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Family, Peer, and Internet Counseling

Families are increasingly involved in therapy processes, when this seems like it might be helpful. In treating autism, for example, Ivar Lovaas of UCLA achieved good results by training parents to be therapists.

Previous studies showed that intensive therapy with autistic children in clinics could make progress, but the progress was reversed if children went back to a non-treatment setting in an institution or at home. However, the therapy tech­niques of positive reinforcement were easily learned by parents.

When parents took over the therapy at home, positive reinforcement could continue for years. Improvement was much more likely to continue and be maintained over time.

What is an advantage of using parents to do therapy with autistics?

Family involvement in therapy can be valuable in treatment of a variety of disorders, including severe psychiatric disorders like psychoses. It depends upon the family having (1) accurate information about the disorder, and (2) a support system so they could learn about the success and failures of other families doing the same thing (Gunderson and Hoffman, 2005).

What factors are important when families are involved in treatment?

With reliable information and therapist support available, family involvement improves outcomes in studies involving OCD, depression, anxiety disorders, and eating disorders. Not every cultural group is equally like to have family help available. Asian American and Latino consumers of therapy services are most likely to live with family members and receive family support (Snowden, 2007).

For some disorders, like ADHD, researchers find that family involvement is not particularly helpful. For others, like OCD, "family inclusive treatment" helps because therapists can target family accommodation of symptoms that encourages the OCD and keeps it going (Thompson-Hollands, Edison, Tompson, and Comer, 2014).

When is family participation most helpful?

Family involvement is helpful if a family suffers because of a disorder. People with post-traumatic stress disorder (PTSD) view their disorder as a source of family stress (86% in one study). Consequently, 79% expressed interest in family involvement in treatment (Batten et al., 2009).

For some problems, a uniquely effective form of counseling is peer counseling. In peer counseling, people who have "been there" or overcome similar problems are discussion leaders in group therapy, for people dealing with the same issue.

Typical results came from a study of women newly diagnosed with breast cancer. The researchers reported:

Women with breast cancer express the greatest need for counseling at the time of diagnosis and report that the intervention they want is to be able to speak with someone who has the same cancer, but has lived through the crisis of treatment and is leading a 'normal life.' (Giese-Davis et al., 2006)

In this group, peer counseling reduced trauma symptoms, improved emotional well-being, and increased feelings of efficacy about the cancer treatment. The research­ers wrote, "Our findings indicate that peer [counseling] may halt a decline in quality of life that is commonly found in the first year following breast cancer diagnosis."

How can peer counseling help after a cancer diagnosis?

Peer counseling is widely used in drug treatment (for example, the alcoholics anonymous program). In a program to reduce or eliminate heavy cannabis use in a group of urban adolescents that was 91% African-American, peer counseling was far more effective than alternatives. A third of participants were abstinent at a six-month follow-up, compared to 13% in the control group (Mason, Sabo, and Zaharakis, 2017).

Peer counseling has been used in treat­ment programs for teens with antisocial behavior problems. Peers may have more credibility than therapists with that group.

Peer counseling was effective in HIV interventions as well. In that population, peer counselors were found to be best at fostering hope through their own examples.

Peer counseling is effective in helping parents who have lost a child, a situation so painful that "only somebody who has gone through it can really understand." For similar reasons, peer counseling is more credible than therapist counseling when comforting victims of violent crime and giving support to caregivers of Alzheimer's Syndrome sufferers.

In each of the above situations (cancer diagnosis, cannabis overuse, antisocial teenagers, AIDs treatment, loss of a child, victimization by violent crime, care of an Alzheimer's patient) there is a common element. People who have been through the same experience "know what it is about" and might have more acurate knowledge and empathy than therapists, even if therapists are well-intentioned.

What is a common element in situations where peer counseling works best?

Peer counseling has been used to encourage new mothers to breastfeed rather than using bottled formula. The United States Department of Health made this a priority after finding that low income women were far less likely to breastfeed than better educated or higher income women, in the United States. This is another situation in which peers are better equipped to address problems and provide solutions and reassurances.

A typical study showed peer counseling reduced the number of women who refused to initiate breastfeeding from 23% to 9%. Another study, comparing peer counseling with conventional breastfeeding support, showed peer counseling proved more effective, producing tangible benefits such as cutting the incidence of infant diarrhea in half (Anderson, Damio, Young et al., 2005).

Chapman, Morel, Anderson, Damio, and Perez-Escamilla (2010) located 26 high quality studies of peer counseling for breastfeeding. The "overwhelming majority of evidence" supported effectiveness of peer counseling.

The internet is increasingly used for delivering therapy. It is convenient for people in rural areas who lack access to clinics, and it can provide anonymity, which is important for some problems. Sauls (2001) described "e-therapy" as "the new frontier," noting over 200 sites offering on-line therapy when she wrote.

Klein, Richards, and Austin (2005) compared two ways of treating panic disorder, using the internet versus using a manual, both with therapist assistance. A control group was provided with information by telephone contact only. The internet treatment was most effective at reducing agoraphobia and the number of doctor visits.

What factors correlated with success in internet therapies?

Andersson et al. (2009) analyzed suc­cessful internet therapies to see what factors correlated with success. Impor­tant elements were (1) arriving at a proper diagnosis before treatment, (2) providing a comprehensive treatment, (3) making the treatment user friendly and not overly technical, and (4) providing support and a clear deadline for the duration of treatment.

In a variety of studies, therapist assis­tance (as compared to disembodied information) helped to improve out­comes. When programs lacked inter­action with a human counselor, parti­cipants reported missing the human element.

Even in studies where contact was limited to the internet, rather than face to face, therapist empathy and prompting (for example, by email) was reported as helpful. As a rule, enforcement of dead­lines correlated with success in therapy, compared to situations with loose or absent deadlines.


Anderson, A. K., Damio, G., Young, S. et al. (2005) A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Archives of Pediatric Adolescent Medicine, 159, 836-841. doi:10.1001/archpedi.159.9.836

Andersson, G., Carlbring, P., Berger, T., Almlov, J., & Cuijers, P. (2009) What makes internet therapy work? Cognitive Behaviour Therapy, 38, Iss.Sup1.

Batten, S. V., Drapalski, A. L., Decker, M. L., DeViva, J. C., Morris, L. J., Mann, M. A. & Dixon, L. B. (2009) Veteran interest in family involvement in PTSD treatment. Psychological Services, 6, 184-189.

Chapman, D. J., Morel, K., Anderson, A. K., Damio, G., & Pérez-Escamilla, R. (2010) Review: Breastfeeding peer counseling: From efficacy through scale-up. Journal of Human Lactation, 26, 314-326. doi:10.1177/0890334410369481

Giese-Davis, J., Bliss-Isberg, C., Carson, K., Star, P., Donaghy, J., Cordova, M. J., Stevens, N., Wittenberg, L., Batten, C. & Spiegel, D. (2006), The effect of peer counseling on quality of life following diagnosis of breast cancer: an observational study. Psycho-Oncology, 15, 1014-1022. doi:10.1002/pon.1037

Gunderson, J. G. & Hoffman, P. D. (2005) Understanding and Treating Borderline Personality Disorder. Washington, D.C.: American Psychiatric Publishing.

Klein, B., Richards, J. C., & Austin, D. W. (2005) Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37, 213-238.

Mason, M. J., Sabo, R., and Zaharakis, N. M. (2017) Peer network counseling as brief treatment for urban adolescent heavy cannabis users. Journal of Studies on Alcohol and Drugs, 78, 152-157.

Sauls, M. B. (2001, January) E-Therapy: The new frontier. Georgia Psychologist. Retrieved from:

Snowden, L. R. (2007) Explaining mental health treatment disparities: Ethnic and cultural differences in family involvement. Culture, Medicine, and Psychiatry, 31, 389-402. doi:10.1007/s11013-007-9057-z

Thompson-Hollands, J., Edison, A., Tompson, M. C., & Comer, J. S. (2014) Family involvement in the psychological treatment of obsessive-compulsive disorder: A meta-analysis. Journal of Family Therapy, 28, 287-298.

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