=.043; OR=.161) and opioids (B=-3.408; p=.018; OR=.033) related to improved attrition. Late dropout was directly related to higher number of tobacco use cessation attempts (B=.407; p=.039; OR=1.502).ConclusionsIncorporating strategies to improve attendance and completion rates in SUD populations should be a priority. Mobile reminders, offering online therapies, or CM to reinforce attendance to therapy may be considered.DisclosureNo significant relationships.

Online Group Psychotherapy for Addiction During Covid-19

Online therapies can include structured therapy content or interventions that are electronically delivered. These predominantly use videoconferences or email to overcome the distance between a therapist and patient to support, or instead of, face-to-face therapy. The increased acceptance and permeation of computer technology into everyday life has led to the rise of electronic therapy, providing a mechanism that could be used as an early intervention or as an adjunct to existing treatments [1].

Przyszłość nowych technologii w diagnozie psychologicznej i psychoterapii. Analiza jakościowa na podstawie metody delfickiej

Introduction. At present telepsychology and telepsychiatry as a part of eHealth field dynamically develop new methods of help towards persons with psychological disorders using mobile applications, computer programmes, portable sensors, chatbots, artificial intelligence, virtual reality, augmented reality and social robots. The aim of this study was to explore the possible answers for the question how new technologies will be used in the future in psychological diagnosis and psychotherapy. Materials and method. Twelve experts - psychologists, psychotherapists, IT specialists and philosophers - participated in the qualitative study based on the Delphi method. The study was conducted using semi-structured interviews. The questions concerned the use of new technologies in psychological diagnosis and psychotherapy in the near future (until 2030) and the distant future (until 2070). Results. Over the decade, experts expect an increase in the popularity of online therapies, psychophysiological state monitoring methods and virtual reality. Experts' opinions are divided in the assessment of changes in the long term - they range between futuristic solutions (e.g. mind reading) and a return to traditional methods. Experts believe that the mental health professions will not be replaced by machines, and that the direct therapeutic relationship between client and therapist will remain irreplaceable. Conclusions. New technologies will be used more frequently in psychological diagnosis and psychotherapy. Clinical psychologists and psychotherapists should be aware of the possibilities and limitations of new technological solutions

The challenge of security and accessibility: Critical perspectives on the rapid move to online therapies in the age of COVID‐19

This article offers some critiques of the rapid move to online therapies in response to the restriction of movement and in‐person psychotherapeutic and psychological practice, imposed by necessary responses to the COVID‐19 pandemic. The critique is informed by concerns about the security of online therapeutic practice; informed by, but not restricted to, legislation and practice in the United Kingdom. Furthermore, it includes cultural perspectives regarding healthcare provision, specifically with Pacific communities in Aotearoa New Zealand and, more broadly, with regard to disadvantaged and vulnerable clients and communities throughout the world. The article offers a framework that accounts for the challenge of making practical, culturally appropriate, and therapeutic decisions about the security and accessibility of online therapeutic practice.