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The use of information and communication technologies has greatly expanded and has far-reaching implications for social work practice. Following an international review of the literature, this study explored how social workers consider the issues associated with integration of e-therapy into their social work practice. A survey of Israeli social workers revealed that only 4 percent have actual experience with e-therapy. Respondents judged disabled persons and those with mobility restrictions, caregivers of the chronically ill, new parents, the chronically ill, and teenagers as the most appropriate target populations. Attitudes toward benefits, barriers, and training predicted the applicability of e-therapy in practice.
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International Social Work
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DOI: 10.1177/0020872819847747
E-therapy and social work
practice: Benefits, barriers,
and training
Julie Cwikel
Ben-Gurion University of the Negev, Israel
Enav Friedmann
Bar-Ilan University, Israel
The use of information and communication technologies has greatly expanded and has far-reaching
implications for social work practice. Following an international review of the literature, this study
explored how social workers consider the issues associated with integration of e-therapy into
their social work practice. A survey of Israeli social workers revealed that only 4 percent have
actual experience with e-therapy. Respondents judged disabled persons and those with mobility
restrictions, caregivers of the chronically ill, new parents, the chronically ill, and teenagers as the
most appropriate target populations. Attitudes toward benefits, barriers, and training predicted
the applicability of e-therapy in practice.
Diffusion of innovation, information technology, suitability for practice, target populations
The expansion and adoption of information and communication technologies (ICT) provide new
opportunities for facilitating the delivery of welfare and health care services (Finn and Schoech, 2014;
Fitch, 2015; Parker-Oliver and Demiris, 2006), while at the same time posing significant challenges to
the social work profession (Parker-Oliver and Demiris, 2006; Reamer, 2013). This article reports on an
online survey of the actual use of e-therapy, together with their preferences and attitudes of Israeli
social workers, and compares it with international literature on the use of e-therapy in social work.
Changes in social work practice have followed the integration of different waves or generations
of ICT. First generation ICT, starting in the 1980s, included computer databases used for statistics
Corresponding author:
Julie Cwikel, Spitzer Department of Social Work, Ben-Gurion University of the Negev, P.O.B. 653, 8410501 Beer-Sheva,
847747ISW0010.1177/0020872819847747International Social WorkCwikel and Friedmann
2 International Social Work 00(0)
and recording information. The second generation, starting in the late 1980s and gaining momen-
tum into the 1990s and 2000s, referred to expert systems, computer-based assessment programs,
therapeutic games, and treatment packages on computers (Grebel and Steyaert, 1995; Oravec,
2000; Parker-Oliver and Demiris, 2006). With the growth of the Internet, e-health or e-therapy has
become an established means of providing psychological interventions, health care, and psycho-
education in the past decade and is deemed the third generation of ICT integration into social work
(Grady et al., 2011; Oravec, 2000; Wells et al., 2007; Wodarski and Frimpong, 2015). The third
generation treatment modalities used by social workers can be divided into (1) social worker-
assisted interventions (e.g. through Skype, email, FaceTime, or texting) with a live, online practi-
tioner, synchronously or asynchronously, either in an individual or group format, and (2) web-based
treatment programs such as self-help workbooks and smartphone treatment apps, which may or
may not be therapist supported (Barak et al., 2009; Manhal-Baugus, 2001; Reamer, 2013; Zur,
2012). In addition, there are Internet-operated therapeutic programs that include robotic simula-
tions, gaming, and 3D virtual environments, which are either independent or have minimal profes-
sional input of professional guidance (Barak et al., 2009). These fourth-generation advanced
information technologies are so new that their interface with social work practice is still minimal
and thus they are not included in this study (Goldkind et al., 2016).
Early on, social workers raised questions regarding how ICT in social work may raise ethical
dilemmas for practice. These concerns included the preservation of individualized care, mainte-
nance of flexibility in treatment choices, links with community networks and optimizing the use of
treatment time, ensuring confidentiality and data security, limiting depersonalization, and under-
standing non-verbal communication that may be lost in translation (Csiernik et al., 2006; Fitch,
2015). Some types of social media, such as Facebook and Instagram, are public-use websites and
can compromise the privacy of clients as well as that of social work practitioners (Beaumont et al.,
2017). A wide selection of creative treatment methods based on ICT, suitable for children, adoles-
cents, and adults with mental health challenges, have been described (Barak et al., 2008; Grady
et al., 2011; Resnick and Anderson, 2002; Strobl-Reichel, 2015; Taylor and Luce, 2003). To
encourage social workers’ use of ICT, a list of over 60 mobile applications, websites, treatment
programs, and apps that are suitable for social workers and their clients is available (Scott, 2014) – for
example a study used a tracking app (iWander) to monitor the wandering of dementia patients, giv-
ing caregivers and practitioners a way to identify an elderly person who had gone astray and was
unsupervised, alleviating stress among family members (Sposaro et al., 2010). However, this arti-
cle did not discuss the implications of data security and protecting the rights of the clients and their
families. In a recent study from Melbourne, Australia, a clinical social worker joined a team of
clinical psychologists to mount a field study testing the feasibility and acceptability of an Internet-
based intervention (Rebound) to foster post-hospital coping skills and prevent relapse among
young people who had a recent diagnosis of major depression. Rebound is unique in its combina-
tion of social networking, tailored interventions moderated by mental health professionals, and
peer support of others in the web-paced program (Rice et al., 2018).
While the integration of ICT into social work practice appeared early in the field of health and
mental health, recently it has also been incorporated into community-based social work practice.
For example, in the Basque area of Spain, a model program called Saregune was developed in the
town of Vitoria to reduce ‘e-exclusion’ and promote ‘e-inclusion’ of unemployed young people in
order to promote supportive social networks and job training. The model was recognized by the
‘Leonardo Da Vinci Multilateral Projects, Transfer of Innovation Lifelong Learning Programme’
as an effective intervention for reducing the e-technology divide between social strata through
inter-linking programs working at the individual, group, and community levels (Raya Diez, 2018).
In this research, we use the following definition of e-therapy (synonymous with telehealth,
Cwikel and Friedmann 3
telemental health, and online counseling) (Grady et al., 2011; Harris and Birnbaum, 2015; McCarty
and Clancy, 2002): the establishment of a therapeutic session between a social worker and a client,
using ICT such as webcam, email, or video-conferencing to establish a therapeutic encounter, syn-
chronously or asynchronously (Manhal-Baugus, 2001; Menon and Miller-Cribbs, 2002; Parker-
Oliver and Demiris, 2006; Strobl-Reichel, 2015). The advantage of e-therapy is that it provides
opportunities for private communication, unlimited by geographic barriers. These features, cou-
pled with the relative low-cost and increasing access to electronic communication, contribute to
the current trend toward provision of online mental health and social welfare services by use of
e-therapy (Harris and Birnbaum, 2015). Sometimes social workers may start to use e-therapy when
a client moves away and wishes to remain in contact through Skype or email. At other times, social
workers may offer e-therapy to their clients outside of regular clinic or office hours.
Meta-analyses of different e-therapy interventions by mental health professionals (not nec-
essarily social workers) have shown their efficacy relative to other types of face-to-face inter-
ventions and in comparison to control groups receiving a placebo care option (Andersson et al.,
2005; Grady et al., 2011; Kuester et al., 2016; Reger and Gahm, 2009). Examples of empirically
tested e-therapy protocols include cognitive behavioral therapy (CBT) for the treatment of
depression (Andersson and Cuijpers, 2009; Kessler et al., 2009), Internet-based treatment for
anxiety (Andersson et al., 2005; Austin et al., 2010), preventing eating disorders (Beintner
et al., 2012; Celio et al., 2000), and alcohol addiction (Blankers et al., 2011). A more recent
study from Sweden showed that six sessions of Internet-based CBT (iCBT) delivered to preg-
nant women (weeks 12–28) with depressive symptoms, supplemented by phone feedback on a
regular basis from a CBT-trained therapist, was an effective way to treat their depression
(Forsell et al., 2017). Studies have shown that Internet-based interventions based on iCBT can
be an effective method of service delivery for mothers facing symptoms of post-partum depres-
sion (PPD) (Danaher et al., 2013; King, 2009; Pugh et al., 2014, 2016). A joint Australian–US
group developed a web-based workbook with a dedicated website (MomMoodBooster), deliv-
ered over six sessions to mothers with symptoms of PPD (Danaher et al., 2013; Milgrom et al.,
2016; O’Mahen et al., 2014, 2015). A further study by this group showed that when supported
by low-intensity phone coaching, the program was effective in reducing depressive symptoms
and had good adherence (Milgrom et al., 2016).
By contrast, a recent study found that iCBT programs were not better than the usual care treat-
ment by a general practitioner (GP) for clinical depression, and there were many problems with
uptake and dropout, despite telephone support and reminders (Gilbody et al., 2015). Others have
noted that the overall research designs were relatively weak, generating small effect sizes in most
studies of e-therapy for mental health problems (Postel et al., 2008). Hence, e-therapy has become
a legitimate tool for clinical interventions in social work, yet it is not a therapeutic panacea (Csiernik
et al., 2006; Fitch, 2015; McCarty and Clancy, 2002; Parker-Oliver and Demiris, 2006; Ramsey
and Montgomery, 2014; Wodarski and Frimpong, 2015).
Advantages of e-therapy include greater access to underserved populations, to persons with dif-
ficulties with physical access, such as the disabled, the incarcerated, parents caring for infants, the
elderly and those living in remote locations, and providing possibilities for treatment access out-
side of regular service hours (McCarty and Clancy, 2002; Reamer, 2013, 2015). This wider access
is particularly relevant to those who suffer from stigma, which may stymie their motivation to seek
social work services and mental health treatment (Capurro et al., 2014; Csiernik et al., 2006;
Parker-Oliver and Demiris, 2006; Reamer, 2013; Taintor, 2002). However, providing e-therapy and
using Internet therapeutic programs may require technical skills from both clients and social work-
ers in order to overcome glitches with hardware and software (Atkinson et al., 2009; Barak and
Grohol, 2011; Grady et al., 2011; McCarty and Clancy, 2002).
4 International Social Work 00(0)
While many have extolled the advantages of e-therapy, the Clinical Social Work Federation
(CSWF) warned in 2001 that the use of e-therapy could accentuate the already prevalent disconnec-
tion between individuals and promote alienation (Menon and Miller-Cribbs, 2002). A series of arti-
cles have focused on how integrating ICT into social work practice can avoid ‘e-exclusion’ of
already disadvantaged populations (Eito et al., 2018; Lopez, 2015; López Peláez and Marcuello-
Servós, 2018; López Peláez et al., 2018; Raya Diez, 2018). This also prompted an examination by
the National Association of Social Workers (NASW), which issued standards for ethical and legal
social work care using ICT (Lopez, 2014; NASW, 2006). The Australian Association of Social
Workers (AASW) similarly updated its Code of Ethics to relate specifically to social workers’ ethi-
cal responsibilities in the use of ICT including e-therapy (AASW, 2016; McAuliffe and Nipperess,
2017). Both of these national codes emphasized the need for added security and protection of data,
and recommended adding informed consent procedures and the use of secure encrypted digital soft-
ware to protect client confidentiality (AASW, 2016; Lopez, 2014; Reamer, 2017).
However, studies of the actual use of e-therapy in social work have shown that few have ven-
tured to include e-therapy in their practice. For example, in a 2007 survey of social workers, psy-
chologists and other mental health professionals in the United States, Wells found that the vast
majority could not see themselves using e-therapy in practice, and in fact less than 2 percent of the
social workers had ever done so (Wells et al., 2007). A study of direct practice social workers
showed that only 3.7 percent used email with clients, and 87.7 percent believed that it was unethi-
cal to conduct therapy through email with clients (Finn, 2006). A recent study that proposed to
interview 20 social workers who had used e-therapy eventually managed to interview only two
practitioners who had done so (Strobl-Reichel, 2015). A study of social work supervisors in mental
health agencies found that the use of ICT for therapeutic purposes ranged from 10.5 percent (mobile
therapeutic games) to 18 percent (e-therapy), with a higher level of usage among supervisors’
agencies with a positive approach to technology (14% of agencies) (Goldkind et al., 2016).
A recent review of all available social work mental health ICT interventions found but six studies
that included social workers and used valid outcome measures (studied published between 2004 and
2013; Ramsey and Montgomery, 2014). Another review of all types of ICT interventions used by
social workers found 17 articles published up until 2012. Only seven were rated good quality in
terms of research design. Seven of the articles dealt with parenting, five with health care, and five
with families with children (Chan and Holosko, 2016). Another recent review of ICT and social
work practice found 70 different articles published between 2006 and 2016 including ICT and social
work; however, the bulk focused on social work practitioners and students, and only 16 articles had
a population intervention focus (child/youth [6 articles], elderly [4 articles], and low socioeconomic
status [SES] or social service consumers [6 articles]). Furthermore, 77 percent were from Anglophone
countries, primarily the United States and the United Kingdom, suggesting that there is still a need
for diffusion of ICT into global social work practice (López Peláez et al., 2018).
According to Rogers’ diffusion of innovation theory (1995), a practice innovation can be
characterized by certain patterns of adoption, with individuals ranging from early to late adop-
ters of innovations. Specifically, innovators (2.5% of a typical group) were found to be inter-
ested in social trends and in touch with innovative groups outside their own community. Early
adopters (13.5% of a typical group) were considered more discriminating about the innovations
they adopted and were effective opinion leaders in their social network. These two groups com-
prise the change agents who introduce innovations to others, made up of early majority (34%),
late majority (34%), and laggards (16%). Thus, those who introduce innovation are a select
group within their profession (Borbas et al., 2000). This model of innovation diffusion has
often been used to describe the uptake of IT technology in different professions and is suitable
for understanding the diffusion of e-therapy into social work practice (Helitzer et al., 2003;
Cwikel and Friedmann 5
Moore and Benbasat, 1991). According to the literature reviewed, it appears that social workers
are still in an early stage of adoption of e-therapy practices (Ramsey and Montgomery, 2014;
Wells et al., 2007). In fact social workers as a group were characterized as ‘late adopters’ of ICT
in general (Goldkind et al., 2016).
The research aim of the present study was to describe the extent of use of the e-therapy by social
workers and the populations they see as suitable for e-therapy in their practice. The first goal of the
survey was to evaluate at what stage of innovation social work practice is in relation to diffusion
of innovation theory. Are we in the early adopter stage or in the broad diffusion stage? The second
goal was to describe the target populations deemed appropriate for e-therapy by the social work
professional community. The third goal was to understand which of the factors influence the per-
ceived quality of communication and perceived comfort using e-therapy with clients.
Based on the results of the international literature review on e-therapy use in social work, we devel-
oped a questionnaire (Barak et al., 2009; Finn and Barak, 2010; Finn and Schoech, 2014; Parker-
Oliver and Demiris, 2006; Reamer, 2013; Strobl-Reichel, 2015). Given the lack of definitive
research on who is more likely to use e-therapy in social work, we did not propose specific hypoth-
eses. The questionnaire included topics such as the use of e-therapy in practice, attitudes toward the
suitability of e-therapy techniques for various target populations, and various therapeutic tasks, for
example intake, supervision, using projective treatment tools such as therapeutic cards or art mak-
ing, crisis intervention, establishing a treatment setting (10 questions). The questionnaire had 25
questions, of which 9 asked about the suitability for specific populations (see Tables 2 and 3 and
the factor analysis below), and 5 questions asked about training and supervision, on a 1- to 5-point
Likert-type scale reflecting endorsement of the statement (1 = strongly disagree to 5 = strongly
agree). In addition, the questionnaire included information about the participants’ professional
background and experience with other electronic media (e.g. Skype, email, WhatsApp) along with
standard demographic questions. Dependent variables included the degree of agreement with the
following: ‘e-therapy allows for quality communication with clients’; ‘I feel comfortable giving
treatment using e-therapy’ (both on a 1 to 5 Likert-type scale, with 5 indicating high quality or
comfort); and ‘Is e-therapy suitable for your target population (treatment suitability, yes–no)?’
The questionnaire was distributed to social workers attending a national social work confer-
ence, and they were supplied with an addressed envelope to return the completed questionnaires,
with signed informed consent. Of the 55 questionnaires distributed, 38 were returned completed
(return rate 69%). The questionnaire was then uploaded to Qualtrics and widely distributed via
social media to Israeli social workers currently employed in the field. An additional sample of 85
useable questionnaires was completed, creating a final sample of N = 123 (questionnaires = 30.9%
and online questionnaires = 69.1%).
Statistical procedures
We first examined the distributions of the descriptive variables regarding the demographic features
of the population, and then tested for differences between demographic and professional groups on
the mean value of the dependent variables relating to e-therapy, using t-tests or chi-square analyses.
We used a general linear model, with repeated measures analysis of variance (ANOVA) to test the
differences between the suitability of different treatment elements and different populations with
6 International Social Work 00(0)
post hoc tests of differences between variables. Finally, the questions about the use of e-therapy in
social work practice were factor analyzed using a Varimax rotation to reveal the major factors that
explained support or lack of support for e-therapy practice. The factor analysis is a common data
reduction statistical procedure, which shows the major factors that explain the observed variance
in the data. In order to characterize the different experiences with e-therapy, each respondent
received a factor score that was generated from the factor analyses results, and these were used to
predict the perceived quality and convenience of e-therapy as an intervention in social work.
Our sample was 11 percent men and 86 percent women.1 The mean age was 45.21 (SD = 10.88):
19 percent of the sample were aged between 70 and 55 years, 25 percent were between 54 and 45
years, 28 percent between 44 and 35 years, and 24 percent between the ages of 34 and 25 years.2
Most were married (63%), 19 percent were single or living with a partner, and 15 percent had a dif-
ferent family status (divorced, widowed). The majority were secular (68%), 18 percent traditional,
and 14 percent religious. The mean of education was 17.5 years (SD = 2.55), which shows that the
mean fell at 2.5 years of post-Bachelor of Social Work (BSW) education (BSW educational level is
15 years since Israel has a 3-year BSW program). The mean number of years of professional experi-
ence was 16.19 years (SD = 11.15): 22 percent had between 0 and 5 years of experience, 24 percent
between 6 and 15 years, 25 percent between 16 and 25 years, and 24 percent between 26 and 41 years.
Approximately half worked full time (46% were working part time and 54% full time).
In terms of field of specialization in social work, respondents could choose more than one
answer: 24 percent were in management, 53 percent family and casework, 17 percent case man-
agement, 12 percent community work, 11 percent empowerment and clients’ rights, and 8 percent
research. The professional work environment was 27 percent in families and the welfare services,
45 percent health and mental health, and 25 percent other professional environments such as
criminal justice or educational frameworks.
Only 4 percent of the sample had actual experience with e-therapy and had received training; 96
percent had never used it or received training. Those with e-therapy experience worked in the fields
of health, in treatment of drug addicts and mental health, had 18 or more years of experience, and
had an advanced degree in social work. The small number of persons with e-therapy experience
invalidated statistical comparisons with the subsample that had never used e-therapy in practice.
However, approximately one-third (37%) thought that the population they were working with was
suitable for e-therapy treatment, and 28 percent thought that was feasible in their current work
environment. The mean value for agreement with the statement (scaled from 1 (disagree) to 5
(strongly agree): ‘e-therapy allows for quality communication’ was 2.7 (SD = 0.92, 20.2% agreeing
or strongly agreeing), while slightly fewer ‘feel comfortable delivering e-therapy’ (mean = 2.34,
SD = 1.34, 18.7% agreeing or strongly agreeing). Those who thought that e-therapy was suitable
for their target population were much more likely to agree with ‘e-therapy being a quality com-
munication’ and to ‘feel comfortable delivering e-therapy to my target population’ (t(113) = 5.45,
p < 0.001, t(111) = 3.95, p < 0.001, respectively).
While 51 percent received supervision regarding social work with clients, only 4 percent had
received training for e-therapy. When asked whether they regularly used other types of electronic
communication (Skype, WhatsApp, SMS, etc.) for their own daily use, 81 percent said they used
SMS and WhatsApp regularly, 57 percent used Facebook, and only 15 percent said they regularly
Cwikel and Friedmann 7
used Skype. On checking whether social workers who used Skype on a regular basis felt more
comfortable using e-therapy with their target population, we found a significant difference between
social workers who do not use Skype (mean = 2.17, SD = 1.25) and the ones who do (mean = 3.41,
SD = 1.46) (t(117) = –3.707, p < 0.05). There were no significant relationships between other types
of electronic communication and any other dependent variable, except that Skype use increased
agreement that e-therapy is suitable for their target population (reached near significance (p = 0.06)).
We analyzed the relationship between age and comfort of using e-therapy with their target popu-
lation using chi-square analysis. The relationship between age and perceived fit of e-therapy for
their target population was significant, with older workers (those aged 45–55 years) more likely to
endorse e-therapy for their target population and younger workers (aged 25–44 years) more likely
to say that e-therapy was not suitable (χ2(3) = 8.74, p = 0.03).
Younger social workers were more likely to work with families and in the welfare services and
the older social workers more likely to work in areas of health and mental health (average age of
welfare workers was 41.8 years (SD = 10.02) and in the health group, 46.5 years (SD = 10.8),
t = –2.01 (df = 83), p < 0.05). When examining the relationship between age and endorsing e-ther-
apy, controlling for target population (welfare vs health/mental health), the chi-square between age
and e-therapy suitability was no longer significant. The relationship between gender and perceived
fit of e-therapy was not significant (χ2(1) = 0.156, p = n.s.). Those who worked full time were more
likely to think e-therapy was suitable for their target population compared to those who worked
part time (47.5% and 29.1%, respectively, χ2(1) = 4.05, p < 0.05). This relationship, however, was
not explained by the different type of target population as the chi-square remained significant even
after controlling for target population (χ2(1) = 3.58, p < 0.05).
We evaluated whether professional experience was associated with judging e-therapy as a quality
communication mode. Using ANOVA and post hoc tests, we found that experienced social workers
(16–25 years of experience) ranked the quality of e-therapy higher than those with less experience
(6–15 years), F(3) = 2.819, p < 0.01. We found that social workers with experience of using e-therapy
were more comfortable using the technique than those without experience (mean = 4.67, SD = 0.58
compared with mean = 2.42, SD = 1.297) (t(80) = 2.978, p < 0.05). However, the small number of
respondents renders this result preliminary and in need of further research.
There were significant differences in the evaluation of whether e-therapy is feasible for dif-
ferent social work interventions using repeated measures ANOVA with post hoc tests (F = 30.71,
p = 0.000; see Table 1). All values above ‘3’ indicate a positive endorsement, values close to the
mean of ‘3’ indicate a neutral position, and all those below ‘3’ demonstrate a somewhat negative
or negative evaluation. The rank shows which variables differed from one another, so that, for
example, all those ranked ‘2’ did not differ from each other significantly but were significantly
different from the other ranks. The most endorsed aspect of social work intervention using
e-therapy tools was supervision, which was significantly more positive than all other aspects of
social work intervention. This was followed by establishing a therapeutic setting, making a treat-
ment contract and setting treatment goals. Neutral values were given to conducting an intake
interview, using crisis intervention and being able to use a wide variety of treatment modalities.
The ability to terminate treatment and to use projective treatment tools were deemed less appro-
priate for use in e-therapy. The limitations on understanding non-verbal communication were
seen as a negative aspect of e-therapy.
Again using a repeated measures ANOVA, we examined the mean difference between the per-
ceived suitability of using e-therapy with different target populations (F = 49.64, p = 0.000) and
found a significant difference between the first-ranked population (the disabled and those with
restricted mobility) and all other populations. Caregivers, parents, those who are chronically ill,
and teenagers were given a positive endorsement, while working with the elderly was thought to
8 International Social Work 00(0)
be less appropriate. The lowest level of fit was found for families living in poverty, which was
significantly different from all populations except people in trauma (see Table 2).
Finally, we examined what issues and barriers are identified by practitioners with regard to
e-therapy. The foremost issue was the need for quality training by an experienced practitioner and
the need for technological support in real time. These concerns were strongly endorsed by the
sample, following the ability to conduct evaluations and use questionnaires online, scheduling
flexibility, and the need to deal with complex ethical issues. E-therapy was deemed appropriate for
specific populations, limiting its applicability in practice, as shown in Table 3. There was signifi-
cant concern about the technological side of using e-therapy, which was ranked in a similar fashion
to the statement that e-therapy improves access to populations that otherwise would not receive
services. Respondents were neutral about the ability of e-therapy to maintain privacy and confiden-
tiality and whether it is the appropriate modality in times of crisis. There was concern about the
external interference during sessions, which was ranked with the lowest endorsement.
In order to understand the relationships between beliefs regarding e-therapy and the perception
that e-therapy is a quality way to communicate with clients, we used factor analysis with Varimax
rotation for data reduction and to generate factor scores that later predicted the applicability of e-ther-
apy in their practice. Two variables were loaded after being reverse recoded (limits a variety of treat-
ment techniques and interventions in times of crisis). Three factors resulted: benefits, the need for
training, and barriers to e-therapy use, together explaining 51.13 percent of the variance (see Table 4).
The three factors were then entered into two regressions to explain the perceived quality of
e-therapy and the convenience of e-therapy. As Table 5 demonstrates, only benefits and barriers are
good predictors of e-therapy perceived quality of communication (adjusted R2 = 0.497, p < 0.001).
As Table 6 demonstrates, all three factors – benefits, training, and barriers – are significant predic-
tors of the perceived convenience in using e-therapy (adj. R2= 0.282, p < 0.001).
The first goal of this study was to evaluate at which stage of innovation professional social work is
in relation to diffusion of innovation theory. We showed that in Israel, the social work profession
is still in the innovator–early adopter stage as only 4 percent of social workers in our sample had
used e-therapy, similar to what was found in other studies, despite the years that have passed since
Table 1. Rank, mean, and SD of perceived fit of e-therapy to social work interventions.
Rank Intervention task Mean SD
1 Can receive online supervision 3.53 1.11
2 Can establish a stable therapeutic setting using e-therapy 3.38 1.12
2 Specifying a therapeutic contract can be done online 3.24 1.14
3 Setting treatment goals can be done online 3.07 1.00
3 Intake can be made online 3.00 1.30
3 Suitable for crisis intervention 2.86 1.20
3 Useful with a variety of intervention techniques 2.78 1.07
4 Meaningful termination of treatment can be managed online 2.41 1.11
4 Can be used with projective tools (cards, art making, etc.) 2.17 1.07
4 The use of e-therapy allows the therapist to perceive the
client’s non-verbal communications
1.99 1.19
SD: standard deviation.
Cwikel and Friedmann 9
its inception (Ramsey and Montgomery, 2014; Wells et al., 2007). The early adopters of this new
technology and those who felt most comfortable with contemplating using e-therapy were more
experienced in social work in general and in Skype use specifically, and more likely to work in
health or mental health frameworks and to work full time. Apparently, these populations feel the
most comfortable trying innovative modes of practice and should be the target of training for
e-therapy. These results contrast with other findings showing that older people in general have
more negative attitudes toward using IT, perhaps because they have fewer years of experience of
using it on a daily basis (see e.g. Woodward et al., 2011). However, the population of social work-
ers with experience are still in the midst of their professional career and apparently have more
confidence in their clinical skills, similar to findings in a study of social work supervisors (Goldkind
et al., 2016). However, there was a significant portion of social workers in our study who felt that
e-therapy was suitable for their target population, who could be viewed as the ‘early majority’ who
are ready to consider using e-therapy in practice with appropriate agency supports.
Table 2. Rank, mean, and SD of perceived fit of e-therapy to client populations.
Rank Population Mean SD
1 The disabled and those with restricted mobility 3.95 0.89
2 Caregivers of disabled 3.63 1.1
2 Parents of babies 3.46 1.07
2 Chronically ill 3.47 1.04
3 Teenagers 3.11 1.22
4 Elderly 2.59 1.20
4 People who have experienced trauma 2.47 1.11
5 Families coping with poverty 2.22 0.96
SD: standard deviation.
Table 3. Characteristics of e-therapy that affect social work practice.
Rank Characteristic Mean SD
1 Requires training by an experienced e-therapist 4.42 0.91
1 Requires training to use e-therapy 4.38 0.96
2 Requires unique professional supervision 4.23 0.93
2 Requires accessible technical support in real time 4.23 0.93
2 Can be used with evaluation questionnaires 4.08 0.99
2 Allows flexibility in scheduling, which is an advantage 4.04 0.96
3 Appropriate for specific populations 3.76 1.05
3 Raises complex ethical issues 3.68 1.11
3 Might cause technological difficulties, which I do not know how to handle 3.64 1.07
3 Improves access to services for populations that otherwise would not receive them 3.58 0.99
3 Suitable for evaluating progress in treatment 3.54 0.89
4 Can be combined with other Internet technologies such as WhatsApp 3.36 1.15
4 Can maintain the client’s privacy when using online treatment 3.32 1.15
4 Confidentiality of client data is possible 3.18 1.13
4 Limits appropriate professional treatment response in times of crisis 3.12 1.19
5 Can minimize external interference during sessions 2.72 1.05
SD: standard deviation.
10 International Social Work 00(0)
The second goal was to describe the social work interventions and target populations deemed
appropriate for e-therapy by the social work professional community. The highest ranked type of
practice endorsed by social workers was receiving online supervision, following by establishing a
therapeutic milieu, therapeutic contract, and goals. This suggests that given the lack of actual experi-
ence, social workers would prefer to use ICT methods under supervision, which is a protected work
Table 4. Factor analysis about applying e-therapy in practice.
Variable Benefits Training Barriers
Intake can be made online 0.732
Can establish a stable therapeutic setting while using e-therapy 0.706
Meaningful termination of treatment can be managed online 0.700
Allows flexibility in scheduling, which is an advantage 0.691
Can make an assessment of treatment progress online 0.684
Suitable for evaluation forms and program evaluation 0.684
Specifying a therapeutic contract including goals and objectives can be
done online
Using e-therapy enables meeting therapeutic goals 0.602
Can maintain the client’s privacy when using online treatment 0.568
Easy to integrate the online treatment with other technological means
such as SMS, Instagram, WhatsApp
The use of e-therapy requires supervision from a person who is
experienced in e-therapy
Before starting to use e-therapy, a social worker must undergo
appropriate training
Requires an appropriate unique professional training 0.826
Requires accessible technical support in real time 0.607
May cause technological difficulties, which I do not know how to handle –0.780
Limits the use of a variety of intervention techniques –0.597
Raises complex ethical issues –0.579
Limits appropriate professional treatment response in times of crisis –0.508
During e-therapy, external interference can be minimized
Suitable only for specific populations
Can be used with projective tools (cards, art making, etc.)
Improves access to services for populations that otherwise would not receive
Allows the therapist to perceive the client’s non-verbal communications
Can receive online supervision
% variance explained 25.2% 14.3% 11.6%
Loading included only when values are >0.50; items in italics not included in factor analysis.
Table 5. Estimates of the factors when predicting e-therapy perceived quality.
Factor Estimate Significance
Intercept 2.607 0.000
Benefits 0.592 0.000
Training 0.015 0.834
Barriers 0.292 0.000
Cwikel and Friedmann 11
relationship, before trying out e-therapy skills on their client populations. Establishing a therapeutic
alliance was viewed as an important issue among our respondents, consistent with a study showing
that therapeutic alliance could be just as easily established in both e-therapy and face-to-face client
interactions (Cook and Doyle, 2002) and another study showing that e-therapy can promote a posi-
tive therapeutic alliance among practitioners who receive training (Lopez, 2015).
Conducting an intake was given a neutral ranking, while crisis intervention, using a variety of
techniques, termination of treatment, using projective tools, and perceiving non-verbal communi-
cation were all seen as less appropriate or difficult to do using e-therapy. E-therapy limits the
understanding of non-verbal communication, a concern raised by several in the field (Grady et al.,
2011; Oravec, 2000; Recupero and Rainey, 2005; Sucala et al., 2012). Social workers recognized
that e-therapy can be adapted for establishing a therapeutic contract and articulating goals in ther-
apy. However, respondents were not sure about conducting an intake interview or engaging in
crisis intervention using e-therapy.
The preferred populations for e-therapy use included the disabled and those with restricted
mobility, caregivers to those who are housebound, parents of infants or small children, those who
are chronically ill, and teenagers. There were negative attitudes toward the use of e-therapy with
the poor or elderly, closely reflecting the existence of barriers of income and education, both shown
to curtail ICT use in the general population (Wright and Hill, 2009). While clients with limited
mobility were considered a highly suitable population among our surveyed social workers, research
shows that this population group has significant limitations in using e-therapy and IT technologies
(Newby, 2016). Furthermore, older adults with physical limitations were less likely to make use of
IT interventions than those without limitations (Gell et al., 2013).
Interestingly enough, the ranked intervention methods and populations closely reflect the rec-
ommendations of the American Telemedicine Association (Grady et al., 2011) and a Canadian
review on e-therapy (Harris and Birnbaum, 2015). These position statements suggest that e-therapy
is suitable for community and outpatient settings and can be used in diagnostic assessments. For
example, the Internet was found suitable for screening for PPD among mothers in the community
(Le et al., 2009; Teaford et al., 2015). Furthermore, the challenges of overcoming technological
glitches were of concern to the potential e-therapist in concordance with other research,
which showed that technology is viewed as a barrier to establishing good therapeutic alliance in
e-therapy, particularly for clients with low levels of computer literacy (Haberstroh et al., 2008).
Similarly, attention to ethical issues was a major concern in our study as well as in others (Manhal-
Baugus, 2001; Reamer, 2013).
As noted by several researchers, the issues of training and developing confidence in e-therapy
skills has rarely been addressed in undergraduate, graduate, or continuing education for social
worker practitioners (Fitch, 2015; Perron et al., 2010; Robbins et al., 2016). Training at the under-
graduate, graduate, and continuing education levels is the obvious route to greater incorporation of
e-therapy into practice and the development of ‘e-social work’ which includes all types of ICT
interfaces (Eito et al., 2018; López Peláez and Marcuello-Servós, 2018; López Peláez et al., 2018).
Table 6. Estimates of the factors when predicting convenience of using e-therapy.
Factor Estimate Significance
Intercept 2.323 0.000
Benefits 0.608 0.000
Training –0.288 0.025
Barriers 0.332 0.009
12 International Social Work 00(0)
One exception is an innovative practicum that taught e-therapy and face-to-face counseling skills
to Master of Social Work (MSW) students, who then developed practice skills by providing e-ther-
apy to undergraduate social work students (Mishna et al., 2013). Our findings point to the impor-
tance of training and supervision in establishing confidence in the use of e-therapy in social work
practice, by increasing the functional or psychological benefits and decreasing the barriers associ-
ated with e-therapy use in practice (Zeithaml, 1988). Benefits that should be emphasized in train-
ing, which were cited by social workers in our study, include the following: the ability to establish
a therapeutic setting, flexibility in scheduling, suitability for developing assessment or for use with
evaluation questionnaires, integration with other technologies, and that it improves access to popu-
lations who might not otherwise receive services. Frank discussion of the ethical issues in the use
of e-therapy in practice is also warranted and supported by findings from a recent review. Each
practitioner should take responsibility for safeguarding the confidentiality of client data and should
use e-therapy within the security and ethical guidelines in their regional jurisdiction in accordance
with ethical codes of practice (Lopez, 2014; Reamer, 2017).
While this survey used both online and direct survey collection, the sample may not be repre-
sentative of all different sectors of social workers. Furthermore, it would be advisable to replicate
this study with other samples of social workers in other countries, to make international compari-
sons. The small number of social workers with e-therapy experience also limited the analyses in
the study. Future research should use mixed methods to incorporate the experiences of social work-
ers who have used e-therapy into practice, and to give real-life suggestions for the successful
incorporation of e-therapy into social work practice.
The diffusion of innovation theory suggests that in order to promote the use of e-therapy and
other ICT methods in social work practice, it would be wise to start by training and supervising
social workers in the field. Training should focus on developing e-therapy skills by emphasizing
responsibilities such as for data security, benefits, and barriers in the adaptation of this innovation.
Supervision using ICT seems to be the best way to start social workers on the road to digital liter-
acy, followed by supervised clinical work with clients.
In the international social work community, it is clear that some countries are beginning to
incorporate ICT into social work practice, while other countries are just in the initial stages of
adapting this innovation. National social work associations can be proactive in setting ethical
guidelines for ICT practice, thus reducing some of the barriers reported by social workers in trying
to devise the optimal way of using ICT. However, undergraduate and graduate programs in schools
of social work and in-service training have a crucial role to play in order to ensure that these tools
offer the most benefit to social work clients and practitioners.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
1. 3 percent were missing data on gender.
2. 4 percent were missing data on age.
Julie Cwikel
Andersson, G. and P. Cuijpers (2009) ‘Internet-Based and Other Computerized Psychological Treatments for
Adult Depression: A Meta-Analysis’, Cognitive Behaviour Therapy 38(4): 196–205.
Cwikel and Friedmann 13
Andersson, G., J. Bergström, P. Carlbring and N. Lindefors (2005) ‘The Use of the Internet in the Treatment
of Anxiety Disorders’, Current Opinions in Psychiatry 18(1): 73–7.
Atkinson, L.N., L.S. Saperstein and J. Pleis (2009) ‘Using the Internet for Health-Related Activities: Findings
from a National Probability Sample’, Journal of Medical Internet Research 11(1): e4.
Austin, D., B. Klein, K. Shandley and L. Ciechomski (2010) ‘Training Clinicians Online to Be E-Therapists:
The “Anxiety Online” Model’, in J. Bennett-Levy, D.A. Richards, P. Farrand, H. Christensen, K.M.
Griffith, D.J. Kavanagh, B. Klein, M.A. Lau, J. Proudfoot, L. Ritterband, J. White and C. Williams (eds)
Oxford Guide to Low Intensity CBT Interventions, pp. 459–67. Oxford: Oxford University Press.
Australian Association of Social Workers (AASW) (2016) ‘Social Media, Information and Communication
Technologies: Part 3. Ethics and Practice Guidelines’. Available online at:
Barak, A. and J.M. Grohol (2011) ‘Current and Future Trends in Internet Supported Mental Health
Interventions’, Journal of Technology in Human Services 29(3): 155–96.
Barak, A., L. Hen, M. Boniel-Nissim and N. Shapira (2008) ‘A Comprehensive Review and a Meta-Analysis
of the Effectiveness of Internet-Based Psychotherapeutic Interventions’, Journal of Technology in
Human Services 26(2–4): 109–60.
Barak, A., B. Klein and J.G. Proudfoot (2009) ‘Defining Internet-Supported Therapeutic Interventions’,
Annals of Behavioral Medicine 38(1): 4–17.
Beaumont, E., P. Chester and H. Rideout (2017) ‘Navigating Ethical Challenges in Social Media: Social
Work Student and Practitioner Perspectives’, Australian Social Work 70(2): 221–8.
Beintner, I., C. Jacobi and C.B. Taylor (2012) ‘Effects of an Internet-Based Prevention Programme for Eating
Disorders in the USA and Germany – A Meta-Analytic Review’, European Eating Disorders Review
20(1): 1–8.
Blankers, M., M.W. Koeter and G.M. Schippers (2011) ‘Internet Therapy versus Internet Self-Help versus
No Treatment for Problematic Alcohol Use: A Randomized Controlled Trial’, Journal of Consulting and
Clinical Psychology 79(3): 330–41.
Borbas, C., N. Morris, B. McLaughlin, R. Asinge and F. Gobel (2000) ‘The Role of Clinical Opinion Leaders
in Guideline Implementation and Quality Improvement’, Chest 118(2): 24S–32S.
Capurro, D., K. Cole, M.I. Echavarría, J. Joe, T. Neogi and A.M. Turner (2014) ‘The Use of Social Networking
Sites for Public Health Practice and Research: A Systematic Review’, Journal of Medical Internet
Research 16(3): e79.
Celio, A.A., A.J. Winzelberg, D.E. Wilfley, D. Eppstein-Herald, E.A. Springer, P. Dev and C. Barr (2000)
‘Reducing Risk Factors for Eating Disorders: Comparison of an Internet-and a Classroom-Delivered
Psychoeducational Program’, Journal of Consulting and Clinical Psychology 68(4): 650–7.
Chan, C. and M.J. Holosko (2016) ‘A Review of Information and Communication Technology Enhanced
Social Work Interventions’, Research on Social Work Practice 26(1): 88–100.
Cook, J.E. and C. Doyle (2002) ‘Working Alliance in Online Therapy as Compared to Face-to-Face Therapy:
Preliminary Results’, Cyberpsychology & Behavior 5(2): 95–105.
Csiernik, R., P. Furze, L. Dromgole and G.M. Rishchynski (2006) ‘Information Technology and Social Work
– The Dark Side or Light Side?’, Journal of Evidence-Based Social Work 3(3–4): 9–25.
Danaher, B.G., J. Milgrom, J.R. Seeley, S. Stuart, C. Schembri, M.S. Tyler, J. Ericksen, W. Lester, A.W.
Gemmill, D.B. Kosty and P. Lewinsohn (2013) ‘MomMoodBooster Web-Based Intervention for
Postpartum Depression: Feasibility Trial Results’, Journal of Medical Internet Research 15(11): e242.
Eito, M.A, M.J. Gómez Poyato and C. Marcuello Servós (2018) ‘E-Social Work in Practice: A Case Study’,
European Journal of Social Work 21(6): 930–41.
Finn, J. (2006) ‘An Exploratory Study of Email SSE by Direct Service Social Workers’, Journal of Technology
in Human Services 24(4): 1–20.
Finn, J. and A. Barak (2010) ‘A Descriptive Study of E Counsellor Attitudes, Ethics, and Practice’, Counselling
and Psychotherapy Research 10(4): 268–77.
Finn, J. and D. Schoech, (eds) (2014) Internet-Delivered Therapeutic Interventions in Human Services:
Methods, Interventions and Evaluation. New York: Routledge.
Fitch, D. (2015) ‘A Conceptual Framework for Information Technology in Social Work Practice’, Advances
in Social Work 16(1): 15–30.
14 International Social Work 00(0)
Forsell, E., M. Bendix, F. Holländare, B.S. von Schultz, J. Nasiell, M. Blomdahl-Wetterholm, C. Eriksson,
S. Kvarned, J.L. van der Linden, E. Söderberg and J. Jokinen (2017) ‘Internet Delivered Cognitive
Behavior Therapy for Antenatal Depression: A Randomised Controlled Trial’, Journal of Affective
Disorders 221: 56–64.
Gell, N.M., D.E. Rosenberg, G. Demiris, A.Z. LaCroix and K.V. Pate (2013) ‘Patterns of Technology Use
among Older Adults With and Without Disabilities’, The Gerontologist 55(3): 412–21.
Gilbody, S., E. Littlewood, C. Hewitt, G. Brierley, P. Tharmanathan, R. Araya, M. Barkham, P. Bower,
C. Cooper, L. Gask and D. Kessler (2015) ‘Computerised Cognitive Behaviour Therapy (cCBT) as
Treatment for Depression in Primary Care (REEACT Trial): Large Scale Pragmatic Randomised
Controlled Trial’, British Medical Journal 351: h5627.
Goldkind, L., L. Wolf and J. Jones (2016) ‘Late Adapters? How Social Workers Acquire Knowledge and
Skills about Technology Tools’, Journal of Technology in Human Services 34(4): 338–58.
Grady, B., K.M. Myers, E.L. Nelson, N. Belz, L. Bennett, L. Carnahan, V.B. Decker, D. Holden, G. Perry,
L. Rosenthal and N. Rowe (2011) ‘Evidence Based Practice for Telemental Health’, Telemedicine and
E-Health 17(2): 131–48.
Grebel, H. and J. Steyaert (1995) ‘Social Informatics: Beyond Technology. A Research Project in Schools of
Social Work in the European Community’, International Social Work 38(2): 151–64.
Haberstroh, S., G. Parr, L. Bradley, B. Morgan-Fleming and R. Gee (2008) ‘Facilitating Online Counseling:
Perspectives from Counselors in Training’, Journal of Counseling & Development 86(4): 460–70.
Harris, B. and R. Birnbaum (2015) ‘Ethical and Legal Implications on the Use of Technology in Counselling’,
Clinical Social Work Journal 43(2): 133–41.
Helitzer, D., Heath, D. Maltrud, K. E. Sullivan and D. Alverson (2003) ‘Assessing or Predicting Adoption
of Telehealth Using the Diffusion of Innovations Theory: A Practical Example from a Rural Program in
New Mexico’, Telemedicine and E-Health 9(2): 179–87.
Kessler, D., G. Lewis, S. Kaur, N. Wiles, M. King, S. Weich, D.J. Sharp, R. Araya, S. Hollinghurst and
T.J. Peters (2009) ‘Therapist-Delivered Internet Psychotherapy for Depression in Primary Care: A
Randomised Controlled Trial’, The Lancet 374(9690): 628–34.
King, E. (2009) The Effectiveness of an Internet-Based Stress Management Program in the Prevention of
Postpartum Stress, Anxiety and Depression for New Mothers. Minneapolis, MN: Walden University.
Kuester, A., H. Niemeyer and C. Knaevelsrud (2016) ‘Internet-Based Interventions for Posttraumatic Stress:
A Meta-Analysis of Randomized Controlled Trials’, Clinical Psychology Review 43: 1–16.
Le, H.N., D.F. Perry and X. Sheng (2009) ‘Using the Internet to Screen for Postpartum Depression’, Maternal
Child Health Journal 13(2): 213–21.
Lopez, A. (2014) ‘Social Work, Technology, and Ethical Practices: A Review and Evaluation of the National
Association of Social Workers’ Technology Standards’, Social Work in Health Care 53(9): 815–33.
Lopez, A. (2015) ‘An Investigation of the Use of Internet Based Resources in Support of the Therapeutic
Alliance’, Clinical Social Work Journal 43(2): 189–200.
López Peláez, A.R. and C. Marcuello-Servós (2018) E-Social Work and Digital Society: Re-Conceptualizing
Approaches, Practices and Technologies. New York: Taylor & Francis.
López Peláez, A.R., R. Pérez García and M.V. Aguilar-Tablada Massó (2018) ‘E-Social Work: Building a
New Field of Specialization in Social Work?’ [E-Social Trabajo: Construyendo un Nuevo Campo de
Especialización en el Trabajo Social?], European Journal of Social Work 21(6): 804–23.
McAuliffe, D. and S. Nipperess (2017) ‘E-Professionalism and the Ethical Use of Technology in Social
Work’, Australian Social Work 70(2): 131–4.
McCarty, D. and C. Clancy (2002) ‘Telehealth: Implications for Social Work Practice’, Social Work 47(2): 153–61.
Manhal-Baugus, M. (2001) ‘E-Therapy: Practical, Ethical, and Legal Issues’, Cyberpsychology & Behavior
4(5): 551–63.
Menon, G.M. and J. Miller-Cribbs (2002) ‘Online Social Work Practice: Issues and Guidelines for the
Profession’, Advances in Social Work 3(2): 104–16.
Milgrom, J., B.G. Danaher, A.W. Gemmill, C. Holt, C.J. Holt, J.R. Seeley, M.S. Tyler, J. Ross and J. Ericksen
(2016) ‘Internet Cognitive Behavioral Therapy for Women with Postnatal Depression: A Randomized
Controlled Trial of MumMoodBooster’, Journal of Medical Internet Research (JMIR) 18(3): e54.
Cwikel and Friedmann 15
Mishna, F., D. Levine, M. Bogo and M. van Wert (2013) ‘Cyber Counselling: An Innovative Field Education
Pilot Project’, Social Work Education 32(4): 484–92.
Moore, G.C. and I. Benbasat (1991) ‘Development of an Instrument to Measure the Perceptions of Adopting
an Information Technology Innovation’, Information Systems Research 2(3): 192–222.
National Association of Social Workers (NASW) (2006) NASW & ASWB: Standards for Technology in Social
Work Practice. Washington, DC: NASW.
Newby, J.M. (2016) ‘Healthy Mind, Healthy Body: Recent Advances in Internet-Delivered Interventions for
Chronic Physical Conditions and Their Comorbidities’, in R.G. Menzies, M. Kyrios and N. Kazantzis
(eds) Innovations and Future Directions in the Behavioural and Cognitive Therapies, pp, 261–4.
Samford Valley: Australian Academic Press.
O’Mahen, H.A., H. Grieve, J., Jones, J. McGinley and J. Woodford (2015) ‘Women’s Experiences of Factors
Affecting Treatment Engagement and Adherence in Internet Delivered Behavioural Activation For
Postnatal Depression’, Internet Interventions 2(1): 84.
O’Mahen, H.A., D.A. Richards, J. Woodford, J. Wilkerson, E. McGinley, R.S. Taylor and F.C. Warren
(2014) ‘Netmums: A Phase II Randomized Controlled Trial of a Guided Internet Behavioural Activation
Treatment for Postpartum Depression’, Psychological Medicine 44(8): 1675–89.
Oravec, J.A. (2000) ‘Online Counselling and the Internet: Perspectives for Mental Health Care Supervision
and Education’, Journal of Mental Health 9(2): 121–35.
Parker-Oliver, D. and G. Demiris (2006) ‘Social Work Informatics: A New Specialty’, Social Work 51(2):
Perron, B.E., H.O. Taylor, J.E. Glass and J. Margerum-Leys (2010) ‘Information and Communication
Technologies in Social Work’, Advances in Social Work 11(2): 67–81.
Postel, M.G., H.A. de Haan and C.A. De Jong (2008) ‘E-Therapy for Mental Health Problems: A Systematic
Review’, Telemedicine and E-Health 14(7): 707–14.
Pugh, N.E., H.D. Hadjistavropoulos and D. Dirkse (2016) ‘A Randomised Controlled Trial of Therapist-
Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression’, PLoS
ONE 11(3): e0149186.
Pugh, N.E., H.D. Hadjistavropoulos and C.M. Fuchs (2014) ‘Internet Therapy for Postpartum Depression:
A Case Illustration of Emailed Therapeutic Assistance’, Archives of Women’s Mental Health 17(4):
Ramsey, A.T. and K. Montgomery (2014) ‘Technology-Based Interventions in Social Work Practice: A
Systematic Review of Mental Health Interventions’, Social Work in Health Care 53(9): 883–99.
Raya Diez, E. (2018) ‘E-Inclusion and E-Social Work: New Technologies at the Service of Social Intervention’,
European Journal of Social Work 21(6): 916–29.
Reamer, F.G. (2013) ‘The Digital and Electronic Revolution in Social Work: Rethinking the Meaning of
Ethical Practice’, Ethics and Social Welfare 7(1): 2–19.
Reamer, F.G. (2015) ‘Clinical Social Work in a Digital Environment: Ethical and Risk-Management
Challenges’, Clinical Social Work Journal 43(2): 120–32.
Reamer, F.G. (2017) ‘Evolving Ethical Standards in the Digital Age’, Australian Social Work 70(2): 148–59.
Recupero, P.R. and S.E. Rainey (2005) ‘Informed Consent to E-Therapy’, American Journal of Psychotherapy
59(4): 319–31.
Reger, M.A. and G.A. Gahm (2009) ‘A Meta-Analysis of the Effects of Internet- and Computer-Based
Cognitive-Behavioral Treatments for Anxiety’, Journal of Clinical Psychology 65(1): 53–75.
Resnick, H. and P.S. Anderson (2002) ‘Introduction to Technology for Social Work Practice’, Journal of
Technology in Human Services 20(1–2): 5–10.
Rice, S., J. Gleeson, C. Davey, S. Hetrick, A. Parker, R. Lederman, G. Wadley, G. Murray, H. Herrman and
R. Chambers (2018) ‘Moderated Online Social Therapy for Depression Relapse Prevention in Young
People: Pilot Study of a “Next Generation” Online Intervention’, Early Intervention in Psychiatry 12(4):
Robbins, S.P., J.A.R. Coe Regan, J.H. Williams, N.J. and M. Bogo (2016) ‘From the Editor – The Future of
Social Work Education’, Journal of Social Work Education 52(4): 387–97.
Rogers, E. (1995) Diffusion of Innovations, 4th edn. New York: The Free Press.
16 International Social Work 00(0)
Scott, C.L. (2014) ‘What Is Information Technology, Why Is It Important, and Why Isn’t Social Work Using It
More?’, in Using Information Technology in Social Work. Annapolis, MD: NACSW Convention.
Sposaro, F., J. Danielson and G. Tyson (2010) ‘iWander: An Android Application for Dementia Patients’, Paper
Presented at the 2010 Annual International Conference of the IEEE Engineering in Medicine and Biology
Society (EMBC), Buenos Aires, Argentina, 31 August–4 September, pp. 3875–8. New York: IEEE.
Strobl-Reichel, K. (2015) Incorporating E-Therapy into Practice, Social Worker Perspectives. School of
Social Work, St Paul, MN: St. Catherine University.
Sucala, M., J.B. Schnur, M.J Constantino, S.J. Miller, E.H. Brackman and G.H. Montgomery (2012) ‘The
Therapeutic Relationship in E-Therapy for Mental Health: A Systematic Review’, Journal of Medical
Internet Research 14(4): e110.
Taintor, Z. (2002) ‘Online or E-Therapy’, in T. G. Plante (ed.) Encyclopedia of Psychotherapy, vol. 2, pp.
261–70. New York: Elsevier Science.
Taylor, C.B. and K.H. Luce (2003) ‘Computer-and Internet-Based Psychotherapy Interventions’, Current
Directions in Psychological Science 12(1): 18–22.
Teaford, D., D. Goyal and S.G. McNiesh (2015) ‘Identification of Postpartum Depression in an Online
Community’, Journal of Obstetric, Gynecologic, & Neonatal Nursing 44(5): 578–86.
Wells, M., K.J. Mitchell, D. Finkelhor and K.A. Becker-Blease (2007) ‘Online Mental Health Treatment:
Concerns and Considerations’, Cyberpsychology & Behavior 10(3): 453–9.
Wodarski, J.S. and J. Frimpong (2015) ‘Application of E-Therapy Programs to Social Work Practice’, in J.S.
Wodarski and S.V. Curtis (eds) E-Therapy for Substance Abuse and Co-Morbidity, pp. 1–10. Cham:
Woodward, A.T., P.P. Freddolino, C.M. Blaschke-Thompson, D.J. Wishart, L. Bakk, R. Kobayashi and
C. Tupper (2011) ‘Technology and Aging Project: Training Outcomes and Efficacy from a Randomized
Field Trial’, Ageing International 36(1): 46–65.
Wright, D.W. and T.J. Hill (2009) ‘Prescription for Trouble: Medicare Part D and Patterns of Computer and
Internet Access among the Elderly’, Journal of Aging & Social Policy 21(2): 172–86.
Zeithaml, V.A. (1988) ‘Consumer Perceptions of Price, Quality, and Value: A Means-End Model and
Synthesis of Evidence’, The Journal of Marketing 52(3): 2–22.
Zur, O. (2012) ‘Telepsychology or Telementalhealth in the Digital Age: The Future Is Here’, California
Psychologist 45(1): 13–5.
Author biographies
Julie Cwikel is the founder and Director of Israel’s first academic center on women’s health at Ben-Gurion
University of the Negev.
Enav Friedmann is a lecturer at Bar-Ilan University in Israel. She is working in the field of consumer behavior
and decision-making, as well as social marketing.
... Prior to the coronavirus disease 2019 (COVID-19) pandemic, information and communication technologies (ICTs) had transformed professional fields including social work practice, globally (Mishna et al., 2014Berzin et al., 2015;Barsky, 2018;Reamer, 2018;Cwikel and Friedman, 2020). ICTs had permeated practice in three distinctive ways: formal, blended and informal . ...
... Unlike formal and blended ICT treatment, informal ICT use lacks protocols and encompasses varying security protection. While there is a growing body of research on formal and blended ICTs (Wodarski and Frimpong, 2015;Cwikel and Friedman, 2020), the lack of research on social workers' informal ICT use (Mishna et al., 2020), indicates a need for research to address the ethical and relational considerations (Finn and Barak, 2010;Perron et al., 2010;Mishna et al., 2012). Building on our previous studies (Mishna et al., 2012(Mishna et al., , 2014, the purpose of the current study was to examine social workers' informal ICT use in four countries: Canada, the USA, Israel and the UK. ...
Information and Communication Technologies (ICTs) permeated social work practice before coronavirus disease 2019 (COVID-19). In addition to ICT-based formal services (e.g. e-counselling), social workers used ICTs informally as an adjunct to face-to-face practice. Building on our previous research, our cross-sectional online survey examined social workers’ informal use of ICTs in four countries: Canada, the USA, Israel and the UK. The survey was administered through Qualtrics software among social workers across Canada (n = 2,609), the USA (n = 1,225), Israel (n = 386) and the UK (n = 134), and analysed using IBM SPSS Statistics version 26. The findings substantiate the ubiquitous use of informal ICTs in social work practice, as an adjunct to face-to-face treatment, across the four countries. Given the current, unprecedented context of COVID-19, we discuss the meaning of our findings related to access, ethical considerations (e.g. professional boundaries) and supervision in the context of restricted face-to-face practice. We discuss the implications for social work practice, education and research, and conclude that in the COVID-19 context, there is an even greater need for research, clinical discussion, supervision and policy on informal ICT use in social work practice.
... Most of the analysed articles focus on both (e.g. Breyette & Hill, 2015;Cwikel & Friedmann, 2020;Hobbis, 2018;Hodge et al., 2017;Lamberton et al., 2016;Lolich et al., 2019;Macdonald et al., 2017;Rönkkö, 2018 to mention a few). However, the included articles focus on both different digital tools and different practice settings and this can have implications for the interpretations of the results on a more general level. ...
... Here, the most common category of clients is young people and children and their families (e.g. Breyette & Hill, 2015;Cwikel & Friedmann, 2020;Dolinsky & Helbig, 2015), where social media and digital communication are common tools. Other categories that seem to be prioritised are those that relate to the context of handling clients within a clinical setting (Mishna et al., 2021;Reamer, 2015). ...
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The social worker-client relationship is described as essential to social work but is a broad and multi-layered concept. Today, the relationship is strengthened and challenged by digitalisation. The aim of this configurative literature review is to understand how research on social work from 2015 to 2020 describes and analyses digitalisation’s significance for the social worker-client relationship. Three themes depict the benefits and disadvantages of digitalisation, how digitalisation generates new ethical questions and dilemmas, and the different theoretical perspectives used. Future research should go beyond the pros and cons of digitalisation and should use various theoretical approaches to challenge data, illuminate client perspectives, and pose additional questions.
... From the 1990s through the 2000s, computer-based assessment programs and therapeutic games grew. Since then, etherapy has become an ever more present means of providing interventions (Cwikel & Friedmann, 2020). From 2015 through 2017, the NASW, CSWE, ASWB, and CSWA co-created the Task Force for Technology Standards to review literature regarding the use of technology across human services and education, while reviewing relevant statutes and licensing regulations to establish consensus (Reamer, 2019). ...
... Technology could also alleviate accessibility issues for some, through the use of text messaging platforms, which does not require an intense number of resources in order to communicate. Scholars suggest training focus on developing digital therapeutic skills along with centering responsibility for data security, benefits, and barriers to adoption of new technologies (Cwikel & Friedmann, 2020). An additional consideration to enhancing digital capacities within the field of social work is continuous evaluation of ethics surrounding technology. ...
As technological advances continue to develop, delivering macro human service through social work innovations becomes a new priority for the discipline. Digital technologies offer potential applications using tablets, smartphones, cloud computing, artificial intelligence, and wearable technology to enable whole new possibilities for human services. As a result, policymakers and community organizers alike can access the existing information much faster, and potentially connect with hard-to-reach communities to make meaningful decisions. Incorporating the latest digital trends from business and industry settings to macro social work practice are highlighted. By utilizing digital technology, human service organizations can become more proactive and citizen-centered, potentially transforming personal and economic capacity. (Encyclopedia of Social Work)
... Granholm [4] believes that there is space to develop the blended social work method, which combines face-to-face and online care. However, Cwikel and Friedman [19] and Bullock and Colvin [3] observed that social services professionals show little interest in integrating communication technologies ...
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We carried out a case study with a group of female victims of gender violence (n = 39) with the objective of evaluating a blended psychotherapeutic intervention. The results show that blended therapies with mobile text messages combined with face-to-face group therapies significantly improved the health of these women. Mood states and the symptoms of depression were measured with a PHQ-9 personal health questionnaire and evolved positively. In the group of women (n = 39) the scores improved from an initial 13.5 (SD = 7.2, range 3–34) to 6.0 at the end of the period of messages (SD = 5.2, range 0–18), which was a significant difference (t (39) = 2.02; p = 0.000). Most of the women stated that the messages had helped them improve their mood (91.6%) and their general health (83.3%), which made them feel more connected to their social environment (80.6%). We observed that adherence to medication for each woman improved. With mixed therapies and mobile phones, social service professionals can incorporate technology into daily practices and offer personalized attention and daily counseling to victims of gender-based violence.
... Clinical care and training in psychotherapy is a crucial part of competency training (i.e., online, e-or otherwise framed) (Nelson & Sharp, 2016;Pickens et al., 2019). In a recent study, however, Cwikel and Friedmann (2019) found that clinical social workers, at least prior to the pandemic, were considered "late adopters" of information and communication technology. One of the reasons for this late adoption may be related to the identified barrier of "need for quality training by an experienced practitioner…" The study concluded that "training should focus on developing e-therapy skills by emphasizing responsibilities such as for data security, benefits, and barriers" in using information and communication technology. ...
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Licensed Clinical Social Workers (LCSWs) have been integrating technology into psychotherapy practice for at least two decades, but the COVID-19 pandemic dramatically shifted the primary method of service delivery for diagnostic assessment and therapy to telebehavioral health. By developing telebehavioral health competencies, the 250,000 + LCSWs in the US can ensure and enhance the quality of care both during and after the COVID public health emergency (PHE). This article applies an evidence- and consensus-based, interprofessional telebehavioral health (TBH) competency framework to the field of social work. This framework was developed by the Coalition for Technology in Behavioral Science (CTiBS), initially published in 2017. It has seven competency domains: (1) clinical evaluation and care; (2) virtual environment and telepresence; (3) technology; (4) legal and regulatory issues; (5) evidence-based and ethical practice (comprised of Standards and Guidelines and Social Media); (6) mobile health and apps; and (7) telepractice development. The framework outlines three competency levels (novice, proficient, and authority) covering 49 specific objectives and 146 measurable competencies or practices. The TBH competencies support existing in-person clinical practices and are intended for trainees and practitioners who are implementing TBH in practice. This competency framework can also be used to integrate clinical social work professional development, research, and training. Additionally, considerations for other behavioral health professions regarding licensure, certification, and policy may apply to clinical social work. Future research is needed on implementation and evaluation of the competencies.
Background Telehealth, or healthcare offered through the internet, computers, and other devices for communication, is rapidly increasing with changing times and technological advancement. For quality and security of such services, it is crucial that professionals are competent in offering such service. Still, lack of professionals’ training has been identified as one of the barriers to implementation of telehealth. Thus, to improve such training, it is crucial to identify professionals’ knowledge, experience, and perspectives towards challenges and opportunities of using telehealth. Objective The review’s objective was to answer the research question: what is known in the literature about challenges and opportunities of telehealth service provision from the perspective of health professionals? Methods Arksey and O’Malley’s five-stage approach for scoping studies was used for the review. Studies were collected across four databases: Scopus, PubMed, ProQuest and EBSCOhost. The data from the 22 included studies were reported by using frequency counts and categorization of health professionals’ experiences. Results The findings of the review led to three categories: (1) study demographics, (2) challenges for telehealth, and (3) opportunities for telehealth. The most frequently reported challenges were issues related to communications, inadequate technology, or support, and need for training and knowledge to use the technology. The most frequent categories of opportunities related to improved access to services, benefits related to sharing of information sharing and experience and training of using technology. Discussion Further research is needed to explore health professionals’ experience of training, and to understand the type of support, resources, and training content they need to enhance their competency in telehealth provision.
Conference Paper
In Albania is difficult to discuss about the research in the field of innovation because often the efforts invested in this aspect have been experimental and do not go deep into the problem. The purpose of this paper is to find a description and reference of the history of innovation, its definition, combination of various dimensions in the literature as well as its determinants studied up to today. The study in this aspect tries to have theoretical depth, producing new and systematized knowledge based on careful literature review, it aims at a systematic literature review in order to consolidate the concept of innovation in a less developed field and without a strong research base in the Albania. An alternative way to set in motion economies that are experiencing a slowdown in their growth, it is the innovation, which it has been treated as the new industrial revolution (Kumar and Sundarraj, 2016). Of course, it highlight the new paradigm according to which the engagement of new technologies and the use of existing technologies in different ways, enable the creation of a new economy and new opportunities for further developments. According to Taalbi (2017), it is confirmed a positive relationship between innovation and performance, so innovative firms actually have better performance. According to the recent data of June 2022 from the Word Bank, Albania is the last in the region with 0.15% of GDP for the research and development expenditure. Albania not only has the lowest level in terms of research and development but also has a deep difference with both European and regional countries.
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The increase in the need for e-counselling is apparent in recent years due to its convenience to provide counselling support from remote locations. Despite the increasing number of e-counsellors, few studies have been conducted especially in the Malaysian context that highlight e-counsellors’ self-beliefs when providing e-counselling. Thus, this study was conducted to identify the level of counselling self-efficacy among e-counsellors in Malaysia and identify whether there is a significant difference between social factors, namely age groups, education levels, years of counselling experience, counselling licensure and registration status, on self-efficacy levels. A simple random sampling method was employed to select 159 e-counsellors in Malaysia who have prior experience in e-counselling implementation using any online-based medium. Larson’s (1992) Counselling Self-Estimate Inventory was adapted for purpose of data collection in this study. The analyses used were independent sample t-test and one-way analysis of variance. The findings report that e-counsellors have moderate levels of counselling self-efficacy overall, where a high level for one of the sub-construct pertained to application of basic counselling skills. E-counsellors who completed postgraduate studies had higher self-efficacy compared to e-counsellors with a bachelor’s degree. Registered and licensed e-counsellors reported higher levels of counselling self-efficacy compared to their counterparts. No significant differences were found for e-counsellors across age groups and years of counselling experience. This study recommends for professional counselling bodies, supervisors and counselling educators to revise and improve the education and training for counsellors at all social levels, especially in highlighting the practices of e-counselling.
Based on the theory of planned behavior (TPB), this study aimed to examine factors influencing therapist uptake of digital mental health interventions in Israel. Two hundred twenty-nine mental health professionals recruited through a convenience sample completed a background and demographic questionnaire, as well as the TPB-based electronic-therapy attitudes and process questionnaire. Regressions were used to examine the contribution of attitudes, perceived behavioral control, subjective norms, and behavioral intentions. Intention to use and use of digital interventions were significantly predicted by attitudes, subjective norms, and perceived behavioral control, as suggested by the TPB. The use of cognitive behavioral therapy (CBT) and higher perceived behavioral control increased the likelihood of using digital interventions. Having a positive attitude, having expectations/social pressure from one's professional environment, and having a sense of control over the process were found to predict the intent to use, as well as the actual use of, digital interventions.
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Major depression occurs in 5–10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group. Objective To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence Design Randomised controlled trial. Setting Online and telephone. Population or Sample Self-referred pregnant women (gestational week 10–28 at intake) currently suffering from major depressive disorder. Methods 42 pregnant women (gestational week 12–28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care. Main Outcome Measures The primary outcome was depressive symptoms measured with the Montgomery-Åsberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed. Results The ICBT group had significantly lower levels of depressive symptoms post treatment (p<.001, Hedges g =1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p=.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression. Limitations Small sample size and no long-term evaluation. Conclusion Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.
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One of the most challenging aspects of my role as editor in chief has been writing editorials that I thought would be of interest to the readers of this journal. Over the past four years I have written about a variety of topics including transitions, scholarship, competency-based education, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, peer reviews, and trigger warnings, among others. As my term comes to a close with this issue, my last editorial glances into the future to speculate about what our profession might look like in years to come and offers ideas about some of the possibilities and potential constraints that lie ahead for us as social work educators. However, not having any specific expertise in future forecasting, I invited several leaders whom I consider to be visionaries in social work education to muse along with me about the future of social work education. Here is this result of this collaboration.
This article describes how information systems research in the human services can be facilitated with a conceptual framework that addresses the fundamental roles of data, information and knowledge in understanding organizational information systems. Using methodologies originating in information systems and organizational research, the resulting conceptual framework explains how we are to understand information technology from the perspectives of clinical social work, supervision, social work administration, policy, and community collaborations. It concludes by reminding us that to the extent we have done little to educate our students on the differences between data, information and knowledge, and to educate them based on research performed in our human services agencies, is the extent to which our professional practice relative to technology will not advance in the 21st century.
This paper defines the concept of e-inclusion in reference to programmes and projects that promote social inclusion through the use of new technologies. This concept is related to e-social work, defined as the use of ICTs in the field of social work and social services. To illustrate the implications of e-inclusion and e-social work, a case study is presented on a community involvement project using new technologies as a means and as an end. The SAREGUNE project for community use of new technologies was set up in Vitoria (Spain) in 2004. Ten years later, it gained recognition as a European e-inclusion scheme within the ‘Leonardo Da Vinci Multilateral Projects, Transfer of Innovation’ lifelong learning programme. This article explores the origins of the idea and its significance in the fight against the digital divide and in the processes of intercultural and social inclusion within the city's historic central district. A process of deconstruction, construction and reconstruction of the scheme is used to identify and describe the movements of rotation and revolution within the process of social inclusion, the levels of integration of e-social work at individual, group and community level, and the impact of the project in terms of e-inclusion.
This paper presents a theoretical reflection on e-social work by considering a case study: an intervention programme with vulnerable people, included in the services catalogue of a non-governmental organization (NGO), Zaragoza Red Cross Assembly. This programme cares for older people with a home assistance system mediated by information and communication technologies (ICTs). The digital convergence of the Spanish Red Cross and the digitalization of internal processes were accelerated by the use of ICTs as a tool in the aftermath of the 2008 crisis: first, to manage bureaucratic matters; second, to coordinate professionals and third, to interact with users. The text is divided into five sections including an introduction and final remarks. The first section describes the intervention programme and its evolution from a traditional social work vision to an e-social work perspective. The second section describes and analyses the intervention programme and the incorporation of ICTs in this NGO, over more than two decades. The third section describes professional contributions to the implementation and adaptation of social work to new social and technological circumstances and users’ requirements based on these intervention experiences.
New technologies have transformed the nature and practice of social work. A wider range of available digital procedures has opened up a broader dimension regarding research, therapies, interventions and social networks in the field. Using meta-analysis methods, this article reviews the current situation of the application of information and communication technologies (ICTs) in social work. A search of the literature reveals 70 articles using different methodological approaches over the period 2006–2016. The descriptors for the search were ICTs, information systems, technological systems, social work and e-social work. The main findings are that most studies on ICTs and social work focus on the impact, potential and specific uses of technologies in different aspects of social work, the ethical issues involved and the special attention that should be given to social workers’ educational programmes. This scenario is a changing reality that must be taken into account: it is an irrefutable fact that new technologies are affecting social work and will be reflected by researchers and practitioners who should address and deal with these new trends in social work. The results allow us to identify four key recommendations to assist social workers in successfully adopting and implementing ICTs in their daily practice.
Abstract The portable, accessible nature of technology affords social workers opportunities to venture outside traditional service contexts by engaging in the virtual realm. This qualitative article uses two small-scale exploratory case studies to investigate the concept of ethical challenges in online peer networking and blogging by a social work student and social work practitioner. The article seeks to address the opportunities for and complexities of navigating technology and social media, while also emphasising the need for social workers to acquire a range of skills and competencies, and use well-established frameworks to engage in ethical online practice. KEYWORDS: E-Professionalism, Social Work, Technology, Ethics, Social Media, Blogging
Chapter 49 considers Anxiety Online - a 'virtual' online clinical assessment and treatment service, and describes an online clinician training program for online low intensity practitioners (‘etherapists’) to work ‘in’ the Anxiety Online virtual clinic, and the challenges and solutions involved.
Little is understood about the scope of information and communication technology (ICT) use in practice for agency-based social work professionals, and still less is known about how such practitioners acquire and avail themselves of opportunities to learn about ICT tools. This study asked a sample of social work field supervisors (n = 371) to describe their personal and professional ICT use, to rank the technological sophistication of their agency, to describe the barriers and facilitators to ICT use in their organizations and to operationalize environmental opportunities for acquiring new skills and knowledge. The authors examine factors that may influence technology use: asking if organizational culture is related to uptake in the professional context, and if self-reported individual resistance to innovation and change can explain voluntary adoption of ICT tools. The results offer a portrait of how agency-based social workers are using technology in personal and professional life, describe how these supervisors learn about developing technologies for practice, and highlight the gaps in technology infrastructures among agencies, pointing to directions for further exploration.